Peanut-Dachshund-Cushing Diagnosis?

[squeezy p-z]

My almost 13 year old dachshund, Peanut, was diagnosed with Cushings in July 2010 and started Lysodren then. She weighs 17 lbs. and is on 125/mg twice per week.

I question my vet's diagnosis of Cushings as Peanut show few (if any) symptoms. She has a slightly distended belly and a voracious appetite (she's always been a hungry dog; this is nothing new). She doesn't drink or pee a lot and has a great coat.

In June 2010 her alt phos was 1146, ALT was 273, platelets, WBC, triglycerides, and lymphocytes were also elevated.

Below are the test that have been done:
10/9/2010 ACTH Stim; 7.9 to 12.4; increase to 125mg twice a week
Aug/Sept 2010; Problems with lysodren (Pustules on stomach, diarrhea, lethargy; reversed with Pred and cut to 125mg/wk
8/5/2010 ACTH Stim; 2.6 to 3.2 after another 4 days of lysodren at 375mg/day; Begin maintenance 1/4 tab M,W,F
7/29/2010; ACTH Stim; 7.7 to 10.2 after 7 days of lysodren at 250mg/day; Continue loading
7/20/2010; Chest and abdominal ultrasound; No evidence of adrenal tumor; Cushing is pituitary based; Leaky mitral valve; Liver and adrenals slightly enlarged
7/14/2010; Low Dose Dex Suppression Test; Positive diagnosis for Cushing's bases on test results.
8/2/2009; Urine Cortisol Creatinine Ratio; Cortisol 6.5 5-55 Reference; Creatinine 269.7 100-500 Reference; Cushing's syndrome is highly unlikely. This is what really concerns me. She had the same elevations in her blood work when this test was performed. When I questioned the vet, she said the UCCR can be negative but Cushings can still be present.
7/19/2009; Bile Acid; Pre-meal 6 <10.0 Reference ; Post-meal 12.3<20.0 Reference ; Bile acids are within normal ranges.

Since March 2011 Peanut has been battling very frequent GI issues usually the day after taking Lysodren. Her belly gurgles, she's letargic, won't eat, has diarrhea (with mucous, blood, and grass mixed in) and just feels lousy. This usually happens once a week and resolves within a day. When she's not having GI issues she appears to feel good.

Based on the info provided above, do you Cushing's experts think Peanut's diagnosis is correct? We have a vet appointment in a week and I want to come armed with the right questions to ask my vet.

1. Could Peanut's frequent stomach issues cause elevations in liver enzymes? Could she have chronic pancreatitis or inflammatory bowel problems or some type of liver problem?
2. Can LDDS/ACTH tests result in a false positives due to stress? Peanut freaks out at the vet.
3. Why was urine cortisol normal if she has Cushings?
4. Should I run any other test on her.

Thanks in advance for reading my post. I'm looking forward to your insights. I just want to do the right thing for my baby.

Many thanks,
Nicole

[Harley PoMMom]

Hi Nicole,

Welcome to you and Peanut! So sorry for the circumstances that brought you here but very glad you found us.

The Urine Corticoid : Creatinine Ratio (UCCR) test has a good sensitivity (98%) of ruling out/in Cushing's. Since Peanut's ratio, which I calculated at 7.5, is well below the usual reference range of <13, and since she is not displaying strong symptoms, IMO Peanut diagnosis of Cushing's is highly unlikely.

The liver enzyme, ALP, can be elevated by a variety of things, and GI issues is one of them.

My boy, Harley, was dx'd with pancreatitis via an ultrasound and later confirmed by a Spec PL test. Was Peanut having GI issues before the treatment of Lysodren?

Has diabetes and any thyroid problems been ruled out? I am sorry to ask all these questions but the more we know about your precious girl the more meaningful our feedback will be, ok?

Please know we will help you in any way we can so ask all the questions you want. ;):)

Love and hugs,
Lori

[squeezy p-z]

Hi Lori,

Thanks for responding so quickly. Yes, Peanut has always had GI issues. They have just increased in frequency since she started the Lysodren. She's had colitis quite a few times prior to starting Lysodren, but has never been diagnosed with pancreatitis.

Her elevated liver enzymes started back to 2004 (alk phos 264) and they have increased steadily year after year. Nothing has shown up in her blood work to indicate thyroid problems or diabetes. I'm assuming this would show up on a regular CBC workup?

My current vet, who is an IMS, is convinced she has Cushing's even though she doesn't have the classic symptoms. She completely discounted that the UCCR was normal and based her diagnosis entirely on the LDDS test.

Peanut has been on Lysodren for 10 months now. If she wasn't cushinoid wouldn't the Lysodren be killing her adrenals and she would become Addisonian? I hate to think I could be treating her for a disease she might not even have.

