My REMI - back again with questions

[RemiCash]

Hi - I am Mary Lou - Mom to Remi and Cash - 2 boston terriers that are my joy.

Remi is 8 yrs. old and Cash is 6 yrs. old
In the spring of 2010 I had a full blood panel done on Remi - all normal except for an elevated alk phos to 290. Three months later, it was rechecked and stayed the same. Sept. it increased to 330 and 2 days ago, the value is 430.

Remi shows no other signs/symptoms. He is overweight but has been. His weight has stayed steady the past 3-4 yrs. at 31.5 lbs -- yes, too much for him. He is much better at around 26 lbs. -- he is a little bigger of a boston.

My vet wants to proceed with other testing. I am just not sure that these values are extremely high and I have been devastated by what all I have read regarding Lysoderm.

Am I jumping the gun? I did take a morning urine and took it to her today to be sent to the lab. I figured that was the least invasive test and should be a good starting point. She has cautioned me that this test may have a false/negative and other tests can be done.

I am feeling today like I have been punched in the stomach. I am so very worried. Any advice/comments will be more than appreciated.

thank you

[StarDeb55]

Welcome to you & your pack, Mary Lou! An elevate alkd phos is one of the first signs that may point a vet at Cushing's. Remi's results are elevated, but not nearly as severe as most Cushpups are. Alk phos results are frequently in the thousands in our babies. There are a number of other things that may cause an elevation in alk phos. I am assuming that Remi had some type of general lab work done such as a super chemistry panel since you have an alk phos result. There are common abnormalities in liver function tests that most of our babies share, so it sure would help us if we could see those actual results, including normal range & reporting units. You will need to post only the abnormals. If you don't have copies of the labs, your vet should be happy to give them to you. Most of us do keep files on our pups at home as you never know when they might come in handy, especially if you end up at a strange vet.

Symptoms include a voracious appetite, excessive urination & drinking, muscle wasting especially in the rear end, skin & coat issues. Does Remi suffer from any of the above? When it comes to overweight, does the overweight for Remi appear to be more like a "pot-bellied" appearance?

Is the urine test that is being done a urine cortisol/creatinine ratio? If it is, this is a good first step. A negative UCCR will totally rule out Cushing's, a positive simply means that Cushing's is a possibility, further testing required. Has diabetes & thyroid been ruled out? Symptoms for both of these problems overlap with Cushing's which is why I'm asking.

When it comes to using lysodren, please don't be afraid of the drug. It's a serious medication, but so is trilostane, the other option used to treat our pups. I have, now, treated 2 pups with lysodren. My first boy, Barkley, was successfully treated with lyso for nearly 8 years, crossing the bridge at 15 from medical causes unrelated to his Cushing's.

Looking forward to hearing more. Please let us know what the UCCR results are.

Debbie

[RemiCash]

Oh, thank you so much. As I said, I feel like I have been hit in the stomach.

I have only had one super-chem panel done and that was the one that showed the elevation to 290. The high-limit for that lab was 212. All other lab results were within normal limits. That was in July 2010.

I then had my vet's office run just the alk phos - twice now. The first time, it was the same at 290 to 310 (with her high-end being a little higher, I believe 230).

This time - with a time span of 11 weeks between tests, his alk phos is 430 (again, at my vet with her high end being 230).

Yes, that is the urine test that is being run. My vet didn't seem to happy about me doing this as the first step as she wanted to do the ACTH Stim along with it. I just figured it wouldn't do any harm to have it run immediately and when we get the results, I have asked for a personal conference with her.

[lulusmom]

Hi Mary Lou and welcome to the forum.

If the only abnormality on bloodwork is the mild elevation in ALKP and Remi is asymptomatic, I personally would not be rushing to spend money on any tests for cushing's. You should not treat a dog that is not displaying overt symptoms commonly associated with the disease so even if tests were consistent with cushing's, you can't confirm a diagnosis without symptoms.

Cushing's is a disease that you will see elevated ALKP with all other liver enzymes normal; however, with absolutely no symptoms, I think hepatic nodular hyperplasia would be a logical suspect too. This is a condition that is seen in middle aged to older dogs that causes benign lesions on the liver. They don't do anything really but they will cause elevations in ALKP and there are no symptoms associated with this condition. Unfortunately, the only way to diagnose this is to do a liver biopsy and in my layman's opinion, that too is premature at this point.

If Remi was my dog, I think I'd talk to my vet about nodular hyperplasia and the possibility of putting Remi on liver support like milk thistle and/or SamE with a recheck of liver enzymes in 60 to 90 days. If Remi has cushing's, other blood and urine abnormalities will eventually show up.

Based on the information you've given us so far, I think it's way to premature to even be thinking about lysodren or any other cushing's treatment so please don't upset yourself over the horror stories you may have read about lysodren. I have two cushdogs, both little guys, 4 lbs and 6.5lbs, and both are on pretty healthy doses of Lysodren. Lulu was diagnosed at 3 years old and is now 9. Jojo was a rescue and who the heck knows how old he was but he was diagnosed in 2007. He was a grumpy old man then and he's still a grumpy old man but without the bad symtpoms of cushing's. :D

I absolutely love Lysodren for obvious reasons. It's been around for half a century and has allowed many debilitated cushdogs, including my own, to reclaim their good quality of life and live out their normal life expectancy. If prescribed by a knowledgable vet who follows proper protocol and if monitored by a pet owner who has taken the time to educate themselves, it's not a scarey drug at all and side effects can be greatly reduced or eliminated entirely. If that's not enough to calm your frazzled nerves, then perhaps it might help to know that if Remi were to ultimately be diagnosed with cushing's, we're here to hold your hand, share our experiences with you and guide you as much as we can. You are not alone.

Glynda

[RemiCash]

I am so grateful that this group was recommended to me.

I have been thinking about this all evening......I asked the vet to proceed with the urine test and it was sent out today -- should have those values back in 2 days.

The last super blood chem that Remi had was back in July 2010 when the 1st elevation was noted. Perhaps it is time to have another blood chemistry for all the values run.

I'm so glad I have found you guys because all kinds of questions, etc. are running through my mind. I need to get past the point of being devastated and make sure I am Remi's advocate.

Being that this latest value was just done yesterday -- do you all think I should ask for a complete blood panel again? I thought I had a copy of the July chemistry but do not. I will go to the vet's tomorrow and get a copy of that.

[frijole]

I agree with Glynda. Could be early sign of cushing's but maybe not. Just keep an eye out and monitor. No need to rush to treat without symptoms. Bookmark this site and if you need us, we're here. :D;) Hug your dog for me. Kim

[apollo6]

Welcome from me and Apollo
I have attached a quick lesson on Cushing which may help.
http://www.kateconnick.com/library/cushingsdisease.html
Take it slow before you do anything. It took me almost a year before Cushing was finally diagnosed. That came after major changes happened to Apollo.
Sonja and Apollo

[RemiCash]

My vet wants me to proceed with testing. Any thoughts on doing this now or is just repeating blood tests every 8-10 weeks the way to go at this point? She said she would talk to me after the urine test results come back.

[gpgscott]

Welcome, sorry you have issues but glad you are here.

I wonder what urine testing is being ordered as it is my understanding the UC:CR is commonly done upon receipt of the sample right in the local Drs. office.

You aren't reporting any Cushing's symptoms. What is important to understand about Cushing's is that it is not iteself a disease. It is a physical manifestation of damage being caused to internal organs caused by chronic overproduction of cortisol. It is well accepted that you have to have multiple symptoms and correlating labs for a proper diagnosis.

I would not agree to further Cushing's specific testing at this time without some sound rationale.

Looking forward to hearing more.

Scott

[RemiCash]

The only symptoms, so far, is the 430 elevation of his alk phos -- no other blood values are elevated but the last total chem panel was done in July 2010.

At a minimum, that is probably what I should have done. I am having the UCCR urine test done (though my vet wanted me to know this is not a good test without the ACTH stim test). She sends this test to outside laboratory. I just hate subjecting Remi to further testing without symptoms. There is no hair loss, no increased water or food consumption, etc. etc. No aggression issues (I have read where that can be a problem)???? The only thing has been his weight. The July bloodwork did not show a thyroid issue. The only blood work check every 10-12 weeks have been an 'in-house' alk phos test only. With an increase of a little over 100 points in 6 months....to the current level of 430 / high norm being approx. 220. So, approx. 200 points higher than normal.

On the other hand, I would not want to do further damage to him by not finding the reason for the elevated alk phos.

Does anyone here feel it will hurt to wait until the beginning of March for a full blood chem and further diagnostic testing.....assuming the UCCR comes back negative??

[RemiCash]

Just another note -- the only other change I have noticed in Remi (aside from weight gain over the last 2 years) is larger neck.

However, he is a boston terrier, and that just may be his shape or the weight gain.

[RemiCash]

TODAY'S UPDATE:
First, let me say -- I am so happy I have found this forum. Your input helped me ask all the right questions to my vet. Here is the info:

The UCCR urine test came back today as NEGATIVE. My vet cautioned me, however, that she is still suspicious of Cushings and IF Remi has it, he is in the very early stages.

We discussed the great info I got from k9cushings group and she agreed with all of that.

Our next steps:

1st week in March, Remi will go for his annual vet visit and a super blood chemistry panel, abdominal x-rays, a bile acid test and an ACTH stim test. This is all blood work and he only needs to be there for 2 hours and have a 12 hour fast. Depending on those values (unless the ACTH stim absolutely identifies Cushings), he will then have a liver ultrasound.

