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  #11  
Old 04-17-2009, 08:15 AM
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

I sure wish we would acquire a member whose dog is currently being treated with trilostane at Davis! I am REALLY curious as to what their most up-to-date recommendations are in terms of dosing.

And I must confess that some of my thoughts about dosing stem solely from my experience with my own Cushpup. It was five years ago now that we started treatment, and the studies about the advantages of twice daily dosing were just starting to appear. I felt so convinced that twice a day would be a better approach that I prevailed on my specialist to let us go that route, even though it was not "officially" recommended. We ended up having to make a lot of dosing changes along the way, and it always felt doubly complicated to me because of trying to arrive at the best combination of morning and evening doses. So I ended up wishing that we had just started out with once a day, and only increased from that if it seemed as though we needed to.

I just wanted to put my "cards out on the table," so to speak, so you'd know where my bias is coming from.

Marianne
  #12  
Old 04-17-2009, 08:17 AM
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Thanks Glynda!

Or I may start calling you "The Oracle" from now on

But the thread and the DVM article are the things I've read - I'm wondering where this point you mentioned below came from, that is:

"They also recommend that when you go from once daily to twice daily dosing, you drop the mg a bit."

And Marianne I wish that pesky server issue gets resolved so I can go and read up on your experiences in more detail. What timing!

Thanks for your information, as always,

John II

Last edited by John II; 04-17-2009 at 08:23 AM. Reason: included message to Marianne
  #13  
Old 04-21-2009, 06:46 PM
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hi John,
How is Angelina doing? Is she on the 60 mg dose now? Is that once a day or 2 X 30 mg per day?

All the Best.
John (Roxee's Dad)
  #14  
Old 04-24-2009, 07:45 PM
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hi John,
Hope all is well with you and Angelina.
John (Roxee's Dad)
  #15  
Old 04-25-2009, 07:27 AM
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hello All (especially John who watches out for Angelina and me ),

Sorry to have dropped out for a while - but I was afraid that if you knew what I was up to I might be banished from the group.

So - here goes, I started Angelina on 2 X 30 mg per day of Trilostane last Monday. She seemed to tolerate it well and the symptoms that tend to reappear approx 8 hours after her morning dose disappeared after her evening dose.

Monday, Tuesday, Wednesday, she seemed fine.

On Thursday Angelina was moving like she did before we started the Trilostane at 30mg once per day. Walking like an old lady dog. She only went for a very very short walk that morning (only as far as the front yard).

So I held off the Thursday evening dose. Gave her the Friday morning dose, as usual, and called the specialist, Friday afternoon for advice.

Unfortunately, he's on holiday until May 8 . So I asked for the resident also on the case - he's on holiday until next Tuesday . I asked the receptionist if there was someone else I could talk to - and she promised to have another specialist call me back.

I should mention that apart from a little geriatric leg action Angelina seemed fine. And I'm wondering if we've just unmasked some arthritis.

6pm Friday evening Angelina, though obviously quite eager for dinner, had turned up her nose at the usual food. I didn't know if that was due to:
1) the Trilostane affecting a dog's taste in food (as I've read in other threads)
2) the inappetance that can also be a warning of low cortisol or
3) the fact that I squeezed the contents of a fish oil capsule into it

4 hours after I called the specialist, I got a call back. Since it was now after 7pm - I'm thinking it was by a doctor whose shift had just started and had discovered my abandoned note.

Well these vets seem to all be cut from the same cloth as far as dosing is concerned. They're all telling me (despite my repeated concerns) that because Angelina's ACTH Stim numbers were quite high, her dose needed to be increased AND they have other maltese sized dogs on double that dose with no side effects. (I could almost hear him say "So there!") They would not recommend reducing her dose without an ACTH stim test. I should continue with the twice daily dose, keep a close eye on her, and bring her in if I have any concerns.

At 10pm Friday night - I offered Angelina her dinner again - which she finally ate - begrudgingly.

So today (Saturday) Angelina got her 6am morning dose with breakfast and her 6pm evening dose with dinner (at 6:41pm - I got home late) and she seems fine. She was VERY interested in the BBQ chicken I brought home. So no appetite problems - she would have eaten the whole thing if she could get to it.

In other news Angelina seems to be developing patches of slightly (so far) darker skin on either side of her abdomen.

I think that's all I have to report.

