Possible Cushing's, 8.5 y/o male Boxer (Sweet Jordan has passed)

[Somesie]

Hello, All, and thanks in advance for any help you can offer. I've been reading and searching around the forums, but now that we are in process with the vet, I wanted to try and get some solid advice for next steps, as we have an ultrasound scheduled for tomorrow morning and frankly, I'm not even100% sure that's the correct thing to be doing, which is where I need some help.

Jordan is our 8.5 year old male Boxer, who's generally been a healthy boy, with a few exceptions, until recently. About five years ago, he had a bad bout of acute pancreatitis, which lead us to switch he and our other Boxer to a raw diet from premium kibble. They did great on raw but when we moved overseas, first to Italy and now Germany, raw became prohibitive in a number of ways, cost among them. For the past two+ years, they've been on Ziwi Peak, who's praises I can't sing highly enough.

About three months ago, Jordan had a scary bout of acute tummy trouble once again. Emergency vet didn't do any tests other than xray to make sure there was no obstruction, and I didn't then know to ask for enzyme level check, but the regular vet has subsequently done blood work (I don't have but will try to get numbers) that showed his enzymes were in a "grey area." Given that those tests were done at a time when he was asymptomatic, it's a safe bet he's got some chronic pancreatitis happening, so now he's been on Wellness Core Low-fat for about two months. I hate it, but he loves it and hasn't had a tummy ache since.

In the meanwhile, there are other symptoms that have progressed for maybe about six months...it's hard to say because at first they were an annoyance that I thought was behavioral. Long story short, he's gone from being overly interested in horse biscuits (we walk on a farm) and the occasional Kleenex to a point where now, he is positively obsessed with finding things to eat while we walk. He spends the whole walk with his nose to the ground, sometimes eating dirt, even. Additionally, he lives and dies by feeding times here in the house. We feed at 0800, 1400, 1800, and again before bed, usually around 2100. If one of those meals is late, he will sing you a tune that'll break your heart. Additionally, there have been a few times recently where his entire body is shuddering (I'm not talking a butt-wiggle, here, I'm talking shivering the way a dog does when they're in pain) while he waits for his dinner to be served up.

He still plays with his daddy in the evening, a routine since he was a pup, but in general he is more lethargic and less interested in just being his normal old happy self. If it's not related to food, he's not very excited about it. This was the symptom that has lead me to press the issue with the vet(s). I took him in for a general exam about six weeks ago, at which time the vet said he needed a lump removed from his side. He did all the normal pre-surgery blood work and other than the 'grey area' pancreas enzymes, said all was normal. Surgery was fine, but afterward his water consumption went through the roof and I made the doc check his cortisol/creatinine via urine test. That number was 33, so doc said no Cushing's. He was convinced the water consumption was reaction to anesthesia and would decrease back to normal. It did after about a week, but in thinking about it, his water consumption has been higher over the past six months or so, at least, than it was previously. It's not what I would consider excessive and he's not having accidents in the house or anything, but it's more than he used to drink.

After his surgery recovery, he's still been so obsessed with food and just 'not himself' that I decided we needed a second opinion. Took him to a new vet, who I finally like (that's been a challenge over here) who actually listened to my long story of symptoms and subtle changes in behavior and she tested his thyroid. This is about a month ago now, and she sent us home with a diagnosis of hypothyroid and medication for same. Oh...I forgot...the other major symptom I was worried over was that his coat has thinned pretty drastically. I was all kinds of happy with the thyroid diagnosis, until I got home and read more, to find out that his hunger and hair loss are not really consistent with that diagnosis. I decided to give the pills a month, which it's now been, and there's been no improvement in his behavior or coat. Past that, he's actually been getting little 'pimples' here and there, with green pus. Only a couple, but still concerning given everything else.

Geez, this is long. Sorry. Last week I called the vet back and told her flat out, I don't care what the creatinine/cortisol test at the other vet said, I really think he has Cushing's and I want you to test for it. She said that the CC test (his result was 33, btw) was not the most conclusive anyway and that she would do a low-dose dex test. She rang this morning and that came in at 21.3. She said that below 18 rules out Cushing's, 18-22 is inconclusive, and above 22 is considered conclusive.

All of that, to say this: She was not terribly confident in her delivery of this information, and it kind of felt like she was leaving it to me to decide what the next steps should be. She suggested an ultrasound, which we now have scheduled for tomorrow a.m. But in addition, she also suggested we could just put him on meds for Cushing's and see what happens, doing another low-dose dex test again in a few weeks after he's being medicated. That freaked me out a bit, as from what I've read so far, these medications are not something to be taken lightly.

My questions are as follows:

1) Is the ultrasound the appropriate next step, and what exactly are we looking for?

2) Should I be seeking a specialist, given the relative timidity with which the vet seems to be approaching this? Mind you, that is my perception, and you have to kind of factor in a bit of language barrier and a LOT of cultural barrier. Our conversations are in English, because I don't have enough German. Her English is passable, but certainly not fluent. And don't get me started on the cultural differences. In that regard, she's actually the best vet we've found, which is why I really want her to work out.

OK. That's all I can think of for now. Thanks in advance for any advice you can offer, and again...sorry for the dissertation-length introduction.

Best,
Jenn

[Somesie]

Two quick additional things...

He has developed a pot-belly.

I just read that the low-dose dex test should be done fasting, which his was not. The site I'm reading (kateconnick.com) also says that the blood tests are administered four and eight hours later, which is not what was done. He hadn't fasted, the vet did a baseline blood test and then took blood again ONE hour later, not four and eight hours, as is suggested by that site. Now I'm having even further doubts in our vet....AAAAAAAAAARRRRGGGHHHHHHHHHHH. So frustrating. There is nothing, absolutely NO THING that makes me miss the States more than when we need a vet.

Help, please?

[lauraperla]

Good morning Jenn, welcome to you and to Jordan. I'm sorry your poor boy is going through all of this but I can at least tell you that you have come to the right place for help! I am pretty new here too and there are others who are much more expert in testing and interpreting who will I am sure be along soon to give you more detailed advice.

Many of us with a Cushpup seem to have quite a frustrating time getting to a point where we know whether it is Cushings we are dealing with. I think bearing in mind, as you say, how powerful the drugs involved are, I would want a more definitive diagnosis before moving on to the medication stage. Having said that it may be that there are already some additional clues in the lab results of the bloodwork that has already been done, it would be a great start to post that information in detail if you have it, and attempt to obtain it if you don't.

I'd also recommend you start to measure Jordan's daily water intake, and work that out as a ml/kg amount.

Is his hair loss symmetrical? What areas are affected by it? Have you looked online at any pictures of calcinosis cutis to compare it to the spots you describe?

I am wondering whether your vet is actually performing an ACTH stim test, the non fasting and the 1 hour apart sampling would be the usual protocol for that test. I found it hard enough to get my head around all the technicalities let alone do it in a different language. Is there anyone you know with fluency in both languages who would help you as a translator?

It was a big learning curve for me to understand that it was my role to learn as much as I could (and I'm still learning and have a long way to go) about this condition in order to advocate for my girl and get the very best for her. Like you describe I found it very strange coming to the realisation that the decision making needed a strong input from me, I had always thought of the vet as the expert. I'm realising more and more that the vet may be the technical expert, but no-one knows this girl like I do or has so much invested in her. I owe a huge debt of gratitude to everyone here for helping me so much with that. Do not feel daunted, we are all here to help and support you, you're not alone with this.

Laura and Saoirse xx

[Somesie]

Thanks, Laura. I just finished reading a long thread, wherein this woman's Boxer died the other day. I'm completely freaking out. I hadn't heard of the calcinosis thing, but just Googled that and he definitely doesn't have those. They really look just like pimples, and behave so, as well. I popped it and it scabbed over and is gone. Gross...sorry...but I guess detail is important here.

Now I'm not sure about which test was done, based on your feedback. Thanks a ton for that, as I would feel much better knowing he at least got "a" test done properly, even if it wasn't the one I thought it was. I just rang, and you're right - it was the ACTH that was done. Hm. I asked her about ultrasound v low-dose dex test, and she said that in the ultrasound, she will be looking for enlarged adrenal glands, which would confirm Cushing's. I asked about why ultra-sound v low dose test but language barrier got in the way and I had to settle for 'first the ultra sound would be better.' You can see my frustration...(not her fault, btw, I recognize it's on me to learn the language of my host country. But there's no way that's happening in enough time to deal with this stuff....)

Thanks for helping me at least clear up what test he had done; that's progress!!

I will keep you all apprised, and appreciate in advance everyone's help. Right now I'm leaning in the direction of going to the ultrasound tomorrow and then depending on the results possibly seeking an internal med specialist.

Best,
Jenn

[Somesie]

Oh...and yes, I may have one of my girlfriends go with me tomorrow to help with the linggity (our "Italian" word for language). Thanks again, Laura!

[Somesie]

From the reading I've done so far, doesn't it seem like the vet would have started with the low-dose test, rather than ACTH and ultrasound? Or is she maybe just trying to be financially conservative on my behalf? The ACTH was only 90€ and she is doing the US herself, and mentioned (unsolicited) that it wouldn't cost anything if she didn't find anything. Which....umm...odd?? I may have misunderstood, but I really think that's what she said. So maybe she's being financially conservative and/or non-invasive? She said he won't be anesthetized for the US tomorrow.

[lauraperla]

Hi again Jenn
I think the ultrasound is a very good diagnostic tool for your vet to use, she will be able to look at the adrenal glands and see if they are both enlarged, or if just one is, she will also be able to scan his abdominal area to check for any other conditions that he may have that may be causing cushings like symptoms, and she will be able to look at his liver and get an idea of how it is coping at the moment.
I am glad you have a friend that can help, it will ease the stress for you.
Cushings diagnosis seems much more akin to detective work than a straighforward linear cause and effect model.
I and many others here too have found it useful to keep a notebook or file, there's so much information to deal with!

[labblab]

Hi from me, too, Jenn!

I'm also so sorry that you are having these worries about your boy. But we'll do our best to help you sort things out. Laura has already given you some great info, and I agree with her that the ultrasound can be a very useful tool, not only to view the appearance of the adrenal glands, but also to see whether there are any apparent issues with other major organs that may be contributing to your dog's symptoms. One caution, though -- the adrenal glands are not easy to visualize, so it takes high resolution ultrasound equipment to see them clearly. Here in the U.S., it is often the case that only specialty clinics have equipment of this caliber. So you may want to double-check that part with your new vet before proceeding. If there is any issue about the equipment, you may want a referral to an IMS sooner rather than later.

As far as the ACTH vs. the LDDS, both tests are used as diagnostic tools. They each have their pluses and minuses, and different vets have different preferencees regarding their use. Here's a link to a chart that helps explain their comparative strengths and weaknesses:

http://www.dechra-us.com/files//dechraUSA/downloads/Client%20Literature/47901_VETORYL_10mg_Diag_Testing_brochure_4pg_3_1_p s.pdf

As you'll see, the ACTH is less likely to falsely diagnose Cushing's in a dog who does not have the disease (less "false positives"). On the other hand, the LDDS is less likely to miss diagnosing Cushing's in a dog who does have the disease (less "false negatives"). Also, the ACTH is the test that is ultimately also used for treatment monitoring purposes if medication is begun.

My own specialist used only the combination of an ACTH test and an abdominal ultrasound to diagnose Cushing's in my dog. However, my boy was pretty straightforward -- EVERY classic symptom and an ACTH result that was extremely high. As Laura has said above, there is no doubt but that a Cushing's diagnosis can involve detective work since there is no single test that can diagnose the disease with certainty. Symptoms are the most basic part in determining whether or not the diagnosis seems reasonable.

In your case, with many compatible symptoms but a borderline ACTH, I agree that an ultrasound is a very good idea. However, if the adrenal glands show no abnormalities on ultrasound (no enlargement or no growths), you may want to revisit the LDDS testing in order to plug that result into the decision-making puzzle, as well. A "negative" on the LDDS and a normal ultrasound would make the Cushing's diagnosis much more questionable.

And as far as other testing, do you know whether your dog has exhibited elevated liver enzymes and/or high cholesterol? Both of those results are common with Cushpups.

Marianne

[frijole]

Jenn,

You said the vet did a ldds test (which does require draws pre, at 4 hrs and 8 hrs) however the result you described with her explanation of over 22 being cushings is a description for an acth test which is an hour or two long.... so I'm not sure which test you actually had done. I don't suppose they gave you a copy of the lab report?

Absolutely NOT to giving cushing drugs while you figure things out... sorry but this is a total red flag that this vet does not understand how to diagnose or treat. So... yes I would be seeking help from an IMS if you can locate one.

Can you tell us where you are in the event we might be able to help you locate a specialist? Thanks. Kim

[Somesie]

Marianne,

Thank you SO much for that chart link - that is going to be very valuable. As to liver enzymes and/or cholesterol, I think I recall that his liver enzymes might have been slightly high on his most recent blood work, but I'm not sure whether they even tested cholesterol. I rang that vet this morning to ask for a copy of all of his blood work, and she didn't even understand me well enough to answer the question, so I have to call back this afternoon.

Kim - I was mistaken, sort of, about what test was run. The vet originally told me over the phone that it would be the LDDS, but she described the ACTH protocol. She just misspoke in naming the test (and subsequently quoting the price. I wondered why it was 30€ more than she had quoted me, so this explains it). So, to be clear it was ACTH that was done. I don't have the lab report, as it just came in today and we're going in for the US tomorrow, so I will be sure to get it then. Thanks for confirming my innate 'red flag' feeling about her having offered to medicate before a more conclusive diagnosis. We are near Heidelberg, Germany. Somewhere the other day I found a link (probably on here) about IM specialists here and I found one in the document who is a little more than an hour away.

My thinking at the moment is to let the vet do the US tomorrow and see what she recommends based on that, then perhaps take everything to either a specialist or at least our old vet (who was very good but has NO bedside manner). Thoughts?

Thanks again, everyone. I got a little scared by reading some of the stories on here this morning. He's only 8-ish, and is the apple of my eye...I am quite worried.

Best,
Jenn

[labblab]

I just wanted to come back and clarify some info contained in that diagnostic chart that I gave you above. It relates to the "Typical" results for the ACTH test. I am very surprised to see that Dechra has listed these results as being "typical" for the post-ACTH:



• In normal dogs, pre-ACTH cortisol concentrations are usually between 0.5 μg/dL and 6 μg/dL (14 and 165 nmol/L) and post-ACTH concentrations between 17 μg/dL and 22 μg/dL (470 and 606 nmol/L).*

I actually think that is a misrepresentation. Just as your vet has told you, a result lower than 17-18 ug/dl is usually considered to be normal, and the range between 18-22 ug/dl is considered to be borderline or equivocal. I didn't want you to see this chart entry and question what your vet has told you. Because her interpretation is consistent with what I believe is generally accepted to be the case. Here's another chart in that regard:

http://www.idexx.com/pubwebresources/pdf/en_us/smallanimal/snap/cortisol/cortisol-acth-stimulation-protocol.pdf

Sorry for the confusion! And here I thought that Dechra chart was so great...:o

Marianne

[Somesie]

Thanks, Marianne. It was still helpful in broadening my understanding of the tests.

Also, I forgot to mention earlier that he did have his cortisol/creatinine ratio tested, with a result of 30. This was right after he had his little fatty tumor removed, because his water consumption was so crazy I had the vet test for it. He told me that was normal and definitively said Jordan did not have Cushing's. Despite the myriad symptoms he's displaying, the guy was very dismissive and basically said there's nothing wrong with him. That's what sent us in search of a second opinion/new vet, who at least tested his thyroid further and found that we do, in fact, have SOME sort of problem happening.

For clarity, when I refer to taking him back to our 'original' vet or a specialist...that original vet has not been involved in this at all. He's pretty competent, so maybe I'll give him a shot at this after we get the ultrasound tomorrow. I would really, really like things to work out with this new girl, but I was really alarmed by her offer of meds without a conclusive diagnosis, as well as by her to some degree placing the onus on me to decide what the next steps should be.

Thanks again, all.

Jenn

[frijole]

If possible, find out if the ultrasound machine being used is considered high resolution. As you would imagine, while the ultrasound can be very very helpful in diagnosing, it is only as good as the skill of the person giving the test, reading the film and the equipment being used.

Regarding the vet that dismissed the symptoms - I once talked to a former vet worker who said the vet she worked for never ever ever diagnosed cushings. The reason - he didn't want to treat it. Just sharing - sad but true.

Sending you the best, KIm

[Somesie]

Regarding the vet that dismissed the symptoms - I once talked to a former vet worker who said the vet she worked for never ever ever diagnosed cushings. The reason - he didn't want to treat it. Just sharing - sad but true.

Sending you the best, KIm

Wow. That is disheartening, to say the very least. Well, this guy got his wish...the only time he'll ever see me again is tomorrow when I go to pick up copies of all of Jordan's blood work.

I've had about eight straight hours of research on this stuff today. Time to get out and ride my bike before I go crazy.

I can't say thanks enough, everyone. Keep the information coming - I appreciate it so much!
Jenn

[lulusmom]

Hi Jenn and welcome to the forum.

I only have a minute but wanted to tell you that have a world renowned specialist in endocrinology in Zurich, which is about three hours from Heidelberg. Her name is Claudia Reusch and her passion is hypercortisolism (cushing's). She was one of the first to publish a study on the effectiveness of Trilostane and was also one of the first to publish a study on the non-efficacy of Anipryl. I realize Zurich is not close but perhaps you can call or write to Dr. Reusch and ask for a reference from her for someone closer. Here's her contact information.

Prof.Dr. Claudia Reusch
Universität Zürich
Veterinärmedizinische Fakultät
Klinik für Kleintiermedizin
Winterthurerstrasse 260
8057 Zürich
Switzerland
Internal Medicine 1997
Active Diplomate
Academia

Tel: +41 44 635 8301 +41 44 635 8930
Email: creusch@vetclinics.unizh.ch

[JDG]

I'm afraid I am unable to offer explanation regarding Cushings lab results and specific testing myself as I myself am still trying to take it all in. I will share that I have felt all the same confusion and concern while trying figure out how to help my own best buddy.
My Shadow has had quite a bit of testing over the past few months after I brought him to the vet because of loss of muscle mass and thinning hair. His labs showed liver enzyme elevation as well as increased cholesterol and triglycerides. His further testing specific for Cushings all came back inconclusive.
I know this is hard.
I would try the ultrasound (Shadow has now had 4 of them, showing gallbladder issues) as it's un-invasive (as long as your dog will let them do it). The ultrasound can give a good picture of anything else they may see that can help explain your dog's symptoms or lab abnormalities.
I wish you both luck tomorrow.

