Bella:Atypical Cushing's diagnosis confirmed

[LuLuO]

Hi everyone. Our vet suspects that our Bella may have CD. A little back story on Bella to introduce us:

We adopted Bella, a senior mixed breed, two years ago. At the time she was believed to be between 10 and 12 years old. At the time I saw her at the shelter, I was told she had a UTI. No biggie. It was close to closing time and I wanted to discuss adopting Bella with my husband. I talked with my husband and we decided to adopt her. But when I went back the next morning at opening, she was gone. I was told she was adopted. I thought I was being fibbed to so, long story short, after some investigation and some phone calls I found out she was not adopted and had been pulled because she was going to have surgery for bladder stones. I believe they were using her as a teaching case at a local veternarian because this was a high kill shelter. Lucky for her I think in a strange sort of way. Anyway after talking with the vet I paid extra money for IV and close monitoring. They removed over 20 bladder stones from this 25 pound dog and some of them were more than an inch in diameter. After many months of patience and love and medication she recovered nicely.

Shortly after we adopted her, I had bloodwork done. All was normal. in 2009, she had an elevated ALT level of just over 400. She also had excessive water consumption and always seemed hungry. We tested for Cushing's with the LDDS test but it was inconclusive. We did another test and bloodwork was sent off to some University but that reslult was also inconclusive. I decided to watch and wait.

Fast-forward to this year. Her ALT level is now above 1300. She is consuming 32 ounces of water a day and the vet says she should consume no more than 24 ounces and he considers that the high end for her. She still has a ravenous appetite, and that has only gotten worse. So we are doing the LDDS test again this Friday. He is fairly confident that it will be positive.

But, what if it comes back inconclusive again? Has anyone here ever had that happen? I think other than CD we'd be looking at liver disease and she has no sypmtoms of liver disease, except excessive drinking/urination.

Anyway, sorry to write a book. I just wanted to introduce myself since I'll be poking around this site until we find out what is going on.

[littleone1]

Corky and I would like to say hi and welcome all of you.

Have you had an ACTH stimulation test done? This test can help with diagnosing Cushings. Also, has she been tested for thyroid problems? Some of the symptoms of hypothyroidism are the same as those of Cushings. There is no one test that can definitely tell if it's Cushings. You might also want to have an ultrasound done on her adrenal glands and her liver. Cushoid dogs usually have an enlarged liver.

Other members will be along that can offer you more advice than I can. You have found a very wonderful group of very caring, supportive, and knowledgeable people.


Terri

[Squirt's Mom]

Hi LuluO and welcome to you and Bella! :)

Trying to do some catch up here...which is unreal...and saw your post. How is Bella doing today? Has she had the LDDS yet? I highly recommend she have an abdominal ultrasound performed on a high resolution machine. This test saved my Squirt's life.

You might mention the possibility of Atypical Cushing's to your vet as well. Atypical is a form that involves intermediate (sex) hormones but not cortisol and is often the culprit when the standard Cushing's test are not conclusive. Here is a link from our Resource section:

http://www.k9cushings.com/forum/showthread.php?t=198

Let us know how things are going for you and Bella when you get a chance.

Hugs,
Leslie and the girls - always

[LuLuO]

Hi everyone. Sorry I haven't updated. The kids have been sick. We've been dealing with ear infections and hand food and mouth disease. Ugh. Anyway, an update on Bella:

LDDST test came out perfect. She is supressing as she should, according to the doc. We are now scheduled to do the testing through the University of TN. She'll go in for that on Thursday 6/9. Can anyone tell me about how long it will take to get the results of that test back? She is the first patient in the practice to get this test.

