Cincinnati Cushing's dog (Lucky, border collie mix) ACTH stim protocol question

[Lucky's pal]

Hello all,
I've already read a wealth of information on this site by reading the previous posts, but since all of us are in unique situations I thought I would write and introduce myself and Lucky. My upload of the picture failed, so you'll have to imagine my beautiful 46 pound gold and white border collie mix for now. She has the classic cushings symptoms, but has not had a DEFINITIVE diagnosis of cushings. About 2 years ago she started drinking excessively. I took her to my vet at the time in Austin and they ran bloodwork and could find nothing unusual, so we did nothing but wait and see. There were no other symptoms for probably around 2 years. Then, shortly after we moved to Cincinnati, she started panting. It was summer, so the logical conclusion was that she was hot, but this heat was nothing like Texas heat and she never panted there. So I knew something was up. Then I noticed that I could see her tail through her hair, something that had never been visible before because she has very thick long hair. I really thought that it was silly to even mention that, but apparently not.

Anyway, my first call was to an animal communicator (ie psychic). Are you all still with me? She confirmed that something was going on internally and was very seriously wrong. She couldn't be specific but she was alarmed and prompted me to take her to my vet soon. The vet immediately suspected cushings due to the following symptoms: excessive thirst (and therefore excessive urination, although never any accidents in the house), panting, hair loss, chubby belly. The vet then went about trying to rule it out with a urine test, x-rays, ultrasound, and bloodwork. For some reason he thought that he was saving me money by not doing the ACTH stim test for $250, but at that point I had already spent close to $1000 for the rest of the testing. Since everything pointed to cushings, he recommended starting her on Vetoryl. She very quickly responded, stopped panting, quit drinking excessively, and her hair started growing back really really thick (thicker than before I think).

She was doing great for 4 months, until last week when I woke up to vomiting. She proceeded to walk around the house and vomit 8 times (of course she left the wood floors and moved to the one carpeted room). I called the vet and he recommended that I not give her the Vetoryl. She was fine for the remainder of the day. Since we were not sure if it was a fluke where she ate something bad (she loves cat/deer/anything stinky poop), I gave her her Vetoryl the next day. She was fine that day, but when I came home the next day, as soon as I walked in the door I knew we still had a problem. She had thrown up all over the carpet again. I took her to the vet the next day. That was about one week ago and I haven't given her Vetoryl since. The vet talked to the lab and they said that it can take 30 days to get out of her system. She's been fine since I stopped the vetoryl.

Of course, the question will soon be what is the next step? Although the vet hasn't suggested it, I think I should have her precortisol level checked in a week or 2 to see if it's going back up. I think the vet said it was at 2.1 when they checked last week. I don't have all the lab results... I'll have to get them from the vet.

Anyway, that's my story, for now. Thanks for reading. I'm glad to have found this forum and I appreciate any of your insight. By the way, Lucky is around 11 years old. She was a stray so it's hard to say for sure, but I've had her for around 10 years. I have one other dog and 2 cats.

Alice

[StarDeb55]

Alice, welcome to you & Lucky! I'm sorry to hear that Lucky is having so many problems at the moment. As you can see, we love to see the numbers from all the labs that have been done on Lucky. Please post them as soon as you can. We do tend to play "20 questions" with new members, so I will get started.

I do need to correct one thing you have posted.


excessive thirst (and therefore excessive urination, although never any accidents in the house)

This is a common misconception on parents of newly diagnosed cushpups. The pups are peeing too much, therefore they must drink to excess to keep up with the excess urination. It's imperative that Lucky be allowed free access to water as a cushpup can become dehydrated very quickly.

I really can't comment too much on Trilostane usage as I am a lysodren parent. I am almost certain that Trilostane does clear from the pup's system in something like 10-12 hours, so the lab saying that it takes 30 days doesn't sound quite right to me. Since the GI upsets appear to be happening 36-48 hours after the trilo is given, I have a real concern about this being Trilo related. Cushpups are extremely prone to pancreatitis, & this is my first thought when I read Lucky's story. Did the vet run any labs at the time of the vomiting incidents to see if either/or her amylase/lipase is elevated? Those are the 2 levels that would indicate pancreatitis. I would definitely ask the vet about this as pancreatitis can be life-threatening, if serious enough. If I were in your shoes with one of my boys, I would insist on these 2 levels being checked, & to be on the safe side a full chemistry panel to make sure Lucky's kidney function is ok. Serious kidney function impairment can cause vomiting, also.

