Eskimo spitz Cushings

[jtbama]

Hi, I am new to the forum but have been doing some research ever since my vet told me my dog might have cushings. Well today I found out that she does have it according to the ACTH results which were Cortisol sample 1 4.5 ug/dl and one hour later sample 2 was 32.4ug/dl. Flurry is my eskimos name, she started drinking, eating and panting excessively about 3 or 4 weeks ago and thats what triggered me to take her to the vet. Flurry has a small patch of missing hair on both her elbows, which I noticed a few months ago but never thought anything about. My vet has not recommend any more testing and has recommended starting treatment with lysodren. I guess my question would be what do you guys think. I think that I would rather have her on vectoryl(trilostane) according to what I have been reading. I also would like to know if this is a pituitary or adrenal so if it is adrenal I might go with surgery. Flurry is 9 years old

Moderator's Note: I have manually approved your first post so other members can start responding. Please check you e-mail, especially your junk or spam folder, for a note for k9cushings that you should respond to, so we can get your membership approved.

[Cyn719]

Hi and welcome to the forum:). I am so sorry for the reasons that brought you here but you and Flurry have come to the right place. The members here are the best! They are so knowledgeable and they will always be here for you. I was going to ask you to post any other bloodwork that you have but I see you mentioned the vet didn't do any. I would assume an ultrasound will be needed to check the glands. The experts will be by to give you their advice. Hang in there! Its a lot to absorb but we will get you through it!!

Hugs

[frijole]

Welcome from me as well. While your dog does have symptoms of cushings' it is not an easy disease to diagnose and you should always do multiple tests to confirm the dx. Trust me - I had one dog that DID have it and I had one that was misdiagnosed.

You are wise to determine which type of cushings it is and the test you want done is the LDDS test (low dose dex suppression test) and it is an 8 hr test. (draws taken at 4 and 8 hrs) I would also highly recommend an ultrasound. It gives you a good look at what is going on with the organs. We have seen many cases where the ultrasound showed other issues and confirmed a misdiagnosis.

Other illnesses can result in false positives on tests and therefore the need for multiple tests before giving a drug such as lysodren.

I used lysodren with Haley successfully for over 4 1/2 yrs. She passed away at the age of 16 1/2 from non cushings issues. So if it is cushings - your dog can live a very normal life.

PS The ultrasound needs to be done on a high resolution machine which not all vets have so you might have to go to a 3rd party to have it done.

[addy]

Hi and welcome from me as well,

Kim is right in that Cushings is hard to diagnose as other illness mimic it and no one test is perfect.

Both Lysodren and Trilostane work well as long as your vet has experience with the drugs. I chose Trilostane because my Zoe has IBD and the endocrinologist felt Lysodren may be too hard on her system and that her colitis would most likely flare up so Trilostane gave me the ability to stop and start the drug where as with Lysodren I would lose the load if I stoped it and then have to reload.

It took me a year to make up my mind:)

hugs,
addy

[Squirt's Mom]

Hi and welcome to you and Flurry! :)

The ACTH is more often used as a monitoring test but some vets do use it in the diagnostic phase. However, IMHO, that is not enough testing to base starting treatment on. ;) Here's why - my Squirt had the LDDS, HDDS, ACTH, 2 ultrasounds and the UTK panel. All five tests said she had the pituitary form of Cushing's. But after the second U/S I was told she had a tumor on her spleen. Once that tumor was removed, her cortisol returned to normal. The stress of that tumor was causing her body to release excess cortisol which caused the cushing's tests to come back positive.

This was in 2008 and she didn't show any signs until this past summer when she was put on a maintenance dose of Lysodren because she is Atypcial. Trilostane is not recommended for Atypical pups - I would not know she was Atypical if I hadn't done the UTK panel...a test not usually given.

Cushing's is a very slowly progressing condition which brings me to a concern. You said Flurry started showing signs about 3-4 weeks ago. Cushing's just doesn't come on that rapidly. Most folks think their baby is simply showing signs of aging and the diagnosis, or suspicion, of Cushing's comes about from routine labs for procedures like dentals. For this reason, if nothing else, I would insist on further testing. I would insist an abdominal ultrasound be part of that testing. ;) This test will help determine whether it is pituitary or adrenal based as well as let the docs get a look at many other organs that could be causing her problems. As one of our mods says, this test "gives you the biggest bang for the buck".