[zoesmom]

Here's a link to UTK's page (vet endocrinology/tests/etc). If you scroll down to "3-G" you will see that they do batch runs of the test once a week (I assume that's what your vet is planning to do - the adrenal panel that tests for atypical cushings - i.e. the intermediate adrenal hormones - since Bella's other cushings tests have come back normal? Think it also says to send the sample on Mon-Thurs. They have some very specific submission guidelines for how to prepare and submit samples, which I assume your vet has already looked into. Also, there's a number you can call at the very bottom at that page and they can probably answer any questions. Not positive, but seems like the wait has usually been about 2, maybe 3 weeks, to get the results. Dr. Oliver, I believe, will send back a report to your vet with his interpretations/recommendations for treatment, based on results. Others may be along who've had the test recently that can tell you exactly how long they waited to hear back.

http://www.vet.utk.edu/diagnostic/endocrinology/general.php

[Harley PoMMom]

Sue is correct, the Lab at the Univ. of Tenn. is very specific on how they want the samples done and sent...be very certain your vet knows this information.

When I had the full adrenal panel done on Harley we received the results back in 7 days.

Love and hugs,
Lori

[LuLuO]

Here's a link to UTK's page (vet endocrinology/tests/etc). If you scroll down to "3-G" you will see that they do batch runs of the test once a week (I assume that's what your vet is planning to do - the adrenal panel that tests for atypical cushings - i.e. the intermediate adrenal hormones - since Bella's other cushings tests have come back normal? Think it also says to send the sample on Mon-Thurs. They have some very specific submission guidelines for how to prepare and submit samples, which I assume your vet has already looked into. Also, there's a number you can call at the very bottom at that page and they can probably answer any questions. Not positive, but seems like the wait has usually been about 2, maybe 3 weeks, to get the results. Dr. Oliver, I believe, will send back a report to your vet with his interpretations/recommendations for treatment, based on results. Others may be along who've had the test recently that can tell you exactly how long they waited to hear back.

http://www.vet.utk.edu/diagnostic/endocrinology/general.php

I know our vet was in touch with the people at TN. They actually called him back while I was on the phone with him. He was telling me about the guidelines and such while we were deciding which day was the bets for her to come in and I was mistaken when I said Thursday. I meant Wednesday 6/9. She had been scheduled for a dental on Thursday 6/10 but we have postponed that so as not to stress her out too much.

She is going in at 7am so that he has enough time to get the samples frozen and FedExed. I guess two to three weeks isn't so bad. We are going out of town over 4th of July and Bella is staying in a kennel so I'd really rather not start her on any meds right before then and then leave her. I'd be so worried.

Thanks for the info. :)

[StarDeb55]

You want to make absolutely sure that the sample for UTK will arrive on Friday, if they blood is being drawn on Thursday. There is no one in the lab on weekends/holidays to receive FedEx shipments.

Debbie

[LuLuO]

You want to make absolutely sure that the sample for UTK will arrive on Friday, if they blood is being drawn on Thursday. There is no one in the lab on weekends/holidays to receive FedEx shipments.

Debbie

Thanks. I misspoke. The sample is being done on Wed 6/9 not Thu. :)

[LuLuO]

Our vet just left me a message and he said no doubt that Bella has Atypical Cushings. So now I'm off to do some searching on this board and elsewhere. I am expecting a call back tonight or tomorrow so we can further discuss the next steps. I'll get the exact numbers and such from him on Thursday when I take her in for ther Dental.

Any advice is appreciated.

[apollo6]

Just want to welcome you. I am new to all this also. You are in the right place. Don't be afraid to ask questions here and also your vet.
There are no stupid questions.

[BeachgirlK]

Good luck to you and Bella. I am currently undergoing lysodrene induction ("loading") with my Great Pyrenees Sonoma after undergoing many inconclusive tests just like you did. So far, it seems to be going well. I am home most of the time, so that is nice, but with two dogs, it is difficult to measure water consumption, especially during these hot months.

The posters here are a great resource and have been in valuable to me. Be sure to use this forum as much as possible!

