Adrenal Dependent Cushings with secondary Diabetes: Squeaker needs a specialist!!!!

[bichons9]

Squeaker has had no side effects from Trilostane..but I have so many issues when compounding is needed ..but more important....How many doses /day are most people giving their pups? Once or twice /day? Squeaker was on 6mg @ 6am...then went to 6mg@ 6 am and 3 mg @ 6pm..now he is on 15 mg @ 6 am only...Updates on BID or SID suggest that Vetoryl may only last 12 hours. I am just wondering what all of you really knowledgeable members think about this. I am sure it's a coincidence that this am Squeaker's BG > 600..but it made me think..Thanks for reading... Atricle-An Update on Vetoryl https://pubmed.ncbi.nlm.nih.gov/29606727/

[labblab]

https://docs.google.com/document/d/1...3SPQe-fDc/edit C-T SCAN

https://docs.google.com/document/d/1...MLy6v7Eaw/edit 2nd ACTH Stim test..First test on 4/27/2021 was Pre= 7 post= 44.4 ..I don't know why 1st test is not showing up in google docs??? Please let me know if this worked..Thanks again!!!!

Unfortunately, when I click on the Google doc links, I get a banner saying that my access is denied. Perhaps you need to reset the viewing parameters to allow for public access?

Marianne

[labblab]

Squeaker has had no side effects from Trilostane..but I have so many issues when compounding is needed ..but more important....How many doses /day are most people giving their pups? Once or twice /day? Squeaker was on 6mg @ 6am...then went to 6mg@ 6 am and 3 mg @ 6pm..now he is on 15 mg @ 6 am only...Updates on BID or SID suggest that Vetoryl may only last 12 hours. I am just wondering what all of you really knowledgeable members think about this. I am sure it's a coincidence that this am Squeaker's BG > 600..but it made me think..Thanks for reading... Atricle-An Update on Vetoryl https://pubmed.ncbi.nlm.nih.gov/29606727/

I saw that you had posted this reply on another member’s thread, but I’ve taken the liberty of moving it here so it can join your other questions and updates that are specific to Squeaker. That way all of his info will be consolidated in one place, especially since I’m not sure whether or not that other member will be returning to the forum soon.

As far as the frequency of trilostane dosing, clinicians have bern debating for years as to whether once vs. twice daily dosing is more desirable. My personal opinion is that a lot seems to depend on the individual metabolism of any given dog. Some dogs seem to do fine on once daily dosing and that’s certainly an easier regimen for an owner to follow. However, for other dogs, the clinical benefit does wane before the end of a 24-hour time period and symptoms may rebound daily as a result. For those dogs, twice daily dosing indeed appears to be preferable.

In Squeaker’s case, diabetes may be the most important factor. We’ve been told that twice daily dosing is generally preferable for diabetic dogs so that cortisol levels can be controlled as evenly as possible at all times during a day/night. The goal is to avoid peaks and valleys in cortisol that may have a similar effect on glucose levels. I see you started out with once a day dosing, then shifted to twice daily, and have now returned to once daily. Did the vet give you a reason for returning to once daily?

Marianne

[bichons9]

NO..he has changed dosage a few times..wanted to start low low... but wants Cortisol <10 so increased to 15 once a day. I really would prefer to give twice a day..I do not think that the DVM thinks it through or maybe he likes once a day..I will ask him next week...he sounds overwhelmed with the CT results and has his partners consulting on what to do....Plan was for MY other DVM to do Adrenalectomy until they saw CT results and ESPECIALLY BECAUSE IT IS THE right adrenal gland??? He and others have not had Adrenal Cushings WITH Diabetes at same time before..but I don't know..I am afraid at times to ask more questions even though I constantly do practically every day...but the dosage has been changed and compounded a few times so now, I would have to give 10 mg caps and then 5 mg caps 12 hours later. I would like to do this but am not sure whether the unequal doses makes a difference. As a HCP, I don't think so but I just don't know what to do. What do you think?? There's an ER DVM that takes over on weekends..I may ask him what he thinks, though who knows if he will opine on the matter. My head is spinning 24/7.. Marley with Pulmonary Hypertension on 8 meds/day..Suzie has been an insulin-dependent diabetic 4 years, 2 needed ACL and luxating patella surgery but only Squeaker could have it..Marley too weak for surgery? Elliott in remission no longer needing insulin...and so..Bonnie and Trouble only 2 not in need of all of the above. Any advice from all will be greatly appreciated. P.S. I wanted to send him the updated articles on Trilostane but decided not to ...yet...Thanks Lablab!!!!