Like you, I was more afraid of Lysodren than Trilostane when I first entered the Cushing's world and started reading. After I have been around awhile and learned a tiny bit, I no longer feel that way. Lysodren is my preference. Both are life-saving drugs when protocols are followed. Trilostane is NOT safer than Lysodren in spite of what you may be told or have read. What makes it seem safer is the short life it has in the body compared to Lysodren. If a crisis were to arise, the Trilo would leave the body sooner than the Lyso would. However, Trilo has the exact same potential for damage as Lysodren. Both are powerful drugs that demand respect. You make your decision based on what the tests show and which drug your vet has had the most success with. Even after all of that, some pups just do better on one than on the other. ;)

So, here's your homework assignment for today. :p Call your vet and get copies of all the testing done so far on Flurry to diagnose the Cushing's. You are asking for the actual results, not the invoice you usually get at check-out. The ACTH and any chem labs that were done. Post the complete ACTH report here and just the abnormal values on the lab report. Be sure to include the units of measurement for each value (ug/dl, mnol/L, U/L, etc) and the normal ranges for each.

Now, the most important thing for you to know. You and Flurry are not alone on this journey. We will be with you every step of the way. Never hesitate to ask questions - read, read, read then ask more questions. Remember, if this is Cushing's, it is a slowly progressing condition so you have time to learn a bit about it before you start treatment.

Hugs,
Leslie and the gang

[marie adams]

Welcome to you and Flurry! :) You have come to the right place for answers!!!

I used Lysodren for my Maddie because at the time that is what the vet was comfortable with. With the help of everyone here we were successful in our loading and maintenance. Every dog is different, but we had no side effects at all. There will be adjustments with both drugs. I can tell you I wanted the Trilo when researching before I had taken Maddie to the vet for the official testing, but I finally figured out what was wrong with her once I found the link to Cushing's Disease--she had so many of the symptoms that there was no doubt, but it was a process of seeing the panting, ravenous appetite, drinking, slowing down, shaking in her hind legs. She did start to have problems with her elbows getting sore and red. Once she got on a maintenance dose her quality of life improved a lot.

The experts have experience with both drugs so you are in good hands. Just keep asking as many questions as you need to because someone will be there with an answer or research it for you. :)

Hang in there because you will be learning so much about Cushings...which is a good thing.

Take care!!!

[jtbama]

Thanks so much for the quick reply
Ok here is what I got on her tests
ACTH
4.5 ug/dl starting
32.4 ug/dl 1 hour later

GLU 95 mg/dl
BUN 17 mg/dl
CREA 0.8 mg/dl
TP 470 u/l
ALT 470 u/l
ALKP 2000 u/l

[jtbama]

I got an ultrasound schedueled for next week, checked and they said they do have a high resoultion machine.

[Harley PoMMom]

Thanks so much for the quick reply
Ok here is what I got on her tests
ACTH
4.5 ug/dl starting
32.4 ug/dl 1 hour later

From the ACTH stim results, it does seem that Flurry's cortisol is elevated.




GLU 95 mg/dl
BUN 17 mg/dl
CREA 0.8 mg/dl
TP 470 u/l
ALT 470 u/l
ALKP 2000 u/l

Could you post the reference ranges for these levels for us, please...Thanks!

[jtbama]

The reference were

GLU 70-143
BUN 7-27
CREA 0.5-1.8
TP 5.2-8.2
ALT 10-100
ALKP 23-212

results and normal ranges combined in following post.

[Squirt's Mom]

Results with normals combined for easier reading.

GLU 95 mg/dl Normal - 70 - 143
BUN 17 mg/dl Normal - 7 - 27
CREA 0.8 mg/dl Normal - 0.5 - 1.8
TP 470 u/l Normal - 5.2 - 8.2
ALT 470 u/l Normal - 10 - 100
ALKP 2000 u/l Normal - 23 - 212

[Harley PoMMom]

Will be looking forward to seeing the findings from the ultrasound.

For the TP, is 470 u/l the result?

[jtbama]

Sorry should have put them together, here they are correct numbers


GLU Normal 70-143 Results 95mg/dl
BUN Normal 7-27 Results 17mg/dl
CREA Normal 0.5-1.8 Results 0.8mg/dl
TP Normal 5.2-8.2 Results 5.9g/dl
ALT Normal 10-100 Results 470U/L
ALKP Normal 23-212 Results >2000U/L

[lulusmom]

Good for you for scheduling an abdominal ultrasound. I was going to suggest that myself but I didn't want to sound like a broken record. :D I'll be very interested to hear about the findings so please make sure you post them when you have them.