We will then proceed from there. The purpose of the bile acid test is that an elevation in the bile acid will also show this sort of increase in his alk phos levels.

She assured me that he is in no danger waiting for the beginning of March but, of course, if anything changes, I would take him in immediately.

I guess I should consider all of this a blessing. Usually Cushings is found when an alk phos is elevated much higher than Remi's and an animal is also showing clinical signs/symptoms. He is not.
She said if we find this early, he would be treated early and that Remi should be able to live out his 'normal' life span -- whatever that is for him.
__________________
I will continue to update you guys and be a part of this group. THANK YOU SO MUCH

[lulusmom]

Hi Mary Lou,

If a UC:CR is normal, you can rule out typical cushing's so I have no idea why your vet is so hell bent on doing an acth stimulation test. This test is neither cheap nor necessary for dog with a normal UC:CR and absolutely no symptoms. Can you tell us why your vet still suspects cushing's?

I don't want to repeat myself but if it were me, I would not spend the money for anything but a blood chemistry and as I mentioned before, I would put Remi on liver support now to see if that helps bring down the ALKP. Also worth repeating is that even if abnormalities consistent with cushing's show up on the next blood chemistry and you spend more money to pursue a diagnosis, your vet can't confirm the diagnosis in the absence of symptoms and she most certainly should not prescribe treatment such as Vetoryl (Trilostane) or Lysodren unless Remi is symptomatic.

Your vet is probably familiar with two reknown specialist in endocrinology, Drs. Audry K. Cook, BVMAS, MRCVS, DACVIM, DECVIM and Mark E. Peterson, DVM, DACVIM. Both lecture frequently on cushing's and other endocrine disorders. I'd like to share their response to a few questions on the Top 10 questions asked regarding diagnosing hyperadrenocorticism (HAC) and suggest that you share this information with your vet. You can find this excerpt and other valuable information at http://www.dechrace.com/top10_diagnosing.html


Question: Should I test for HAC if a dog has an elevated alkaline phosphatase (ALP) activity but no other abnormalities?

Answer: No, Many older dogs have elevated ALP activity but are still clinically normal. There are several reasons for increased serum ALP, including drug induced, breed related, idiopathic vacuolar hepatopathy and hepatobiliary disease.

Question: When should I perform a urine cortisol:creatinine ratio?

Answer: This is a screening test for HAC with a very high negative predictive value. This means that a normal ratio essentially excludes the diagnosis. A positive result supports HAC but a more specific test is needed to establish the diagnosis. This test is a good choice if you have a low index of suspicion for the disease.

I think given the fact that Remi's only abnormality is mild elevation of ALK, the index of suspicion for cushing's would most definitely be "low".....so low that a cushing's savvy vet probably would not do a UC:CR and most certainly would not do an acth stimulation test based solely on elevated ALK.

You may also want to share an excerpt from a paper written by Dr. Rhett Nichols, DVM, ACVIM, that can be found in our Helpful Resources section, entitled Canine Cushing's Syndrome: Diagnosis and Treatment. http://www.k9cushings.com/forum/showthread.php?t=210&highlight=rhett


The most important criteria for making a diagnosis of Cushing’s syndrome or hyperadrenocorticism (HAC) is the patient must have signs and symptoms consistent with the disorder. The importance of signalment, history, and physical examination findings cannot be overstated. The predictive value for HAC based on a positive screening test result increases in direct proportion to the number and severity of clinical signs and biochemical changes occurring in the disease. A dog with at least three of the typical signs of hyperadrenocorticism (e.g., polyuria and polydipsia, panting, and polyphagia) and a positive LDDS or ACTH response test has Cushing’s syndrome until proven otherwise. If there are no clinical signs (e.g., a clinically normal dog with an elevated ALP) the patient either does not have the disorder or may have subclinical Cushing’s syndrome. In the latter case, a wait and see approach is advised whereby the patient is followed clinically and with laboratory testing over time. In the dog that has signs and symptoms of Cushing’s syndrome and the screening tests are negative, consider repeating the tests in 3 to 6 months or initiating a workup for atypical Cushing’s syndrome.

There are over 150,000 new cases of cushing's diagnosed every year and Boston Terriers are at the top of the list of breeds that seem to be predisposed to the disease. So yes, it's entirely possible that at some point in Remi's life, he will be ultimately diagnosed with cushing's but not until he has overt symptoms consistent with the disease. I know it's easier said than done but try not to worry about cushing's until Remi gives you a reason to.

It will be very interesting to see if Remi has any new abnormalities on his bloodwork that is scheduled for March and I am praying that everything is normal.

Glynda

[gpgscott]

Mary Lou,

Neither Glynda or I am a vet, but there is nothing you have posted which warrants an ACTH.

ACTH is Cushing's specific, it is invaisive, hard on the pup, expensive, and in itself non-conslusive.

If Remi does develop Cushing's symptoms you WILL know it. From what you are posting at present there is no Cushing's.

Please stick around and read and post. I would hate to see you subject Remi or yourself to un-needed testing.

Scott

[RemiCash]

WOW, thank you both. I am going to read and print the articles and have it all in-hand for his vet visit beginning of March.

Do you think the bile-acid test (I understand this is just a blood test) is indicative?

Do you think or know anything if possibly his diet could be contributing to what his vet is calling "liver failure" -- which also frightens me. He gets his dog food with some home-cooked on top of it. I have been feeding Blue Buffalo Weight Management which is lower in fat but still 20% protein.

[RemiCash]

Also, what is involved with an ACTH stim? I thought it was just blood work ????

[frijole]

Also, what is involved with an ACTH stim? I thought it was just blood work ????
This test is done to measure the cortisol levels. The substance they use is VERY expensive and so the tests are expensive. There is ZERO reason to do one if you have ruled out cushings which you have. Yeah. You ruled out cushings AND saved some bucks. :D

Is your vet saying the liver is failing because of the alk phos reading you posted? If so - I agree with Glynda's posting by respected vet specialists that said that liver enzymes can be high in older dogs. If there are no symptoms I would not be worried about it. I used milk thistle for my dog and it did bring her levels down. Kim

[RemiCash]

I have 'heard' of milk thistle.....is this an herb or an Rx? I will ask my vet about it.

I do think it is important to run a full blood panel, though. Remi has not had one since July of 2010 when it first showed the elevated alk phos. At that time all other values were normal and the alk phos was the only elevated one.

Also, do I misunderstand the literature? It states that the UCCR can have a false/positive? Again, the only symptom is weight gain but his weight has been the same for the past 14 months - 31.5 lbs. In fact, at one point, he was 33 lbs. but the 31.5 lbs has been steady the past 8-9 months.

[forscooter]

Hi,

I just wanted to jump in here and throw in my two cents. I had two dogs with Cushing's disease and my vet also said in the absence of symptoms, which all of the literature supports as Glynda mentioned, you do not treat. There is no test that is 100% accurate in diagnosing Cushing's. That's why they look at the complete picture with symptoms and lab work combined. I too am perplexed why your vet would insist on the ACTH in light of the UC:CR.

The UCCR can have a false positive, yes. And the other tests used to diagnose Cushing's can as well. Again, there is no absolute conclusive test. IF the UCCR was positive, that's when follow-up testing would be done. You wouldn't want to rely solely on the UCCR. The UCCR is useful to rule out Cushing's, which it looks like you have done. A positive test just means further investigation is warranted.

I just want to spare you the expense and time of the ACTH, and also the possibility of a misdiagnosis. We have seen dogs given a Cushing's diagnosis who do not have it. They can become very ill if treated with these medications when it is not Cushing's.

Older dogs can have elevated alk phos levels. I agree with using some sort of liver support such as milk thistle given your vet's approval.

I hope this helps...I just don't want to see you go through all of this and possibly have some repercussions that can be nasty! :)
Beth

Ooops...and Milk thistle is OTC...not Rx. I forgot to answer that part! : )

[jrepac]

Sheesh,
I hate to pile on here, but your vet is leading you down a path that is not needed in regards to Cushings. With a negative UC:CR, there can be no Cushings present. Now, maybe the test came back on the high side, which is why she is concerned? And, that Alk Phos of 430, could indicate the early stages of Cushings, but certainly not warrant aggressive treatment for Cushings at this point, particularly if you have no symptoms present. And, it could be something else entirely. I would not spend what will likely be around $200 (or more) getting an ACTH test done.

When a dog has Cushings, the high ALK phos will always be there...usually well over 1000...can even be 2000 or more....so, please don't panic over a reading of 430. But, liver support via milk thistle (or Marin) may be advisable.

Personally, I can tell you that my dog was sub-clinical Cushings in the early stages; she had ALK Phos over 700, but the other tests were negative. Yet, she had clear symptoms of Cushings. In our case, she developed the Cushings over a period of 18 months...I was just recognizing the symptoms very early on. But, w/out obvious symptoms--excessive eating, drinking, aggressive behavior, skin problems, etc., I doubt you'd want to treat aggressively at this point. Certainly not w/lyso or trilo, which would aggressively lower cortisol levels, when it is probably not warranted.

Maybe get an ultrasound? That could be helpful....and hopefully, your vet did (or will do) a thyroid test.

Jeff & Angel Mandy.

[RemiCash]

Thanks again -- I just sent my vet a note asking about the milk thistle. The only thing I am going to agree to right now is a complete blood panel and, of course, his annual exam. This will be the first week in March.

The only symptom Remi has is his weight.....that is partly our fault without a doubt because he is spoiled and gets lots of extras.

