Tippy (12 y/o IG/Dachshund Mix) - Pancreatitis/PDH?

[hunt323]

We have been on here for awhile researching cushings. There is a wealth of information and alot of good advice.

We have a 12 year old mixed IG/Dachshund who was diagnosis ed with Cushings about 2 years ago. It started with a bout of pancreatitis where she was given an IV and since then a few bouts every year. She does not seem to have the classic signs of cushings. She does drink periodically a lot of water, but not everyday, normal urine and no accidents in the house, she does pant but usually only when she gets nervous or hot, no potbelly, normal hair and most of the time she is able to jump without any problems. The only positive sign is her bouts with pancreatitis.

In 12/08 she had a LLDS test with the following results:

Pre-dex 6.9 range 1.0-6
post 4hr 1.4 range less than 1.5
post 6 hr 3.6 range less than 1.5
diagnosis PDH

Her ACTH Cortisdol test was done in 8/10 (since our vet wants to start putting her on trylostane)

Pre ACTH 3.8 range 2-6
Post ACTH 21.1 range 18-22
Triglycerides 399 range 20-150
Spec cPL > 1000 range >400
diagnose consistent with pancreatitis and PDH

So here is our basic questions, if we were to start treatment would it prevent the symptom or due you wait for more symptoms? The vet is pressing us to start the meds and also leads us to believe that treatment would reduce the pancreatitis bouts.

[Franklin'sMum]

Hi and welcome to you and your pooch :)

Her latest ACTH result is within the normal ranges (albeit the post result is at the upper end). With her trigs and spec cPL, is she on a low/no fat diet? Was this test done after a fast (ideally 12 hour fast)?
Was there any other tests (cbc, profile, etc) where there were results out of the normal range?
When my little boy was diagnosed last year, at that time I had only read the expected life span of an untreated cush pup, and I jumped the gun and started him on trilo. My vet at the time was not cushings savvy, and I was clueless. When I found these wonderful people here, they held my hand through my panic attacks, and educated me. I owe them my baby boy's life, and I will forever be grateful to each and every one of them.
We did further testing, and an ACTH assay revealed PDH, U/S revealed PDH. so we continued on trilo at a reduced dosage. Earlier this year, I took him off trilo, and we managed to get the adrenal hormone panel done (at University of Tennessee, Knoxville). The results were high normal cortisol, and 4 of 5 intermediate hormones elevated. We've been doing melatonin and lignans since mid July, and I got him stimmed last month- the cortisol was down to within normal ranges. That may just be Franklin, though. Each pup reacts to each thing differently.

Most vets won't start treatment unless the pup has strong symptoms. If you little girl seems well and happy in herself, and not uncomfortable in any way, if I was you I'd speak to the vet about trying melatonin. It can (not always) reduce cortisol levels. Usually not to the extent that the main drugs lysodren/ mitotane or vetoryl/ trilostane do, but it may help.
Melatonin is naturally in the body, and I don't know of a pup who has reacted badly to it. Some do get sleepier than usual, but that seems to be about it.

IMO, if she doesn't have symptoms (aside from the pancreatitis), I personally wouldn't begin trilostane. Does she get stressed going to the vet's office?

Could you please tell us how much your girl weighs, and what dose the vet wants to put her on (if the dose has been mentioned)? If she was having an active bout of pancreatitis at the time of the testing, that can also skew test results.

Others will be along shortly to ask more questions :) Look forward to hearing more about your girl, and please read the improtant information for new members in the resources section and ask heaps of questions. We'll do our best to help you understand your options

Jane, Franklin and Bailey xxx

[Harley PoMMom]

Hi and welcome to you and your precious girl from me and my boy Harley! Cushing's can be a very hard disease to diagnose that is why strong symptoms are a huge part of the diagnosis.

Non-adrenal illnesses, like pancreatitis, can create false postives on Cushing's tests, so with that in mind and if it were me, an ultrasound would be the next diagnostic test that I would have done.

An ultrasound, done on an optimal machine and read by a qualified person, can tell alot about the pups internal organs, especially the adrenal glands.

My Harley has pancreatitis too, and is on a formulated diet for this. He gets fed several small meals throughtout the day and his diet is very low in fat. Is your pup on a low-fat diet? How much does your girl weigh?

