PB my doxie & I Need Your Advice

[Sushi-Q]

PB is my family's cherished first doxie (we have 2 now), long-haired, 11 yrs old. He was adopted from a puppy mill at age 3. He has gone for regular check-ups and vaccinations, and in overall excellent health. But for the past year or so, I noticed the gradual increased drinking, obsessive licking of the floors, then sporadic accidents in the house which was attributed to a bladder infection (which cleared up with antibiotics). But since that infection (last Nov), he's had more accidents. The senior panel check-up last year and the junior panel this year were normal, but the vet did mention some diseases that perked my ears up--Cushings, Addisons...I thought those were only for humans. So I started to look up Cushings first, and the symptoms matched. I called the vet back, we agreed to do a low-dose dexamethasone test.

I should mention here that my husband has been unemployed for the past 2 years. I work at a small company that is wonderful to me and like family, but not exactly a highly paid job. Hubby is not afraid to work and took on anything that came his way, temp work mostly. Now he works a very physically demanding job in the warehouse of the office I work at, hopefully he will find a better job soon that offers health insurance. He needs it as he had cancer in 2004. We are paying over $500 a month for his private insurance now, mine is covered at work. He has anxiety disorder and the main trigger is, you guessed it, money. Money is tight now, but we are managing okay as we both have always been careful with it.

That said, here's the situation: PB had the test, results came back showing he has it. I will write what it says, & I'm no expert so please bear with me:
Cortisol sample 1, 4.0
Cortisol sample 2 DEX, 3.4 (HIGH)
Cortisol sample 3 DEX, 2.3 (HIGH)

My vet does not seem too experienced with Cushing's and consulted with a specialist who wants to do an ultrasound and various other tests. Vet is aware of our financial situation and tries to avoid extra expenses, so he said based on the test results he is leaning towards PDH rather than adrenal, and asked me if I wanted to start PB on vetoryl, 10 mg at first. PB weighs around 15 lbs.
This is the problem: the vet did not tell me at first, when he mentioned the drug, that I would have to have more tests done, at the 1 to 2 week level, then about 2 months after that, then at regular intervals hereon after. When he did go into detail, at our 2nd phone consultation, he gave me a quote of around $490 a test. I nearly keeled over--the meds I can handle, at $50 a month, even $100 if the dosage is upped. But we're looking at $1000 in the very near future. We already paid over $300 for this LDD test. I hung up and cried and did not tell hubby. I went and got the prescription today, but have not ordered it yet. He is asking me why I have not but I told him I need more time to research this. He would have a traumatic anxiety episode if he learned of the test costs, that it will be ongoing, not a one-time-only thing.

Thing is, he loves our dogs more than anything. That is what will cause him anxiety, that he wants the best for them, but he cannot afford it right now. We would not hesitate if this were a life-and-death situation requiring emergency care. From what I've read, and correct me if I'm wrong, a dog's life will not be shortened or lengthened by treating this, but it will improve the quality of his/her life. Many owners are not even aware of this disease, and think the symptoms are merely age-related (we did). Of course I want the best quality of life, for my children, and my dog-children. But that doesn't mean I can always offer the best.

I am turning to you all for your input, as I've read thru some posts here and feel like you are such a wonderful community who will not judge, but really help. My most urgent question right now is, after the 2 initial tests (I can't recall the name) after the dog starts the vetoryl, how many times a year approx. will it have to done, assuming he does well on it? I am trying to get a handle on how much annually this will all cost.

Thank you for reading my long post.

[mytil]

Hi and welcome to our site. I am sorry you are facing these issues; we all know how stressful it is.

Firstly I think with just one test, the LDDS, this does not diagnose Cushing's and I am glad you found us. Cushing's is a slow progressing disease so please do not feel you have to rush into giving the meds yet. I am not sure where you live, but if you are close to a teaching university, you may be able to get some price breaks in at least the initial testing to confirm Cushing's.

The LDDS results, along with the symptoms, do points towards Cushing's but there is another inexpensive test that and RULE OUT Cushing's - it is a UC:CR test.


Urine Cortisol/Creatinine Ratio Test: Considered a screening test, this cannot diagnose Cushing's, but it can rule it out. A urine sample is examined for the relative amounts of cortisol versus a normally excreted protein metabolite, creatinine (the latter is used to control for the degree of dilution of the urine). The greater the ratio, the higher the cortisol level. High cortisol in urine is suggestive of high cortisol in the bloodstream. Many conditions other than Cushing's disease can cause false positives, so this test is not considered diagnostic. Nonetheless, if the cortisol/creatinine ratio is okay, the dog is not likely to be Cushingoid, so this is a good screening test

Also, has your vet ruled out any other conditions (thyroid problems) as the symptoms are similar.