I'm sure some of the Trilo parents will be weighing in, so welcome. We are here to help in any way we can. Someone is usually on the board 24/7 as we have quite a few members in Australia. Alison, one of our administrators, will usually hold down the fort overnight.

Debbie

PS- Can you tell us if any other Cushing's diagnostic testing was done besides the ACTH?

[littleone1]

Hi Alice,

Welcome to you and Lucky. There is a wealth of information from very caring people on this site. I wish I had some answers for you, but I'm relatively new to treating Cushings with Trilo. Corky has only been taking Trilo for 19 days.

I hope your vet is able to get this resolved. I know that I read somewhere that if I would have to switch Corky to Lysodren, he would have to be off the Trilo for 30 days. Also, Corky has an adrenal tumor. When he had the adrenal panel done, if we were going to do surgery, Dr. Oliver said that we would probably want Corky off of the Trilo for a couple of weeks or so before the surgery was done. However, this is not an option for Corky.

I wish you the best.

Terri

[StarDeb55]

Alice, I went back & re-read your post, I need clarification on a very important point, if you wouldn't mind.


The vet then went about trying to rule it out with a urine test, x-rays, ultrasound, and bloodwork. For some reason he thought that he was saving me money by not doing the ACTH stim test for $250

Are you saying that the only test that was done that was directly related to a Cushing's diagnostic test was an abdominal ultrasound? The other thing I need to ask is when you say urine test, was this a urine cortisol:creatinine ratio? If it was a UCCR, this is a rule out test only. This means that if the test was normal, you are definitely not dealing with Cushing's, positive or elevated means that Cushing's is possible further diagnostic testing is needed. Cushing's is probably the most difficult condition to diagnose in our pups as there is no single test that is 100% diagnostic. Was diabetes & hypothyroid ruled out? I'm asking about these 2 problems as their symptoms overlap with Cushing's.

After re-reading your post, I'm very concerned about the accuracy of Lucky's Cushing's diagnosis. A UCCR & abdominal ultrasound really isn't sufficient testing to nail down a diagnosis. Lucky may not have Cushing's, & this may be why he had such a severe reaction to the Trilostane. Both drugs for our pups are very serious medication, but they can be lethal if given to a non-Cush pup.

Debbie

[lulusmom]

Hi Alice and welcome.

Alrighty then, let's start with the diagnosis. You said that your vet did not make a definitive diagnosis. It is dangerous to prescribe Vetoryl for a dog that is not cushingoid so I am assuming that you meant to say that your vet diagnosed cushing's but did not determine if it was adrenal or pituitary? If Lucky has symptoms consistent with cushing's, abnormal blood and urine analysis yet tested negative for cushing's, meaning cortisol was not elevated, then she should not be on Trilostane. If this is the case, she very well could have atypical cushing's which involves the elevation of adrenal hormones other than cortisol which calls for a much different and certainly safer treatment.

Unfortunately, I am merely speculating at this point and it would really help us put all the pieces of the puzzle together if you could tell us exactly which tests were done by your vet and can you please post those results. Common diagnostic test would be the Low Dose Dexamethasone Suppression Test (LDDST), that acth stimulation test and to help differentiate between pituitary and adrenal, most vets use the High Dose Dexamethasone Suppression Test (HDDST) and/or the abdominal ultrasound. If you do not have copies of these tests, your vet should be happy to provide them. It helped me to write down a chronological log with test names, dates of tests, test results, date of treatment, date and results of of acth stimulation tests after treatment and dates and adjustments to dosing. If you can do that, we should have Lucky's complete history.