We are here for you and your girl, remember that, you're not alone on this journey. Ask all the questions you want and we will try our best to answer them.

Love and hugs,
Lori

[jrepac]

Based on those test results, I'm not sure how/why your vet is diagnosing PDH cushings disease....seems "borderline" to me. And, since you say there are no symptoms, why the rush to treat w/trilo. I too, went thru the "borderline" phase for about a year, but also had obvious symptoms (urine accidents, UTIs, belly sag, dark skin, etc.). One of the vets wanted to start lysodren and I said absolutely not...but, we did start on generic anipryl (a less powerful, and likely less efficacious drug). A year later, got a confirmed Cushings diagnosis from UTK w/elevated hormones as well...so we have added melatonin & lignans to the regimen.

Anyway, my point is, that this does not seem 100% cushings to me.

[littleone1]

Corky and I also want to welcome both of you.

I agree with what others have said. If there are no symptoms of Cushings, I wouldn't treat it. When Corky was diagnosed with Cushings, I wasn't able to start the treatment because he was taking two antibiotics. His symptoms actually went into remission for 7 months. His IMS recommended that we didn't treat it if there weren't any clinical signs. Once the signs appeared again, with the tests that were done, I started giving Corky Trilostane. Along with his test results and the U/S, Corky was definitely diagnosed with adrenal Cushings.

I know this can be very confusing at times, but we're all here to help you and your furbaby.

Terri and Corky

[labblab]

Hello from me, and I want to "second" Lori's suggestion that you consider an abdominal ultrasound prior to starting trilostane treatment. Your dog's LDDS is indeed consistent with pituitary Cushing's. But as has already been said, the LDDS is more vulnerable than the ACTH to registering an abnormal result due to other, nonadrenal illnesses as well -- such as pancreatitis. It is true that Cushpups are prone to pancreatitis attacks, but pancreatitis can certainly arise in dogs who do NOT have Cushing's. So without other typical Cushing's symptoms, I would not feel comfortable starting treatment without further confirmation of the diagnosis. And I do think the ultrasound would be a really useful tool in that regard.

Marianne

[hunt323]

Wow, what a quick response, thanks to everyone. I'll answer a few of your questions.


Her latest ACTH result is within the normal ranges (albeit the post result is at the upper end). With her trigs and spec cPL, is she on a low/no fat diet? Was this test done after a fast (ideally 12 hour fast)?
Was there any other tests (cbc, profile, etc) where there were results out of the normal range?
We have had her on a low fat diet for the past 2 years, additionally, we have been feeding her small meals every 3-4 hours to help with the pancreatitis. She did fast for 12 hours prior to the test. Also, she does get very nervous and begins panting when we take her to the vet. I believe this may affect results.


Was there any other tests (cbc, profile, etc) where there were results out of the normal range?
We do have several CBC results that I can post later this week, but her liver enzimes are high and her lipase is high.

Also we did have an ultra sound done and I will post the results later this week. ( we are out of town and the results are at home)


Could you please tell us how much your girl weighs, and what dose the vet wants to put her on (if the dose has been mentioned)? If she was having an active bout of pancreatitis at the time of the testing, that can also skew test results.

She weighs about 16 lbs and at the time of the test she was displaying any signs of pancreatitis. Also she usually does have a good appetite sometimes a little too much.


We've been doing melatonin and lignans since mid July, and I got him stimmed last month- the cortisol was down to within normal ranges. That may just be Franklin, though. Each pup reacts to each thing differently.

We are not familar with melatonin, will have to do more research on this.

Once again thanks,

Bob, Cindy, Tippy (our sick girl) and Woofy (9yr old IG)

[labblab]

That will be great when you have the chance to post the actual CBC and ultrasound results. Elevated liver enzymes are a common finding in Cushpups. And if Tippy's ultrasound happened to reveal that both her adrenal glands are enlarged, that would also be indicative of pituitary Cushing's. So this additional info will all contribute to confidence in the diagnosis.

Marianne

P.S. I took the liberty of editing your thread title so as to include additional info about Tippy :). But if you should ever like the title changed in any way, just let me or any other Administrator or Moderator know and we can take care of that for you.

