Mandy - Heart Attack and Cushing's Treatment?

[foxandhound]

Hi there, My name is Annie. My beagle, Mandy is an 11 y/o Spayed girl. She is vibrant, plays, runs, enjoys her walks, great skin and coat, normal thirst and urination. She has an great quality of life and she has always had that beagle appetite. She has hypothyroidism, which we treat daily. Aside from this, she is completely asymptomatic.

Well, we had her annual bloodwork done and her ALK levels were 6xs the normal range. We retested the bloodwork and the UR:CR ratio. This time, ALK was 6xs the normal range and the ratio was abnormally high. We basically had three vets weigh in...Vet A was our former vet (a little pricey), vets B and C work together at the same clinic, we saw them on different days.

Vet A said not to treat an asymptomatic Cushing's dog. He said to test to discern location and if it was adrenal-based, we could consider surgery. He said meds would be pointless and possibly damaging.

Vet B said that Dex-Meth Supression and chemotherapy must begin. I asked her what medications she recommended. She said she couldnt remember, but it started with an A...she did not indicate anything about the difference between the types of Cushing's or any difference in treatment. I asked if the meds pose any risks and she told me the greater risk was to not treat the dog.

Vet C suggested a sonogram and an ACTH test. She wold also like to treat an asymptomatic dog, she mentioned good success with Trilostane.

Ok. Can you sense my frustration. Where do I go from here? :( I will absolutely do further testing, but treatment? What's going on?

[foxandhound]

I should also add that my 2 year old Sheltie-mix had normal bloodwork and a normal urinalysis, but never had a urinalysis performed. So, we were pretty sure there was some type of mix-up. Vet C re-did his bloodwork and his GGTP levels came back as 4xs the normal range. Vet B called me to tell me this and she suggested an immediate sonogram. I told her that he was completely asymptomatic and I wondered if it was another bloodwork mixup. I asked why not a bile-acids test and she said it would probably be inconclusive. She said he may have a gall bladder blockage. I spoke again to Vet C and she said not to do a sonogram and instead to retest his blood in a month. What the heck? I would never want to forego a diagnostic on my little guy, but this conflict of opinion and information is painful. My Sheltie is also asymptomatic. :) :( :X

[HarrysMom]

We started seeing liver enzyme elevation with my Harry last December before we started seeing any symptoms (othehr than good appetite). We did an ultrasound first to rule out any other source of liver elevation. Our vet at that point said Cushing's was a possbility, but just to periodically do blood panel and recommended having Harry on Denamarin. When liver enzymes continue to elevate in April despite Denamrin, and Harry's hunger became worse, we went for Adrenal Panel which showed hyperestrinism, but not full Cushing's. We put Harry on melatonin and flaxseed lignans (Atypical treatment). The internist recommended LDDS test eventually, but only when his symptoms deteriorate because she did not want to treat a dog unnecessarily. It was only when Harry started to urinate and beg more that we pursued a LDDS test (last week). We are now going to do another ultrasound to see what kind of Cushing's.

If I had to do all of this again, I would have done LDDS back in April or earlier this summer rather than wait for now, but who knows. Hope this helps.



Yunhee

[frijole]

Hi Annie! I know your frustration firsthand. :D Those that specialize in treating cushing's agree with vet A. If they are symptomatic - hold off on treating. But treating cushing's is not a waste of time so I disagree with him. Vet B sounds really over their head and Vet C is more on course but... your dog hasn't been diagnosed with cushings!

All you have right now is blood work that indicates something is wrong and it could be cushings. Normally a series of tests and an ultrasound are done (on a high resolution machine). This way you can know which type of cushings it is and treat accordingly. So it is really premature to throw out drugs and discuss anything at this point.

There are other illnesses that could cause the high readings and it would be helpful to see the entire blood panel results before making any recommendation as to the next step. Could you post any readings that are high and low (& give us the range for normal)?

I'm sorry but I did not understand your second post about your other dog. Are they saying that dog has cushing's and not the first? :confused::p;)

Tell us all you can about your dog, any meds she is on or was on. Don't worry - you aren't the first to come here confused. There are vets with varying levels of experience and it seems you got caught in the middle. With a little more information I'm sure we can help you or at least answer some questions and help you manage your way thru this. Hang in there! Kim

[foxandhound]

I adore you guys and I am just so thankful for your responses. I am starting to browse the other threads and I see just how wonderful this forum is. Actually, I started crying reading some of them. It's really nice to know that I have somewhere where we can talk. Means a lot to me.

For Mandy, she had some protein in her urine, it is labeled as 3+.
ALT was 191 (range is 12-118), ALK was 773 (range is 5-131). GGTP was 12 (range is 1-12). Her BUN/Creatinine was 46 (range is 4-27). Her Uc:CR ratio was 36 (greater than 13 is consistant with Cushing's). She has a grade 4/6 heart murmur.

Mandy is on a homemade raw diet and has been for about 3 years. Lo-fat and skinned cuts of Chicken, Beef, Turkey, Lamb, Vension, organs, bone, veggies. She gets Soloxine 0.3mg 2x/day. She also gets sardine oil, salmon oil, Glucosamine, Milk Thistle, Sam e, Glycoflex, Honest Kitchen Sparkle, Berte's Zyme, Berte's Green Blend, Berte's Probiotics.

Is melatonin and flaxseed lignans supplements for liver problems and/or Cushing's? We just started the Sam e! Did your LDDS test not show what type of Cushing's? I guess it's not definite?

What do you mean by a high resolution machine, maybe not a portable machine? The sonogram DVM that Vet C suggested is mobile?

Foxy is my other dog, not Cushing's suspect. Maybe a bile-blockage candidate. I mentioned him because Vet B wants to sonogram him and Vet C does not. It's madness to go through this. He has a GGTP of 47 (range is 1-12) with no symptoms and no other deviations. I am really scared of this. He is as normal as ever...running, playing, eating, normal stool and urine. I thought I should bring him up and see what you guys could say about GGTP levels.

Foxy is on a similiar diet to Mandy, just a bit more fat content. His supplements are similiar, just no liver supplements. :)

[foxandhound]

Here are pics of them. Mandy was more overweight then, quite lethargic, and had grain allergies as well as skin/coat problems. Actually, that was before we discovered the hypothyroidism. Since then, she has been running, playing with a toys. A whole new dog! Still, here's some faces to the names.

http://doggy-biscuit.livejournal.com/239429.html

[HarrysMom]

I would pay attention to protein in urine along with BUN, creatinine and phosphorous (these are kidney values). What were your dog's BUN, creatinine and phosphorous? High BUN/creatinine ratio for people, at least, can indicate kidney failure, high protein diet, steroid meds, and urinary tract blockage among other things. Cushing's can cause proteinuria, but your dog could have some other kidney issues.

Given the liver values and proteinuria, if Mandy was my dog, I would pursue ultrasound. This would rule out any kidney and liver abnormalities, including tumor and cysts, etc.

Proteinuria can indicate a serious disease - in fact, my vets were always moroe concerned about my Harry's proteinuria rather than liver enzyme values. I would also do a urine protein / creatinine ratio - this test really tests for how much protein is in urine. You may also do a urinalysis to rule out any urinary infection because this, too, can cause proteinuria. There are other disease that could cause these symptoms such as lepto, tick borne illnesses (these two can cause elevation in liver enzymes along with kidney damage) as well as any inflammation in body. You need to make sure that proteinurai is not a sign of a kidney disease (glomerulonephritis or "GN"). You have to treat GN with low protein diet and some ACE inhibitors.

Have you also done a blood pressure test? Many dogs leaking protein in urine also have high blood pressure (along with Cushing's dogs).

I myself have waited all this year on LDDS test, so who knows if that was a mistake. However, I do regret not getting that done earlier.

I hope I don't scare you, but my Harry went through the exact same thing as your dog. No symptoms for both proteinuria (GN) and possible Cushing's other than some good appetite, protein in urine and weird liver values (and elevated cholesterol as well).

Yunhee

[foxandhound]

The BUN/CReatinine is elevated bc of her diet, according to the 3 vets, all said no big deal. Foxy's is a little elevated too. I didnt mention it because it's always been elevated and always associated with diet. Cholesterol is normal for both pups.

I'm not sure I understand this test...I have these values separately, can I divide to make a ratio? ;) I dont know.
"urine protein / creatinine ratio - this test really tests for how much protein is in urine."

Mandy's urinalysis was totally normal except for the 3+ protein. Her urinalysis last month had no protein. She has had bladder infections in the past. You guys are always one step ahead of me, huh? I asked the vet if this could be an infection and she said not likely. She gave us Clindamycin last month as a preventative measure and Mandy finished taking it 3 weeks ago. This bloodwork and urinalysis (showing protein) was done this week.

Is there blood pressure med on the market? We did not have a blood pressure test. No one offered one. How do we rule out Lepto, Tick Illness, Inflammation, and GN?

[frijole]

Wow I really enjoyed your album - lots of wonderful fun photos. I can tell you love and spoil your furry friends. :D We have albums here if you click on our names you can see our dogs photos.

Meanwhile onto your questions -

melatonin and flaxseed is used to treat dogs that have atypical cushings. not all dogs are diagnosed as atypical. 85% are diagnosed as having pituitary cushings. There is also adrenal cushings. All of this is found and discussed in great detail in our reference section.

I mentioned the high res ultrasound because not all vets have the quality needed and the experience reading the films that you would want. Getting an ultrasound helps the vet know what's going on inside with the organs.

Sonograms are not the same as ultrasounds - not as detailed so you don't get as much information from the reading. The ultrasound will look at all of the organs and you can tell if there are tumors or other issues going on.

FYI lots of dogs, including mine had alk phos levels of over 2000 so 700 is not too bad. ;) What stands out to me is the bun/creatine readings which can be caused by pancreatitus, kidney and other issues. The comment re the Uc:cr test was interesting - it can be used to rule out cushings but NOT to diagnose it. Does your paperwork actually show that at 30 it is classified as cushings?

Given what you have shared and the fact your dog is active very healthy I do think that an ultrasound would be a good next step. I am kind of surprised that the vets all 3 went down the cushings path so quickly. Are you in a city where there are specialists? If so I would probably go that route to assure you have someone with a tad bit more knowledge reading the ultrasound.

Kim

[foxandhound]

Ok, so atypical is the one caused by vet intervention, setroids, etc?

I am so sorry I keep calling it a sonogram. It is an ultrasound done by a DVM-internist ultrasound specialist mobile-guy? How can I be sure he has the equipment we want? Should I get his contact info and ask him? lol. The funny thing is, vet C, my normal vet will not be able to be there. Only vet B can be present and this bothers us immensely. Why would vet C schedule it on a day she wouldnt be there? :(

The labwork says "consistant with Cushing's, but not indicative."

What tests could show us if there is pancreatitus, kidney and other issues? I guess the ultrasound. Maybe both dogs need it. I have actually shown that Bun:Cr ratio to 4 vets and no one thought anything of it bc of the diet. Is this a dangerous value?

I am in Deerfield Beach/Boca Raton, Fl.
The Ultrasound is quoted at $380 for the first dog and $325 for the second. $85 for the LDDS test. $300 for ACTH test. Is this reasonable pricing? Money is an issue. We dont have much. :(

ps. the albums are so cute. :) I will make one too. I like this place!

[BestBuddy]

Hi Annie,

I just wanted to welcome you ,Mandy and Foxy too. Your pics are great and just looking at their faces made me smile.

It looks like you are still trying to get diagnosis and until you get a definite positive for cushings then you don't treat.

Jenny

[mytil]

Hi and welcome from me too.

There are several tests that need to be performed to get a positive diagnosis for Cushing's and I am a bit worried when I hear that a dog is showing no clinical signs (symptoms) and the tests were not performed but let's start treatment.

Here are some great sites http://www.k9cushings.com/forum/showthread.php?t=180 that go into more detail about the different testing etc.

In my opinion I would not start any medical treatment.

Terry

[labblab]

Hello Annie!

After re-reading your original post, I'm feeling a little confused and just want to check on a couple of things. I'm thinking that none of your vets are actually recommending that you proceed with treatment without additional testing of some sort. Is that right, or am I interpreting things wrong?

It sounds as though Vet A wouldn't medically treat a dog without symptoms, regardless (but would consider surgery if an adrenal tumor were found via more diagnostics). Is it the case that Vet B is first recommending a Low Dose Dex Test (LDDS), and if that is positive would then move forward with treatment (perhaps with Anipryl?) regardless of outward symptoms? And that Vet C is recommending an ultrasound and ACTH test and if those indicate Cushing's, she would treat with trilostane regardless of outward symptoms?

It also sounds as though an ultrasound has already been scheduled (on a day that only Vet B will be present). But maybe you are wondering whether an ultrasound is the best "next step" as opposed to one or more diagnostic blood tests? If I'm understanding this wrong, please let me know (cuz it sure wouldn't be the first time that I've been addled :o :p). But I want to try to make sure that I've got the big picture in my head before writing any more.

Marianne

[frijole]

Here is an article on atypical cushings from our resource section.
http://www.k9cushings.com/forum/showthread.php?t=198

I have never had to deal with kidney or pancreatitus issues so hopefully one of our members that has can tell you if there are any specific tests for that but certainly an ultrasound will get you what you need. And I am sorry for confusing you.... I was thinking CT scan when you said sonogram. FWIW "Ultrasound" is the procedure, and "sonogram" is the image produced from an ultrasound.

To find out if the machine is high resolution - just ask. They should know. Most regular vet offices cannot afford to have one and therefore send their patients elsewhere (to specialists) when they want the best images.

I used to live in Lighthouse Point! Sorry I can't recommend a vet - too many years ago. But here is a site to find specialists should you want to check into that.

http://www.k9cushings.com/forum/showthread.php?t=182

I paid $500 for an ultrasound (but it was on a high res machine at a specialists' office), $100 for the ldds and $125 for the acth test. Prices vary alot and I'd say the only one out of line that you mentioned is the acth at $300. Kim

[foxandhound]

I'm thinking that none of your vets are actually recommending that you proceed with treatment without additional testing of some sort.
It sounds as though Vet A wouldn't medically treat a dog without symptoms, regardless (but would consider surgery if an adrenal tumor were found via more diagnostics). Is it the case that Vet B is first recommending a Low Dose Dex Test (LDDS), and if that is positive would then move forward with treatment (perhaps with Anipryl?) regardless of outward symptoms? And that Vet C is recommending an ultrasound and ACTH test and if those indicate Cushing's, she would treat with trilostane regardless of outward symptoms?


Hi Everyone, sorry if I have confused anyone. What Marianne has interpreted above is 100% correct. :)

We are still turning the wheels and seeing who should or could care for our dogs and who should do the diagnostics. In hearing the opinions of these vets, I was able to get an idea of how they view the disease and some insight as to their experience with the disease. Vet B is borderline scary to me. She would be the vet present during the ultrasounds and IMO, she is not experienced to handle this. Vet C put vet B in charge of this although Vet C has been our vet for years. This almost tells me that Vet C doesn't care enough about it or she believes Vet B is competant. I do not know how she could think I would be comfortable with diagnostics from Vet B when Vet B has a different opinion on how to handle this. The different info from Vets B and C indicate that they have not consulted and this is kinda how mistakes in medicine happen. The communication and consulting between them just isnt there.

It's probably also worth my noting that if Mandy does have Cushing's, she is probably a dog that fits into the category below considering her past history. I almost feel like vet A may understand the disease the best, but I am not sure:
"Alternatively, some dogs become very uncomfortable if arthritis, allergies, or other inflammatory conditions are unmasked once the excess cortisol is removed, paradoxically reducing the animal's quality of life. Another consideration relates to pituitary tumors themselves. These tumors continue to be somewhat responsive to blood cortisol levels, so it is possible that controlling cortisol release at the adrenal level may hasten the growth of a pituitary tumor, as the pituitary tumor is no longer kept in partial check by excess cortisol levels. Neurologic signs from a pituitary macroadenoma may then present themselves." (from http://www.kateconnick.com/library/cushingsdisease.html)

I guess one of my biggest questions is, is it customary to treat Cushing's with chemotherapy for a dog that is fairly asymptomatic. As I understand it and I may be mistaken, these drugs do not reduce tumor sizes, they simply manage the symptoms and allow pets to possibly have a second chance at a good quality of life. What if the pet already has a good quality of life? What was vet A saying... and was he on to something?

Lastly, my healthy, happy Sheltie does have that high GGTP level and again, vets B and C want to treat it differently. Again, this sets off an alarm to me. Vet B says ultrasound, no bile acids test. Vet C says re-do bloodpanel in a month and couple it with a bile-acids test.

[foxandhound]

I canceled the ultrasounds for both of these dogs since vet C was unable or was not present to speak with us/answer further questions. Also, she had already told us that she would not be present during the ultrasound, whereas Vet B would be present. That really made my boyfriend a bit peeved. I also wanted to get more info on whether the ultrasound was hi-res, if the ultrasound guy was an internal-med specialist, who would do a biopsy during the ultrasound if something was found (probably vet B and I dont feel great about that). Etc. It was my mistake to not ask these questions, but honestly, I just couldnt get a clear handle on things when vets B and C were telling me to go about it differently, but they work at the same location, and should probably consult with one another?

Am I full on nutty to request this info and be peeved about the lack of consulting between vets?

[Rebelsmom]

Hi and welcome from sunny Daytona, FL.. I don't believe you are nuty at all in canceling your u/s until you feel more comfortable with your vets. I had issues with my first vet and ended up switching to another farther away, but more exp with cushings. Although I am new to this disease (Rebel was diagnosed in March) I have had some exp in dealing with idiot vets. I believe that if you are not comfortable with your vet now then gather up all your pups paperwork and move on! I have been very fortunate to find a great group of people at my new place that care a great deal about all animals and love them just as they were there own.

I also agree that more testing needs to be done to diagnose Cushings before starting any treatment. I'm sure someone has already mentioned that Cushings is a slow progressing disease and treatment doesn't have to be started right away. As far as testing prices yours seem about what might are. I pay around $275 for the ACTH stim tests and paid around $400 for his u/s. Cushings does start out expensive, but once it's confirmed and your pup is regulated on whatever meds then the costs level out some.

My best advice is take a deep breathe and listen to your gut. No one knows your pups more than you do. If I hadn't gotten away from my first vet I might still be looking for answers.

[HarrysMom]

With regards to Urine Protein / Creatinine test - you have to take in the first morning urine to get it tested. Basically, it tests for how much protein is in the urine after adjusting for periodic factors. Basic urinalysis basically indicates that there is protein present, UPC test gives the degree of protein.

I think your vet is not all that experienced in kidney diseases. Unless a culture shows a growth of specific bacteria, you should never just give an antibiotic as a preventative measure because some bacteria WILL NOT respond to a given meds. You are just developing a whole batch of clindamycin resistant bacteria.

Please also note that Cushing's and kidney disease will also predispose a dog to frequent urinary tract infections. I think this is another reason do pursue an ultrasound.

You should ask your vet about doing a blood pressure - most vet offices will have the equipment. Depending upon whether you are dealing with protein losing kidney disease or high blood pressure, the vet would prescribe ACE inhibitor and / or other blood pressure meds such as amlodipine.

I would ask for another urinalysis and CULTURE. If this shows no bacteria growth, then I will pursue a UPC test.

Also ask for specific BUN and creatinine number. Yes - high protein diet could cause BUN to be abnormally high.




I'm not sure I understand this test...I have these values separately, can I divide to make a ratio? ;) I dont know.
"urine protein / creatinine ratio - this test really tests for how much protein is in urine."

Mandy's urinalysis was totally normal except for the 3+ protein. Her urinalysis last month had no protein. She has had bladder infections in the past. You guys are always one step ahead of me, huh? I asked the vet if this could be an infection and she said not likely. She gave us Clindamycin last month as a preventative measure and Mandy finished taking it 3 weeks ago. This bloodwork and urinalysis (showing protein) was done this week.

Is there blood pressure med on the market? We did not have a blood pressure test. No one offered one. How do we rule out Lepto, Tick Illness, Inflammation, and GN?

[labblab]

No, you are not nutty at all! It makes total sense to me to cancel this expensive and important procedure until you feel confident that the results will be accurate and meaningful. And I agree that the totally different diagnostic/treatment recommendations by Vets B and C are unsettling. Do they know that you've asked them both for recommendations?

As for the ultrasound, it may actually turn out that it is not that big a deal as to which vet is present at that time (unless some biopsy would actually be involved). I'm guessing that the ultrasound itself would be performed by a specialized technician, and so it may or may not matter which of your two vets is actually on-site that day. But I would also want to know who is going to read and interpret the results of the images, and when the interpretation is going to occur. Because that is just as important as the quality of the images themselves. And you do want your primary vet to be the recipient of that information. Depending upon the answers you get to your questions about the ultrasound, you may want to defer the whole thing and instead consider a referral to an internal medicine specialist before any further diagnostics are performed.

As for treating asymptomatic dogs, our experience here is that most experts are very cautious about moving forward in the absence of overt symptoms. I am no expert myself, but I think there are a couple of main reasons. The first is that both diagnostic blood tests (the ACTH and LDDS) can be skewed by the presence of other, nonadrenal issues or illnesses. Abnormal liver readings can also result from conditions other than Cushing's. So in the absence of observable symptoms, the accuracy of a Cushing's diagnosis based solely upon blood tests always remains questionable. Secondly, overt symptom resolution is one of the most important methods of judging appropriate dosage and effectiveness of the treating drugs.

Based on everything you've written so far, I do think I'd start off first with an ultrasound. If an adrenal mass or tumor is revealed, then you can consider the advisability of surgery as Vet A suggested. Since adrenal tumors can be cancerous, removal may be advisable regardless of Mandy's overt symptom profile. Also, with an ultrasound you'll have the chance to see if there are visible abnormalities in her other organs that would account for the lab elevations.

If nothing abnormal is evident, then you may even want to hold off on further Cushing's-specific testing unless Mandy does start to exhibit some overt symptoms consistent with the disease. If you do want to test further, the ACTH (as vet C recommended) may be a better choice than the LDDS because the ACTH is less likely to return a false positive if a dog does not actually have Cushing's and is instead being affected by some other nonadrenal illness. Again, I am no expert. But I just wanted to throw these thoughts out for your consideration.

Marianne

[foxandhound]

Thanks Rebelsmom. Honestly, it's exactly how we feel about the sitaution. I didn't want to say it, but you said it for me!!!!! ;) These vets should know when to refrain from bs-ing me and know when to hand it off to a specialist. It's pretty frustraiting to have to educate yourself and realize that you are getting opinions from people who have no business going further with it. I don't mean to sound harsh, but they have indicated to me that they just aren't on the same page and I don't really love where we are going with it.

Harrysmom, I thank you sincerely. It's odd when someone online can give you a better sequence of testing than your own vet. :( I am so thankful!!!! Ok, so Mandy will get a blood pressure test, an LDDS, a urine culture, and a UP:Cr ratio. Can we do urine culture and UP:Cr at the same time? If these tests come back with poor results, we will go for ultrasound! Does this sound like a good treatment plan???? It's too bad that my vet didnt give me this treatment plan. :(
I am a little upset about the antibiotics.

Who should deal with Cushing's and kidney problems...maybe an endocrinologist?

