What is the aim of Vetoryl® monitoring?
Vetoryl® is a medicine that delivers major clinical benefits to a patient. Every dog with Cushing’s is different, in their clinical presentation of the disease as well as in their response to Vetoryl®. Personalised monitoring is required to ensure the appropriate dose for that patient is obtained. After initiation of treatment, it needs to be ensured that the prescribed dose of Vetoryl® is adequate to control clinical signs of Cushing’s.
Gaining the clinical picture
Assessment of serum cortisol concentrations alone is unreliable for the monitoring of Cushing’s therefore paying particular attention to the clinical signs is vital to achieving treatment success. To do this, excellent owner communication is vital to truly understand how a dog is doing on Vetoryl. Motivating an owner to take control of their dog’s condition right from the point of diagnosis is of benefit to everyone involved in the dog’s care. Explaining the need for good record keeping at home and providing the tools to enable consistent and effective monitoring can help get owners on board.7,8
When re-evaluating a patient receiving Vetoryl, it is important to
It is important to assess and record the clinical signs in a standardised way, especially to ensure continuation of care in cases managed by multiple clinicians. The Cushing’s Clinical Score has been developed to make it easy to record and keep track of the most important clinical signs. This can help you answer the following questions:
- Is the dog showing signs of being unwell?
These include any signs of vomiting, diarrhoea, lethargy and decreased appetite.
- Is the dog still showing signs of Cushing’s?
These include thirst/urination frequency and volume, appetite, appearance and general demeanour.
- Is the dog improving as expected following treatment?
When interpreting the Cushing’s Clinical Score, there isn’t a ‘cut off’ value, or a set score change, which indicates action is required. This is because the score shouldn’t be interpreted as a one off number- but should be monitored over time, in the individual patient.
Each dog will have their own starting score which we would take as their baseline. With treatment we would expect this to reduce (ideally down to 0), and providing the score is reducing or remaining at a constant low level (for which you and owner are happy that the maximum possible clinical improvement has been made) then the dog is doing well.
If, however, the score slowly starts to increase over time, or there is a sudden increase during a routine check-up, this would then warrant further investigation and possible dose adjustment.
Performing a routine physical examination provides an opportunity to look for signs that the dog is unwell and/or has concurrent disease. You are also able to check that your physical findings support the clinical history provided by the owner.
There are specific time points in the monitoring process that can act as reference points to ensure your patient is progressing as expected. Different clinical signs take different time periods to see a response to treatment. It is important to emphasise this to owners. If dogs are not responding as expected, consider whether a change in dose is required.
First recheck at 10 days
Owners should have noticed that the dog is drinking and urinating less. The animal should be less ravenous and excessive panting should have reduced. Lethargy is another clinical sign of Cushing’s that rapidly responds to treatment; even at the first 10 day check many owners have noticed that their dog has more energy.
The overall aim of treatment with Vetoryl is to improve the quality-of-life of dogs and as a result their owners. Recent research1,2 highlighted that it is not just the clinical signs of Cushing’s that impacts on a dog’s quality-of-life. Consideration of specific treatment needs for individual patients as well as their owners are important to optimise the quality-of-life for dogs with Cushing’s.
The scientifically validated CushQoL-pet questionnaire has been developed to help assess quality-of-life within your monitoring consultations. It is recommended to complete this at least every three months to facilitate communication and to work with the owner to decide the next steps of their dog’s management.
The following video shows the importance of monitoring both the owner and the dog's quality-of-life.
Owner factors and observations of their dog’s quality-of-life should not be overlooked and should form the basis of defining how well a dog with Cushing’s is being managed.
Click here to download the QoL questionnaire
Whilst owner observations and a physical examination are critically important in a monitoring consultation, an objective measure is also required to identify dogs with sub-clinical hypocortisolism and at risk of progressing to an overt iatrogenic hypoadrenocorticism. Interpretation of monitoring blood tests need to be made in light of a clear understanding of the clinical picture.
- If the dog is ‘unwell’ (vomiting/diarrhoea, abdominal pain, off their food). Vetoryl must be stopped, serum electrolytes analysed and an ACTH stimulation test performed as this is the gold standard test for iatrogenic hypoadrenocorticism3
- The ACTH stimulation test can then be interpreted to help you decide if the dog is unwell due to hypocortisolism (pre- and post-ACTH cortisol <40 nmol/l) or due to another reason (post-ACTH cortisol >40 nmol/l).
If you have ruled out that the dog is unwell, a Pre-Vetoryl Cortisol (PVC) should be performed.
- If the dog is showing clinical signs of Cushing’s disease and the PVC concentration is in agreement, an increase in dose frequency or an increase in dose should be made.
- If the dog is showing no clinical signs of Cushing’s, the PVC result will help guide you whether treatment can continue at the current dose, or whether alternative action needs to be taken.
