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Ask Dr. Michael Salkin Your Own Question
Dr. Michael Salkin
Dr. Michael Salkin, Veterinarian
Category: Dog Veterinary
Satisfied Customers: 24450
Experience:  University of California at Davis graduate veterinarian with 44 years of experience
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Salkin. I'm writing with interest in your opinion on placing

Customer Question

Hello Dr. Salkin. I'm writing with interest in your opinion on placing my Cushings disease baby girl dog (10 years old) on Cabergoline vs Trilostene. In a Brazilian study, Cabergoline showed 42% success in obliterating the PDH tumor and with very little side effects to the dogs and those who did well (10 year old dogs as well), lived another 4 years on average. I am told by my vet that Trilostane has 100% accuracy but what I read online shows a low longevity and high rate of death by a years time and terrible side effects. Due to the cushings, Diamond became diabetic and now almost blind. She is on 3-4 units of insulin 2x per day (I wish my vet would have mentioned that if I didn't start her on something right away that she would have gotten this). My fault for not studying further. It has been 3 months since diagnosed. I don't just want to treat the "symptoms" of cushings - I want to rid her of the tumor non-surgically in hopes that normal adrenal function will return. In exa
Submitted: 1 year ago.
Category: Dog Veterinary
Expert:  Dr. Michael Salkin replied 1 year ago.
Aloha! You're speaking to Dr. Michael Salkin
Studies are underway in the United States concerning cabergoline therapy for PDH. Please note that we've seen tumor size decrease but none have disappeared - at least with the current dosing regimen which is as follows:
0.07 mg/kg per week orally. The dose is divided by 3 (0.023 mg/kg; 23.3 micrograms/kg) and given every other day (every 48 hours). Yes, 42.5% of treated dogs were considered responders and 41% of cabergoline treated dogs were still alive 4 years later (Castillo et. al 2008). This is a very exciting development.
Let me know if you can open this link: http://veterinarymedicine.dvm360.com/cushing-s-disease-update-targeting-pituitary-glands?eid=229611825&bid=1147574
Customer: replied 1 year ago.
Aloha, and thank you for the quick response. The information you had noted is the same in the study which I researched and provided to my veterinarians. I was hopeful to hear/see something other than that. Thank you for the link - I had also seen that while researching but cannot seem to find the actual written case study/ies in order to further provide and substantiate my alternative approach to my vet, who, as noted, is quite reluctant to use anything except Trilostene.The dosage you recommended is the same from the study, but what was not noted in the study, nor can i find online is how, if at all, is the dosage adjusted when a canine is currently taking insulin. As I first noted, Diamond has become diabetic due to the cushings and is currently taking 3-4 units 2x per day.Can they be taken together?
Would/should the cabergoline and/or the insulin be adjusted upon initial start of therapy?
What are signs of needing to adjust either one as the treatment goes along (as I am told the diabetes will reverse with cushings treatment)?
What are the tests along the way and how often?
And, what test range levels would lead to needing to transfer to Trilostene?
Cabergoline seems to have initial stomach upset and no other adverse effects - can a stomach medicine be given as well (whether simple pepto or prescription)?I will be taking the ACTH test on Friday in order to start a therapy and wanted to compare different case studies as far as the cabergoline. Either way, I will go off-label and attempt the 40% chance with no side effects to start.Thank you again for your time and should you find more studies along the way, I would be interested in hearing about them.
Expert:  Dr. Michael Salkin replied 1 year ago.

Here's the complete study for you: http://www.fcv.unl.edu.ar/archivos/posgrado/especializaciones/espsaludanimal/informacion/material/250411/ENDOCRINOLOGIA%202010/Cabergoperros.pdf

Have Diamond's vet peruse it before discounting it. There's no information concerning cabergoline's use in dogs suffering from concomitant diabetes but as the cortisol level drops you will need to make adjustments downward in Diamond's insulin and so rechecking blood glucose levels often would be prudent. You'll need to discuss a schedule to have this done and discuss the costs with Shelby's vet. I have no manner in which to determine what his vet will charge you. In addition, just as if you were treating with trilostane, regular ACTH stim testing would be necessary to assess response to therapy with cabergoline and the frequency of such testing should be left to Shelby's vet to determine. It's usually performed at 30 and 90 days and then every 3 months thereafter. Yes, an over the counter antacid such as famotidine (Pepcid) dosed at 0.25 mg/lb every 12-24 hours should be helpful if cabergoline causes GI distress. Please continue our conversation if you wish.

Customer: replied 1 year ago.
Thank you again. Your link was the study I had mentioned in my original question. I was originally writing to see if you knew of further written studies.I'm not quite sure who Shelby is but I'll assume you're answering more than one question at a time but the answers seem to correlate accordingly to my questions.I didn't question the cost. I'm not concerned about that - just the norm so I can compare what is usual (my vet is one of the most expensive in our state and has a habit of over pursuing visits for simple matters, much less a serious one). I am more than willing to do what it takes.What wasn't answered was the question of when, if ever, to switch to Trilostane. At what levels would, and/or timing show the cabergoline treatment is not working and would constitute a switch (remember, my vet truly only wants to use that drug so am asking for values)?
Customer: replied 1 year ago.
Also, the case study did not mention weight of dog... wouldn't dosage change accordingly?
Expert:  Dr. Michael Salkin replied 1 year ago.

No, there aren't any other finished studies that I'm aware of. My apologies, yes, I had Shelby on my brain when I should have typed "Diamond". Don't let Diamond know that I did that, please. The rest of the post pertains to Diamond alone. Your costs are likely to range between $2000-3000 during the first year of managing Diamond's Cushing's and diabetes. The 2008 study suggested that a poor response to cabergoline after 3 months of treatment should dictate a switch to trilostane. The complete study I posted above did adjust for weight. Dogs received a total of 0.07 mg/kg cabergoline per week. Good control is indicated by favorable clinical signs as well as a post-ACTH serum cortisol of 1.45-9.1 micrograms/dL no matter the treatment prescribed. Make sure I've answered all of your questions, please.

Customer: replied 1 year ago.
You have now and thank you.
Expert:  Dr. Michael Salkin replied 1 year ago.

You're quite welcome. I can't set a follow-up in this venue and so would appreciate your returning to our conversation with an update - even after rating - at a time of your choosing.

Customer: replied 1 year ago.
I would be more than happy to share my gained experience and knowledge. I am hopeful that Diamond's experimentation helps lead to an eventual cure or at least a further understanding or study that can be used in future treatments by other veterinarians. In reality, it's an animal living in a human world helping another animal... as well as the human species. God bless my little girl. Again, many thanks for your assistance.
Expert:  Dr. Michael Salkin replied 1 year ago.

I appreciate it. I studied with the "inventor" of the first treatment for Cushing's in dogs - mitotane - and I'm very excited to hear of more studies being performed in an attempt to treat the source of the Cushing's rather than the inevitable sequelae.

Customer: replied 1 year ago.
How incredible! I have read those studies, which were the precursor to today's medications. Again, knowledge leads to knowledge. I don't, however, find enough veterinarians sharing their findings. Sad. For all of my special needs pets, I have found more useful information from the universities around the world. On the brighter side, I will look forward to giving you good news as well as any case materials should you desire. Aloha.
Expert:  Dr. Michael Salkin replied 1 year ago.
we've remained friends for over 45 years! I'll watch for any future communiques from you. No need to reply at this time.