John II

Last edited by John II; 04-25-2009 at 07:35 AM. Reason: included daily walk information
  #16  
Old 04-25-2009, 09:34 AM
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hi John,

Regarding information on twice daily dosing, check out page two of the monitoring flowchart for dogs whose clinical signs are not controlled for a full day. It say to slowly increase the dose and divide twice a day. In other words, if a dog is getting 60mg a day, you would increase to something like 80mg divided which would be 40mg twice daily. This is also recommended by UC Davis. This information is not really clear in the article included in the Vetoryl/Trilostane information posted by Marianne, I did verify the UC Davis protocol on twice daily dosing via an audio of one of Dr. Edward Feldman's lectures. He used that exact example I mentioned above.

If a post stim number is within the desired range of 1 - 5 but the dog is still showing overt symptoms, this is a pretty good indication that twice daily dosing should be prescribed. Angelina's post stim was definitely well beyond the desired range. The correct way to determine if a dog needs twice daily dosing is to do a urine cortisol creatinine ratio which requires that the pet owner bring in a urine sample collected the morning before the acth and before meds and meal. If the ratio is abnormal, that is a good indication that the once daily dose is not lasting through the night. It looks like your vet made the call to switch to twice daily dosing based solely on unresolved symptoms that could be explained by the high post stim number as opposed to proof that the current once daily dose was not adequately controlling the cortisol overnight. However, I do recall that you mentioned that Angelina's symptoms seem to get worse at night which your felt was a good indication that twice daily dosing may be necessary.

http://www.dechra-us.com/File/vetory..._Flowchart.pdf

Every dog responds differently and it could be that Angelina will do just fine on a 100% increase in dose; however, I personally don't think that a post stim number 13 ug/dl after only two weeks of treatment is high enough to make me feel comfortable with that kind of an increase. Just be ever vigilant in watching for signs that cortisol may be too low.

I'm not sure about that Trilostane affects a dog's taste in food. It sure had no effect on either one of my chow hound's taste buds. Their appetite did decrease by they never turned their nose up to food. This is definitely a sign that cortisol can be too low and you should never give Trilostane to a dog that is not eating normally. If either one of mine looked the slightest bit off and wasn't doing their normal head dive into the bowl, they were off Trilo for a few days or until they were back to normal. Try eliminating the fish oil on a meal and see if that makes a difference. If not then you can rule that out as a factor which would make Trilostane the bigger suspect.

I am about as far from a medical professional as you can get but I still respectfully disagree with your vets and don't think that Angelina's numbers were that high after only 15 days of dosing. All dogs respond differently to Trilostane so the fact that another Maltese has done well on the same dosing regimen is irrelevant. A perfect example is my two cushdogs. My 4.5 lb Pom was on 30mg once daily for two years and my then 10 lb Pom was on 15mg twice daily and both were effectively controlled.

You know Angelina best so if you think something is not right, and a cushdog that doesn't eat normally is not right, then don't continue to dose her.

Hope this helps.

Glynda aka The Oracle
  #17  
Old 04-25-2009, 03:10 PM
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Glynda to the rescue!

So, going by the flowchart you basically stick to the initial dose for a full month, unless there are signs of:
1) Post-ACTH serum cortisol <1.45 μg/dL (<40 nmol/L) and clinically well
2) Corticosteroid withdrawal syndrome
3) Hypoadrenocorticism
(If its points 2 or 3 you discontinue the dose and have an ACTH stim test done to determine the problem).

However if:

Post-ACTH serum cortisol >1.45 μg/dL (>40 nmol/L) and clinically well*

But wait! I see an asterisk on the flowchart - which leads to:

* If the post-ACTH cortisol is >9.1 μg/dL (>250 nmol/L) and the clinical
signs of HAC are marked then you should consider a dose increase
at this stage. Increase dose by smallest increment possible.

So an increase after day 14 is advised? Since this is Dechra's chart the "smallest increment possible" they would be talking about would be 30mg? That's the smallest they are making now (from memory). If that's the case, unless I'm completely confused, then a 30mg to 60mg jump is what they are advising?

Note all the question marks?

So the problem at this point is not the increase in dose, but the splitting the dose in two? Which should only happen after day 30? Which leads to:

[QUOTE=Lulusmom] In other words, if a dog is getting 60mg a day, you would increase to something like 80mg divided which would be 40mg twice daily. [QUOTE=Lulusmom]

So, eventually the dose is likely to be bigger?

And as far as determining twice daily dosing:

[QUOTE=Lulusmom] The correct way to determine if a dog needs twice daily dosing is to do a urine cortisol creatinine ratio which requires that the pet owner bring in a urine sample collected the morning before the acth and before meds and meal. If the ratio is abnormal, that is a good indication that the once daily dose is not lasting through the night.[QUOTE=Lulusmom]

[QUOTE=Lulusmom] Just be ever vigilant in watching for signs that cortisol may be too low. [QUOTE=Lulusmom]

This morning after breakfast - and her morning dose - I took Angelina out for a short walk. The way she was walking was painful to watch. But I couldn't be sure if it was signs of "Corticosteroid withdrawal syndrome (“relative” cortisol deficiency characterized by weakness, stiff gait)" or Hypoadrenocorticism (e.g.weakness) - I hate the way the symptoms overlap! So. should I discontinue for a few days or rush Angelina off for another ACTH stim test? Or just cut back to the 30mg per day?