Is there a specific diet recommended for liver stability? I just bought 4 cans of W/D to supplement the Blue Buffalo weight management.

My Cash is only 17 lbs (he should be more like 16 lbs.) but I'll take the 17.

Remi had LP surgery on both knees - 8 months apart. He spent about 6 months of no to low activity and that is when his weight started to increase. He was always around 26 lbs. So, since 2005 he has gone from 26 lbs. to his current 31.5 lbs. I know for a dog, this is a lot.

He is a happy dog, bright-eyed, constantly wanting to play with his tennis balls and his brother, Cash. No panting, beautiful coat, no thinning of hair, no nothing....just elevated alk phos.

I guess I need to ask this question -- aside from being older (now 8-1/2 yrs. old), are there serious conditions that could escalate the alk phos other than cushings?

[RemiCash]

I have asked my vet to start Remi on Milk Thistle. Per my other thread, his urine (UCCR) was within normal limits. We will pursue and do the full blood chemistry in March. In the meantime, and probably continual, I want him on the milk thistle.

My problem: The cost doesn't concern me as much as the pill. It is the chewable and as large as a button. Remi is right on the mark for 1-1/2 pills (since he is 31 lbs.). If he were 30 lbs. he would only get one pill.

I cannot get him to take it as a chewable. I had to cut it (with a pill cutter) into 6 pieces and get him to take it coated with a little soft margarine.

When I went on the Denamarin website, it says it shouldn't be cut or crumbled. The Denamarin is $55 for 30 pills.

Does anyone know of another brand or another source. Again, I'm not concerned about the cost, just getting the proper dosage into Remi.

[Administrative Note: If you wish to read a general discussion about milk thistle that resulted from the questions above, you will find RemiCash's related thread here: http://www.k9cushings.com/forum/showthread.php?t=2948]

[RemiCash]

Well everyone -- I have had REMI ON THE MILK THISTLE for 6 weeks now. I purchased the Denmarin capsules, rub them with a little butter and down they go first thing in the a.m.

Remi went to the vet last Thursday for his checkup and for a complete super-chem blood panel.

We should have the results some time today. I am so anxious to see if there is an improvement.

The UCCR was negative. All I know for sure, he is looking really good, very spunky, beautiful shiny coat (no loss of hair anywhere), energetic, etc. I'm sure hoping I hear good news today and will post when I get the results.

This forum is invaluable! Thank you

[RemiCash]

Remi had a full blood panel this past week - the results yesterday were all values normal except his alkp is elevated, again, to 468. It has reached that level in 1-1/2 yrs. from normal.

He will be having an ACTH STIM test on Thursday.

UCCR was negative

Any advice?

[Bichonluver3]

Welcome from us also. Our Chloe has Atypical Cushings and her treatment is different although the symptoms are the same. The really knowledgeable folks are already giving you very valuable advice. They will lead you in the right direction and do away with a lot of your fears. So, take a deep breath, make yourself a cup of coffee, read all you can, listen to those who have lived with this disease and realize, like I did, that life goes on with a few changes. Cushings is NOT a terminal disease but, if in fact, Remi does have Cushings, it is manageable. Take one step bat a time. You and Remi are family now and we are all here to support you:D.
Love, hugs and tail wags,
Carrol & Chloe

[StarDeb55]

Could you clarify something for us, please? You have posted that the UCCR is negative. You, also, posted in January that the UCCR was negative. Does this means that you now have 2 UCCR results that are negative or just one? Whether it's one or two, you can rule out cortisol based or regular Cushing's, when the UCCR is negative. I'm a little clueless as to why your vet is insisting on ACTH, unless you are doing the UTK full adrenal panel to rule out elevations in the associated hormones.

Debbie

[RemiCash]

I'm sorry - only one UCCR Test

Today's was Remi's ACTH Stim test:

Results - "suspect Cushings"

with a range of 18-20 -- Remi's results were "20"

My vet feels that the UCCR and the ACTH both have a false/negative rate and that we should proceed with the high dex test.

I need a week or so to digest all this and post here. If that will definitely rule out the Cushings, then I will proceed, along with a bile acid test and an abdominal x-rays. He has had neither of those.

Comments?

[StarDeb55]

The following is a quote from a paper presented at the international small animal vet conference in 2002:


The test does provide a good screening test for hyperadrenocorticism and values in the normal range make a diagnosis of hyperadrenocorticism highly unlikely.

This paper gives an excellent summary of the diagnostic testing available for Cushing's including each test's sensitivity & specificity. I have had 2 vets, my general practice vet & a derm vet, tell me that without a doubt a negative UCCR rules out Cushing's. I had been concerned about Cushing's in my 10 year old Lhasa for about a year, so had the UCCR done. Anyway, here's a link to the full paper which you might find helpful, & you might want to printout for your vet.

http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2002&PID=2552

Debbie

[RemiCash]

thank you very much. I will print it out.

any thoughts, though, on persuing the reason, other than Cushings, for the slowly increasing alk phos levels?

[StarDeb55]

Alk phos has a number of sources in the body besides the liver, including bone, & the intestinal tract among several others. An elevated result may not necessarily be due to Cushing's.

This is a quote from Dr. Mark Peterson on his blog for vet's. I will provide the full link at the end. You will want to check his post from 2/1/11 about which pups should be worked up for Cushing's. Look on the right side for "view posts", then click on the one for hyperadrenocorticism.


Who should NOT be tested for hyperadrenocorticism?

Testing for Cushing's syndrome is not recommended if the only abnormality is an increased serum alkaline phosphatase (SAP) activity on a serum chemistry panel, and the dog is otherwise apparently healthy. It is difficult enough to interpret endocrine tests in dogs with clinical signs of the disease; if they have no clinical signs, all of the endocrine tests may be difficult to interpret because of false-positive and false-negative results. The first step in workup in these dogs may include an abdominal ultrasound or bile acid testing.

http://endocrinevet.blogspot.com/

Debbie

[labblab]

My vet feels that the UCCR and the ACTH both have a false/negative rate and that we should proceed with the high dex test.

I need a week or so to digest all this and post here. If that will definitely rule out the Cushings, then I will proceed, along with a bile acid test and an abdominal x-rays. He has had neither of those.

Hi!

I've not had the opportunity to reply to you before this, but since you're asking for comments, I'll go ahead and throw my hat into the ring :o ;)...

In the absence of symptoms other than a mildly elevated Alk phos, I personally would not pursue additional Cushing's diagnostics at this point in time. I'm assuming that your vet is actually suggesting a low dose dex test rather than a high dose dex test? The LDDS is the only one of those two tests that can be used as an initial screening test for Cushing's. The HDDS is used in an attempt to determine whether a dog suffers from the pituitary or adrenal form of the disease, but it only has interpretive value if the general diagnosis of Cushing's has first been established through a positive ACTH or LDDS.

It is true that a "negative" result on the LDDS is a very reliable indicator that a dog does not have Cushing's. So if you do decide to proceed with the LDDS and Remi tests negative, then you may feel as though it was worth the money and the 8 hours of testing time that Remi will need to undergo. But in my mind, here's the "catch" -- even if Remi does indeed test "positive" on the LDDS, I'm still not sure where you go with that information. In the absence of any other observable symptoms, I do believe that a Cushing's diagnosis always remains suspect. And the LDDS is actually more vulnerable than is the ACTH as far as yielding a false positive in a dog that does not actually have the disease. Your vet seems to be focused on "false negatives." But for an apparently healthy dog like Remi with no overt symptoms, I'd personally be much more concerned about starting treatment based on "false positives." Here is a quote from Dr. Edward Feldman, a renowned authority on Cushing's:


Dogs chronically exposed to excess cortisol usually develop
a classic combination of clinical signs, some of which
may be dramatic. These common signs include polydipsia,
polyuria, polyphagia, abdominal enlargement, alopecia,
pyoderma, panting, muscle weakness, thin skin, and lethargy.
It must be remembered, however, that not all dogs with
hyperadrenocorticism develop the same signs. From this
long list of potential signs (plus others), most dogs exhibit
several (but not all) of these problems.
Hyperadrenocorticism is a clinical disorder, and animals
afflicted with this disease must have at least some clinical
signs or the diagnosis must be questioned.

Quoted from: http://www.k9cushings.com/forum/showthread.php?t=209

If it were me, I would hold off on additional Cushing's testing for the time being and just continue to monitor Remi's appearance, behavior, and regular labwork.

Marianne

[RemiCash]

I'm tending to agree with all this. I think rather than proceeding with the LDDS (yes, I meant that instead of high dex), I would rather put the $$ into the bile acid study which, if I understand correctly, it the only test strictly for the liver. My vet said there is a med for the slow bile process. I also have him on milk thistle.

If I decide to do nothing, then I will test his alk phos level only in the recommended 3 months.

He is completely asymptomatic. I realize that can change at any time and, of course, my vet says no treatment without a definitive diagnosis.

[lulusmom]

I'm glad to hear that you are not going to pursue testing for cushing's at this time and that your vet agrees that you cannot confirm a diagnosis in the absence of symptoms.

With the only blood abnormality being elevated alkaline phosphatase, Woofer could have something else going on that is causing this elevation. Bad dental is always suspect. How are Woofer's teeth and gums? As Deb said, this liver enzyme can be elevated by any number of things and sometimes, it can be elevated and return to normal for no apparent reason. If it were me, I wouldn't spend the money on a bile acid test just yet either. I'd continue with the liver support and retest liver values in 60 to 90 days to see where things are.

