tag:blogger.com,1999:blog-1407531601642815094.post7430426100314929504..comments2024-03-02T02:10:32.227-05:00Comments on Animal Endocrine Clinic: Working Up the Asymptomatic Dog for Cushing's Disease Dr. Mark E. Petersonhttp://www.blogger.com/profile/10804290441832222507noreply@blogger.comBlogger25125tag:blogger.com,1999:blog-1407531601642815094.post-80101358321800182842016-01-23T10:14:46.543-05:002016-01-23T10:14:46.543-05:00I agree. Monitoring is the best "treatment&qu...I agree. Monitoring is the best "treatment" in dogs like yours.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-32850243567580363242016-01-23T02:49:55.472-05:002016-01-23T02:49:55.472-05:00Hi Dr. Peterson.
Much like the other people who h...Hi Dr. Peterson.<br /><br />Much like the other people who have posted, our 10 year old lab mix was first discovered to have elevated ALP levels last year. We just started some additional testing a month ago, and discovered she has dilute urine as well.<br /><br />We just got an abdominal ultrasound done today. Everything looked fine. From what I remember the vet saying, there were some minor blemishes on the liver and spleen. She aspirated the spleen, but was unable to get to the liver due to it's location, fat between the entry point and the liver and a lack of desire to anesthetize our dog. She also took a urine sample for a culture to test for a hidden UTI. The only symptom we really have is that over the last 7 months she's gained 5 pounds (from 45 in May to 50 now, despite food being cut in half). She did have surgery last February for a sarcoma as well.<br /><br />Otherwise our dog is asymptomatic. She does develop hot spots, and recently she has lost hair from the back of her legs, but that seems to be related to itchiness.<br /><br />The vet seemed to be of the opinion that if everything comes back negative from today's tests, it's best to leave our dog alone. I'm inclined to agree, as it is starting to feel like we're chasing an abstract number for the sake of the number itself.<br /><br />What do you think?Unknownhttps://www.blogger.com/profile/05843639269951026357noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-46559206318300224522015-12-17T11:20:33.558-05:002015-12-17T11:20:33.558-05:00I would check with your veterinarian and the drug ...I would check with your veterinarian and the drug company. I an not familiar with Telmisartan.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-12237633949208955832015-12-17T08:38:31.899-05:002015-12-17T08:38:31.899-05:00Dr Peterson, may I just ask a very quick question...Dr Peterson, may I just ask a very quick question regarding the use of Telmisartan in a dog also taking Vetoryl? My JRT (weight 8.7kg) is on 20 mg vetoryl and has just been prescribed a half dose of Telmisartan in an effort to gain control of her high proteinuria levels. She also takes 5mg Fortekor/Benazepril. Are there any contraindications between these drugs?Anonymoushttps://www.blogger.com/profile/13871670165972067230noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-91632393497005575132015-08-22T10:16:23.816-04:002015-08-22T10:16:23.816-04:00The fasting sample should be collected on a separa...The fasting sample should be collected on a separate day from when you are doing an ACTH stimulation test.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-86674270242848730292015-08-21T19:29:23.676-04:002015-08-21T19:29:23.676-04:00Dr. Peterson: Back with a question about Abbie...Dr. Peterson: Back with a question about Abbie's treatment -- she has been on twice-daily Vetoryl for three weeks. Fourteen-day post-ACTH did show a drop in cortisol to 11.3 so at least we are going in the right direction. Unfortunately, her UPC jumped back up to 5.6 and we are now gradually lowering enalapril and starting telmisartan. A super-chem was done right after ACTH. Cholesterol was doubled and triglycerides tripled and I am thinking the lack of fasting may have contributed to these increases.<br /><br />Question: With Vetoryl being given at 7:30 am after morning meal, how do we schedule a fasting blood test? Should a morning dose be skipped the day after the ACTH so that she is fasting? Or is the lack of fasting not a significant factor in test results? <br /><br />Due to adding telmisartan, my vet wants to do a super chem 7 days after she has been on a twice daily dosing without the enalapril. This will be a week after her 30 day ACTH but would still have same issue of fasting.<br /><br />Thanks in advance for your guidance!<br /><br />Judy H.judymaghttps://www.blogger.com/profile/09466270333671210222noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-9948461630501717432015-07-31T09:33:09.157-04:002015-07-31T09:33:09.157-04:00Given these values, I'd consider raising the d...Given these values, I'd consider raising the dose now. Now "safe" amount to go up.. every dog is different. Once any dose adjustment is made, I'd recheck another ACTH stim test in 2-3 weeks. That all said, if your dog is stable, it's not wrong just to wait either. Talk to your vet again about your concerns and what to do.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-5758461003001366252015-07-31T07:06:35.299-04:002015-07-31T07:06:35.299-04:00Dr Peterson,
