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Old 04-16-2009, 03:59 AM
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John II John II is offline
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Default Angelina 13.5 year old/13kg Maltese Cross on Trilostane

The adventure continues on a new server - once again, thanks to Natalie.

So after 15 days of dosing Angelina once every 24 hours with 30mg of Trilostane – it was testing day.

Four family members plus much loved dog descended on the specialist centre.

Angelina weighed in at 13.04kg – 15 days earlier she was 13.123kg. Every little bit helps

The specialist appeared – we had an update chat. I made sure they checked her electrolytes and I handed him a urine sample I collected that morning (not that they asked for one – but after Roxee’s recent experience with a UTI, I wanted to check things out). I also told the specialist that Angelina usually wound up back on the cool bathroom floor by about 4:30pm – around 11 hours after her dose.

Finally he led Angelina away. She was surprisingly agreeable and walked off with him – until he reached the front door – where she stopped when she realised she wasn’t leaving. Then he had to pick her up.

15 minutes later she was back. And we were given the option of waiting with her for 50 minutes until the post-ACTH injection blood sample was to be taken. I was expecting them to wait 2 hours. But I was happy that we could take Angelina outside and she was therefore getting the less stressful option. The nurse appeared after 50 minutes and took her away for another 15 minutes or so.

Then Angelina was back. I questioned the specialist regarding the sound of her heart and lungs – which he said sounded fine. Her blood pressure was still high at 190. The specialist told us he would call with the results the next day.

After we got home Angelina was panting (didn’t help that it was a very warm day for Autumn -28 degrees Celsius – that’s just over 80 degrees Fahrenheit – anything over 25 usually leads to some panting). Her respiration was clocking in at 84 breaths per minute. But her total water intake for the day was only 650mls. All in all she seemed to handle the ordeal well.

At 3pm the next day the specialist rang with a summary. But we Cushings Net people are not summary people – so I asked him if I could get the full results emailed to me – and they were – see below my ramblings. Also at the end of the results are the accompanying “General Interpretive Guidelines” which may be helpful to members and visitors.

As expected the specialist has recommended Angelina’s Trilostane dosage be increased to 2 doses of 30mg per day (one every 12 hours) – an excerpt from the report:
"Angie was examined for a recheck of her hyperadrenocorticism. Her blood pressure remained mildly elevated today . Her examination was otherwise unchanged, which is not surprising at present.”

I put it to him that my research (aka Leslie) seemed to indicate that the full effect of a particular dosage of Trilostane didn’t become apparent until at least 30 days after beginning that dose. He didn’t seem concerned – due to the lower dose we started with.

Now I’m feeling about the same way about the 60mg dose as I did about the 30mg – before the first day. Oh the troubled sleep I had last night!

John – what dose is 13lb Roxee on?

Today, I swung by the specialist centre to do some more brain picking (I think I do better in person than on the phone). Turns out it was the specialist’s day off – but I spoke to another one of the doctors who saw Angelina on her first consult (there were three in all). He was similarly unconcerned about the increase in dosage. When I questioned if I should have Prednisone on hand he assured me that by the time I was aware that Angelina was experiencing side effects and gave her the antidote (as I think of it) the Trilostane would already be wearing off.

Since Angelina was due to get her monthly heartworm pill today – I held off starting her second daily dose of Trilostane. I know everyone says you can give them both – and I’ll have to do just that, this time next month – but I’d just as soon keep things as simple as possible on her first 60mg day.

Now, can someone tell me about milk thistle dosage for dogs? And omega 3 (fish oil) capsules?

John II

14-04-2009 The Urine Test

URINE COLLECTION METHOD Voided
URINE VOLUME (ml) 50.0
URINE COLOUR Yellow
URINE TRANSPARENCY Opaque
URINE SG 1.019
URINE GLUCOSE Negative
URINE BILIRUBIN Negative
URINE KETONES Negative
URINE HAEMOGLOBIN Negative
URINE pH 6.5
URINE PROTEIN ++ (1 g/L)
URINE UROBILINOGEN Normal (less than 20umol/L)
URINE RBC/HPF Less than 5
URINE WBC/HPF Less than 5
URINE CASTS, NUMBER Negative
URINE BACTERIA Negative
URINE FAT Occasional
URINE EPITHELIAL CELLS, TYPE Squamous
URINE EPITHELIAL CELLS, NUMBER Occasional
URINE EPITHELIAL CELLS, NUMBER Negative
URINE SPERM Negative
URINE CRYSTALS, TYPE Amorphous crystals
URINE CRYSTALS, NUMBER Occasional
URINE CRYSTALS, NUMBER Negative
URINE DEBRIS Negative

Minimally concentrated urine may reflect ongoing hyperA. Mild
proteinuria is unexplained: consider a UPC to further assess.
No evidence of UTI.