Glynda

[RemiCash]

His teeth and gums are good. Honestly, my gut just tells me he does not have Cushings. I am concerned about the liver values increasing 200 points in 8 months to his 468 level but in the whole scheme of things, that doesn't seem that high to me. Of course, it is well over 200 points higher than it should be.

I think I am just going to recheck his values in the 60-90 day time frame, unless something else pops up.

[lulusmom]

I think I am just going to recheck his values in the 60-90 day time frame, unless something else pops up.

Good idea!

[StarDeb55]

Just to show you how apparently easy it is for an alk phos level to go up, my derm vet commented to me last week that he swears that if someone sneezes on these guys, their alk phos goes up. :D:rolleyes: I really had to laugh at that one.

Debbie

[RemiCash]

Someone on the WOOF BOARD (Boston Terrier forum) stated that her (human) alk phos has a rise when her vitamin D levels are low. She was wondering if that is possible in dogs. I haven't been able to find anything to substantiate that.

[RemiCash]

Hi everyone -- it's me, Mary Lou, again, with REMI.

An update: In March I had a full blood chem profile done and all results were normal except for elevation of the alk phos to 468. We did the ACTH Stim which was "questionable" or high-normal, I believe my vet said but did not confirm Cushings. I decided to not do further testing but rather waited until yesterday and did another alk phos (only) blood test. His level is now 595. I have a call in to my vet to see what her next recommendations are.

Remi's levels have increased to this level over a 1-1/2 yr. period. I believe they were normal in May 2009 and are now up to 595.

I really don't know what our next step should be. Previously, my vet wanted me to do the LDDS, which I haven't done, a bile-acid study and abdominal x-rays.

Remi has no symptoms, of any kind -- he just turned 9 yrs. old (boston terrier) on June 12th.

His past UCCR was negative.

Any suggestions? thoughts?

[StarDeb55]

I would not waste $$ on an abdominal x-ray. It's really not going to show you what you need to know. The money would be better spent on an abdominal ultrasound on a high resolution machine to not only visualize the adrenals, but all of Remi's internal organs.

Even if you proceed with the LDDS, & an ultrasound, Cushing's savy vets will not treat a non-symptomatic dog. Symptoms are a huge part of monitoring the effectiveness of both drugs that are used to treat, trilostane & lysodren.

Debbie

[littleone1]

Hi Mary Lou,

I agree with Debbie. An ultrasound would be much more beneficial. There might be something else that is causing the elevation. I hope you'll soon be able to find out what is going on with Remi.

Terri

[RemiCash]

Thanks -- do you think I should do the LDDS?

Also, what are your thoughts on the alk phos level of 595? Is that extremely HIGH?

[Squirt's Mom]

Hi Mary Lou,

Good to hear from you again! :)

I agree with Debbie, as long as Remi isn't displaying any signs, I wouldn't spend money on the Cushing's tests as those signs are critical in both diagnosing and monitoring when treatment is started. With a previous negative UC:CR, that is the first step I would take when/IF the time comes to look at Cushing's again. ;)

I'm not sure what the normal ranges are for the liver values, but those are not nearly as high as many we have seen - some in the 3000+ range. ;) Also, that is a slight increased over that length of time - if there was something really serious, I would expect those values, along with others, to have increase much more. If you are concerned, the best test is the abdominal ultrasound Debbie mentioned. Not only would you see the liver but many other organs as well. Any abnormalities that might be present would be much more likely to be seen with the U/S. It is non-invasive tho Remi would more than likely be sedated in order to ensure he remained still.

Let us know what the vet says and what you decide to do.

Hugs,
Leslie and the gang

[RemiCash]

I just spoke with Remi's vet.....we have an LDDS and a bile acid study scheduled for July 20th. I am hoping we will have some answers from this. She said abdominal x-rays are a waste and if the other tests warrant it, we will go to our Pittsburgh specialty hospital for an ultrasound.

[Squirt's Mom]

Hi Mary Lou,

We agree 100% with her that abdominal xrays are a waste. An abdominal ultrasound is an altogether different test.

I also think the LDDS is a waste at this point. ;)

Hugs,
Leslie and the gang

[RemiCash]

I'm hoping he doesn't have Cushings, of course -- but I am also very concerned as to what is causing the increasing elevations in the alk phos. There is nothing else wrong with him that I know. She considers this elevation of 100 points since March as major.

[RemiCash]

Didn't know, for sure, to add this note to my old thread; i.e., Referred here from a fellow Woofer, Remi:

Remi had his low dose tex test and a bile acid study this past week.

I am sending up thanks - both were completely within normal limits.
His previous urine creatinine was negative and the ACTH Stim was questionable.

My vet thinks he just may have some bile sludge causing the elevated alk phos.

I am so impressed with this site and have recommended it to others. I thank God that we are NOT dealing with a Cushings diagnosis and consider ourselves very fortunate. Thank you all for your concern and help and resources.

[lulusmom]

Hi Mary Lou,

I have merged your latest post with your original thread. I am thrilled to hear that Remi does not have cushing's and that doesn't mean that you can forget about us. :D I really hope you will check in every now and then and let us know how you and Remi are doing.

Hugs,
Glynda

[Squirt's Mom]

Hey Mary Lou,

You posted perfectly! :D

I am so happy for you that Cushing's does not seem to something you and Remi will have to deal with. If you would like to post the results of his tests, we will be glad to look at them if you like.

Hopefully, you can get the sludge cleared out and Remi will get back to feeling better. When Squirt had gall bladder sludge, we used Burdock Root and it did help.

Now, just because Remi doesn't have Cushing's, that doesn't mean you can just disappear. Oh, noooo.....it would be so wonderful if you would drop in from time to time and let us know how he, and you, are doing. You can post on this thread any time...it will remain open for you.

Hugs,
Leslie and the gang

[RemiCash]

Most of you probably don't remember me as it has been awhile since I've been on board. My Remi (now a 10 yr. old boston terrier) and I have been on the Cushings road for 2 yrs now with the only symptom an elevated alk phos.

I came on board here when we first discovered his elevations. All the tests were done - bile acid, neg.; ldds, neg.; acth stim - negative.....all other blood chems are normal including all other liver values.

His alk phos levels actually declined 6 months ago to 500 - but he was just in for a check up and it has risen to 800. We just did a full blood chemistry and an abdominal x-ray - ALL BLOOD CHEM VALUES ARE NORMAL EXCEPT THE ALK PHOS AT AROUND 800 (don't have the exact # yet). Abdominal x-ray was normal everywhere except for an enlarged liver. My vet is sending me to the specialty hospital for an abdominal ultrasound.

First question - your thoughts on this ultrasound - if all his other values are normal - what could the ultrasound show? - xray showed nothing else - all else normal -kidneys, intestines, etc - no sign of any tumors but, obviously, she cannot see INSIDE the liver.

question 2 - approx. 6 months ago his alk phos had dropped to the 500 level described above - I then started both my bostons on a new food recommended by my other boston's breeder - PURE VITA GRAIN FREE TURKEY. Does anyone know if a grain-free diet is the wrong diet for elevated alk phos levels.

I will schedule the ultrasound but am at a loss - my vet said she is diagnosing REMI with PRIMARY LIVER DISEASE..........I'm not sure what that means ????? THANKS EVERYONE

[labblab]

Hi Mary Lou,

Welcome back again to you and Remi, although I am so sorry that you are having additional worries! You will see that I've merged your new post into your original thread about Remi. This way, it will be easier for our members to catch up on Remi's entire history here.

I'm sure folks will soon be by to offer out their thoughts. And I'll try to stop back by again, myself, later on in the day when I have more time to post.

Marianne

[labblab]

Hi again!

An abdominal ultrasound really does offer big advantages over x-rays in terms of revealing any possible abnormalities within organs themselves. So at this point, since you've been toying with the possibility of an ultrasound for a long time anyway, it seems like a reasonable diagnostic test given the fact that Remi's ALKP is rising again. I'm guessing your vet is wanting to determine whether the source of the elevated ALKP seems to be Remi's liver itself (primary liver disease), or whether there may be something else going on internally that could account for that lab elevation.

Is Remi displaying any symptoms or problems that are obvious to you?

Marianne

[RemiCash]

No symptoms, at all - we did the get result yesterday of his alk phos from the full blood chemistry which was sent out and it is 575. The week before, when she ran an in-house alk phos test only, it was 800. I'm at a loss -- as I said, he is happy and playful as always and no other symptoms. the 800 alk phos was taken at the same time he had his booster shots - don't know if there is any correlation there.

[labblab]

Well, the 575 result is surely more reassuring, isn't it! I would guess that the in-house result of 800 is related to the testing process itself rather than the booster shots. If the blood was drawn and the boosters given during the same vet visit, I can't see how the boosters would have had the time to have any effect on lab results. There are often variabilities in results from different labs. But this is a really BIG variability. I'm guessing that your vet will feel that the 575 is probably the more accurate result.

Are you still planning to go forward with the ultrasound? If the liver appeared enlarged on x-ray, it still seems to me as though it would be a good idea, just to find out for once and for all whether there are any obvious liver abnormalities that could account for this chronic ALKP elevation.

Marianne

[RemiCash]

Hi - yes, we will be doing it next week sometime, as soon as I can get the appointment. There was no other elevated value in his entire blood chemistry results except the alk phos - everything else within normal range and this is how it has been for over 2 yrs. now.