I guess in this day and age, with the internet, it's pretty common for owners to come in fairly well versed and requesting diagnostics that a vet may not suggest. :/ I should have been on the ball with this earlier.

Mandy's blood creatinine is not very low. It is 0.4 (range is 0.5 to 1.6). Her bun to creatinine is 45 (range is 4-27). I do not have a bun number. Has this maybe been overlooked by these vets as not a problem?

[frijole]

Yes, endocrinology is the specialty. I believe I provided a link this a.m. so you can search for board certified specialists in your area.

You are doing a fantastic job! It is frustrating when you can't trust the advice you are getting and even more so when it conflicts... I have spent the last 9 months in this same boat with my 2nd dog (first one had cushings and treated her for over 4 yrs with zero problems). What is most critical is finding someone with the experience required AND the ability to communicate with you. I am sure there are plenty of options where you live.

Kim

[HarrysMom]

For culture, you would want urine collected through cystocentesis (needle) because the culture has to be sterile. For UPC, you want urine collected from peeing because you do not want any blood from the needle.

I would do the culture and urinalysis first, and if this rules out an infection, then I would ask for UPC. Note that you are trying to find potential causes of proteinuria - infection definitely would cause this. Note that, if your dog has an ifnection, after your dog is finished with antibiotics, you will need to do another urinalysis and culture about 3-5 days after finishing the meds to make sure that the infection is completely treated (and this repeat urinalysis could rule out proteinuria NOT caused by an infection).

With your dogs' high protein diet, you would definitely want to rule out protein losing kidney disease because you do NOT want to feed high protein to a dog losing protein in urine. This is because large protein molecules can "puncture" kidney cells and causing further loss of protein in urine. Note that healthy kidneys do not lose protein this way.

It seems that given the rise in liver enzymes, you may still need to do ultrasound. This will rule out any adrenal tumor and liver issues.

I think in addition to an endocrinologist, you could also do with a well qualified internal medicine specialist, esp since your dog has other potential health issues.


Harrysmom, I thank you sincerely. It's odd when someone online can give you a better sequence of testing than your own vet. :( I am so thankful!!!! Ok, so Mandy will get a blood pressure test, an LDDS, a urine culture, and a UP:Cr ratio. Can we do urine culture and UP:Cr at the same time? If these tests come back with poor results, we will go for ultrasound! Does this sound like a good treatment plan???? It's too bad that my vet didnt give me this treatment plan. :(
I am a little upset about the antibiotics.

Who should deal with Cushing's and kidney problems...maybe an endocrinologist?

[labblab]

Annie, I just want to make sure that you had a chance to see my reply #19 on the previous "page." I think we were writing out replies at the same time, and so you may never have seen mine due to the timing of our postings.

In that reply, you'll see that I agree with HarrysMom in terms of thinking that an ultrasound may still be a good initial diagnostic. The question is just who will perform it (because I also think a specialty referral is a good idea).

Also, if you do proceed with Cushing's blood testing, I'm thinking there may be reasons why the ACTH would be preferable to the LDDS in Mandy's case. I write about that in more detail in that earlier reply.

Marianne

[foxandhound]

Hi! I just saw it!!! :D Thank you! Thank you! Thank you EVERYONE!!!! I would be lost without this place!

"And I agree that the totally different diagnostic/treatment recommendations by Vets B and C are unsettling. Do they know that you've asked them both for recommendations?"

Absolutely. Vet C knows. I called twice, left messages with receptionists. I even came in to see her and since she was busy, I wrote a 2 page note. Called again today, she was busy. I think they are annoyed with me and I'm annoyed with them. :/

"....unless some biopsy would actually be involved."
I can't deal with the thought of Vet B doing it if it had to be done. Those just bothersome.

"both diagnostic blood tests (the ACTH and LDDS) can be skewed by the presence of other, nonadrenal issues or illnesses. Abnormal liver readings can also result from conditions other than Cushing's. So in the absence of observable symptoms, the accuracy of a Cushing's diagnosis based solely upon blood tests always remains questionable."

This makes me believe that we should go the route of the urine testing and then sonogram and maybe skip the Dex test now. What do you guys think?

I thought a raw diet was not really a high protein diet, more like a quality protein diet with the moisture content not removed. (?)

[Rebelsmom]

Don't beat yourself up with not having this information before taking your pup in. We have all believed and trusted that our vet has our pups best interest at heart and kow what they are doing. Some of us find out the hard way that it's not always the case. I was in your situation not that long ago and found this website extremely helpful. My first vet brushed off my own Cushings diagnosis Oct of last year and told me to stop reading the internet. My new vet spent 10 mins with Rebel and thought right away he looked like a Cushings dog and started in with the tests. She also told me to get as much information as I could on my own and welcomed my opinions from my fellow Cushings people. :)

I also agree with the other that an u/s is probably a good place to start.

[frijole]

Yep. Ultrasound gets my vote too. You could get a false reading on the ldds test and that is probably where Marianne was headed next. I know if happens... it happened to me more than once! :rolleyes: Big bang for the buck on the ultrasound.

Kim

[lulusmom]

Hi Annie and a belated welcome to you and Mandy.

You've gotten lots of good feedback from a lot of folks and I'll try not to repeat anybody or cause you to go on information overload. Both are very easy to do around here. :D My comments follow your own in shaded boxes below:


Vet A said not to treat an asymptomatic Cushing's dog. He said to test to discern location and if it was adrenal-based, we could consider surgery. He said meds would be pointless and possibly damaging.

Vet A is partially correct. If a dog has been correctly diagnosed, treatment is anything but pointless and if prescribed by an experience vet who used proper protocol and the drug is administered by an educated pet owner, adverse reactions can be limited and/or eliminated entirely. To say meds are possibily damaging is very misleading. In order to correctly diagnose a dog with cushing’s, many factors must be considered and symptoms are one of the biggest factors.


Vet B said that Dex-Meth Supression and chemotherapy must begin. I asked her what medications she recommended. She said she couldnt remember, but it started with an A...she did not indicate anything about the difference between the types of Cushing's or any difference in treatment. I asked if the meds pose any risks and she told me the greater risk was to not treat the dog.

Even if Mandy’s Dex Suppression test results are consistent with cushing’s, without symptoms, a complete diagnosis cannot be made and treatment is ill advised until such time as symptoms are observed. There are two effective treatments for cushing’s; lysodren which is a chemo drug that should not administered to a dog that is not symptomatic and Trilostane (Vetoryl), which is an enzyme blocker that interferes with the synthesis of cortisol. This drug should not be given to a dog with no symptoms either.

If Vet B cannot remember the name of a drug that she is proposing to prescribe, I’d say you better think twice about entrusting her with Mandy’s care. Also, the only drug that starts with an A that is prescribed for treatment of cushing’s is Anipryl and this drug is rare effective. Experienced vets don’t have this drug in their arsenal when prescribing treatment for cushing’s unless the dog is severely debilitated or is so senior as to preclude the use of lysodren or trilostane. The developer of Anipryl doesn’t even use it unless the dog has very mild symptoms, isn’t a good candidate for lysodren and trilostane or the pet owners cannot afford the bloodwork that is necessary to monitor treatment.


Vet C suggested a sonogram and an ACTH test. She wold also like to treat an asymptomatic dog, she mentioned good success with Trilostane.

It really is a very bad idea to treat an asymptomatic dog with Trilostane.


For Mandy, she had some protein in her urine, it is labeled as 3+.
ALT was 191 (range is 12-118), ALK was 773 (range is 5-131). GGTP was 12 (range is 1-12). Her BUN/Creatinine was 46 (range is 4-27). Her Uc:CR ratio was 36 (greater than 13 is consistant with Cushing's). She has a grade 4/6 heart murmur.

I will say that all of these blood and urine abnormalities are commonly seen in dogs with cushing’s; however, non adrenal illness can yield these abnormalities too which is why it is very important that adequate diagnostics (ACTH, LDDS, Abdominal ultrasound) be done and that the dog is symptomatic before confirming a diagnosis.


The BUN/CReatinine is elevated bc of her diet, according to the 3 vets, all said no big deal. Foxy's is a little elevated too. I didnt mention it because it's always been elevated and always associated with diet. Cholesterol is normal for both pups.

Blood abnormalities due to diet are usually eliminated if a dog is fasted for 12 hours. Was Mandy fasted? Cushingoid dogs often have a high BUN/creatinine ratio. Heart and liver issues can also cause a high BUN/creatinine ratio.


I'm not sure I understand this test...I have these values separately, can I divide to make a ratio? I dont know. "urine protein / creatinine ratio - this test really tests for how much protein is in urine."

Mandy's urinalysis was totally normal except for the 3+ protein. Her urinalysis last month had no protein. She has had bladder infections in the past. You guys are always one step ahead of me, huh? I asked the vet if this could be an infection and she said not likely. She gave us Clindamycin last month as a preventative measure and Mandy finished taking it 3 weeks ago. This bloodwork and urinalysis (showing protein) was done this week.

To arrive at the UP:C ratio you divide the protein by the creatinine. A high UP:C with normal urine sediment and normal specific gravity is not what we see with cushing’s. At least 80% of dogs with cushing’s have dilute urine with low specific gravity. This finding is more common in a dog with a urinary tract infection. Does Mandy’s urinalysis include urine specific gravity (USG)? If so, can you please post?

Clindamycin has a narrow range of bacteria that it addresses and it’s most common use is for oral infections. It is not normally prescribed for urinary tract/bladder infections. Bad teeth and gums can cause oral abscesses and major infections in the mouth, which can elevate liver enzymes. Did any of the vets check Mandy’s mouth? Amoxicillin is a much more broad spectrum antibiotic used for a multitude of infections and is widely used to treat uti’s.


What tests could show us if there is pancreatitus, kidney and other issues? I guess the ultrasound. Maybe both dogs need it. I have actually shown that Bun:Cr ratio to 4 vets and no one thought anything of it bc of the diet. Is this a dangerous value?

A high UP:C ratio needs to be interpreted in conjunction with other values such as creatinine, BUN, microalbumin, etc. If BUN is the only elevated value, it’s usually not a big concern to a vet.


Ok, so atypical is the one caused by vet intervention, setroids, etc?

No, cushing’s that is caused by oral or topical medication is called iatrogenic cushing’s. Atypical cushing’s is diagnosed when cortisol is normal but other adrenal hormones are elevated. Elevated cortisol is the identifying characteristic in pituitary and adrenal dependent cushing’s.



I should also add that my 2 year old Sheltie-mix had normal bloodwork and a normal urinalysis, but never had a urinalysis performed. So, we were pretty sure there was some type of mix-up. Vet C re-did his bloodwork and his GGTP levels came back as 4xs the normal range. Vet B called me to tell me this and she suggested an immediate sonogram. I told her that he was completely asymptomatic and I wondered if it was another bloodwork mixup. I asked why not a bile-acids test and she said it would probably be inconclusive. She said he may have a gall bladder blockage. I spoke again to Vet C and she said not to do a sonogram and instead to retest his blood in a month. What the heck? I would never want to forego a diagnostic on my little guy, but this conflict of opinion and information is painful. My Sheltie is also asymptomatic. :) :( :X

I believe Shelties are genetically predisposed to gall bladder disease which would definitely impact bile flow and increase GGT. I read that when GGT is the only liver enzyme elevated, the probability of liver disease is greater than if ALT alone is elevated. Dogs with gall bladder and liver disease don’t always show symptoms. The liver is an amazingly forgiving organ and a dog may not show any symptoms at all until 70% of liver function has been lost. Gall bladder disease can be silent until it ruptures so I do understand why vet B suggesting imaging.

[HarrysMom]

A high UP:C ratio needs to be interpreted in conjunction with other values such as creatinine, BUN, microalbumin, etc. If BUN is the only elevated value, it’s usually not a big concern to a vet.

.

Lulusmom.
I have been dealing with my Harry's proteinuria for two years, and I disagree that proteinuria is only a concern if other kidney values are elevated. This is certainly not true. Glomerulenephritis often happens without elevation of BUN, creatinine and phosphorous, but can be just as dangerous. Moreover, it will eventually cause kidney damage untreated, and GN combined with BUN and creatinine increase pose a particular challenge. Any protein in urine is a concern because it is an indication of other processes (e.g. cancer, immune mediated disease or infection) in the body.

Just a clarification - UPC is a separate test. You do not divide urine protein from urinalysis and divide by creatinine from blood. You actually have to run a separate urine test to get UPC.

Yunhee

[Squirt's Mom]

Hi and welcome to you and Mandy! :)

I am wondering if you can clarify this statement -



Mandy's blood creatinine is not very low. It is 0.4 (range is 0.5 to 1.6).

0.4 is below the normal range given so I am wondering if you meant to say her creatinine is low or if there is a typo in the value given for it. This value will tell you more about the functioning of the kidneys than the BUN or the BUN:creatinine ratio. The BUN can be affected by several factors that can be controlled but the creatinine value will start to elevate only after the kidneys begin to lose function. So if the BUN is high but the creatinine is low, then the kidneys are probably ok and the ratio can be lowered by addressing factors that can cause elevations in the BUN. If the ratio is high because of elevated creatinine, then you may well be looking at an altogether different deal. This is the little I have learned in my recent dip into the canine kidney disease pool...and I hope my old brain has that straight but if not, someone will be along to correct me, thank goodness!

Hugs,
Leslie and the girls :D - always

[lulusmom]

Lulusmom.
I have been dealing with my Harry's proteinuria for two years, and I disagree that proteinuria is only a concern if other kidney values are elevated. This is certainly not true. Glomerulenephritis often happens without elevation of BUN, creatinine and phosphorous, but can be just as dangerous. Moreover, it will eventually cause kidney damage untreated, and GN combined with BUN and creatinine increase pose a particular challenge. Any protein in urine is a concern because it is an indication of other processes (e.g. cancer, immune mediated disease or infection) in the body.

Just a clarification - UPC is a separate test. You do not divide urine protein from urinalysis and divide by creatinine from blood. You actually have to run a separate urine test to get UPC.

Yunhee

I appreciate Yunhee's comments to my post with respect to the UPC. I too have a dog that has had proteinuria for over two years and we monitor her closely. Believe me, I do not take this lightly and have spent much time discussing this issue with my dogs' internal medicine specialist. I've also done a lot of research on the subject and after reading my post, I realized that I did not go far enough in my comment so as to not mislead anybody. My revised comments are as follows:

A high UP:C ratio must be interpreted in conjunction with other values such as creatinine, BUN, microalbumin and most certainly urine sediment and urine specific gravity. If four vets are not concerned with the high UP:C ratio, I deduced, based on posts thus far that urine sediment and urine specific gravity are normal, BUN is high and creatinine is low or normal. I don't believe Mandy's vets, based on the abnormal values posted, would automatically want to do extensive kidney function testing before ruling out more likely causes such as diet, cushing's syndrome, urinary tract infection and oral infection. The latter three share a number of blood and urine abnormalities.

In discussing my Lulu's proteinuria with her specialists, they were not overly concerned as other urine and blood results were normal and therefore they felt it was secondary to the disease. Of course I never totally trust anybody so I referred to my trusty Textbook of Veterinary Internal Medicine (Stephen J. Ettinger, DVM, DACVIM and Edward C. Feldman, DVM) which reads as follows:

The incidence of glomerulopathies in dogs with Cushing’s exceed 50 per cent. This protein loss seldom causes significant hypoalbuminemia and has not been related to development of edema, ascites, or pleural effusion. This made me relax a bit.

I am aware that the UPC is a separate test and I do believe I was correct in stating that to determine the UPC ratio, you divide the protein by creatinine. At least that's the formula Antech Diagnostics uses. If anybody is aware of another formula, it would be great to hear from you. Please see a copy of my own dog's test attached. If you cannot read it, the protein is 96, creatinine is 132.6 and the ratio is .7 If you do the math, it is 96 divided by 132.6 = .723982 rounded to .7

559

I understand Yunhee's concern because my dog has proteinuria too and I know that it can be a precursor to renal failure. In my opinion, the cause of proteinuria should be determined; any underlying diseases should be addressed; and the dog should be closely monitored via routine blood and urine analyses.

I am not a veterinary or medical professional, lab tech or even a janitor in a medical building so nothing I post here should be misconstrued as a diagnosis or a professional interpretation of laboratory tests. My "layman's" comments regarding Mandy's circumstances should not be interpreted as being appropriate for any other members' dogs.

Glynda

[foxandhound]

I think this conversation has gone too far. Just kidding. I love it and I find it very helpful. I think all possibilities should be discussed at length and analyzed for all of us. It helps me immensely and I hope it helps others too. Two heads are better than one type-thing! :D I have to read this and really get back to you. ;) It's a bit to digest.

[HarrysMom]

I actually agree with you, Glynda.
In Harry's case, there we no symptoms. He was a perfectly healthy trail running dog who could keep up and beat us on 3+ hour runs - at age 10.
And then all the sudden, his routine urinalysis showed proteinuria, which got us to urine culture, UPC and ultrasound along with tick, lepto, hypothyroid, lupus and chest x-rays to rule out cancer, immune mediated disease, infection, etc. Everything was normal, except Harry had a slight antibody reaction to some tick borne illnesses. Harry's UPC started at 1.5 way before his Cushing's symptoms started. However, starting this spring, when his hunger became worse, and Alk Phosphatase crept up to 600-1000, his UPC jumped to over 2-3. We think Harry had idiopathic proteinuria, but Cushing's probably pushed it a notch higher.
Our regular vet and the internist were much more concerned about Harry's UPC than his liver values - because there was something going on with his kidneys (definitely GN). I think they were concerned because GN combined with chronic renal failure have much worse prognosis.
I think in this case, GN is not likely unless you could not find any other cause of proteinuria like UTI. I would not spend $ on UPC until urinalysis ruled out infection.

Yunhee

[foxandhound]

Abnormalities or noted importances from Mandy's labwork from 30 days ago...fasted 6 hours.
pH 8 (normal 5.5-7)
Urine Protein 3+ (what does 3+ mean?)
Platelet count 603 (normal is 170-400)
Neutrophils 77% (normal is 60-77)
AST 67 (normal is 15-66)
ALT 164 (normal is 12-118)
ALK 838 (normal is 5-131)
GGTP 17 (normal is 1-12)
Creatinine 0.5 (normal is 0.5-1.6)
BUN/Creatinine 40 (normal is 4-27)

Abnormalities or noted importances from Mandy's labwork 3 days ago, 12h fast, 30 days of Sam e, Milk Thistle, Probiotics, 1 week of Clindamycin:

Urine Protein 3+
ALT 191 (normal is 12-118)
ALK 773 (normal is 5-131)
Creatinine 0.4 (normal is 0.5-1.6)
BUN/Creatinine 45 (normal is 4-27)


Her gravity, sediment, and all else was normal both times. Her teeth are much better than years back, before the raw diet. We bruush her teeth too and feed meaty bones. The vet said her teeth and gums were good, one tooth may fall out at some point. I asked if she could have a dental and the vet said she didnt need one. Her last dental was 3 years ago. In the past, she has had quite a few UTIs and bladder infections. Nothing in years. Nothing since the raw diet. So about the BUN/Creatinine, I'm not too nervous yet. It's always been high since we feed raw, even in our younger dog's bloodwork taken years back. I heard that Dr. Dodds has documented normal bloodwork of rawdogs and BUN/Creatinine is always higher, can't find it though. More on the diet, as far as I know, rawfeeding does not mean high-protein. It's actually much, much less in protein than most of the newer grain-free kibbles. Do you guys think I need to change her diet? :(

Regarding the urine protein, clearly the vet's Rx of Clindamycin did not help. Protein was still found. This is making me nervous wreck bc no one in that office bothered to discuss it with me. I had to find it on the sheet. So, should we do a urine culture first or a UP:C ratio, or both? Then, do an ultrasound? Or do it all, any combination? How does a urinalysis rule out infection- do you mean urine culture? I am honestly asking. My boyfriend kept saying I bet she has an infection and Vet B said "No, not with these values." (referencing the most current labwork)

Can I deduce the UP:C as 3/0.5 = 6 for the 1st labwork and 3/0.4 = 7.5 for the second labwork? It doesnt work that way. It cant. lol!

[HarrysMom]

The only way you can tell if there is an infection is by doing a culture. Many UTIs don't show up on plain urinalysis. Not all UTIs result in white blood cells and visible cocci or rods. I have two cats with renal failure and a dog with proteinuria - I've had too many UTIs, and none have been diagnosed the same way. Before doing a UPC test, I would do a urinalysis and urine CULTURE. Ask the vet to do it through a needle to ensure that the sample is sterile. If there is an infection, the culture should show which antibiotic would work on the bacteria. No UTIs show up on blood work (some cases, higher than normal value of neutrophils can indicate an infection, but not always. BUN and creatinine will be normal unless the infeciton had gone up to the kidneys).
If the results do not show an infection, then I would do a UPC test. This is done through the first in the morning pee sample. You cannot divide urine protein with blood creatinine to get this value - both values have to come from the urine.

Yunhee

[foxandhound]

Thank you so much. So sorry to hear about these problems in so many of our pets. We do the best we can. All of us. Is there a thread for success stories? I cant tell you enough just how thankful I am for the dialogue here, it's a real learning experience. I am a mess over all of this. If anything comes up in the further testing, I will absolutely revise the diet. She gets 75:25 raw meat to veggies. I would change it. Absolutely.

Thank you for the advice on the sterile urine culture. Why are you not suggesting UP:C as well? Is it an expensive test maybe?

Ok, so far on the list for Mandy is the sequence of blood pressure test, urine culture, followed by UP:C if needed, and sonogram, then LDDS.

What exactly was done for your dog to rule out "tick, lepto, lupus, immune mediated disease, infection"?

I am really glad you guys responded. :)

EDIT: I cannot believe I forgot to mention it, but Mandy has quite a few lumps. A few were aspirated and revealed lipomas. The vet never mentioned it again. I never thought of it. :/ :/
EDIT: A special thank you to LuLu's mom, you answered a ton of my questions. I followed it 100%.
EDIT: Squirt, I meant Mandy had low creatinine, but not "very" low according to Vet B. Can you believe I am still holding onto gems from Vet B? I gotta just start over and erase that experience. :(

[HarrysMom]

If your dog has an infection, UPC will likely be high anyways, so the test will be useless. I know what you are going through - I am going through my harry's Cushing's diagnosis now and have been dealing with proteinuria for a while (and that experience was very stressful).

When we could not find any infection, we did tick panel and lepto test and thyroid panel to rule these out. Note that these things were done to find out potential causes of proteinuria - in your case, I will wait for the urinalysis and culture.

Yunhee



Thank you for the advice on the sterile urine culture. Why are you not suggesting UP:C as well? Is it an expensive test maybe?


What exactly was done for your dog to rule out "tick, lepto, hypothyroid, lupus and chest x-rays to rule out cancer, immune mediated disease, infection"?

I am really glad you guys responded. :)

[foxandhound]

Oh, thank you Harry's mom! Is a tick panel only really for high-tick areas? We live in South Fl. What do you feed Harry exactly? Did Harry get an ultrasound? :) Sorry for my questions...