[gpgscott]

Welcome,

You have already been given good advice, the fact of the chronic pancreatitus makes the LDDS suspect but the results of the ultrasound should help clear that up.

Looking forward to hearing more when you get home.

Scott

[Harley PoMMom]

We do have several CBC results that I can post later this week, but her liver enzimes are high and her lipase is high.
Bob, Cindy, Tippy (our sick girl) and Woofy (9yr old IG)

Lipase is non-specific because there are digestive lipases, intestinal lipases, lipoprotein lipase and hepatic lipase, hormone-sensitive lipase, and lysosomal acidic lipase.

The spec PL tests for the lipase that is specific for the pancreas only. One time I had Harley's amylase and lipase checked the same day I had a spec PL test done. Harley's amylase and lipase were both with-in the normal ranges but his spec PL was 464 (0-200.)

Here is some information about this test:
The Spec cPL® Test is a revolutionary test that allows you to quickly and confidently rule in or rule out pancreatitis in dogs.

With more than 95% specificity and sensitivity, this test far outperforms other test methodologies so you can treat confidently.
http://www.idexx.co.uk/animalhealth/laboratory/speccpl/
http://www.idexx.com/view/xhtml/en_us/smallanimal/reference-laboratories/testmenu/innovative-tests/spec-cpl.jsf?SSOTOKEN=0

Here are some links to a couple articles about pancreatitis that I hope you will find useful:

http://www.idexx.com/pubwebresources/pdf/en_us/smallanimal/education/diagnosing-treating-pancreatitis-roundtable.pdf

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

We are here to help in any way we can, looking forward to hearing more about Tippy.

Love and hugs,
Lori

[hunt323]

Sorry not to get back with the Ultra sound and CBC results sooner.

On 8/10/10 her ultra sound assesment was as follows:
1. Bilaterally symmetric adrenal glands upper nomal in size-consistent with PDH (along with previous LDDST) vs normal(and false positive LDDST)
2. Kidneys r/o nephrocalcinosis/nonobstructing nephrolith +/- mild pyelonephritis left kidney
3. Intra abdominal mass r/o lipoma, liposarcoma, other
4. Elevated ALP>>ALT=r/o cushings, othervacuola hepatopathy, nodular hyperplasia, primary hepatobiliary disease
Last CBC
8/5/10 2/8/10
RBC 8.10 8.3 range 5.50-8.50
HCT 54.9% 57.7 37.0-55
HGB 19.1 18.7 12-18
MCV 67.7 69.9 60-77
MCH 23.62 22.59 18.5-30.0
MCHC 34.9 32.5 30-37.5
RDW 15.6% 15.7 14.7-17.9
%RETIC 0.7 0.4
RETIC 57.3 36.3
WBC 7.98 10.06 5.50-16.9
%NEU 70.4 73.2
%LYM 18.4 15.0
%MONO 8.5 7.7
%EOS 2.1 3.7
%BASO0.6 0.4
NEU 5.61 7.36 2.0-12.0
LYM 1.47 1.51 0.5-4.90
MONO .68 .78 0.3-2.0
EOS .17 .37 0.1-1.49
BASO 0.05 0.04 0-0.10
PLT 489 399 175-500
MPV 11.49 13.09
PDW 19.8 20.1
PCT 0.6 0.5
BUN 17 16 7-27
CREA 1.0 1.1 0.5-1.8
CA 10.8 11.4 7.9-12
TP 6.9 7.0 5.2-8.2
ALB 3.6 3.7 2.2-3.9
GLOB 3.3 3.3 2.5-4.5
ALT 169 222 HIGH 10-100
ALKP 968 784 HIGH 23-212
TBIL <0.1 0.6 0-0.9
CHOL 274 284 110-320
AMYL 1280 771 500-1500
GLU 101 103 70-143
NA 157 157 144-160
K 5.7 5.0 3.5-5.8
CL 117 118 109-122

As I mentioned before, she really does not have any strong symptoms other than pancretitis bouts occasionally. ( The low fat and small meals every 3-4hrs seems to help.)

Our vet poistion is why wait for the symptom to develop, we should treat her now. My understanding is that trylostane only treats the symptoms and not the disease. Will it help with the pancretitis and should we start the treatment or wait?