Actually you can reduce your ACTH monitoring costs by reading the post results only.

Keep us posted
Terry

[Squirt's Mom]

Another way to save sometimes, depending on the size of your pup -

How to Extend Your Supply of Cortrosyn and Lower the Cost of ACTH Stimulation Testing
http://endocrinevet.blogspot.com/2012/03/how-to-dilute-and-store-cortrosyn-for.html


And another link you might find helpful -

Financial resources
http://www.k9cushings.com/forum/showthread.php?t=212

[labblab]

Hello and welcome to you and PB!

I am so glad you've found us. :)

I do not have time to write a lengthy reply right now but I hope to put your mind at ease, at least a bit. Based on what you've told us so far, I do not think you need to rush into Cushing's treatment. In fact, even if finances were not an issue, I think many specialists would hold off on treatment at this stage of the game unless PB's excessive thirst and urination were really causing a problem for you.

Cushing's is a very slow-developing syndrome. And while it is true that over a long period of time, cumulative damage can occur in relation to the organs and also the quality of the dog's life, these issues typically do not become acutely severe in a short amount of time. And, depending upon the age of the dog, they may not necessitate treatment within the dog's normal lifespan. As time goes on, PB may develop problems that are more disturbing to both him and to you. If that occurs, then treatment may become a more pressing consideration.

At this point, you do indeed have a "positive" LDDS result. However, PB's numbers on this test do not point definitively to the pituitary form of the disease. As the specialist says, an ultrasound would probably be the next best step in evaluating PB's adrenal glands and other internal organs. But as you already know, this is a relatively expensive test. Also, typically, Cushpups exhibit certain lab abnormalities as well: elevated liver enzymes and cholesterol levels, for instance. If PB's recent standard blood/urine panels have not exhibited any abnormalities, this is another reason why I would not encourage you to rush into treatment. If PB does indeed have Cushing's, it would appear to be at an early stage. And in the absence of those characteristic lab abnormalities, he may not even have Cushing's at all, and the LDDS result may have been a "skewed" positive result based on some other issue that is/was present.

The bottom line is, I think you can take a deep breath and wait and see how things develop. If other worrisome symptoms appear, you can certainly proceed with additional testing at that time. I do believe I would opt for some repeated regular blood/urine testing at more frequent intervals than you may have performed in the past -- doing the testing every 3-6 months rather than waiting for a year. That regular lab testing should be relatively inexpensive in the scheme of things. And if that testing starts to reveal abnormalities that are of concern, then that would also be reason to proceed to more involved diagnostics. But at this stage, I do not think it is unreasonable to hold off on the expense and responsibility associated with ongoing Cushing's treatment.

Marianne

[Sushi-Q]

Sorry, I tried to post earlier but was logged out after writing a long reply (and I don't type fast either!) so I gave up then read once again how to avoid this. Hope it works this time :)
Anyways, thank you all so much for your helpful replies, I am so grateful. Let me reply first to Terry. Here is what I see on PB's recent physical:
BUN 8 (ref range 6-31)
Creatinine 0.4 (LOW) (ref range 0.5-1.6)
BUN/Creatinine Ratio 20

Is this what you were asking about?

Squirt's Mom, my vet said sorry but they do not save cortrosyn, they use the whole vial. In other words, this is not a private one-vet practice and they follow the same steps. I was very disappointed that he didn't even want to learn about it. But I understand.

Marianne, what are those liver enzyme and cholesterol tests called? His check-up is full of codes mostly and I am not familiar with some of them. The vet called me at work with the results, so I only half listened because of the activity around me. This junior panel was done on 7/27 as a follow-up to PB's recent bladder infection. He said everything was normal, but mentioned the possibility of Cushings for the 1st time. After I researched it, I called him back and we did the LDDS on 8/31. I could get back with the results once I know what to look for.

I need to know, at what point should I get more concerned? PB has excessive drinking, peeing, thin flaky skin, dull coat, voracious appetite, and sometimes does not want to go for a walk after a couple of minutes. What further tests do you all recommend, if any beyond what Marianne suggested, which sounds wise? Maybe after reading what I wrote, any more to advise me on?

Thank you for allowing me to exhale at last! I was so relieved to see your replies; PB & I appreciate it.

[mytil]

Hi again,

To help with your posts when you log in you can click the little box beside Remember Me. Also, if I am going to do a long post mid-way, or get called away from the computer, I just copy it in case I get bumped off the site or net.


The test results you mentioned have to do with kidney functions. Was this just an excerpt from a blood panel?