[Harley PoMMom]

Sorry should have put them together, here they are correct numbers


GLU Normal 70-143 Results 95mg/dl
BUN Normal 7-27 Results 17mg/dl
CREA Normal 0.5-1.8 Results 0.8mg/dl
TP Normal 5.2-8.2 Results 5.9g/dl
ALT Normal 10-100 Results 470U/L
ALKP Normal 23-212 Results >2000U/L


The elevations in the ALKP and ALT are typically what is seen in a dog with Cushing's disease. The glucose, BUN, creatinine, and total protein, all are within their normal ranges, which is great!

[jtbama]

Just wanted to give an update on flurry, been kinda weird this week with her, she has been acting normal, eating, drinking all seems to be about normal. Is this normal with cushings?

[Maya]

Hello and welcome from me and Maya!:) Just to let you know that Maya had no Cushings symptoms at all before she was diagnosed. At that time she had a bad urine infection and the vet wanted to run routine blood tests to find out why she kept having these reoccurring urine infections( she had had about four in the past two years, She would actually pass blood) Her results indicated Cushings- liver enzymes were very high. Next step was ACTH test followed by the ultra sound which just confirmed all the other test results. I found it very hard to believe Maya had Cushings because she was not ill and acting totally normal, but sadly she did have it! You seem to be going in the right direction towards a reliable diagnosis. I think the ultra sound will give you more answers. This forum is great and the people are very kind hearted,very knowledgeable and they offer great support.
Hugs from Leah and maya

[lulusmom]

No, it is not normal for symptoms to disappear without treatment and if they did, I would question the diagnosis. I was glad when you said you made an appointment for an abdominal ultrasound because 1) inadequate testing was done to confirm a diagnosis, starting with a full blood chemistry instead of the inhouse mini panel and 2) I had some concerns about the high ALT. Yes, we usually see mild elevations in ALT with cushing's but I don't believe 470 would be considered mild. I'm not a vet but I've done a fair amount of research on canine liver disease and I believe a four fold increase is high enough to suspect that there may be more than cushing's going on.

I had a similar situation last year with one of my cushdogs. I took him in for his annual senior panel because he wasn't acting like himself. I didn't think it was anything serious but he was overdue anyway. I think I took him to the vet on Thursday and of course, they never call me, I called them but it was four or five days later because of the weekend and a holiday. By that time, Jojo was actually perfectly normal again but when I got the results of his bloodwork, I was floored. If I posted all of the abnormal values here, including ALT that was higher than Flurry's, anybody who can interpret lab work would think he was on death's door. He was acting perfectly fine so I waited two months and redid bloodwork and it was as normal as his has ever been. That kind of stuff happens so let's hope that's what happened to Flurry. Her bloodwork today may look a whole lot better.

[jtbama]

Well flurry is done with the ultrasound and the vet said her adrenal glands look normal, also kidney spleen look good also. They are going to get me a copy of the measurements for my record in a day or two. The vet asked if flurry had a thyroid test yet and I told them no so I went ahead and let them pull blood and will get results from that tommorow. I am not sure how to take this news as good or bad because if it turns out it is cushings then it will probably be the tumor located on the pituitary gland which is very risky for surgery and she will have to go on meds. I will keep you posted on what happens next, thanks for all your help

[Harley PoMMom]

I would not start any kind of treatment for Cushing's because a confirmed diagnosis is highly unlikely if the adrenal gland looked normal and Flurry is not displaying any Cushing's symptoms.

The Cushing medicines, Lysodren/Mitotane and Trilostane/Vetoryl are strong drugs and should not be given unless a confirmed case of Cushing's is diagnosed.

Please do keep us posted.

Love and hugs,
Lori

[jtbama]

Flurry symptons started coming back this week couple days before the ultrasound, her food, water intake and panting was back up high again. Flurry has hair missing on her elbows but the vet was saying thats not to uncommon for a stress point and most cushing dogs have hair on sides thats missing. The vet also said her belly didnt appear as pot belly and her skin was not thin, so flurry does have the painting, food and water intake symptons of cushings and also the ACTH test is showing cushings. I am going to get her results from thyroid today and go from their, prob a low dex test next.

[Squirt's Mom]

Hi,

I agree with Lori. Based on the ultrasound report on the adrenals plus the fact that her signs have disappeared, there is no need for treatment for Cushing's right now. In a pup with Cushing's, the adrenal glands are usually 1) both enlarged, or 2) one is enlarged and the other is very small, even withered. Normal adrenal glands on the ultrasound indicate they are functioning normally - which they would not be with Cushing's. So for now, unless Flurry starts showing signs again or the upcoming test results indicate a problem, I wouldn't worry about Cushing's right now...and certainly, do NOT start any treatment.