I'm at a loss here. Should I quit giving her the Lysodren and see what happens? Should I request another UCCR and see what the results are? If the UCCR is negative will the vet tell me it's just because the Cushing is under control because of the Lysodren? If her liver enzymes are decreased when I take her to the vet in a week or so then can I assume she does have Cushings and they Lysodren is working?

Sorry for so many questions, I just want a definite answer on whether or not she has Cushings?

[littleone1]

Hi Nicole,

Corky and I also want to welcome you and Peanut.

I don't have anything to add, as Lori has given you quite alot of information. I hope that Peanut's issues get resolved.

Terri

[apollo6]

Dear Nicole
Welcome. I can not give you input on the tests. But I also have a mini dachshund, Apollo, 12.5 years old. He has had buts of pancreatitis through out his life, his cushing's pituitary based. He did have the hair loose, still dealing with skin issues, hind leg weakness, muscle wasting. When first diagnosed his liver enzymes were extremely high. If Peanut's cortisol levels were extremely high when you first started treatment and are now within the normal range then something must be working right. If Peanut's is throwing up when her/his dosage is changed then it is the medication. I can not give input on Lysodren. Please ask us more questions and hopefully we can help.
Hugs Sonja and Apollo

[addy]

Hi and Welcome,

Others will be along soon to comment further on your post. They tend to ask a lot of questions, please don't be put off by that.

My Zoe has colitis for the last 3 years as well as being diagnosed with Cushings June 2010. Her gastro panel always came back normal, she had slight elevations in her ALK and cholesterol. She is on a daily dose of Metronidazole since October 2010. Her blood work showed normal ALK and cholesterol in January 2011 (high side of normal). I believe it was due to the metronidazole finally controlling her colitis. Her Cushings at that time was not controlled.

Lysodren can cause gastric upset in our pups. It is a common side effect.

I don't think you can do a low dose dex test while on Lysodren but our moderators will all be a long soon to voice their opinions.

Glad you found us.


Addy

[Roxee's Dad]

Hi Nicole :) and a belated welcome to you and Peanut from me too.

Just a quick question I would ask myself..... What symptoms has the Lyso cured? Usually the reason for treating cushings is to help with the symptoms, not to cure cushing's.

So if Peanut is not drinking excessively, or stealing food, and not panting, or is not suffering hair loss... I only question the reason for treatment?

I am sure other will also chime in very soon. :)

[lulusmom]

Hi and welcome to the forum.

John has hit the nail on the head with his assessment of why treatment is prescribed. A study done by UC Davis explained it best by saying that with rare exceptions, cushing's in dogs is neither a rapidly progressive nor a life threatening condition that requires a rapid response to treatment. It is a chronic progressive disease that ultimately causes unacceptably bothersome clinical signs for the pet owner. So with that being said, I would have the same question John has. I would also ask if your vet has suggested that you put Peanut on liver support such milk thistle and/or SAMe. You can buy these over the counter or you can purchase the veterinary formulas called Adenosyl or Denmarin. This will definitely help in reducing the liver enzymes.

I know this sounds odd but dogs with normal adrenal glands are resistant to Lysodren and much less likely to experience an adverse reaction. Back in the early 1940's when they were testing Lysodren healthy dogs were given some fairly high doses for as long as a year and they survived. For this reason, a misdiagnosis is always a possibility when a dog seems to be resistant to the effects of lysodren. So, if Peanut doesn't have cushing's, his chances of experiencing total adrenal necrosis are slim. However, I do believe gastric upset is a real possibility since this is the number one side effect listed for Lysodren.

Glynda

[squeezy p-z]

Hi All,

Thanks for your responses. When I first started treatment on Peanut I wasn't convinced that I was doing the right thing. My vet told me she was 100% confident in her diagnosis and if Peanut was her dog then she would definitely treat her because Cushings can cause other problems if left untreated.

Could the LDDS test she performed have yielded a false positive and then along with the elevated liver enzymes and slight pot belly led my vet to the wrong conclusion?

John and Glynda, I'm not sure the Lyso has cured any symptoms. Peanut still eats like a pig and has a little pot belly after being on the Lyso for 10 months. Her coat has never been bad and she doesn't drink or pee a lot. She has no accidents in the house when I'm at work. She only pants when I walk her, but it's 90+ outside so I pant too. For years, she's had summertime skin allergies usually July-Sept. She also has a heart murmur and leaky mitral valve.

Addy, what led to Zoe's diagnosis? Was she exhibiting classic Cushing symptoms? I also did bloodwork on Peanut after a course of Metro for colitis and the alk phos was not reduced.