What do you guys generally think should happen if the culture is negative and the proteinuria does not go away. Are ACE-inhibitors given for these dogs regardless of blood pressure? I read that "The use of angiotensin-converting enzyme (ACE) inhibitors to reduce proteinuria in dogs with glomerulopathies is now considered the standard of care." (from http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=88239)

Also, what dogs are at-risk for thromboembolism? "Low dose aspirin (0.5 to 5.0 mg/kg PO q12h) is often administered to prevent thromboembolism in at-risk dogs and may have the added benefit of attenuating progressive glomerular injury through inhibition of platelet cyclooxygenase."

[foxandhound]

I believe Shelties are genetically predisposed to gall bladder disease which would definitely impact bile flow and increase GGT. I read that when GGT is the only liver enzyme elevated, the probability of liver disease is greater than if ALT alone is elevated. Dogs with gall bladder and liver disease don’t always show symptoms. The liver is an amazingly forgiving organ and a dog may not show any symptoms at all until 70% of liver function has been lost. Gall bladder disease can be silent until it ruptures so I do understand why vet B suggesting imaging.

Where did you read that? I read that it could be a bile-bloackage or slow-down of some sort, possibly some sort of stones (?), It could also have something to do with a recent fatty meal?

So, here are Foxy's bloodwork abnormalities 1 year ago:
GGTP 16 (normal is 1-12)
Specific gravity of urine is slightly elevated here too. Vet said it was fine. Foxy just has "concentrated urine" she said.


Foxy's bloodwork abnormalities/changes 30 days ago:
GGTP 6 (normal is 1-12)
Urea Nitrogen 32 (normal is 6-31)
BUN/Creatinine 46 (normal is 4-27)
Urine gravity: 1.070 (normal is 1.015-1.050)
Urine pH: 8 (normal is 5.5-7)

Foxy's bloodwork a few days ago:
GGTP 47 (normal is 1-12)
BUN/Creatinine 25 (normal is 4-27)
Specific Gravity: 1.406 (normal is 1.015-1.050)
pH 6.5 (normal is 5.5-7)

[Sabre's Mum]

Hi

I just wanted to give you a link to a copy of the article that Jean Dodds did on nutrition ... the reference to BUN is on page 4.

http://www.homevet.com/petcare/documents/immunenutrition.pdf

Angela and Flynn

[labblab]

I know I'm diverting the focus away from your current conversation about possible renal issues, but if you do decide to pursue Cushing's blood testing, I wanted to add a bit more as to why I'm thinking that the ACTH might be a better choice than the LDDS in Mandy's situation. The LDDS is the more "sensitive" test for Cushing's, meaning that it is less likely to falsely return a negative result if a dog does indeed have the disease. But the ACTH is a more "specific" test, meaning that it is less likely to falsely return a positive result if a dog doesn't really have Cushing's. For a dog who does not exhibit any overt symptoms of Cushing's, the better choice may be to opt for the test in which you can place the greatest confidence that a positive result actually does indicate that the disease is present.

Here's a set of testing recommendations given by Dr. Rhett Nichols (http://www.k9cushings.com/forum/showthread.php?t=210)that has always seemed pretty reasonable to me:


Final screening recommendations

What if the patient has only biochemical changes and no or mild clinical signs suggestive of Cushing’s syndrome?
The ACTH response test may be the preferred test. In these patients, it may be better to miss a diagnosis of HAC [Cushing's] in early stages by using a test with lower sensitivity than falsely diagnose HAC by using a test with lower specificity.

Is nonadrenal illness present?
The LDDS and ACTH response tests can give false positive results in the face of nonadrenal illness, but the LDDST is more likely to do so. Thus, the ACTH response test is recommended when nonadrenal illness is present.

What if the patient has moderate to severe clinical signs of HAC and has no known nonadrenal illness?
The LDDST is preferred as the initial screening test. This test has a higher sensitivity as compared to the ACTH response test.

Is an AT [adrenal tumor] suspected?
The LDDST is recommended because the sensitivity of the ACTH response test for HAC caused by an AT is only 62%.

Has the Cushing’s syndrome suspect been treated with a cortisone
preparation?
The ACTH response test is the preferred test if an animal has a definitive or questionable history of receiving exogenouscorticosteroids and has signs compatible with HAC...

Marianne

[HarrysMom]

We run on the trails, so we do get ticks (I just found an attached tick on my back a few days ago - and now I myself am on doxycycline).

I first found out about Harry's proteinuria when I started to feed him grain free high protein diet. When I mention to my vet, she suggested urinalysis to make sure Harry's kidneys were OK. When it came back with proteinuria, she checked Harry's old records (we just moved and used to have a different vet) and found out Harry's urinalysis a year prior also showed proteinuria. She ran UPC and it came back 1.5 (>0.5 is abnormal).

Our vet first cultured the urine to ensure that there was no infection (there wasn't). She then re-did UPC to ensure that the first UPC was not an abnormality. When that was abnormal, she started to hunt for other potential causes (cancer, tick illness, leptop, lupus, hypothyroid etc.). This involved ultrasound and tons of other blood tests. The only weird result was that Harry did show a slight antibody reaction to two tick borne illnesses. His adrenal glands also showed a slight bilateral enlargement. He was put on doxycycline for a month and then UPC improved slightly (although way above normal). He was also put on low protein prescription diet (Royal Canin MP).

Six months later, Harry's blood test started show a slight elevation in Alk Phos (in 200s) and high cholesterol. I also noticed that Harry's appetite was getting great (he used to be a picky eater). The vet and I discussed Cushing's, but decided to watch.

Two months later, Harry had an episode of vomiting. We did another blood test, and this time his Alk Phos and ALT numbers were a lot higher. We did another ultrasound, tick and lepto. Everything normal except slight bilateral enlargement of adrenal glands.

Two months later, further elevation in Alk Phos and ALT. UPC also suddenly jumped from under 2 to 3. We ran U Tenn Adrenal Panel (including ACTH) - came back as hyperestrinism, but normal cortisol. We put him on Atypical Cushing's treatment of melatonin and lignans. Harry was also put on benazepril.

I would also note that to date, Harry's blood pressure has been normal. Benazepril was to treat his proteinuria only. So far, Benazepril has not impacted Harry's blood pressure much, and I understand that this drug does not really influence BP. If a dog has a high blood pressure, you'd go with other drugs like amlodipine.

Recently, we saw Harry's hunger get even worse, and his coat even thinner. He was also peeing and drinking more. We also noticed that Harry was not able to be as fast during our morning runs. That is when our vet and I agreed that we should now investigate a full Cushing's route and start the treatment. We ran LDDS, and it was positive. Should we have treated earlier? - perhaps, and I do have some regret. However, as you can see, my dog was largely asymptomatic like yours, and initially, all we had to go by was some elevated numbers in urinalysis and blood test. This has been a long, slow progression.

Hope this helps.

Yunhee


Oh, thank you Harry's mom! Is a tick panel only really for high-tick areas? We live in South Fl. What do you feed Harry exactly? Did Harry get an ultrasound? :) Sorry for my questions...

What do you guys generally think should happen if the culture is negative and the proteinuria does not go away. Are ACE-inhibitors given for these dogs regardless of blood pressure?

[Rebelsmom]

I just wanted to say to all of you after reading all your informative posts that I'm glad we have each other. You guys have obviously dealt with a lot more than I have and pretty much seem to know more than some vets I've dealt with.

You have found a great forum Annie and looks like a great amount of information. You guys make me feel like I should put on a dunce cap! lol

Wishing Foxy and Mandy all the best.

Melissa

[Squirt's Mom]

Thanks for clarifying that info on the creatinine for me! That makes me feel better! A high protein diet can cause the BUN to elevate as can other factors such as dehydration and swallowing blood.

If you would like to get an idea of how much protein is actually in the diet she is currently eating, you can do so at the following link:

http://nutritiondata.self.com/

You will enter what you are feeding and the amount each meal and it will calculate the nutrient values for you, including all vitamins and minerals.

I am not a proponent of raw feeding myself but know many who follow this method with success. Unless there are good, solid, medical reasons for changing her diet, I would not do so right now. The more changes you make, the more difficult it can become to pin-point the current problem. ;)

Hugs,
Leslie and the girls :D - always

[lulusmom]

What do you guys generally think should happen if the culture is negative and the proteinuria does not go away. Are ACE-inhibitors given for these dogs regardless of blood pressure? I read that "The use of angiotensin-converting enzyme (ACE) inhibitors to reduce proteinuria in dogs with glomerulopathies is now considered the standard of care." (from http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=88239)

Also, what dogs are at-risk for thromboembolism? "Low dose aspirin (0.5 to 5.0 mg/kg PO q12h) is often administered to prevent thromboembolism in at-risk dogs and may have the added benefit of attenuating progressive glomerular injury through inhibition of platelet cyclooxygenase."

If the culture is negative, I believe your vet would start to eliminate other possible causes, including cushing’s. We’ve had a few members report that their vet prescribed Viagra to reduce hypertension in an effort to alleviate the pressure on the kidneys. I’m not sure but I don’t think it would be wise to prescribe an ACE inhibitor to a dog with normal blood pressure. You should ask your vet. With respect to ACE inhibitors and Aspirin, here’s a link to info on both:

http://www.ehow.com/about_5398366_enalapril-aspirin-dogs.html

I am also including a link below to a page on “Urinalysis: Testing a Urine Sample on Drs Fosters and Smith website. I found this to be much easier reading than some other sites which confuse the heck out of me.

http://www.peteducation.com/article.cfm?c=0+1302+1473&aid=3136

If you want to know more about Shelties predispostion to gall bladder issues, you can google it. I just did and got lots of hits.

http://www.google.com/search?hl=en&rls=com.microsoft:en-US&rlz=1I7GGLJ_en&&sa=X&ei=MNriTJeqEcL_lget1rTcDA&ved=0CBIQBSgA&q=shetland+sheepdog+gallbladder&spell=1

[foxandhound]

Thanks everyone. I do appreciate it. <3 :)
We are "interviewing" another vet in a few days. Well, you know what I mean. This advice has been crucial for me.

So, we started giving the dog's probiotics and enzymes again, but we are almost out. What brands do you guys use?

[addy]

Hi,

Interviewing vets, we all sure do alot of that, don't we;) I hope you find a good one. It can be so difficult.

My non Cushing dog uses Animal Essentials Enzymes and Probiotic. My Cushing dog eats raw patties so I don't use an enzyme but I do use Culturell probiotic available at Walgreens, etc. She is 18 pounds and get 1/2 capsule each night in her food.

I have also heard Berts has a good enzyme and probiotic.

I wanted to tell you my dog had no symptoms except thinning coat and skin when we tested her last May. Her blood work was pretty good, just a slight elevation in her ALP which I believe was from her colitis flare up she was having when we tested. Her cholesterol was elevated too, has been for awhile. Her T3 and T4 runs a tad low but it is borderline for treatment.

I had to stop the chronic diarrhea before treating, which took awhile. We then started on melatonin and lignans to see if she could stay healthy in regard to her colitis flare. That lasted about 4 months. We were 4 weeks way from retesting her to see her numbers when she is not in a flare and she started another colitis flare. Now I have to postpone test.

I worry alot that she will develop diabetes or some other complication from the Cushings but I also worry about starting her on lysodren based on tests given when she was ill.

I feel like it is a catch twenty-two sometimes. My IMS is waiting for stronger symptoms and a retest because we have to worry the lysodren will bother her colitis.

I just thought I'd tell you my Zoe's story. It is hard place to be, I know. It is a weighty decision to make. If Zoe had stronger symptoms, I would not hesitate.

Follow you heart and gut. It will tell you what to do.

Hugs,
Addy

[foxandhound]

Berte's..that's the one we use!!! I was thinking of switching bc someone told me to use probiotics with CFUs in the billions, not millions??? I found one the other day, but it seems like a gimmicky pet product so it's unreasonable in price. Also, I was told to use enzymes from animals, not plants? Not sure how/why. Something about digestibility and usefulness.

This is really helpful. Zoe sounds a lot like Mandy. No real symptoms, so when a couple vets start talking about urgency with Cushing's chemo, it's unsettling and sounds like a decision made considering their business and not my pet's wellfare. I'm pretty sure the decrease in Cortisone levels could give her less of a quality of life. Of course, no way to be certain. It's a hunch. I would consider the chemo is her quality of life depended on it. I would also consider removing an adrenal tumor, but with her grade 4/6 murmur, not sure. :/

I also just have to ask, with all of these Cushing's drugs, do any of them reduce tumor size? Are they mostly geared towards battling symptoms? I'm not sure I understand their mechanism of action. Can someone point me the way or just sum it up in a sentence or two? :)

[labblab]

I also just have to ask, with all of these Cushing's drugs, do any of them reduce tumor size? Are they mostly geared towards battling symptoms? I'm not sure I understand their mechanism of action. Can someone point me the way or just sum it up in a sentence or two? :)
Neither Lysodren nor trilostane reduce the size of pituitary tumors. Their mechanism of action differs, but both result in lowered levels of circulating cortisol which relieves both overt symptoms and also systemic internal damage caused by Cushing's. Some adrenal tumors do shrink as a result of Lysodren treatment, but not all adrenal tumors are responsive to the medication.

Marianne

[foxandhound]

Hi everyone! Mandy has an appt on Monday for her low-dose Dex, repeat bloodwork, and urine culture.

A few concerns though. :( The vet office scheduled it for 3:30pm and like most offices, they close at 5pm, so am I missing something. I thought the Dex test was an 8 hour adventure or so? Something about baseline test, give hormone, repeat test? I am not sure though. Can this be done in 1.5 hours? Also, does a urine culture have to be done with the first urine of the day, even if done by cystocentesis?

Please advise. :) Thanks so much. We would be lost without you guys.

[addy]

Zoe has had urine cultures done by cystocentesis and they were not first urine of the day. If you are referiing to the UC:CR creatinine urine test that must be first morning catch before eating or drinking and some will do 3 mornings and mix the urine and then test.

Whenever I discussed the low dose dex test with a vet, they wanted Zoe there all day as it is a long test. I thought the draws were every four hours. I never had it done because of Zoe's stress levels for that long of a test. She has trouble fasting that long and I would have to take her in and out, I could never leave her all day, her stress would alter the test.

I am not sure what you vet has in mind.

Hugs,
Addy

[lulusmom]

I believe your vet is doing an acth stimulation test. They do a baseline draw to determine the resting cortisol, then they inject a stimulating agent, usually cortrosyn, and then they do a one hour (post) blood draw. It is the post draw that is used to assess the level of circulating cortisol. Please be sure to post the results when they are in.

Glynda

[foxandhound]

No, the ACTH test was $300. The Low Dose Dex was $90, so we opted for the low dose Dex and a urine culture. Can this be done at 3:30pm? I thought the Dex test had to be done every 4 hours? The office must be confused, right? I will absolutely post results, but I am pretty sure the results will be meaningless if the test is not done correctly. :( What do you guys think?

[frijole]

You are right - the LDDS test is an 8 hr test. You need to call them in the a.m. first thing for clarification. Don't waste your gas going in at 3:30. Also, the urine should be captured from first one in the morning. Kim

[foxandhound]

Thank you so much. Lots of bad luck with vets lately. :/
You guys are awesome!!!!!

So, the urine culture if collected by cup should be 1st morning sample and if collected by fine needle, it could be anytime? Or better do it ,in the AM?

[labblab]

If urine is being collected to perform a UC:CR test to help diagnose Cushing's, Kim is right that it should be from the first pee of the morning. If the urine sample is being collected to check for an infection, I don't think the timing makes any difference, regardless of whether you are "catching" it or whether it is drawn by needle. But hopefully others will confirm that.

Marianne

[jrepac]

Hi there,
I happened to read thru all of these posts and understand your confusion. I went thru a lot of this as well in 2007/2008 w/my own Mandy, who passed on recently. It is not uncommon to see multiple vets, with varying levels of experience and different opinions on treatment. I know I did!

But, Cushings is very tough to diagnose and you may be in the early stages of it, based on some of the numbers you posted. However, the lack of overt symptoms would make me want to be certain...in my case, I saw the symptoms and recognized them as Cushings (since Mandy was my 2nd cushpup).

I would not rush into treatment w/out a firm diagnosis, because something else could be going on...it is worth getting an ultrasound and the ACTH test, which has fewer false positives than the LDDS, so I am also in agreement with Marianne's post below. At least the ultrasound will make sure there are no adrenal tumors present, which you will want to be sure of. Once you have a firm diagnosis of cushings, you can then consider treatment options...of which there is also great debate amongst the vets and the owners. There are a lot of things to consider when selecting a course of treatment. But, be wary of a vet who wants to rush to treat w/out confirming the disease.

Best of luck to you and I look forward to your next update. The pics are great, by the way! :)

Jeff & Angel Mandy

[Harley PoMMom]

If I am getting Harley's urine sample checked for bacteria/infection, then I always have it drawn by an ultrasound guided Cystocentesis. This procedure is the most sterile way to collect urine without having to worry about getting outside bacteria in the sample.

Love and hugs,
Lori

[foxandhound]

Hi everyone, just wanted to check in again. We had an illness and death in the family and I lost my job so I had to take a small break from this. Mandy is still asymptomatic aside from lab results. We are still searching for another vet. We have seen 2 vets since this posting and decided against both. We have another appt with another vet on Monday. So, I hope that goes well!

Just had a couple questions here. To refresh, Mandy's last labs showed the following abnormalities.

Protein in urine: 3+ (I have no idea what units this is in, none listed)

White Blood Cells in urine: 0-1HPF (again, no idea, but instead of saying "none seen", it says 0-1HPF)

ALT: 191 (range is 12-118)

ALK: 773 (range is 5-131)

Blood Creatinine: 0.4 (range is 0.5-1.6)

BUN/Creatinine: 45 ratio (normal ratio is 4-27)

Cortisol/Creatinine: 32 ratio (normal is less than 13)

Urine Creatinine: 80 (normal is 100-500)

Here's what I think we will do. We will request a Urine Protein to Creatinine Ratio. We will be taking a urine culture by sterile cup (morning urine). I dont think we can afford an ultrasound guided Cystocentesis, but I dont know how much it is. Is it expensive? We will also finally get the blood pressure test and discuss Benazapril for proteinuria even if her blood pressure is normal. I keep reading about that so I hope this vet will have heard of it. We will also discuss diet for proteinuria since we feed raw, but whatever changes need to be made will be made. I have no idea what we are looking at here...high BP, renal failure, glomerular disease, cushings.

We will wait to get these results and then make any medicated changes, the retest. Then we will try to firm up Cushings. At this time, a few vets have told us that Mandy's labs do not give reason to treat Cushings yet, so we should hold off. ????????????????? So confusing.

Am I saying anything totally left field here? Money is very, very tight so I kinda have to proceed accordingly. I have an emergency fund for our pets and I am reserving this for the ACTH/Dex/Ultrasound, but even if Cushing's is confirmed, when should we consider acting on it and giving chemotherapy? When symptoms occur or the proteinuria and ALK worsens? What made you start treatment?

Thanks guys. Happy New Year. Hopefully we will have a great new vet this new year!

[Harley PoMMom]

If Mandy has untreated Cushing's diease this could lead to high blood pressure. The excessive cortisol and the high blood pressure is probably causing the protein loss in her urine.

If her blood pressure is normal, if Mandy were my pup, Benazapril would not be my first choice of medication for her. Getting her cortisol under control would be my first concern. I believe if you can do that then the protein loss will resolve. Could you get an ACTH stim test done?

Is Mandy having any Cushing symptoms?

Love and hugs,
Lori

[foxandhound]

Hi Lori, Thanks for responding. Means the world to us. To be completely honest, I have heard that it is not wise to treat the Cortisol until Mandy shows an abnormal Cortisol *AND* symptoms of Cushings that would decrease her quality of life. Mandy does not show those symptoms. Right now, her quality of life is almost excellent. No excessive thirst or urination. No lethargy. She is doing great. She can almost keep up with my 2 y/o dog.

Mandy's cortisol is normal, 8.3 (range is 5-55). Her creatinine is 80 (range is 100-500).

I also understand that even treating abnormal Cortisol levels can really damage the quality of life in an asymptomatic dog, it can unmask a lot of problems that were otherwise regulated with Cortisol. ????? I really havent a clue. These are just things I have read.

I have read that Benazapril is a treatment for proteinuria. So, I thought it would be more wise to try and tackle the proteinuria since her Cortisol is normal.

Gosh, this is pretty confusing for me since her Cortisol is normal. What should I do? This is one of the reasons we left our first vet and her staff.

[foxandhound]

Here's the link about the Benazepril....You are the second person here to suggest it is not a good idea. Does it have bad side effects or something?

I feel like I have to babysit our potential vet and go in there fully armed with info or we will be diappointed.

http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=88239

This info is from page 2:

The use of angiotensin-converting enzyme (ACE) inhibitors to reduce proteinuria in dogs with glomerulopathies is now considered the standard of care. Typically benazepril (0.25-0.5 mg/kg PO) is given once daily. If there is not a reduction in proteinuria after four to six weeks of administration, the frequency can be increased to twice daily or double the ACE inhibitor's dosage. Adequate blood pressure control of hypertensive dogs may also lead to a reduction in proteinuria and slow the progression of disease. Because ACE inhibitors are relatively weak antihypertensive agents, additional antihypertensive agents (amlodipine, 0.05-0.1 mg/kg q24h PO) may be needed if hypertension persists (systolic blood pressure >170 mmHg) after the initiation of ACE inhibitor administration. Low dose aspirin (0.5 to 5.0 mg/kg PO q12h) is often administered to prevent thromboembolism in at-risk dogs and may have the added benefit of attenuating progressive glomerular injury through inhibition of platelet cyclooxygenase.

[Harley PoMMom]

Most definitely get her blood pressure checked, elevated blood pressure can cause protein loss in their urine.

My boy was dx'd with high blood pressure and put on 2.5mg Amlodipine BID which controlled it for a while then it spiked to 180. His vet rx'd 2.5mg Benazepril SID which brought his blood pressure down to 150.

In the beginning when my boy was losing protein in his urine it was because of his elevated blood pressure, so I would definitely get this checked first.

[foxandhound]

Will do!!!!!! Thank you! Your help is so so very appreciated.

BTW, regarding Corstisol. I apologize, I think I goofed. I guess you are talking about blood cortisol and I am talking about urine cortisol. Hence ACTH test which would be better than low dose dex for us? I am guessing we cannot assume normal blood cortisol even if the urine cortisol is normal? Or can we?

[Harley PoMMom]

Maybe try this article: http://www.marvistavet.com/html/body_glomerulonephritis.html

[gpgscott]

I am sorry to hear of the upsets in your life and offer condolances for your recent loss.

It seems from what you have posted Mandy has normal cortisol and so most likely normal intermediates with the exception of the elevated estradiol mentioned in November. Estradiol is slower to respond to treatment but also does not usually cause the volitale and dangerous changes brought on with unstable cortisol.

I think I would stick with a hyper-estrinism treatment and watch the blood pressure which seems to be an issue for Mandy. Usually estradiol is monitored on an every three month basis and a stim is not required.

Scott

[Harley PoMMom]

Cortisol/Creatinine: 32 ratio (normal is less than 13)

Urine Creatinine: 80 (normal is 100-500)



This is, I believe, an UC:CR test, which is high. Was this sample taken at home? Was Mandy stressed at all when the sample was taken?

