Is ACTH Testing Necessary?

[Paris]

My 13yr. old wire haired dachshund Parker spent 4 days hospitalized with Pancreatitis during which time they began to suspect Cushing's. She has all the classic symptoms, as well as poor clotting factor which I have not read anywhere is a symptom. They did an ultrasound which showed Parker has tumors on both adrenal glands which reinforced the Cushing's diagnosis, and would seem to indicate it is the adrenal variety. Am I correct in understanding that the ACTH test is to diagnose the pituitary type of the disease, and if so would this be called for when ultrasound has clearly shown tumors on the adrenal glands? Is any further testing necessary to confirm Cushing's before beginning treatment?

[labblab]

Paris, welcome to you and Parker. I surely hope that Parker is recovering from her acute pancreatitis attack, and perhaps is back home with you again?

I am just going to throw out a few thoughts of my own to you in response to your question, and I'm sure that others will also be by as well. As you may already know, the ACTH is one of two blood tests that are commonly used to diagnose Cushing's. The other is the LDDS (low dose dex test). The ACTH is also used as a monitoring tool to judge the effectiveness of either Lysodren or trilostane treatment once Cushing's of either type has been established and one of those two medications is administered.

One of the drawbacks to the ACTH as a diagnostic tool is that it does a poorer job than the LDDS at identifying dogs who suffer from the adrenal form of the disease. Dogs with adrenal Cushing's MAY return a "positive" result on the ACTH, but they often will not. So if Parker is suffering from classic symptoms and you already have evidence of adrenal tumors from the ultrasound, then I personally don't think the ACTH would be the diagnostic blood test of choice. With classic symptoms and firm evidence of adrenal tumors, I don't even know whether an LDDS would be all that helpful right now. It is more easily affected by other, nonadrenal illnesses. So if Parker is just now recovering from acute pancreatitis, one might expect that she could have a "positive" LDDS result just from the effects of that illness alone. A general strength of the LDDS, however, is that if a dog tests "negative," you can place a high degree of confidence in concluding that the dog does not have Cushing's.

Give the presence of the adrenal tumors, what is your vet suggesting as a treatment plan? Was Parker hospitalized at your general vet's practice (and the ultrasound performed there), or has she been seen by any specialists thus far? The reason why I am asking is because I am guessing that you will really want to make sure that any further imagining of her adrenals be undertaken with the most sophisticated equipment possible, and with specialized interpretation and feedback regarding treatment options. So any more info that you can give us in that regard will be really helpful.

Thanks so much in advance,
Marianne

[Paris]

Parker is back home. The ultrasound was done at an emergency hospital (not her regular vets), which is 3 months old, and I believe has state of the art equipment. I have since visited her regular doctor to re-do some of the tests to make sure the Pancreatitis is in check (which it is), and talk to her about the next step. Parker's vet is not a specialist. She seemed to think the ACTH test should be done to confirm Cushing's. She is going to consult with the doctor who performed the ultrasound who is an internal specialist, and then I guess we'll talk about treatment options. She has talked to me about both Lysodren and Trilostane treatments neither of which sound particularly safe. I have to do something though as the symptoms seem to be getting worse everyday.

[Harley PoMMom]

Hi and welcome to you and Parker from me and my boy Harley.

Am I correct in understanding that the ACTH test is to diagnose the pituitary type of the disease

ACTH Stimulation Test: A blood sample is taken as a baseline. Then, a dog is given an injection of ACTH, the hormone which stimulates the adrenals to release cortisol. One to two hours later, blood cortisol levels are measured. Given that a dog with Cushing's has a constantly overworked, overproducing set of adrenals, the cortisol reserves are much greater, and the Cushingoid dog will be able to respond to the ACTH with greatly elevated cortisol output. This test doesn't differentiate between forms of Cushing's (adrenal vs. pituitary). It is considered diagnostic 80-95% of the time. Half of adrenal tumors will not respond on this test, and 15% of dogs with pituitary tumors will not respond. Nonetheless, it is an easy test and is often used along with a low dose dexamethasone suppression test to diagnose the presence of Cushing's disease. It is also used as a monitoring test for dogs who are being treated for Cushing's disease with Lysodren.
http://www.kateconnick.com/library/cushingsdisease.html

The ACTH stim test is used as a monitoring test for Trilostane/Vetoryl also.