It would also help us understand exactly what is happening with Lucky if you can tell us how much she weighs and what dose of Vetoryl she has been given. The normal treatment monitoring protocol dictates that an acth stim test be done 10 to 14 days after initiation treatment and if the dose is not adjusted another stim should be done at 30 days and then every 3 months (I think) thereafter. How many acth stim tests has Lucky had since starting treatment and can you tell us if and when any change in dosing was made? I know this is a lot of questions but in order for us to provide you with meaningful feedback, we need a lot more information.

Others can confirm this but I do recall that we have had members report that their dogs cortisol continued to drop on the same dose of Vetoryl for up to three months so even if no increase in dose was prescribed for Lucky, it is possible that her cortisol continued to drop as well. Again, it will help make this determination with complete information from you.

You mentioned checking the pre cortisol level and that your vet said the last stim test was 2.1. If you are referring to the pre acth, also known as the basal cortisol level, then this number is low normal and if your vet was referring to the post acth cortisol level, that that would also be a great number for a cushdog being treated. After Lucky crashed, your vet should have checked the electrolytes and run an acth stimulation test so s/he should have the post cortisol level as well. Were both of these tests done?

Trilostane's enzyme blocking abilities start to diminish any time after 8 to 12 hours which is why most dogs recover from any adverse reactions rather quickly after discontinuing the dosing. So yes, Vetoryl may be out of the system within 24 hours, however, there are many documented cases of dogs that took months for cortisol to climb high enough to see a return of symptoms.

I just took a look at what I've written and must apologize for jumping all over the place and repeating myself here, there and everywhere. I have been up to my eyeballs in work this week, am totally sleep deprived and too tired to edit this mess. I also see that Debbie posted while I was typing so please excuse the legitimate duplication. FYI, based on the information you have provided, I share Debbie's concerns regarding a correct diagnosis.

Glynda

[Lucky's pal]

I will get all the test results from my vet and post them. Thanks for the replies so far.
Alice

[lulusmom]

Hi Alice,

I forgot to tell you that Lucky is a beautiful girl and I wish the avatar picture were bigger so I could tell if her coat is as lush and gorgeous as it looks. Perhaps you can start an album for Lucky?? To make an album, go to your user cp and click on "pictures and albums" (left side of your usercp page) then follow the prompts. Is Lucky's brother or sister the white dog (Lab?) I see in the picture?

Bless you for rescuing Lucky from the streets. It is easy to pick up on just how much you love her and I figure that the day your paths crossed was probably the luckiest day of Lucky's life....and probably yours too. Is that how she got her name? I love Border Collies and am amazed by their intelligence. I love watching them in agility trials.....they make everything look so incredibly easy. From what I've seen, Border Collie mixes appear to be just as smart.

Glynda

[Casey's Mom]

Welcome Alice and Lucky!

Your Lucky looks a little like my Casey who is also a border cross. Lovely doggies aren't they? You will get some good advice on this site once the more experienced members can see your test results. You are doing a great job just by being here and asking questions.

Believe me I know -I ask lots of questions and Alison is great for those middle of the night panic attacks!

[Lucky's pal]

Hi all,

This is the history of what has been done so far to diagnose Lucky's condition. There are way too many numbers to type them all into this post, so I'm going to summarize and just put in the values that were flagged as either high or low.

On 6/11, she had a blood chemistry, CBC, and complete urinalysis.
Chemistry:
ALT 131 high
Bilirubin, total 1.82 high
cholesterol 333 high
PO4 .5 low (alert value?)
Protein, total 8.0 high
Albumin 3.8 high
LDH 290 high
Anion Gap 22.3 high

CBC:
MCH 26.2 high
MCHC 37.8 high
NEU% 77.4 high
LYM% 10.8 low

Urinalysis: everything seemed normal
T4 2.10 normal

Next she had x-rays, 3 views which did not reveal anything abnormal.

