Vetoryl bid -dose?

RE: Vetoryl bid -dose?

Andrew Kent — Mon, 13 Mar 2017 21:46:54 GMT

[quote user="Gillian Mostyn"]

[quote user="Gillian Mostyn"]The case I was earlier discussing has done brilliantly on desmopressin....so we're just waiting for the seizures to start now.. [/quote]

The dog continued to do well on BID vetoryl and desmopressin.... until it suddenly started with seizures last night and unfortunately needed euthanasia. I guess my suspected diagnosis of a tumour in there was correct

[/quote]

Sorry to hear that Gillian - but as you say, perhaps inevitable in the end!

Andy

RE: Vetoryl bid -dose?

Gillian Mostyn — Mon, 13 Mar 2017 21:41:50 GMT

[quote user="Gillian Mostyn"]The case I was earlier discussing has done brilliantly on desmopressin....so we're just waiting for the seizures to start now.. [/quote]

RE: Vetoryl bid -dose?

Thomas Johnson — Fri, 24 Feb 2017 16:15:03 GMT

[quote user="Nicola M"]

I had a 16kg dog booked in for me today to do an ACTH stim on. The dog presented to my colleague with PUPD in November, has GHP bloods (ALKP elevated otherwise and) then an ACTH stim (post stim 651).

He was started on 60mg vetoryl once daily-next ACTH stim was 25 post stim so dropped down to 30mg once daily. From notes the owner reports was better on 60mg (but post stim level too low to keep on this).

On 30mg once daily post stim was initially 104, then 104 3 weeks later.

Then 31st Jan was PUPD again and lethargic, post stim 190 so was increased to 30mg in morning and 10mg in evening.

post stim test today is 100. But clinical signs-wise owner reports still PUPD. glucose 5.4.

So my initial plan was to increase evening dose to 20mg based on clin signs but wondering how high can go for total daily dose with bid dosing (at 60mg once daily cortisol was 25-if that dose is split to twice daily then if vetoryl doesn't last 24hrs then presumably we're less likely if we have to go up to 30mg bid....)?

[/quote]

I would consider reviewing the initial diagnosis, a post ACTH cortisol of 651 is high, but I'm not convinced it's high enough to be certain that the dog has Cushing's.

RE: Vetoryl bid -dose?

Gillian Mostyn — Thu, 23 Feb 2017 18:17:31 GMT

Well it seems DI cases are like buses...

The case I was earlier discussing has done brilliantly on desmopressin....so we're just waiting for the seizures to start now..

I had another case last month that became suddenly very PUPD - almost overnight. ACTH stim and all routine bloods normal. Also given desmopressin, and immediate 'cure' for excessive drinking (and it was impressive - peeing every 30 mins or so!)

Happy days....so far!

RE: Vetoryl bid -dose?

Nicola Cole — Thu, 23 Feb 2017 17:22:56 GMT

I had a 16kg dog booked in for me today to do an ACTH stim on. The dog presented to my colleague with PUPD in November, has GHP bloods (ALKP elevated otherwise and) then an ACTH stim (post stim 651).

On 30mg once daily post stim was initially 104, then 104 3 weeks later.

Then 31st Jan was PUPD again and lethargic, post stim 190 so was increased to 30mg in morning and 10mg in evening.

post stim test today is 100. But clinical signs-wise owner reports still PUPD. glucose 5.4.

RE: Vetoryl bid -dose?

Rob Loxley — Fri, 03 Feb 2017 13:43:14 GMT

[quote user="Gillian Mostyn"]I wondered about DI? Tumour causing both diseases?[/quote]

Have seen a few of these due to expanding pituitary tumors

[quote user="Gillian Mostyn"]If so, would you do a water deprivation test or just trial therapy?[/quote]

If everything else is ruled out, I'd skip the WDT

[quote user="Gillian Mostyn"]Do you think a scan would be useful, or just an academic exercise?[/quote]

Would you refer the dog for surgery (http://www.rvc.ac.uk/small-animal-referrals/advanced-techniques-and-specialist-procedures/hypophysectomy); is radiotherapy an option for these (my understanding was it would shrink the tumor still leave you with pituitary dysfunction)

RE: Vetoryl bid -dose?

Andrew Kent — Fri, 03 Feb 2017 10:07:38 GMT

We do see cases that get hyperadrenocorticism with concurrent diabetes insipidus due to the reasons you describe so I think a desmopressin trial is very reasonable in these circumstances. MRI of the brain might allow you to be more confident but obviously an expensive test so often not performed.

You could consider increasing the trilostane dose, some cases do seem to require more significant suppression than this to control the clinical signs but this could be something to consider if the desmopressin trial fails.

Let us know how it goes!

Andy

RE: Vetoryl bid -dose?

Gillian Mostyn — Fri, 03 Feb 2017 09:46:37 GMT

Thanks.

