Complicated Cushings case

RE: Complicated Cushings case

Kara Gibson — Tue, 21 Aug 2018 05:22:28 GMT

I would definitely try twice daily dosing. I've had a case that's confirmed pituitary dependent Cushings and had been on 30mg vetoryl with excellent ACTH stim results, verging on too low. However the dog was still profoundly PU/PD, having checked for other disease (kidney, infection etc) a change to 10mg BID has made a huge difference to her symptoms.

RE: Complicated Cushings case

Anthony Dennison — Mon, 20 Aug 2018 10:45:33 GMT

[quote user="Anthony Dennison"]

Thank you all for your replies. I will have a chat with the owner today about possible options and see what she wants to do.

[/quote]

Going to try twice daily Vetoryl. Given the size of the tumour, the vascularity and the very close association with the aorta and vena cava, surgery would require a pre-op CT angiogram and a specialist surgeon. Insurance limit has been reached, which means the owner is paying for it out of her own pocket so she can't really afford surgery at the moment. Will see how she gets on.

RE: Complicated Cushings case

Anthony Dennison — Mon, 20 Aug 2018 08:47:56 GMT

Thank you all for your replies. I will have a chat with the owner today about possible options and see what she wants to do.

RE: Complicated Cushings case

Andrew Kent — Sat, 18 Aug 2018 13:55:21 GMT

[quote user="Anthony Dennison"]

[quote user="Andrew Kent"]

Otherwise adrenal-dependent dogs can do well with trilostane but often require fairly high doses to control so I might give 30mg twice daily as a starting point.

[/quote]

Even if the ACTH stimulation tests are coming back well within normal limits? If I go to twice daily dosing will I not make the dog Addisonian?

[/quote]

with your 24-hour post-ACTH cortisol at 170 I think you could likely go to twice daily dosing without causing issue but always small risk of iatrogenic hypoA

Andy

RE: Complicated Cushings case

Dexter Smith — Sat, 18 Aug 2018 10:32:36 GMT

[quote user="Sarah Keir"]I think Vetoryl only suppresses some of the cortisol pathways and there can be other steroidal hormones causing signs that you are not suppressing or measuring.[/quote]

If that is the case how about using it in combination with Ketoconazole in the hope that it will take care of some of the other pathways. Has anyone ever tried this before?

RE: Complicated Cushings case

Alistair Graham-Evans — Sat, 18 Aug 2018 08:14:35 GMT

[quote user="David Mills"]

It is so difficult to make a dog Addisonian with trilostane, I doubt it as a legitimate side effect.

[/quote]

I managed it quite easily with one of my dogs! I am the proud owner of 2 dogs with Cushings syndrome.

I have found Trilostane to be far from a benign drug and can easily cause hypocortisolaemia and depression but with normal electrolyte levels. I have had better results long term with low dose bid treatments.

RE: Complicated Cushings case

David Mills — Fri, 17 Aug 2018 21:01:53 GMT

It is so difficult to make a dog Addisonian with trilostane, I doubt it as a legitimate side effect.

RE: Complicated Cushings case

Sarah Keir — Fri, 17 Aug 2018 19:46:42 GMT

Hypothyroidism does not fit with PUPD and a normal TSH suggests the body is not trying to make more T4 so as you say, non-thryoidal suppression. I think Vetoryl only suppresses some of the cortisol pathways and there can be other steroidal hormones causing signs that you are not suppressing or measuring. I am sure someone more intelligent than me will come along and negate all that! So come join SAMSoc - the Small Animal Medicine Society - for direct access to numerous friendly medics! (Ian Ramsey is on it - endocrine God)

Sarah

RE: Complicated Cushings case

Tricia Goulden — Fri, 17 Aug 2018 19:32:25 GMT

[quote user="Anthony Dennison"]

[quote user="Andrew Kent"]

Otherwise adrenal-dependent dogs can do well with trilostane but often require fairly high doses to control so I might give 30mg twice daily as a starting point.

[/quote]

Even if the ACTH stimulation tests are coming back well within normal limits? If I go to twice daily dosing will I not make the dog Addisonian?

[/quote]

I had a case of a Labrador with a normal ACTH and suspected HAC. The LDDS supported HAC and I started 60mg/ day of trilostane based on clinical presentation. 32kg dog. He is now on 120mg daily. Monitoring was clinical and monitoring improvement in urine SG. He is doing well a year on. I would increase the dose to 30mg bid as suggested or 60mg once a day. I would also consider supplementing thyroxine with a free T4 that low

RE: Complicated Cushings case

Anthony Dennison — Fri, 17 Aug 2018 17:00:40 GMT

[quote user="Andrew Kent"]

Otherwise adrenal-dependent dogs can do well with trilostane but often require fairly high doses to control so I might give 30mg twice daily as a starting point.

[/quote]

Even if the ACTH stimulation tests are coming back well within normal limits? If I go to twice daily dosing will I not make the dog Addisonian?

RE: Complicated Cushings case

Andrew Kent — Fri, 17 Aug 2018 16:16:04 GMT

Hi Anthony,

Agree that it would be worth a discussion about surgery although are some risks. Further abdominal imaging (ie CT) could be helpful in advance to look for vascular invasion.

Otherwise adrenal-dependent dogs can do well with trilostane but often require fairly high doses to control so I might give 30mg twice daily as a starting point.

Andy

RE: Complicated Cushings case

Joyce Whitehead — Fri, 17 Aug 2018 16:14:43 GMT

Could pain be causing some of the PD/PU? I’ve had a few old dogs who have presented as Pd associated with chronic pain, and I’m guessing this swollen adrenal is sore, especially with the ant abdo pain you found. Maybe try some pain relief?

I know of course this doesnt explain the deteriorating coat etc.

RE: Complicated Cushings case

Anthony Dennison — Fri, 17 Aug 2018 13:51:59 GMT

[quote user="Tricia Goulden"]

No to mitotane. I would check freeT4 & urine SG. What weight is the lab & what dose of trilostane?

[/quote]

Dog is 28kg and on 30mg Vetoryl once daily. post ACTH cortisol has been at the lower end of normal so wouldn't want to increase the dose anymore.

Free T4 <3.9. Idexx says suggestive of non thyroidal illness but cannot rule out Hypothyroidism. Last USG was normal, can't see it on the record but the vet who referred the dog to me has done one and wasn't concerned about it.

RE: Complicated Cushings case

Tricia Goulden — Fri, 17 Aug 2018 13:44:43 GMT

No to mitotane. I would check freeT4 & urine SG. What weight is the lab & what dose of trilostane?

RE: Complicated Cushings case

Rob Loxley — Fri, 17 Aug 2018 13:42:56 GMT

Would suspect growing adrenal gland tumor (given it's size may not be in its normal anatomical position?), measuring ACTH would rule out PDH, surgery would be a thought but may be risky from what you say re blood vessels. You could still get mitotane last time I looked but was over £800...
Interesting ref the cortisol levels but recurrence of symptoms, there's not some other cause PUPD - another primary liver dx, UTI, pituitary mass etc.?
In cushingoid dogs with progressive expanding pituitary masses and PUPD despite good cortisol control I've tried desmopressin for central DI.