On 6/16, she had an ultrasound which revealed:
"Right adrenal gland is larger than normal with a width of 10mm (normal <7.5mm), but it has a normal shape and echogenicity.
Left adrenal gland demonstrates normal size, shape and echogenicity.
Remainder of the study was unremarkable; liver, spleen, kidneys, urinary bladder, medial iliac lymph nodes, stomach, small intestine, colon and pancreas appeared normal.
No enlarged abdominal lymph nodes were detected."
"Changes involving the right adrenal gland, along with the history of panitng and PU/PD are suggestive of hyperadrenocorticism, and lab testing is recommended. Otherwise, this study is considered within normal limits"

The final test done to rule out Cushings was the urine cortisol-creatinine ratio, done on 6/16:
Urine creatinine 15.2
Urine cortisol 3.4
Cortisol/creatinine ratio 70.2 high

Apparently this did not rule out the Cushings, so based on these tests, my vet recommended to start her on Vetoryl (trilostane). She started at a fairly low dose for her weight of 49 pounds... 60mg/day.

She responded within 1-2 weeks, drinking less water and not panting anymore. Within another 2-3 weeks, her hair started getting thicker and fuller.

At one month, we had her resting cortisol level checked. It was 3.6. One problem I see now is that she had never had her resting cortisol level checked before this point. In any case, the dosage was determined to be appropriate and she continued on this for the next 3 months.

Everything was going fine until she started vomiting profusely. I didn't give her the Vetoryl that day and she seemed fine later. I gave her the Vetoryl the next 2 days, after which she started vomiting again. She hasn't been on Vetoryl since 10/20.

On 10/22, she had another chemistry profile:
Bilirubin 2.91 high
PO4 1.0 low
LDH 306 high

Resting cortisol: 2.1

That's all to date. Lucky is drinking a little more water than she was before but none of the other signs are apparent yet. I'm tempted to do another resting cortisol to see what is going on. Shouldn't it be going up if she's not on anything to lower it? Also, would an ACTH stim test tell us anything more?

Thanks,
Alice

[gpgscott]

I'm tempted to do another resting cortisol to see what is going on. Shouldn't it be going up if she's not on anything to lower it? Also, would an ACTH stim test tell us anything more?

Thanks,
Alice

Welcome Alice,

The diagnosis can be maddening.

I would not waste time on resting cortisol, in fact we have had Drs. leave the resting cortisol out to save money. The important number is the stimmed number.

In a typical case of PDH you can see bilaterally enlarged adrenals as they are being over worked and so sometimes increase in volume. Usually and enlargement of only one adrenal is indicative of ADH. On the other hand in your case the enlargment does not seem to be extreme, so maybe it is just a physical anomoly.

Vomiting, lack of energy, and lack of appetiete are all signs of low cortisol and the common approach is to cease medication and have an ACTH right away.

Please check back frequently, I am sure there will be lots of response to this new information later today.

Best to you and Lucky. Scott

[StarDeb55]

Unfortunately, you absolutely can't make a diagnosis of Cushing's based on a urine cortisol:creatinine ratio. This is simply a rule out test meaning that if it's within normal limits, you absolutely aren't dealing with Cushing's. Elevated results indicate Cushing's is a possibility, but further diagnostic testing is required. The usual steps to take after a positive UCCR are either an low dose dexamethasone test, or an ACTH stimulation test. Did Lucky have either of these tests done?

The ultrasound is highly suspicious for an adrenal tumor since one adrenal gland is significantly larger than the other one. If Lucky is dealing with an adrenal tumor, surgery is a distinct possibility offering the hope of a permanent cure. Did the vet say anything about an adrenal tumor?

There are 2 things on the general labwork that really raise an a red flags for me, the elevated bilirubin, & a normal alkaline phosphatase. By far & away, a huge percentage of cushpups will have an elevated alk phos. Sometimes this elevation can be into the 1000's. An elevated alk phos is usually what tips off a vet to start looking at Cushing's. I don't beleive I have ever seen a cushpup with an elevated bilirubin. Elevated bilirubin is very suspicious for some type of primary liver disease, not Cushing's. Cushing's does cause elevations in some liver function values because the liver is stressed because of having to process the tremendous amount of cortisol that the adrenals are producing. On the off chance that there is some type of primary liver disease in play here, this may be why the urine cortisol was elevated. Just to let you know, I'm a medical lab technologist with 29+ years experience, so I'm kind of used to looking at these types of numbers.