[Squirt's Mom]

Hi Jenn and welcome to you and Jordan! :)

Man! A language barrier on top of an already confusing condition like Cushing's! :eek: Bless you heart! But in spite of that, it sounds like you are doing a find job, Mom! :)

Have his thyroid levels been checked to see if the current dose is controlling that? As one with a thyroid disease that causes Hypothyroidism, I can tell you that increased appetite and thirst, fatigue, irritability, hair loss, thinning dry skin, increase in need to pee, and weight gain are all signs that those levels are too low. The same is true for hypothyroid pups and this condition is often the cause of the cush signs parents see. So making sure the med is working and thyroid is functioning properly is important. There is also a form of hypothyroidism called Sick Euthyroid Syndrome that is the result of untreated Cushing's, just to further confuse the issue. ;)

An abdominal ultrasound saved my Squirt's life so I cannot recommend this test strongly enough. She tested positive on five cush tests - LDDS, HDDS, ACTH, ACT panel and two ultrasounds. After the second ultrasound, I was told about a tumor on her spleen. Once the tumor was removed, all those tests except the UTK panel were negative. Squirt has a form of Cushing's call Atypical in which her cortisol is normal but her intermediate, or sex, hormones are elevated. She has been well controlled since '08, I am thankful to say. :):cool:

I want to tell you, too, that most of our babies here who have crossed The Bridge did not leave us due to Cushing's, or complications from Cushing's, but rather from totally unrelated issues. But how well I remember our first few months after hearing that word, Cushing's, for the first time. It seemed I never saw success stories and could only see that my Sweet Bebe was dying - that is seldom the truth for our babies, tho. With the correct diagnosis, and proper treatment and monitoring, these precious souls can and do live out their normal lifespan....often longer because of the increased care and attention they receive from us, their parents. ;) Cushing's is NOT synonymous with a death sentence. And now you have a very strong support system - the k9cushing's family, of which you are both a part now. Ya'll will not take one step alone; we will be with you all the way.

Keep up the good work and stay in touch!
Hugs,
Leslie and the gang

[KarenJ]

I just finished reading a long thread, wherein this woman's Boxer died the other day. I'm completely freaking out.

Hi Jenn,

It was me who lost my Boxer, Maggie on Sunday. But please know that it wasn't the Cushings that she died from. The vet is pretty sure the she had something else going on. I had opted not to do an ultrasound so we'll never know if she had an underlying condition. Cushings is very slow moving. You are better to be sure that's what you're dealing with and treat it appropriately rather than jumping in with treatment before you have all the facts. I feel for you and know what you're going through right now. You've found a great forum to help you and if there is anything I can do, please ask!

Karen

[Somesie]

You people?? Are awesome!

Zurich is not so far away as to be unfeasible, especially via train, which my little buddy would positively adore...just think of all the new friends he would make!

I've had a bike ride to clear my head this afternoon and also stopped by the first vet to grab up his lab results from the past weeks. Once I translate, I'll post anything pertinent. To my frustration, though, I have to say that at first glance (you can figure out most of the words) it seems like most of his numbers are within normal ranges.

As to re-testing his thyroid, I will see if she can do that tomorrow, as he's been on the meds for a month now and was supposed to be tested at this point anyway. Thanks for the reminder.

Thank you all so much for your kind words and reassurance, it is immeasurably comforting and the information is helpful.

Karen, specifically, to you...I am so very, very sorry for your loss. I was sobbing like a baby for a good half hour this afternoon, thinking of it. I hope you take comfort in knowing the good life you provided for Maggie and in that she is no longer in discomfort. Honestly...that's what's had me at my wit's end these past weeks. If I have to hear "he has six months to live" or something equally horrible, I will handle that, but I'll be damned if I am going to continue to sit here watching him be miserable, for any length of time. He has to come first here, as Maggie did for you. Bless you.

Thanks again, everyone. I'll see if I can decipher these lab tests and post some info later on. Right now, his highness and his sister the princessa are demanding some attention, and I'm only too happy to oblige.

Jenn

[Wolfgang]

Jenn,

I am sorry I have no information to offer but wanted you to know I lost my Wolfgang due to kidney failure unrelated to his pdh cushings. The trilostane he was on allowed him a normal life. His hind end weakness was mildly improved on it ( so likely unrelated to the cushings ) and he lived the remainder of his life ( prior to onset of late stage renal failure ) being the goofy, loving, zoomy old man he was. Your beautiful baby can live a totally normal, long life as a cushbaby. Its impossible not to worry but try not to as youre being a loving, responsible mama. The members here are truly an incredible bunch.

[frijole]

I've been on this forum/with this group for over 7 yrs. and it started with a vet that was clueless so we do understand. I wanted to add that my Haley was treated using lysodren for cushings for 4 1/2 years. She passed away at 16 1/2 unrelated to cushings.

Trust me, cushing's is really not that difficult to manage once you get thru the diagnosis and dosing stages. It becomes a breeze. So don't lose one minute of sleep over that ok? Hugs, Kim

[marie adams]

Hi Jenn, welcome to you and Jordan!:)

I can see you have gotten a lot of info already and it is just your first day here. Keep asking your questions and your concerns. Everyone is wonderful here and so knowledgeable. Who knew Addy would know someone in Zurich to refer you to!!!;)

Believe me you will go bonkers researching because that is what we do when we don't know enough about it--Cushing's. We have all been there and done that.:D I also had a few vets that didn't end up knowing as much as I did thanks to everyone here. You will find a vet who can help!

Take care!!! Keep going for a bike ride to keep you sane!!!:D:)

You are now part of the family!!!

[Somesie]

OK...so we've been this morning for ultrasound. Let me recap the high hard ones, and then I would really appreciate some feedback, because I'm not sure what to do next:

8.5 yr old male Boxer, 36kg

Symptoms: thinning coat, voracious/obsessive appetite to the point of pica (Kleenex is "the other white meat" in our house), somewhat excessive drinking but no accidents inside (I'm home with them, so he can go out whenever he wants), hypothyroidism, lethargy (basically a lack of interest in most things unless they relate to food)

Labs: Other than the hypothyroid, for which he's now been medicated for just over four weeks, all of his lab values have been normal with the exception of elevated liver alkaline phosphatase (forgive my spelling, please), for which he has tested at 279 and 235 when it's supposed to be <147. 279 was on 9 Feb before his fatty tumor surgery and 235 was on 18th Feb, afterward. The tests on 18th were done because of vastly excessive drinking, which the doctor attributed to surgical anesthesia. At that testing, his urea, sodium, and creatinine were also elevated, which is consistent with dehydration. The water consumption ultimately went back down to his norm, so he hasn't had blood tests since, with the exception of our new vet doing a thyroid panel and subsequently putting him on thyroid meds for hypothyroid. The first vet did also do a urine test on the 18th, when I first began to suspect Cushing's. The cortisol/creatinine ratio was 30, so that vet ruled out Cushing's because it was less than 33. (Which lead to me seeking out the second/new vet, because my boy is symptomatic and I knew something was wrong)

ACTH value was inconclusive, at 21.3 with the vet saying that 18-22 indicate possible Cushing's.

Abdominal ultrasound, done this morning, showed normal liver and spleen consistency and an enlarged adrenal gland. In answer to the question several people asked - yes, it was a high resolution machine. The doc said that the gland she could see was enlarged - should be around .7 (centimeters, I think?) and was at .95.

Based on his symptoms, the ACTH, and the ultrasound, she has diagnosed Cushing's and says that we caught it in quite an early stage. She wants to put him on 120mg of Vetyrol per day, based on his weight, permanently. She indicated that the elevated liver phosphatase and hypothyroid are both consistent with Cushing's and that while we should keep him on the thyroid med for the time being, we would likely be able to discontinue it once he's been on the Vetyrol for some time. I asked about Lysodren (I know nothing past the names of these meds, mind you) and she said she had heard of it but that it isn't available here in Germany. She was quite confident in that Vetyrol is the only Cushing's treatment here.

So. I didn't take the medication today, because I wanted to get some feedback here first, and may very well call our old Stateside vet, too. My questions are as follows:

Have we done sufficient diagnostic testing to be at a point where we can be comfortable in the Cushing's diagnosis and considering medication? If not, what further tests are indicated?

Is Vetyrol the right approach, given all of the above? I'm not 100% sure, but if for some reason Lysodren is preferable, I'm guessing that we could get it via the American veterinary system.

So. Once again, thank you to everyone for their help so far, and I look forward to hearing your thoughts as to what we might do going forward. At this point, while I'm concerned about our next steps, I am comforted at least by the fact that I have a vet who is taking us seriously and trying to help. I just want to make sure that her version of 'help' is what will be absolutely the best for my boy.

Thanks again...
Jenn/Mom to Jordan the Love Sponge and Barkley The Boss

[Somesie]

One last thing...vet did not even mention the possibility of surgically removing the affected adrenal gland. Is that something that should be alarming? Should we consider it?

[Somesie]

Squirt has a form of Cushing's call Atypical in which her cortisol is normal but her intermediate, or sex, hormones are elevated. She has been well controlled since '08, I am thankful to say. :):cool:


Hugs,
Leslie and the gang


Leslie...can I ask, what medication is Squirt on for this type of the disease? Should this be something I should be thinking about, since Jordan's urine test for cortisol did come in at the normal range? Or does the inconclusive ACTH overrule the urine test?

Thanks!
Jenn

[lauraperla]

Hi Lynn!
Good work, so pleased to see you are tackling this all so well, you've taken so much on board already. Jordan should be very very proud of his Mum.
Thank you too for giving me a smile, we too have had the 'kleenex as a food group' experience many times.
In adding my thoughts I would stress as per my original post to you that I'm a newbie here too and I'm sure there will be lots of others dropping by who have much more wisdom to share than me!
I'm glad you got clear feedback from the u/s, curious to know (and not sure how relevant this is as S is pdhd) whether the other adrenal is normal sized, or shrunken.
If I were in the situation you are in with the knowledge I have now I would probably feel I had sufficient 'proof' to feel comfortable with a Cushings diagnosis. I'd still want to seek clarity on a couple of things. Firstly I think 120mg is quite a high starting dose for a 36kg dog, S is 34kg and her vetoryl dosages varied between 50 and 90mg. Having said that it wasn't effective with her anyway! Secondly I'd want to research further which is the best treatment for his specific case. While your vet said Lysdoren is not used in Germany, I suspect it is exactly the same as the UK and its that its not in general practice use in Germany, so if you were to refer to an IMS it may be an option to you (which is exactly what I've done over here). My advice on this would be to seek the views of our great folk here and if the scales tip in favour of Lysodren, consider an IMS referral before starting to treat. I think as your vet's assessment is that he is at an early stage of Cushings, I'd be tempted to spend a little bit of extra time making sure I had the best treatment option.

There's a few things that you can do straightaway that will support him regardless what route you go. You will see that many here use milk thistle to support liver function. I'd also be tempted to supplement with some fish oil , and also a glucosamine / chondroitin combination. Again were I back at day 1 of life with a cushdog I'd have started supplementing all these immediately.

Start a photo diary and update it monthly, it will be invaluable to you in monitoring progress.

Well done on the great work! And give Jordan a hug from us too xx

[labblab]

Hi Jenn,

It will be a couple of hours before I can type a more complete reply, but since I know it's later over there than here, I wanted to at least add this note. Given all the information you have on hand, if it was me, I probably would go ahead and start treating with Vetoryl -- of course with very close monitoring and stopping treatment at the first sign of an adverse reaction.

Having said that, here are my other suggestions. I would start at a lower dosage -- no more than 90 mg. total. This will mean getting the Vetoryl in both 60 mg. and 30 mg. capsules. But this is better, anyway, so that you will have the ability to make dosing changes more readily.

Also, I would want repeat bloodwork before starting. I would want to confirm that the kidney values are indeed back to normal, that the thyroid supplement is at the correct dose, and also I would want a baseline of the current ALKP (alk phos) level before starting treatment.

I'll be back with more thoughts later.
Marianne

[Squirt's Mom]

Hi Jenn,

If only one adrenal was visible, then it would be very difficult to determine if Jordan has ADH, the adrenal form of Cushing's which can be cured via surgery to remove the gland and tumor. Since the majority of cush pups, 85%, have PDH (pituitary based Cushing's) this is probably why the IMS didn't suggest removing the adrenal that was visible. With PDH, both adrenals are usually enlarged; with ADH, one gland will be very large while the other is much smaller, even atrophied. So based on what she could see, surgery would not be the best approach for Jordan as removing an adrenal gland won't affect PDH.

I agree with Marinanne, too, about making sure the thyroid is controlled and the kidneys are functioning properly then testing his cortisol level one more time. Cortisol is one of the body's natural responses to stress of any kind, external or internal, and a kidney issue would qualify as internal stress. ;)

As for Atypical, which my Squirt has - she was on lignans and melatonin only until this past summer when her signs suddenly become very strong. At that point, we put her on a maintenance dose of Lysodren along with the lignans and melatonin. The combination of lignans and melatonin has the potential to address all the elevations in the intermediate hormones, lowering them into normal ranges. Lysodren has the same action, only stronger, with the possible exception of estradiol. Estradiol can be produced outside the adrenal glands where the Lyso cannot reach as it works solely on the glands. When her signs became strong, her cortisol level was at the upper limit of normal hence the decision to start the maintenance dosing. In Atypical, there is no loading phase, instead the pup goes straight to a spaced dosing of Lysodren (maintenance dosing). So, the simple answer to your question is that her Atypical is being treated with lignans, melatonin, and Lysodren at a maintenance rate. ;) She gets the lignans once a day, melatonin twice daily, and the Lyso twice a week at 125mg per dose (Squirt weighs about 15 lbs).

To answer the second part of your question - should Atypical be something you need to look at...anytime there is accelerated adrenal activity the intermediate hormones - Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone - can become elevated whether Cushing's is in play or not. When you need to consider the UTK panel, which tests for this form, is when all the usual tests (LDDS, HDDS, ACTHs) come back with normal cortisol levels yet the pup still exhibits Cushing's signs. Atypical can cause the same signs as conventional Cushing's (conventional meaning the cortisol is elevated). When we first started this journey, Squirt's signs were very mild and her tests were all either borderline or barely elevated. In spite of some fairly heavy pushing (not from this group!), I refused to start her on any treatment until she had been thoroughly tested, and I was completely convinced of the form she had and the best treatment for it. My stubbornness is why I had the UTK panel done - I had to be sure I had done all I could to find out all I could before starting her on any treatment. This stubborn thoroughness also led to her tumor being found so I always encourage folks to do as much testing as is possible before starting treatment. ;) You're doing a good job of this. :)

Hope this helps!
Hugs,
Leslie and the gang

[Somesie]

OK...I'm having trouble using the quote feature here, so please forgive...

Laura - what do the glucosamine/chondroitin and fish oil supplements do, with regard to Cushing's?

Leslie - So if I'm understanding you correctly, the US didn't really tell us whether he has ADH or PDH? I thought by virtue of the enlarged gland, that meant ADH...but that's wrong? And as for the possibility of atypical...since he is exhibiting classic symptoms, but his ACTH test was inconclusive, and his cortisol/creatinine was within normal range, might that be what I'm looking at? I wonder if I should proceed with further diagnostics.

Marianne & Leslie - good call on another blood panel and thyroid, I will definitely do that before we proceed. I didn't have the heart to let her take blood this morning for thyroid re-check. He was such a super-trooper during the US that I just wanted to reward him by being done. Also, if we do go the route of medication, I'll see about starting at a lower dose. One thing that concerns me is that the vet didn't mention that he'd need another ACTH two weeks after starting, and then every 90 days thereafter as maintenance. I'm guessing this is the first time she's ever had a Cushing's case (she's young). I don't mind her learning with my pup, but it means I will have to be very well-informed on my own, so that I can help her learn and we don't make a mistake.

I've set up a phone consult with our old vet from SC on Friday, providing him all of the diagnostics thus far and asking how he would proceed. Meanwhile, I'm interested in any other suggestions or comments, as I want to make the most informed decision possible.

Thanks again, everyone. You all are proving to be an invaluable resource. Lil' Buddy is fast asleep at my side, as we speak. I think I may tip over and join him. :)

Best,
Jenn

[labblab]

OK, I'm back again with a few more thoughts to add. Just as Leslie has already explained, the only time that adrenal surgery is considered is when there is actually a tumor growing on the adrenal gland itself. It is too bad the second adrenal gland could not be seen on ultrasound, but it sounds as though the one that could be visualized appeared only to be enlarged -- there was no evidence of an abnormal growth or mass. And as Leslie has said, enlargement of both adrenal glands is consistent with the pituitary form of the disease.

Both Vetoryl (trilostane) and Lysodren (mitotane) are accepted treatments for Cushing's of either form. So if Vetoryl is more readily available in Germany, there is probably no reason not to use it. With either drug, there will always be a minority of dogs who do not respond as wished. If that were to be the case with Jordan, you could then consider making a switch to Lysodren.

Optimal initial dosing as been a moving target ever since Vetoryl was first introduced. As more research has been compiled, the recommendations have shifted steadily downward in the belief that unwanted side effects can be minimized when dosing is started low with subsequent adjustment upward if needed, rather than vice versa. Dechra, the manufacturer of Vetoryl, lists an initial dosing range of 1-3 mg. per pound in their published literature. But the vets who serve as their technical reps have verbally recommended to our members (and to vets attending conferences) that it is best to start at the lower point of the range. In Jordan's case, this would be approx. 80 mg. Since you can easily put together a dose of 90 mg. (combining a 60 mg. and a 30 mg. capsule), I would not want to start any higher than that. You can then always increase (or decrease) the dose as needed based on subsequent monitoring ACTH testing.

As far as additional testing prior to starting treatment, I honestly don't know what else I could really recommend (aside from the basic bloodwork that I mentioned above). Jordan does have several classic symptoms. Both the UCCR and ACTH are consistent with one another, in that they are both right below the diagnostic threshold. The treatment decision would be easier for us if they were both more highly elevated. But in the absence of any other reasonable explanation for Jordan's symptoms, Cushing's does appear to be the leading candidate. I'm not sure I'd even bother with an LDDS, because if Jordan is truly in the early stages of the disease, he might fall within the small percentage of dogs who test negative on the LDDS even though they do suffer from Cushing's.

