To treat or not to treat?

[Harley PoMMom]

, his results were 7 and later 10.4, in other words the cortisol is not under control. Physical effects I observed showed small improvement, but not dramatic.

Could you clarify his results for me, was the 7 a pre and the 10.4 the post?

If the vet wants to increase the dosage to 30 mg and prefers it to be split, as an option you can give 20 mg in the morning and 10 mg at night.

Hugs, Lori

[inheriteddog]

I goofed in explaining the ACTH results. These are the ACTH tests used to determine if Vetoryl is working to control cortisol, not to be confused with the tests to find out if the dog has Cushings (hence the results are not pre and post). I should have said the 7 was from his test in March (following two weeks of treatment) and 10.4 from April (another 3-4 weeks later). It thus can be concluded that the dosage was not working.

[inheriteddog]

I goofed in explaining the ACTH results. These are the ACTH tests used to determine if Vetoryl is working to control cortisol, not to be confused with the tests to find out if the dog has Cushings (hence the results are not pre and post). I should have said the 7 was from his test in March (following two weeks of treatment) and 10.4 from April (another 3-4 weeks later). It thus can be concluded that the dosage was not working.

New note: It is May 20. Kobe has been on Trilostane compounded 30mg/daily, in divided doses of 15mg morning and 15 evening for three weeks. About to do a new ACTH stim test Monday to monitor effectiveness of new dosage. I have not noticed difference in outward symptoms over the 20mg treatment. Some reduction in drinking and peeing. Still pretty hungry. Skin infections come and go. Bad infections between toes, treated with antibiotics for two weeks; infections subsided but did not fully resolve, they popped back up after ended pills. No obvious side effects from Trilostane, just not sure they are working much. Anticipate vet will want to increase dosage.

Question for experienced pet owners. My understanding of ACTH stim test to monitor Trilostane is that one sample is taken 4-6 hours after medicine is given to measure cortisol level. Nothing else is done, before or after sample is taken. Is this correct? The reason I ask is that I am confused by how the vet is doing the testing, requiring me to drop off dog early in day, and last month I could not pick him up until later afternoon. Seems like an awfully long time if all they need is a few minutes to take one sample. Please advise.

[labblab]

Hi again. As far as the ACTH stimulation test, the procedure is identical regardless of whether the test is being performed to diagnose Cushing’s or whether it is being used to monitor treatment. The results are just interpreted differently depending upon the purpose of the test. An initial baseline cortisol sample is first taken. Then the stimulating agent is injected. Then, an hour later a second cortisol sample is drawn after the stim agent has had time to act. So there should always be both a pre- and a post-stimulation cortisol level reported with every ACTH test. Typically the post-stimulation level is the one that’s of greatest interest. But the pre-stimulation baseline level can also add context.

On occasion, members in Canada and elsewhere in the world have reported a two-hour delay between the initial baseline draw and the post-stimulated draw, sometimes even with post- values reported at both the one hour mark and the two hour mark. But here in the U.S., it is typically just a one-hour test. I’d not be surprised if it took your vet longer than just an hour to get Kobe settled and to proceed with both of the blood draws as well as giving the stimulation agent. But I’m not sure why your vet would require Kobe to stay most of the day. Actually, that would be a good question to ask.

Marianne

P.S. Just wanted to add that you may be confusing the ACTH stimulation test with the “Pre-Pill” Vetoryl monitoring protocol that has recently become more common in Europe. Some vets in the U.S. are using it, too. With the pre-pill protocol, only a single resting cortisol level is taken immediately *before* the next daily dose of Vetoryl is given. So there is no stimulation agent involved with that, and only a single blood draw.

[inheriteddog]

Finally got to talk to vet regarding latest test results. As I expected, the dose of 30mg daily had only small impact, so he wants to increase to 40 (twenty twice daily). Due to lag in getting a response, I already ordered refill on the 30mg to avoid interruption in treatment. We will begin 40 at end of month. Kobe's improvements include his tail looking better, somewhat reduced drinking and peeing, occasional bouts of playful energy, which I haven't seen in a while. On the other hand, he still craves food, pants, and his skin infections are spreading and not responding to shampoos. Two weeks of Simplicef helped his paw infection until the medicine ran out, then they popped up again. I suspect the infections are triggered by fleas (many in the area due to dry weather). Topical flea med is of moderate help. I don't want to try oral anti-flea med because Kobe has had seizures in the past.
Compounded Trilostane is more affordable than the straight kind. Vet wants to test every new dosage but I informed him that I can't afford a test every month. By standard practice, new tests won't start to spread out until the condition stabilizes at desired degree. That could be a while. Fortunately, no adverse reactions to Trilostane yet.
Any suggestions re shampoos for skin lesions and crusty spots?