[Squirt's Mom]

Hi Bob and Cindy, and welcome to you and Tippy! :)

Trilostane and Lysodren both treat the cause of Cushing's, which is elevated cortisol. They work in different manners, but both do treat the condition by controlling the release of cortisol.

If Tippy were my pup, I would not start treatment right now for Cushing's. My priority would be the pancreatitis and possible abdominal mass. In the first place, the stress from an inflamed pancreas could skew the tests for Cushing's since the body will naturally release excess cortisol and other hormones in response to any stress. Also, the Cushing's tests that she has had so far are borderline, in fact, the ACTH is within normal range. The LDDS does seem to indicate PDH but the LDDS is known to show false-positives in face of non-adrenal illnesses - like pancreatitis.

I understand your vets thinking in wanting you to start treatment to help the pancreatitis. Cush babies are prone to pancreatitis...however, not all pups with pancreatitis have Cushing's - sometimes it's just the pancreas.

Another thing that caught my eye is this on the ultrasound report -


3. Intra abdominal mass r/o lipoma, liposarcoma, other

IF I am understanding this correctly, they saw a mass of some sort in the abdomen. If this is right, then this mass would be another source of stress for Tippy also causing release of cortisol. My Squirt was originally diagnosed with PDH based on five Cushing's specific tests but a splenic tumor was found also. Once that was removed, her cortisol returned to normal making that original diagnosis of PDH "highly questionable."

For all of these reasons, I would take my time and make sure Tippy actually has Cushing's before starting Trilo or Lyso.

Just my 2 cents worth from the peanut gallery!

Hugs,
Leslie and the girls :D - always

[Harley PoMMom]

Hi Bob and Cindy,

Welcome from me and my boy Harley! On your U/S report there are some things that are concerning me as well.


Kidneys r/o nephrocalcinosis/nonobstructing nephrolith +/- mild pyelonephritis left kidney

Nephrocalcinosis is a condition characterized by calcium salt deposits in the kidneys which may affect it's ability to function.

Nonobstructing nephrolith is a stone that has formed.

Mild pyelonephritis means that the left kidney has a mild infection.

Did your vet address any of these issues?

We are here for you and Tippy so please ask all the questions you want, ok?

Love and hugs,
Lori

[apollo6]

Welcome Bob and Tippy and your family.
Apollo is a 12 year old dachie, weighs 10 lbs. He probably had cushings for over a year or more before he was diagnosed.
Symptoms: hair loss on tail, ears, both sides of body, ingrown hair, skin liaisons , dark skin, pot belly, sores that would not heal, extreme increase in thirst.
Apollo has had buts of pancreatitis his whole life.
I did the tests: full blood panel, urinalysis, ultrasound of his abdominal to determine which cushing he had-there are three kinds. It took me a long time before I decided on treatment. Apollo is on Trilostane and is doing well, seen a lot of improvements, but may have other issues. This is a very tricky disease. Don't jump into treatment until you are really sure. I don't understand labs, but others will be able to give you input. If Tippy is doing well for now , don't jump into treatment right away.
Sonja and Apollo.

[hunt323]

The abdominal mass was biopsied and turns out to be a fatty mass. With respect to the kidneys, the vet didn't even mention it since I think she was intense on the cushings diagnosis. Is this something we should address with her?

Thanks for the responses, it makes me feel more confident that maybe I should wait to start the treatment until more signs appear.

[apollo6]

dear Bob
an ultrasound of the abdominal would show if one or both adrenal glands are enlarged. Not sure if you had one done. The ultra sound would show if the kidneys are enlarged , also the liver and scaring on the pancreas from repeated buts of pancreatitis. these are the organs that can get effected by the over production of cortisone in the body resulting in elevated reading in these categories. I am not experienced in reading, but some of the other members can give you more input.
Take it slow.

[Harley PoMMom]

With respect to the kidneys, the vet didn't even mention it since I think she was intense on the cushings diagnosis. Is this something we should address with her?

Thanks for the responses, it makes me feel more confident that maybe I should wait to start the treatment until more signs appear.

I would definitely bring this to her attention, Trilostane is generally not used in pups with liver or kidney problems and Lysodren should be used cautiously in pups with liver or kidney problems.

Love and hugs,
Lori