So this is all a long-winded way of saying that I'd probably move forward with the Vetoryl after double-checking that basic bloodwork. But I definitely would lobby to start at a lowered dose. Here's a link to a resource thread that provides a lot of important info re: Vetoryl treatment and monitoring, including the need for periodic ACTH tests:

http://www.k9cushings.com/forum/showthread.php?t=185

Marianne

[lauraperla]

I'd use glucosamine / chondroitin because the excess cortisol produced by the cushing's can mask the signs of arthritis, and if that happens over a long period of time the joint damage can be significant.
Tbh I've known so many older dogs develop arthritis somewhere or other that I'd probably use it generally as soon as the dog got into middle age. Taking some myself probably isnt a bad idea either!!

[Somesie]

Thanks, Marianne. I'll read up on everything I can, but pending the conversation with our SC vet on Friday, I'm definitely leaning in the direction of starting meds, hopefully as early as next week. I'm so relieved, almost excited, at the prospect of getting him some relief.

Not to get too far ahead of myself, but can anyone give me an idea how quickly I might see changes in his behavior, to where he returns to his happy-go-lucky self?

Thanks, Laura, too, for the supplement info.

I welcome anybody else chiming in, too.

Best,
Jenn

[lulusmom]

Hi Jenn,

I'm probably going to be the lone hold out here but there are too many questions in my mind that need some answers before I would start Vetoryl treatment. I'm trying to get this post typed in between interruption at work so excuse me if I ramble or confuse you. I've number my lists of concerns below.

1. I'm not certain if your vet felt that perhaps Jordan's bouts with pancreatitis might be attributed to high cortisol. There are many breeds of dogs who are over represented when it comes to bowel or intestinal problems and because the Boxer breed is one of them, I would question whether cushing's had anything to do with Jordan's intestinal issues. At the same time, Boxers are definitely a breed that seems to be predisposed to cushing's so when I hear Boxer at any age over 5, my head is screaming "cushing's". :o

2. It is very curious that the drinking and peeing improved after the fatty tumor was removed. Whenever I hear that a suspected cushdog has a fatty tumor removed, I remember my old internal medicine specialist telling me about one of his patients. I don't have time to tell you the whole story but this dog had cushing-like symptoms that resolved once the fatty tumor was removed. There is an adrenal hormone called estradiol that can cause the same symptoms, blood, urine and organ abnormalities as cortisol. This is the only hormone that can be found outside the adrenal glands and it particularly likes fatty tissue. I might add that my old IMS was hugely interested in adrenal steroids and was convinced that it was the estradiol that was causing this dog's problem.

3. Was a urine analysis done as part of Jordan's screening for cushing's? Dogs with cushing's have dilute urine with low specific gravity and they usually have a urinary tract infection at the time of diagnosis. Because the urine is so dilute, not a whole lot of white blood cells are picked up on a normal urinalysis so a urine culture and sediment should be done. A dog can drink lots of water for any number of reasons and it's not always because they aren't concentrating urine and are trying to stay hydrated.

4. I believe you mentioned that in doing your research, you didn't see where voracious appetite and thinning coat are symptoms of hypothyroidsm. They are both hallmark symptoms of hypothyroidism, as are thinning coat and skin problems. Excessing drinking and peeing are not common with hypothyrodism. Can you please obtain a copy of the test your vet did to assess thyroid hormones and post the results here? You mentioned that it has now been a month on meds and that you were going to have the thyroid checked again. Can you please post the results of that test as well?

5. If the lab interpretation on the UC:CR indicates that anything below 33 is normal, then a 30 would be considered normal and in the U.S., normal pretty much rules out cushing's. In my opinion, when you are pursuing a cushing's diagnosis, there is no such thing as a borderline UC:CR. In Jordan's case, it sounds like the normal result was disregarded because of persistent symptoms and an acth stim test was done, the results of which were borderline.

6. Abdominal ultrasound showed slight enlargement of one adrenal gland and a normal liver. It appears that your vet could not visualize the other gland so there is not way to know if it is of normal size, smaller or atrophied. The latter two would indicate a functional adrenal tumor but with a normal liver and normal UC:CR, I'm not so sure it's secreting cortisol.

7. The ALKP activity is very curious to me. Firstly, both results you posted would be considered very mild for a cushdog but not so for a dog with low thyroid. You also wouldn't see ALKP improvements without effective treatment and Jordan's ALKP improved after the lipoma was removed. I'd be very interested to see where the ALKP is today. Were there any other blood abnormalities that are commonly seen with cushdogs on the last two blood chemistries, such as cholesterol, triglycerides, glucose? I may have asked you that already and if I did, I apologize if I didn't remember your response.

It may very well be that Jordan has cushing's and you've been tipped off early but for me, there are just too many inconsistencies, overlapping symptoms with other conditions that have not been ruled out and no follow up bloodwork.

[Somesie]

Lulu's Mom - thanks for putting so much time into this for me, I can't tell you how appreciative I am. Some of your questions have occurred to me, and some I wouldn't have known to ask. I'll answer them the best that I can, and appreciate any further feedback you might offer.

1) In all honesty, I don't remember if I've ever even mentioned the pancreatitis to this vet. He had a suspected acute bout 5 yrs ago and has had occasional trouble since. When he had the acute tummy trouble a few months ago, we never did get an actual pancreatitis diagnosis, because the ER vet didn't do any lab work. Frankly, he may or may not have chronic pancreatitis...we're just feeding him as though he does.

2) Water consumption has crept up gradually and remains higher than it used to be...say, maybe...a year ago? Immediately after his fatty tumor removed, it went vastly, crazily up for about four or five days. Like, he was getting up in the middle of the night to drink. After those few days, though, his consumption went back to pre-surgery levels, but not below. Does that make sense? That's why the vet attributed it to the anesthesia.

3) Urine specific gravity shows it was 1016 and should have been > 1030. Is this a significant finding one way or the other?

4) This appetite thing confuses me...I've read that hypothyroid causes a decrease in appetite. I'll see if I can get the thyroid panel results to post here. I didn't get him retested today because I felt like he'd been through enough with the ultrasound, and also because my mom (a nurse) said it would probably be better to give the thyroid meds another week or so...she said in people they don't usually test until at least six weeks. I plan to have a full blood panel, to include retesting the thyroid, sometime next week, and will post those results.

5) You are absolutely correct about the urine test being disregarded in favor of ACTH, partially at my insistence. Actually, I first asked her (the new vet) to please do another urine test because I just couldn't believe that nothing was wrong with him. Honestly, I was so mad at how dismissive the first vet was of me that I questioned whether he had actually even done the test or just lied to me. (Cynical, I know). So anyway, when I told her I wanted his cortisol tested again, she said that the urine test wasn't as accurate and recommended the ACTH. But yes...you are correct...urine creatinine/cortisol tested negative for Cushing's, and ACTH was borderline; and yes, this is part and partial for my reticence to medicate just yet. But what else do I do? What else can you recommend? Anything? I just want my little kiddo back to his normal self. This is so frustrating.

6) Correct

7) No other abnormalities...sugars, cholesterol, etc., were all normal. As mentioned above, I'll get a full blood test done again next week, and now (thank you) I'll know to watch this number specifically.

Thank you, seriously, for your time and effort here. Can I ask...if you wouldn't start medicating at this point, what would you do? What should I be asking for next?

Best,
Jenn

[labblab]

Jenn, I'm sure Glynda will be back to talk with you further. In the meantime, I wanted to ask one more question about Jordan's previous thyroid testing. You mentioned that a thyroid "panel" had been done. Here in the U.S., a full thyroid panel involves some add-on testing that is typically not included in a basic blood profile. However, the results of a more complete thyroid panel can help determine whether a thyroid insufficiency is a primary problem in and of itself, or whether it is likely secondary to a separate endocrinological problem such as Cushing's. If Jordan had such a panel performed and it pointed to his low thyroid as being a secondary problem, I think that would give greater credibility to the Cushing's diagnosis.

Also, I'm glad the question about appetite and hypothyroidism has come up because I have been confused about it myself over time. I've seen a few references to increased appetite in hypothyroid dogs. But while most of my reading has cited weight gain as a very common symptom of hypothyroidism, I've not necessarily seen the weight gain linked to increased appetite or greater food intake -- instead, due to changes in metabolism. So a hypothyroid dog can be eating the same amount or even less, but still be gaining weight. I've typically viewed voracious appetite as more of a Cushing's indicator. But I'd also welcome more info in that regard.

Just thought I'd throw in these added thoughts.
Marianne

[lulusmom]

I would do exactly as you are doing before starting treatment. A fresh blood chemistry, including thyroid values makes perfect sense to me but then as you can see, we all have our own opinions and experiences. There is no doubt that you will make an educated decision on Jordan's behalf and it was not my intention to change your mind about treating but felt the need to be my anal self and point out whatever stuff was swimming around in my head as I read through your thread.

I should correct myself on the symptoms of hypothyroidism. Big appetite is not the usual symptom but obesity is, due to the slow rate of metabolism. I've had two dogs with hypothyroidism and they actually had increased appetites, got really fat and unlike their mom, who runs warmer and warmer as the pounds mount, they were extremely sensitive to cold. Does Jordan seek out warm places or cold places?

I believe your mom is correct about the timing of retesting because I know for a fact that moms are usually always right. :D If Jordan doesn't have hypothyroidism, testing the waters with thyroid supplementation is usually the way to go. It's pretty benign in comparison to Vetoryl or Lysodren, as the worst that can usually happen is the dog is thrown into hyperthyroidism and they start drinking and peeing buckets. Did you happen to notice a difference in Jordan's drinking and peeing after starting the thyroid supplementation?

I'm really stymied by the UC:CR. Do you have a copy of the results with you? If so, can you recheck to make certain that normal is defined as being less than 33? That actually seems a bit high compared to the lab interpretations I've seen here in the states. Also I forgot to ask if you collected the urine specimen from home or was it collected in the vet's office?

[Somesie]

Thanks for the clarification on appetite...that makes me feel slightly less crazy!

The two blood tests done at the first vet were basic, not a full thyroid panel, and they showed nothing untoward. Then the new vet did the more complete panel and diagnosed hypothyroid. I don't have those test results, but I'll see if I can get them next week when we do the blood work. When she did those tests, the vet didn't mention whether it was primary or secondary...just gave the supplementation and sent us on our way. If the thyroid meds were going to make a difference, wouldn't I have seen at least a small indicator of that by now? There's been no change, positive or otherwise. His drinking has remained the same as before supplementation, too, Lulu's Mom.

UC:CR sample was collected here at home, and yes, I do have a copy, with which I verified - his result is 30, 'norm' is listed as under 33. Do you know what the norm value is in the States? I'll look that up and see what I can find.

Don't worry about changing my mind or further confusing the situation, anybody. I welcome the input, especially before tomorrow, as it gives me great questions to pose to our vet in SC, who I trust quite thoroughly.

Oh...hot/cold sensitivity. I'm not 100% sure how to answer that one. In the mornings, he demands to cuddle next to me under a blanket, and even if I'm not currently using one, he makes his point known by pawing at the couch as if to lift an imaginary blanket. That would lend itself to cold sensitivity. As well, he didn't fight me on the fleece jacket this winter, which was definitely a change from previous years. Aside from that, though, and the usual seeking out of sunbeams, I haven't noticed him seeking a specific place or places in the house...I think it's kind of the same temp throughout, mostly. I guess I would err on the side of yes, he's a little cold sensitive.

At this point, I lean in the direction of this being actual Cushing's, because the thyroid meds haven't touched his symptoms at all. That said, I am quite bothered by the borderline ACTH and 'normal' UC:CR. I would really like something more conclusive before I start throwing meds at him.

Keep the thoughts coming...any and all. I'll keep reading today and report back anything significant, and will give a full report after talking with Dr. Jay, hopefully sometime tomorrow afternoon, my time.

Best,
Jenn

[labblab]

Jenn, I know I've gone back-and-forth on this, but once again I'll throw out the suggestion of performing an LDDS. If it returns a squarely "positive" result, it may give you a higher comfort level re: the Cushing's diagnosis. Plus, the results may give you further indication as to whether the disorder is pituitary-based. Here's a summary as to the usefulness of the test (taken from this article by Dr. David Bruyette (http://veterinarymedicine.dvm360.com/vetmed/Medicine/ClinQuiz-Interpreting-low-dose-dexamethasone-suppr/ArticleStandard/Article/detail/580093)):


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.

If the eight-hour postdexamethasone administration cortisol concentration is above the reference range, then evaluate the baseline and four-hour postdexamethasone administration cortisol concentrations to see whether cortisol suppression occurred during the eight hours. If at least 50% cortisol concentration suppression is present at the four- or eight-hour time points, the definitive diagnosis is PDH and additional adrenal function tests are not needed.

As is the case with the ACTH, the LDDS cannot give you a definitive diagnosis. But it would be one more piece to fit into the diagnostic puzzle.

Also, as to the question mark re: the UCCR result... Ever since reading this comment (also by Dr. Bruyette), I've felt less comfortable about relying on a single urine sample as a sole Cushing's indicator:


Urine cortisols can be a problem. Many studies have shown that the only way to accurately gauge urine cortisol levels is to obtain the first morning voided urine sample on 3 consecutive days and then pooling the urine to run a UCCR. When done in this fashion it is likely an accurate test. Otherwise there is likely too much day to day variation to make a single random cortisol very helpful.

We do often recommend the UCCR to our members as an easy, inexpensive initial diagnostic tool. But after reading Dr. Bruyette's comment, I try to suggest to folks that they go the route of collecting a pooled sample rather than relying on a single "catch." I don't think a pooled sample is commonly employed anywhere here in the States, but it sounds like the results might be more accurate. So that might be another option for you, as well -- to rerun a basic UCCR, but this time based on a pooled sample.

Marianne

[Somesie]

Couple of quick things...

After reading around on here some more (don't know what the heck would happen right now if I had a day job, btw), I think it's worth mentioning that my little buddy sometimes has tremors. They seem to be related to excitement - most often when my husband and I arrive home from being gone for awhile, or else in relation to food. This morning at the farmer's market, for instance, the turkey farmer always has scraps for my pups on Thursday mornings, so as soon as we get there, Jordan assumes the 'sit' position and waits. Today, there were three or four people ahead of us in line, so he had to wait a few minutes. I looked down to notice his entire body was just shuddering in anticipation. This? This breaks my heart. Could this be related to excess cortisol being released? Is it a possible further indicator in favor of a Cushing's diagnosis?

I rang the vet this morning to ask for a copy of his thyroid tests, so I will post those results when I pick them up this afternoon. When we spoke, I tried to get some clarification on the ultrasound yesterday. She said that she could only see one adrenal gland and that this was common because the enlarged one can block the other one. I asked if it was simply enlarged, or if it was a tumor, and she said it was "like" a tumor. I got the distinct impression we were having a language barrier issue, so I'm not sure how much weight to give that. Can anyone think of a further line of questioning I might pursue? I did ask if she feels it is PDH or ADH, and she said ADH. Given what I've read thus far, I don't think she should actually be able to make that statement as conclusively as she did, which once again puts her expertise into doubt...the very last thing I need.

I emailed the specialist in Zurich this morning. I'm not confident enough at this point to start medicating him, I don't think. I'm torn...I just want his symptoms abated and want my happy boy back.

He's sleeping soundly at the moment, but Momma's fixin' to have a bit of a breakdown.

Thanks again, everyone....you have all been such a huge help so far. Keep the responses coming, please.

Jenn

[labblab]

I'm so glad you've contacted Dr. Reusch. I'm sure any information she can give you will be really, really helpful. And if it could be arranged, even a single consultation with her would be invaluable.

Also, here's a link to another member's thread where unexplained tremoring is discussed. Many members have noticed tremoring after treatment is begun, but I saw it in my own Cushpup both before and after diagnosis.

http://www.k9cushings.com/forum/showthread.php?t=2052

Marianne

[Somesie]

Thanks Marianne...that was actually the thread I'd been reading that prompted me to mention his tremors. Do you think it is further indication of a positive diagnosis for Cushing's?

[Somesie]

BTW, I'm not hovering over the forum awaiting responses. I'm working, so it's easy to hop over here and look for updates. I'm worried...but not compulsive (yet).

:o

[Squirt's Mom]

Hi Jenn,

I think you are doing exactly as you should right now - pursuing every avenue, ruling out all you can, before starting treatment for Cushing's. A consultation with Dr. Reusch would be a great idea. Cushing's is confusing enough without a language barrier on top. So hopefully, Dr. Reusch will be a bit easier to communicate with and be able to give you a more definitive diagnosis and plan of action.

Remember that Cushing's progresses at a snail's pace, meaning we usually have plenty of time to make sure we truly are dealing with this condition and not something else. With so mant of Jordan's testing being iffy for a firm Cushing's diagnosis plus the language difficulties with the GP, I think adopting some of my stubbornness might be beneficial. ;):p It is perfectly natural for us to want immediate relief and improvement for our babies but with Cushing's, it is usually best to take our time - and, boy, do I know how hard that is do to!

You are doing a great job, Jenn, so don't get discouraged. The answer is out there and you will find it and find a way to help your sweet boy.

Hugs,
Leslie and the gang

[Somesie]

Speaking of immediate relief...that was exactly what I just came here to ask. I've read a little about flax lignans and melatonin on here. Is there a possibility that while we try to figure this out, I might use those to give him some type of relief from the ravenous hunger?

If so, in what dosage?

Even if we do decide to medicate, it will be a few weeks before we can begin, because we're scheduled to be away for a long weekend coming up and I don't want him adjusting to the medication while they're at camp and not under my supervision. Meanwhile, having read even more about how my poor boy feels like he's starving to death even right after he eats...the thought of that is absolutely killing me. I know I'm new to this forum, but I've been watching these symptoms for months now already and am positively desperate to find him some immediate relief.

Thoughts?

Jenn

[Somesie]

More. Sorry.

Just picked up the thyroid test from the vet and am quite concerned. I thought she had done a more thorough thyroid 'panel' but the paperwork she gave me just says 'total thyroxin (t4) .8. One month earlier, almost to the day, his total thyroxin was 1.6, within the normal range of 1-4.

Suggestions? Comments?