Urine sample was AOK so no reason to suspect UTI really. Dog is otherwise doing brill...Constantly ravenous so I have no reason to suspect functional liver issues really.

She doesn't dribble or leak urine, and with a sg of 1.005 she really does have a full bladder all the time. During hospitalisation for her bloods we were taking her out every 30mins and she was doing big, normal wees.

I am strongly tempted to trial desmopressin..

RE: Vetoryl bid -dose?

emerald — Fri, 03 Feb 2017 09:33:14 GMT

Cushings looks under good control.

I would check for UTI as dogs with Cushings prone to these. Also what about the poss of USMI?

BAST to check liver ok?

Just a few thoughts x

RE: Vetoryl bid -dose?

Kara Gibson — Fri, 03 Feb 2017 09:19:11 GMT

I have a case similar to this in a Tibetan Terrier although she is also showing signs of preogressive cognitive dysfunction. Having tried all sorts to get her to try and sleep through the night better (messing aroudn with water availability, keepinbg her more active in day, long term Selgian and Aktivait and melatonin before bed) I eventually suggested a trial of desmopressin drops at night and that seems to have done the trick! Might be worth a therapeutic trial?

RE: Vetoryl bid -dose?

Gillian Mostyn — Fri, 03 Feb 2017 08:52:21 GMT

Well, I knew it would be too good to last! The early improvement faded and now the dog is more PUPD than ever. (8 yo FN Boxer). Yesterday's blood results are below. Urine s.g. currently 1.005.

So - any ideas anyone? Andrew Kent?

I wondered about DI? Tumour causing both diseases? If so, would you do a water deprivation test or just trial therapy? Do you think a scan would be useful, or just an academic exercise?

(Sorry about formatting...editing making no difference!

Sorry....I'm a bit baffled...

Total protein              62          g/L            (54.0 -77.0 )
Albumin                    34          g/L            (25.0 -40.0 )
Globulin                   28          g/L            (20.0 -47.0 )
Albumin Globulin  ratio    1.2                        (0.6  - 1.5 )
Sodium                     147         mmol/L         (142  -157  )
Potassium                  5.9         mmol/L         (3.6  -6.6  )
Na:K ratio                 25                         (25.0 -35.0 )
Chloride                   107         mmol/L         (99   -119 )
Phosphate                * 2.1         mmol/L    High (0.8  -1.6  )
Urea                       6.0         mmol/L         (3.0  -9.0  )
Creatinine                 68          umol/L         (40   -  150)
Alk Phos                 * 1350        U/L       High (0.1 -150.0 )
ALT                      * 136         U/L       High (5.0  -66.0 )
Glucose                    5.2         mmol/L         (3.5  -  6.5)
Cholesterol              * 10.1        mmol/L    High (3.8  -7.0  )

Serum quality              Good

Serum quality post sampl   Good

                          HAEMATOLOGY
RBC                    7.13        x10

^{^12}

/L   (5.9  -8.4  )

Hb                     16.9        g/dl  (14.2 -20.0 )
HCT                   51.8        %    (43.0 -60.0 )

MCV                    72.7        fl      (60.0 -80.0 )
MCH                     23.7        pg     (22.0 -25.9 )
MCHC                   32.6        g/dl   (30.8 -35.5 )
RBC distribution    14.9        %   (12.9 - 17.8)
Reticulocytes          47.8        X10

^{^9}

/L  ( 20  - 151 )
Platelets               428         x10

^{^9}

/L   (108  -562  )
WBC                    13.84       x10

⁹

/L   (5.9  -14.5 )
Neutrophils          * 83.9% 11.61 x10

^{^9}

/L  High (3.1  - 9.4 )
Bands                  0.0%  0.00 x10

^{^9}

/L   (0.0  -0.3  )
Lymphocytes       11.8%  1.63 x10

^{^9}

/L  (0.8  - 4.7 )
Monocytes             3.9%  0.54 x10

^{^9}

/L (0.0  - 1.6 )
Eosinophils      *  0.3%  0.04 x10

^{^9}

/L  Low  (0.1  - 1.4 )
Basophils             0.1%  0.01 x10

^{^9}

/L  (0.0  -0.2  )
Blood Film Examination     A smear from the EDTA sample was examined. Red cells

                           appear normocytic and normochromic.
                           Mild neutrophilia with no evidence of toxic changes.
                           Other white cells appear of normal morphology.
                           Platelets appear adequate and are of normal morphology.
                           No evidence of clots or clumps in the submitted EDTA
                           sample.

                          ENDOCRINOLOGY
Basal cortisol             38          nmol/L         (27.5 - 125 )
Cortisol post ACTH         132         nmol/L         (<500 br="">

RE: Vetoryl bid -dose?