Just some interesting info for you - Pituitary based Cushing's is not usually treated via surgery in the USA. In The Netherlands this surgery is performed on PDH pups but here it has just started being done over the last few years. In fact, one of our members here had a pup who was one of the first to undergo a hypophysectomy (removal of a pituitary tumor) in the US. Here we treat with meds and do so successfully most of the time. As this surgical procedure is perfected here, we may see more of these surgeries in our cush babies but for today, Lysodren or Trilostane are the preferred treatments. Every advancement in the treatment of canine Cushing's is one step closer to a possible cure. ;)

Do let us know what the test results are and how Flurry is doing.

Hugs,
Leslie and the gang

[jtbama]

Ok, got results for the Total T4 test and the vet said it was borderline, Flurry had a 1.1 reading, they said normal was between 1.0 and 4.0. The vet recommended doing a TSH test to further check on the thyroid and said they can have those results to me tommorow off of the same blood they used for the total T4 test. I told the vet to go ahead and run that test and we will go from their, what do you guys think about the results on the thyroid, any of you familiar in that area, Thanks

[jtbama]

I got the TSH test back and the results were normal so the vet has said the thyroid is normal. I am going to get the Low Dose Dex test done next week to see what they show

[Squirt's Mom]

Thanks for letting us know her thyroid function seems to be good after all. Now on to the next step! :) Let us know how she does!

Any questions about the LDDS (Low Dose Dexamethasone Suppression test)?

Hugs,
Leslie and the gang

[jtbama]

If the low dose dex test comes back as showing pituitary dependent cushings, would that be enough evidence to start treatment with lysodren or trilostane. The ACTH test has already come back postive for cushings

[Harley PoMMom]

If other non-adrenal illnesses are ruled out and an ACTH stim test with a LDDS test results are positive towards Cushing's PLUS if clinical symptoms of Cushing's are obvious then, I believe, treatment should begin.

[jtbama]

Ok got the results of the low dose dex test Pre test 4.4ug/dl 4hour result .8 ug/dl 8hour result 1.2ug/dl. What do you guys think from this reading. Vet is saying the results that its not definate cushings from results.

[labblab]

Ok got the results of the low dose dex test Pre test 4.4ug/dl 4hour result .8 ug/dl 8hour result 1.2ug/dl. What do you guys think from this reading. Vet is saying the results that its not definate cushings from results.
Oh dear! The LDDS test result does cast a big question mark over things. Can you check the test result sheet and see what the cut-off number is for a normal result at the 8-hour point? For most laboratories, the normal cut-off is around 1.4 ug/dl. If that is true for the lab that analyzed Flurry's test (and based on what your vet has said, I'm assuming that's the case), the test is NOT consistent with Cushing's. And for most dogs, this rules out the diagnosis. However, a very small percentage of dogs can have a "negative" result on the LDDS but still have Cushing's -- as demonstrated by a "positive" ACTH stim test. Here's a quote from an article by Dr. David Bruyette (http://veterinarymedicine.dvm360.com/vetmed/Medicine/ClinQuiz-Interpreting-low-dose-dexamethasone-suppr/ArticleStandard/Article/detail/580093)that explains this possibility in more detail:


When interpreting LDDS test results, first evaluate the eight-hour postdexamethasone administration cortisol concentration. If it is above the reference range, the dog probably has hyperadrenocorticism (false positive results may occur in dogs with nonadrenal illness). If it is within the reference range, either the dog does not have hyperadrenocorticism or there is a 5% to 10% chance that the dog has PDH. (The dog may have early pituitary disease and the pituitary gland is still responding to a pharmacologic dose of dexamethasone by decreasing ACTH production, thereby reducing serum cortisol concentrations.) In those cases, an ACTH stimulation test is warranted.

Things would have seemed a lot more clear-cut if Flurry's result on both the LDDS and the ACTH would have turned out the same. :o

How is she doing right now in terms of symtoms? At this point, I'm thinking that it will really have to be her symptoms that finally end up guiding you and your vet in terms of a treatment decision.

Marianne

[jtbama]

Thats what I was afraid of a unclear answer, I will get a print out to confirm the reference levels on the test. The vet is wanting to check her blood again for calcium, liver enzymes and see if anything has changed from the last test. Flurry's sytmptons seem more random now than constant, water intake is down, food intake still high, painting is not as bad but still has moments. I am really not sure what to do now

[jtbama]

Who is Dr. Bruyette, is he a specialist ? It looks like what he is saying from that quote that flurry will need the ACTH test but she has already had that one and it was positvie for cushings. Does that mean that she is in that 5 to 10 % that the low dose dex test would not confirm

[Harley PoMMom]

Who is Dr. Bruyette, is he a specialist ?