[Squirt's Mom]

I know what you mean about that hunger getting to you. When Squirt's signs strengthened last summer, it was the hunger that broke my heart, too. The look in her eyes is one I don't think I will ever forget. She would finish her meal, clean the bowl inside and out, clean the floor and wall as well as the towel her bowl sits on, then look up at me clearly saying, "Please help me, I am starving...please." She spent every waking moment looking for something, anything, to eat, always with that desperate look in her eyes. It was awful for both of us. :(

If Jordan's hunger is driven by elevated cortisol, I don't know of anything that will help other than lowering the cortisol via treatment. The lignans and melatonin fall under a method of treatment called Nutriceuticals - the use of diet, supplements and herbs as a medical approach. This method does not usually produce immediate results but rather has a cumulative effect, building over time to therapeutic levels. The lignans and melatonin usually take about 3-4 months to work, and would have little to no effect on the cortisol tho melatonin does have the potential to lower it a little bit. Having said all that, using them would probably be alright and might provide a bit of relief by giving Jordan the ability to rest better via the melatonin. Elevated cortisol throws the circadian rhythm off and melatonin can help bring that back in line. ;) If he has any digestive issues like colitis or IBD, be cautious and slow with the lignans. The dosages are available here -

http://www.vet.utk.edu/diagnostic/endocrinology/pdf/TreatmentInfoAtypicalCushings201107.pdf

Hope some of this helps!
Hugs,
Leslie and the gang

[labblab]

More. Sorry.

Just picked up the thyroid test from the vet and am quite concerned. I thought she had done a more thorough thyroid 'panel' but the paperwork she gave me just says 'total thyroxin (t4) .8. One month earlier, almost to the day, his total thyroxin was 1.6, within the normal range of 1-4.

Suggestions? Comments?

Jenn, here's an example of the full thyroid panel that I spoke about earlier:

http://ahdc.vet.cornell.edu/docs/Canine_Thyroid_Testing.pdf

While a basic T4 reading (like Jordan had done) can be used to screen for thyroid issues, it can't identify the source of the problem. To do that, other measurements need to be taken, as well.


Measurement of free T4 (FT4) with a valid assay can be useful for diagnosis of true hypothyroidism and differentiating it from the euthyroid sick condition. Euthyroid sick dogs may have low T3 and /or T4 levels due to other non-thyroid factors (e.g. medications, non-thyroid disease, nutrition, etc.).

It's not uncommon for Cushpups to exhibit decreased T4 levels, and if the hypothyroidism is secondary to the Cushing's, your vet is correct that the problem may resolve once the Cushing's is under control. But some dogs do suffer from genuine hypothyroidism in addition to Cushing's. For them, continued thryoid supplementation will always be needed.

FWIW, my dog was also diagnosed with hypothyroidism prior to identifying his Cushing's. We had not done a complete panel so did not suspect, at the time, that there was anything else involved other than the low thyroid. However, after thyroid supplementation did not improve his symptoms at all, we launched into further diagnostics. And voila, that's when the Cushing's was identified. :o

Marianne

[Somesie]

Thanks, Marianne. I am home today with a bug myself, and am spending all my time reading and learning on here. What a resource you all are!

The more I read, the more bothered I am by Jordan's normal UCCR and borderline ACTH. His symptoms, though, are classic Cushing's. I am so torn.

Still awaiting a call from our SC vet, but at this point I am planning to collect urine for the next 3 days (try not to be jealous of my life) so we can get another UCCR done as well as full blood panel early next week. Monday is a German holiday, so Tuesday is the earliest we can continue.

Meanwhile, he did do a brief Boxer Burn through the house after walkies this morning, so all is not lost. :D

Thanks again!
Jenn

[Somesie]

Marianne...just to be clear, what test can successfully determine whether the hypothyroid is caused by the Cushing's?

[labblab]

Jenn, be sure to refrigerate the urine during the interim.

P.S. I just saw your new thyroid question, but I am headed out the door. I'll post another reply later on.

[lauraperla]

Jenn,
I sympathise fully on the hunger issue. I felt utterly wretched for Saoirse when she was at that stage.
I found the only alleviation I got at all was to be really strict around foodstuffs in the home. So food was always stored well away in cupboard, even fruit bowls. I moved 'doggy central' into the hallway rather than in the kitchen. I also stopped using the kitchen as my hang out, I used to do any work I had on my laptop at the kitchen table, so I switched room and worked in our guest room. I also used the hide chew bones you get to keep her busy without piling on big calories. Had to be careful with those though as the skin on her nose was and still is quite thin.

[Jenny & Judi in MN]

when we were getting Jenny's maintenance dose corrected and she went through the ravenous stage someone here suggested frozen green peppers. She loved them!

Jenny is diabetic too so she isn't supposed to snack but watching her act so hungry was tough. hugs, Judi

[labblab]

OK, I'm back again. And as I understand it, I think the patterning of the "Free T4" and the TSH results are particularly useful as far as investigating thyroid dysfunction in a dog with a suspected illness such as Cushing's. Not every laboratory can perform this testing, though. So finding a lab to perform a more complete thyroid panel will be a good question for Dr. Reusch if you have the chance to talk with her or with a specialist that she recommends (or with your current vet, for that matter).

Marianne

[Somesie]

Marianne...thanks. I just chatted with my Mom about t4 versus a full panel, and she said it would be a good addition to the stuff I plan to have done next week. She is also going to look into whether thyroid dysfunction could cause the slight adrenal enlargement we saw. Meanwhile, still waiting for our phone consult, which I am guessing may not happen until Monday. So...I continue reading and learning.

Laura...I just read your whole story with Saoirse. How's she doing today? I hope you're enjoying the holiday!

Thanks for the green pepper suggestion. I might have to consider cooking up and then freezing some veg...that's a good idea. He loves ice cubes, so frozen veg would likely go down a treat.

Best,
Jenn

[lauraperla]

Jenn, I think I lost days of my life to the reading and learning stage! And continue to do so (and indeed wonder how people coped with all this before the internet and what a marvellous tool it is in these situations).
Our snack list features carrots (and it seems they taste most delicious when stolen from a horse!), apples (ditto), banana, and she does like a nice chunk of turnip too. I have charcoal dog biscuits and she gets a couple of those a day.
Thank you for taking the time to read Saoirse's story, that's very sweet of you. Its been some journey. And thank you, today she's having quite a good day. I went to take her for a short walk but she headed off to her indestructible ball, she wanted to play. Only managed a short time but she enjoyed it. I also gave her a nice warm doggy bubble bath today- because of the fragility of her skin I've been careful about giving too many baths, both my horses have skin conditions and over the years I've found with them the less messing you do, the better the skin copes because you're holding on to the natural oils rather than washing them away. She loved her bath and is now snoozing by the fire (its a miserable rainy day here, typical holiday weather lol!)
I hope you have a lovely Easter and Jordan is keeping his Boxer chin up!

Laura and Saoirse xx

[Somesie]

SC vet rang. He thinks we probably are dealing with either Cushing's or maybe even atypical Cushing's, but that he would definitely not be medicating just yet. He suggested, as have some of you (thanks) the LDDS first, as well as T4 and TSH. If the LDDS doesn't come back conclusive for Cushing's, at that point we'll have to seek out a specialist.

He did say, in answer to one of my questions above, that no, there really isn't a way for her to know conclusively at this point that it is even Cushing's, much less to have told me as she did yesterday that it is ADH. He was very careful not to throw her under the proverbial bus, but this conversation confirmed my suspicion regarding her inexperience.

And? He refused to send me a bill. Bless.

In case anyone is interested, he said he would prefer Cushing's go untreated for six months to medicating without a confirmed diagnosis. Said these drugs are, "nothing to mess around with."

So. Tuesday I will set up the LDDS, and I will report back. Meanwhile, if a anyone has other suggestions for keeping his little (pot) belly more comfortable, I am all ears.

Thanks for all your help and support, y'all.

Best,
Jenn

[lulusmom]

YES! SC Vet is right on!

[lulusmom]

Now that I've stopped dancing on my desk about your SC vet's voice of reason, what's an "SC" vet? :o

[Squirt's Mom]

:D:p:D ROFLOL :D:p:D

[labblab]

Jenn can correct me in the morning, but I've assumed she's referring to the South Carolina vet that they previously saw here in the States. ;)

Marianne

[Somesie]

You guys are funny! And yes, Marianne is right...Mt. Pleasant, SC, just outside of lovely Charleston.

Little man and I are both feeling better after a decent night's sleep and reassurance from our beloved Dr. Jay. The more I look at this, the more I am suspecting atypical Cushing's. I read an article about it last night, wherein the owner described her dog becoming very afraid of certain things, almost overnight. It may be totally unrelated (I would never have thought to even mention it here), but over the past...I don't know, year? He has developed this little quirk about being afraid to go outside sometimes at night. It ranges from being totally fine some nights, to just requiring that I be the one to open the door for him instead of my husband (?!?), to my having to actually get his leash and go out with him. Even more strange, frequently, once I grab the leash and head for the door, he is fine and goes out without it...he just needs to see it, and me, as though we are a security blanket of sorts. Lil weirdo.

Anyway, I am looking forward to the LDDS results and moving on from there. I haven't heard back from the doctor in Switzerland, but through this site I located two IMS specialists who are within about an hour. I may contact one of them, regardless of the test results, so that we can be a little more confident in our treatment, whatever that ends up being.

Once again...thank you, thank you, thank you!
Jenn

[Somesie]

Heard back from Zurich specialist, who did not have a specific referral but suggested one of the local animal hospitals. I knew of one we hadn't tried, and a little research turns up the fact that they have an IMS who....drumroll please....studied at UC Davis!!! ENGLISH!!! Woo hoo! Oh...and he also specializes in ultrasound! The place is only 12 minutes away. I'm ecstatic, needless to say.

I will be at their door on Tuesday, first thing!

Best,
Jenn

[labblab]

GREAT NEWS!!!!

We'll be right there alongside you on Tuesday. ;) :)

Marianne

[lauraperla]

That is fantastic news Jenn, I am so pleased for you. Can't wait to hear how it goes .
Can I suggest you organise some notes beforehand - making a summary from your posts here would be perfect- to take with you? I found that I had so much to tell the IMS that having a sheet of notes was a great prompt and stopped me babbling on endlessly!

[Somesie]

Excellent plan, Laura. I will probably take the email synopsis that I sent to our vet back home, along with all the various lab paperwork.

They went to the dog park with their Daddy this morning, as he had to run out to get me all manner of drugs...I feel like a bucket of smashed crabs. Bronchitis or whatever. Hubby is taking good care of us all today!

I will keep you all posted!
Jenn

[Somesie]

Quick question, folks...we have an appointment scheduled at the IMS but couldn't get in until next Wednesday, the 18th. I was thinking of having our current vet do the LDDS between now and then, instead of waiting for them to do it, so that we could go in loaded with all of our results from UCCR, ACTH, and LDDS. Jordan knows this vet so it would be less traumatic, plus the IMS wanted me to fast him for the appt next week, and it isn't until 12.30 in the afternoon...the idea of withholding food for that long when he's usually begging by 7.30?!? Um. No.

So, question is two-fold - is the LDDS something I can trust her to do correctly without much experience, so long as I go in knowing the protocol? Two - can I bring him home between the initial blood draw and take him back at the four and eight hour marks, or is the injection she gives him such that she will need to monitor him? She let us come and go for the one hour between draws for the ACTH. I'd far rather bring him home with me if I can.

Thanks!
Jenn

[lauraperla]

Good morning Jenn,
My IMS ran a whole range of tests on our last vet hospital consultation even though we had an encyclopaedic history of 2 years results (including bloods and acth as recent as 2 weeks prior) to give them. So my gut feeling would be for now to hold off on any more tests for Jordan til the 18th, the IMS will work through his own diagnostic protocol.
How are you feeling? Hope your breathing is a bit better,
L & S x

[labblab]

Wow, if your appointment doesn't even begin until 12:30, the LDDS testing will run late into the evening. Does the IMS know that you have that specific test in mind?

Perhaps you could use this first appointment as a non/fasted "meet-and-greet" consultation, you can use the time to figure out an overall testing strategy, and then schedule a dedicated laboratory day that begins first thing in the morning? Just a thought that might make things easier on Jordan. And yes, I would definitely ask if you can take him home between blood draws.

Marianne

[Somesie]

I only spoke with the receptionist, but the time of day was part of my concern. That's why I'm thinking of getting it done at our current vet and going in for a non-fasted consultation, like you're thinking, Marianne. It seems reasonable that this vet can do the LDDS and the IMS can interpret the results of it along with everything else, which is what I really want him to do anyway.

I'm on the mend, with any luck, thanks! I have been to the doc and have antibiotics, and am about to lie down in my lawn chair to enjoy (and let the mongrels enjoy) the nice sunny weather. :cool:

Best,
Jenn

[Somesie]

We've been to our regular vet this morning for part one of the LDDS, and my boy is resting peacefully, with a bright, pretty yellow bandage covering his IV port. I'm glad I chose to have her do it, as she and her staff are so warm and gentle with him, which has not been typical of the European vets we've visited. Only slight bother is that she insisted he didn't need to be fasted. Based on everything I read, we went in hungry despite her instructions, and I had to mention it to her, lest she give him a treat after the procedure (which she then did anyway, before I even realized it had happened! :( I hope that one little treat doesn't muck up results for the rest of the day). I want to give her the benefit of the doubt that maybe European protocol is different, but you'll recall that the IMS told us to come in fasted on Wednesday!

In any event, we should have the results back by Wednesday morning, and then our appointment with the IMS is at noon-thirty, so I should have lots to report by then.

Hope all of you and your fur-babies are well.

Best,
Jenn

[Sabre's Mum]

Jenn ... I would think IMO that the little treat would not have affected the results.

We look forward to what the IMS has to say about Somesie.

All the best
Angela and Flynn

[labblab]

I wouldn't think the treat should be a big issue, either. Also, apparently it depends upon the lab doing the analysis as to whether or not fasting is required for the LDDS. So giving your vet the benefit of the doubt :o, perhaps she checked in advance and found out that the lab she's using said it was "OK" for Jordan to eat.

Marianne

[lauraperla]

Good luck for Wednesday! I will be thinking of you and Jordan x

[Somesie]

Thanks, everyone! We've had a stretch of such good days, probably due mainly to how inactive I've been while down with the sick. Lots of quiet cuddling....just what the doctor ordered!

I'm hopeful we'll have the LDDS results tomorrow a.m., so will posts those results along with our impressions from the afternoon appointment with the IMS. I'm taking Barkley to day camp for a few hours while Jordan and I are at the clinic, so she can have some fun with her friends instead of being left home alone. :D

More soon. Thanks again for all of the support; you all are great!
Jenn

[Somesie]

Hey all...nothing like coming down to the wire...I just heard back from the vet that his LDDS was normal, as follows:

pre-injection: 2.7
four hour: .8
eight hour: .6

She only gave me the range for the pre-injection, which she said shoudl be between .9 and 4.5.

I have to leave in a half hour to take him to the IMS. Right now, I'm thinking atypical Cushing's, based on a normal UCCR, borderline ACTH stim, and normal LDDS.

On the off-chance that anyone is on here at this hour, please feel free to chime in with your opinion on weather I'm headed in the right direction, as well as letting me know any questions I might want to ask the doc this afternoon, tests to run, etc. I have a list of my own, but would love further input.

Thanks muchly, more soon...
Jenn

[labblab]

Wow, the LDDS result is an eye-opener, that's for sure! I know you're enroute to the IMS now, so I will be SOOOOO anxious to hear your report. As we've said earlier, it is only a very small percentage of Cushpups who will test negative on the LDDS. So yes, combined with the negative UCCR, huge question marks are thrown back up as to what is really going on with Jordan. Since the IMS trained at UC Davis, he should be very familiar with the full adrenal panel performed at the veterinary lab of Univ. of Tennessee at Knoxville (to test for Atypical). And presumably, samples could be sent to them for analysis from Germany. And maybe the IMS will want to repeat the ultrasound in an effort to view the other adrenal gland. Anyway, I'll keep checking in today for word about your consult!

Marianne

[Somesie]

Marianne...that would have been my thought as well, and yet...

This guy basically questioned the validity of atypical Cushing's even being a real disease. For real. He said it is 'very controversial' and that it requires 'testing a whole panel of hormones' and then basically sort of blew it off as if this wasn't really even an option. I'm a bit flabbergasted by that aspect of the visit.

On a positive note, he did a thorough exam, and did in fact do another ultrasound, in which I have a much greater degree of confidence than the previous one. Everything looked good, including the one adrenal gland he visualized, which he said was perfectly normal. Try as he might, he could not find the second one, which he said is quite common with Boxers because of their deep chests. (Also, I hadn't fasted him, so there was a lot of gas to try and see through.)

So now, we have a normal UCCR, borderline ACTH stim, normal LDDS, but a fairly classically symptomatic dog. What. The. Heck?!?

Without throwing our current vet under the bus, he said Jordan shouldn't have been medicated for hypothyroid without doing a complete thyroid panel first, instead of just t4. His recommendation was to stop the soloxine and do a full thyroid panel in about a month, after it's out of his system, and go from there. Past that, though, he wasn't a heck of a lot of help in the way of why my baby is ALWAYS hungry and has lost so much hair.

Color me...partially relieved, mostly annoyed, thoroughly confused.:(

I am inclined at this point to start giving him flax and melatonin. Giving the rest of the world the benefit of the doubt that there actually is such a thing as atypical Cushing's, Herr Doktor (sorry, I'm annoyed with him, probably unreasonably), isn't that how it would be treated?

I guess my main questions for you all are as follows:

1) You're me, what do you do?
2) Assuming it is atypical Cushing's, is there any medical benefit in doing the full UTK panel? Or would it just be peace of mind ("just"?!) of knowing what's causing his symptoms?
3) Anybody know what could be wrong in the thyroid department that could cause such voracious appetite? Because low thyroid shouldn't.

aaaannnd....past that, I kinda just want my Mom.

Love to hear your thoughts. Thanks for all the support!!
Jenn

PS I've now got zero remaining confidence in our vet, which is such a huge disappointment. :(

[Squirt's Mom]

Hi Jenn,

Bless your heart. Sounds like a crappy day. :( But, don't despair...the answer may yet be out there along with a solution.