[foxandhound]

Thank you so much Scott. Very kind of you.
I'm confused, What is estradiol? hyper-estrinism treatment? Maybe that's the more advanced term for some of Mandy's bloodwork? Can you explain? I am so overwhelmed that I might have missed that.

Yes, it was taken at home, in the morning, not stressed. :)
it is high, but only because Creatinine is low, Cortisol is normal. From what I've tried to read, in most cases of Cushings, Cortisol will be high and then UC:CR will be high. In Mandy's case, it was opposite, but still lead to a high ratio (ie: low creatinine still yielded a high ratio). What do you guys make of that? I heard that the ACTH test should be done when the UC:CR test is high because Cortisol is high. Not sure though.

[Harley PoMMom]

I just skimmed through your Thread and I can't seem to locate if you had a full adrenal panel done on Mandy, did you have one done? This measures the 5 intermediate hormones...Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone.

[foxandhound]

No, I didnt. Do you suggest that? Gosh, I had no idea about that one. Honestly, I am BEYOND upset with the vets we have seen. I feel like I have to lead them. No one even mentioned the proteinuria. No follow up with me. Nothing. No suggesting of a culture, UP:CR, or this panel of tests either. So sad. So very sad.

That link you gave me was wonderful. Explained a lot.

[Harley PoMMom]

For the most part, an ACTH stim test is done when an UC:CR test comes back elevated. But with Mandy not having any Cushing's symptoms I don't know if the ACTH test would benefit you.

Stress and/or any illness can cause a high result on the UC:CR test.

Usually dogs that have elevated cortisol have elevated intermediate hormones too.

[Harley PoMMom]

When Harley's blood pressure was high his UPC was 2.6 (RR </=0.5), when we got his blood pressure under control his UPC dropped to 0.6.

High blood pressure definitely takes a toll on the kidneys and causes protein loss.

[foxandhound]

I'm so sad that niether vet ever even talked to me about a blood pressure test. I guess it is very possible that could be the cause of the proteinuria.

"Usually dogs that have elevated cortisol have elevated intermediate hormones too."

Since Mandy did not have an elevated cortisol, should we hold off on ACTH and maybe do the atypical cushings/adrenal panel instead?

[Harley PoMMom]

The full adrenal panel comes with an ACTH stim test...this test is usually pretty pricey.

I believe the cost of the adrenal panel is $140.00 and then your vet will tack on money to do the blood draws. Only the lab in Tennessee ran by Dr. Oliver does this kind of testing. Your vet would have to specially mail the blood draws to Dr. Oliver's lab.

I would get Mandy's blood pressure checked first and see what that is.

[foxandhound]

Will do!

one more thing...http://www.vet.utk.edu/diagnostic/endocrinology/index.php

On the site, it says "Adrenal Panel (Combined Dex Supp / ACTH Stim)" is $165, so would this be an all-day test? and is this the same one that measures the Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone? I guess it measures everything, low dose dex and ACTH?

[Harley PoMMom]

If you are getting that one done, "Adrenal Panel (Combined Dex Supp / ACTH Stim)" $165, then it will be an all day test because the dex test takes 8 hours.

I've only ever gotten the full adrenal panel with the ACTH stim test done.

Let us know how the blood pressure check goes, with my boy they have found that taking his blood pressure from his right rear leg is best. I also take a towel from home with me and go in with him while they are taking his blood pressure...best of luck to you and Mandy.

Love and hugs,
Lori

[foxandhound]

Thank you so much Lori! Much love to you and Harley! xoxo Happy New Year!

[Harley PoMMom]

Happy New Year!! If you have any questions, please do not hesitate to ask, ok? :)

[foxandhound]

Thanks so much!!!! You guys are THE BEST!!!! So much love to everyone! Thank you! Thank you! Thank you!

[Harley PoMMom]

Another good article about Proteinuria in dogs: http://www.petplace.com/article-printer-friendly.aspx?id=4040

Love and hugs,
Lori

[gpgscott]

Sorry, my mistake, I see the reference to hyper-estrinism was by someone responding to you in November about their pup. I am sensitive to this issue as I treated my pup for it for about three years. It is an elevation of primarily estradiol which is one of the hormomes which can cause Cushing's symptoms.

You can spend hours and many dollars chasing a diagnosis. If this was my pup, I would concentrate on the basics right now such as a standard blood panel, urinalysis and blood pressure (if that is an issue) and go from there. With normal cortisol and no symptoms you really have nothing else to treat.

Scott

[foxandhound]

Hi Scott,

Right now, we will be doing a blood pressure test, urine culture, UP:Cr ratio, and if we dont get answers, we will probably scratch our heads and rethink things. At that point, I would not be sure whether to go for the Ultrasound or full panel adrenal..

Is the urine cortisol similiar to the blood cortisol? Should we maybe do another UC:Cr to recheck the cortisol?

[Harley PoMMom]

UC:CR and an ACTH stimulation test are different:


Dogs with hypercortisolemia have increased excretion of cortisol in their urine. This excretion can be compared to creatinine excretion, which should be fairly constant in dogs with normal renal function. False-positive elevation of the UC:Cr (i.e. elevation not related to Cushing's disease) can occur in patients with gastrointestinal, renal, lower urinary tract, liver, neurologic, or immune-mediated diseases or congestive heart failure.1
http://veterinarymedicine.dvm360.com/vetmed/Medicine/ArticleStandard/Article/detail/357729


The ACTH stimulation test is a simple and safe screening test in the diagnostic evaluation of dogs with hyperadrenocorticism (Cushing's syndrome). It's also used to monitor dogs on medical therapy (e.g., Lysodren, Trilostane, etc.).

Simply put, it's a test of adrenal gland reserve; it checks how the adrenal glands respond to a certain hormone. This hormone is called adrenocorticotrophic hormone, also known as ACTH. ACTH is made in the pituitary gland (pea-sized structure located at the base of the brain) and travels through the bloodstream to the adrenal glands (small paired glands buried in fat in the front of each kidney).

ACTH stimulates the adrenal gland to release cortisol. The ACTH stimulation test involves measuring the concentration of cortisol (which is made by the adrenal glands) in a patient's blood before ("pre") and after ("post") an injection of synthetic ACTH.

Hope this helps.

Love and hugs,
Lori

[foxandhound]

Hi guys, well today we saw yet another vet who isnt right for us. We asked by phone how much it would cost for bloodwork and we were told $70. We found out later that it would be $220 and that would include an unneccessary/bonus fecal and HW test (that we alreday had done a month ago). The office visit was $90 and the vet is a general dvm, not specialist, but ok, not a deal breaker. We were still faithful that we were in good hands. We waited in the office and exam room for an hour and a half before anyone came.

The vet came, we talked about Mandy's proteinuria, possibly high blood pressure, high ALk, high ALT, Cushings and atypical Cushings. Well, this vet couldnt make up his mind about treating an asymptomatic dog with chemotherapy or not. He thinks cortisol may be ruining the liver and kidney, but he is also not sure if the cortisol is high to begin with. To update you, we already had a Cortisol:Creatinine ratio and the cortisol was normal, the creatinine was low.

Well, he left the room and the tech came back with a $1200 estimate. Ok, so I started asking about some of the estimate items. I asked about the $220 Antech bloodwork and some guy who was standing outside eavesdropping comes right in, in a tie and suit and tries to sell us on this package. I guess he has the job of closing the pitch? Who was this guy, I still dont know. Anyhow, he didnt convince me since I can get that bloodwork for $70-80 at other offices.

Today, we decided to go for a protein to creatinine ratio and the ACTH/full adrenal panel with U of Tenn. $80 for the ratio and $300 for the ACTH (that's a huge markup). We also requested a blood pressure test ($40?). The vet told us that the protein: creatinine did not have to be the first of the day, but honestly, he didnt sound 100% certain. :(

We left Mandy at the office and we told the staff that she had not had anything to eat in 14 hours (because of bloodwork and the wait at the vet office) and she had not drank anything in hours. We asked them to give her water, take her potty, and take the BP before and after some much needed treats that we left for her. Well, that wasnt honored. None of it.

When we came to pick up Mandy, the vet tech told me that "Mandy's blood pressure was 170, it was normal." Umm, BP has 2 values? Is this girl out of it or what? I guess she meant systolic is 170 and I thought 170 is high or high-normal. For a case of proteinuria, Mandy may benefit from BP meds. I asked her how many times they took the BP. She said "once." I then said, "I asked for it to be taken before and after her meal, she was fasted." To this, she got angry and said, "they did test it twice." Wow, what kind of backpeddling is this? I told her about the BP meds and proteinuria and this time, she became condescending and ambiguously told me that "the doctor does not wish to prescribe BP meds for a dog who doesnt need them."

Then, I asked for the doctors notes and the Mandy's file, I said I wanted a copy of the BP. She told me it wanst ready and wont be for another few days. And that was it. $500 gone. Bad experience. My SO was really upset with this. Hopefully the ACTH will give us some meaningful info.

[foxandhound]

Since the vet tech only told me 170, I guess they used the doppler method to get the BP. I'm finding that this is not as accurate as the oscillometric method. I doubt they measured it twice as I had asked. Ugh. Poor service. When we picked up Mandy she drank so much water and wanted to pee immediately. They didnt give her any water and I doubt they took her out. :(

[frijole]

I'm so sorry this happened... I have been thru 'vet hell' myself and it is not fun. At least you didn't get suckered into the $2000 package. :D Run. Forest. Run.

http://www.k9cushings.com/forum/showthread.php?t=182

Not sure if you saw this link before but it will take you to a directory of specialists by state, city... hopefully you can find someone near you. If you tell us where you are located maybe someone here can help with a suggestion?

So sorry... these things happen and it is so frustrating... just know you aren't alone. Hugs, Kim

[foxandhound]

Hi guys, we cant really afford a specialist just yet. We just did the UTK ACTH full adrenal panel, BP test, protein to creatinine, urisol to creatinine, and a urine culture. This has been over a grand so far. I dont know what I'm doing as Mandy is in good spirits and I will probably have to repeat all of these tests if she starts showing bad symptoms. I'm praying she continues on with the good quality of life. Waiting on results. :(

It's like a puzzle and I have to piece it together bc the vets I have worked with arent on top of it. Sad, but true.

Yesterday was strange, Mandy urinated 6xs on our walk, but she does not do that in our backyard. I think she is marking? I let her out, she plays, she pees once, plays, investigates and comes inside. I do not know if she is spayed as we adopted her at age 7 and the vets cannot confirm it. No accidents inside. Basically, I am hoping she has an infection. She has seemed to develop the skeletal face and large pot-belly since I started this thread. And, that might be linked to the protein loss in her urine and we dont know what's causing that. That is just about her only "symptom". I cant think of hunger as a symptom bc she is a beagle and has always been a food thief since day one. :P She moves from cozy warm beds to the cold floor than back to the bed. Who knows.

****Is it true that if you dont treat for Cushings even in a borderline asymptomatic dog, the high Cortisol levels will continue to destroy her liver and kidneys????

Right now, we are waiting on the ACTH to discuss her Cortisol. Her urine cortisol came up as normal.

[frijole]

****Is it true that if you dont treat for Cushings even in a borderline asymptomatic dog, the high Cortisol levels will continue to destroy her liver and kidneys????

Right now, we are waiting on the ACTH to discuss her Cortisol. Her urine cortisol came up as normal.

My dog Haley was diagnosed with cushing's over 5 years ago and the folks on this forum helped me save her life as I had a vet over her head. I'm no vet but have been here reading and helping ever since.

Most dogs diagnosed with cushing's find out accidentally - like when they get a blood panel done for teeth cleaning. That's what happened to me and I had never heard of cushing's before that. Looking back my dog had cushing's for many many years before I knew. I treated her successfully with lysodren for over 4 yrs and she lived to over 16 1/2 yrs and it wasn't her liver or her cushing's that took her life.

My point is that most dogs go a very long time before being treated and the world's best specialists all agree - you do NOT treat a dog that doesn't have symptoms.

The urine test that you had done ruled out cushings and that means there was no cortisol. So doing an ACTH test would be an absolute waste of time and money. You mentioned funds were tight and I just hate to see you throw any more away. Kim

[Harley PoMMom]

When Harley gets his BP taken the results are given to me as a single value.


As when you get your own blood pressure taken, the cuff is inflated until the beating pulse is no longer heard. Then air is slowly allowed to escape the cuff. At the point the beating pulse is heard again, that is the blood pressure. In people, the first sound of the pulse is called the systolic pressure. As more air is let out of the cuff, there is a point when the sound of the pulse suddenly becomes louder. This is the diastolic pressure. However, when using a doppler in animals, it is often difficult to detect this volume change. For this reason, the blood pressure is often expressed as a single value. Other non-doppler blood pressure machines use electronic methods to detect the blood pressure. These machines can determine both systolic and diastolic pressure.
http://www.petplace.com/dogs/blood-pressure-in-dogs/page1.aspx

How was Mandy at the vet while she was getting her BP done? Although I am no expert, 170 does not seem that high to me, but I would keep an eye on it. ;):)

Cushing's Disease takes a long time to do internal damage, many dogs go years before they get diagnosed and treated properly and then most of these dogs live out their normal life-span.

Love and hugs,
Lori

[foxandhound]

Mandy tested positive for Cushings?????. :/
And more drama...Another vet got on the phone to talk to me and wasnt sure if it was Mandy's test. She said she had no paperwork on it, but "it looks like it is Mandy's" (by process of elimination).

I paid for the full adrenal panel and ACTH sent to Tennessee. The vet tells me that they have the Antech results and Mandy tested positive. I got really angry because I paid $300 for the full test to Tennessee. After some back and forth, the manager said that they will redo the test at no charge and submit it properly. He asked me to come in when he is present, I assume bc the madhouse of teenage and twenty-something employees are not competant. What a mess!

So here's all I know: Mandy had a regular ACTH test with Antech and it came back positive. I am so sad. Can this tell me anything about typical or atypical??

Kim, I dont know where I would be without the help on this forum. The urine cortisol was a bizarre test and after seeing 3 vets, no one could really answer my question. Her cortisol was normal, her creatinine was low, so it made the ratio HIGH. A high ratio usually means Cushings is possible, but from what I read, a high ratio is high because the Cortisol is high and not because the Creatinine is low. Maybe the ACTH was a waste and these results are not Mandy's. Maybe these results are Mandy's and a normal urine Cortisol can still mean Cushings. :(

Lori, they made me pay for the BP test and then they did it without me bring present. I assume she was stressed. I read that 170 is on the high end. I guess 180 is really high though. I heard that the doppler method (the one that gives just one number) is not as effective as the cuff method.

[Harley PoMMom]

If you got the full adrenal panel done, this comes with an ACTH stim test. Why did they do an additional ACTH stim test and send it to Antech?...Just wondering??? :confused:

Harley BP is checked with the cuff method (doppler).

[Squirt's Mom]

Hi,

What a cluster...!!! :eek::mad:

If it were me, I would do my best to put this test debacle out of my mind completely. It doesn't sound as if they are sure who's is who's and a process of elimination ain't gonna cut it when diagnosing my dog. So until you have results in your hand that you KNOW are indeed Mandy's, don't take anything they say about her to heart, ok? One would think there would be enough identifying info on those papers to make a clear distinction, but it sure doesn't sound like it so don't worry just yet. Now I have to wonder if someone went home with their baby thinking all was well when it may not be at all. :rolleyes:

I am glad they are going to redo the UTK panel for free - that is only right. Tell everyone involved that sample DOES NOT go to their normal lab but is shipped directed to UTK. Funneling it through the usual lab results in extra expense to you and risk to the sample due to the delay. Some of these vets take so much training! ;):p

Hang in there!
Hugs,
Leslie and the girls - always

[addy]

Time for deep breaths. Always remember to breathe. I sometimes forget in a panic:o


Okay, we just had the full adrenal panel for UTK done on January 6th. The blood draw has to be frozen and shipped overnight to UTK. I believe UTK does the analysis of the full adrenal panel samples on Mondays Wednesday and Fridays. It will take a week or more to get the results. The last time it took me 2 weeks but that was right before a holiday.

UTK has specific requirements for vets to submit for this test and the requirements are listed on their website. I grilled our lab tech about when Zoe's draw would be sent to UTK. She assured me that it would be overnighted that afternoon.

If you have this test redone you must make sure the vet is following UTK's procedure requirements.

Also please note that an ACTH can give false positives as well as false negatives.

From what I have read the MOST IMPORTANT TEST for Cushings is the history of the dog and a physical examination. This was stated by Dr. Feldman, I believe, UC Davis. This is because no one test is perfect. If your dog does not present symptoms, some vets will not even go down the road of testing for Cushings.

I just got done emailing Dr. Allen from Dechra, the manufacturers of Vetoryl (Trilostane) I do not have his exact quote but he said that unless Zoe had strong symptoms, I should wait to treat her and that they do not have absolute proof that waiting to treat will definitely result in some of the rarer developments Cushings can cause, like blood clots, etc.

So my point to all of this lengthy dialogue is you have time to sort things out and one positive test does not necessarily make a Cushing dog. I think Kim's Annie tested positive five times:eek:!!!!!

Hugs,
Addy

[Squirt's Mom]

The difference in the usual ACTH that Antech and other labs do and the UTK panel is in the hormones tested for. When Antech and others run an ACTH they are testing for cortisol ONLY. When UTK does their assay they test for cortisol and five other hormones, the intermediate, or sex, hormones. These are estradiol, progesteron, OH17 progesterone, aldosterone and androstenedione. So the 'normal' ACTH done by labs other than UTK cannot tell us anything about the intermediates only about cortisol - UTK is the only lab in the world we know of doing this study and testing on the intermediates.

Hope that explains a little bit about the test differences.

Hugs,
Leslie and the girls - always

[foxandhound]

Lori, I paid for the full adrenal, but there was some confusion and they think they submitted the test to Antech (no full adrenal), but then again, they are not sure if it is her test. They think it is her test, but who knows. They are re-doing it, full panel UTK. At this time, they believe the Antech ACTH test result positive for Cushings is Mandy's, but no one is 100%.

I made a mistake, you're right doppler is the cuff. The other method that is superior is the oscillometric method. Maybe that involves a cuff as well, not sure.
"Two methods of "indirect" blood pressure measurement are also used. One uses a Doppler system and the other an oscillometric system. The oscillometric system is probably more accurate but doesn't work well for pets weighing less than fifteen pounds making it impractical for use in most cats and many small dogs. It measures both systolic and diastolic pressure. The Doppler system only measures systolic pressure. It can be used in any size patient but is not considered to be as accurate and requires a trained operator." from http://www.vetinfo.com/dbloodpressure.html

[foxandhound]

Hi Leslie, you're right, someone else's pup may gone home on a clear bill of health, but this could be their test. So sad. Honestly, this is the second time that a vet office would have to redo the test. I will ask them to do it in front of me, to show me the the labeled info, etc. :( I dont care bc I am still searching for a good vet and their impression of me can be whatever they want to it be, I need meaningful results.

Can someone tell me a little more about the false positives with ACTH testing? Also, can a dog test positive with ACTH and have problems with the intermediate sex hormones as well? Would that be typical and atypical?

Addy, good point! I will study the requirements from UTK and bring them in, make sure they do it correctly. Does it have to be overnighted the same day? I agree to wait on treatment, but so many of the vets Ive spoken to view it differently. Do you think that waiting to do treatment can cause more damage to the liver and kidneys?

Now that we are redoing the test, should be done in the morning, after fasting? It should, right?

Honestly, I feel like if I didnt have you guys to guide me, we would be lost and I wouldnt be able to watch these vets and techs like a hawk. Too bad you cant trust them to be up to date with info and efficient. It's asking too much, huh?

[foxandhound]

I need some clarification on the procedure so I know what to watch for, I just dont trust these people.

What type of tube should the sample be in? Plain plastic tube without polymer gel/serum separating?
Should it be shipped with ice packs?
What is gel-ACTH, how will I know which method the vet office is using?
If samples are hemolyzed, the vet office should not submit them and they should redo the ACTH test in a week and then submit it?

Here are the directions from UTK:
Please do not send samples in serum-separator tubes (polymer-gel-tubes). This causes hemolysis of samples and the gel is known to precipitate drugs.
Clot at room temperature, centrifuge within 1 hour, remove serum and freeze.
Alternatively, store blood samples in the refrigerator for 2 to 4 hours to clot, centrifuge, remove serum and freeze.
Ship samples in insulated container with adequate cold packs and insulating materials (peanuts, paper), being careful to pack to avoid leakage or breakage (plastic tubes are recommended).
All Adrenal function tests use serum samples.
Collect baseline serum sample (2.0 ml.).
Centrifuge sample as soon as possible, separate and freeze.
Administer the ACTH Stim test. Collect Post-ACTH serum sample (2.0 ml) at 1 hr (2 hrs if gel-ACTH is used).
Centrifuge sample as soon as possible, separate and freeze. (NOTE: If samples are grossly hemolyzed, repeat test in one week).
The following hormones will be assayed: Cortisol, Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone.

[Squirt's Mom]

Hi again,

Debbie can tell you more about what UTK is needing re the sample and so forth so hopefully she will be along and help us understand a bit more. When Squirt has hers done it is shipped in dry ice is about all I can tell you! :p

Ok - true, or conventional, Cushing's involves cortisol. Anytime the cortisol is elevated the pup is considered to have true Cushing's even if the intermediates are elevated, too. If a pup has only elevations in any of the five intermediate hormones but the cortisol is within normal range, that pup is said to have Atypical Cushing's.

Elevated Cortisol = true Cushing's
Elevated intermediates only = Atypical

Hope that answers the question!

Hugs,
Leslie and the girls - always

[addy]

I think ask them have they ever sent samples to UTK and do they know the requirements and "here they are, by the way, I just happened to bring them along just in case. When will you be sending the samples? Will they be going overnite? Gee, the requirements are pretty specific but I don't have to worry about them being done wrong, do I?"

I would start there.:D Ideally they should prepare and submit the same day. Don't have test done on a Friday.

Aytpical is when the cortisol is not elevated but some or all of the intermediates are elevated. Typical is when the cortisol is elevated and some dogs like my Zoe, have all her intermediates elevated as well as her cortisol.

Stress and other illnesses can give a false positive on an ACTH test. From what I have read, dogs that have symptoms but tests are inconclusive (borderline) have the adrenal panel done to test for atypical because the intermediates can cause the same Cushings symtoms as high cortisol.

In our case, we had mild symptoms and a high UC:CR test (but I had a similar experience as you and test was not done correctly so who knows?) which warranted further testing. Zoe was presenting hair/coat skin issues mainly at the time and mild elevation in ALP and cholesteral. IMS said do UTK panel and ultra sound. Low and behold, enlarge adrenal glands showed up and UTK panel was marked "significant adrenal activity":eek: Yet she had such mild symptoms and blood work was fairly normal.

Let's wait and see what your UTK panel shows. I fasted Zoe for her test but she also had other blood work done. It might not be required but may be a good idea to fast if your dog does not have a problem with fasting.

Hang in there. Sometimes finding the right vet is so darn hard. We have had four.

Usually Cushings is a slowly progressing disease. Getting the right diagnosis is important. You have time. When I freaked out about kidney problems and diabetes if I waited to treat, my IMS said, but you could end up with that anyway or even if she was not a Cushings dog so I felt I had time. We started this journey last April.