14-04-2009 Biochemistry with Electrolytes- Canine

Na 145 mmol/l (139-153) (Sodium)
K 5.9 mmol/l (3.9-5.9) (Potassium)
Cl 107 mmol/l (93-122) (Chloride)
Calcium 2.82 mmol/l (1.9-2.9)
Phosphorus 1.53 mmol/l (0.8-2.1)

Bicarb 20.9 mmol/l (12-26)
Anion Gap 23 mmol/l (14-32)
Urea 13.2 mmol/l (2.5-10.0)
Creatinine 81 umol/l (50-150)
Glucose 5.2 mmol/l (3.3-6.8)
Bilirubin 7.0 umol/l (0-6)
AST 128 U/l (18-80)
ALT 590 U/l (16-90)
AlkPhos 3205 U/l (1-150)
T Protein 77 g/l (52-80)
Albumin 39 g/L (23-40)
Globulin 38 g/l (25-45)
CreatKinase 235 U/l (73-510)
Amylase 727 U/l (333-1500)
Lipase 1495 U/l (77-750)
Cholesterol 10.50 mmol/l (3.5-9.0)


14-04-2009 ACTH Stimulation Test

Cortisol, resting 157 nmol/L (15-170)
Cortsiol, 1 hour 382 nmol/L



General Interpretive Guidelines
Normal dog:
* post-ACTH cortisol 170-470 nmol/L

Hyperadrenocorticism (hyperA):
* post-ACTH cortisol > 600 nmol/L consistent with hyperA
* post-ACTH cortisol 470-600 nmol/L equivocal

* failure of cortisol levels to increase significantly following ACTH
administration in a dog with typical clinical and laboratory features of
hyperA does not exclude the diagnosis. For further assessment a low dose
dexamethasone suppression test may be useful
* adrenal function tests, such as the ACTH stimulation test, may yield
a false positive test result in a sick or stressed dog with non-adrenal
disease
* this test does not differentiate between pituitary and adrenal-
dependent hyperA (an endogenous ACTH assay, abdominal imaging or a high
dose dexamethasone test may be useful for further assessment) For the
endogenous ACTH test, please contact the laboratory for the special
sample collection protocol.

Post-medical therapy for hyperA, results should be interpreted in light
of adequacy of clinical control. Target values depend on the drug used:

Mitotane or ketoconazole:
* baseline cortisol < 100 nmol/L post-ACTH cortisol 28-100 nmol/L

Trilostane:
* baseline cortisol 28-55 nmol/L post-ACTH cortisol 28-55 nmol/L

Iatrogenic hyperA:
* baseline cortisol < 55 nmol/L post-ACTH cortisol < 55 nmol/L

Hypoadrenocorticism:
* baseline cortisol < 55 nmol/L post-ACTH cortisol < 55 nmol/L
* this test will not distinguish between primary (adrenal) and
secondary (pituitary) hypoadrenocorticism
  #2  
Old 04-16-2009, 07:44 AM
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Lulusmom Lulusmom is offline
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hi John,

For those of us that are used to seeing acth stim results in ug/dl, I've done the conversion:

Pre 5.7
Post 13.8

Was the stim done within 4 to 6 hours of dosing? Did you have an acth stim done before starting treatment? I ask because a post number of 13.8 as compared to a pre treatment post of something like 25 or 30 is a pretty darn significant drop in just 15 days.

Given that Angelina's symptoms seem in increase in the evening, this is a pretty good sign that once daily dosing may not be appropriate. It drives me nuts that you have a drug that is known to have a short half life (12 hrs) and you have studies that have proven that twice daily dosing is more effective yet Dechra still recommends dosing once daily to start.

I may agree that Angelina would probably do better on twice daily dosing but I absolutely do not agree with the large increase your vet has prescribed. I personally am more comfortable with UC Davis protocol. They have established their own treatment protocol based on their experience with Vetoryl/Trilostane. They found a great disparity in the dosing that Dechra recommends based on weight by following that protocol, they had a great many dogs that had adverse reactions. As a result their dosing protocol is much more conservative and in my opinion, much safer. They prescribe 1mg/kg to start which means in Angelina's case, they probably would have started her anywhere from 10mg to 15mg per day. That's quite a huge difference from Dechra. They also recommend that when you go from once daily to twice daily dosing, you drop the mg a bit. For instance, if you are giving a dog 30mg once daily, you would drop the mg to say something like 20mg twice daily. This makes perfect sense to me as there is an overlap between the two doses.