The IMS is right about Atypical being controversial. But I happen to think there is value in having these hormones checked when everything else has been ruled out yet signs persist. For a couple of reasons - 1) if Atypical is a precursor to true Cushing's, in which the cortisol is elevated, then by learning of the possible connection, we can be ahead of the game when, if, the cortisol does rise; 2) if Atypical is an indication of problems elsewhere, then we can use the elevations to guide us and our vets in looking at other possibilities. For example, my Squirt's Androstenedione remains elevated but the vets aren't worried about it, tho it concerns me, of course. ;)

Treating Squirt with melatonin and lignans brought most of her elevations back in range; I think all of them have been normal again at one time or the other. They worked for her from '08 until last summer, when her signs became very strong and testing showed her cortisol was rising. We started her on a maintenance dose of Lysodren in addition to the melatonin and lignans, and she has been well controlled since. By the time I needed to use the Lyso, I was well past being afraid like I was when I first started down this road with her. I had time to learn. ;)

Of course, the treatment (melatonin/lignans) for Atypical is quite mild so if you wanted to save the cost of the test, you could simply start and see if it helps Jordan or not. Now, you will need patience as it takes 3-4 months for most pups to start showing improvements. You can find the dose he would need and where to find them here:

Treatment Option Sheet
http://www.vet.utk.edu/diagnostic/endocrinology/pdf/TreatmentInfoAtypicalCushings201107.pdf

Here is a link to the Helpful Resource Section thread where you will find other links as well -

http://www.k9cushings.com/forum/showthread.php?t=198

Hope this helps! Oh, and be prepared - you will hear other views from the members here, too. But that is a good thing. Being well-informed helps us make the best decisions. Research on your own and if you find something interesting on the topic, share! We are all here to learn. ;)

Hugs,
Leslie and the gang

[labblab]

Well...now things are just as clear as mud, right??? :o

Here's some initial thoughts, in random order. I do agree re: the benefit of a full thyroid panel. As we talked about earlier, even if Jordan is hypothyroid, a full panel can help distinguish between primary hypothyroidism and low thyroid function that is secondary to some other condition (such as Cushing's). You may still end up giving thyroid supplementation, but you'll have a better picture of the condition as a whole.

As far as Atypical, it is true that the diagnosis is controversial among different specialists (or at least the ramification of elevated intermediate hormones is controversial). I figured that this IMS would at least be aware of the issue, having trained at Davis. But it may also be the case that the Davis group is not "big" on Atypical as a bona fide condition -- I just don't know about that. And yes, it would take the full UTK panel to actually identify any hormonal elevations in addition to cortisol. But as Leslie has said above, some of UTK's suggested treatment options are essentially benign, so there probably is no real risk in trying them even without the panel. But as she also points out, it can take a long time to see any benefit even if they do end up helping.

Re: the ultrasound -- is he saying that the one adrenal that he could see was not even enlarged, in his opinion? If it is of normal size, then we're left with a symptomatic dog but only one single indicator of possibly abnormal adrenal activity (the ACTH).

AYE YI YI!!!!!!!!!!!!!!!!!!!!!!!

I think I'm gonna take some time and re-read your entire thread from beginning to end, and see if a light bulb goes on for me. I may not be able to do this for a day or so, but I will definitely be back...

Marianne

[Somesie]

Thanks, Ladies. So much, really. As frustrating as today was, the culmination of several months of frustration, I can at least take comfort in that he isn't dreadfully ill and whatever this is seems to be progressing very slowly. At the moment, he is standing outside the bathroom demanding his nightly wrestling match, with no regard for the fact that Daddy is...otherwise occupied! :D So, he can't be feeling too bad, right?

In answer to your question, Marianne...yes, the one adrenal he did visualize wasn't even enlarged, so your summation is spot-on....symptomatic dog with only one indication of abnormal adrenal activity, and even that (ACTH) was borderline, not actually positive. I'd love to hear your thoughts if you do have time to read through all this and it prompts some ideas. Don't rush, though...we're going to be on holiday for a few days, starting tomorrow; pups will be at camp. It's our ten-year anniversary this weekend and our first honeymoon was positively craptastic, so this is our do-over! I'm kind of relieved that he won't be on any medications while we're away, and that he's been in such good spirits for the past week or so...it makes me feel better about being away.

Also, thanks for validating that the IMS isn't some sort of crackpot and that there is actual professional debate over atypical Cushing's. It's still frustrating, but at least I don't feel like I've got yet another in a growing list of crappy vets.

I'll keep checking in, probably even take a peek while we're away for the weekend, so keep the thoughts coming. I appreciate the support!!

Best,
Jenn

[Somesie]

Leslie...and/or whoever else has experience with this...

Thanks for the link to the lignans/melatonin dosages. Following UTK's links to appropriate sources of lignan, I am reading the label information for the pills offered by some of these vendors, and one of them (a 78mg pill dosage) says that it contains the same amount of SDG lignan as would be found in a tablespoon of ground flaxseed. For the life of me...I can't figure out why I would buy/give him pills if I can just give him all-natural, ground flax seed? Am I missing something? Can't I just buy Bob's organic flax seed and grind it in my spice grinder? Because if I can, then I can start giving him that today, as opposed to having to wait for pills to be delivered. Your thoughts?

They did fine at camp while we were away, and he's been pasted to my side, recovering (read: snoring), since we picked them up this morning. He did do a quick and hilarious Boxer Burn :D before laying down, so I do believe he's happy to be home!

Thanks for your help on the flax, and everything else!

Jenn

[Squirt's Mom]

Hi Jenn,

The ground flax seed may work just as well. Several of us here used the ground flax hulls but I found them too expensive to use and they caused some digestive upset. If the SDG amount is correct and the seeds don't bother Jordan, I know of no reason not to use them.

Hugs,
Leslie and the gang

[Somesie]

Thanks, Leslie. Maybe I'll start him out on the ground seeds, since I have them on hand, but order up some of the pills online with the melatonin (which, strangely, I cannot seem to find here) online. If you have a vendor/manufacturer preference, I'm all ears.

Best,
Jenn

[Squirt's Mom]

Hi Jenn,

I use the NOW brand melatonin but there are many good ones available. It comes in a capsule which means I don't have to grind it up to put it in her feed. All Squirt's meds go into food or it's a battle worthy of historians! :p

Hugs,
Leslie and the gang

[Somesie]

Just got back from the aphotheke; I wanted to get started on this right away (patience may be a virtue, but it is most certainly not one of mine), so I tried to find some on the German economy. Holy WOW!!!:eek: 35€ (so, like 48$!!!) for 90 5mg pills!!! And, the pharmacist said it requires a prescription! Needless to say, I will have to await my order from drugstore.com.

Great idea on the capsules, by the way...I will follow suit; thanks. Dumb question, but as I understand, this should be given every twelve hours, so, morning/night. Will it make him sleepy in the daytime? Or at all, I guess? Or does it not have the same effect on dogs as humans?

Thanks again!
Jenn

[Squirt's Mom]

Hi Jenn,

Yes, you can expect Jordan to be sleepy at first. Most pups adjust fairly quickly to the dose, tho. Squirt has been taking 3mg AM and PM for four years now and I can't tell she has taken anything morning or nite. Seems like it took her a couple of weeks at the outside to adjust but she was never lethargic from it, she just took some long morning naps for a while. :D

Hugs,
Leslie and the gang

[labblab]

Jenn, I hope you had a great trip!!

As promised, while you were gone, I did go back and read through your entire thread. And I confess that I remain as stumped as I felt last week :o. Everything about Jordan seems to scream Cushing's except for the test results. :confused:

Out of curiosity, what explanation did the new IMS offer for all the symptoms? Is he just focused on performing a full thyroid panel in a month, and then going from there? I don't disagree that it's a reasonable start. But if the result is hypothyroidism that is seemingly secondary to another disorder, I believe I would still want to retest for Cushing's a bit farther down the road. Perhaps it remains the case that Jordan is in the very early stages.

As for "what would I do?" Hmmmm... I do agree that there is no harm in adding the flaxseed and melatonin. Whether or not you'll see any improvement, it will be interesting to find out. With a post-ACTH of 21, I do believe that Jordan is at a cortisol level where maintenance dosing of Lysodren would be recommended by UTK if he indeed suffers from elevated intermediate hormones. But from what you've said, Lysodren itself is not readily available to you in Germany, plus it doesn't sound as though you have a vet who gives credence to an "Atypical" diagnosis and would wish to prescribe it anyway.

So I guess I'd go with your current plan -- giving the flaxseed and melantonin, and retest the thyroid. Depending upon those results, I'd consider revisiting cortisol testing again once a bit more time has passed.

Marianne

[Somesie]

Thanks, Leslie! I was actually able to find some melatonin today, so I'll get him started on it tonight. I swear, at the moment it's hard to believe that anything at all is wrong with him. He has been in such good spirits all week since we got back! Today he's been following me around in my cleaning chores all day, trying to distract me into playing just about every time I turn around. It's cracking me up!:D

Marianne...thanks for looking at it all again and for your thoughts on our next steps. I will see how the next thyroid tests go, and we'll go from there, I guess. Right now, I'm just appreciating that for whatever reason...he seems to be feeling really good this week.

Oh, and thanks, we did have a really great weekend! Very relaxing and romantic, and lots of silliness - a perfect second honeymoon!

I'll keep you all posted as we get further into the flax and melatonin. Oh, speaking of which, today will be day three of ground flax seed in their bedtime snack (Barkley is getting a tiny smidge, too, as I read of some potential benefits to arthritis), with seemingly no ill effect on their tummies. Oh my gosh...here he comes again with the Frisbee!!:D

Stay tuned! Thanks for your help!!
Jenn

[Somesie]

Hey all...just a few quick thoughts. We're just over a week into the flax/melatonin "cocktail," to no real results one way or another, which I suppose is a good thing. He doesn't seem overly tired from the melatonin, nor is he having any ill effects from flax seed in his dinner, so right now I guess we just wait it out to see if they end up having some positive impact down the road.

Meanwhile, I got an interesting email today from our vet in SC. I'd sent him a little care package (because he refused to bill us :)), along with an update on the most recent tests, etc. Direct quote, "I have had a number of dogs over the years that have all the signs of cushings but we never get a diagnosis and some get better and others don't. Time will tell." Interesting, if a little disheartening. I appreciate the candor, though.

I've read that Cushing's can make them more prone to infections, including of the skin. Just before we started heading down the Cushing's testing path, he had a sinus infection, and then today, he had an actual pimple on his cheek, which has never happened before. Gross. But with everything else, I become more and more convinced that maybe this is in fact a case of atypical, which makes me hopeful that the flax and melatonin will put a dent in his symptoms...the hunger, at the very least. I just want him to be comfortable. On that note, he's not as perky as he was when we first got home last week, but neither does he seem like he's miserable, so I guess we will hold onto that and be grateful, and continue to hope for further improvement.

I'll keep y'all posted. I check in here quite a bit to see if anybody else is having similar issues, as well as to follow some of your pups.

Hope everyone has a good day, and a great weekend...
Jenn & Co

[Squirt's Mom]

Hi Jenn,

Good to hear that Jordan is doing well. The lower perkiness could well be due to the melatonin but that should improve as he adjusts.

How nice that your vet didn't charge you! His note is correct tho I can see how it would be disheartening. Cushing's is so hard to diagnose at times. The tests can show positive when it isn't really Cushing's at all and pups can have many of the signs yet the testing says they aren't the result of cortisol. The "wait and see" approach is often the right one to take when things aren't clear-cut. This is where the slow-moving characteristic of Cushing's is a boon - we usually have time to "wait and see". ;)

You're doing a great job, Mom! Keep up the good work!
Hugs,
Leslie and the gang

[Somesie]

OK...here's what I have...

It says, "Cortisol-Kreatit says inin-Quotient" 30.0, with a reference range <33 being normal; 33-50 as "grey area/control recommended" (that's the Google translation of 'graubereich kontrolle empfehlenswert'); and, greater than 50 is definitive hyperadrenocortisolism.

Beneath that, it says:

Cortisol in urine 69.1 ug/l
Creatinine in urine 72.0 mg/dl

Soooooo....can you do the math on that? Does it make any sense?


Meanwhile, he's been doing pretty well these past few weeks. He's still pretty hungry, but he just seems a little perkier, for lack of a better way to put it. We're continuing with the melatonin/flax treatment, and I'm going to have his thyroid retested in about another two weeks. Past that...if anyone has any further suggestions, I'm all ears.

Thanks again!
Jenn

[lulusmom]

Okay, Jenn. Jordans creatinine and cortisol are in the same reporting units as Chance's so let's do the same formula and see where we go.

Cortisol Conversion (69.1 ug/dl x 27.6) = 1907.16 nmol/L
Creatinine Conversion (72mg/dl x 0.886) = 6.3792 nmol/L

UC:CR = 1907.16/6.3792 = 298.97

According to Antech Diagnostics lab interpretation, Jordan's UC:CR is abnormal (very high). I wonder if somebody got the decimal places wrong but even then, 30 would be greater than 13 so still abnormal. :confused::confused::confused:

[labblab]

Glynda, unless Jenn has made a typo, Jordan's creatinine was reported in units of ug/l, whereas Chance's was reported in units of ug/dl. So that would account for a ten-fold difference of some sort...

I am too mathematically challenged to figure it out without some thought :o. But if we're trying to find a reason to move the decimal point so that 29+ rounds up to 30, that could be it.

Jenn, can you double-check the units for Jordan's creatinine?

Marianne

OOPS! I mean the cortisol was reported in units of ug/l -- not the creatinine. SHEESH!!!!!! This is so hard to keep straight! :o

[lulusmom]

Marianne, I figured that out after I posted and didn't know if it was typo but doing the conversation from ug/l to ug/dl, the result would be 30 so it's still abnormal according to Antech.

[labblab]

Yes, that is odd, also because I've never seen a "grey area" discussed in conjunction with UC:CR norms.

But even if the UC:CR were to be considered elevated, we're still stuck with the borderline ACTH and the negative LDDS. So it seems the questions would remain, regardless...

Jordan's symptoms seem to cry out "Cushing's," so the test results remain such a puzzle! Maybe Jordan is still in the early stages, and the test results will shift once a bit more time passes. But Jenn, is Jordan actually looking better to you now? And he's "off" the thyroid meds, is he not?

Marianne

[Somesie]

Thanks again, ladies. Leave it to this one to be a little mystery man, I guess!

No typo....the results are as written. Thanks for helping to figure it out. I still don't understand why the reference ranges are different, though...wasn't it >13 for Chance? I definitely don't understand the differing reference ranges...shouldn't the conversion formula put them all on a level playing field?

Regardless, I will bring it up with the vet when we go in to test his thyroid in a few weeks. I would be dismayed, but unfortunately not terribly surprised, if all three of the vets involved had missed something in reading the test results. :mad: It annoys me to think that if somebody had just properly tested his thyroid to begin with, we might not be in our current holding pattern. No wonder veterinary care is cheaper here...you get what you pay for. (OK. That was probably uncalled for. But I'm leaving it.:p)

He is off the thyroid meds, so the only thing he's getting now is flax and melatonin. He doesn't look better, physically, but he just seems to be in a little better spirits lately. He's not so punky all day long, he's been more chipper on our walks - running and playing a bit, and following me around the house in my daily routine, which for awhile had stopped in favor of lounging on the sofa. Yesterday, he actually played a little bit with some neighborhood dogs while we were out walking, which was nothing short of a small miracle. I've been working on his aggression with these dogs for over two years, and we finally have them all to the point where they are excited to see one another, but only because all four of us owners shower them with treats. Usually, once the treats are done, they either ignore one another or still end up getting into a scrap, but yesterday Jordan chased after one of them and actually ignored when one of the others tried to get in and mix it up.

So...weird, little things like that that I notice only because I'm with them almost all day, every day.

Thanks for your interest in and help with this. I'll bring it up with the IMS when we see him. As always, I welcome any additional thoughts/suggestions.

Best,
Jenn

[labblab]

Hi Jenn,

I know you and I have been conversing a bit on another thread re: nonfunctional pituitary tumors, and I wanted to come back here to talk a little more about Jordan. Please bear in mind that my thoughts right now are based only on speculation and not on educated reading -- I need to find out more about nonfunctional pituitary tumors, myself! But remind me, has Jordan's labwork shown elevations in liver enzymes, cholesterol level and/or triglycerides? Does he still exhibit a hearty appetite? If so, I'm guessing these would make a nonfunctional pituitary tumor more unlikely. Without hormonal involvement, I wouldn't think you'd see evidence of systemic effects on the liver and blood readings. Also, loss of appetite is a common system of enlarged pituitary tumors, whether functional or not.

But I honestly cannot remember whether Jordan's lab profiles exhibited any abnormalities. Can you remind us?

Thanks!
Marianne

[Somesie]

Thanks, Marianne. He did have elevated ALK, but not cholesterol or triglycerides, and he definitely still has the appetite. I have been doing some studying of my own since discovering that thread yesterday, so I appreciate the additional links you posted in his/her forum.

Jordan's symptoms don't seem to match those of the panhypopituitarism referenced in the Merck link you provided, but I was reading about somatotroph adenomas and acidophilic pituitary adenomas yesterday (with which his symptoms are more consistent), so I need to match that research up with what you guys provided this morning...to see what are the differences. I'm also going to read the thread you provided from that previous member, but this is pretty heavy reading on just my first cup of morning coffee! We've got a lovely day here for a change, so I'm going to enjoy a good bit of it outside with the pups and DH, then continue reading this afternoon while the three of them nap.

From what I've read so far, I still think our logical next step is the full thyroid panel, which I'm going to schedule soon. It seems like the jury is out on how long the thyroid meds stay in their system, so I wanted to err on the side of six versus four weeks before re-testing. Depending on what more I can learn about these non-functional tumors, and pending the results of the thyroid panel, I will definitely be keeping the possibility of cranial MRI or CT in the back of my mind.

Also, I just have to say that I find it absolutely remarkable the amount of time and energy that you and some of the other core members (Leslie, Glynda, Kim come to mind, but there are others) put into this forum. That kind of selfless generosity of spirit seems so rare these days, but in reality...it's all around, if you just look in the right places. It's been heartwarming, to say the least, to see people giving so freely of themselves. Thanks...very much.

If I find anything of interest to add to the discussion, I'll post here and/or the 'arockkid' thread.

Best,
Jenn

[Somesie]

Jordan is scheduled for a full thyroid panel on Thursday afternoon. I had a little bit of a language issue with the receptionist scheduling the appointment and am unsure whether or not he needs to be fasted for this test. She told me 'no food for four hours before,' but then in the next breath she said something about giving him his medication within that timeframe, when I had just explained to her that he wasn't currently on any medications. Needless to say, not a lot of confidence in our communication, past getting the appointment time and reason correct.