~Karin

[LuLuO]

Our vet suggested Lysodren. I asked about Melatonin and he said that we could certainly try it but he feels that Lysodren is the better option. I admit that I am a bid scared of Lysodren even though I know it has helped in many cases. I am afraid to make the wrong choice for Bella.

Four years ago I made a decision regarding a treatment for my wonderful kitty that, in retrospect, was the wrong decision and he suffered because of it. A completely different situation, but I am a bit gun-shy.

Below are her numbers. Any advice would be much appreciated.

Test / Baseline / Normal Range / Result / Normal Range

Cortisol - 42.0 / 2.1 - 58.8 / 187.4 / 65.0 - 174.6
Androstenedione 1.7 / 0.05 - 0.57 / >10 / 0.27 - 3.97
Estradiol 82.7 / 30.8 - 69.9 / 81.2 / 27.9 - 69.2
Progesterone 0.21 / 0.03 - 0.49 / 2.6 / 0.10 - 1.50
17 OH Progesterone 0.26 / 0.08 - 0.77 / 4.62 / 0.40 - 1.62
Aldosterone 49.6 / 11 - 139.9 / 288.0 / 72.9 - 398.5

Moderator's Note: I have merged your new thread with Bella's UTK panel results into Bella's original thread. We normally like to keep all posts on one pup in a single thread as it makes it easier for other members to review the pup's history. I have also modified Bella's thread title to indicate that the UTK panel results are in. If you would like another title, please feel free to PM me or another member of the administrative staff & we will be happy to do that for you.

Debbie

[apollo6]

wait until the senior member give you input.

[LuLuO]

wait until the senior member give you input.

Oh. Okay. Sorry.

[frijole]

Dr Oliver is known world wide as an expert in atypical cushings. He usually reviews the tests that are sent in and his comments are on the bottom of the results. He makes specific recommendations to vets for treatment based on the results. I trust what he says.

What I don't know is whether or not your vet is following Dr Oliver's recommendation. Did you get a copy of the test results? If you do, get the sheet with Dr O's comments and recomendations. Read them. If they match what your doc is saying - then you can sleep well at night. :)

When lysodren is recommended for atypical cushings, it is because all or most of the sex hormones are elevated. Lysodren is the only drug that I know of that can treat all. Flax and melatonin only lower some hormones. Therefore you need lysodren. Also, usually with atypical the dosage is lower.

Can you tell us what the recommended dosage amount is for your dog as well as your dog's weight? When are you going to start treating?

Don't worry - we will help you!!! All will be fine. Kim

[StarDeb55]

As Kim has said, we would really like to see what the treatment recommendations are from UTK. The one thing I will comment on is that Bella's cortisol is only slightly elevated which should mean that you would only need a maintenance dose of lysodren, & not have to do a full blown loading. Has your vet said anything about maintenance dosing or having to load?

Debbie

[frijole]

:) Great minds Deb... I was just posting the same thing about the cortisol levels not being very elevated. So I am thinking a lower dose - not a true load is what is probably recommended. If so - this will be a piece of cake for you!! Lucky you!! Way less stress.. trust me - I've been thru this a couple times. :(:eek:;)

[LuLuO]

Thank you so much.

I have a copy of the results and there is an attached sheet that says "Treatment Option Considerations" and it lists 14 different things. The comments section of the results sheet states "Values are increased as indicated. Some veterinarians consider items 2-6, attached sheet, if symptomatic." So I guess that would be:

2. Melatonin
3. Melatonin Implants
4. Lignan
5. Maintenance dose of Lysodren
6. Lysodren

The vet does want to load her with Lysodren. If that is the path I choose then we will begin on the 8th of July (we are going out of town over the 4th so don't want to begin before then). She weighs 26 pounds and the script is for 500mg tablets - give 1/2 tablet twice a day for 9 days then as directed. On day 9 she would go back for another blood test to check that it is working.

Our vet is willing to work with me on whatever I choose to do. How would we go about just doing a maintenance does as oppposed to the loading? Dose? At what point would we do more testing to see if it is working?