I don't remember whether or not we have asked you, but was diabetes an hypothyroid ruled out? This is very important as these 2 problems have symptoms that overlap with Cushing's.

Lastly, when it comes monitoring either lysodren or trilostane with ACTH stim testing, the most important of the 2 values is the post value. Do you have the post value results? About the only time that I know a pre or baseline value comes into play is when both the pre cortisol & post cortisol are very similar. For instance, a pre of 1.5 & a post of 1.8, these types of number would indicate a non-stimulatory response.

Right now, IMHO, I would hold off any further trilostane for a few days, talk to the vet concerning the above information, especially whether or not Lucky has an adrenal tumor. I'm not sure at this point in time that doing a low dose dex test would be worth either the time or the money, but this is something to ask the vet. I'm really not trying to trash your vet, but treatment, in my opinion, was started with incomplete diagnostics. Cushing's is one of the most difficult diseases to diagnose as there is no single test that is 100% specific or sensitive. Most GP vets have little experience with treating the disease, so this is why we frequently recommend you see a vet internal medicine specialist.
We see this on these boards frequently, & this is why we encourage owners who are facing a Cush diagnosis to get educated, learn about the disease, & don't ever be afraid to ask questions of the vet. Your vet & you have to work as a team for Lucky to have a successful treatment. If you have a vet who gets annoyed that you are researching & asking questions, I'm sorry, you need to find another vet.

Debbie

PS- Just a reminder, as Glynda asked earlier, could you post the trilostane dosage that Lucky has been on? Please post if there have been dosage changes along with the dates of the change. What is your pup's current weight? And we really need to see the post values for any of the ACTH stim testing that may have been done.

[Harley PoMMom]

Hi Alice,

A belated welcome to you and Lucky from me and my boy Harley. Scott is so right as this cushings journey can be so maddening, but that's why we are here to help you in any way we can.

It looks like you already received some really good advice so I won't duplicate anything else that was said.

Here is a quote from and a link to an article about the UC:CR test tho:


The urinary cortisol:creatinine ratio (UCCR) is best used to rule out the diagnosis of HAC. Most studies have found that almost all dogs with HAC have an elevated UCCR, but the majority of dogs with an elevated UCCR do not have HAC.1,5-7 Accordingly, if the ratio is normal there is little chance the dog has HAC, but if the ratio is high, another screening test such as the LDDST or ACTH stimulation test must be done to confirm the diagnosis. However, one study did find the sensitivity to be only 75%1, giving a chance for a false negative of 25%. Therefore, even if the ratio is normal, if there is still a very high suspicion of HAC, another test should be performed.

http://www.dcavm.org/04sept.html (scroll about 25% of the way down the webpage above to where the article begins)

Remember Alice you are not alone on this journey, we are here for you and Lucky, ask all the questions you want and we will try to answer them as the best we can.

The one thing I will stress is that one does need to have their pup properly diagnosed of cushings in order for one to get a proper treatment plan for their pup, and sometimes that proper diagnosis can take a while.

My boy Harley has Atypical cushings and PDH, as of right now I am treating his Atypical cushings only because his cortisol levels are within the normal ranges. I would of not known this if I wouldn't of done addition testing.

When Harley first started drinking and peeing excessively, I thought because of his age at 12y/o at that time, that he was showing the signs of diabetes. I took him to the vets and his glucose came back normal but other things on his bloodwork alerted his vet that Harley should be tested for cushings.

Alas our cushings journey began...so far Harley's had a LDDS test, UTK full adrenal panel, 2 endogenous test, 2 ultrasounds, lots of bloodwork done, and 2 ACTH tests...that's just since Feb 09. :eek: and that was just to confirm what type of cushings he had so that I could make sure he was getting the right treatment. Now I'm not saying you should put your Lucky thru all of these tests, no way, I had to because Harley was such a bugger to figure out :p:), but if I were you I would definitely want more testing done, at least a LDDS test and a ACTH test or a UTK full adrenal panel which comes with a ACTH test.