Anyone have any recommendations? This is for a full thyroid panel. A Google search netted about equal yes v no responses.

Thanks,
Jenn

[labblab]

Jenn, in a couple hours I'm taking my Peg in to the vet for her 6-month check of her phenobarb level and liver function. I'll ask him about fasting for the full thyroid panel. I can't remember whet we did back when Peg had her thyroid panel done, although I'm guessing she might have been fasted because we did a bunch of other bloodwork at the same time. Is that the only thing you're having done this week -- just the full thyroid?

Marianne

[Somesie]

That'd be great if you would ask, Marianne, thanks. He's only scheduled for the thyroid panel, nothing else.

Thanks again. He's having an 'off' couple of days, which has me a little bummed. Felt like we were doing better for awhile there.

Thanks again,
Jenn

PS Why's Peg on phenobarb, if you don't mind my asking? Hope your appt goes well!

[labblab]

Thanks for the well wishes on our appointment! And thanks for asking about my girl. Peg is my nearly 8 y/o non-Cushpup black Lab girl who came to heal our broken hearts when we lost our beloved Cushpup Barkis :o.

She was bascially a healthy happy girl (although with allergies) until a little over a year ago when the wheels started to come off the cart :eek:. She developed grand mal seizures of unknown etiology. It was at that time that we ran a full thyroid panel through the Michigan State lab. I was crossing my fingers that maybe low thyroid was the cause of her seizures cuz thyroid issues are generally so easy to solve with supplementation. It turned out that all her thyroid levels were fine, but we were still glad we'd done the full panel because phenobarb will skew her thyroid readings from this point on. So at least we had a pretreatment baseline. Then three months after we started the phenobarb, she developed acute pancreatitis that took a while to get a handle on. So all in all, the first half of 2011 was pretty nerve-wracking for us. But her seizures have been 100% controlled so far :), and she hasn't had any more pancreatitis flares after changing her diet and adding in some probiotic supplementation. So I've got my fingers crossed that all her results will come back within range today so that we don't have to make any changes!

I'm really sorry to hear that Jordan is back-sliding a bit again. The roller-coaster ride can feel so discouraging. Just when you think you can breathe, something changes and you're back to worrying again. Like you, I'll be really interested in getting the results of his complete thyroid panel!

Marianne

[Somesie]

Marianne, I hope all went well yesterday! I have an unfortunately vast experience with seizures, via our girl Barkley, so I know how scary that can be. I'm glad to hear she's being maintained well with her meds and diet, though. We've been really fortunate to be able to wean Barkley off of medication (she was on potassium bromide) and just monitor her activity level, as hers are definitely brought on by stress and fatigue. Hers are not grand mal, though...they're cranio-facial, much less severe than what you're dealing with.

Anyhoo, I have changed Jordan's thyroid test to the 11th of June. They told me yesterday that the doctor would be on holiday (Which... "Welcome to Europe...we're closed." This is my life.) after Thursday, which got me to thinking, why pay for a test whose results I'm not going to be able to act on for two weeks? It's like loaning them money. Plus, this will give a little more time just in case there is, in fact, any medication lingering in his system.

The lady I spoke with today had better English, so I reiterated my question about fasting, to which she responded, "Yes, please." So, there you go. Thankfully, we were able to get a morning appointment.

Meanwhile, he keeps just laying around, often in his crate, which makes me extra sad. Blah. My sweet, sweet little lamb.

Thanks again,
Jenn

PS My snarkiness re: European holiday/language barrier shouldn't be taken seriously. I realize I'm the guest here. I kid, because I love (very much).

[labblab]

Oh Jenn, I'm glad you got to repeat your question about fasting because I'm afraid I totally forgot to ask my vet about it yesterday! :o

We got caught up in discussing so many things that I was trying really hard to remember to ask all my questions about Peg, and so I forgot about the thyroid. But it sounds as though you've gotten your answer. I tried to do some quick Googling myself yesterday evening, and it seems to me that even if fasting is not necessary, it won't harm the results. If you really wanted a definitive answer, you could perhaps ask which laboratory will be performing the analysis and then contact them. Because sometimes different labs even have different norming recommendations. But that might be overkill. If it was me, I'd probably just go ahead and fast Jordan.

I'm sorry your test has to be delayed, but I also understand your thinking about this. So this just means we have to stay patient for a while longer!

Marianne

[Somesie]

Hey there, me again. Came back with an interesting (to me, anyway) thought. As I mentioned earlier, I never got a terribly straight answer as to how long it would take for the levothyroxine to be out of his system. It occurred to me this morning that this return to sluggishness/disinterest has been going on for probably just under a week now, and that he's been off the levothyroxine for what will be five weeks on Wednesday.

Sooooo....here I go again, Dr. Google. Sure enough, what information I can find says that it generally takes 4-6 weeks for the thyroid to stabilize at a given level. I wonder if what I'm seeing could be as simple as his thyroid settling in at a low level once again? Still doesn't explain his hunger, but at least it's something. Now I kind of wish I'd kept the Thursday appointment. Still, we likely wouldn't get results until the doctor is back. Dang. Now I really am annoyed at the lengthy Euro-style vacation.

Anyway. Did everything go OK yesterday with Peg, Marianne? Hope so! No worries over forgetting - your own baby has to be your priority, that's as it should be! Since I now have the morning appointment, I figured I would fast him regardless, and am going to have them do a more complete blood panel, not just thyroid. Might as well get a good picture of everything he's got going on when we take him in. I'll probably take in a urine sample, too. Argh! I can't believe I have to wait another two freaking weeks! Actually, almost three! :mad:

Oh well. No sense dwelling.

Best,
Jenn

[Somesie]

Hello All...

Just a quick update, as I am very annoyed and probably need to cool off a bit before saying much.

We just got Jordan's thyroid test result back, wherein his TSH is normal, at .25 with the normal range being less than 30, and t4 is 1.6, with normal being between 1.5 and 4.0.

I THOUGHT I had been explicitly clear in asking for a FULL THYROID PANEL, which to my understanding would also have included free t4, but that is not what I got. I don't know enough about these tests to know if, based on the results they did provide, the free t4 might have been helpful. Can anybody advise?

Right now, I'm headed out on my bike for a bit to cool off. I'm about fed the h*ll up with veterinary "care" in this country.

Thanks for any help you all can offer, I really appreciate it!

Best,
Jenn

[labblab]

Hi Jenn,

How incredibly frustrating! Yes, the Free T4 would have been important and it is always included in a full thyroid panel here in the U.S. The full panel that was analyzed at Michigan State on behalf of our Peg included the following values: T4, T3, Free T4 by dialysis, Free T3, T4 Autoantibody, T3 Autoantibody, TSH, and Thyroglobulin Autoantibody. This is truly the "whole ball of wax." But at a minimum, you would have wanted the Free T4 in addition to the TSH.

Since Jordan's T4 came back right at the lower threshold of normal, this is why the Free T4 would have been useful (explanation taken from an IDEXX Lab report):


Dogs with clinical signs of hypothyroidism and low or low normal T4 concentrations may be evaluated further by submission of free T4 and canine TSH...In a dog with clinical signs of hypothyroidism, a decreased free T4 supports the diagnosis of hypothyroidism, and a normal free T4 indicates the dog is likely euthyroid [normal]...

Increased canine TSH values may occur in dogs with untreated primary hypothyroidism. Sick euthyroid dogs [altered thyroid results secondary to a different medical condition such as Cushing's] are expected to have low normal TSH concentrations...
Since Jordan is a symptomatic dog with a low-normal T4, you would have wanted the Free T4 in order to judge whether his thyroid function is "truly" low. That would have been Step 1. Had the Free T4 also come back low, that's the point at which you would look to the TSH for further guidance.

Unfortunately, you only have Step 2 in terms of the TSH. But as far as the TSH, is there a lower threshold given for the normal reference range (you've told us the upper threshold is 30)? Knowing exactly where Jordan falls with the TSH reference range may give at least a bit more information. But unless I'm missing the boat, without the Free T4, I don't think you can judge whether or not he truly has a thyroid abnormality or not. :(

I think the vet owes you a repeat test -- including the Free T4 -- free of charge!

Marianne

[Somesie]

Um. Yeah. Free thyroid test? That won't be happening. I expressed my dissatisfaction in a fairly pointed email response, to which the doctor (ahem) did not take kindly, shall we say? Apparently they don't like it when you call into question their intellectual and professional curiosity. He invited us to find a new doctor. Which, not for nothing, I was already prepared to do or I wouldn't have expressed myself thusly. I know that my frustration has amassed over three different vets now, and that he bore the brunt of it, but still...he's supposed to be the specialist, and I expected him to be a solution to the past problems, not an addition to them.

So. I don't know what to do now, except I guess maybe go back to vet #2 and have her do an ACTUAL full thyroid panel. Geez. What a mess.

Meanwhile, his appetite has actually become more manageable over the past month or so. He is still hungry, but not nearly as aggressively, desperately so. For example...he used to start lobbying for breakfast by no later than 7.30, sometimes as early as a few minutes after seven. Now? Sheesh...there was a day last week when at 8.00, I finally initiated! That would never have happened two months ago. Same thing with snack times and dinner. He's all too happy to get fed, but he's not desperate. And the pica out on our walks has subsided almost completely (he still can't resist a nice smelly horse biscuit...but hey, who can?).

We've been using the melatonin/flax combo for about six weeks now, but I'm hard-pressed to credit that with the appetite correction, because that would mean that it started working immediately, whereas everyone says it generally takes several months.

Eesh. Yeah. I think I've just talked myself into investigating a full thyroid panel somewhere else. I'm just so tired of him getting poked and prodded. Poor thing.

Euthyroid, just to be clear, is associated with Cushings, though, right? Because I'm confident that he doesn't have typical Cushing's, at least. Atypical, I don't know, because Dr. 'Dorkenstein' doesn't believe it exists.

Gaaaahhhhhhhhhhhh!!!!!!!!!!!!!!

Me thinks happy hour has arrived. I don't care what time it is.

Let me know your thoughts and, as always, thank you a billion times over. This forum has been more helpful than all of the vets combined.

Best,
Jenn

[labblab]

Wish I could be joining you in Happy Hour right now!! :) But dang, I still have to wait a while cuz it's just now lunchtime here...:o

Just to clarify definitions: "euthyroid" means normal thyroid function. It's "sick euthyroid" that is associated with Cushing's or other primary illnesses having ramifications on thyroid function and test results. So a dog without any thyroid issues is "euthyroid." A dog who comes up with thyroid testing abnormalities secondary to another condition is "sick euthyroid." A dog who has low thyroid function that is not due to another condition is simply "hypothyroid" or suffers from "primary hypothyroidism."

I honestly don't know whether elevations in adrenal hormones other than cortisol can also affect thyroid readings. In other words, I don't know whether the "sick euthyroid" syndrome is also associated with Atypical Cushing's. Maybe somebody else here does know. But I suppose it's possible since it does involve endocrinological abnormality and impact.

Remind us, what was Jordan's previous T4 level that prompted Vet #2 to medicate? Also, aside from the diminished appetite, how is he doing in terms of his other symptoms?

You know, if it was me, I might just let the testing slide for the time being if he is currently showing general improvement. His T4 this time around was within normal range -- barely, but within range. And if he is actually looking better now that he is "off" the thyroid supplement, I might just leave things alone for the time being and give yourselves a breather...

Marianne

[Somesie]

Marianne,

Just got off the phone with my Mom, who said almost exactly what you did...give him a break for a bit and see if he continues to improve.

The t4 that originally prompted medication was .8 (Which, btw...I can't believe that you, a total stranger who I'm not paying for services rendered has a better grasp on my dog's case than the medical 'professional'!!!!!!!!!!!!)

As to his other symptoms, we seem to have good and bad days. And even on the 'bad' days, it's not like he won't get out of bed or anything. He just has less energy on our walks and lays around a little more during the day, versus higher energy walks and then following me around the house during the day. He still demands a wrestling match every night with his Dad, so again...even the low-energy days aren't really horrible. Water consumption is about the same...more than he used to drink, but not causing incontinence or other problems. His coat has not improved one iota; it looks awful...thin all over, and broken, stubby hair where his collar rubs.

All things considered, we're inclined to just keep an eye on him for awhile. Mom told me to tell the vet, "I've been kicked out of better places!" Which made me laugh...

Ha! Speaking of the nightly wrestling match! I just heard the first whimper.

Thanks again for your input, I just can't thank you enough. I'll keep you posted. Anybody else who wants to chime in ... please, feel free!

[Somesie]

Also? At this point you don't really feel like a 'total stranger' anymore, so...I take that back. And if you're ever in Germany, I'll happily pay you in really good beer and pretzels!!:D

[Somesie]

Hey, All...I'm back again.

You're gonna love this. We had to take Jordan in to the ER vet yesterday, and since fell out with the one near home, we had to go to the only other one we know, which is our very first, original vet that we had here in Heidelberg...the only vet in the county that we've not seen for Jordan's Cushing's symptoms.

We had to do a follow-up appointment today with the main Dr. there, so when he asked what the problem was (Yesterday, he kept squatting to pee but nothing came out. By the time we got to the vet...he peed just fine. He likes to take a trip to the ER about every six months, just to flirt with the ladies, so far as I can figure...) I gave Dr. Mauer a very brief history of the past six months, ending with the fact that he has been confirmed not to have Cushing's and that the last Dr. (an IM specialist)told us less than two weeks ago that, "He looks fine to me."

The next thing out of the good Dr.'s mouth? "But he looks exactly like a Cushing's dog." I swear...you just can't make this stuff up. So then I had to give him a more detailed explanation of everything we've done so far, including that the IM basically told me there's no such thing as Atypical Cushing's, to which, he responded, "There most certainly is such a thing." He was well-informed on the topic, and referenced a 'famous' US Dr. - I want to say, Feldman, maybe? Anyway, since the urinating problem seems to have come and gone, he asked that we table today's appointment so that he can collect all of the test results from the three vets we have seen, and decide from there what to do. Can you believe this?? After all we've been through, I hadn't even bothered to take his previous test results with me today. I had consciously considered and rejected the idea, deciding that they wouldn't listen to me anyway, so why bother? Go figure. He actually said to me, on his way out of the office, "Internal medicine is my hobby." Of all the dumb, dumb luck.

We go back on Thursday, and depending on what he sees in all of the previous test results, in addition to the full blood panel we had done today, we'll decide our next steps. It sounded like he will probably want to do a full hormone panel, as he was mentioning one of the secondary hormones, specifically...I forget the name, but it has the number 17 in it. He mentioned Vetoryl, which is why I am back here today. From the reading I've done, it was my understanding that Vetoryl only helps if cortisol is the issue, and that it can actually worsen symptoms if they're caused by secondary hormones? Can anyone confirm, deny, or otherwise enlighten?

So. Sorry...but that was a long-winded way of asking, "Can Vetoryl be used to treat atypical Cushing's?" :o

As always, thanks for your help. I'll do some searching around on here, too, to see what I can find on my own. I just wanted to update Jordan's case and see if anyone had anything to offer.

Best,
Jenn

[Squirt's Mom]

Hi Jenn,

I am one who would not use Trilo (Vetoryl) on a pup of mine who had elevated intermediate hormones, which is what Atypical is. There is much debate on this subject but I choose to follow the recommendations of those who are the pioneers in this area - University of Tennessee in Knoxville (UTK). Here is what they have to say about the use of Trilo in Atypical pups -


Trilostane. Now available in the U.S. as VetorylTM from Dechra Veterinay Products. NOTE: Trilostane always increases 17-hydroxyprogesterone (some cross-reactivity with pregnenolones in assays??), and frequently increases estradiol and androstenedione as well. LysodrenTM may be preferred for Atypical Cushing’s cases. FURTHER NOTE: Care should be used in switching from trilostane to LysodrenTM. Allow adequate time for either drug’s effects on the adrenals to subside before switching treatments. (E.g., one month off drug; normal or increased stim-cortisol levels).

Several here feel differently and have no problem using Trilo in their Atypical pups. For me, I don't understand the use of a drug that will elevate the very things I want lowered. :confused: My Squirt is Atypical and we are a Lyso household. ;)

Hugs,
Leslie and the gang

[Somesie]

Thanks, Leslie! From the reading I've done this afternoon, I find myself firmly on the same page with you, so at least now I'm going in fairly informed for our visit on Thursday. He can convince me (or not) why I should change my mind. Meanwhile, I think we can probably get access to Lysodren via the US medical system, so if he's open to that, we can discuss it. In the meanwhile, I'm just glad somebody is finally taking us seriously.

I'll keep you posted. Thanks again!!
Jenn

[Somesie]

Hey, Everyone...

I hope all is well with you and yours. I just wanted to check in with a minor update. Yesterday's vet visit turned into just a consult, much to everyone's frustration, I think, except my little man, who was thrilled to get treats and flirt with the ladies without having to pay the usual needle toll.

The good news is that all of his Tuesday blood work came back normal except for very slightly elevated alkaline phosphatase. It was 303, with an upper limit of 212. The doc gave us 3 options: an ACTH stim test for the 17HPO hormone, which is the only other hormone his lab tests for adrenal illness; a Vetoryl trial; or a Lysodren trial.

He was pushing me to do something, and even got a little short with me when I kept asking questions and posing 'what-if' scenarios, asking me if I wasn't prepared to do something, then why did I come to him for this? I had to remind him that I didn't, in fact, come to him for this but for an unrelated(?) issue.

I am not prepared to put Jordan through another ACTH stim, benign as it may seem (death by a thousand needle punctures doesn't seem so benign to him, I'd bet) to test for just the one hormone, because the only thing those results can do is rule out or leave open the option of Vetoryl, and there's no way I'm using Vetoryl on a dog whose cortisol levels are normal, regardless of what his other hormones are doing. Can someone please confirm or refute my logic here? I'd appreciate it.

As for trying Lysodren, I'm open to that, but he's only been on the flax/melatonin combo for about two months now, and much of what I've read says you have to give it more time than that. Since his appetite has become manageable (it's 0812 now and he hasn't yet asked for breakfast...absolutely unheard of two months ago) and his blood work was for the most part normal, it seems to me that the conservative (and kind, I hope?) approach is to do nothing further until we give the requisite four months of melatonin/flax protocol time to do its thing. Again...I'd appreciate anybody's thoughts on that.

I am going to look into milk thistle (thanks Laura) as a liver supplement in the meanwhile. I would appreciate any feedback y'all have to offer on the matter. I'm so tired right now....I need some help here, to see clearly and make sure I'm doing the best I can by my sweet baby boy.