BUN 8 (ref range 6-31)
Creatinine 0.4 (LOW) (ref range 0.5-1.6)
BUN/Creatinine Ratio 20

Is your boy on a high protein diet? It looks as though these values, with the exception of the creatinine are within the normal.

Terry

[goldengirl88]

Sushi-Q
I feel for you, as I am retired and on a fixed income, and the testing and meds can get over whelming. Would you Vet consider a payment plan? If you have a long standing relationship, have always paid him, and love your dogs, just maybe he will help you. My dog just started on Vetoryl on August 22, and a split 10 Mg dose on August 25th, so she just had her 2nd ACTH test done. The Vet said she will need another one in one month, and then every 3 months there after if everything is ok. The ACTH test is 175.00 at my Vet and we always do an early detection profile to ensure how other things are working in her body, so if there is any problems like kidney or liver etc. it could be corrected early. The cost of that is 75.00. So I am looking at 300.00 every 3 months, plus meds and any emergency situations. Maybe you could see if your Vet has a less expensive laboratory?? My Vet is willing to work with me if I can't pay it all that day. He said "we are a team and we will work together." He knows there isn't anything I would not do for this dog. I know there are some dog groups out there that help with medical bills if your dog is sick and you cannot afford to pay. Does anyone on here know of any groups that could help her? It would be good for everyone in this situation to know. We have had to seriously change our lifestyle and cut back everything to help our dog, and sometimes that is still not enough. Also, search the web for a board certified Vet pharmacy that you can purchase the drugs from cheaper. They will have the certification right on their website. You can slso go onto the Board of Pharmacists website,that is what I did. My Vet even called them to make sure they got the drugs straight from the manufacturer like he does. I have to give one dose of 10 mg in the morning, and one at night as that is better at controlling the symptoms in my dog. That is twice as expensive that way, but I do it cause she needs it to be twice a day. You don't want to pay some fly by nite on the web for "sugar" pills, that are absolutely no good. Good luck and let us know how you make out. Tipper and I will pray you get the help you need.

[lulusmom]

Hi and a belated welcome from me.




Squirt's Mom, my vet said sorry but they do not save cortrosyn, they use the whole vial. In other words, this is not a private one-vet practice and they follow the same steps. I was very disappointed that he didn't even want to learn about it. But I understand.

I sure don't understand your vet's attitude because it's simply not acceptable. I thought you mentioned that your vet was concerned about costs and was trying to help you. :confused: This is such an easy thing to do to help you and any other pet owner with a cushdog under his care. As for multiple vets in one practice using the same steps, that's as it should be as long everyone is following current protocol. Current protocal says that for smaller dogs, you only have to use 5mcg per kg of weight and can store the remaining cortrosyn for future use. There is no excuse for remaining ignorant when a pet owner has given you the opportunity to learn something which provides step by step instructions published by a renowned internal medicine specialist. Continuing education is a good thing, especially if you are a general practitioner who chooses to treat cushingoid dogs.

My husband is out of work so I know how tight money is and how expensive this disease can be. If your vet can't get with the program and isn't willing to follow protocol and save you undue expense, I'd recommend that you find another vet asap. As I recall, you mentioned that you didn't think the vet has much experience anyway. I see that you live in So Cal and if you let me know your approximate location, some of us here in So Cal might be able to give you a name or two of an experienced vets.

I noticed that you posted on another thread that you paid $312 for an LDDS test and gave the following breakdown of costs:

$258 for the Cortisol
$5 Biohazrd waste mgmt
$50 Dexameth

I am assuming you meant $258 for cortrosyn; however, this stimulating agent is not used for the LDDS test. Dexamethasone is used for the LDDS and cortrosyn is used for an ACTH stimulation test. Is it possible that the $313 was a combined price for both tests? If so, that's not a bad price. If it's not for both tests, you are being charged an exhorbitant amount. Can you please take a look at your paperwork again and make sure your breakdown is correct?

How much does PB weigh and can you take a look at the prescription you picked up and tell us what medication and dose was prescribed?

Glynda

[labblab]

The two liver enzymes that are most likely to show Cushing's elevations will show up on a labsheet as "ALP (or ALKP)" and "ALT." Cholesterol will often be noted as "Chol." Thyroid function will be marked as "T4," and "Glu" or "Glucose" will indicate whether blood sugar is elevated to a level consistent with diabetes. The lab values you gave earlier relate to kidney function, and apparently there were no problems there for PB.

Do you already have copies of his most recent labwork? If so, the most helpful thing would be to list any results that are marked as abnormal. If you don't have the full reports, it would be great if you request copies from your vet. And then we can move onward with suggestions as to any additional testing.