Last night's dinner was fish oil free and although Angelina paused to consider it - she did finish every bit of it.

Thanks Glynda for such a thorough response!

John II
  #18  
Old 04-25-2009, 04:58 PM
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Talking Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hi John,

Here in the US, a lot of vets (including UC Davis) use compounded versions of Trilostane when needing to adjustment a dose that isn't available from Dechra. Lulu was too small for the 30mg available from Dechra so we had no choice but to have her 20mg compounded. We ultimately increased to 30mg which is where she stayed until we switched to Lysodren almost two years later.

I'm glad that you took the time to check out the Dechra flowchart. The chart is meant to be a general guide but as my vet explained to me, you have to look at the big picture. She had never treated with Trilostane but after researching, she decided that it was best to have an acth stim test before starting treatment so that she would have a baseline to compare to the 14 day post stim test. This told her how quickly and how much the cortisol had dropped in a two week period. I hadn't found the cushings forum yet so I hadn't witnessed all the disparities from dog to dog when monitoring treatment so I was very grateful that she was so thorough. Jojo's cortisol continued to drop after the 2 week stim so had she increased his dose right away, his cortisol would undoubtedly have dropped too low. She did a great job considering Jojo was her first Trilostane patient.

Trilostane has a short half life and its enzyme blocking abilities start to diminish after 8 to 12 hours. This is why some dogs will eventually require twice daily dosing if symptoms don't resolve on a single dose. Since every dog is different, you don't know at which hour the Trilostane begins to wane so when you go to twice daily dosing, there are hour(s) in the day that there can be an overlap in dosing. This is why it is recommend that you up the dose a bit and split in two. Like I mentioned before, if a dog was at 30mg once daily, you'd up that to maybe 40mg and split it into 20mg twice daily. In essence you could have an overlap of a total of 40mg. If you simply double the dose like your vet did, a possible overlap would be 60mg. That's a big difference in my opinion.

Jojo was a mess when he first came to us and not only was he extremely weak in the hindquarters, he walked with an incredibly stiff gait. This is a rare symptom of cushing's called pseudomyotonia and sometimes it resolves once the cushing's is controlled and sometimes it doesn't. Jojo still walks like he is on pegged legs but his IM doesn't seem to think it has progressed or will be a problem for him in the future.

I hope all this makes sense but if not, Marianne is excellent in explaining much better than I can and hopefully she can clear the fog I've created in your head. I trip over my own words sometimes, become too verbose, lose my place, need access to spellcheck and eventually put people to sleep or maybe just into a catatonic state.

Glynda
  #19  
Old 04-25-2009, 07:21 PM
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hi John,
Glad to see you back. Can't help much with the once or twice a day dosing. I'm still trying to figure out what the best route is for Roxee. Thinking about a UTK panel but will make that decision within the next few weeks.

Regarding her apetite....When the trilo kicked in, Roxee got very, very picky about what she will eat. It has to smell good otherwise she would and still does walk away. Worried me at first but this was a good sign that the trilo was having a positve effect. I have her to 4 meals a day now trying to keep the weight on her. The more and more I read, this (weight loss) seems to be an unspoken side effect of trilo. Oh BTW - her potbelly is completely gone now.


Quote:
Jojo was a mess when he first came to us and not only was he extremely weak in the hindquarters, he walked with an incredibly stiff gait. This is a rare symptom of cushing's called pseudomyotonia and sometimes it resolves once the cushing's is controlled and sometimes it doesn't. Jojo still walks like he is on pegged legs but his IM doesn't seem to think it has progressed or will be a problem for him in the future.
Glynda just gave me some homework, (pseudomyotonia) this is exactly Roxee's symptoms. Since starting treatment, it has improved somewhat. She doesn't hardly fall over anymore so hoping it continues to improve.

Well, keep up the good work with Angelina and keep us posted.

All the best to you and yours including a belly rub for Angelina (if she'll let you)
John (Roxee's Dad)
  #20  
Old 04-26-2009, 12:33 AM
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Default Re: Angelina 13.5 year old/13kg Maltese Cross on Trilostane

Hello All,

Even before I read the 2 new posts, I just want to submit my apologies all round for my earlier post because I should not be trying to think this through on 3 hours sleep!

John II
 

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