Like I mentioned my boy had me going in circles, my stomache tied up in knots and alot of the time crying my eyes out, but thankfully these wonderful and amazing people here took my hand, dried my tears and guided me...They helped me understand this Cushings Disease...my gratitude to all of them is unmeasurable. And Alice they are here to help you and Lucky the same way the helped me, so hang in there, ok.

Hugs.
Lori

[Lucky's pal]

Hi all,

I'm pretty sure diabetes and hypothyroid was ruled out, but I'll have to ask my vet to know for sure.

We never did either the LDD test or the ACTH stim test. The diagnosis was based on the fact that Cushings could not be ruled out and that Lucky had the classic symptoms. She was not ever definitively diagnosed.

She weighed 49 pounds when we began this ordeal. Last week, she weighed 44 (after throwing up for 2 days and being on id canned food for a few days).

I'm pretty sure the ultrasound ruled out an adrenal tumor. I posted the findings before, and basically it only said that one gland was slightly larger than normal (and the other one).

There has been some concern about her liver, but the vet said that the numbers were fine now. When I saw the number of items that were not in the normal range, I was surprised.

Thanks,
Alice

[StarDeb55]

The following is a quote from a paper presented at the World Small animal vet conference in 2005. I have only posted the important section that applies to Lucky's case, & I have added the bold/color for emphasis.
Here's is the link to the full paper.

http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2005&PID=11021&O=Generic


Clinical use: In general, the UCCR test has a high sensitivity, so a normal UCCR value virtually eliminates the possibility of HAC. That is, the test can rule out HAC. However, the sensitivity is not 100% (and was as low as 75% in one study), so a normal UCCR in the face of a high suspicion for HAC should be followed up using another screening test. The specificity is poor overall, so a positive test result must be confirmed using a screening test with greater specificity.

Debbie

[StarDeb55]

Alice, I wanted to think this over for awhile before I posted in depth to you. Some of what I'm going to say is going to be to the point about the way Lucky's vet has handled the diagnostic testing that has been done, but I do not want you to feel that anything that I say is aimed at you. To many of us have learned from the "school of experience" that a lot of our GP vets who have taken care of our family pets for years, doing a good job with their basic health care needs, do not know SQUAT about proper diagnostic procedures to pin down a diagnosis of Cushing's. It is critical that proper diagnostic testing be done as there are a number of other medical problems that can mimic Cushing's. We have one member, Leslie, whose pup showed symptoms of Cushing's, had all the proper diagnostic testing done, several tests were even repeated, all testing pretty much confirmed a diagnosis of pituitary Cushing's. One of the treating vet's for this pup, noted the presence of a mass on the spleen on an abdominal ultrasound which a previous vet either forgot to mention, or felt it wasn't significant. To make a long story short, this pup was taken to surgery to remove the splenic mass, all testing post-surgery has shown that her cortisol is within normal limits, & her treating vets are now saying that the original diagnosis of pit. cushing's is now highly suspect. I'm relating you Leslie & Squirt's story, to demonstrate how extremely difficult it can be to get an accurate diagnosis. In Lucky's case, with the elevated UCCR & symptoms that are present, there is a distinct possibility that you are, indeed, dealing with Cushing's, but I feel confident in saying that no "cushing's savy" vet would start treatment based on an elevated UCCR, a mildly abnormal ultrasound, & symptoms without further testing such as an ACTH or low dose dex test.

Believe me, we all understand about the expenses involved in taking care of a cushpup. Cushing's is not cheap to get diagnosed & treatment initiated. I am now taking care of my 2nd Cushpup, & literally, hate to see my credit card bills every month because of his care, as I really had not recovered from my 1st boy's medical expenses when I got the 2nd diagnosis 18 months ago.

I would strongly urge you to get a referral to an internal medicine specialist who has the speciality training to deal with all endocrine disorders such as Cushing's, along with the possibility of a primary liver disease problem that I raised earlier. Lucky's situation needs to be sorted out by a vet that has the background & training to diagnose & take care of him properly, & frankly, IMHO, your current vet does not have the necessary knowledge to do this.

Debbie

[Lucky's pal]

Thanks, all. It appears that I do need to take her to a specialist. I will do so. Lucky appears content and not in any pain. Is this an urgent matter, do you think? Or can it wait until she starts demonstrating symptoms again?

