Management of Cushing's case

Re: Management of Cushing's case

Kate Richardson — Wed, 03 Jun 2015 12:01:14 GMT

Just another thought if the dog is poorly controlled clinically- have you checked for a concurrent UTI? very common in my experience, so if I am not getting the control I expect clinically with a particular dose, I always check for a UTI- they can be hard to shift in Cushings cases, 3-4 weeks abs minimum.

Re: Management of Cushing's case

Robin Grimmer — Wed, 03 Jun 2015 09:49:38 GMT

I agree with the above posts. Better to let the dog become slightly Cushingoid again rather than Addisonian! We had an interesting case recently. A Border terrier with classic HAC, presumed pituitary dependent. Cant remember what dose of trilostane he was on, but not excessive. Was doing v well until was attacked by another dog. Subsequent to this became unstable and ended up Addisonian. Had to stop the trilostane and start on Florinef.

Re: Management of Cushing's case

Luca Poddighe — Wed, 03 Jun 2015 09:26:44 GMT

[quote user="Matt Hilary"]I'll check but we've got capsules available in 10, 30, 60 and 120mg sizes. The costs for each are similar so management on a single capsule SID would be ideal.[/quote]

Probably it won't affect this case but bear in mind that from Dechra you can order directly even 5mg capsules if they help to tweak the dose. I discover this talking with their help line.

Re: Management of Cushing's case

Luca Poddighe — Wed, 03 Jun 2015 09:24:54 GMT

[quote user="Martin Atkinson"]Remember you are treating a dog not numbers. I wouldn't worry about being 'marginally under-controlled' if the symptoms are under control. [/quote]

I completely agree with Martin on this. I'm under the impression that symptoms are not controlled well here, am I wrong?

Re: Management of Cushing's case

Andrew Kent — Tue, 02 Jun 2015 11:23:49 GMT

SID vs BID dosing is largely a matter of opinion and an interesting discussion point but, to support your decision Matt, I routinely start all my HAC dogs on BID dosing.

My experience with it (and I think, to some degree the literature) suggests that BID dosing may allow a lower total 24 hour dose than SID dosing which is interesting - but I think it depends on personal preference and before my residency I used SID dosing routinely.

It does seem that your case is requiring quite big doses for control, which would worry me a bit - which aspect of its clinical control is not adequate?

Just my thoughts,

Andy

Re: Management of Cushing's case

Martin Atkinson — Tue, 02 Jun 2015 11:15:47 GMT

[quote user="Matt Hilary"]He's currently on 60mg BID Vetoryl and is marginally under-controlled (though probably needs more time to see a full benefit) - latest post-ACTH result 227 (ideal range 50-200).[/quote]Remember you are treating a dog not numbers. I wouldn't worry about being 'marginally under-controlled' if the symptoms are under control.

Like Rory I would always start with sid treatment and if I thought it wasn't controlling the symptoms perform my cortisol /ACTH test 24 hours post dosing.

Re: Management of Cushing's case

Matt Hilary — Tue, 02 Jun 2015 11:12:54 GMT

[quote user="Luca Poddighe"]

I would agree with starting on 90mg sid and recheck (ideally repeating bloods) in 2-3 weeks. I would be worried of starting on 120mg sid directly because, even if you haven't mentioned the weight of your patient, it seems a big dose to start with and secondarily if your problem it is to try to reduce costs with 4 tablets sid you'll not cut the cost down, then I'm aware that possibly if the patient starts to improve the client will be more motivated to continue the therapy, hopefully

[/quote]

I'll check but we've got capsules available in 10, 30, 60 and 120mg sizes. The costs for each are similar so management on a single capsule SID would be ideal.

The owners are actually on board and very motivated - they have had a dog with Cushing's recently so are used to regular testing etc.

Re: Management of Cushing's case

Luca Poddighe — Tue, 02 Jun 2015 10:35:23 GMT

Re: Management of Cushing's case

Rory Bell — Mon, 01 Jun 2015 23:51:02 GMT

Sounds like a good plan to me, keep me posted if that does not work!

Re: Management of Cushing's case

Matt Hilary — Mon, 01 Jun 2015 18:02:51 GMT

Many thanks Rory - appreciate the input.

In this case relatively little change after 1 month on current dose so hoping switch to 90mg SID will improve things.

Re: Management of Cushing's case

Rory Bell — Mon, 01 Jun 2015 17:29:16 GMT

Hi Matt

Generally speaking I'd usually start with SID dosing and then let the client know that if there is a diurnal variation in thirst / urination we might have to consider BID dosing. Most dogs in my experience do ok with SID dosing

If he was very well controlled on 60mg BID I'd be tempted just to go with 60mg SID; if he was clinically doing really well then maybe you don't have much to lose by trying 60mg SID? Worst case scenario, he's underdosed and you end up having to go for 90mg. If you feel that he's not all that well controlled at present(based on clinical signs) then I agree with your decision to go with 90mg SID; I'd be a bit worried about overdosing the dog with 120mg SID.

Hope this helps

cheers