80%-85% of of dogs with cushing disease have PDH while 10%-15% have ADH. Some dogs with cushings disease do have both, PDH and ADH.

Did Parker have a low platelet count? Was anything else on the lab report marked abnormal, if so, could you post those values here with the reference ranges and the units of measurements.
How much does Parker weigh? And what are all of Parker's symptoms? I am sorry for all the questions but the more we know about your precious girl the better we can help you help her, ok?

Just remember you are not alone on this journey anymore, we are here for you and Parker.

Love and hugs,
Lori

[Harley PoMMom]

Did they do a spec PL to monitor her pancreatitis?

[StarDeb55]

Welcome to you & Parker! Marianne & Lori have gotten you off to a good start. I have a few other comments.


They did an ultrasound which showed Parker has tumors on both adrenal glands which reinforced the Cushing's diagnosis, and would seem to indicate it is the adrenal variety
Actually, this is considered to be bilateral enlargement of the adrenal glands, meaning both are enlarged which is consistent with a diagnosis of pit Cushing's, not adrenal. In adrenal Cushing's an ultrasound more commonly shows only one enlarged adrenal, with the other adrenal of normal size or sometimes even shrunken.


Am I correct in understanding that the ACTH test is to diagnose the pituitary type of the disease, and if so would this be called for when ultrasound has clearly shown tumors on the adrenal glands? Is any further testing necessary to confirm Cushing's before beginning treatment?
ACTH testing usually can't determine the type of Cushing's that the pup may have. The low dose dex frequently can determine this. The problem with the low dose dex is that it can generate a false positive in the face of non-adrenal illness. In Parker's case with pancreatitis, if any testing such as an ACTH or low dose was done, the results may be questionable because of the pancreatitis. Were either of these tests actually done?

IMO, if no Cushing's diagnostic testing was done except for the abdominal ultrasound, I would wait until Parker's pancreatitis has cleared up, have an ACTH done. If the ACTH is elevated, that result along with the ultrasound result should confirm the Cushing's diagnosis. From personal experience, this is all my Harley had done when he was diagnosed. The only difference was that his ACTH was actually the full adrenal panel from the Univ. of Tenn., Knoxville which checks the cortisol level, along with the 5 associated sex hormones that the adrenals produce.

If you are considering using trilostane, the ACTH would really be a necessity to get a baseline cortisol, so you & your vet can monitor how well the cortisol is being controlled, compared to the untreated levels.

Hope this helps.
Debbie

[StarDeb55]

I wanted to expand on the comments concerning the use of the ACTH or what we call a "stim test" to monitor either of the medications used to treat. Until your pup is stabilized on whichever medication you might choose to use, it will be necessary to closely monitor their cortisol level to insure that the medication dosage is appropriate. If the cortisol were to drop critically low, this can be a life-threatening condition, if not treated promptly. This why the routin monitoring of medication with stim tests is not a luxury but a necessity. Once stabilized on medication, the number of required stims decreases pretty dramatically, along with the expense. For instance, my Harley is on lysodren. My GP vet who manages his Cushing's requires that a stim be done every 4 months. As long as the pup is clincally well, some vets who are using lysodren will only require a stim twice a year. Of course, if there is any dosage change, a stim will be needed one month after the change to confirm that the dose of lysodren is appropriate.

I can't comment a whole lot on the frequency of stims with trilostane usage, as I have never used the drug. I do know that when initiating trilostane, a stim is needed at the 10-14 day mark. If that stim is within range, then the next one would be at 30 days because the cortisol will frequently continue to drop during the 1st 30 days with trilostane treatment. After that, I'm not sure as to the frequency.