Alice

[StarDeb55]

Strong symptoms are a huge part of making the diagnosis, & a Cushing's savy vet will probably not initiate any treatment without symptoms. Cushing's is a slowly progressing disease that can literally take years to the damage to the internal organs that comes with the disease. If I were in your position, I would go ahead with a referral, & have the specialist take a look at everything. If the specialist does confirm Cushing's, they will discuss with you whether or not it's appropriate to treat without apparent symptoms. You have time to get this sorted out, get a correct diagnosis, & learn what you're dealing with. One other thing you need to look for when going to a new vet, whether or not they're a specialist, is that they will work with you as a team. You want a vet that does not get offended when you tell them you are researching the problem, & will be asking questions. Working as a team is the best way to insure the success of Lucky's treatment. As hard as it is to say, we have actually had members report that their vets have become highly offended when they ask questions & let the vet know that they are researching their pup's health problems on their own. One of the best things you can do is to become an educated, knowledgeable owner as you are Lucky's only voice & advocate. With that thought, I would strongly encourage you to take a look at the important information section of the forum where you will find a huge number of links concerning all aspects of Cushing's disease including several that deal with proper diagnostic procedures.

Debbie

[Harley PoMMom]

Hi Alice,

Was Lucky ever checked for pancreatitis? Collies, among other breeds, have been shown to have an increased relative risk of chronic pancreatitis. There is a test called a cPLI that can test for pancreatitis. Lucky might just have a mild case of pancreatitis, on your bloodwork tests do you see lipase and amylase listed? Lipase and amylase are enzymes associated with the pancreas.

The reason I am asking is because of Lucky throwing up, and some of her bloodwork is an indicator of pancreatitis.

Here is a really good article on pancreatitis that was posted to me from Susy, one of the Moderators here.

http://http://dogaware.com/wdjpancreatitis.html

Hugs.
Lori

[StarDeb55]

Alice, I want to make a couple of more points, especially concerning what you may be dealing with when it comes to the symptoms that Lucky was showing prior to initiating the Trilostane. You may be dealing with standard Cushing's, either pituitary or adrenal, where there is an elevation in cortisol. It's also possible that you may be dealing with Atypical Cushing's which occurs with or without a concurrent elevation of cortisol. Atypical is when one or more of the associated hormones that the adrenals produce are elevated. The last possibility is a non-adrenal illness. Of these 3 problems, standard Cushing's; standard Cushing's + Atypical; non-adrenal illness of some type could all cause an elevation in the urine cortisol results. It's doubtful that strictly Atypical would elevate a UCCR, but I'm not 100% sure about that. The UCCR determines the presence of an elevated cortisol, but it can't tell you why the cortisol is elevated. Cortisol is what is termed one of "fight or flight" hormones, so when a pup is ill, for whatever reason, more than likely their cortisol will elevate because of the stress of the illness.

It would not be worthwhile checking another pre-cortisol level. This is another error on your vet's part. The post-cortisol value on the ACTH is absolutely the most important of the 2 values when testing as we have explained to you earlier. Right now, I would not give any further trilostane, get the referral to a specialist, & make sure you provide copies of all of Lucky's records for the specialist to review. I strongly suspect that whatever specialist you see will want to do their own diagnostic testing which may include a low dose dex test, ACTH, &/or abdominal ultrasound. The one question I would definitely ask the specialist is what medication they prefer to use to treat Cushpups. If it happens to be trilostane, we have been strongly recommending that prior to initiating treatment with trilo that you have the full adrenal panel done at the Univ. of Tenn., Knoxville to get an idea of the levels of the associated hormones. If any of these associated hormones are elevated, trilo is not the recommended treatment for Atypical.

Debbie

[lulusmom]

Hi Alice.

Debbie has done a great job of explaining everything to you and I wanted to validate everything she has told you. I also wanted to let you know that elevation of adrenal hormones other than cortisol (atypical cushing's) can cause an abnormal UC:CR ratio.