I would appreciate your advice. My d...Dr Peterson,<br /><br />I would appreciate your advice. My dog, a chihuahua, weighs 2.7kg, is on 3mg of vetoryl twice daily. She started vetoryl about a month ago. On the 10th day of vetoryl, an acth test was done and the base cortisol shows 96 nmol/l and post acth 349 nmol/l.<br /><br />Then on the 30th day, the second acth test was done. This time, the cortisol level worsened, the base is 118 nmol/l and post 566 nmol/l.<br /><br />My vet suggests to continue current dosage and see if her cortisol will trend down in 1.5 months time. <br /><br />My question is 1) is this usual that cortisol on the 30th day is worse than on the 10th day of medication, 2) if the cortisol level remains uncontrolled and does not trend down, and if my vet is to recommend an increase, what is the safe level to increase? is it by half of current dosage or 10% or 20%?<br /><br />Thank youBrian Chanhttps://www.blogger.com/profile/00876920893485955494noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-48936496690989355652015-07-24T14:38:40.782-04:002015-07-24T14:38:40.782-04:00Possible, but unlikely to make a difference for a ...Possible, but unlikely to make a difference for a dog on Vetoryl.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-23971625558940927602015-07-24T10:19:36.606-04:002015-07-24T10:19:36.606-04:00Dr. Peterson -- thanks for all your input! I rece...Dr. Peterson -- thanks for all your input! I received the Vetoryl yesterday and Abbie will get her first dose on 7/29 with an ACTH (along with superchem panel and UPC) scheduled for 8/11 assuming all goes well until then.<br /><br />Question: Abbie is prone to yeast flare-ups in both ears. To keep this under control, I flush her ears with Vet Solutions Ear Cleansing Solution followed by Mometamax every couple of weeks. If the yeast is widespread, there have been periods when Mometamax is applied daily for a week to ten days with flushing every few days. Is the amount of mometasone in the Mometamax significant enough to affect cortisol levels?<br /><br />Judy H.judymaghttps://www.blogger.com/profile/09466270333671210222noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-60008454493781129682015-07-16T19:16:27.951-04:002015-07-16T19:16:27.951-04:00As long as the treat contains some fat (Trilostane...As long as the treat contains some fat (Trilostane is a fat-soluble drug), that would be fine.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-73151084672667862402015-07-16T19:16:27.313-04:002015-07-16T19:16:27.313-04:00As long as the treat contains some fat (Trilostane...As long as the treat contains some fat (Trilostane is a fat-soluble drug), that would be fine.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-4226481706620483872015-07-16T10:37:19.992-04:002015-07-16T10:37:19.992-04:00Dr. Peterson: Thanks for your reply. Just want t...Dr. Peterson: Thanks for your reply. Just want to clarify Abbie's dosing/feeding schedule when we start twice daily trilostane --<br /><br />I now feed her first meal at 7:30 and her second meal at 3:45 with same portion at each meal. I would give her 10 mg. with the morning meal. I really don't want to change the timing of her 3:45 meal but could reduce it. Since the trilostane does need to be given with food, is a small snack (a few pieces of kibble with a teaspoon of canned food) before the 10 mg. evening dose at 7:30-8:00 sufficient? <br /><br />Judy H.judymaghttps://www.blogger.com/profile/09466270333671210222noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-42092058719599175642015-07-16T08:48:32.142-04:002015-07-16T08:48:32.142-04:00Twice daily administration is needed for the best ...Twice daily administration is needed for the best control, and that's why you need here. Yes, monitor a complete biochem panel every time you retest.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-4743042805282208702015-07-15T16:20:23.913-04:002015-07-15T16:20:23.913-04:00Dr. Peterson: Thank you so much for your quick re...Dr. Peterson: Thank you so much for your quick reply. Can you explain why twice daily dosing would be preferable for Abbie? I now feed her first meal at 7:30 and her second meal at 3:45 with same portion at each meal. I know trilostane needs to be administered with food. If twice daily dosing is best, is a small snack with the evening dose, i.e., few pieces of kibble plus a teaspoon of canned, be sufficient? Abbie currently weighs 24 lbs. so I would expect that 20 mg. of trilostane daily (once or split into two doses) would be the best starting dose.<br /><br />Because Abbie is on enalapril, I know that extra caution needs to be taken when on trilostane. Should a full renal panel be run with every ACTH or are serum electrolytes by themselves sufficient?<br /><br />Judy H.judymaghttps://www.blogger.com/profile/09466270333671210222noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-32019518999878066722015-07-14T22:01:47.528-04:002015-07-14T22:01:47.528-04:00Yes, I would start trilostane now (1 mg/kg twice d...Yes, I would start trilostane now (1 mg/kg twice daily). I see no reason to recheck the ACTH stimulation test. The values are already too high.