I did try Denosyl for about six months a few years back and it had no effect on her liver values. Then I did the bile acid test in 2009 and it showed her liver was functioning ok which eased my mind somewhat.

Peanut takes Lyso on Sun and Wed. She doesn't get gastric upset with every pill, but she definitely gets it more frequently than she used to. For example, I gave her a pill on Sunday, she was fine on Mon, Tues morning she definitely had some gastric problem but by Tuesday night she was fine. Sometimes the gastric problems are just gurgling, gas, and loss of appetite and other times they appear to be full blown colitis like symptoms.

Are there any other tests you would recommend running?

If there is a reduction in Alk phos in the bloodwork she's going to get done on the 18th can I assume the Lyso is working and she really does have Cushings?

[lulusmom]

The last stim test appears to have been don on 10/9/2010 and the results were high, pre 7.9 and post 12.4. Your vet recommended an increase in maintenance to 125mg twice a week. I will tell you that it is rare that an increase in maintenance dose is effective in bringing a post stimulated cortisol that high down to within the therapueutic range of 1 - 5 ug/dl. Usually anything over 10 ug/dl is normally going to require a reload.

Have you had any acth stim tests done since October? If not, it is highly likely that not only has the cortisol not gone down but it has risen in all these months. I have two dogs treating with Lysodren and it is imperative that you stay on top of monitoring, especially when any changes in dosing is required.

Lysodren has a cumulative effect so if you give a dose on Sunday, you aren't going to see the full impact of that dose for 48 hours so the time frames you mention when Peanut gets gassy after dosing makes perfect sense.

[addy]

Addy, what led to Zoe's diagnosis? Was she exhibiting classic Cushing symptoms? I also did bloodwork on Peanut after a course of Metro for colitis and the alk phos was not reduced.


We started out with hair loss. It was her only Cushing symptom. She also drank more water for her, which, she never really drank much water, so it was not excessive or extreme. Just something I noticed, I did not consider it a problem. Zoe has not followed classic much of anything:rolleyes::rolleyes:

Her cortisol was sky high, yet, her symptoms were mostly coat/tail issues. As time went on hind leg weakness appeared. She stopped jumping on the bed at night, then stopped all the time, followed by not jumping on the sofa, then, not wanting to go up or down the basement stairs (we used to play jump in the basement rec room) followed by her back legs trembling off and on/ then front leg trembling/increased appetite (she had been Miss Hoover for a long time but recently started looking outside for things to eat:eek:)

Hugs,
Addy

[squeezy p-z]

Lulus mom,

When Peanut's cortisol levels were within the normal range after her second loading (2.6 to 3.2) she was so sick that I had to give her prednisone. She wouldn't get out of bed or eat and her allergies got so severe she developed pustules on her stomach. I brought her to the vet and she said to stop the lysodren, give the pred, and let her recuperate. She then eased back into the lysodren and didn't want to reload her since she got so sick. My vet's theory is to treat the dog individually not the disease by the book. She didn't want her to be miserable just the get her cortisol #'s where the "textbook" says they should be.

I have not done an ACTH since October. I guess I should schedule one soon. However, I don't want to reload if she's going to get that sick again. She was pathetic and didn't have much of a quality of life when her levels were normal. Now, other than the gastric issues, she's a happy dog with a good quality of life.

Can I assume that having the cortisol still high (with the dose of lyso I'm currently administering) is better than having it totally out of control with no lysodren?

[addy]

Can I assume that having the cortisol still high (with the dose of lyso I'm currently administering) is better than having it totally out of control with no lysodren?

I am not sure I can answer this but I can tell you that for my own pup who has just started treatment with Vetoryl (Trilostane) I went into treatment knowing that because of her colitis, I may have to allow her numbers to run higher than "normal".

Hugs,
Addy

[lulusmom]

Hi Nicole,

I'm so sorry for not seeing your question until now, thanks to Addy. To answer your question, yes, sometimes you have to treat the dog and not the numbers and to do otherwise can create a serious quality of life issue. Prednisone is a synthetic steroid prescribed for dogs with severe allergies and arthritis. Cortisol is the body's natural equivalent of prednisone and because cushdogs produce way too much of it, they are self medicating themselves and allergies and arthritis are not a problem until these conditions are unmasked when cortisol is reduced with treatment. When this happen, it can be debilitating for a dog so one must weigh the benefit of treatment and decide whether to treat at all or deviate from established protocol and let the cortisol run high enough to maintain control of allergies.

You know Peanut better than anyone and nobody here would be presumptuous enough to tell you what to do. That is a very personal decision but I will tell you my feelings on the matter. If it were my dog and an alternative treatment was not effective in controlling the allergies, I believe high cortisol is much preferrable to the discomfort, and sometime agony, of festering infections and constant itching.