You have time.

Hugs,
Addy

[Harley PoMMom]

Atypical Cushing's involves only the hormones Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone. A pup with Atypical will not have elevated cortisol.

Conventional, or what is also called true Cushing's, does involve elevated cortisol and may also involve any of the other hormones - Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone.

If a pup has only elevated estradiol, it is called Hyperestrinism.

Excessive lipemia (fat in the blood) can affect the results of the ACTH assays. So a very light meal or fasting is a good idea.

Hope this helps.

Love and hugs,
Lori

[Harley PoMMom]

What is gel-ACTH, how will I know which method the vet office is using?


"Cortrosyn" and "ACTHAR gel" and another agent called "Synacthen" are actually synthetic forms of ACTH that when injected, stimulate the adrenal glands to release their reserves of cortisol into the blood stream.

There are many vets who use the gel, but the Cortrosyn or Synacthen do seem to be the stimulatory agents preferred by Internal Med Specialists, many of whom find the ACTHAR gel to be less reliable as far as getting consistent results is concerned.

Did you get a bill of sale or a break down of what was done? If so, it should say what kind of stimulation agent that was used.

[foxandhound]

I have a bill of sale, but all it says is ACTH stim Adrenal- Tenn

I didnt get any info on the stim agent. :( What should I do if they tell me it's gel based? Try to get a refund and get it somewhere else? I know that sounds extreme, but I am at my breaking point with these vet experiences gone wrong. lol.

[foxandhound]

Lori,

I read that you wrote the following of Harley...I feel the same way. I feel like I am overlooking symptoms and seeing them now or seeing them psychosomatically. lol. What made you think that you should have started Lysodren sooner? How is Harley now? Is he still doing well on Lysodren? I just dont get it, when to start, not to start, I am pretty sure that was Mandy's positive test. She wont really jump up, maybe she has some rear leg pain, her drinking has increased, she seemed confused about where to lay today, and she didnt keep up on our walk. Today was an "off" day and it scared me. :*(
I am so afraid of Lysodren, but more afraid of ruining her organs by ignoring the high Cortisol. This next week will be hard on me. We are re-doing the test on Monday. Maybe I can expect the results by the following Monday. I am pretty sure this is progressing since I started this thread and THAT is scary. It went from no symptoms to...symptoms...but no accidents in the home. She still pees on a nice schedule. Goes out 5-6 times a day. Marks or urinates more only on walks. I dont know. So confusing.

"Harley's symptoms were excessive drinking and urinating, ravenous appetite, pot-belly, panting, minor weakness in his rear legs and he started to lose the hair on his tail.

In the beginning his cortisol remained in the normal ranges so we only treated the high estradiol. Looking back now...Harley had ALL the cushings symptoms and I should have loaded him on Lysodren then. We did not start him on the Lysodren until his cortisol rose to 18.5 ug/dl and it's only been a maintenance dose. I have done alot of testing on my boy...full adrenal panels, endogenous tests, LDDS test, 2 ultrasounds, etc... His last full adrenal panel done in Nov. 09 showed that his estradiol has decreased from 132 to 96 and some of his symtoms have also waned. He is no longer the piggy who wants to eats everything in sight, he does not drink or urinate excessively anymore and he does not pant alot. He does have a rat tail...poor Harley."

[Harley PoMMom]

My boy was dx'd with pancreatitis along with his Cushing's...Thank God for the excellent U/S!! Unfortunately when I tried to load him with Lysodren his pancreas could not tolerate it.

We then did a 2 month wash-out period and started Vetoryl. On the 10th day I took him for his scheduled appt. (ACTH stim, Chemistry, CBC). The Chemistry panel came back that his kidney values were elevated so he had to stop taking the Vetoryl. Harley is dx'd with kidney disease now, so I am not treating his Cushing's. Harley is doing pretty good considering all he is going thru...his appetite is good, he plays and goes for short walks.

Harley's endogenous test results were high even though his ACTH stim tests were normal...it was confusing!!! I do believe that one should treat based on numbers AND strong symptoms.

What I wished I would of done, was, instead of doing the maintenance dosing of Lysodren, I should of either loaded him with the Lysodren or started him on Vetoryl, when his cortisol first became elevated. Don't be afraid of Lysodren, we will help you if you choose to use this medicine.;):)

Love and hugs,
Lori

[foxandhound]

Harley sounds like a good boy and hanging in there. Sorry to hear about his kidney problems. Sounds like he is enjoying life though and that's the most important thing to hope for! Is it often recommended to stop treatment if kidney disease occurs or gets to a certain level? Basically, if the urine culture comes up negative, I wonder if treatment is warranted to stop the proteinuria,,,would Lysodren possibly stop the proteinuria? For me, that is the scariest part. What is the endogenous ACTH?

Last thing, Mandy's thyroid medication was increased from 0.2 to 0.3mg bid since a T4 test showed low thyroid. The t4 is now normal, but a full T assay panel was not done. Is it dangerous to increase T meds without a newer full panel T assay?

Lots of love!

[foxandhound]

Hi everyone, sorry to post again, but Mandy is not well. I think we are maybe dealing with pancreatitis, not sure. It's my first time with these symptoms. She started yesterday with diarrhea and today, more diarrhea, vommitting, and the most drinking I have EVER seen from her. I am scared. We were going to the vet tomorrow to re-do the ACTH test that they "accidently" submitted to Antech instead of UTK. My boyfriend thinks it was intentional and they thought they could charge us $300 for an Antech ACTH and we wouldnt notice. :(

However it happened, I lost a week here since we wont get the results for another week or longer and on top of it, Mandy is ill right now and I am not sure if she should have the ACTH until she perks up a bit. I am hoping to avoid a false positive or something. What should I do? I think I will call our previous vet, since she has known Mandy since we got her. I like that place and I like that vet even if she scared me about treating Cushings. I want to treat it if that's what it is. So scared.

[foxandhound]

I read that if you suspect pancreatitis, you should feed a low fat, low protein, high fiber diet? What homemade items should I feed until we test the amylase and lipase tomorrow? I guess diarrhea and vomitting could be anything though. Ideas?

[AlisonandMia]

I haven't read your entire thread but I think when you have vomiting and diarrhea that feeding nothing is the safest way to go - whatever the cause turns out to be. Resting the GI tract is always the safest option. If it is acute pancreatitis then any food (or even drink) can be a problem as the arrival of stuff in the stomach stimulates the pancreas into more activity which is not what you want.

You could offer Pedialyte or similar (check there is no xylitol in the ingredients though).

Alison

[frijole]

Hi! I agree with Alison - I would withhold all food. If Mandy is drinking gobs and gobs of water she might end up vomiting it. That happened to me once. So if she keeps vomiting put the water up and let her tummy rest.

Regarding the acth test - forget about that for now. With her being sick it is sure to impact the results. The vet will probably want to do a blood panel to figure out what is going on.

I did buy Pedialyte and mixed it 50/50 with water. But that was after a good 24 hrs of fasting and after I went to the vet. Sending warm thoughts your way. Kim

[foxandhound]

Thanks guys. It tough. She went from awesome, no symptoms to this in a weekend. :(
One more question, the 2nd vet (not the one I have been seeing for years) did a Protein:Creatinine ratio with urine that they collected mid-day and not first catch. Should we re-do the ratio with first catch of the day? :(

[frijole]

I know you are concerned about cushing's dx but right now I would just focus on whatever is ailing her and causing the diarrhea and vomiting. It could be that it isn't cushing's but something else so I wouldn't be concerned with redoing the urine test right now either. Hope Mandy is feeling better. Is she still vomiting and having diarrhea? Good luck, Kim

[littleone1]

Hi,

Just a quick comment about thyroid medication being increased without a full panel being done. Corky has been on Thyroid meds for over 10 years. His meds have been increased or decreased only with a T4 being done. About a year ago, we also did a FreeT4.

Terri

[lulusmom]

I agree with Kim that as long as Mandy is not feeling well, I would not have any cushing's diagnostics done. Any illness can cause a transient elevation in cortisol so make sure all testing is done under optimum conditions....low stress, eating normally and healthy poops. :)

With respect to your question about increasing Mandy's thyroid meds without doing the proper testing, you'll know if the dosage is too high because it will throw Mandy into "Hyper"thryodism and she will start drinking and urinating excessively.

[Squirt's Mom]

How is Mandy this morning? When Squirt had her acute pancreas attack, I was told to withhold all water and food as anything by mouth triggers the pancreas to release enzymes which will keep the organ inflamed - and possibly cause permanent damage to it or other organs. She, too, had vomiting and diarrhea.

As Glynda said, doing an ACTH while she is sick is a waste of money, time, and would be an unnecessary stress on Mandy. An illness can cause the cortisol in the body to rise in NORMAL response to the stress of the illness which will show up on any Cushing's test. So you may end up with a positive when it isn't Cushing's at all but pancreatitis causing the cortisol to rise. This would hold true if it were something like a UTI, even. So let Mandy get well, then redo the UTK panel.

Anxious to hear how she is today.

Hugs,
Leslie and the girls - always

[Harley PoMMom]

I read that if you suspect pancreatitis, you should feed a low fat, low protein, high fiber diet? What homemade items should I feed until we test the amylase and lipase tomorrow? I guess diarrhea and vomitting could be anything though. Ideas?

Amylase and Lipase, both of these, when elevated, can be indicators of pancreatitis. But other things can make these values be high, especially the lipase, lipase is non-specific because there are digestive lipases, intestinal lipases, lipoprotein lipase and hepatic lipase, hormone-sensitive lipase, and lysosomal acidic lipase. :eek::eek:

To really confirm if Mandy has pancreatitis then I would ask your vet about having a spec PL test done on her. The spec PL will test for the lipase that is specific for the pancreas only. It has more than 95% specificity and sensitivity at diagnosing pancreatitis. Here is a link with info about this test: http://www.idexx.com/view/xhtml/en_us/smallanimal/reference-laboratories/testmenu/innovative-tests/spec-cpl.jsf?SSOTOKEN=0

The usual diet for a dog with pancreatitis is very low fat, moderate protein and high in carbohydrates.





Thanks guys. It tough. She went from awesome, no symptoms to this in a weekend. :(
One more question, the 2nd vet (not the one I have been seeing for years) did a Protein:Creatinine ratio with urine that they collected mid-day and not first catch. Should we re-do the ratio with first catch of the day? :(

Although I am no vet, as far as I know one does not need the first morning urine for an UPC test.


Urine creatinine excretion is very stable and is used in the ratio to adjust the urine protein concentration, which can fluctuate according to urine volume and concentration.
This makes the test robust and provides valid results regardless of the patient’s hydration status or urine concentration ability.
http://www.banfield.net/journal-archive/2005/nov-dec-2005/02-diagnosing-chronic-rena-disease-in-cats.pdf

Love and hugs,
Lori

[foxandhound]

Hi everyone, thanks so much for the well wishes and clarification on whether to proceed to testing during times of illness.

Unfortunately, Mandy took a turn for the worse. Just a few days ago, she was playing, running, and wrestling our other pup, and now, it doesnt look so good.

She was unable to walk well or stand up on her own today. It is painful to watch. Is this possibly a thrombo-embolism?? :**(

The diarrhea has stopped, she passed 2 normal stools in the morning and afternoon, and she has had no further episodes of vomitting. She has a bit less appetite, but still eats her meals up like we are used to.

We rushed her to the vet and the vet said that she just cannot care properly for Mandy since so many problems are concurrent and beyond the scope of general medicine. I agree with her, I just didnt know where to go. She recommended what appears to be an affordable speciality clinic. Mandy has a 4/6 murmur, elevated liver enzymes, proteinuria, and now problems standing and walking. :(

She referred us to an IMS whom we are seeing tomorrow. We decided not to go to the clinic tonight since the general vet would be there and we prefer to be seen by the specialist. Our vet told us that treating Mandy for Cushings if it is in fact Cushings is a catch-22 because the arthritis, inflammation, allergies, and other problems can and will resurface and cause poor quality to Mandy's life.

She also said that BP meds, pain meds, and anti-inflammatories can cause further kidney damage and to discuss with the IMS. She will be checking in with the IMS and we will all communicate.

Mandy's urine culture came back negative. God, I wish this was just a UTI. We will have bloodwork done tomorrow and discuss high resolution ultrasound.

I am so miserable. Last night, I stayed up until 8:30am, slept til 10:30am, and here I am now. My eyes are hurting me. Mandy is finally sleeping, dreaming, making little dream noises as she usually does. I love her so much. I am so scared. So scared. This sounds like a thromboembolism to me? Should I give some baby aspirin I kinda forgot to discuss this with our vet. :( EDITED TO ADD: She really isnt sleeping, she snores for a few minutes, then wakes up. I wish she could sleep and heal, but she is restless and unable to move much.

[foxandhound]

I am so scared. If anyone has anything to say about pain and inability to move back legs as much, or thromboembuli, please talk to me. Mandy demonstrated that she wanted to sit with me on the couch, but she couldnt get up. We are together, next to each other now on the couch. Tonight, she will get a nice cooked meal, a boiled steak with the fat cut off, some boiled potatoes or rice, and an egg. Just ya know, stuff she loves loves loves that wont alter the bloodwork too much. I am losing my mind, full of fear. Mandy has only been with us 3 1/2 years or so. She changed my life. I was going to go to medical school, but I am applying to vet school next year because of my Mandy.

She is a snuggler, a lover, she stares deeply into my eyes and I in hers. I can see her beautiful soul. I know she loves me and that was the first time I ever opened myself up to a pet in over 11 years since I lost my cat. Something about Mandy felt special and our bond is strong. I know I need to pull it together for her, but I'm a mess, crying, typing, wishing I didnt quit smoking.

I expected my Foxy, 2y/o to stay by Mandy, try to play with her, or something, but he just seems nervous and he watches from a distance. However, when we left for the vet without him, he was objecting and seemed distraught, and when we came back from the vet, he was so freggin happy to see her, he was kissing her and jumping all around. They are the best of friends, but I guess he is picking up on Mandy's needs.

[AlisonandMia]

Thromboemoli is a possibility - but probably not the most likely. Some sort of arthritic/spinal/soft-tissue thing is more likely, statistically speaking.

Sounds like she needs a thorough exam from a vet. If her kidneys are possibly compromised I'd be wary of aspirin without a vet's say so. Aspirin is a NSAID and, as I understand it, can have a similar effect on the kidneys as the other NSAIDS.

Alison

[Harley PoMMom]

About the Thromboemoli, can you feel her pulse in her rear legs and do her rear legs feel cool or warm to the touch?

[addy]

I don't know what to say or how to help except to tell you I know what you are feeling, I have only had my Zoe for the same time, 3 1/2 years. She has been sick most of that time except the first year and now Cushings.

I understand how you feel and no sleep makes it worse. I pray tomorrow you will find some answers even thought it seems like an eternity away.

Hold on to the thought she is still eating and voiding normally again. That is a positive. Just hold on to that until you see the specialist.

Waiting is the hard part, fraught with worry. Try to sleep.

Hugs,
Addy

[gpgscott]

I know you are concerned about cushing's dx but right now I would just focus on whatever is ailing her and causing the diarrhea and vomiting. It could be that it isn't cushing's but something else so I wouldn't be concerned with redoing the urine test right now either. Hope Mandy is feeling better. Is she still vomiting and having diarrhea? Good luck, Kim

I think Kim is exactly on track here.

Cushing's is not immediately harmful, I also would concentrate on getting Mandy stable and well and then plan a systematic diagnostic process.

Scott

[gpgscott]

I am so scared. If anyone has anything to say about pain and inability to move back legs as much, or thromboembuli, please talk to me.

If you are talking about what is commonly referred to as a saddle block I have had an experience with a cat. If my experience was typical there is no mistaking it. It brought about total loss of control below the waist and much pain. A vet will diagnose it rapidly by lack of pulse, as has been suggested cool feet are another clue.

Scott

[frijole]

I don't understand why your vet is even discussing cushings right now... the dog is very sick - at least from the description. With the vomiting and diarrhea I am surprised Mandy isn't at the hospital on IVs or at least wasn't checked to make sure she doesn't need fluids.

I don't want to scare you but is there a large animal hospital in your area? Does the specialist you are talking about seeing tomorrow have a cell phone you can call? I just think I'd take Mandy in... but not to the same vet you have been talking about.

Again, this is not cushings you are talking about and I wish I could tell you what it is but I cannot. I will be sending prayers and warm thoughts your way. Kim

[foxandhound]

Thank you everyone. We would be so alone without your knowledge and compassion. I mean it. This is a scary time for us since this is such a drastic change.

The vomitting and diarrhea have not occured since Sunday. On Monday, our vet did several blood pressure cuff readings in front of us while we held and comforted Mandy and during that time, we chatted and I was the one talking about Cushings sx and rx. All of Mandy's vitals were in the normal range, though her diastolic blood pressure was borderline-high. She said Mandy appeared slightly dehydrated, but since Mandy drank in front of her, she did not believe hat Mandy required overnight care.

All this aside, Mandy was struggling to stand and move; I made the call. The ER vet told me to give 1 baby aspirin. I'm not sure what happened, but Mandy improved a lot and her drinking decreased. Her walk and ability to stand up was not back to 100%, but it became 80% better. Which to me, went from it looked like she was dying...to she became energized, alert, more able, and almost back to herself. She ate that nice dinner I was telling you guys about. ;)

The aspirin was given to her around 9pm, it is now almost 4am and she is again having issues when attempting to stand. She has not slept well in possibly 2 days, I am hoping she will rest now. I will discuss her restless symptoms and the saddle block with the IM vet.

What does this mean? Sudden onset arthritis or thromboemboli or saddle block? How to distinguish? What tests to expect or request?
I just saw that the animal hospital that we are going to, Cooper City VSSF...happens to have many negative google reviews. :( Any insight is very helpful. Very, very appreciated too. I think I will finally catch a few more hours of sleep now. Thank you. So much. :*)

[AlisonandMia]

I think the response to the aspirin suggests very strongly that it was arthritis or something similar. I know that aspirin helps with the tendency to clot but I don't believe it dissolves clots - just stops them forming.

My 18 month-old papillon hurt her back last week and the pain was radiating down one leg so she was very very lame on that leg (it looked like there was something seriously wrong with her knee). A dose of Metacam had a similarly dramatic effect on her well being too. And the time scale was similar as well.

It really sounds like some sort of muscular-skeletal thing to me.

Alison

[frijole]

Are you living where it is extremely cold and snowing? That can make the bones ache... also if they crawl on drifts they can hurt discs etc.. happened to one of my dogs. This doesn't explain why she had the diarrhea/vomit earlier but...

I would write everything that has happened in a journal with dates etc so when you go to the specialist you can remember it all.... can be hard sometimes. Good luck!!! Kim

[addy]

Just wanted to tell you thinking about you today and hoping you get some answers. I found some times it helps to take a notebook to write things down, your questions on the way to the appointment or things that come up durring the visit.

Zoe was drinking more water and urinating longer and losing weight with worsening hind legs weakness. I was terrified it was diabetes. Turned out it was not. Waiting for tests to find out what is going on. Could just be cortisol rising.

Point is, sometimes we fear things and symptoms look like our fears but then it is something completely different. ;)


Gosh, too bad we all can't have an in home vet:D

Hope you got some sleep. Sometimes when I get all scared I take one of Zoe's melatonin:rolleyes: I think it is a placebo effect as it is only 1 mg and should not mean anything but for some reason, I sleep for a few hours. Funny how our minds work:rolleyes::o

Corssing everything we can for you.

Hugs,
Addy

[gpgscott]

I also agree that it sounds like pain and judging from your description of the mobility issues is a spine issue. Asprin must be used with extreme care due to gastric bleeding issues, I remember reading somewhere that either pepcid or tagamet (famantodine, ranantinine) should be administered with asprin. There are many good non steroidal anti inflamatories which are easier on the pup than asprin.

Hope you learn more soon.

Scott

[Squirt's Mom]

Mornin' sweetie,

You have had a rough few days. :(

Is Mandy any better this morning or about the same? Does she she a doc today? When you described the reaction to the aspirin my first thought was of inflammation somewhere causing her back-end problems. Aspirin is a great anti-inflammatory as well as blood thinner. For whatever reason, I am glad it helped Mandy. That has to be so very scary and sad to see her not be able to move. :eek::(

When you talked of looking into Mandy's eyes and seeing her soul, I knew exactly what you meant. I not only see Squirt's amazing soul in her eyes, I see my own as she sees it - which is with much more forgiveness and acceptance than I do. I see a better me in her eyes which makes me strive to be that person she sees.

I have no doubt that Mandy knows you are doing all you can to figure out the problem and get her the help she needs. She knows you are giving her your very best, your all - and loves you all the more for it. You are a good mom; don't forget that when things get tough. Mandy could have no one better on her side than you.

Keep your chin up!
Hugs,
Leslie and the girls - always

[jrepac]

Hhhmm....sounds like it could be arthritis or some sort of injury to hips or back that is causing pain. The fact that she can rise better after the aspirin tablet does suggest that. Just be careful w/the baby aspirin; you may want to visit Petco or PetSmart; they should have BUFFERED doggie aspirin, which is less likely to cause stomach upset.

Until this and other stuff gets taken care of, I would say put the ACTH test on that backburner....particularly since you are not seeing very many Cushings symptoms at this stage.

I hope Mandy feels better soon!

Jeff & Angel Mandy

[littleone1]

I'm glad to hear that Mandy is doing better. Corky takes baby aspirin when needed for his arthritis. His IMS said that I could give it to him as long as I give him his Pepcid AC.

I hope Mandy continues to improve.

Terri

[foxandhound]

We saw an IMS earlier today and when we got there, we realized he was a cardiologist, I kinda thought we would see a liver/kidney specialist (it's a specialist and surgical hospital with about 20 internal med specialists), but I guess based on her murmur and leg pain, they matched us. He was very good, but you know me, I scrutinize everything. More on this later. Mandy had an evaluation, an abdominal ultrasound, and thoracic ultrasound. All I know is, it was so high res that they didnt even have to shave Mandy. :D I thought she'd come back shaved, but no. LOL.

As it turns out, Mandy does have a very small nodule on her left adrenal, but the right adrenal is normal in size. They are pretty sure the nodule is not a secretory adrenal tumor since there is no concurrent atrophy of the other adrenal gland, both are the same size. Does this sound right to you? They said if it is pituitary based, not to treat until symptoms like constant urination, constant thirst, skin infections, hair loss occur. They think the postive ACTH could have been from the kidney problems.

They said that the recent increase in thirst was likely due to the increase in soloxine and that t4 is ok to measure thyroid levels especially if we are talking about a 0.01mg increase. They said that the water consumption will likely taper off since the change was very recent.

She has an enlarged liver, her liver and spleen have some mottled texture. Nothing further was explained there except the Alk P enzymes and intermediate elevated platelets which is present in "Cushings patients and patients without Cushings".

She has a very mild chronic mitral valve disease, no heart enlargement and her risk of heart failure is very low for now. Also, there is no evidence of pulmonary arterial hypertension, which is usually seen in Cushings dogs. It seems they think the leg pain was sudden onset arthritis?