Consult the PVC flowchart for more information.
The Pre-Vetoryl Cortisol has been shown to correlate better with clinical control, is more repeatable, less expensive, and easier to perform than ACTH stimulation tests and therefore is a more effective monitoring method in dogs that are not showing signs of iatrogenic hypoadrenocortisolism.5,6 Read more about the background to the PVC here or watch the following video by Professor Ian Ramsey on how to perform and interpret:
In summary
- Monitoring of dogs receiving Vetoryl is to ensure appropriate and adequate control of Cushing’s
- Monitoring of a dog’s condition should move towards a more comprehensive approach, placing more emphasis on at-home monitoring by the owner and not relying exclusively on laboratory measurements
- Whilst it could be seen as desirable to rely solely on owner observations and physical examination, an objective measure is also required to ensure that treatment remains suitable for those dogs whose owners’ observational skills are inadequate or for those dogs who are developing subclinical hypoadrenocorticism that could progress to an overt, life threatening disease
- The Pre-Vetoryl Cortisol correlates better with clinical control3, is more repeatable10, less expensive, and easier to perform than ACTH stimulation tests and therefore is a more effective monitoring method
Since the Pre-Vetoryl Cortisol test does not feature on the Vetoryl Summary of Product Characteristics, informed owner consent for ‘off-label’ monitoring should be obtained.
You should request an owner completes the score before EVERY monitoring consultation. This saves time within a consultation and limits the amount of stress to the pet before taking their serum cortisol sample. You can also request owners record this as frequently as they would like between visits and to record these in their logbook. Recording the score on the clinical notes at every consultation also provides a standardised measure for assessing improvements in clinical signs over time, even when the patient is seen by different vets.
You can ask an owner to complete the CushQoL-pet as often as you see fit. However it is recommended to repeat this every three months to be able to examine meaningful score differences.
To obtain the score for the CushQoL-pet, add up the scores for all answers and divide by the greatest possible score:
CushQoL−pet Score= Σ of the question scores / total maximum score
This provides a rating between 0 and 1 (0 indicating the best possible QoL and 1 indicating the worst possible QoL).
It is recommended to obtain a score at diagnosis which is the baseline score and follow-up will see score improvement (become closer to 0). A change in score of +/- 0.10 indicates a substantial change in QoL and a score of +/- 0.05 indicates a slight change in QoL.
The majority of owners, especially those committed to treating hyperadrenocorticism, are unlikely to miss signs. It is also possible that by placing more emphasis on their role as the primary monitors of their own dog’s condition, they may be more likely to notice signs sooner. In addition, it is hoped that they may also be more observant of signs of poor control. The benefit of the Cushing’s clinical score is that it has been shown to be reliable for repeated measures by an owner over time. However some owners are
unreliable or do not directly engage with the attending veterinarian. In these circumstances in-clinic assessment and monitoring with Pre-Vetoryl Cortisol should be more frequent if possible.
Direct your clients to the Vetoryl owner website. Here they will be able to download a log to keep a record of their dog. Printed log books can also be ordered by your practice free of charge if the owner is not able to use the online version for any reason.
Please visit our dedicated Pre-Vetoryl Cortisol page.
Supporting you
Dechra Provides you with an extensive range of resources is also available to help with treatment and monitoring. In addition, a range of materials are also available to help you manage Cushing’s disease.
1. Schofield, I et al (2019) Development and evaluation of a health‐related quality‐of‐life tool for dogs with Cushing's syndrome. Journal of veterinary internal medicine 33(6): 2595-2604
2. Schofield, I et al (2019) The Cushing’s clinical score: development of a primary-care practice tool to quantify the clinical signs of dogs with hyperadrenocorticism. (Abstract) British Small Animal Veterinary Association Congress, Birmingham.8.
3. viii Internal report VET60
4. Behrend et al (2013) Diagnosis of Spontaneous Canine Hyperadrenocorticism: 2012 ACVIM Consensus Statement (Small Animal) JVIM 1-13 27(6):1292-304
5. Macfarlane L., Parkin T. And Ramsey I.K. (2016) Pre-trilostane and 3-hour post-trilostane cortisol to monitor trilostane therapy in dogs. Veterinary Record 179: 597-605
6. Midence J.N et al (2015) Cortisol concentrations in well-regulated dogs with hyperadrenocorticism treated with Vetoryl. Journal of Veterinary Internal Medicine 29: 1529-1533
7. Niessen, S et al (2012). Evaluation of a quality‐of‐life tool for dogs with diabetes mellitus. Journal of Veterinary Internal Medicine, 26(4): .953-961
8. Niessen, S et al (2017). The big pet diabetes survey: Perceived frequency and triggers for euthanasia. Veterinary sciences 4(2): 27
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