Debbie

[apollo6]

Welcome, I am Sonja, Apollo, (11year old dachshund) read my thread-Apollo , Trioslane,
These are the tests I did
Sept 16, 2009-blood panel-showed elevated readings above normal
January 2010-ultrasound-adominal showed both adrenal glands enlarged almost equally, enlarged liver

May 25, 2010-blood panel
ACTH Stim Test-showed elevated cortisol
Blood pressure-normal(may be high in cushing pup)
Urinalysis-Antech-may show elevated readings
Urine Culture MIC
As you can see this was over a 9 month period. The symptoms, Apollo had that made me suspect something was not right: loss of hair on both sides of trunk, loss of hair on his beautiful ears, loss of hair on his tail, dark skin on his under belly, weakness in his hind legs, increase in thirst above normal. He also had buts of pancreatitis. He also has back problems. You are right , you need to determine what kind of cushing (PHD(pituitary tumor) adrenal tumor(if one is enlarged and other isn't) or Atypical.)he has, if he does. It can mask other problems.
Senior member will ask you to post the test result data, to give input. Also if you can you should go to an internal medicine specialist in endocrinology, and familiar with treating cushing. There are many forms of treatments. You don't have to make a decision right away, learn what you can about this disease, ask questions, listen to your gut feeling. We are here to support you through this journey.

[Paris]

I do not have Parker's test result numbers at this time. Her symptoms are that she is drinking double the water that she used to, her hair is thinned on her back, she is constantly begging for food, sleeps more than usual, has a pot belly, weakness in hind legs. The results of her ultrasound as explained to me are not that her adrenal glands are enlarged, but that there are tumors on them. I think it's a good idea to have the blood work tested at Univ. of Tennessee as that seems to provide the most comprehensive picture of exactly what's going on. I understand that ACTH testing is necessary down the road when treatment begins. I just don't see it's value at the present time to help me determine IF Parker indeed has Cushing's, and if so what type.

[labblab]

I agree with you that the Univ. of Tennessee testing may be the most efficient way to cover all your bases with a single stone. I believe they will peform a combined ACTH/LDDS/extended adrenal panel. That way, you'd have a pre-treatment ACTH baseline as well as the results on the LDDS and other intermediate hormones. This may give you a clearer picture of the activity that the adrenal tumors are generating.

The combined test is option 3(h) on this list of UTK lab tests:

http://www.vet.utk.edu/diagnostic/endocrinology/pdf/endo_tests_info_07.pdf

Marianne

[Paris]

Thank you all for your input.

Paris

[zoesmom]

Hi and welcome -

I think you are on the right track. Just to be sure that there are tumors on both adrenals and that it's not just a matter of bilateral enlargement, can you also ask for a copy of the ultrasound report and post the notes from it here? If it is two tumors, then they should have given the measurements of each in the u/s report. I'd also ask if the u/s was done using hi-resolution equipment. If not, that might be something further to consider, although if the tumors were clearly defined, maybe not necessary . . . . assuming you would use drug treatment approach. But I'd be sure to ask about what type of equipment was used. And knowing what was in that u/s report would definitely help to reaffirm that the adrenal diagnosis is correct..

Are you also aware that in many cases of adrenal tumors, surgery can provide a permanent cure? Depends on the tumor size/location, the dog's overall health, age, etc. If the dx is correct and that's something you would consider, then you should definitely discuss it with a specialist. Those kinds of surgeries are expensive, though, and for that reason, many opt to treat with drugs. Adrenal surgery should be done by board certified surgeons - usually those at teaching vet schools or with vet practices in large metro areas. Otherwise, the drug approach (lysodren or trilosane) is still a good option. Sue

[SavingSimon]

Not only can you get a copy of the ultra-sound results, if they have a good ultrasound machine, you can get a copy of the disc of the ultrasound - and that is way cool - you can look at the inside of your dog too. (Or maybe that's just cool to me - I'm weird like that, I watch my dog's surgeries and stuff). But still, YES. You have a right to every report and every paper that has ANYTHING to do with your dog. You paid for it, and it belongs to you just as much as those that did it, and usually they are more than happy to help out and give it to you.

[apollo6]

Just to let you know we are hear for you, the symptoms are the same as Apollo, but Apollo has lost most of the hair on his ears and tail. He does have hind leg weakness, gets tired more frequently.
Not sure what you mean about the tumors on the adrenal glands? On Apollo's ultrasound it showed both adrenal glands were enlarged within a cm of each other, meaning his is more likely a pituitary tumor. Like you , I did not want Apollo on either medications, it took me a long time before I could get myself to but him on Trioslane. He has been on it since June 25th, 10mg , weighs 10lbs, sometimes less. I wanted to go slow and not have him on a high dose, when reading about the drug. It is important you know which kind of cushing he has that will determine which treatment is best for him.