She has multiple kidney cysts and this is linked to her excreting protein in her urine. The 48 hour urine culture came back negative, but it was done by free catch, I fogot to tell them them too. So much was going on. :( We were instructed to change her raw homemade diet to 50% meat/organ/eggs and 50% veggies. There are no worries about Phosphorus levels yet. Glomerulonephritis was not discussed but now that I am typing this, I am wondering if that's what is developing here.

As I figured, We were given blood pressure meds for the proteinuria altough Mandy has normal BP. They said this medication would be needed for the rest of her life. Specifically, an Rx for Enalapril which kinda has me confused since I'm pretty sure it is excreted through the kidneys whereas Benazapril is excreted via the liver (or, did I say it backwards?).

So, some questions...
1. Why use a med that is hard on the kidneys for a patient with kidney problems????????? The vet's answer: it is FDA approved for use in dogs. Ok. :/ What do you guys make of that? He said he will change it to Benazapril *if* Mandy vomits or starts showing lack of appetite?
2. What the heck to give Mandy for the hind leg pain or arthritic flair-ups bc aspirin is a no-no on anti-inflammatories?
3. What are some kidney supplements you guys can recommend? I have heard vitamins (E, B complex, coQ10)?

Thanks guys. We are home now and there is some relief and some more panic. Some much needed sleep for all of us. <3 <3

[foxandhound]

I justed typed up a special thank you to everyone, i hit backspace accidently, and it's gone. :/ :/ :/ It was a thank you for your help, guidance, knowledge, and compassion when I needed it most. I dont really find that warmth among friends and some family members when discussing my dogs. Most people I know who care for pets dont do it the way we do it. (We = you guys!) We love our furry doggy and kittie soulmates. Abandoning them in times of illness and need is simply not an option though most of the people I know have done so to their pets. Mandy is still loving her belly rubs, meals, walks, and snuggle time, and that is worth everything to me. I do not have a single friend or family member who cares for their pet as we do. It's kinda lonely. You guys have made it less so. I knew you were out there. Thank you from the bottom of my heart.

[frijole]

Great update and it sounds like this vet was very thorough and worth the trip huh? Your case sounds very much like my Annie. She's my 2nd dog that was diagnosed with cushings... but later we found out she most likely does not have it... (5 false positives on acth and one on ldds) She too has a small adrenal growth and her legs all of a sudden gave out. She has a heart murmur but also pretty severe inappetence.

I am going to direct you to a thread I started on a product called duralactin. It is 100% natural product used as an anti inflammatory! I learned about it from the head of the small animal science department at Kansas State Univ Vet Hospital. So far it has really helped Annie. Please consider trying it. No script needed either - bought online!

But first read for yourself, google and see the testimonials. Hope it gives you relief! Kim

http://www.k9cushings.com/forum/showthread.php?t=2635

[addy]

I second what Kim said:D Great update.

It sounds like the specialist was thorough. I was on Mary Strauss' website dogaware.com the other day and she has some info on diet and kidney disease along with some links to some new studies and new thinking about protein and kidneys. If you have not been on her site, maybe check it out. I always learn something from Mary. She also writes for the Whole Dog Journal.

If i need to go that route with my Zoe, I will try the Duralactin Kim suggested. I read her links a while back and was impressed.

Hope you get some sleep:)

We are always here for you.

Hugs,
Addy

[lulusmom]

Hi Annie,

I see that you had a few questions that have not yet been address so I'd like to take a crack at them. :D Please see my text in blue below.



As it turns out, Mandy does have a very small nodule on her left adrenal, but the right adrenal is normal in size. They are pretty sure the nodule is not a secretory adrenal tumor since there is no concurrent atrophy of the other adrenal gland, both are the same size. Does this sound right to you?

Yes, that sounds correct. If the nodule was a functional adrenal tumor and secreting cortisol, it would have shut off the feedback between the pituitary and the adrenals, causing the remaining adrenal gland to shrink or atrophy from lack of use.

They said if it is pituitary based, not to treat until symptoms like constant urination, constant thirst, skin infections, hair loss occur. They think the postive ACTH could have been from the kidney problems.

I personally believe this to be very sound advice. Any nonadrenal illness, as well as extreme stress can cause transient elevations in cortisol which can yield a false positive ACTH stim result.

They said that the recent increase in thirst was likely due to the increase in soloxine and that t4 is ok to measure thyroid levels especially if we are talking about a 0.01mg increase. They said that the water consumption will likely taper off since the change was very recent.

I believe I mentioned a few days ago that if a dog is receiving too much soloxine (thyroxine), s/he will start drinking and peeing in excess. This is the hallmark symptom of hyperthyroidism. Hopefully, the specialist is right and the water consumption will abate. If this should happen, that would be pretty good evidence that Cushing's may not be involved.

She has a very mild chronic mitral valve disease, no heart enlargement and her risk of heart failure is very low for now. Also, there is no evidence of pulmonary arterial hypertension, which is usually seen in Cushings dogs. It seems they think the leg pain was sudden onset arthritis?

Did any of the vets rule out hip displaysia, cruciate ligament injury or luxated patella? Any xrays? I noted that Mandy's pain seemed to get better with aspirin. This would indicate that there is some sort of inflammation that the aspirin is addressing which would be odd if Mandy had cushing's. Cortisol is the body's natural anti-inflammatory so if Mandy had elevated cortisol, she would be self medicating herself and would probably not be feeling any pain. A lot of pet owners don't know their cushdog has arthritis until treatment brings cortisol levels down.

As I figured, We were given blood pressure meds for the proteinuria altough Mandy has normal BP. They said this medication would be needed for the rest of her life. Specifically, an Rx for Enalapril which kinda has me confused since I'm pretty sure it is excreted through the kidneys whereas Benazapril is excreted via the liver (or, did I say it backwards?).

So, some questions...
1. Why use a med that is hard on the kidneys for a patient with kidney problems????????? The vet's answer: it is FDA approved for use in dogs. Ok. :/ What do you guys make of that? He said he will change it to Benazapril *if* Mandy vomits or starts showing lack of appetite?

Since you originally posted about possibily giving Mandy enalapril for the proteinuria, I did a bit of checking around and found an interesting study that showed improvement in proteinuria in dogs with confirmed glomerulonephritis via biopsy. That sounds pretty promising to me.

2. What the heck to give Mandy for the hind leg pain or arthritic flair-ups bc aspirin is a no-no on anti-inflammatories?

Do you have a confirmed diagnosis of arthritis? As I mentioned above, if Mandy has high cortisol, she is probably not suffering from arthritic pain. Cushdogs do experience hind end weakness due to the muscle wasting (catabolic effect of excess cortisol). Did any of your vets mention this as a possibility? Sorry to answer a question with more questions but more information is needed. For instance, there are some effective nonsteroidal anti-inflammatory (NSAID) drugs, such as Metacam, that are great for arthritis but I would not recommend any NSAID unless I knew for a fact the dog does not have cushing's. NSAID's and steroids are a really bad mix for a number of reasons but mostly because both adversely impact the liver and can cause serious GI problems. If you know for a fact that Mandy's problem is arthritis, you may want to talk to your vet about adaquan injections. We've had members who report really good results.

3. What are some kidney supplements you guys can recommend? I have heard vitamins (E, B complex, coQ10)?

One of my favorite sites for info on kidney stuff is Dogaware.com. You can find some great information there, including diet and appropriate supplements.

http://www.dogaware.com/health/kidney.html

[foxandhound]

Kim and Addy, that is wonderful. We will definitely try it for sure! So glad to know that there is something to help since the IMS said Mandy will be on BP meds for proteinuria probably for the rest of her life. Kim, are you able to know why the inappetance? Has anything helped?

LuLu's mom, what a godsend you are! So so thankful for your checking in on us. Means so much. I have been a member of a couple yahoo groups, but never received the level of care and info like this. Really feels good to be here.

Yes, that sounds correct. If the nodule was a functional adrenal tumor and secreting cortisol, it would have shut off the feedback between the pituitary and the adrenals, causing the remaining adrenal gland to shrink or atrophy from lack of use.
Is any adrenal shrinkage expected of pituitary cushings? I guess I am asking bc the ACTH has a higher chance of coming back with a false positive. The IMS told me that the ACTH and LDDS are just a waste right now, but he thinks the intermediate sex hormones may show us something.

Not sure if you guys remember, but the recent vet we saw intentionally/unintentionally sent our ACTH to Antech. Yep, I paid $300 and they sent it to Antech who charges like $30 and doesnt test the intermediates. They almost pulled a fast one on me, but thanks to you guys, I caught it. Also, they told me Mandy's UP:Cr was missing, then they said it they found it and it was normal, yesterday when the IMS requested it, they told me that they never sent the sample. We paid them over $500 for three tests and none of them were done correctly, one not even done at all. Even the BP was only taken once, but I was told they would take at least 2 readings. Honestly, lies and lies. Of course, the people at that office think I am crazy and I think they are thieves. Long story short, we have a credit with them to redo the tests there and I guess we will though I would rather get my money back and do those things at my former vet's office.

I believe I mentioned a few days ago that if a dog is receiving too much soloxine (thyroxine), s/he will start drinking and peeing in excess. This is the hallmark symptom of hyperthyroidism. Hopefully, the specialist is right and the water consumption will abate. If this should happen, that would be pretty good evidence that Cushing's may not be involved.
You DID mention this!!! Man, you are smart cookie and low and behold, her water consumption has decreased a lot. It's not normal per say, but normal for her as opposed to two days ago, she was drinking 3xs what she normally does.

Did any of the vets rule out hip displaysia, cruciate ligament injury or luxated patella? Any xrays? I noted that Mandy's pain seemed to get better with aspirin. This would indicate that there is some sort of inflammation that the aspirin is addressing which would be odd if Mandy had cushing's. Cortisol is the body's natural anti-inflammatory so if Mandy had elevated cortisol, she would be self medicating herself and would probably not be feeling any pain. A lot of pet owners don't know their cushdog has arthritis until treatment brings cortisol levels down

That's an excellent explanation and no, no one looked at her hips or knees. It was such panic that it escaped me to request that. Very possible, but guess what- Mandy wrestled my other dog today and she bounced around and play bowed with my other dog. She is still slow upon getting up, but she can get up and she started jumping on the beds and couches again. She can jump on me too. What kind of inflammatory attack would that be that would happen so dramatically and just kinda resolves so fast. I know it will probably happen again, those things are not just one time incidents. Also, she finally slept throughout the night. Finally! I was so worried bc she wasnt sleeping.

Cushdogs do experience hind end weakness due to the muscle wasting (catabolic effect of excess cortisol). Did any of your vets mention this as a possibility? Sorry to answer a question with more questions but more information is needed. For instance, there are some effective nonsteroidal anti-inflammatory (NSAID) drugs, such as Metacam, that are great for arthritis but I would not recommend any NSAID unless I knew for a fact the dog does not have cushing's. NSAID's and steroids are a really bad mix for a number of reasons but mostly because both adversely impact the liver and can cause serious GI problems. If you know for a fact that Mandy's problem is arthritis, you may want to talk to your vet about adaquan injections. We've had members who report really good results.

Thank you, I will look into this for sure. So so helpful! I am sad that we cannot use aspirin and typical arthritis meds. Hopefully, adaquan and duralactin.

[lulusmom]

Hi again. I've put my comments in blue again below.


Is any adrenal shrinkage expected of pituitary cushings?

No, both adrenals are usually enlarged with pituitary dependent cushings. Here's a an explanation I posted to another member's thread that may help:


Hi Janis,

An endogenous acth test does not measure cortisol...it measures the amount of acth in the blood. Dogs with pituitary tumors will have normal to high amounts of acth in their blood because the lesion/tumor is causing the pituitary to continuously release acth into the bloodstream. Depending on the stage of disease, feedback between the pituitary and the adrenal glands may not be lost yet so the amount of acth in the blood is still normal. As the disease progresses, feedback is eventually lost between the pituitary and the adrenal glands and the pituitary just keeps on releasing acth and the adrenal glands respond by cranking out the cortisol. Dogs in this stage of the disease will usually have high acth levels in their blood as well as high levels of cortisol.

An adrenal tumor secretes excess cortisol independent of the pituitary gland. The adrenal tumor could care less about the pituitary gland or the acth it releases and pumps out the cortisol at will. The pituitary gland responds by saying, "hey, there's enough cortisol in the blood so I don't have to release any more acth." This is why dogs with adrenal tumors have low circulating acth and the gland that does not have a tumor will atrophy. It atrophies (shrivels up) because it eventually shuts down from lack of use because the pituitary gland is no longer releasing acth.

It's not an easy thing to explain but I hope I've helped you understand a bit more about the endogenous acth test.

Glynda

I guess I am asking bc the ACTH has a higher chance of coming back with a false positive.

Actually, the LDDS test is more likely to yield a false positive in the face of nonadrenal illness or stress.

The IMS told me that the ACTH and LDDS are just a waste right now, but he thinks the intermediate sex hormones may show us something.

Since Mandy is asymptomatic at the moment and you don't treat a dog with no symptoms, I would agree that it would be a waste of money to do an acth or ldds at this time. Unless there are troublesome issues that your vet thinks could be caused by elevated sex hormone, I'm not sure I'd spend the money for a UTK adrenal panel either. Mandy seems to have been on a rollercoaster ride lately and I personally would take some time to let everything calm down a bit before deciding how to proceed. I would, however, continue with the liver support.

Not sure if you guys remember, but the recent vet we saw intentionally/unintentionally sent our ACTH to Antech. Yep, I paid $300 and they sent it to Antech who charges like $30 and doesnt test the intermediates. They almost pulled a fast one on me, but thanks to you guys, I caught it. Also, they told me Mandy's UP:Cr was missing, then they said it they found it and it was normal, yesterday when the IMS requested it, they told me that they never sent the sample. We paid them over $500 for three tests and none of them were done correctly, one not even done at all. Even the BP was only taken once, but I was told they would take at least 2 readings. Honestly, lies and lies. Of course, the people at that office think I am crazy and I think they are thieves. Long story short, we have a credit with them to redo the tests there and I guess we will though I would rather get my money back and do those things at my former vet's office.

You aren't the first person to cross swords with your vet. I don't consider myself to be difficult to deal with but I've had my share of run-ins with gp vets. I tend to get along much better with specialists. Can you get a copy of the acth stim test that was done by Antech and post the results here? Just curious to see how elevated the cortisol was.

[foxandhound]

You are wonderful, explained everything! About this endogenous test, is that the UTK test? :) xoxo

I will definitely post the Antech ACTH test results tomorrow when I get them. I dont know much about this disease, as you can tell, but I know how to come in fully armed bc I have been let down by some of these people. I try to make comments and ask questions to sometimes imply I know more than I do even if I dont. LOL. A great technique to scare people into being straight with you!

[lulusmom]

If only there was one totally accurate and credible test we could do to give us all of the information we need, we wouldn't have to talk about three or four tests and confuse the heck out of you. Most of us are hugely confused until the light bulb goes on and that doesn't happen overnight. To answer your question, the endogenous acth test is not the UTK adrenal panel. The endogenous acth test is done after an acth stim test or an ldds test is positive for cushing's but you don't know whether it's due to a pituitary or an adrenal tumor. The endogenous acth makes that differentiation.

Glynda

[foxandhound]

You can say that again! The confusion is definitely in the testing and diagnosis steps, the methods of treatment, the decision to treat, the symptoms, well- it's everwhere. :) Thanks for the clarification. Means a lot. Is the endogenous ACTH a better test than the high dose dex test? I only find mentions of HDDS online so aside from hearing some members mention it, it is beyond me.

[foxandhound]

Here is the first ACTH test via Antech:
Cortisol Pre: 3.6 ug/dL
Cortsol Post: 22.8 ug/dL
Normal range for post-ACTH is 5.5-20ug/dL. Post ACTH results greater than 20ug/dL suggest Cushings.
What could this mean, as this value is not too high above 20?? :confused:

The second test will be the UTK Adrenal-ACTH and we will do it next week. ;) It possibly is a waste, but.....if anything is going on with those intermediate sex hormones, we would definitely want to know. I will demand that I am present during the test and that I can take Mandy home in between the blood draws or be present with her since the false positives can occur in stress and non-adrenal illness as I learned here. It's the best I can do snce I already paid for the test and they are not going to refund me for their mistake. :/

I called Dr. Oliver's office to ask if Mandy should have her hypothyroid medication prior to the ACTH test, no one has called me back. Any ideas? :confused:

[lulusmom]

Annie, thanks for posting the results of the stim test. With a post of 22 ug/dl, it's still possible that whatever was making Mandy feel horrible could have pushed the cortisol over 20 ug/dl. I remember when I switched my dog from Trilostane to Lysodren and after more than 30 days her post stim was 22 ug/dl and she was asymptomatic. It wasn't until her post cortisol was over 25 ug/dl that she started showing symptoms again. So, you just never know but if Mandy has typical cushing's, her cortisol will continue to rise and she will become symptomatic.

Since you've already paid for the UTK adrenal panel, you might as well go through with it. It should only take about an hour and a half at the vet's office. The soloxine won't skew the acth stim test. My Lulu is also hypothyroid and unless she is being fasted for a full blood panel, I do not withhold her thyroxine for her the acth stim tests. I'll be interested to see what Dr. Oliver or his staff may have to say about it.

Glynda

[foxandhound]

Oh Glynda, you are the best, thank you for looking at it! Mandy westled her brother and ran in the yard today. Very bizarre. I expect that is not the last we see of those sudden symptoms. I guess its ok now to restest, not ideal, but Ok. Is that LuLu in the pic? If so, geez, what a cutie. My vet never told me to withold Soloxine prior to bloodwork. I asked too. Ugh. Annoying.

BTW, you like thyroxine? It kept crumbling on me so we switched to soloxine. I'll post when Dr. Oliver or his staff replies.

[foxandhound]

Hey guys, I have just a couple questions...if anyone knows anything, much appreciated.

Could a kidney infection not show on up on free-catch 1st morning culture? I am asking because Mandy today tried to urinate about 9 times on our 20 minute walk. The first urination was 8-10seconds long, the others were about 2 seconds long and I'm not sure if she's marking or what, but she doesn't do that in our yard and she doesn't demand to go outside, she goes as often (5-6xs/day) as our other pup.

I dont know if this is a rxn to her increase in Soloxine or what. The drinking has gone back to normal levels. Initially, she was drinking excessively and now she is not. We have not started the Enalapril for proteinuria yet. We are waiting on a more recent UP:Cr.

Should we maybe do a free T4 equilibrium test? I dont really know much about thyroid, are the other levels in a panel as important, and why? I cant find that info on hemopet (?).

You know why I am asking these silly questions? I just found out that "Vets usually use thyroxine on a twice daily basis for a month to two months, and then once daily after that. In dogs, there is a large reservoir of T4 in the tissues and once this supply is replenished it is reasonable to supplement once daily instead of twice daily, unless serum levels fall below normal levels again as serum levels are checked on a routine basis. "
Our vet has had Mandy on Soloxine twice daily for years. :/ Could this do damage to Mandy?

Could oversupplementing thyroid meds for 2 years possibly cause further endocrine problems and kidney problems? :*(

[Harley PoMMom]

Hey guys, I have just a couple questions...if anyone knows anything, much appreciated.

Should we maybe do a free T4 equilibrium test? I dont really know much about thyroid, are the other levels in a panel as important, and why? I cant find that info on hemopet (?).

You know why I am asking these silly questions? I just found out that "Vets usually use thyroxine on a twice daily basis for a month to two months, and then once daily after that. In dogs, there is a large reservoir of T4 in the tissues and once this supply is replenished it is reasonable to supplement once daily instead of twice daily, unless serum levels fall below normal levels again as serum levels are checked on a routine basis. "
Our vet has had Mandy on Soloxine twice daily for years. :/ Could this do damage to Mandy?

Could oversupplementing thyroid meds for 2 years possibly cause further endocrine problems and kidney problems? :*(

First...there are no silly questions, if you have a question, it is important and needs an answer and we will do our best to help you, ok?

Here is a quote from an article from our Resource Thread by Dr. Dodds, it is long:


Diagnostic and Treatment Misunderstandings About Thyroid Disease

Veterinarians commonly are confused about which tests are necessary to accurately diagnose thyroid dysfunction in the dog and cat, as well as another animal species. During case review, many veterinarians contact us about the reference normal ranges provided by their commercial clinical laboratory. Many colleagues assume that these reference ranges are finite and apply to all breeds and breed types [toy and small breeds have higher basal levels, while large or giant breeds and sighthounds have lower basal levels], as well as all ages and physiological circumstances. For example, veterinarians are generally unaware that the printed reference ranges on laboratory reports typically pertain to adults, and not to very young, adolescent, [higher basal levels] or geriatric animals [lower basal levels].

Furthermore, these reference ranges are intended as general guidelines and may not apply to individuals that are athletic, performance animals; under general anesthesia; undergoing sex hormonal change; a pregnant or nursing mother; obese; a patient that is ill or recovering from illness, or taking specific drugs that might influence thyroid function (e.g. corticosteroids, phenobarbital, potentiated sulfonamides, dietary soy and soy phytoestrogens, insulin, narcotic analgesics, salicylates, tricyclic antidepressants, furosemide, phenylbutazone, and o, p1-DDD ). Daily diurnal rhythm fluctuations and the presence of circulating thyroid autoantibodies also changes basal thyroid levels. However, knowledge of these variables that affect thyroid function and circulating levels of thyroid hormones does not preclude their measurement. It is especially frustrating when a veterinarian tells the client that thyroid profiles cannot be measured accurately because the patient is receiving drugs such as corticosteroids or anticonvulsants. As long as the effects of these drugs are taken into account, there is no reason to avoid measuring thyroid function, especially when thyroid dysfunction may be an important underlying component of the patient’s clinical problem.

While diagnosing thyroid dysfunction in companion animals can be particularly frustrating, especially when used for wellness screening of potential breeding stock, veterinarians may fail to appreciate that a simple total T4 test is usually nondiagnostic. In fact, the in-office testing of T4 has recently been shown to produce unreliable results in 52% of dogs and 62% of cats, and therefore should not be used even as a general diagnostic screening test. Complete thyroid profiling is the most accurate and correct way to diagnose thyroid dysfunction when coupled with clinical information about the animal. For genetic screening, thyroid testing requires not only thyroglobulin autoantibody (TgAA), but also circulating T3AA and T4AA, because not all dogs with autoimmune thyroiditis have positive TgAA, even though T3AA and/or T4AA are elevated [about 6% false negatives, presumably because the epitopes involved weren’t recognized by the TgAA reagent.] Another significant problem is diagnostic over reliance on the canine endogenous TSH test. This test in the dog, unlike the equivalent one in humans, is only ~70% predictive, with a 20-40% discordancy rate (both false positives and false negatives occur).
In the cat, accurately diagnosing hyperthyroidism can be complicated when the animal has concurrent nonthyroidal illness or is very old. In geriatric cats with hyperthyroidism, the T4 can be suppressed to within the upper half of the normal adult reference range, not only because of the cat's age but also because of they commonly have other illnesses. Furthermore, the free T4 assay measured by equilibrium dialysis can provide misleading information, because the assay may be elevated in about a third of cats with pre-existing liver, kidney, and gastrointestinal disease. While some of these cats may also be hyperthyroid, others are clearly euthyroid.