Thanks so much.

[StarDeb55]

The dosage is within the acceptable range which is 25-50 mg/kg, to get to kilos divide Bella's weight by 2.2. This dose is 42.4 mg/kg. When it comes to loading, there is no set timeframe for a dog to load. Some dogs can load very quickly 2-3 days, others can take forever. Ask Kim about taking forever to load. This is where the owner's vigilance plays a crucial role. You will need to be looking for any change in behavior. For instance, for the pup who has been inhaling their food in 30 secs, they pause while eating to look at you, & it takes them a minute to finish. The signs can be very subtle. At the end of day 8 or 9, if you have not picked up on any loading signs, then it is very important to get that ACTH to see where you are, because you don't want to risk an overload.

Maintenance dosing on lysodren is very simple. You take the total daily dose & spread that out over 2-3 day during the week. For a loading dose of 500 mg., you could give 1/2 tab on Mon, 1/4 tab on Weds. & Friday, I'm not totally sure about the appropriate time frame to recheck when starting with just maintenance dosing but making an educated guess, I would say no longer than 1 month. When using lysodren, whether loading or maintenance, it's critical that your vet give you prednisone to have on hand, in case you suspect that Bella may be suffering from a low cortisol emergency. Signs of low cortisol emergency would include nausea, diarrhea, vomiting, & lethargy. I have now treated 2 pups with lysodren & I absolutely would not ever be without prednisone. This is especially true if you do not have an emergency clinic close by.

IMO, as slightly elevated as Bellas's cortisol is, I would want to try maintenance dosing first. Your dose is toward the high side, & you don't need to erode very much of the adrenal cortex. I'm thinking maintenance dosing will get the job done. If she were my dog, I would be very hesitant to do a full blown load at this point in time. Loading can be rather nerve wracking, even after you have had to go through it several times.

Debbie

[frijole]

I would tend to agree with Deb... but I'd really like to hear from someone who has an atypical dog for their input...

Tell us again what Bellas symptoms are. You mentioned appetite. What else?

[StarDeb55]

Kim, that would be me, but Harley had a major elevation in cortisol.

Debbie

[addy]

thought I would chime in, not sure if it helps anyone, but Zoe was just diagnosed wiith typical and atypical. I did not get a copy of the sheet with the 14 options but her report said at the bottom

These results indicate presence of increased adrenal activity. (SIGNIFICANT)
Comments: Values are increased as indicated. Some veterinarians consider items 1-6, 8 on sheet (scanned), if symptomatic. Various
treatment options attached for your consideration. So they seemed to have recommended same first six options for Zoe except for #8, which I don't know what that is. Waiting for Dr.Oliver to get back from vacation.

if you want to compare

her values were:
Test: Result: Normal Range** Result Normal Range**
(post ACTH)
Cortisol ng/ml 47.7 2.1-58.8 304.4* 65.0-174.6
Androstenedione ng/ml 1.05* 0.05-0.57 7.69* 0.27-3.97
Estradiol pg/ml 114.8* 30.8-69.9 102.2* 27.9-69.2
Progesterone ng/ml 0.99 0.3-0.49 5.91* 0.10-1.50
17 OH Progesterone ng/ml 1.18* 0.08-0.77 20.33* 0.40-1.62
Aldosterone pg/ml *** 33.9 11-139.9 357.1 72.9-398.5

she was very stressed that day, they had to muzzle her. never had to do that before.

IMS wants to load with low dose lysodren, acth after 7 days.

Thought is was interesting they said same options for a dog with typical and atypical.

Zoe symptoms are rat tail, alopecia, tires out easy and wants to lick everything and chew. Also has thin skin on belly.


Addy

[StarDeb55]

Addy, thanks for the input. Unfortunately, Zoe has a very significant elevation in her cortisol which will require a lysodren loading. Bella's elevated cortisol is very slight, so it may not be necessary for Bella to have an all-out load. My Harley & Zoe's UTK panel results are quite similar & Harley had to loaded.