[bichons9]

I changed to anyone that has link..hope it works...CT scan https://docs.google.com/document/d/1...it?usp=sharing

2nd dex test https://docs.google.com/document/d/1...it?usp=sharing

[labblab]

Hello again! Yes, I’m now able to view those documents — thanks very much for changing the permissions. Unfortunately this is a busy day for me so I haven’t yet had the time to write down my thoughts. But I will definitely try to get back with you either today or tomorrow. I at least wanted to pop in now, though, to let you know that you were successful in allowing us to view those documents. Good job ;-).

Marianne

[bichons9]

Thanks.... for letting me learn from you...pdf's, google docs, sheets???? Well, at least I learned how to deal with PDF documents!!!

[labblab]

OK, I’m finally back again and so sorry for the delay. After again reading through the CT report, I wish I could give you some simple answers to your questions. But I’m afraid it looks as though little Squeaker has a lot going on, and once again, my recommendation would be to enlist the help of a specialist to sort it all out. Since I’m not a vet myself, I’m afraid all I can do is offer some basic impressions.

First, as far as the adrenal mass, I think Glynda hit the nail on the head in her earlier reply to you. If the tumor was causing the right adrenal gland to be pumping out cortisol, you’d expect the left adrenal gland to be smaller than normal. However, in Squeaker’s case, his left adrenal gland actually seems to be enlarged. So if he does indeed have Cushing’s, we have to suspect that it is a *pituitary* tumor that is causing the excessive cortisol as opposed to the adrenal tumor. The adrenal tumor does carry other “negatives,” however. It may be malignant, and it appears as though it has invaded the caudal vena cava, which is a major blood vessel. As you already know, that invasion makes surgery much more risky if not impossible. The report states that there is another larger mass near the liver, which may or may not be connected to the adrenal tumor. There are other issues for Squeaker, as well, which all contribute to a very complicated picture. So as I say, I’m afraid it will require someone with a lot of expertise to determine an optimal treatment plan for your little boy.

As far as the results of this second monitoring ACTH stimulation test (as opposed to a dexamethasone test which is a different type of test that is used for Cushing’s diagnostics only), it’s true that your goal would be to lower a Cushpup’s post-ACTH result to at least approx. 9 ug/dL or less. The trilostane has lowered Squeaker’s cortisol significantly from the initial 44, but it’s still not down within desired therapeutic range. If Cushing’s were his only problem, I’d feel more comfortable about coaching you regarding the monitoring protocol. But as I say, the combination of all his issues makes me more uncertain as to how Cushing’s fits into the overall puzzle, including exactly which physical factors aside from a possible pituitary tumor may be fueling his elevated cortisol.

I’m truly sorry that you have so many worries from all your furkids on your shoulders! I cannot even imagine how stressful it must be for you. But again, I think the best thing you can do for your own peace of mind is to try to enlist the help of a specialist to guide you. Please do feel free to continue to ask us questions and to share updates, but I’m afraid there’s a lot about Squeaker’s situation that is just outside of our skill set. But that doesn’t mean we won’t want to continue to hear how things are going, so please do keep us in the loop!

Marianne

[bichons9]

Thank You and all for caring..I do not get email notices that you respond so I am sorry that I did not see this message sooner. Right now I am trying to keep his BG as low as I can by giving regular insulin every few hours, in addition to his Vetsulin. As far as the Cushings...I just don't know...will look for an endocrinologist ..but 2 only want to consult with my DVM's..not with me. Squeaker is active, eating, happy...I have read some of what you suggested in some VIN articles..not sure the DVM'S have!!!! However, when DVM's wanted to and did keep Squeaker overnight simply to encourage me to get some sleep..I was shocked....at NO CHARGE..but reminded me that they will try to stabilize Squeaker but that things are not going to get better..We'll see ..They don't know for sure anything...and I am willing to spend every hour of the day caring for him...and Suzie and Marley and Bonnie and the others...as always. Squeaker has gained >1 lb and I will hope that he continues to be happy!!!! Thanks!!!!