Regarding treatment of thyroid disease, the most common confusion surrounds the expected thyroid values for patients receiving appropriate doses of thyroid supplement thyroid supplement, and whether the therapy should be given once or twice daily. In the dog, Larry supplement is best given twice daily, even though the label directions which of which have been the same for many years indicate once daily dosing. The reason that twice daily dosing is preferred is to match the typical 12-16 hour physiological half-life of thyroxine in the dog. Monitoring of thyroid therapy should be performed at 4-6 hours post dose, and at that time the T4 and free T4 values should be in the upper third to 25% above the laboratory’s normal reference range. Rechecking thyroid profiles on animals receiving thyroid supplement is best accomplished by performing the complete profile, and is essential for those animals with autoimmune thyroiditis to determine whether the autoantibodies present are waning. If the client has financial constraints and the case is not thyroiditis, a post-pill T4 and freeT4 will usually suffice. Finally, in the cat treatment with methimazole should be given twice daily or by topical application to the ear, as recently published data indicate that once a day treatment has an unreliable therapeutic effect. When monitoring cats on methimazole, it doesn't matter when the sample is drawn in relation to giving the medication, as the turn over time is long.

http://www.k9cushings.com/forum/showthread.php?t=2256

Also, here is a post from another member that e-mailed Dr. Dodds:




I previously had emailed Dr. Jean Doods with some questions and thought I post my questions and Jeans responses here as well for anybody who might be interested.

“Optimal therapeutic response levels should be in the upper 1/3 to 25% above the upper limits of the resting optimal ranges at 4-6 hours post-BID thyroid medication.”
Explanation:
Geriatric Therapeutic Optimal Levels:
T4 2.20 – 4.50 ug/dL
FT4 0.70 - 2.00 ug/dL
T3 40 – 70 ug/dL
FT3 1.6 - 3.5 ug/mL

Question: How often should I have his thyroid function tested and what tests should be done?
Answer: Every 6-12 months; test T4 and freeT4.
Question: I have read that we should test not only for T4 but also Free T4 – is this correct and what does the Free T4 value in conjunction with the T4 value supposed to tell me?
Answer: Definitely, because freeT4 is the biologically active tiny fraction [0.1 %] of total T4 .
Question: How to convert T4 value from nmol/L to ug/dL
Answer: you must divide the nmol/L by 12.87 to convert it to ug/dL

Nathalie

Hope this helps,

Love and hugs,
Lori

[Squirt's Mom]

Hi Annie,

Whether this carries across species, I don't know, BUT....whenever my thyroid meds are increased, my potty breaks increase. My endo doc said that is because when the levels drop the body holds water and when the meds bring the levels back up, the body releases the excess fluids it has stored up. Then she grinned and increased them again. :p

This may be what you are seeing in Mandy with the extra pee stops on her walks.

This sounds odd and looks even odder, but when she pees if you will sniff the pee you can tell quite a bit about it. If there is no or very slight odor, the urine is more than likely normal. If it has a strong odor, then an infection is probably present. The coloring will also help - pale yellows = good; dark yellows/oranges = infection. You can take a white paper towel and soak up some of her urine from the grass or other non-dirt area to see the color. It doesn't take much. In our cush babies, the urine is usually almost clear unless they are on treatment so if there is no color, don't panic.

Hugs,
Leslie and the girls - always

PS. After a little while, the neighbors will stop asking why you are squatting and sniffing when Mandy pees. :p

[foxandhound]

Hi guys, thanks so so so much, we will get the thyroid panel asap and we will make sure to dose Mandy 4-6 hours before. Very, very important stuff. Dr. Oliver has not yet contacted me back about thyroid dosing prior to adrenal panel. :(

Mandy's drinking has increased again a bit, her urination habits on walks are still the same, she pees 7-8 times, but only the first time is an actual urination lasting 6-7 seconds (not immense). And the hind legs are in pain again. My neighbors will definitely think it's bizarre to smell and saturate a paper towel with urine, but no big deal. You make me LAUGH!!!!! :D I did so tonight and nothing funky (yet). I just hope she doesnt have a kidney infection or some bacteria that did not show on the culture. :(

I started to think about what Yuhnee said about tick borne illnesses. None of the 3 vets we have seen mentioned it, but I think we might want to test for it since we have some symptoms: hind leg problems, protein in urine, intermittant high platelets. We are in S. Fl, on Comfortis, and I dont see ticks, but I hear of other people dealing with them (?).

Which labs test for these tick illness antibodies aside from Michigan? Does Antech? What is the rate of success with this "titer" testing? Maybe we could start a round of antibiotics and retest the blood to see if the kidney and liver values go down?

[foxandhound]

Mandy's Protein:Creatinine Ratio was 12. :( :( :( The reference range is 0.5 and under.
Today s not a good day, she is hiding in the corner and having hind leg problems again. This is so sad to watch. It literally came out of nowhere and that's it. One day, it's running and playing. The next day my Mandy is hiding, wants to be left alone, doesnt want to interact, and cant stand up very well.

If someone could talk tick borne illnesses with me and tell me about their success with the testing or if they didnt test and just started antibiotics? Would be so helpful. So helpful.

[addy]

The on again off again hind leg weakness just is so confusing, isn't it? Tears our hearts out:mad:

I am trying to remember the thread on tickborne illness but drawing a plank. Hoping Glynda or Lori will remember and be along soon for you.


Thanks for helping me out the other night, Annie.

Could she still be adjusting to the change in thyroid meds?

Did her marking while walking just start? Zoe has done that since we brought her home 3.5 years ago. Only does it on walks, like a boy dog. Zoe doesn't do it in the yard either. I always thought she was a female marker and if her intermediate hormones are out of whack, makes sense :rolleyes:

Hugs,
Addy

[Harley PoMMom]

Here is a link that has a lot of info on TBD: Tick Disease in Dogs http://sites.google.com/site/blackgsd/

The test laboratories: http://sites.google.com/site/blackgsd/testlaboratories

Hope this helps,
Love and hugs,
Lori

[lulusmom]

Mandy's Protein:Creatinine Ratio was 12. :( :( :( The reference range is 0.5 and under.
Today s not a good day, she is hiding in the corner and having hind leg problems again. This is so sad to watch. It literally came out of nowhere and that's it. One day, it's running and playing. The next day my Mandy is hiding, wants to be left alone, doesnt want to interact, and cant stand up very well.

If someone could talk tick borne illnesses with me and tell me about their success with the testing or if they didnt test and just started antibiotics? Would be so helpful. So helpful.

Annie, with Mandy stopping and peeing frequently on her walks, it sounds like she may have a urinary tract or bladder infection. Did your vet do a full urinalysis to check for a UTI before doing the Protein:Creatinine Ratio. Do you know for sure that your vet did a urine culture? If there is any blood or inflammation at all, the P:CR can be skewed even higher than 12. Knowing that Mandy may have cushing's, your vet should have done a urine culture because 1) cushing's is an immunosuppressive disease so you have to assume that more likely than not, there's infection present and 2) dogs with cushing's usually have PU/PD and low urine specific gravity, meaning the urine is diluted out making it very difficult to detect blood or white blood cells without doing a urine culture. What did your vet have to say about the high P:CR?

With respect to tick borne illness, I'm not sure that's what you are dealing with because bloodwork will show anemia, low platelet count, and low white blood cell count. I don't recall Mandy having any of those abnormalities. Can you double check that?

[foxandhound]

Thought I should put it all together since it's muddled over pages.
Here's Mandy's mystery diagnosis...Still a mystery with many sudden acute symptoms.

I think this might be a tick borne disease, but honestly, I dont know. What freaks me out about the tick diseases is that they are hard to diagnose, so as I am reading, many people start with intense antibiotics and see if any change is noted. I will go and harrass my vet again. I think that's how they construe me. Today I called and they told me they were booked. I told them my dog was probably dying and with a UPC of 12, I need to come in asap. Appt monday. I dont like getting confrontational over it, but last time we were there when Mandy could not stand up, they served people who needed vaccines and out of country traveling certificates. Maybe bc we would take a long time? :/

Here's Mandy's info:
-11 y/o active, playful, Beagle girl goes in for routine bloodwork, high ALT, ALP, BUN:Creatinine (Normal BUN, Low Creatinine), High Platelets, Normal Blood Pressure, 1 month later sudden onset symptoms surface (most notable is lethargy and arthritis)
-Urine protein: Creatinine 12 (ref range is 0.5 or lower...SCARY!)
-Urine culture: Negative after 48 hrs, no growth, collection: free catch of morning urine
-Intermittant High Platelets
-Diagnosed with kidney disease, multiple kidney cysts, IMS said cause unknown, could be chronic or from infection
-Small node on adrenal, but both adrenals are same size and normal size, so ACTH Stim was likely false positive due to non-adrenal illness
-Liver and spleen mottled, liver enlarged
-Cortisol: Creatinine 8.3(normal cortisol) : 80 (low) = 32 ratio (high)
(Cortisol was normal, Creatinine was low so the ratio was higher than normal)
-Sudden Bad breath (but is on raw diet, just decreased protein levels by 1/3, IMS and vet say that teeth are good)
-Mandy is hypothyroid, but it was controlled with 0.2mg Soloxine BID, There was a Sudden decrease in T4, we adjusted thyroid meds to compensate (dosage is now 0.3mg BID)
-Sudden Lethargy, uninterested in interaction, affection, etc
-Sudden Muscle Wasting, lost 1-1.5 lbs, body appears smaller
-Sudden Hind leg problems, onset arthritis, comes and goes
-Sudden Increased drinking and urinating, seems resolved and then comes and goes
-Sudden deep breathing, also comes and goes

[foxandhound]

Did your vet do a full urinalysis to check for a UTI before doing the Protein:Creatinine Ratio. Do you know for sure that your vet did a urine culture? If there is any blood or inflammation at all, the P:CR can be skewed even higher than 12. Knowing that Mandy may have cushing's, your vet should have done a urine culture because 1) cushing's is an immunosuppressive disease so you have to assume that more likely than not, there's infection present and 2) dogs with cushing's usually have PU/PD and low urine specific gravity, meaning the urine is diluted out making it very difficult to detect blood or white blood cells without doing a urine culture. What did your vet have to say about the high P:CR?

I am so thankful for your response. Always thankful for everyone's insights, where would we be without your help and kidness? Yes, the urinalysis showed no blood or RBC, but there were some WBC (0-1HPF). A culture was done with a free catch morning sample, it was negative, no growth. That was weird. I thought there would be an infection. Mandy's specific gravity has always been normal on every urinalysis. My vet has not seen the UP:CR yet. It was actually done through the vet that we had the credit with since his office never sent the UP:CR sample and they sent our ACTH to Antech. Can you believe that after a positive ACTH test and after a high UP:CR that vet has NEVER EVER EVEN CALLED US BACK TO TALK ABOUT THE TEST RESULTS. We have an appt on Monday with our current/former vet. The IMS-cardiologist was called at home about it (embarrassing, but what were my options?!) and told us to start the Enalapril (The med that should prevent protein loss and help the kidneys, but is broken down by the kidneys and can cause kidney damage.) If you could only see my face. :X

With respect to tick borne illness, I'm not sure that's what you are dealing with because bloodwork will show anemia, low platelet count, and low white blood cell count. I don't recall Mandy having any of those abnormalities. Can you double check that?
I keep reading that the symptoms can mimick so many other illnesses, even kidney failure, and often blood tests will not show abnormalities in blood cells until chronic stage has occured and at that point, it might even be too late to treat. God, that's nuts. Read that from Lori's link. I always overlooked Tick disease, but I just realized that Comfortis does not protect against ticks. Somehow, that didnt occur to me.

[lulusmom]

Hi again,

I am really stymied with the hugely elevated UPC yet Mandy's creatinine and BUN appear to be normal, as does albumin. Did your vet base that diagnosis on the UPC and the ultrasound findings? Did he happen to mention why the BUN and creatinine would be normal?

From what I understand, Beagles are predisposed to Amyloidosis and Polycystic Kidney Disease. Did your vet mention either one of those. I believe the ultrasound did show cysts on the kidneys. Did the vet suggest a biopsy? Again, I believe you would see more abnormalities than just an elevated UPC with these conditions. :confused:

http://www.petplace.com/dogs/renal-kidney-amyloidosis-in-dogs/page1.aspx

http://www.vetinfo.com/polycystic-kidney-disease-dogs.html

The only condition I could find where you would see a highly UPC ratio with normal creatinine and BUN is urinary stones in the lower urinary tract. Did your vet mention the possibility of stones?

http://www.vet.chula.ac.th/~tjvm/full_text/v40/v403/403_PDF/13%20TJVM_40_3_Original11.pdf

[foxandhound]

My answers to the questions below will be regarding my 30-something IMS cardiologist, not my general vet since she passed this case off to the animal hospital for the non-standard diagnostics, but I am going back to see her on Monday and discuss lab results/tick illness/stones?
Well, Mandy's creatinine is low, not normal per say, but not too low either. But the other values are in fact normal.

Did your vet base that diagnosis on the UPC and the ultrasound findings?
No, he based it only on the Ultrasound. The UPC came in yesterday, the staff called him at home, he said nothing except to start the Enalapril. I asked them to mention tick illnesses and he said he will call me on Monday?

Did he happen to mention why the BUN and creatinine would be normal?
No, he didnt. :(

From what I understand, Beagles are predisposed to Amyloidosis and Polycystic Kidney Disease. Did your vet mention either one of those.
No.

I believe the ultrasound did show cysts on the kidneys. Did the vet suggest a biopsy? Again, I believe you would see more abnormalities than just an elevated UPC with these conditions.
Yes, cysts were present, but no Polycystic Kidney Disease. I do not know what the difference would be in forming cysts vs. full-on polycystic disease. He did not suggest a biopsy. I agree that more abnormalities would/should occur with those types of kidney diseases.

Did your vet mention the possibility of stones?
No, and he was the one to perform and interpret the ultrasound. :confused: I am wondering if this low (but quality) protein, high veggie, high fiber diet is suitable for a doggu who might be forming stones? Wouldnt he see the stones?

BTW, the Enalapril is causing Mandy to lose some interest in wolfing down her meals. I knew Enalapril was the wrong med. I hate the idea of giving our pets something that doesnt make sense just bc the FDA says hey, no prob.

[addy]

Hi Annie,

Just wondering how Mandy is doing. Thinking of you.

Hugs,
Addy

[foxandhound]

Hi everyone!
Thanks Addy for the sweet hello.
Mandy is doing phenomenally. About 3 days after giving her Enalapril, she was running, playing, wrestling with so much energy. She wanted to jump all over and she loved her walks!!!! All was perfect. All seems perfect.

However, the blood results came back today and are really, really bad. My vet wasnt in so another vet told me that Mandy's Alkaline Phosphatase is now in the thousands. Also, her Up:Cr went from 12 to 8 (normal is 0.5 and under). It decreased, but not enough. Also, the vet said her Blood Protein and Blood Calcium are now very abnormal. Everything is just much much worse. I will get the actual values tomorrow. I asked the vet what to do and she started talking about an ultrasound. I told her, "no offense but you havent read our file, we had an u/s done a couple weeks ago, can you have my regular vet call me." Even then, I know our regular vet's knowledge of this is limited.

Could these elevations be from the Enalapril?

So, I am assuming this is how it will be until she shows signs of Cushings. Right now, she is doing so well, but I am pretty sure the hind leg problems, lethargy, and pain will come back soon. Along with the need to be alone, hide in corners by herself and so on. :( Maybe then, her specialist will revisit the idea. Right now, he was against treatment. He said until he sees constant drinking and urination, skin infections, and so on, the Cushings treatment is pointless. Anyhow, where do we go from here...a phosphate binder or something? So sad.

[foxandhound]

Mandy's Alkaline Phosphatase is now 1986 :( :( :( (range 5-131)

Here are the rest of the high values, my specialist said to increase the Enalapril and no big deal. :/ ?????

ALT is 186 (range 12-118)
Total Protein is 7.8 (range 5-7.4)
Albumin is 4.8 (range is 2.7-4.4)
GGTP is 21 (range is 1-12)
Phosphorus is 6.3 (2.5-6)
Calcium is 11.7 (8.9-11.4)
Chloride is 129 (102-120)
Cholesterol is 453 (92-324)
Triglycerides is 441 (29-221)
Amylase is 1560 (290-1125)

Urine Protein:Creatinine is 8 (range is 0.5 and under)
Blood in Urine: 2+ (this is new for us)
Protein in Urine: 3+

[addy]

I wish I could comment on labs, but can't, hopefully Deb will.

Zoe had 2 plus blood in urine. IMS said not worried about it because they look at one of the other values to see blood, I forget which one and that the 2 plus was from the dip stick so it could be from the needle, etc. I am sure I skipped something in that explanation but I do know she looked at one of Zoe's other values for blood.

That was new for us too.

Hang in there, someone will comment on labs soon, Annie.

Hugs,
Addy

[foxandhound]

My Mandy had a heart attack today. :(

Well, for the last 2 weeks, Mandy has had a bit dry cough. Mandy never coughed during or after exercise. Her quality of life is very high...exercise, home cooked diet, my mom and I work from home so we are always with her, she has a younger bro who admires her, kisses her, and loves her. Well, she would cough seldomly when lying down or drinking. I didnt really think that this was a cardiac-related cough, but I'm no expert. We had an ultrasound 4 months ago and it was good. Mandy has a 3/6 murmur, but no heart enlargement, no high blood pressure, no chamber enlargement, etc. Still, Mandy was prescribed Enalapril for her proteinuria, a likely complication of Cushings. Ok, so we thought hey, she is coughing. Let's get her to the vet. Well, our vet was a no-show to our appointment so we went to another vet. This second vet was a quack, he gave us antibiotics without even inspecting her mouth or throat. Ok, so the cough has subsidded a bit. A week passes and no changes are seen in her demeanor or activity level.

As the sun was setting, she was running and wrestling with our other dog and within seconds, she was on the ground. She collapsed in a lying-down position, her eyes were lifeless, her tongue just laying outside her mouth. She wasn't breathing. I massaged her and held her, whispering I love you and please come back. It was very traumatic, but I kept thinking- if this is happening, let it be here and let it be peaceful. She regained breathing within 30 seconds or so. She came back with very heavy panting and a moments later, she was somewhat conscious again, eyes moving, tongue back in her mouth. Her tongue and gums were blue-purple, but they were regaining color. She stayed in that lying-down position and I stroked her and gave her kisses. This went on for another few minutes.

Then, she gets right up and runs over to the kitchen for a treat. It was all so hard on us. I have been a mess ever since. She was dying in front of me and then came back. This is telling of what will happen in days to months, I'm sure. :(

Our vet said she Mandy had heart attack, but since Mandy stabilized we decided against the after hours emergency Vet. We are calling Mandy's cardiologist for an appointment tomorrow.

Just wanted to know what can we expect, what can we do. Mandy seems to have mild Cushings (positive ACTH, small nodule on one adrenal gland, but the other adrenal gland is normal in size). I guess I'll call it mild unless you consider extreme Proteinuria and a Heart Attack as complications of Cushings. And, they may very well be. :(

Is this a sign? should we now start to treat Mandy's cushings (pending re-do of all tests)? Or, would treatment be deadly with heart issues and kidney issues?

Mandy's ALK is at almost 5000. :eek::eek::(

[foxandhound]

Some brief notes on Mandy...
-13 y/o fairly active, playful, Beagle (BARROOOOOOO!!! BAROOOOO!)
-intermittant coughing in seated or lying down position, dry cough, unproductive, seldom coughing, some days no coughing
-3/6 murmur, mitral value degeneration, at low risk for sudden heart failure said the Cardiologist a few months ago
-high ALK (the number is now nearing 5000), high ALT, Normal BUN, Low Creatinine, high Platelets, Normal Blood Pressure
-Proteinuria due to Cushings and/or Kindey cysts (She is now on Enalapril BID)
-Diagnosed with Kidney disease, multiple kidney cysts, IMS said cause unknown, could be chronic or from infection
-Small node on adrenal, but both adrenals are same size and normal size
-ACTH Stim was slightly positive
-Liver and spleen mottled, liver enlarged
-Cortisol was normal, Creatinine was low so the ratio was higher than normal
-was on raw diet, now on homecooked LOW PROTEIN diet (sadly, she looooooves meat!)
-She is hypothyroid (Soloxine dosage is now 0.3mg BID)

Since we started the Enalapril there has been no more hind leg weakness and her water consumption is normal, urination is normal, skin is great, but she does often prefer the cold hard floor or in front of our AC handler, and she has the pendulous abdomen and ravinous appetite. Otherwise, she is doing great on her walks and enjoying her golden years.

Looks like heart disease might be the most major problem now. What can I do? Is it now time to consider treatment for the Cushings even though she isnt having accidents, losing hair, or experiencing decrease in quality of life? Is not treating her possibly causing her heart and protein- via urine loss problems?

I am so scared. I feel like the end is here. I love her so much.

Here are some Mandy pics...Mandy is my first dog. She opened my world to doggies and the bond they can have with us. So, we would love your help.
http://beaglepix.livejournal.com/349367.html

[mytil]

My goodness what a scare. I am wondering how your vet knew if she had a heart attack - did he take a blood sample to check for certain enzymes etc (like they do with humans)?

This happened to one of my dogs years ago and I too, thought heart attack but it was that he fainted due to congestive heart disease.

So she is not taking any medications to treat specifically the Cushing's right? Where there any tests performed trying to diagnose Cushing's? If so, please post the results here. If she is not having the classic Cushing's symptoms, why does your vet think she has Cushing's?

IMO, I would not treat the Cushing's until the heart issues are taken care of.

Terry

PS - a persistent cough can be a sign of congestive heart failure and I am very happy you are seeing a specialist!

The photos of your pups are great!

[frijole]

I'm curious as to whether or not Mandy has cushings. You said the acth was slightly positive but cortisol is normal. ??? The acth test measures cortisol. Could you get the results/numbers for that test? Have you done more than one test? Sounds like you witnessed a miracle. Are you seeing a regular vet or a specialist? Kim

[Squirt's Mom]

Hi,

Oh, my! How scary that was....and still is! And I agree, Mandy is a miracle to have survived a heart attack. :eek: But what a blessing for her that you were right there with her when it happened. I have no doubt she heard your pleas and felt the love flowing between you so she had to come back.

Is her liver itself alright? Those values are really getting up there! There is no concern over any of the nodules on the liver or spleen?

Please keep in touch and let us know how sweet Mandy is doing...and how you are doing.

Hugs,
Leslie and the gang

[foxandhound]

Hey everyone, Mandy is now on agressive treatment for Heart Failure and it's killing me since I felt very strange about giving Enalapril to a Chronic Kidney patient (it's metabolized in the kidneys) and feeding a low protein diet. There is a lot of new research indicating that low protein diets are not helpful, but Mandy had protein loss in her urine, so I dont know what I could have done or how to proceed.

Mandy is now on Furosemide, Pemobendan, and Enalapril. :(

Last ultrasound in January was good. She went from having a normal heart, normal size, no enlargement, and a low chance of sudden heart failure to complee heart failure, severe enlargement, severe congestion, dialated arteries, severe mitral value regurgitation. Her life expectancy is unknown. IMS said it happened so unexpectedly and so fast. He was shocked.