With that as well as all the Cushings tests, ACTH stim, LDDS, bile acid study, abdominal x-ray - ALL NORMAL......I just cannot imagine what this is. I doubt it would be cancer because in a 2 yr. period.....he would not be here and I would assume other values such as calcium, etc. would be elevated.

My vet is still thinking a "sludge" (slow bile) - I guess we need to find out.......

[RemiCash]

I have been posting on and off for the past 3-1/2 years trying to find a reason for Remi's elevated alk phos levels.

in 2011 his ACTH stim and low dose dex were normal and his alk phos levels were holding around 700. This year they have been escalating (he will be 11 in June). He has no symptoms except his big appetite (which he has always had) and I do notice a little pot belly.

Anyway - my vet has had him on ursodial plus 2 antibiotics for the past 8 weeks. Instead of his alk phos going down - it was tested today and actually increased 100 points (from the last blood work) to 1180. We chose to do a ACTH today and his value is 22.9

My vet said that makes him official. He will start Trilostane tomorrow. It does not seem as scary to me as the previous drug -- which is actually chemotherapy.

Any encouragement, thoughts, etc. - I would appreciate. We have been keeping on top of this and we should be catching it at the very beginning. I do not know the dose yet as I have not picked the pills up from the vet. She said they will be $88/month and a repeat ACTH Stim in 3 weeks and then every 3-4 months.

Mary Lou

[mytil]

Hi Mary Lou,

It has been a while and thank you for posting again about what is happening with your Remi. There are a number of conditions that can cause this elevation (liver disease, trauma, toxins, bacterial infections, lack of blood flow to a portion of the liver for any reason (blood clots, low blood pressure, shunts and even bile duct blockages).

Was the ACTH the only test your vet performed to come to this diagnosis? I know tests were performed back back in fall of 2012 and they were all negative.

Here is some additional information on Trilo you may want to read through - http://www.k9cushings.com/forumshowthread.php?t=185

Terry

[labblab]

Hi Mary Lou and welcome back!

I have just now re-read your entire thread, and you are probably going to want to slap me silly -- but I still question your vet's decision to start Cushing's medication, even with this tiny increase in the ACTH result from 20 to 22. This is just minimally over the diagnostic threshold, and it seems to me that we are still in the situation where the elevated ALKP remains the only clear abnormality. Your vet has been champing at the bit to treat for three years now, but throughout this entire time period it sounds as though Remi has remained outwardly fine without any behavioral abnormalities or concerns. So I still have to question the validity of a Cushing's diagnosis. Over this period of time, I would have expected to see some additional symptom development in a genuine Cushpup.

At age 11, I do not really understand the basis for beginning the expense and clinical monitoring associated with trilostane treatment in the absence of more worrisome symptoms. Are any of Remi's other lab values abnormal? Did the ultrasound reveal any problems or irregularities, especially with either the adrenals or the liver?

Having said all this, if you do decide to proceed with the trilostane, please know that current recommendations are to begin with doses no greater than 1 mg. per pound. Initial doses greater than this are more often associated with uncomfortable side effects and even the risk of overdosing. Please do keep us updated as to your decisions and how things proceed for you guys.

Marianne

[labblab]

Just wanted to pop back to add a couple more things. First, to warn you that drug treatment for Cushing's does not necessarily lower elevated liver markers. Some dogs do see improvement in lab values; others continue with consistent elevations (as was the case with my own Cushpup). So if the sole purpose of beginning the trilostane is to lower the ALKP, you may or may not see a significant benefit.

Secondly, has Remi had a recent bile acids test perfomed? Since your primary concern remains focused on his liver, I'm thinking it would be a good idea to reassess his actual liver function. That might be a better indicator of the presence of genuine damage than is the elevation in his ALKP.

Marianne

[RemiCash]

thanks - no -I chose to not have the ultrasound done a while back but instead we tried the trial of ursodial alone which decreased his alk phos by 80 points to 1017. Then we tried 6 weeks of ursodial combined with 2 antibiotics and the alk phos increased to yesterday's level (either 1150 or 1182). So, yesterday we repeated the acth stim with the 22.9 level.

The only things I see with Remi - he does get overheated and looks for cool flooring and/or will stick his head in his water dish (he has always gotten overheated, though, since he was a puppy). I keep a baby swimming pool for him in the summer months.

he has slowed a bit - but he is also going on 11 yrs. of age.

he is getting the potbelly

he will always EAT but does not look for food unless someone is eating or gives it to him.

he drinks a "little bit" more water - not non-stoppable.

the overheating, however, has increased.

he still runs, plays with his tennis balls, eats well and loves life

I don't know. I have known my vet for many years and she is a friend and a neighbor, as well as a professional with a great reputation.

I'm scared.

[SoggyDoggy]

Hi Mary Lou,

I've been new to the board since you were here last, but I have to agree with Marianne. Your vet does seem to be rushing in. I had an appointment with my IMS today, and even she said to me then, as is often repeated on this board, that cushing's is usually treated when the symptoms warrant it. If you are treating from concern for liver values, then I would urge you to please once again consider that ultra sound.

I too said "don't bother" when first diagnosed and now vehemently wished I had done it. I found out just two weeks ago (when I finally did have an ultra sound after ever increasing alkp test results) that my boy has a massive tumour on his liver, which was responsible for the spike in his liver values, which in turn prompted the testing and subsequent diagnosis for cushing's. He was started on Trilostane, but the question now comes in as to whether it was even needed in our situation, and as of today, we are ceasing the trilo.

I'm not saying that this is going to be your situation, but the ultra sound is a great way to get a look at what is going on in all of the organs. There could be an issue with his liver, especially if it was previously enlarged in an X-ray, or other organs, but it will also give you a look at Remi's adrenals, and tell you for sure or not if you are dealing with cushing's.

As we all know, all dogs are different and will present differently, but I do urge you to reconsider the ultra sound again. As I said, I wish I had done it 12 months ago.

Good luck with whatever you choose to do.

[mytil]

Hi again,

Has your vet checked for hyperthyroidism?

Terry

[labblab]

I really do agree with Naomi's suggestion about first proceeding with the ultrasound. It is not an invasive test, and may supply information that changes your perspective re: Remi's situation.

Marianne

[RemiCash]

Just thought that I would update: Remi took his 3rd dose this morning of Vetoryl. So far, there have not been any symptoms associated with the pill BUT I AM ASSUMING it is far too early. I do notice (surprisingly) that he is drinking less water but definitely still drinking. He also sleeps through the night - which had not been the case for the past 4-5 months. He does not need to go outside and pee during the night. He was just restless - do not know if that was a symptom or not.

Someone asked about the thyroid - his thyroid values were normal as were his other liver values. Bile acid was normal.

[Harley PoMMom]

So glad to hear that Remi is doing so well, and unfortunately, adverse effects can happen at any time but so far so good, YAA!!

Restlessness can be one of the symptoms of elevated cortisol so the fact the Remi is sleeping through the night and drinking less is a good sign that his cortisol is decreasing.

Was an ACTH stim test scheduled for a check on his cortisol in 10-14 days?

Love and hugs, Lori

[RemiCash]

His ACTH Stim repeat is scheduled for 3 weeks on June 2nd. DO YOU THINK THAT IS TOO LONG?

He really seems better than I expected.....which now makes me think that perhaps I had missed some symptoms.

We, of course, are on FULL DUTY WATCH of him -- someone is always in the house with him -- if I need to go show a house (realtor), then Bill stays home and the other way around if he needs to leave his office. Yesterday, we both had to go so I took both dogs in the car with me so I would be right there. I don't want to do that, though, here on in, as the temps are getting in the 80's.

[labblab]

Can you tell us how much Remi weighs, and also what dose of Vetoryl he is taking? Dechra's published literature recommends testing 10-14 days after every dosing change. However, we are aware that some specialists have adopted an initial testing schedule that varies a bit. If Remi was my own dog, my comfort level with an alternative testing schedule would be somewhat affected by the size of the dose. So that is why I am wondering about his weight and his dose.

Marianne

[Trixie]

I'm new here too so you are probably more versed in all this than I am but is your pup on any liver supplement? Before our Cushings diagnosis my dog had a very high alk so we started on Denamarin as a first defense before starting any testing. Maybe you have already tried/been on this? It did lower my dogs levels quite a bit after 2 weeks. Once she went off it she did spike back up and a few weeks later tested positive for Cushings. She was drinking so much water that it was sacry for me...ten times the normal amount. Perhaps the pot belly is just from the enlarged liver? Doesn't seem like the Cushings symptoms are very obvious with your dog, though my dog did not have all of them either. If you haven't had your dog on Denamarin maybe it's worth a try to see if it helps lower the alk.
Barbara

[RemiCash]

Hi and yes, he had been on Denmarim for many months. Last year, it worked and reduced the alk phos. This year, he had been on it for 4 months, and it did nothing. I have taken him off of it as it really gave him an upset stomach.

[RemiCash]

Can you tell us how much Remi weighs, and also what dose of Vetoryl he is taking? Dechra's published literature recommends testing 10-14 days after every dosing change. However, we are aware that some specialists have adopted an initial testing schedule that varies a bit. If Remi was my own dog, my comfort level with an alternative testing schedule would be somewhat affected by the size of the dose. So that is why I am wondering about his weight and his dose.

Marianne


Hi - REMI is a big boy for a boston terrier - he is 31 lbs. He is on 60 mg. (which is recommended doseage for 22 to 44 lbs.) - once a day.