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-76887329227404668742015-07-14T09:45:22.353-04:002015-07-14T09:45:22.353-04:00Dr. Peterson: I am a long time member of the k9cu...Dr. Peterson: I am a long time member of the k9cushings.com forum. The administrators suggested I post here with questions regarding my 12 year old beagle, Abbie, who is my second Cushing's pup (first was also a beagle). I adopted Abbie in 2003 when she was 7 years old. She was diagnosed in 10/2015 with Cushing’s (PDH) via ultrasound, symptoms (significant PU/PD, lethargy, potbelly), blood test results and ACTH. Treatment with Lysodren was started (my vet did not use Vetoryl at all). Cortisol was lowered after loading but it was not possible to maintain control during maintenance, including after a mini-load when pre and post dropped to below 1. After 7 months it was decided to switch to Vetoryl. Last ACTH on 6/10/15 was pre of 5.4 and post of 15.6. Thirty days after stopping Lysodren Abbie is asymptomatic for Cushing’s. <br /><br />Consistently high urinary protein levels led to UPC test on 4/21/15; result was 5.0. BP average was 168 systolic. Treatment was immediately started with 5 mg. enalapril once a day. Two weeks later UPC result was 4.7. Enalapril increased to twice a day. Two weeks later UPC result was 4.9. BP average lowered to 124 systolic. Amlodipine added (one week on 2.5 mg. once a day, one week on 5 mg. once a day). Latest UPC result on 6/17/15 was 4.8. My vet has been consulting with an IMS regarding proteinuria treatment but not Abbie's IMS.<br /> <br />Abbie has hx of frequent soft stools with periods of diarrhea since adopting her 5 years ago. One reason may be that she eats as many crispy dead worms as she can grab! She has been on and off metronidazole, 125 mg. 2x/day; she is currently on it. Food is Purina DCO dry mixed with small amount of Royal Canin LF canned. After trying many different foods with varying fiber levels, this combination helped more than others to control soft stools. I give Abbie S-Adenosyl 225 daily and Forti-Flora on her evening meal. Superchem on 6/17/15 showed continued elevated ALP, cholesterol and triglycerides as well as slightly elevated potassium. Current treatment plan is to continue current meds and re-test BP with renal panel in 2.5 weeks. Follow-up ultrasound to be done in October. FYI, at my urging, my vet has consulted with Dechra re Vetoryl.<br /><br />Questions: in light of high, uncontrolled proteinuria, would you recommend starting Vetoryl even though Abbie is not showing any symptoms? If/when we do start Vetoryl, would you recommend doing an ACTH prior to treatment to get a more accurate measure of cortisol since last one was 30+ days ago?<br /><br />Thank you!<br /> <br />Judy H.judymaghttps://www.blogger.com/profile/09466270333671210222noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-41768062250262785952015-07-14T08:59:30.462-04:002015-07-14T08:59:30.462-04:00The brand name product is recommended. Who knows w...The brand name product is recommended. Who knows what's really in the bulk product? Sometimes it works and other times it doesn't.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-73854592151589531782015-07-14T06:19:56.187-04:002015-07-14T06:19:56.187-04:00Dr Peterson,
In your opinion, is there any differ...Dr Peterson,<br /><br />In your opinion, is there any difference between taking Trilostane in the branded form, Vetoryl, or from bulk ingredient compounded generically?<br /><br />I am using Vetoryl to compound into smaller dosage. But I understand there is a cheaper option of compounding the same dosage from bulk ingredient.Brian Chanhttps://www.blogger.com/profile/00876920893485955494noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-44922914914752893402015-06-30T07:34:34.041-04:002015-06-30T07:34:34.041-04:00As long as the appetite is good and no vomiting, I...As long as the appetite is good and no vomiting, I would not be concerned. Make sure you keep in contact with your vet during this initial Vetoryl treatment.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-64301534820586712002015-06-30T06:52:56.433-04:002015-06-30T06:52:56.433-04:00Dr Peterson,
This is the third day Kooky has sta...Dr Peterson, <br /><br />This is the third day Kooky has started her treatment on Vetoryl. So far, she is doing well, appetite is still the same, drinking as usual, energy is the same. The only thing I noticed is that her stools are soft, not watery or runny. The first two days, the stools were ok, today, it is soft. I am unsure if it is diarrhea, perhaps very mild diarrhoea. The shape of the stools are well shaped except that it is soft.<br /><br />Even before her treatment with Vetoryl, she does gets soft stools from time to time and it resolved after a few days. <br /><br />So I appreciate your advice if this is a cause for concern?Brian Chanhttps://www.blogger.com/profile/00876920893485955494noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-70053407547009437502015-06-22T23:30:46.840-04:002015-06-22T23:30:46.840-04:00We have no evidence that trilostane would accelera...We have no evidence that trilostane would accelerate the growth of a pituitary tumor. It's a possibility, but not ever proven to occur and I wouldn't withhold treatment based on a possibility.<br /><br />Trilostane has a low rate of serious adverse effects, especially if monitored carefully. We know use dosages that are much lower than Dechra used in the reported clinical trials and that has helped.Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-73931272286466554122015-06-22T02:13:38.941-04:002015-06-22T02:13:38.941-04:00Thank you for your reply, Dr Peterson.