One comment on the lab's comment "Mild proteinuria is unexplained: consider a UPC to further assess." The majority of dogs with cushing's have an increase in protein so mild proteinuria is not unusual. I think in Angelina's case, it is explained. My cushdog Lulu also has mild proteinuria.

Glynda
  #3  
Old 04-16-2009, 08:13 AM
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John II John II is offline
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hi Glynda,

Angelina had her Trilostane dose (on testing day) at 06:05 and had her "Cortisol, resting" sample taken at 10am and then her "post-ACTH cortisol" sample taken at 11am.

We didn't have an acth stim done before starting treatment - but we did have an LDDS and a HDDS (what's the number to divide my figures to convert them to your again?).

LOW DOSE DEXAMETHASONE SUPPRESSION TEST
Resting Serum Cortisol : 132 nmol/L
Post-Dexamethasone Serum Cortisol (3-4 hrs) : 337 nmol/L
Post-Dexamethasone Serum Cortisol ( 8 hrs) : 440 nmol/L

HIGH DOSE DEXAMETHASONE SUPPRESSION TEST
Resting Serum Cortisol : 344 nmol/L
Post-Dexamethasone Serum Cortisol (3-4 hrs) : 290 nmol/L
Post-Dexamethasone Serum Cortisol ( 8 hrs) : 148 nmol/L

Where oh where in the world can I find a specialist who will give me good advice and information like the people of this forum do? The specialist mentioned the Mild proteinuria and suggested the extra test - to which I agreed. Results pending.

Thanks,
John II

Last edited by John II; 04-16-2009 at 06:41 PM. Reason: late night frustration removal
  #4  
Old 04-16-2009, 08:14 AM
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labblab labblab is offline
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Quote:
Originally Posted by Lulusmom View Post
Given that Angelina's symptoms seem in increase in the evening, this is a pretty good sign that once daily dosing may not be appropriate. It drives me nuts that you have a drug that is known to have a short half life (12 hrs) and you have studies that have proven that twice daily dosing is more effective yet Dechra still recommends dosing once daily to start.
Glynda
I realize that my thoughts about once vs. twice daily dosing differ somewhat from other members. But I do not see a problem with starting a dog off with a once daily dose, and then later shifting to twice daily dosing if the dog's response warrants it. And even though UC Davis researchers have been among those to publish studies endorsing twice daily dosing, their clinical treatment protocol to which we refer joins Dechra in recommending that dogs first be tried on a once daily regimen.

I really wish we could get a copy of UC Davis' most current protocol -- the one that we quote here dates to 2007. So perhaps their clinicians are doing things differently now subsequent to additional research studies. But if not, their recommendation doesn't seem unreasonable to me. And that is to first try once daily dosing, but if the symptom pattern and UC:CR test results indicate that once daily dosing is insufficent -- then make a shift.

http://www.k9diabetes.com/forum/showthread.php?t=745

I can imagine that with diabetic dogs, for instance, twice daily dosing might be preferable from the get-go. In that instance, there would be greater benefit from maintaining the most consistent endocrine balance possible. But for dogs without any non-adrenal illness, if the simplest arrangement works, why not "go with it?" At the very least, it may hold down medication costs a bit. Because the majority of dogs that are dosed twice daily seem to end up with a total daily dose that is at least a bit higher.

Having said all that, I totally agree with Glynda that it appears that Angelina is likely a dog who will do better with two daily doses, and also with her preference that Angelina's increase be limited to something like 20 mg. both morning and evening. And based on her ACTH results, I don't think that even Dechra would disagree.

Marianne

Last edited by labblab; 04-16-2009 at 08:56 AM. Reason: To add link.
  #5  
Old 04-16-2009, 12:11 PM
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Roxee'sDad Roxee'sDad is offline
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hi John and Angelina,
So happy you found your way here. Now if we can find JaneRoper and Lola. I just knew that was you in the members list (JohnII)

Quote:
John – what dose is 13lb Roxee on?
Roxee started off on 30 mg once per day, after 30 days she was increased to 40 mg once per day.

All the best to you and Angelina
John (roxee's Dad)
  #6  
Old 04-16-2009, 07:30 PM
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John II John II is offline
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Well that's annoying. I just wrote a response and when I submitted it for preview - I was requested to log in - again! Which I did - you can't argue with software. After logging in I got a blank screen where my preview should have been. Nothing new there - happens all the time. I backed up a couple of screens thinking I'd find the raw form of the response and try preview or submit again - but it was gone! Aargh.

My post must have been so foolish that the server decided it was better to eat it than post it.
  #7  
Old 04-16-2009, 09:41 PM
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Lulusmom Lulusmom is offline
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

John, you timed out before you submitted your post. When you log in, remember to check the "remember me" box and that won't happen.

Glynda
 

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