[labblab]

Thanks very much for this update. I’m sorry to hear that Kobe is in need of an increase, but glad to know that at least some of his symptoms have shown some improvement. I surely understand the financial drain of ongoing monitoring tests in conjunction with the dosing increase. In lieu of performing a full ACTH test at every monitoring visit, perhaps one thing you and your vet may decide to consider is sometimes substituting the single, simple pre-Vetoryl resting cortisol blood draw that I was describing in my previous reply. To find out more about this option, click on this link and then scroll down to the bottom of the page:

https://www.k9cushings.com/forum/sho...ushingoid-Dogs

As far as a shampoo, I was poised to recommend a medicated product that I had used quite successfully a few years ago to control a recurrent staph infection on my non-Cushing’s Lab girl. It was called Douxo Chlorhexidine shampoo, with an accompanying spray and wipes. However, I just checked it out and apparently some changes have been made to the formula fairly recently that have garnered both positive and also negative reviews from owners. Darn! Still, it may be something for you to consider. I know how frustrating the skin situation can be. For us, oral antibiotics would work for the time that my girl was taking them, but the infection always bounced back when she stopped. It took several months, but this shampoo alone finally resolved her problems. But as I say, I cannot vouch for this new formula.

Anyway, continued well wishes to you both, and we’ll continue to watch for your updates.

Marianne

[Squirt's Mom]

My sweet sweet boy, Bud (non-cush pup), has developed some sort of skin issue as of last year. He gets spots that start out itching then the hair comes out leaving a bloody raw area that looks painful but he doesn't act as if it is. He had several tests and all were negative for various bug bites, infections, diseases, and allergies. I did take him off all chicken and beef as they are common food allergens and started giving him some fish oil and coconut oil. Along with those changes, we have been treating him as if it were a fungus and it has helped. We use a topical mix of Betagen and an antifungal who's name I cannot remember (maybe Clotrimazole?). This mix does treat and heal the spots that come up but it doesn't stop other spots from firing up. He is not bothered by this during the fall or winter but once the temperatures start to rise, his skin starts breaking down. We considered an oral antifungal but those are so hard on the liver we decided to try this route.

So Bud and I can empathize with the skin issues and hope you can find something that will help your sweet baby.
Hugs,
Leslie

[inheriteddog]

So now I'm wondering if Kobe is regressing. The past week or so he's been drinking more than before. The skin infections are still bad. As well, he's recently been licking the carpet, something I haven't seen in several months. Does a dog become resistant to trilostane after a time? Or is it likely his condition is simply worsening and the dosage isn't helping anymore? I still plan to increase the dose at the end of the month when the current medicine runs out.

[labblab]

Hi again. In our experience here, it’s not unusual over time to to see the need for trilostane adjustments both up and down. I wouldn’t say that Kobe’s disease itself is necessarily getting worse, but rather just that the current dose is simply not suppressing his adrenal function sufficiently. I’m guessing this is disappointing after initially seeing a better outward response. But we’ll assume that you’ll once again see his symptoms come under better control once he’s consistently on the higher dose.

Marianne

[Squirt's Mom]

This is standard with Vetoryl/Trilostane. It is not a stable drug so it doesn't maintain control very well over time in most dogs. This is why it is so important 1) to know the signs of not only low cortisol but high and 2) to keep up the very sspecific testing schedule for this drug. The monitoring ACTHs are the only way to be sure the cortisol is once again elevated (and rule out other possibilities for the changes seen) so be sure to have that done before the vet increases the dose. Typically increases are no more than 25% of the current dose. Just a reminder....once the dose is increased the testing schedule starts all over at the 2 week mark.

I'm lazy today and haven't read back thru Kobe's thread so I apologize you have already given this info....has his skin been checked for Calcinosis cutis? This is usually diagnosed via a punch biopsy.

Let us know what the ACTH shows and how things are progressing for your sweet baby boy!

Hugs,
Leslie