In Peanut's case, I think you and your vet are on the same page and I'm right there with you. The best approach would be to try to get the cortisol down as close as you can get to the desired therapeutic range to see some improvements in the cushing's symptoms but still high enough to keep the allergies at bay. It might not be easy to find a happy medium but if anybody can do it, you can.

Glynda

[squeezy p-z]

Addy and Glynda thanks for the reponse and reassurance. My goal is to have Peanut as happy as she can be for the rest of her years. If that means her cortisol levels aren't perfect, then so be it.
I have a vet appointment for her yearly checkup on Saturday. I'll let you know where her liver enzyme levels are and what our vet says. I'll probably also end up doing another ACTH in a few weeks. I would be hesitant to increase her lyso now though because her really severe allergies usually start around this time of year.

Keep you fingers crossed that we get good news at the vet....:)

[addy]

I am crossing everything I can for you and Peanut.

Will wait to hear your news.

Hugs,
Addy

[jrepac]

Hi Nicole,

Welcome to you and Peanut! So sorry for the circumstances that brought you here but very glad you found us.

The Urine Corticoid : Creatinine Ratio (UCCR) test has a good sensitivity (98%) of ruling out/in Cushing's. Since Peanut's ratio, which I calculated at 7.5, is well below the usual reference range of <13, and since she is not displaying strong symptoms, IMO Peanut diagnosis of Cushing's is highly unlikely.

The liver enzyme, ALP, can be elevated by a variety of things, and GI issues is one of them.

My boy, Harley, was dx'd with pancreatitis via an ultrasound and later confirmed by a Spec PL test. Was Peanut having GI issues before the treatment of Lysodren?

Has diabetes and any thyroid problems been ruled out? I am sorry to ask all these questions but the more we know about your precious girl the more meaningful our feedback will be, ok?

Please know we will help you in any way we can so ask all the questions you want. ;):)

Love and hugs,
Lori

I recognize that everyone is talking about the pros and cons of treating/not treating at this point, BUT... I'm going to come back to the first few posts on this thread to say "why in the world does your vet think Cushings is present when the UCCR is negative"?:eek:

Any vet worth his/her salt knows that the UCCR is the first step in the proper diagnosis; a negative result pretty much tells you it's not Cushings while a positive result indicates that Cushings MAY be present.

I think your vet has quite possibly made a faulty diagnosis which would explain why the lysodren has NOT helped her symptoms and in fact may be responsible for gastric upset and diarrhea. I recommend you seek out a second opinion; frankly, given what you described, I would question ANY vet who said they were "100% certain" it was Cushings under the circumstances/conditions you described.:confused:

Jeff & Angel Mandy

[squeezy p-z]

I don't have any answer for you, Jeff. That fact still troubles me. The UCCR was done in June 2009. The cushings diagnosis based on the LDDS results, long term elevated liver enzymes, and her only real symptom of an enlarged belly was made a year later.

Could she have developed Cushings between June 2009 and July 2010? Her liver enzymes were high when the UCCR was done and it said Cushings is not likely. Could the LDDS have yielded a false positive because Peanut freaks at the vet?

This vet was my second opinion and my "tie breaker". I went to her because she was an IMS. My old vet thought she had some kind of liver disease (not Cushings because of the negative UCCR). Another vet at the old clinic thought she had some hormonal disorder or possibly Cushings.

Would it be effective for me to do another UCCR now? Would that tell me anything definite? Should I stop the lyso, wait a few months for it to clear her system, and then do another UCCR?

I'm more confused than ever on what the right course of action is.

[jrepac]

We started out with hair loss. It was her only Cushing symptom. She also drank more water for her, which, she never really drank much water, so it was not excessive or extreme. Just something I noticed, I did not consider it a problem. Zoe has not followed classic much of anything:rolleyes::rolleyes:

Her cortisol was sky high, yet, her symptoms were mostly coat/tail issues. As time went on hind leg weakness appeared. She stopped jumping on the bed at night, then stopped all the time, followed by not jumping on the sofa, then, not wanting to go up or down the basement stairs (we used to play jump in the basement rec room) followed by her back legs trembling off and on/ then front leg trembling/increased appetite (she had been Miss Hoover for a long time but recently started looking outside for things to eat:eek:)

Hugs,
Addy

Yup, same here. Those are the symptoms I am used to seeing as well. Plus, seeking out cool places to rest (tile floors, behind toilets, etc.).

Jeff & Angel Mandy

[apollo6]

Dear Nicole
You know what is best for Peanuts. Go by your gut feelings. Sometimes we get so overloaded with this disease we can't think straight.
Hugs Sonja and Apollo