[labblab]

OK, this is a thing that is frustrating for me to write and will be frustrating for you to read -- but Dechra's published dosing chart is actually outdated. It is based on the initial research studies that were performed a decade ago when Vetoryl was first being approved and marketed. Based on intervening research and experience, most specialists and even Dechra themselves are now verbally recommending that dogs be started with doses that are closer to a formula of 1 mg. per pound. So in Remi's case, that would translate into a 30 mg. dose rather than a 60 mg. dose.

It is perfectly reasonable that your vet would have relied upon the published Product Insert. But I do believe that if either you or your vet calls Dechra directly, you will receive confirmation that the revised dosing recommendations are to start lower so as to minimize the risks of unwanted side effects and overdosing. Here is contact information for Dechra's U.S. office in Kansas:

http://www.dechra-us.com/Contact-us-1.aspx

Since Remi is being started at twice the dose that we now see recommended most frequently, you may opt to have a full ACTH performed sooner than three weeks down the road. Or, as an alternative, you might ask your vet about at least performing a resting cortisol level prior to that three-week mark. As long as the resting cortisol is safely above a level of around 2.0, you can have some degree of confidence that this dose of Vetoryl is not driving Remi's cortisol too low.

Do continue to keep us updated as to Remi's progress, OK?
Marianne

[Budsters Mom]

PLEASE CALL DECHRA!!!!
The phone number is listed on the web-site that Marianne gave you the link too. I called them myself. They were very helpful. They answered all my questions, explaining everything. Please do not be afraid to call them. I am very glad that I did! My vet did not have the latest information regarding the use of Trilostane (Vetroyl). Not only did my vet not know, none of the other vets did either. I had to send my vet several emails and personally go in and demand what I needed for Buddy. You need to become informed, particularly when your vet isn't. Please write down all of your questions before you call, then go through them on by one. Ask them to explain anything you are unclear about. Dechra has people standing by to do this. Use them!

Hugs,
Kathy and Buddy:cool:

[doxiesrock912]

Please don't take a chance with your dog's health. Too many vets don't know how to prescribe this medication property.

[RemiCash]

I will call today - thanks

[RemiCash]

I have sent a fax and an email to Dechra. They are located in KS - different time frame than me - I will also call them at the appropriate time.

I will update here with their response. Thank you

[RemiCash]

OK everyone and thanks. I just got off the phone with a wonderful lady at Dechra.

I guess one of the things that they "feel" and I agree -- Remi does not have any other clinical conditions such as allergies, heart, arthritis, etc. Basically, he is a healthy, happy dog.

They agree that the 22.9 acth stim is diagnostic for the Cushings and his desired range in which to fall will be 1.5 to 9.1.

The dose he is on is in the mid-acceptable dose. The desired dose would be 30 mg. to as high as 90 mg. for his size. They felt that, perhaps, my vet put him in the middle range because he doesn't really have any other health problems. HOWEVER, they do recommend a change to the repeat ACTH stim plus electrolytes at 2 weeks vs. 3 weeks.

She also stated that reducing him to 30 mg. would also be ok but does not feel the 60 mg. he is on is a problem. Unlike the Lysodren - Vetoryl is out of the dog's system within 18 hours - so, basically, we have 6 hours without anything in their system, per day.

They have referenced my call and file for Remi and documented everything. I think the good thing is that Remi is not a sick dog or a dog with other issues except a little bit of stiffness from his bilateral lp surgery in both rear knees. I treat him now with K-Laser therapy for that and he has not needed a pain pill for over a year.

I am, HOWEVER, putting a call into my vet right now to discuss all this and especially I want him rechecked at 14 days instead of 21 days.

Will update and I appreciate all the advice and info.

[Boriss McCall]

Good luck.. Sounds like things are going good for Remi. Happy & Healthy other than the cushings is a GREAT thing!!

[RemiCash]

@Boriss -- I notice via your signature that your dog is on 30 mg. Vetoryl - may I ask his weight. I just typed up a bunch of questions and will be taking them to my vet's office in a few minutes. My vet is 3 minutes from my house (and she is also a neighbor) so it is just easier to document everything so she has it right in front of her and can answer all my questions.

thanks again

[Boriss McCall]

He is a big boy as well. He weighs 28lbs. He now takes 30mg at 7am & I give him 10mgs at 7pm. He is doing really good on this dose.
His numbers are at a really good level. There are nights when he is a little more hungry & I probably could get away with raising his evening dose a little. but, for now since he is so happy I don't want to rock the boat. It took us a while to get him on a steady stable dose.
Good luck!

[RemiCash]

Our precious bostons!

[labblab]

I am really glad you called Dechra -- good for you! I confess to being surprised that the rep with whom you spoke was not more endorsing of the 1 mg. per pound formula that has been recommended to others (myself included). But perhaps this is because your vet has already started off with the 60 mg. and thus far, Remi is doing OK on that dose.

In my own defense :o, I will say that it seems preferable to me to start a dog on a lower dose and then work upwards if need be, as opposed to the alternative. There are some practical reasons for this -- you can add smaller capsules together to increase a dose, but you can't split a 60 mg. capsule in half to lower it. But mainly, our experience here is that unwanted side effects seem less likely to occur when dogs are started at the lower end of that dosing range and increases are gradual.

Having said all that, every dog metabolizes the drug differently. And 60 mg. may turn out to be the perfect dose for Remi. The proof will be the combination of his behavior and the results of the monitoring blood tests. I know you are watching him very closely, and will pick up on any warning signs that his cortisol had dropped too low. So the best of luck, and definitely keep us updated.

Marianne

[Boriss McCall]

ha yep.. once a person had a Boston you always have to have a Boston. Love how they are so silly & loving.

[Budsters Mom]

I am so glad that you went ahead and called Dechra. I was really hoping that you would.;):) A lot of vets do not know much about the use of Trilostane (Vetroyl). It has only been approved by the FDA for use in the US since 2008, I believe. You can't expect you vet to know the proper dosages or protocol. That is why, you need to find out for yourself. I was misinformed by my vets regarding ACTH testing and Trilostane dosing. If it wasn't for this forum, I wouldn't have been guided to the right places, for the proper information to protect my Buddy. I'm glad that you got some answers from the source.

Hugs,
Kathy and Buddy:cool:

[RemiCash]

There is no problem - I am happy everyone posted their questions and experience with this. I am inexperienced.

I just had a good half-hour conversation with my vet - she truly believes the 60 mg is the correct dose for Remi. She has suggested I continue the Denamarin and I will do that. She feels he is "right in the middle" of the recommended 30 mg to 90 mg. dose for a dog 22 lbs. to 44 lbs. - Remi is 31 lbs. She also went over all his blood values with me and his electrolytes are perfectly normal, as well as all other liver values. She feels the Denamarin will protect him and advises I still give it for several months until (or if) his alk phos is reduced. As for the dosage - of course, we will know if his values dropped substantially at the recheck, then they will need to be reduced.....hopefully, that is the case and not "increased".

Other than that - he is doing fine. And, again - I am so fortunate because we feel we have caught this in the very early stages before Remi developed secondary problems from having Cushings....we are dealing with a healthy dog (thank God) and I know I sure want it to stay that way.

[RemiCash]

Just an update: Today is day 11 of Remi on Vetoryl.

I can only say he is doing really great - the little bit of a pot-belly he had - IS GONE. He appears to have much more energy. He is drinking less (but as I said - he was not drinking alot---in my mind, anyway) but apparently he was drinking more than now. He is still eating and drinking well, however.

He is much more playful and definitely more restful when he is sleeping or 'lounging'. Still wants to run, jump and chase his tennis balls and play with his brother, Cash, non-stop, preferably.

This is more than I expected in the line of good results and no apparent symptoms of any medication intolerance. I am very careful to give his meds at the same time each day (7:30 a.m.) and also with some Hill's W/D (low residue/low fat). Just enough to absorb the medication. His regular food is at the evening meal.

He is scheduled June 3rd for his repeat ACTH Stim and bloodwork.

[labblab]

This is a great report!! :) :) :)

Thanks so much for the update. You've made my day! ;)

Marianne

[Boriss McCall]

awesome news.. go REMI!!! so happy for you guys.

[molly muffin]

Yay!! Great news!!

Sharlene and Molly muffin

[RemiCash]

Thanks everyone - I sure hope it continues this way. I'm now anxious to see the results of his ACTH on June 3rd. Not sure what to expect there in only 3 weeks....but we will see.

I really believe he is doing well because he doesn't have any other health issues. That HAS TO BE A PLUS for us!

[molly muffin]

Absolutely that is a plus!! :)
Hope the ACTH is right where it should be. :)

Sharlene and Molly muffin

[RemiCash]

THANK YOU ALL.

Remi is doing BETTER each day. My husband and I both think he looks and acts like he has dropped 3 years in age.

I feel so bad because, obviously, this is what was wrong with his #'s, etc. but we just could not confirm the Cushings diagnosis until this last test.

My vet reassured me that we followed the right path by NOT treating until a definitive diagnosis. He's doing really, really good.

[KennyJ]

Gracie's ALP is around 3500. In addition she has a torn ACL that I am trying to treat conservatively. Hope your little one is doing better.





Hi - I am Mary Lou - Mom to Remi and Cash - 2 boston terriers that are my joy.

Remi is 8 yrs. old and Cash is 6 yrs. old
In the spring of 2010 I had a full blood panel done on Remi - all normal except for an elevated alk phos to 290. Three months later, it was rechecked and stayed the same. Sept. it increased to 330 and 2 days ago, the value is 430.