Charlie Lyon — Mon, 30 Jan 2017 13:57:15 GMT

I have one of these cases as well, still pu\pd and pot bellied despite excellent bloods. Going to do an ACTH stim 24 hours post capsule and check BG\fructosamine re concurrent DM. Anything else that can cause lack of response, did read something about adrenal tumours being a cause?

RE: Vetoryl bid -dose?

emerald — Fri, 20 Jan 2017 21:21:12 GMT

At a CPD I did at BSAVA they said it's better bid if patient diabetic as less spikes in cortisol and so smoother control of diabetes.

RE: Vetoryl bid -dose?

Michael Woodhouse — Wed, 18 Jan 2017 00:22:26 GMT

Thanks, Andrew. She's on 30mg, when they are gone I will try her on 10mg bid and see how she does.

RE: Vetoryl bid -dose?

Andrew Kent — Mon, 16 Jan 2017 19:30:46 GMT

[quote user="Michael Woodhouse"]

If the question has been answered, can I drag this marginally O/T?

Is there any clinical benefit to BID dosing? My 10kg Patterdale is Cushingoid.

[/quote]

Hi Michael,

Like many things in medicine this becomes a lot about opinion and individual experience. There is some evidence that twice daily trilostane results in better clinical control than once daily:

Evaluation of 2 Trilostane Protocols for the Treatment of Canine Pituitary-Dependent Hyperadrenocorticism: Twice Daily versus Once Daily.

C. Arenas, C. Melian, and M.D. Perez-Alenza

and that twice daily trilostane often results in a lower overall dose than once daily:

J Am Vet Med Assoc. 2011 Jun 1;238(11):1441-51. doi: 10.2460/javma.238.11.1441.

Evaluation of twice-daily lower-dose trilostane treatment administered orally in dogs with naturally occurring hyperadrenocorticism.

Feldman EC1.

But they are smallish numbers of dogs etc.

For what its worth my experience is in line with this - most BID dogs are controlled on lower total doses and often have better control of clinical signs and this is logical as trilostane doesn't last 24 hours after administration.

The only negative is cost - it can work out cheaper to give a higher once daily dose.

Where possible I always start twice daily - in your dogs case I would start at 10mg BID, I might even be tempted to start at 5mg BID depending on clinical signs but that becomes more complex as you have to get 5mg capsules from Dechra.

Andy

RE: Vetoryl bid -dose?

Anthony Dennison — Mon, 16 Jan 2017 09:51:18 GMT

[quote user="Michael Woodhouse"]Is there any clinical benefit to BID dosing? My 10kg Patterdale is Cushingoid.[/quote]

I think BID dosing is only needed if for some reason the duration of effect of Vetoryl isn't lasting the full 24 hours - ie they become PU/PD at night and urinate in the house whilst the owners are sleeping. Doesn't seem to happen too often.

I had one client that was having problems or overnight urination, but couldn't afford BID dosing so we switched to giving the vetoryl in the evening. Dog was dry during the night and could just go outside during the day. No ideal but client was happy.

RE: Vetoryl bid -dose?

Michael Woodhouse — Sun, 15 Jan 2017 23:23:07 GMT

If the question has been answered, can I drag this marginally O/T?

Is there any clinical benefit to BID dosing? My 10kg Patterdale is Cushingoid.

RE: Vetoryl bid -dose?

Andrew Kent — Sun, 15 Jan 2017 21:51:01 GMT

[quote user="Gillian Mostyn"]

I haven't yet done a repeat ACTH stim yet, but the owner reports a massive improvement with the PUPD - they are very happy.

Thanks again Andrew Kent

[/quote]

Great news :-) Thanks for the update!

RE: Vetoryl bid -dose?

Gillian Mostyn — Sun, 15 Jan 2017 21:32:04 GMT

I haven't yet done a repeat ACTH stim yet, but the owner reports a massive improvement with the PUPD - they are very happy.

Thanks again Andrew Kent

RE: Vetoryl bid -dose?

Andrew Kent — Fri, 06 Jan 2017 06:37:36 GMT

30mg BID sounds perfect :-)

Andy

RE: Vetoryl bid -dose?

Gillian Mostyn — Thu, 05 Jan 2017 22:55:08 GMT

Oops...Note to self, don't rely on my memory....

Just checked actual client record...Dog is a 32kg boxer, and was actually on 70mg sid, so I guess 30mg bid will be a good idea for a starting point...

RE: Vetoryl bid -dose?

Gillian Mostyn — Thu, 05 Jan 2017 22:48:22 GMT

That's great Andy - thank you so much. (I suspected 30mg bid might be a bit excessive!)

RE: Vetoryl bid -dose?

Andrew Kent — Thu, 05 Jan 2017 21:28:39 GMT

Hi Gillian,

Most of the evidence suggests that dogs treated twice daily can require lower total dose than they might with once daily dosing and there are now many medics (me included) who start at approximately 1mg/kg BID as standard.

So in your case I would probably go to 10mg BID but expecting I may well need to increase in the future.

Andy