Thanks muchly, as always,
Jenn

[lauraperla]

Jenn, aside from his appetite, how are his other Cushings symptoms at the moment?
If you feel that these are moderate, I'd think that allowing yourself the rest of the summer to keep going with the melatonin / flax combi would work, and just keeping an eye that he doesn't suddenly become overt in his symptoms. Are you keeping a month on month photo record? great stuff if so, if not I'd recommend it as a way of keeping track (although I hated doing it and deleted it off my laptop earlier today).
Then all being well, at the end of the Summer schedule a general health check, considering an acth as an option then.
As far as supplements go, I think the flax will also be helping skin and fur too but you might also want to add some fish oil or cod liver oil. If you don't already give glucosamine I'd do so as cortisol masked Saoirse's arthritis, I think Jordan being of a similar size and similarly bouncy nature he could be a candidate for it further down the line. Have some cranberry extract to hand and if he has signs of urinary tract irritation, add some of that to his food for a few days.
Oh and don't forget some St John's Wort. Not for Jordan, for you before your next trip to the vet!!!
Love to you all,
Laura x

[Squirt's Mom]

Hi Jenn,

When Squirt was first diagnosed, I was very hesitant to start either of the drugs used to treat. We were lucky to have a vet who was very thorough in the testing phase, who supported my desire to be even more thorough, and who was very cautious in her treatment approach. That caution gave me time to learn about this disease and the treatments available.

Squirt started on Anipryl, then we went to the lignans and melatonin. The Anipryl helped her for about 9 months - 6 months longer than it typically does. The lignans and melatonin helped her and continue to help her...when I have run out of either, I can tell the difference in her behavior so I know they help. ;)

I worried that her cortisol would start to rise and I wouldn't notice it happening...that I would continue to use the "milder" approach to her detriment. HOWEVER...let me tell you that when, if, Jordan's cortisol starts to rise, you will know it! Squirt's started rising last summer and it was obvious...even tho I did miss the more subtle signs like her hair and body shape changing - my niece pointed those out. :rolleyes: Within a few days of that sudden awakening, she was in full blown cush mode....drinking like crazy, peeing all the time, and her appetite was heart-wrenching to see. She would finish her meal then look up at me with the saddest eyes, begging for food as she knew, absolutely knew, she was starving where she stood. :( We started the maintenance dose of Lyso then and she is doing very well today with the Lyso, lignans, melatonin, herbs, diet and supplements she gets daily.

I think you are being wise not to rush into treatment right now. As long as Jordan's signs remain mild, I would continue the path you are on now...but that's just me. ;)

Hugs,
Leslie and the gang

[Somesie]

Hey Everyone!

Well, after telling him just yesterday that we were not going to pursue further treatment yet, I just sent the following email to the vet:

Can you please see that Dr. M gets this message? I know I just told you yesterday that we would be holding off on further treatment for now, but I have since done a lot of reading about Anipryl (L-Deprenyl), and wonder if you might be willing to prescribe it for Jordan? I understand that it has a lower efficacy rate than trilostane or mitotane, and may not work for him, but given our circumstances I would like to try it, for the following reasons:

1) Fewer, less severe side effects
2) Requires no further ACTH testing (He’s been through a lot in the past months, which is why I changed my mind about the ACTH stim test last week).
3) The worst of his symptoms have abated and I feel that Lyso or Vetoryl might be an overreaction to his current level of sickness. However, he is certainly not his old self, and if there’s a chance that Anipryl can bring back some of his personality and make him feel like the happy, healthy pup that he was at this time last year, I would like to take that chance, even if it only helps him temporarily.

We will be out of town for the weekend, but if you are willing to prescribe Anipryl for him (he’s at 38 kilos right now), I would love to pick up a few weeks’ worth on Monday when we return. I’m sorry to be so indecisive on this – I am just trying to be the best advocate that I can for him, and that has taken a considerable amount of research and thoughtfulness, so I haven’t always been able to make a decision right there at the office…I hope you understand.

Please let me know your thoughts, either via email or phone.


I know...it's like I actually want them to think I'm crazy, what with all the back-and-forth and hemming and hawing. And the Germans...they don't have a lot of tolerance for such things, I assure you. But, having had some discussion with Leslie (thank you!) and reading until the wee hours last night, I want to give this a try. I can't imagine the doc will have a lot of trouble with the plan, except for maybe the fact that I'm the one who thought of it instead of him, so hopefully we will be able to grab some up on Monday and see if it helps bring back some of his spirit.

As far as his current symptoms, he really seems to have good and bad days with the appetite, but even on the bad days, it's not quite as bad as it was a few months ago. His drinking does not seem to have improved much, if at all. That's hard to track, since he shares a bowl with sissy Barkley. His coat is slightly improved since the flax/melatonin...it's softer, but still quite thin. I understand that will take the longest to see improvement, though, naturally.

Couple of questions -

1) I am using ground flax seed, that I grind myself. I read a bunch last night about lignan pills v pressed hulls, and now I'm wondering...does he have to get this in some type of pill or liquid form in order for it to be effective? Am I not doing the right thing by using the real deal, ground up? This concerns me gravely, so I'd love to hear somebody's thoughts on the matter.

2) Ah, crap. I forgot my two. Ummm...hold, please. (Getting old s*cks!)

Oh! I know...supplements! As mentioned, his most recent blood work came back looking pretty good, other than mildly elevated alkaline phosphotase. Laura...I got yours, so thanks. What does St. John's Wort do? For me or him? Leslie...if you have a few minutes to share what you're currently using and why, that'd be great, as it seems Jordan and Squirt have some things in common. I finished reading all 45 pages of your thread this morning, so I know some stuff, but not necessarily why. Any help that anybody can offer in this regard is most appreciated.

Hey. This is somewhat unrelated...but he's doing it right now so it's top of mind. He cries sometimes, when he's laying down. Right now, he's practically asleep, but he's doing it. "Cry" might be a little strong...it's more of a quiet little whine. It's so pitiful! Any ideas? He's not one to complain about pain, so I don't think that's it, but I could be wrong. It used to be that this was his precursor to an all-out barkfest, where he wants to get our attention for playtime or some other vital demand, but now he just lays there and whimpers ever so slightly. GAHHHH!!! I want my boy back!!!

A'ight. Sorry for the dissertation. I'm tired. And that's Leslie's fault, for having such an entertaining and informative thread that I was up until ridiculous hours. :p

As always, thanks & sloppy Boxer smooches,
Holla!!
Jenn

[lauraperla]

St John's Wort is a herbal antidepressant! Never used it on animals although I know it can be used but it has lots of contraindications with other meds so I'd only use it under expert guidance!
I've taken it myself though when facing tough times, it works although it induces a slight mania and restlessness which is at odds with my slothful nature!
Lxx

[Somesie]

Anyone...??


Couple of questions -

1) I am using ground flax seed, that I grind myself. I read a bunch last night about lignan pills v pressed hulls, and now I'm wondering...does he have to get this in some type of pill or liquid form in order for it to be effective? Am I not doing the right thing by using the real deal, ground up? This concerns me gravely, so I'd love to hear somebody's thoughts on the matter.

[lauraperla]

I'm sorry Jenn it's not an area I have any experience in. However there are a couple of UK companies who specialise in animal health / nutrition. I've used their horse and dog products and met their reps at horse shows and they've always been well informed and helpful. The 2 companies are Global Herbs and Naf Supplements. They both have helpline numbers on their websites.

[Squirt's Mom]

Hi Jenn,

What counts is the amount of SDG that Jordan gets. If he is getting the amount he needs via the ground seed, then there is nothing wrong with using it. My concern, from my own lack of experience with them, would be regulating the dose of SDG day to day. I have used crushed flax hulls but they were ready to measure with the SDG amounts provided per scoop given. The cost factor sent me back to the capsules. :)

Do you know how much SDG he gets each dose with the seed?

How is he doing? Did you start the Anipryl?


Leslie...if you have a few minutes to share what you're currently using and why, that'd be great, as it seems Jordan and Squirt have some things in common. I finished reading all 45 pages of your thread this morning, so I know some stuff, but not necessarily why.

Missed this, too! :o

Currently, Squirt is on -

*HMR lignans (spruce vs flax), 1- 40mg daily; 3mg Melatonin 2x a day; and Lysodren, 125mg 2x week - for Atypical Cushing's (melatonin also has the ability to lower cortisol slightly)

*4 drops of Burdock root tincture daily - for liver and gall bladder function

*2 drops of Astragalus tincture daily - for immune support

*1 -100mg PS 100 (Phosphatidylserine 100) - for continued mental acuity and aid in lowering cortisol

*100mg SAMe daily - for liver function primarily, tho is has many benefits

*Salmon oil daily - for inflammation

*1/4 tablet daily of GlycoFlex III - for arthritis

* she eats a diet designed by a nutritional consultant that is low fat, moderately high protein, moderate carbs (fairly high fiber)

Think this is all! :p Hope this helps.

Hugs,
Leslie and the gang

[Somesie]

Thanks, Ladies!

I just dropped off the Anipryl 'script and will pick it up at 1800 this evening, so we'll probably get him started on it tomorrow. I say probably only because he's had a really good day today, and if that trend continues I might want to wait a day or so until he starts having 'off' days again...figuring that will provide more contrast so that I can tell if the pills have any effect. It's funny, but the last time we took them to camp for a weekend, this same thing happened - they were both exhausted yesterday when we picked them up, but today he's perkier than I've seen him in awhile - even picked up his Frisbee when I got home from the vet earlier!

As to the lignan/flax situation, I think I might order some pills, because right now my method is far from scientific. I just looked on the interwebs until I found something that told me how many lignans would be in a tablespoon of ground flax, and have been dosing him accordingly. I do think that the flax and melatonin are working, at least to some degree, because his appetite has improved (which is to say, decreased), but I think I'd better be more precise with what he's getting, so that I can give it the best possible chance of succeeding.

Thanks for the supplement suggestions, too - that's very helpful. I think I'll start adding some things once he's been on the Anipryl for a few weeks and we have any idea whether it's going to work or not. I don't want to add anything else at the same time as the drug.

Wish me luck! I'll keep you all posted, of course. Thanks again!

Jenn

[Somesie]

Hey guys...can somebody give me some ideas here? Jordan is peeing brown, as of at least this morning, which is when I first noticed it. I was hopeful that it was from me sharing a red drink with him yesterday, but I can't imagine that's the problem seeing as that's been almost 24 hours ago. He doesn't seem sick, I took his temp and it's normal.

We started the Anipryl on Tuesday, so the timing of this new problem is highly coincidental, to the point of suspect.

Thoughts? Suggestions? I'm so, so exhausted with all of this. I'm on such an emotional roller coaster right now...he's had a fantastic week, more active and alert than in awhile...and now this.

Help?

Jenn

[frijole]

Hi! Call your vet and gather some urine to take in. YOu have to rule out that it is blood. That is what I would do. You might also google anipryl and brown urine to see if anyone else commented online about it. Sorry for the short reply - am off to work. Kim

[Squirt's Mom]

Hi Jenn,

Have you noticed a strong odor with the urine? Does he seem to strain to pee or does it take longer? Is his stream steady? I have a friend who gets kidney stones when she drinks things that have red dye in them, like Fruit Punch, and that was my first thought when you said you shared a drink with him. Squirt didn't have any urinary reactions to the Anipryl but that doesn't mean it isn't possible. ;)

Let us know what the vet says!
Hugs,
Leslie and the gang

[Somesie]

Thanks, y'all. I'd already rung the vet, but he's in surgery until four, so I have to call back then. Meanwhile, I've spoken to my mum, who has me in a panic over kidney or liver failure, so I'm going to run (literally...oh great...add 'in the rain' to that now) up to the train station to retrieve our car, in case the vet says to bring him in immediately.

He has a pretty steady stream, no straining, although now he's starting to be shy because I keep chasing him with the sample jar. It smells...but I honestly can't say I know what I'm looking for there...it smells like pee. I dumped out the sample I tookfrom earlier, in hopes of getting a cleaner one, and when I did, there was quite a bit of sediment in it, as there seems to be in the new sample I just gathered.

So, as much as I'd like to think this is Crystal Light related, I'm having my doubts.

Oh geez...it's a full-on gale storm out there. This day just keeps getting better. I'll probably get back from the train station just in time to call the vet at four, so stay tuned. Please!

Hugs,
Jenn

[Somesie]

Just got off the phone with the vet, and he is saying that the brown urine is a side effect of the Anipryl and not to worry about it?!?!

Does that seem right? Anyone else with Anipryl have this experience? I already searched 'Anipryl/brown urine' and came up with nothing.

I think I'm going to translate the product insert and see what I come up with. This just doesn't seem right....though I'd be thrilled if it is.

Best,
Jenn

[Somesie]

I'm sorry to start a new thread...I didn't know how else to bring this to the forefront.

Can anyone tell me if their pup has experienced discolored urine - in our case, very dark brown - after taking Anipryl? We started on Tuesday, and I first noticed it this morning. I had to call the doc back three times before getting a response, through one of the receptionists, that "The medication can cause this" and not to worry if he is eating, drinking, and feeling fine.

While I would love for this to be the answer, I cannot find anything in the product literature, which I had to translate from German. Additionally, I rang the company here who makes it (selegiline AL, from Aliud Pharma) and after much jumping through language barrier hoops, was told that they cannot say whether it would cause this problem in dogs, but it does not cause it in humans.

Has anyone else had this experience? I've been through too much with this to trust the vet at his word, unfortunately.

Again...sorry for the additional thread, and thanks for any help anybody can offer.
Jenn

[Somesie]

Oy. Can Anipryl CAUSE urine discoloration, not causING. As you can see, I'm a bit of a mess over this.

[jmac]

Hi there,

I can't answer your question, unfortunately, but my dog was on it for a few months and that never happened. I read everything I could on it too, and did not see that. Hopefully someone else will know.

Julie & Hannah

[Squirt's Mom]

Hi Jenn,

I haven't found anything about discolored urine with Anipryl use either. If memory serves, Dr. David Bruyette had something to do with Anipryl - developing it, studying for use in Cushing's, something. Anywho... you might contact him for the answer.

http://www.vcahospitals.com/west-los-angeles/our-team/veterinarians

I will be merging these two threads for Jordan in just a bit so when you see this one gone, it is in his original thread. ;)

Hugs,
Leslie and the gang

[lulusmom]

I have no experience with Anipryl but I don't recall any members mentioning dark urine shortly after starting treatment with Anipryl. I was able to find one site that listed dark urine as a side effect of Selegiline in humans so I'm thinking if it makes a human pee brown, why not a dog. In my search, I also checked the FDA website and could not find dark or brown urine as a side effect listed in any of the summaries of clinical trials Deprenyl Animal Health, Inc submitted to the FDA for approval of Anipryl. It may be that brown urine, with no physical side effects, doesn't actually qualify as an adverse event.

It could be the drug that is the culprit but it could also be a urinary tract infection, bladder stones or kidney stones. Organ failure is also a cause of dark urine but since Jordan appears to be fine otherwise, I think that's an unlikely scenario. Aside from peeing brown, is Jordan's behavior any different, such as licking his penis directly after urinating or assuming the squat or lifted leg posture well after the pee has stopped? Does he pee, walk a few steps and try to pee again?

With the noticable sediment you saw in his urine, if Jordan were my dog, I would get a urine specimen to the vet to rule out the obvious causes before feeling totally confident that Anipryl is the cause.

[Somesie]

I went so far as to call the drug manufacturer here, who said they can't comment on what it might do in a dog, but that it does not cause urine discoloration in humans.

I decided to take him to the local vet, since she was still open, and we just got back. Doc wasn't there, but one of the techs did enough of a test to tell me that it is blood, and made an appointment for 0915 tomorrow. I'm not sure if I should keep that appointment or go back to the vet that prescribed the Anipryl and ask that he examine him and do a more complete urinalysis. Probably the latter...loathe as I am to dare to question him.

As to behavior, his peeing is otherwise normal, no excess squatting or straining or anything. He isn't drinking as much as he was pre-Anipryl, but he is eating fine and drinking what I would consider a normal amount. He seems physically fine, other than I've seen him drool a little bit with no apparent reason.

His Momma, on the other hand, is a flippin' train wreck at this point.

So...blood in the urine.

Any advice is welcome.

Thanks,
Jenn

[Squirt's Mom]

With the presence of blood, my first thought was crystals or stones. But if crystals were present, I would think they would have seen them if they looked - they could see Crys' under magnification. Maybe that wasn't looked at?

I would certainly be taking him to someone asap to find out the cause. I, too, panic and tend to RUN to the vet when I do. :o Of course, then you run the ever present chance of finding out things like lumps on the belly ain't cancer but BOOBS! :rolleyes::D

Hanging with you til we learn what this is!
Hugs,
Leslie and the gang

[lulusmom]

Hi Jenn,

I know it's not funny buy your comment about being a flippin train wreck made me giggle. I've been there, done that so I get it. Every one of my dogs has had blood in their urine at some point from either a urinary tract infection or stones. Chances are Jordan has a UTI which can be remedied with a round of antibiotics. My Lulu is currently on week two of Clavamox for her UTI. So take a deep breath, remember to exhale and try not to worry until Jordan tells you to. I bet your boy is sitting there right now wondering why mom is so upset. :D

[Somesie]

Thanks, Ladies.

First of all...I can't find my other thread merged into this one, but I'm pretty sure it was you, Leslie, angel, who suggested I contact Dr. Bruyette? Um, yeah, BOTH of you?? ROCK STARS!! I emailed him, and within five minutes I had a response that, as suspected, no, the urine discoloration is not a side effect of Anipryl. While the end result is upsetting in that I'm going to have some veterinary problems come tomorrow morning, I cannot even express to you how refreshing it was to get a straight answer from somebody...and so quickly!!

So, that's that. Glynda - you're welcome to laugh at me any time. Lord knows, laughing at myself is the only thing that keeps me even remotely sane. Also, the idea that maybe this is just a UTI or something so benign is very comforting, particularly given that it's 20.00 here and there's not much I can do 'til morning anyway.

Oh...and Leslie...I just checked, and he hasn't any extra boobs, thank goodness!!!

Y'all are angels. Angels, I declare!

So, onward to a very diplomatic chat with Dr. Maurer tomorrow morning, lest I find myself in search of yet another German doctor.