He called it advanced heart disease second to rapid age-related valvular degeneration. I call that second to protein restriction, but who am I to say. :(

I guess I'm just looking for answers and ways to go about this.

My vet said it sounded more like syncope than a Heart Attack, but but either is possible. He said it's more important to focus on why it happened and what damage occured.

He said Mandy's high ALK values were probably due to the adrenal nodule increasing in size (likely Adrenal Cushings) or some type of hepatic blood pooling. He said it wasnt important because her Heart is what is failing.

Well, her pre-ACTH was 3.6, post was 22.8 (normal is 5-20).
Urine cortisol was 8.3 (normal is 5-55)
Urine creatinine was 80 (nornal is 100-500).

I feel like I failed. I dont know what to do. Low protein, high protein, benazepril, enalapril, re-do Cushings tests, treat for Cushings....

[lulusmom]

It would help if you can please post the abnormal values on the most recent bloodwork and urinalysis.

You are correct that the myth that high protein diets are bad for the kidneys has been debunked. A number of studies have shown that protein restrictions can actually be bad for a dog unless the dog is showing overt clinical signs of kidney failure and dogs don't become symptomatic until 70% or 75% of kidney function is lost. Is Mandy symptomatic? Check out the dogaware site for more detailed information.

http://www.dogaware.com/health/kidneyprotein.html

[Harley PoMMom]

This article has a lot of information concerning Proteinuria and Renal Disease: Proteinuria and Renal Disease A ROUNDTABLE DISCUSSION. (http://www.idexx.com/pubwebresources/pdf/en_us/smallanimal/education/proteinuria-round-table.pdf)

Love and hugs,
Lori

[foxandhound]

It would help if you can please post the abnormal values on the most recent bloodwork and urinalysis.

You are correct that the myth that high protein diets are bad for the kidneys has been debunked. A number of studies have shown that protein restrictions can actually be bad for a dog unless the dog is showing overt clinical signs of kidney failure and dogs don't become symptomatic until 70% or 75% of kidney function is lost. Is Mandy symptomatic? Check out the dogaware site for more detailed information.

http://www.dogaware.com/health/kidneyprotein.html

I am confused by it all. :( :( :( No, she is not symptomatic per say except for the proteinuria. Her kidney function is not lost because all of her kidney serum levels are pretty normal. It's painfully bizarre and I feel like with all of the vets we have seen, no one has gotten to the bottom of it.

Lori, that article is advanced and confuses me since Mandy's creatinine is low and in most of those cases, the creatinine is high. Mandy's serum kidney failures make the whole thing hard to grasp since they are pretty normal.

Abnormal values:
AST is high 66 (range is 16-88) Oops! Mistake!!!! EDIT: AST is 78 (range is15-66)!!!
ALT is high 246 (range is 12-118)
ALK is VERY high 4953 (6-131) *****
GGTP is high 17 (1-12)
Creatinine is on the low end 0.5 (0.5-1.6) It has been low in the months prior as well.
Phosphorus in on the high end 6.1 (2.1-6) Vet #5 said to give Phos binder and Anipryl. IMS said no.
Glucose is VERY low 41 (70-138) No one mentioned this one to me. I just saw it now.
Potassium is high 6.0 (3.6-5.5)
Cholesterol is high 368 (92-324)
Amylase is high 1642 (290-1125)
Platelets are high 523 (170-400)
Urinalysis was normal except protein is 2+

I just cannot believe that my playful, active, happy doggy has experienced rapid degenration and heart failure in a matter of months. I feel like it may have been avoided with maybe (??!) Cushings treatment or maybe moderate protein or...Gosh, I dont know. I just dont get it. Mandy is my little ray of sunshine. Today, she is lethargic and kept to herself. She is eating, drinking, and moving around, but she is very subdued and is always laying on the tiles away from us. :( We are not allowed to go on walks or do any activities right now. Mandy doesnt want to either.

[Harley PoMMom]

Many articles about kidney disease reference that in order for creatinine to increase out of the normal range, three out of every four nephrons in the kidneys must be destroyed, so at this stage the disease is considered severe.

[Squirt's Mom]

Hi Annie,

It just broke my heart to hear you say you feel you have failed Mandy. :( I looked back thru her thread a bit and cannot see where you have failed at any time to do the very best you knew to do for her. You have worked constantly to help her regardless of what was going on.

No matter how much we may learn on our own, we are still not vets and at times we have no choice but to rely on their training and education. If they steer us wrong, it is not our failing. When you have been faced with something new, you have taken the time and energy to learn what you could about it to help Mandy. You have then worked with your vets to make things as right as possible. You are a staunch advocate for your sweet girl! You have fought for her health care every step of the way.

When she collapsed, your love fought the Angel of Death for her very life...and you won.

Honey, this is not the framework of failure. This is the framework of a mom who loves her girl and who will go to any length to help her.

I understand how tiring all of this can be, so I want you to do something for me today. Take a few hours just for yourself. Forget about everything else for just a little bit. Do something you really enjoy - go to a movie, out to eat with friends, shopping, read a good book (in a hot bubble bath with a glass of Chocovine! :D ), bake cookies, go for a hike....something just for you, just for your pleasure. We all need to be good to ourselves from time to time; we need it to recuperate and rejuvenate. So be good to you for just a bit today, 'k? :)

You have NOT failed.

Hugs,
Leslie and the gang

[lulusmom]

With respect to the abnormal bloodwork you've posted, the elevated liver enzyme pattern is definitely what we usually see in cushing's as are most of the other abnormalities. I always have an opinion or two, strictly from a layman's point of view mind you, and I'm not afraid to express them. Please see my comments in blue below:



Abnormal values:
AST is high 66 (range is 16-88) Unless this is the wrong reference range, this liver enzyme appears to be within normal range, which is a good thing.
ALT is high 246 (range is 12-118)
ALK is VERY high 4953 (6-131) *****
GGTP is high 17 (1-12)
The pattern in elevations in these three liver enzymes is what we normally see in cushing's. We have seen high ALK like this before but it is in a smaller percentage of dogs. Has your vet or IMS mentioned liver support like milk thistle and/or SAMe?

Creatinine is on the low end 0.5 (0.5-1.6) It has been low in the months prior as well. It is not uncommon for cushdogs to have mildly low creatinine. This is due to the muscle wasting caused by the catabolic effect of cortisol. However, I recently read that Beagles chew through calories like crazy during periods of stress so this is a possibility too.

Phosphorus in on the high end 6.1 (2.1-6) Vet #5 said to give Phos binder and Anipryl. IMS said no. Did IMS mention a possible cause for this mild elevation in phosphorus?

Glucose is VERY low 41 (70-138) No one mentioned this one to me. I just saw it now. You usually see this in a dog who is starved or teeny tiny dogs who don't eat enough to feed their extremely fast metabolism, causing them to have hypoglycemic episodes. Us tiny toy breed lovers alway have karo syrup on hand to rub on gums if our dogs crash. Once again, I think this could be because Mandy is a Beagle. She was probably fasted, right? and majorly stressed out at the vets which caused the blood glucose to drop. This can also be a lab error but I think the other reason is more plausible.

Potassium is high 6.0 (3.6-5.5)

Cholesterol is high 368 (92-324) This is a common finding in cushing's

Amylase is high 1642 (290-1125) This is a pancreatic enzyme and most dogs with pancreatitis will have elevations in both Amylase and Lipase; however, I believe that even though Lipase is normal, a dog can still have pancreatitis. Pancreatitis can also cause high liver enzymes, particularly ALKP. I hope that Lori will drop in and share her experience with this condition.

Platelets are high 523 (170-400) I think a lot of dogs who have blood draws have high platelet counts from the stress and excitement. I know I am pretty stressed and excited when anybody comes near me with a needle. :D

Urinalysis was normal except protein is 2+ One of my cushdogs, Lulu, has consistently had 2+ protein which her internal medicine specialist says is secondary to cushing's. A good number of cushdogs will have proteinuria.


So what is the IMS' plan of action for Mandy at this point?

[frijole]

Annie, I can see why you wanted to read 'my annie's' thread. :( Having read thru it I do see similarities. Did you ever have a blood pressure reading done (other than the one time where you only got one number of 170?)

If I am not mistaken, the only cushings test that has been done (successfully.. wow you have had some bad luck at the vets) is one acth test 3.6/22.8

Your dog is asymptomatic.. occasional increase of water intake that comes and goes. I repeat what I said before... I am wondering about the cushings dx... and this comes from my own experience so maybe I am just more skeptical than most now. ;)

What you have described is exactly what I was experiencing in the early days with Annie who also has a small nodule on her left adrenal gland. She was diagnosed by Kansas State Univ vet school and they said if her BP was high it would classify that tumor as a pheochromocytoma. She was never episodic when they saw her because she'd have an episode and by the time I drove 5 hrs to K State it was over.

Anyway - the muscle wasting in the back end, the episodic problems with standing and walking, the heart murmur, liver enzymes, loss of weight, deep breathing are all things I have seen. Annie also would pee 8 times on a walk. (she never had bladder infection BUT her vulva is enlarged... she is emitting hormones in her urine from the tumor)

Can you describe what you mean by "deep breathing that comes and goes"? When is it?

Have you ever noticed her skin feels hot to touch or looks pinkish? Does her appetite continue to be normal?

BTW Annie is on benazepril for her hbp and not enalapril.

Anyway.. my two cents... the adrenal tumor could be a pheo but I am not an endocrinologist... just a mom that went thru a year of pure hell to find an answer. I'd feel better if you went to a specialist in endocrinology and i would point blank ask them to investigate your case as a pheo.

I will warn you.... there is very little out there in the way of info on pheo's both for dogs and humans... because they aren't discovered typically until after death. I can tell you the only cure is surgical removal and it is very delicate surgery with risks. It is better to have the tumor on the left side.

I could be wrong but honestly... it took me a good year to figure out it was a pheo and Annie went from a good surgery candidate to not a candidate. And most likely a heart attack is what will take her from me.

I know there are lots of good vets in Florida and I pray you find one to help you thru this. You are due one. :p;)

In the meantime - I would give her milk thistle in her food to help bring down the liver enzymes and melatonin to keep her calm (you mentioned restlessness, up at night and the breathing issues) I started with 3 mg a day and slowly added another pill so Annie takes 6 mgs a day.

Kim

[Harley PoMMom]

Glynda is correct that the lipase can be within the normal ranges even when a dog has a confirmed diagnosis of pancreatitis. In fact both the amylase and lipase can be within the normal ranges when a dog has pancreatitis. My furbaby, Harley, suffered from pancreatitis which was confirmed through spec PL testing and his amylase and lipase was tested and was within the normal ranges.

Elevated amylase and phosphorus levels can be an indicator to a kidney problem.

I believe the elevation in the potassium could be from the Enalapril.

Hope this helps.

Love and hugs,
Lori

[foxandhound]

I know this was a couple pages ago, but I wanted to go back to this... Coughing is truly a dangerous symptom of what can sometimes be a greater problem. Such was the case with Mandy. I'm just so sorry that we have had such bad luck with less than helpful "Professionals" in the Veterinary Med Field. We called our Vet and made an appt on day 3 of coughing, but they couldnt fit us in for another 5 days. The staff should have fitted us in, but they didnt. I guess overlooked it and thought the cough wasn't serious because just a few months ago, Mandy's cardio ultrasound was good. I kinda thought we were dealing with inflammation or an infection. Well, we go to the appointment only to wait an hour and then the staff told us that we had to reschedule again as our Vet was too busy and a no-show. LOL. We went to another DVM and he just gave antibiotics. Seemingly, this may have appeared to help. :/ Between these 2 vets, this caused us about 3 weeks of back and forth, all the while maybe Mandy's heart failure was setting in rapidly. The day of Mandy's loss of consciousness, our own Vet's office said they were booked and could not squeeze us in for an emergency. Sorry, but what?! I'm done with all of them. They are a major disappointment. :( I told the IMS office staff about the symptoms and they fit us in immediately, that same day.

***For anyone reading this, coughing is a major issue. Don't settle for anyone less than an IMS if your pup experiences this and don't let any Vet give you the run around. Life saving calcium channel blockers, beta blockers, Diuretics, and ACE-inhibitors can add quality time (months/years) to your pet's life. Unfortunately, heart failure is better prevented than treated, so time is crucial here. Get seen by an IMS at the first sign of coughing. :mad::mad::mad::(

I just had to vent and put that out there. What ever happened to passionate doctors who care about their patient's well being. I just cant find that. Everyone I've met (apart from IMS) is doing the absolute bare minimum to treat my pet. They are mindless about it all. I am the one who had to bring up proteinuria, UPC test, high resolution ultrasound. What a mess. Thank goodness for specialists, even if they dont know the cause (Mandy's diagnosis), they're a step above this!

[foxandhound]

Terry, you are so right. Coughing is scary and nothing to overlook. Somehow, we werent so lucky with this...More on this above...a rant if you will.
In the meantime, thank you so much for the compliment on the pics and words of wisdom on treatment options and testing. It means a lot. And the IMS does think Mandy had a syncopic episode, but this could lead to sudden death next time. He said that's how a lot of Heart Failure patients go. So, we will just keep on truckin day by day.

Leslie, thank you so much for your kind words. I just feel so much warmth and care when you comment. I really was trying to transfer my energy and love to her as I pleaded with her to come back. I told my mom to put our little one back in the house because I didnt want him to see what was happening and I wanted to focus everything in me on making it peaceful for Mandy. Thankfully, it wasnt her time yet and though these past few days have been "off" for her, there is still quality there. Today, we tried to walk down the block, but it wasnt the right time. She started panting and was unable to even walk slow. It was SUCH A CHANGE from running and jumping days ago. You know, I have NO IDEA if her liver is alright. Every single liver value is increased. The IMS kinda ignored it. Her ultrasound doesnt say much about the liver/spleen- just that they are mottled. The ALK value almost in the 5000 is a certain issue, but I guess the IMS sees it as second to the sudden rapid heart failure. I still give the Milk Thistle, Sam e, and as of today, we added 10 more supplements to the mix. I have never spent that kind of money on health food store supplements, but we are going to try anything! :) I bought things I've never even heard of, but that our Cardiologist recommended. I wanted to tell you, the things you said to me really made me want to give you a big hug. It means a lot. More than you know. To not feel alone, to not feel ctazy, to not be greeted with the "it's just a dog" commentary. I am going to look up Chocovine! I am a true sucker for bubble baths and LUSH products. ;) Sometimes, Mandy peeps in and lays on the bathrug next to me.

EDIT: Chocovine...Cabernet and Dutch Chocolate?! Who came up with such a rememdy. Sounds amazing. It's on my list for tomorrow!

I think you are right, if you dont rejuvenate, we cant be the strongest we should be for the ones who need us most.

Lori, Kim, and Glynda- I will write in a few hours. I need to absorb and process the science of it all. It's a lot to take in. I have found a lot in common with Kim's Annie and I need to catch up on some reading there too. Sounds like Kim's Annie and Mandy may have some interesting similiarities. Mandy is finally sleeping a bit. Last night was scary. It was hours and hours of restlessness. It was painful to watch. Tonight seems more at ease, but still not normal. I am hoping she sleeps well soon. xoxo.

[foxandhound]

Hey everyone,

Mandy's condition has taken a turn for the worse. Mandy has started 2 new drugs in the past couple days and we are considering to forego treatment since it seems like it may be ruining her quality of life. We will give it 1 week or so on the new meds, but after that, we might just enjoy our time without them. We will try to seek other therapies and other medications., but I think this is the best of what's out there.

We are experiencing sudden onset of many new symptoms....lethargy, restlessness, loss of appetite, more coughing, inability to go on walks, increased respiration, the list goes on. Basically, none of those symptoms were occuring prior to starting the new treatment except rare coughing. :(

So, she just started Lasix (Furosemide Diuretic) and Vetmedin (Pemobendin for CHF, Mitral Valve Degeneration) just 2 days ago. I dont know which drug is to blame since we were instructed to start both immediately. She is on Enalapril and Soloxine as well.

I think I am not going to feed her a low protein diet anymore although she does have proteinuria. I know a lot of your dogs have proteinuria as well and I guess I just dont hear of anyone feeding low protein. :o:(

I am just thinking that it is now time to give her what she wants, if she wants it. :) She really likes eggs, liver, kidney, sweet potato, steak, pork loin, etc- whatever makes her happy and these foods used to make her real happy! :D She's a beagle, ya know?!

Eating is difficult, but there are some no-way items that she used to be very fond of. She no longer likes salmon oil, fish oil, yogurt, bully sticks, etc. Could she have pancreatitis? She doesnt vomit or show prayer position though. The IMS did not say anything about her amylase levels. Her tummy isnt tender, she always lays on her sides, she's hydrated, and her appetite was very good before starting these new meds.

Oh my Mandy. My first doggy. Only been my doggy for 3 years or so. It's so hard to see the sudden declines. Mandy, please make a turn-around. Just one more Christmas together. We just moved to our new neighborhood, just fenced in the yard, just enjoyed one Winter here and you loved it. You love Winter. The cold breeze, the long walks, seeing the Holiday decorations, finding the perfect patches of grass to pee on. Then when we came home, you would burry yourself in the covers and snooze until it was time for a nice raw meaty bone. Oh, those were my favorite times too. :) Every morning, you would climb into bed with me when Daddy left early. You would press your bum on me and stay close. It was so nice. One of my favorite memories was when the window wouldnt close properly and it was 40 degrees out. We snuggled and kept warm all night. Happily so! You loved the dog park even, especially when it was just you and your Bro running away from me as the park ranger was trying to close up for the night. You would run and howl, then run and howl some more. Everyone was shocked to hear that you were years older than they thought. You were always so young at heart! Your bro looks up to you, he attentively tends to your grooming so lovingly. He kisses and cleans your mouth, ears, and eyeballs. You make funny noises under your breath to encourage him. You guys wrestle and play. And, he always gives you his treats and looks at you with such adoration. You are our doggy hero. Please stay if you can. xoxo.

[addy]

Oh Annie, your post brought tears to my eyes. I can't help you with the different drugs Mandy is taking but if you think you are seeing side effects then follow your gut about it and discuss them with your IMS.

I do know that Lori's pup had no telltale symptoms of pancreatitis yet indeed did have it.

My all time favorite love story is about a beagle. It is a beautiful, beautiful story that I will warn you is both joyful and very sad but the love flowing from the pages is all embracing. It is called Lauren's Story, An American Dog in Paris by Kay Pfaltz.

Sending love and hugs and many prayers that Mandy recovers.

Addy

[foxandhound]

Thanks Addy. I have never read a dog story, let alone one about a Beagle. I will be looking for this one!! Sounds like a much needed sit down and relax day. Thank you for checking in.

It's been about 24 hours since I posted and I learned a lot in that time. After some trial and error- Mandy is now given the heart medication (Pimobendan/Vetmedin) on an empty stomach and then given her meal about 15 minutes later. After another 15 mins, she is then given the lasix/diuretic. It worked a little better and she some of her meal. Granted it was a scrambled egg, pork loin, sweet potato ands zuchinni. I find myself spoiling her since we are moving away from the days of low protein and I just want her to enjoy her food.

I think the diruretic is making her nauseous or causing electrolyte imbalances. It seems to be the med causing inappetance while the heart medication is probably causing restlessness. Today was a bit better. BUT tonight, Mandy was actually sleeping for a bit, eyes closed, in her doggy bed. She moved to the AC handler in a bit, but she is sleeping. I dont remember the time she looked like she was in a deep sleep. This meant a lot to me.

I am a mess of emotions and I think it's hard on Mandy. So, I'm trying to be less sad. Working on it. :o

[foxandhound]

Also, anyone who is wondering....Mandy's cardiologist has suggetsed some supplements and we bought our first package of Pill Pockets today. Mandy used to wolf her pills down in her meals or in peanut butter, but it's just too hard now. So, thank goodness for pill pockets. Man, they're expensive. I just pinch off a small bit and press it on a pill/capsule or I stuff a bunch of pills in one pocket. lol. Sneaky!!!

Here are the supplements in case anyone reading also has a fellow doggito with CHF:
Hawthorne, D-Ribose, Arjuna, CoQ10, L-Arginine, L-Carnitine, Pycnogenol, Taurine, Omega-3s

And here are the Supplements we already gave for liver/kidney/arthritis problems, we are continuing to give these as well:
Psyllium Husk, Milk Thistle, Berte's Green Blend, Berte's Ultra Probiotics, Vitamin B, Vitamin E <--- we no longer give as requested by cardiologist, Glucosamine, Microlactin (found out about this miracle supplement on this forum), Glycoflex Classic, Salmon Oil and Sardine Oil (though Mandy is no longer crazy about these)

And Slippery Elm Bark powder, Honest Kitchen Perfect Form and Berte's Zyme as needed for digestive issues...I rotate through these when we need them. Ya know, sometimes we needed them. I now realize some of those times were probably not from diet and maybe moreso from times of electrolyte disturbences or adrenal nodule growth/secretions or just plain body-function problems. Who knows. :(

Hope this helps anyone reading this. I do feel that these things have added quality time to Mandy's health. I used to kind of laugh at stuff like this, but no more. And I dont care which of my friends or extended family rolls their eyes about it. lol.

[Squirt's Mom]

Hi Annie,

I am so glad to read that Mandy seems to be doing a bit better. Sleeping soundly is a good thing! :)

I had wondered if the meds were causing at least some of what you were seeing. I know from the meds I take it can get to be a bit of a challenge to know when to take what, which ones can, and cannot, be taken together, and how far apart to take certain ones. You have done a good job of researching the new meds to learn about all the ins and outs of taking them. I hope the changes you are making will help Mandy more and more as the days pass.

Did her cardiologist say why they wanted the Vit E stopped? I need to look into that....

Keep up the good work!

Hugs,
Leslie and the gang

[jrepac]

Hi Annie,

I'm catching up on your thread as I've been pre-occupied over the last week w/a new pup! But, I saw your post and wanted to check back in. I can empathize with your situation...I was struggling w/similar stuff w/my Mandy back in the fall before she passed- which we believe was due to a cardiac event of some sort. Even if Cushings is being treated, many of the elevated test results you describe can be present. I too, was dealing w/elevated levels of Alk Phos, Cholesterol, Triglycerides, and protein in the urine. I was following a reduced protein diet, but I would not describe it as low protein. You just wind up juggling/trying to manage a lot of things in a Cushpup; this is not out of the ordinary by any stretch; you do the best you can. And I agree, you reach a point where you simply don't want to deprive them of the things they enjoy!

Ironically, my baby was dealing w/a nasty cough prior to her passing, which in hindsight could have been cardiac related or canine flu. She seemed to have gotten over the cough, but you never really know, right? Infections can stay hidden even without a cough.So, I would second your advice to get a Cushpup (really any pup) checked out fast when a recurring cough is present. Cushpups have weakened immune systems and can easily be struck down by viruses and infections. Canine flu is very severe and I've learned a lot about it since my baby's passing; my new pup was inoculated for it, I am not taking any chances! I think you have had a bit of good luck on your side and you deserve it...you are doing a great job for your baby!

I am very happy to see that your Mandy is at least feeling a bit better and resting; even small steps are good ones and always welcome.

Jeff & Angel Mandy