Dr. David Bruyette is a renown Cushing's expert, here's an excerpt from a bio:
In addition to his duties as Medical Director at VCA West Los Angeles Animal Hospital, Dr. Bruyette practices internal medicine and specializes in endocrinology. He is recognized as one of the leading specialists in endocrinology in the United States.
http://www.vcaspecialtyvets.com/west-los-angeles/departments-doctors

[jtbama]

Ok thanks for the link on Bruyettte. I got some more results in today, Flurrys ALT and ALKP Levels have gotton better but still high, Her ALT has went from 470u/l to 259u/l but its still over the reference range of 10-100, her ALKP level went from over 2000u/l to 1597u/l, still hight to reference range of 23-212u/l. The vet has recommend treating flurry for liver disease with 2 medications for 3 weeks and then re-check her levels. I am not sure why her levels have came down some but they still dont look great.

[labblab]

Who is Dr. Bruyette, is he a specialist ? It looks like what he is saying from that quote that flurry will need the ACTH test but she has already had that one and it was positvie for cushings. Does that mean that she is in that 5 to 10 % that the low dose dex test would not confirm
Yes, it is possible that Flurry is in that very small group of Cushing's dogs who are early on with the disease and who initially test negative on the LDDS. However, it is not only the negative LDDS that still makes the diagnosis seem questionable -- it is the fact that her symptoms seem to increase but then lessen again without any treatment (including her liver values):


Ok thanks for the link on Bruyettte. I got some more results in today, Flurrys ALT and ALKP Levels have gotton better but still high, Her ALT has went from 470u/l to 259u/l but its still over the reference range of 10-100, her ALKP level went from over 2000u/l to 1597u/l, still hight to reference range of 23-212u/l. The vet has recommend treating flurry for liver disease with 2 medications for 3 weeks and then re-check her levels. I am not sure why her levels have came down some but they still dont look great.

I think your vet's current approach makes sense, to give her medication for her liver for awhile and then redo those levels. Even though the ACTH is less likely to give you a "positive" result when a dog is instead suffering from a disease or illness other than Cushing's, it is still possible. Since Flurry's liver values were also higher at the time of the ACTH test, it is possible that something other than Cushing's was acutely affecting both the ACTH test and her liver values at the same time.

Given the normal ultrasound, the negative LDDS, symptoms that come-and-go, and Flurry's newly improving liver values, I really do think your vet is wise in holding off on beginning Cushing's treatment for the time being. It will really be interesting to see what her liver values look like when they are retested. Plus, it gives you another month to continue to evaluate her other external symptoms.

I also believe that if Flurry really does have Cushing's, further down the road we would expect her to have a "positive" result on the LDDS if that test were to be repeated. If the test were to remain "negative" several months from now, I think that would truly make a Cushing's diagnosis very unlikely.

Marianne

[jtbama]

Got flurrys meds today, Amoxicillin, Metronidazole and Denamarin, Re checking blood in about 3 -4 weeks

[Harley PoMMom]

Please keep us updated and wishing you both the best of luck. :)

[jtbama]

Well flurry has been on the meds for about a week and I have noticed one thing thats kinda weird, her bad breath has went away and panting went down some. I am going to ask the vet about this when the she goes in for her update but was just wondering has any of you linked bad breath to cushings ? I didnt think about telling the vet about her bad breath because I never seen it as a sympton of cushings but did see online where kidney or liver disease might cause this.

[jtbama]

Flurry went in for blood work this week and noticed some good improvements, Her ALP is now down to 940, still high but better, her ALT is now normal at 88. She has been on Denamarin for a little over a month and seems to be helping her a lot. Vet still hasnt ruled out cushings yet, just trying to get her blood levels under control before performing another low dose dex test.

[jtbama]

Vet noticed that flurrys total t-4 was low (.4) ref range is 1.0 to 4.0 so we did the TSH test again and this time around it was high so they have decided to put flurry on thyroid supplement (Levothyroxine) and re-test in 30 days. Flurry was kinda borderline on her last thyroid test a couple months ago, the total t-4 was 1.1 but the TSH was normal.

[frijole]

Great that the liver enzymes have improved and it could be hypothyroidism and not cushings which would be great. Easy to treat and cheap too! Keep us posted on how it's going! Kim