Hm. You know, I think it's time that I "out" myself....we're coming home, y'all!! I'll spare you all of the drama (and there has been much)...but I will be in NC by the middle of August, with pupsters and DH to follow soon after. As much as I have adored living in Europe, there is absolutely nothing that can make me long for home like the need for veterinary care, both here and when we were in Italy. After today, I'm ready. So, so ready.

OK. I'm temporarily calm, now that I have a course of action, unpleasant as it might be. Meanwhile, the Woobster asked for his usual evening wrestling match with Daddy, and is now resting peacefully, chasing big scary German bunnies (they grow 'em the size of horses here, I swear) from the comfort of his corner of the sofa.

Bless you all.
Sloppy Boxer smooches,
Jenn & Co.

[Squirt's Mom]

(Threads now merged. :D )

[molly muffin]

Oh my goodness, you have certainly been having the Drama in your life! Yay for coming home!
Well, my molly had blood in her urine, totally freaked me out, turned out to be crystals and a urinary tract infection. That was when we switched her to the S/O food and try and make sure she drinks plenty of water. So far we haven't had any more incidents of crystals and only one other UT infection.
Now she has cushings diagnosis and you'd think getting the water into wouldn't be such an issue, but alas, it is as she isn't a super heavy water drinker unless I give her the S/O food.

Drama, drama drama. LOL I've lived in Germany and their bunnies are super sized! Bet someone is having a blast with those things! hahaha

Take care, all the best in the morning!

[Somesie]

We had a very productive vet visit today, and I have to admit that there may have been a communication problem with the whole, "it's a side effect" thing. Doc took me very seriously, particularly when he saw the sample I was packing.

Long story short, as I am a bit spent, we had a very thorough ultrasound that showed something is quite wrong with his right kidney, but since we hadn't fasted in preparation, the doc was unable to get a decent picture and thus not prepared to diagnose. We are to return, fasted, on Monday afternoon, for another (gratis) ultrasound. He said that based on Jordan's healthy behavior, as well as blood count, that this is very serious but not immediately life-threatening. We determined to stop the Anipryl for the weekend, since it is not vital and might be making extra work for his ailing kidney. We are both curious to see whether suspending the med has any effect on the blood in his urine. Toward that end, I have a theory...I think it is possible that he may have had blood in his urine prior to now, but that I never noticed discoloration because his urine was so dilute from excess water consumption. With the introduction of the Anipryl and subsequent decreased water intake, his urine is now a normal consistency, which means the blood is making it that much darker, causing me to notice the problem. I welcome your thoughts on that...

While I am worried, certainly (enough to send DH off on his own without me for our weekend with friends), I am encouraged to be moving forward with the diagnostic process, and deeply comforted by the fact that my boy is in very good spirits and seemingly no discomfort, much less pain. The doc was very respectful of my input, and very thorough...it's nice to say I have no complaint on that front, for a change.

That's it for now...I hate typing on the iPad!

Best,
Jenn & Co

[Squirt's Mom]

Hi Jenn,

Has his BUN and creatinine been ok? Any protein in the urine?

I hope Mon proves to be uneventful and that what he saw today was a smear on the screen.

Hugs,
Leslie and the gang

PS. I don't know if this works in dogs or not...but one of my kidneys burned up and the other one took over for it. One is shriveled to nothing, the other is huge and not where a kidney is supposed to be (talk about making a tech crazy! :p), but all my labs are fine...that big one is doing all the work for both and grew into a size to handle the workload as my doc explained. So I wonder if it does turn out one is damaged/sick, if the other one couldn't take up the load for Jordan as well?

[Somesie]

Thanks for the input, Leslie...and it turns out, I think you're right, he can probably function on one kidney if that does become necessary. As to his blood levels, the doc didn't do a full panel yesterday, just checked his hematocrit. I'm guessing this is because we just did a full panel last week that showed nothing out of the ordinary except for slightly elevated alkaline phosphotase (what the **** is the abbreviation for that, anyway...so tired of typing it out! :p) He did not mention that there was protein in the urine, so I imagine that means no, but I will ask. What would that signify if there were?

I didn't give the Anipryl today, but his behavior is about on par with where he's been most of the week...pretty good spirits, decent energy level if a little bit lower (but then, so is mine today), and overall not acting sick. Here's the weird thing, though...his urine is back to normal, but now he's showing signs of UTI -- excessive licking and some discharge. What the heck?!

Also, it's pretty tough for me not to point a finger at the Anipryl, given that the bloody urine came and went with the drug. I don't understand how, but I have to believe the two are related. I'm tempted to give it to him tomorrow and see what happens, but I don't want to mess with him like that.

That's all for now. We're enjoying a very quiet, peaceful day, just the three of us (Daddy's out of town), and it's been great.

I'll keep you all posted. Let me know if anything in this jumps out at you.

Best,
Jenn

[Somesie]

Just a quick update...because I know everybody is wondering about my dog's pee :rolleyes:...seems I was wrong and the blood has not disappeared. Doc told me on Friday that he expected it might 'wax and wane' and that appears to be the case. So, perhaps the timing with the Anipryl was/is coincidental after all. We shall see.

Best,
Jenn

[Somesie]

Much cleaner ultrasound today, properly prepped, which confirmed that there are several masses on (in?) his kidney. He is scheduled to have it removed on Thursday. Doc was fairly matter-of-fact, "It needs to come out," like it isn't really a big deal...this, to me, is equal parts comforting and terrifying.

Needless to say, I'll have him eyeball the adrenal glands pretty good while he's in there, and of course the kidney will be tested for cancer. For the life of me, I want to believe that his Cushing's symptoms have all been related to the kidney, and that he'll be back to normal after the surgery, but since his cortisol has tested normal throughout all of this, I have to believe that he still has something going on with his pituitary or adrenals that are causing the out-of-whack hormones/symptoms. I would love it if one of you could tell me that I'm wrong??

I'm not crazy about having this (or any) surgery, but I don't see that we have a lot of choice right now.

Your thoughts/ideas are most welcome,
Jenn

[Squirt's Mom]

Hi Jenn,

Well, like you, I am relieved and worried at the same time. Relieved it is something they can remove and Jordan be ok without; worried there is more than surgery will fix.

Squirt's tumor on her spleen was accountable for her elevated cortisol. When the tumor was removed, her cortisol returned to normal range. So I KNOW without question that non-adrenal illnesses can and do cause elevated cortisol and false positives on the testing. Since the adrenals are involved in both cortisol and the intermediate hormones, it makes perfect sense to me that the elevations in those hormones could also be related to his kidney problem. However, that is just my mind at work, not scientific fact. ;)

We do know that kidney and liver issues can present just like Cushing's so that also makes sense to me.

But for today, love that boy all you can. Make some new, precious memories. Gird yourself with all the strength you can for the coming procedure...and forget about everything else. Once this is behind him, then hopefully you will have a clearer picture of what is, or was, going on with your sweet boy. Right now, the picture is muddled by this kidney thing. ;)

We are with you and Jordan every step, Jenn. If you just need to scream or cry or laugh, we are here for you.

Many hugs and belly rubs,
Leslie and the gang

[Somesie]

Thanks, Leslie...truly, you are an angel. I've been home with them for over three years now, and am having an extremely difficult time with the idea of leaving them completely in a few weeks. I know it's best for them to stay here until we can get everything settled back home, but I just keep having these 'what if' thoughts about being separated from him at such a crucial time.

I'm so tired. We actually cuddled our way into a nap this afternoon, and I never nap.

He's in the kitchen helping Daddy make homemade pizza for dinner...ever the chef's helper, that one!

Thanks again. I'll keep you all posted, of course.
Jenn

[jmac]

Hi Jenn,

I'm hoping for good news and that the procedure goes well. We'll be thinking of you and saying prayers! Keep us posted on how it goes.

Julie & Hannah

[molly muffin]

Hi Jenn,

Lots of good thoughts here. I know the thought of surgery is scary but if the vet was that assured that it has to come out, then, it probably does.

Deal with the other stuff, or possibilities of other stuff after this is over.

Lots of good, positive thoughts your way!

Sharlene

[Somesie]

Jordan is in surgery now. We will know more after 1600 our time, 1000 EST, and I will report back. Please keep us in your hearts. I held it together (mostly) until I had to let the tech take him, and then had to make a bit of a run for it before I had a complete meltdown in the waiting room. I fear that's the last he saw of me...turning tail to run...and I feel like the worst mother on the planet.

I'm going to go ride my bike so hard that my brain shuts down. See you all in a few hours.

Jenn

[Squirt's Mom]

Hi Jenn,

I know that feeling so well. But you did much better than I....I broke down in the waiting room then sat there bawling until I could drive. :o:rolleyes:;) It took everything I had not to go into the OR and "supervise"! :eek::p

A few years down the road from today, Jordan is going to have an ultrasound and you will get to watch everyone go nuts when they see this strange looking organ thingy in his belly and no kidneys. I know from experience, techs can get real excited over this sort of "discovery". :p

Ride hard, clean your house, till a garden, paint the shed - do whatever you need to do for the next few hours to hold onto your sanity...and know we are with you. Tho I'm waiting at the house til you get off the bike as I have NO coordination. :D

Prayers and healing white light flying your way!

Hugs,
Leslie and the gang

[Somesie]

Just rang the vet - he is awake and almost sitting up, we can come get him! Whew!!:D:D:D:D:D:D:D:D:D:D:D:D:D:D

Don't know anything more than that just yet, will update when I can, but I may be busy tonight - loving all over my sweet little boy!

Best,
Jenn

PS Thanks, Leslie!!

[lauraperla]

Fabulous news!
Go spoil your boy, give him huge hugs and kisses from us!

[Squirt's Mom]

:D Woohoo!!! :D

[molly muffin]

Yipppeeeee! Great news! I've been thinking about you both today. :)

[lulusmom]

Woot, Woot!!!!!!!!!!!

[Somesie]

Just a quick note - you all have touched me so, your reactions brought tears to my eyes. Truly...you are all angels. Thank you a million times for all of your positive thoughts and support!!

The doc showed us the kidney, which was literally FULL of some sort of nasty brown mass. The doc seemed fairly intrigued by it, kind of like he hadn't seen anything like it, and when I asked if it was cancer, he said he really didn't know and we would have to wait for the labs.

Because my boy has such a deep chest, they were unable to view the adrenals, but said his liver looked healthy and very much not like a Cushing's liver. Whatever the nastiness was, it was contained 100% within the bad kidney, so it's history now. He gave me a long term that started with 'poly' and I'm going to have to ask my Mom to help me figure out the rest of it, but used it to describe the body compensating for one thing with others, and essentially said he wants him off all medication for a bit because he believes that this might have been the problem that's been causing all his Cush symptoms. I'm cautiously (very) optimistic about that. Since Dr. Bruyette was so great about responding to my last email, I may take advantage of his generous nature to ask that one more question - could this have been causing everything?

Not sure if I will discontinue the flax/melatonin...would love to hear your thoughts on that.

He's beat up pretty good, and his future as a six-pack abs model is definitely in jeopardy, but he was alert and able to walk when we picked him up, and is mostly resting now.

Thank you again....all of you...I'm so touched by the support!

Jenn

[jmac]

Hi Jenn-

YAY!!!!


I'm so glad to hear things went well! I'm glad you were already able to go get him. I'll be looking forward to hearing more about what they discovered. I'm so glad to hear it was contained and that other things looked normal. It would be wonderful if the other issues resolve after this.

I would have been a crying mess leaving either of my dogs like that, so I can totally understand your reaction. Now that he's home just enjoy your time loving and cuddling him! :)

Sending lots of prayers and positive thoughts your way!

Julie & Hannah

[frijole]

Fantastic news!!!!! Sending love, Kim

[Somesie]

Hello, All...

Things are OK here, but it’s been a trial. His first night home was a nightmare that included a 2a.m. vet visit for more pain medication that didn't even put a dent in his discomfort. He and I were up for the whole night, save for about an hour, I think, and my poor husband didn't get much more than that. At our follow up in the a.m., they said he was dehydrated and wanted to keep him for the day for IV fluids. At this point, there was still blood in his pee, too, and I was having some regret at having put him through this.

He was like a new man when we picked him up at six last night, but he deteriorated to the degree that yours truly spent another sleepless night trying to comfort him. I now understand that the symptoms he displayed were pain-related, but at about four this morning, I was pretty sure he was dying and I decided I was going to let him, rather than dragging him out to the ER again in the middle of the night. This, by way of explaining just how bad a night we had. Once we got past the worst, I realized he wasn’t actually planning to check out just yet, which of course is a huge relief but also leaves me with a pup who apparently feels like he got run over by a truck. At our follow-up appointment this morning, they asked if they could just keep him overnight, and we all agreed that would be best for everyone. His kidney function has improved even from yesterday, so it seems like we are definitely headed in the right direction, but he was still (or again, I guess) dehydrated, so they needed to put him back on IV and the vet felt he would be more comfortable staying there, being fed and hydrated 24/7 and also watched/managed for pain. As much as I hate leaving him there, it was unquestionably the best thing for all of us. If I don’t start getting some rest, I’m going to be in the hospital right next to him, and that’s not good for anybody.

So. Things are not great, but we’re headed in the right direction and he is, in fact, healing. No blood in his urine as of the wee hours (Wee hours! See what I did there?!;)) this morning.

I'm exhausted, but encouraged by his blood and urine results this morning. Jeff deserves a medal in all of this...bless his heart. We're going to spend the day doing some special things with Barkley, since she's been such a trooper about Jordan being the center of attention all week. Right now, she's playing with the joy and abandon reserved only for fleece toys, and it is nourishing my soul in a way that only she and her brother can. Must remember to be grateful for all that we have...

Keep my little man in your thoughts, please. And thanks once again for all of the support!
Jenn

[Squirt's Mom]

Oh, Jenn,

How scary for you! I remember when Squirt's pancreas flared up after she came home from surgery. I was terrified and so, so scared she was leaving. I am so glad the ER was close and they were able to provide Jordan some relief. Staying the nite was a good idea even tho I know how incredibly hard that was to do.

I am holding tight to the belief that Jordan will be home for good very soon and will be through the worst portion of his recovery. Before long, he and Barkley will be romping and playing together, providing endless laughter and joy...and, I imagine, plenty of messes to clean up! :D

Hugs,
Leslie and the gang

[jmac]

Hi Jenn,

Sorry to hear it has been such a rough time. I can't imagine how scared and worried you must have been. I'm so glad to hear he is improving and things are looking better, and hope they will be able to better manage the pain so he'll be feeling better soon.

It sounds like it was definitely the right idea to keep him at the vet overnight so he could feel better, and you two could get some rest. Yikes! Can't imagine the exhaustion you're feeling!

Thanks for the update and I'll be thinking of you and hoping he is feeling better soon!

Julie & Hannah

[frijole]

Sending love and healing thoughts your way. Thanks for the update. Jordan knows you are there and no doubt she is feeding off of it. Keep us posted and know we are there with you in spirit. Kim

[Somesie]

We lost our sweet, precious boy to internal bleeding yesterday. I feel like nothing, ever, will fill the gaping wound where my heart used to be. Thank you all so much for your support these past months. Thank you.
Jenn

[lauraperla]

Oh my dear friend, my heart is breaking for you.
Love to you all,
Laura xx

[labblab]

Dear Jenn,

I am very sorry I have not been able to post as regularly lately, and I was stunned to read your tragic news this morning. I was so hoping that this surgery was going to mark the turn-around for your sweet boy. To lose him now, after all you've done to try to heal him, must feel unbearable.

Please know my heart is with you, and Jordan's heart and spirit will always be remembered and honored among his family here. We cannot ease your pain, but we are here to walk alongside you, today and every day from this point onward.

Fare thee well on your passage, sweet Jordan, fare thee well.

And sending enormous hugs to you and your husband from across the miles ~
Marianne

[mytil]

Oh Jenn,

I too am so incredibly sorry to read this - I know you have been there for him always, my heart is with you and your husband!

Please stay with us!
Deep peace of the quiet earth to you
Always in Loving Memory of your boy
((((hugs))))
Terry

[frijole]

Jenn, I am stunned and truly saddened to read this news. I am so very sorry for your loss. Sending love, Kim

[Squirt's Mom]

Oh no, Jenn,

I am just shocked and crushed to hear this. I am so so so sorry, honey. Just at a loss for words....I expected to read that he was back home today, not this.

I know you are devastated and heart-broken, at a loss this morning. Honey, please don't blame yourself in the least. You made all the right decisions for him. No one could have foreseen this happening. Jordan knows you were doing your best to help him live the fullest life possible and he loves you all the more. Today, he is whole, well, strong and watching over you and his family...and he always will.

My deepest sympathies,
Leslie, Squirt, Trinket, Brick, Tasha, and our Angels, Ruby and Crystal

[jmac]

Jenn,

I am devastated to hear this news. I am so very, very sorry for your loss. I can't even imagine how you are feeling. You did everything you possibly could for him and he knew that. I don't know what else to say, except that I hope your happy memories can eventually bring you some peace.

My thoughts are with you...
Julie & Hannah

[Squirt's Mom]

FRIEND

I lost a treasured friend today
The little dog who used to lay
His gentle head upon my knee
And share his silent thoughts with me.

He’ll come no longer to my call
Retrieve no more his favourite ball
A voice far greater than my own
Has called him to His golden throne.

Although my eyes are filled with tears
I am thankful for the happy years
He spend down here with me
And for his love and loyalty.

When it is time for me to go
And join him there, this much I know
I shall not fear the transient dark
For he will greet me with a bark.

~Author Unknown

[lulusmom]

Oh Jenn, I am so incredibly sorry for your loss and like the others, am shocked and heartbroken. I know that words bring little comfort right now but please know that my thoughts and prayers are with you.

Godspeed sweet Jordan.

[Jenny & Judi in MN]

I'm so sorry

[bgdavis]

I'm so sorry for the sudden loss of Jordan. Poor boy, after undergoing the surgery, there was hope. Jordan knows you loved him deeply.
May you find peace.

Bonnie and Angel Criss Ann

[molly muffin]

Oh no. :( Like all the others, I'm stunned and so sad to hear this news. Super big HUGS, again, just so dang sorry. :(

Sharlene

[Steph n' Ella]

Poor little Jordan...after his surgery seemed to go so well. You did everything you could as a pet owner to give him a fantastic life. The rest laid in fates hands for him to heal and recover. <3 to you and the rest of Jordan's family.

[Bo's Mom]

Jenn,
I am so sorry to hear about Jordan. Please know we are all here for you if you need anything.