Remi shows no other signs/symptoms. He is overweight but has been. His weight has stayed steady the past 3-4 yrs. at 31.5 lbs -- yes, too much for him. He is much better at around 26 lbs. -- he is a little bigger of a boston.

My vet wants to proceed with other testing. I am just not sure that these values are extremely high and I have been devastated by what all I have read regarding Lysoderm.

Am I jumping the gun? I did take a morning urine and took it to her today to be sent to the lab. I figured that was the least invasive test and should be a good starting point. She has cautioned me that this test may have a false/negative and other tests can be done.

I am feeling today like I have been punched in the stomach. I am so very worried. Any advice/comments will be more than appreciated.

thank you

[RemiCash]

Remi had his follow-up ACTH Stim test done in week 3 of the Vetoryl - done this past Monday.

My vet feels his results are perfect:

1.9 before and 5.5 after

I am unfamiliar with, to some extent, of the values but according to the Vetoryl info, this appears to be "right on". My vet is continuing him on his dose of 60 mg/day with a repeat ACTH in 10-12 weeks.

She advised me of symptoms, etc. to watch but feels he is doing great.

Our personal observations: Remi acts like a boston that is 7-8 yrs., old (our Cash's age) compared to him being 11 next week. His eyes are brighter; his stomach is deflated (I thought he had just gained weight); his fur was always shiny and beautiful .... but it appears to be even more so. He is very playful, full of energy, sleeps well and less restless at night.

I am very happy with the results and feel much more confident about this entire process. His physical exam was good - no other issues.

[molly muffin]

Hi, That is a good result and I agree with your vet. We'll see where the next ACTH is, if it is continuing to drop or if it levels out.
I think you are doing a great job and obviously it is really showing with how Remi is acting now. :) Yay!

Sharlene and Molly Muffin

[SoggyDoggy]

From what I have learnt Remi's test results look really good, but more importantly, your description of his demeanour and health are even better. Just remember that cortisol can continue to drop so you will need to keep monitoring him closely, but with a result of 5.5 you have quite a bit of movement before he becomes unsafe.

Well done mom, your doing great and sounds like you have a good vet too. Always a plus :D

[RemiCash]

THANKS - I sure hope it continues this well.....I think it will.

My vet has listed all the symptoms to watch....just in case. I just cannot get over the difference in him (for the better) and he was good (or so I thought) before. :)

[SoggyDoggy]

Yep, I remember having that exact same thought, so great to see them perk up like that isn't it? Makes you realise how well they hide their issues and just get on with things. Beautiful boy!

[RemiCash]

You are all so right. I truly thought much of what I was seeing -- since there was no illness or so I thought -- was due to him getting older. However, even in hindsight - we could not confirm the diagnosis - it took continual checking every 3-4 months to see if anything was changing. It was only this last time that the diagnosis was confirmed. It would not have been prudent to treat him (according to all of you and my vet) without a confirmed diagnosis. I am just glad, through this forum and other places, that I persevered and monitored because I know we have caught it before it has done damage to organs, etc.

[Boriss McCall]

I just LOVE it when Boston's are silly & fun. Glad you are seeing your young Remi again. yay!! :D

[RemiCash]

Hi - just looking for info and I can't find anything to compare using SEARCH.

If anyone remembers Remi was finally diagnosed with Cushings and started Vetoryl this year - he is on 60 mg. I have been having his repeat ACTH Stim and his last one, done end of September - post was 1.5

The previous one done in June, his post ACTH was 5.

My vet considers him completely controlled.

Remi was doing great but I see a difference the past month and am wondering if his dosage is too high with the 1.5 post-ACTH

He has weakness, now, in his rear legs - certainly not enough to stop him from doing anything except when he plays and runs, his legs often go out from under him and he winds up on his rear end. I am so concerned about this and not sure I understand.

My vet thought perhaps (since he has had 2 lp surgeries) and is now 11 yrs. old that arthritis has set inl. She has prescribed Previcox. I really do not think that is what is going on - I think it is muscle weakness.

any insight would be appreciated and especially if you all think the 1.5 is too low.

[molly muffin]

Hi
I merged this into Remi's thread so that all the information can be tracked for him in one place.

That is quite a drop from 5.0 to 1.5 in 3 months. If it is continuing to drop then you get get into problems. I'd probably retest to see where he is at. Even a month can make a difference.

hugs,
Sharlene and Molly Muffin

[labblab]

Welcome back, and I am so glad you are checking back in. I have only a moment to post right now, but yes, I am extremely worried that Remi's Vetoryl dose is too high and his cortisol has dropped too low. According to Dechra, 1.45 ug/dl is the absolute bottom of their acceptable treatment range and it is very easily possible that Remi is now below that point. My personal opinion is that his dose should have been lowered back in September so as not to risk dropping too low.

I know you called Dechra when you began treatment and they have a file already started on Remi. I hate that it is Friday afternoon because I urge you to call them immediately for guidance since your vet does not seem to recognize the risk of overdosing. Please call Dechra as soon as you can and watch Remi like a hawk for any additional problems. If there is any question at all in your mind, it is always safer to temporarily withhold the Vetoryl than to risk a crash from overdosing.

Marianne

[addy]

Do you know what the pre number is from the ACTH test in September?

[RemiCash]

I believe the pre was 1.0 - but I am not sure. I can check that today. I will also call Dechra

Everything else seems fine with him, only this rear leg weakness.

Also, we retested his alk phos and it has gone down to 700 from his high of around 1200-1300.

I am going to try to get more info today and proceed. Thanks.

[labblab]

If the "pre" result was indeed 1.0 back in September, then he was already too low then, based on what Dechra has recently been telling our members. In years past, not much mention was made of the "pre" result. But we are now being told that Dechra does not like to see either the "pre" or "post" result any lower than 1.45 ug/dl. So I fully expect that they will advise you and your vet to temporarily discontinue the Vetoryl entirely in order to allow Remi's adrenal reserves to rebound, and then start back again at a lower dose.

And I'm with you -- I'd be more suspicious of low cortisol being the cause of Remi's high-end weakness. As such, if it were me, I'd want to talk to your vet about holding off on giving the Previcox until you get the Vetoryl dosing sorted out. NSAIDS such as Previcox are generally not recommended for Cushpups unless other pain relief options fail.

Please keep us in the loop as to what you find out!

Marianne

[addy]

I had a feeling you were going to tell us her pre was low. I'm with Marianne 100% on this. Patti just went through this with Tipper.
She can tell you what Dechra said about her Tipper.

[RemiCash]

Hi all - I talked with my vet's office yesterday and have sent a fax early this morning to Dechra.

Remi's results were:

June 2013 - after 3.5 weeks on 60 mg. vetoryl
"pre" was 1.5 and "post" was 5.1

continued on 60 mg dose - had end of Sept. 2013 stim and results:
"pre" 1.0 and "post" 1.5

mid-October I began to see 'weakness' in rear legs but my vet feels it is arthritis - mostly due to Remi having had bilateral lp surgery at age 3 and 4-1/2.

I questioned about the 1.0 and 1.5 yesterday and was told that she has many dogs on the vetoryl and has maintained them very well on those numbers.

I sent a fax to Dechra this morning and will post their reply. I hate doing this but I am concerned - Remi shows no other symptoms except the rear leg weakness - I have no idea whether those symptoms "are" or "are not" a result of the Vetoryl. Otherwise - he has good stools, eats well, drinks, well, no loss of appetite, loves to play - he just "looks" different to me than in June/July/August time-frame. At that time he became a "puppy" again - since October, he seems like an "old man". Maybe I am reading way too much into all of this. I trust my vet and have been with her for over 25 years. I do not want to change vets. She has agreed to reduce his dosage to 30 mg. --- IF that is what "I" want.

Does anyone know a good range in which he should be maintained?
Remi is 31 lbs.

[RemiCash]

Just got off the phone with Dechra

I'm so confused -- they, of course, are recommending:

Repeat ACTH Stim to see what his numbers are "now"

AND, electrolyte to see those levels - which may be causing the rear leg issue. They did agree, however, that it may just be arthritis.

They do feel his levels are too low -- their recommendation for "NORMAL LEVELS"

1.45 TO 9.1 -- SO, Remi is 'normal at the 1.5 but not at the 1.0

[Squirt's Mom]

If this is arthritis, a lower dose of the Trilo may help by allowing the cortisol to rise a bit and "treat" the arthritis. With the pre that low, I think I would withhold a day or so and ask for that lower dose asap. But the Trilo parents may have a different take on this. ;)

You're doing good, Mom, hang in there!
Hugs,
Leslie and the gang

[goldengirl88]

After reading your post I wanted to tell you my Tipper went to a .7 pre number and I took her off for a week then lowered the dose, I think you are smart in lowering the dose. You do not want the dog to go into Addisons, so I agree with you on lowering. Blessings
Patti

[addy]

Some specialists approach treatment with those same views on Vetoryl, your vet is not alone in thinking that tight of control is what works. I think Dechra has decided to be a bit more cautious and even Dr. Mark Peterson (endocrinologist) goes so far as not wanting the post below 2. It is my understanding that they believe there is a higher change for adverse side effects.
It very well may be that Remi has arthritis and a bit looser control may make him feel a bit better. I am going through a similar issue with my Zoe. There is a balance we strive to find in all of this and also which battles do we fight. I know it can be hard.
I don’t think you need to switch vets if your current vet is open to allowing you to try something that may help Remi and if it doesn’t, well at least you ruled that out.
We cant cure them, we just want to try to give them a quality of life

[Trixie]

The numbers are too low and yes the dose probably needs to come down but since there are no clinical signs of being too low and the dog is doing well, why not lower the dose just a little...but not by half.
You said the current dose is 60mg and vet said you could lower to 30mg if you wanted to? Did I get that right?
Why does the decrease have to be so much?...how about decreasing just a bit, like 10mg down or 15mg...maybe go from 60mg to 50mg or 45mg and see if that helps bring the numbers up a bit...I mean, you don't want the numbers to go too high. Why even consider cutting by half...that seems like a drastic change.