Glynda

P.S. I am so happy to hear that you are going to be consulting with an internal medicine specialist. Yippee!!! It was an IMS that finally and correctly diagnosed my Lulu.

[StarDeb55]

Thanks, Glynda for the clarification on the elevated UCCR & Atypical. As I said, I wasn't sure about that one.

Debbie

[Lucky's pal]

"Lucky might just have a mild case of pancreatitis, on your bloodwork tests do you see lipase and amylase listed? Lipase and amylase are enzymes associated with the pancreas."

I don't see lipase or amylase on any of the test results. Do you know of any abbreviation that they might use?

Nothing new. Lucky is fine. She's been off trilostane for a week. I should be able to get an appt to an internal medicine specialist next Friday.

Thanks all,
Alice

[StarDeb55]

It's possible these 2 tests might be abbreviated, "amy" & "lip", but they are normally listed under the complete names. With the GI upset type symptoms that you have told us about, I think it would be a good idea to let the specialist know about this, asking about the possibility of pancreatitis. Pancreatitis can be both acute & chronic. Chronic can flare-up when a high fat meal is consumed.

Debbie

[Squirt's Mom]

Hi Alice,

A belated welcome from us to you and your sweet baby, Lucky! :) Glad to have you in our family!

I have read your thread and must agree with Glynda and others in all they have said. Your vet's approach is a bit frightening to me and based on Lucky's reaction, justified.

It was my Squirt that you were told about in an earlier post. I was first told she had elevated cortisol when she went in for pre-blood work for a dental. She then had the LDDS, HDDS, and ultrasound - all of which diagnosed and confirmed pituitary dependent hyperadrenocortisim (PDH), or a tumor on the pituitary gland causing an over production of cortisol. Then she had an ACTH, which showed elevated levels of cortisol, too. Just to be on the safe side, I decided to have the UTK panel run before starting any treatment (I was considering Trilo at the time.) The UTK panel includes an ACTH so that was done again then. The UTK results suggested another ultrasound, which we did and the splenic tumor was then mentioned (it was there on the first one, but the IMS at that time didn't feel the need to say anthing about it to anyone! :mad::mad::mad: ). Once it was out in 9/08, the stressor was removed and Squirt's cortisol level has returned to normal. :D:D:D

Because of Squirt's experience, I simply cannot express strongly enough the importance of thorough testing prior to starting any treatment with either Trilo or Lyso. If I had started Squirt on either med, there is no telling what damage might have been done to her adrenals because the problem wasn't due to true Cushing's but rather to the splenic tumor causing physiological stress which her body responded to, as it should have, by releasing extra cortisol. Once the cause for the stress was removed, the body no longer felt the need to continue over-producing cortisol.

She is Atypical and is being treated for that, only, with melatonin and lignans. She is doing really well, too!

Please take your time to make sure that Cushing's is indeed what you are dealing with before you restart the Trilo or any other treatment. Learn all you can meantime and know that we are here for you and Lucky.

Hugs,
Leslie and the girls

[gpgscott]

Hi Alice,

I am glad to hear that Lucky is off the Trilo and that you have an appointment with a new Dr. next week.

Looking forward to hearing about it.

Scott

[Squirt's Mom]

Hi Alice,

How are things going? Would love to hear from you when you get a chance!

Hugs,
Leslie and the girls

[Lucky's pal]

Hi all. I've looked through the forums and read much of the info, and sometimes there is just so much information that it is overwhelming. I have only one question: Do you feed the dog her normal meal with the trilostane before taking her for an ACTH stim test? We were also planning on running a senior blood profile and checking urine at the same time (she has been on trilo for about a year).

Thanks for clearing that up for me.

[apollo6]

Welcome.
I just started my little dachie on Trilostane, and my Vet said to feed him his food and give him the medication as usual ( easier to do in morning) then about 4 hours after the test is given. I would check with your vet.

[Harley PoMMom]

Since Trilostane is better absorbed when taken with food and the ACTH test has to be done 4-6 hours post pill then giving a low-fat mini meal with her Trilostane should be ok. Very excessive lipemia (fatty substance in the blood) may affect cortisol assay results.

Hope this helps.

Love and hugs,
Lori