I have ano...Thank you for your reply, Dr Peterson.<br /><br />I have another question. I came across from some sources on the internet that Trilostane may hasten the growth of the pituitary gland tumour because of the reduction in cortisol level, is it true? If true, what is the likelihood of this happening? And if the reduction in cortisol level does hasten the pituitary tumour, then wouldn't treating cushing which solves some of the clinical signs but on the other hand, makes the underlying tumour worse, a worst outcome than trying to solve the clinical signs? I am trying to weigh the benefits and risks of both sides, treating or not treating. My primary goal is for my dog to live a happy and good quality of life for the rest of her life. I do not want to take a decision by treating her with a drug that has the potential to do real damage to her life when her quality of life currently appears good. However, assuming if her quality of life now is very bad such that she urinates frequently, or is drinking so excessively, and is panting, I would not hesitate to put her on Trilostane.<br /><br />Or maybe I have misunderstood the potential toxicity of Trilostane? What is the likelihood that a dog would reacts adversely (particularly to Addison's disease) at the low starting dosage of 2.2mg per kg per day? What really scares me is the high number of deaths in the clinical trials indicted on the product insert by Dechra although the dosage used in the trials were 3-5x the standard recommended dosage. <br /><br />I really appreciate your further advice.Brian Chanhttps://www.blogger.com/profile/00876920893485955494noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-6068140551376469812015-06-21T11:27:50.162-04:002015-06-21T11:27:50.162-04:00It certainly doesn't appear to me that your do...It certainly doesn't appear to me that your dog is asymptomatic. Thinning of the skin, slow growth of her hair, and bruises on her abdomen that take some time to heal are present -- and none of these are early signs. The diagnostic tests all point to pituitary-dependent Cushing's disease. I would recommend following your vet's advice and start the trilostane at the recommended dose. <br /><br />Based on the information that you have provided, your veterinarian certainly appears to know what he or she is doing!Dr. Mark E. Petersonhttps://www.blogger.com/profile/10804290441832222507noreply@blogger.comtag:blogger.com,1999:blog-1407531601642815094.post-19346416221592448112015-06-21T07:09:35.951-04:002015-06-21T07:09:35.951-04:00My dog, a Chihuahua, weighing 6.4 pounds is diagno...My dog, a Chihuahua, weighing 6.4 pounds is diagnosed with Cushing. Ultrasound shows enlarged liver, both adrenal glands are enlarged. According to my vet, the LDDS is positive for cushing too - 130mnol/l at 0hr, 75nmol/l at 3hr, and 110nmol/l at 8hr.<br /><br />CBC shows ALP at 690u/l, ALT 203u/l. This was done today. Compared to CBC slightly over 2 months ago, ALP was 507u/l and ALT 164 u/l.<br /><br />As for clinical signs, I don't see my dog is having excessive urination or drinking a lot. I measure her daily water intake for the past one month and it is about 150-160ml per day for a 6.4pound dog. Her appetite is good though but not excessive. The only clinical sign I really see is thining of the skin and slow growth of her hair, and some bruises on her tummy which seems to take some time to heal.<br /><br />My vet suggested to start with vetoryl at 3mg capsule (to be compounded) twice a day.<br /><br />I see that you suggested not to immediately start treatment in your response to this particular article. <br /><br />Do you recommend I start treatment for my dog immediately based on the test results and the elevated ALP/ALT? Or should I wait till a time when the clinical signs are obvious? What would happen to the elevated ALP/ ALT level if I wait? Would waiting be even riskier than taking the risk to put my dog through Vetoryl treatment? I am very concern about the adverse side effects and toxicity of Vetoryl. <br /><br /><br /><br />Brian Chanhttps://www.blogger.com/profile/00876920893485955494noreply@blogger.com