Barbara

[Harley PoMMom]

Given the fact that her post number dropped significantly from 5.1 ug/dl to 1.5 ug/dl in just 4 months has me very worried. If this were me I would definitely decrease her dose of Vetoryl, and I believe a drop to 30mg sounds right.

Hugs, Lori

[RemiCash]

Thanks - I have left a long email for my vet and expect to hear from her. One of the things I have asked is:

Is it safe to stop the Vetoryl for 7 to 10 days and, hopefully, in that time, see if his leg issues get better. Then do an ACTH and blood work and decrease.

I am definitely feeling (you know that 'gut' thing) that this is not right though he doesn't exhibit any other symptoms. Surely with a 1 and 1.5, as someone has said - it is not going to escalate to his high number of 23 in a week or 10 days.

My gut tells me that I no longer feel safe at this level. I will ask about 45 mg. - she has never mentioned that - only the 60 or the 30 or the 10. Perhaps she doesn't carry that one but I will wait for her call and see what she says.

I just know my dog and 'something is not right' -- I like how he was in June/July - honestly, happy and like a puppy - that's when the post was 5.1. Dechra said normal is 1.45 to 9.1 -- why not be in the middle of those numbers and have good quality with his legs while still controlling the Cushings...........those are my thoughts.....at the moment.

[molly muffin]

I think you have your answer right there. Remember, every dog is different and how they react to the drug is different and where their level needs to be is different too. You want Remi where he is at his best. Where the arthritis doesn't bother him so much and he is back to being his normal playful self. For Remi, this is a post of 5.1. You know it, you feel it and that is what you tell the vet that your "goal" is. Whatever it takes to get back up there.

You DO know Remi best and that is what the vet has to remember, not what other dogs do well at, but what Remi does well at.

hugs,
Sharlene and Molly Muffin

[Harley PoMMom]

You DO know Remi best and that is what the vet has to remember, not what other dogs do well at, but what Remi does well at.

hugs,
Sharlene and Molly Muffin

I agree completely! Very well said, Sharlene. ;)

[RemiCash]

Oh well, guys - I just got home from a 2-1/2 hour vet appointment for BOTH Remi and Cash........when it rains, it pours.

Cash woke up this morning and SCREAMED when I touched his face....appears he may have another tooth issue so since he won't let anyone in his mouth to visually inspect this (including me....he is such a baby), my vet has started him on 10 days of Clavamox to see if that will help and then we will take it from there.

My vet and I discussed Remi's dosing in depth. Actually, because I contacted Dechra, they called her last night (and it was their veterinarian vs. the med tech) and I guess I may have been too inquisitive with the drug company because they will no longer speak directly to me. TOO BAD, WHO CARES! Anyway, all seem to feel Remi is well controlled and on the correct dose with an hour's worth of explanation....as to why that is so. So, I'm not sure what I can say to all of you about Dechra at this point, because since I reported what they are documenting as a possible issue, they will no longer speak to me directly.

HOWEVER, when my vet examined Remi's hind-end/leg issues, she determined it to be neurological. We did a series of spine x-rays (as well as him definitely having arthritis in his hips and his 2 LP surgeries) - and lo and behold, he has one crushed disc (appearing to be old) and a newly ruptured disc just below the crushed disc. I guess the way this works, is that discs can continue to crush on down the line (the crushed one is the last T disc and the new ruptured disc is the first L disc). So, we are trying him for one week without any steriods (because of the cushings) but with Previcox, Tramadol and Robaxin. He needs to go back in one week to see if his neuro signs that she did along his spine are any better. IF NOT, she is going to put him on a low-dose steroid, along with his cushings meds and we shall hope. Of course, no running, jumping, stairs, playing, etc..........all of which he does. Remi would never let anyone know he has pain - he is the strong and silent one. The wind blows incorrectly, and Cash will let you know it.

[addy]

Sometimes I wonder when a Dechra vet speaks with our vets that perhaps our vets are not happy about Dechra speaking to us directly rather than going through our vets so perhaps that is conveyed to Dechra? I dont know. :confused

I also wonder if some of the Dechra vets wimp out in the face of a "strong opinionated vet". I really shake my heads at times as it seems they dont even read the material written by the endocrinologists that are spokes people for their company.:(

[RemiCash]

I'm somewhat "bothered" that they will no longer communicate with me but then I tell myself...........this is a drug company.........they don't want anyone who will mess with their data collection.

[molly muffin]

Well I don't like that at all. :( So you questioned your vet. pffftttt that is what a good dog owner does.

I would think in light of the disc problems found that in actuality that they would want those cortisol numbers to come up a bit to naturally control the pain. I mean, isn't that just common sense?????

arggggghhhhh
hugs,
Sharlene and Molly Muffin

[RemiCash]

Well I don't like that at all. :( So you questioned your vet. pffftttt that is what a good dog owner does.

I would think in light of the disc problems found that in actuality that they would want those cortisol numbers to come up a bit to naturally control the pain. I mean, isn't that just common sense?????

arggggghhhhh
hugs,
Sharlene and Molly Muffin

No - misunderstanding - it was DECHRA that didn't like my phone calls, not my vet.

As she explained - while in generalities that all sounds good - increasing his cushings/cortisol levels will only result in temporary improvement and, in time, high cortisone levels (resulting from Cushings) will eat away at the bone marrow and joint fluids until there is nothing left. She said it is not the way to manage. I am going to have to trust her experience and knowledge and hope for the best. I saw the x-rays and saw the discs involved and, of course, Remi has had bilateral lp surgery so his gait is a little different, anyway.

[molly muffin]

Well pffft on Dechra, because everything that I said, still pertains to them too.

Hang in there! I do see what your vet is thinking.

hugs,
Sharlene and Molly Muffin

[Arizona Boston]

What a small Boston world Remi's Mom...

I remember you from the Woof Board back in the day when my Lucy was having LP issues also. And now here we are with both dogs having Cushing problems....

It just goes to show...it's always something!

Hope all goes well for you and your fur babies.

Shelly and Lucy

[frijole]

Wow, that is a small world category moment. What is the likelihood of that happening? :D Kim

[RemiCash]

Hi Shelly - yes, of course, I remember you and I am still a daily member of WOOF - c'mon back!

[thecoz]

Remi's mom: I am a long-time member of the WOOF board too! I rarely post though. Were you on that old "blue board" prior to WOOF?
KJ & Cosmo

[RemiCash]

Yes, I was on there - if you mean the old Org board and then it shut down right after WOOF started. My Remi is 11-1/2 but I have had bostons since 1959.

[RemiCash]

Well pffft on Dechra, because everything that I said, still pertains to them too.

Hang in there! I do see what your vet is thinking.

hugs,
Sharlene and Molly Muffin

I agree - THANK YOU

[thecoz]

Yes, that's it...the old Org board. Cosmo is my first Boston. He's 11 1/2 yrs old. My second Boston is Sam. He's 10 1/2 yrs old.

[RemiCash]

Hi all - I check in but have not posted in quite awhile. I have a 12-1/2 yr. old boston (Remi) with confirmed Cushings. He is on Vetoryl, 60 mg./day and has maintained and down quite nicely with this. He does, however, have a lot of hind end weakness, rear leg issues. He also had some disc issues so how much of this from the Cushings, his bilateral LP surgery when he was younger, or disc issues, I do not know. For almost 10 months he has been on daily Previcox with added Tramadol, etc. I have finally discontinued those to only when needed and quite honestly, he is doing better without them....he was zombie-like on a lot of these meds. His Cushings is well controlled - he has repeat ACTH Stims done every 4 months.

I am interested in your addition of the Milk Thistle -- are you using Denmarin (which is a combo) or just milk thistle and where do you purchase it. How did you determine your dosage, if purchased in non-pet-form? Same question for the salmon oil.

I am just tyring to keep Remi happy (which he is) and as healthy and mobile as possible. Right now he is having a great time in the snow - which surprised me - better than in the grass! I am the one who contacted Dextra and they were very disagreeable, contacted my vet, etc.

[labblab]

Hi Mary Lou, and welcome back!

You will see that I have moved this new post of yours over here to your own original thread. The member's thread to which you replied has not been active here on the forum for several years now, so I think you will have a much better chance of getting some responses from current members here. Plus, everybody will be able to catch up on Remi's history. It's so good to see you here again! :)

Marianne

[molly muffin]

Nice to see you again. So glad to hear that Remi is doing okay and still a happy guy.
I give a joint supplement Dasuquin with MSM for joints. The vets thing it keeps my molly from being in pain from her back leg problems.

For milk thistle I give it separately and I give sam-e also.
I've used this website to order meatonin and lignans when I was trying that and it says that milk thistle should be 2mg per pound of dog weight.

http://www.lignans.net/milk-thistle.html

Maybe that will help you figure it out. I've also given the milk thistle/sam-e combination together, in something like denamarin, except I used S-Adenosyl 100 (you can find this on Amazon.com)

http://www.amazon.com/Adenosyl-SAMe-Small-Dogs-Cats/dp/B00II729M4