Debbie

[addy]

I understand. I thought it might help Bella's mom to recognize not loading may be better for her as it helped me look at her test results and confirm in my mind, zoe needs to load :)

sometimes a visual helps for me

also thought the licking was interesting, i never realized it could be because they think they are hungry!!!!!

Addy

[frijole]

Kim, that would be me, but Harley had a major elevation in cortisol.

DebbieSorry Deb! :D I have oldtimers disease and sorry did not remember dear Harley was atypical... forgive me. :o

[LuLuO]

Thanks so much for all of the responses. We do have a script for Prednisone. We also have two 24-hour emergency clinics within 15 minutes of the house and our vet office takes care of their own emergencies until 10pm.


I would tend to agree with Deb... but I'd really like to hear from someone who has an atypical dog for their input...

Tell us again what Bellas symptoms are. You mentioned appetite. What else?

Her ALT level was above 1300 (up from 400+ last year). She has a ravenous appetite. She gobbles her food up in less than a minute and will steal food if given the opportunity. She is constantly searching for dropped food and crumbs and licking the floor. We monitored her water intake for 10 days and she averaged 4 cups of water a day. Panting. Weakness in her back legs and often needs to be carried up the stairs or she will fall, especially if she's been laying down for a while (this has gotten worse in the 3-4 months). Oddly enough, even with the weakness, she can still take off after a squirrel in the yard. :) But after short bursts of running, she's done. She is between 12 and 14 years old though so it is hard to know if that is due to the Cushings sypmtoms or her age.

In the LDDS she supressed everything just fine which is why we did the testing through TN.

Though I know very little, other than what I've read on this forum and what our vet has discussed with me, I saw that the coritisol didn't look very elevated which also makes me leary to load her on the Lysodren. I'm am very concerned about throwing her into Addison's Disease, which our vet said is often worse than Cushings.

I have a great trust and respect for Bella's veternarian and the other veternarians in the practice. They are honest, straightforward, and willing to explore alternative treatment options if that is what the client wants for their pet. The vet who is currently treating Bella has several other cushings patients and he says all are doing well on Lysodren. He mentioned Trilostane but said that after attending a conference a few months back he is not sold on it though he said it has been used in Europe for quite some time. Bella is the first patient to have any testing done through TN. Not because they didn't suggest it, but because clients declined it. With that being said, I hate to question his suggested course of treatment, but I would do this with any treatment suggested for myself or anyone in my family.

Thanks again for all of your responses. :)

[LuLuO]

I should also add that the results on the paper from TN said:

Indicate presence of increased adrenal activity. (moderate)

I guess that is apparent from the numbers though.

[Bichonluver3]

Chloe has Atypical Cushings and her cortisol is within range. She has been doing well on Melatonin 3mg twice a day and ground flax hull lignans 1/8 tsp per day (1 mg per 1lb body weight as recommended by Tennessee. Extreme thirst, hunger and urinating are gone. her coat seems to be improved. She does do mild panting, at times, but not the heavy, constant panting she was doing. BTW, we live in the desert and, right now, we are all panting. She is also on a low residue diet.
Carrol

[Harley PoMMom]

Her ALT level was above 1300 (up from 400+ last year).

Could you double check that for me...was it her ALP (Alkaline Phosaphatase) level that was 1300 and not the ALT (Alanine Transferase). Just want to make sure that we all are on the same page! ;):) Thanks!

Love and hugs,
Lori

[LuLuO]

Could you double check that for me...was it her ALP (Alkaline Phosaphatase) level that was 1300 and not the ALT (Alanine Transferase). Just want to make sure that we all are on the same page! ;):) Thanks!

Love and hugs,
Lori

I am almost 100% certain that it was ALT. I will call the vet on Monday to double check. Thanks. :)