[Paris]

Pre - 10.9
4hr - 0.9
8hr - 0.9

Moderator's Note: Paris, I have merged your new post with Parker's low dose dex results into Parker'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 refer back to the pup's history, if needed.

[StarDeb55]

Paris, I'm pretty sure that these results are perfectly normal. One of the vet lab charts we use to help in interpreting low dose results shows that when both the 4 & 8 hr. results are <1, this is normal. I would like one or two of the other members to confirm my take on these results.

I reviewed Parker's thread, & I didn't notice if anyone has asked if diabetes & thyroid were ruled out? A lot of symptoms of these 2 problems will overlap with Cushing's.

If both of the above have been ruled out, I think the next logical step is a UTK full adrenal panel. All a low dose checks is the cortisol levels. Elevations in one or more of the associated sex hormones can cause symptoms that are pretty much identical to regular Cushing's.

Debbie

[lulusmom]

I would like to validate Debbie's interpretation of the LDDS results. Those results are normal. Since cortisol is normal and Parker is symptomatic, I would suspect that she has functional adrenal tumors and if you were to do a UTK adrenal panel, it's a safe bet to say that you're going to see elevations in a number of the intermediate hormones.

Is there any possibility that you would consider surgery for Parker, which could be a total cure? If so, I personally think the next logical step would be a consult with a board certified surgeon that has a lot of experience with adrenal tumors. If surgery is not an option, then a UTK adrenal panel will at least tell you which hormones the adrenal tumors are secreting. Hypertension is common with adrenal tumors so make sure your vet checks Parker's blood pressure.

Glynda

[Paris]

Just to clarify, I am Paris, and my dog is Parker. I would not consider surgery...for either of us!!! She is 13, and has tumors on both adrenal glands. Too dangerous, invasive, and I don't want to put her through that. May have a 2nd ultrasound done now that she's through the pancreatitis. Her vet wants to try Trioslane.

[lulusmom]

Just to clarify, I am Paris, and my dog is Parker.

I knew that but my gray matter ain't what it used to be. :D I've edited my post so as to prevent any confusion with members.

Trilostane inhibits the synthesis of cortisol and since the LDDS results say that Parker's cortisol is normal, I am concerned that your vet is suggesting Trilostane. Giving this drug to dog that does not have typical cushing's can have dire consequences. As I mentioned previously, it is most probable that the adrenal tumors are secreting intermediate hormones/steroids. Treatment for this would definitely not include Trilostane because with long term use, Trilostane always elevates one or more of the intermediate hormones. I would highly recommend that your vet contact Dr. Jack Oliver at the University of Tennessee to discuss Parker's case. Dr. Oliver is a world reknown expert on canine adrenal steroids/hormones and his invaluable time is free of charge. Neither you or your vet have anything to lose but Parker could have a lot to gain by getting an expert opinion. If this is something you think you'd like to do, your vet can reach Dr. Oliver by phone at 865-974-5638 and by email to joliver@utk.edu

[StarDeb55]

Paris, I would like to confirm what Glynda has said, it could have dire consequences to give a pup with a normal cortisol either of the 2 medications that are used to treat, trilostane or lysodren. I, too, strongly encourage you to talk to your vet about contacting Dr. O or you can contact him directly. He is absolutely wonderful, kind, caring, & simply wants to do the best for the pups. A number of us have e-mailed him directly with questions. He has always responded, & is usually very prompt about responding.

Debbie

PS- If possible, it would be very helpful for us, if you can get a copy of the ultrasound report & post the US findings for us.

[Paris]

A urine test has also come up negative for Cushing's. Parker's case has been reviewed by a board certified internist who will be doing a 2nd ultrasound to check for several other things, none good.

[lulusmom]

Hi Paris.

What urine test did the IMS do? Was it a urine cortisol creatinine ratio (UC:CR)? If so, adrenal tumors don't always secrete cortisol in which case the UC:CR would probably be negative for cushing's.