Marianne

[Sushi-Q]

Tipper's Mom, is the ACTH the name of the test that is done about a week after starting vetoryl, then about 2 months later, and at regular intervals thereafter? I was quoted $490 for these follow-ups, that is why I am sad and upset. As I mentioned in my 1st post, that is about $1000 for the first 2 tests, in a very short period of time. Under $300, I can somehow swallow. But not $490.
Glynda, and anyone else, please do recommend any vet in my area who is more experienced. I live in the So. Bay area of Los Angeles, so any city like Gardena, Torrance, Redondo Beach, Manhattan beach, Hermose Beach, Lawndale, Lomita...
I checked once again my bill and breakdown for the $312.00, and it does say, on the test, that it is a "Low-dose dexamethasone suppression test" and at the comments on the bottom it says to do the high-dose after hyperadrenocorticism has been diagnosed.
On the bill, it says:
Cortisol(3)DexSuppDEX3, qty 1 @ $257.90
Biohazard waste mgmt @ $5.40
Dexameth 2mg/ml/ml qty 1 @ $49.15

Marianne, the most recent lab work was on 7/27 & I don't see any CHOL. There is ALT(SGPT) 70, Alk Phosphatase 128.

I plan on getting his senior panel test results from last year sent, but all I have now are the results from the so-called junior panel from 7/27. This includes Total Protein, Albumin, Globulin. A/G ratio, ALT. Alk Phos, BUN, Creatinine (which I mentioned was low, 0.4), Glucose, Potassium.
"Comment: Hemolysis 3+ No significant interference."

The above tests were done as a follow-up to what we believed to be his 2nd episode of a bladder infection following a series of peeing accidents in a short period of time. Usually, he has accidents far apart, like once a week, sometimes twice a week. But for 2 weeks in early July he had quite a few.

Also, what is the connection between Cushings and excessive licking of say, kitchen floors? I don't quite understand that.

Thank you all again!

Suzie

[Sushi-Q]

I forgot to reply that PB is around 15 to 16 lbs and the prescription is for 10 mg of vetoryl once a day which I have not gotten yet but if I do need it soon I will definitely get it online for around $35-40 a month versus $60 at vet. He encouraged me to find it cheaper.

[Squirt's Mom]

Outright greed is the only reason a vet wouldn't want to split a vial. That way they can charge for the full amount of the vial with every test. They don't lose money either way but can make more if they don't split the vial. :rolleyes:

I have a little male Chihuahua who has Hydrocephalus and he licks everything, too. Walls, floors, doors, furniture, me, you....if his tongue can reach it, he's kissing it. :p Which means I am saving a whole bunch of money on cleaning supplies! :D But Squirt, my cush pup, is very stingy with her tongue; she rarely kisses anything. So, in my house, licking isn't connected to Cushing's. ;) One of the signs of nausea is "air licking" - flicking the tongue in and out of the mouth, licking the lips over and over. But when I asked the vet if Brick, the Chi, was doing the licking because he was nauseated, Doc said no, or he would have vomited at least once by then...and he never has. He just likes to lick. :)

The "high dose" test is the HDDS and it is used to try to determine which form of Cushing's is in play - pituitary or adrenal. The adrenal form can sometimes be cured via surgery if the pup is a candidate - it is a very serious surgery and not all pups are candidates. The adrenal form, ADH, can be treated via medication, too. So unless you would have the surgery on PB if she has ADH, performing the HDDS would just be an added expense. Most cush pups, 85%, have the pituitary form, PDH, so the odds are that is the form PB has. If I were going to spend money on another test it would an abdominal ultrasound. More expensive than the HDDS but it will also tell you a great deal more. It can help tell the form of Cushing's as well as show many other organs and any issues there. As one of our members used to say - "this test gives the biggest bang for the buck."

Hugs,
Leslie and the gang

[SachiMom]

Hi Suzie,
Sometimes it is a very small world. I just happened to check in today and always try to check up on the doxies. Although I lost mine a few years ago, she burrowed deep into my heart and so now all doxies hold a special place in my heart.
The "girls" are giving you excellent advice. They are the greatest. They have probably forgotten more than I ever knew. And I'm not just saying that, it is true. So I won't even attempt to address any of the testing, etc. However, Sachi's vets were the most caring and wonderful and the office staff was great also. It has been a few years, but she saw Dr. Steve Leibl and Dr. Kim Doane at Hermosa Animal Hospital on PCH in Hermosa. If this is anywhere near you, I would give them a call, and see what their prices are. They were always very forthcoming with me. I was fortunate at the time and could afford my "million" dollar dog, but I know they worked with other pet owners. Oh! don't panic, it wasn't because of Cushings she got the nickname - she had several other expensive issues!!!
Wishing you the best of luck.
Give the doxies a hug.
-Mary Ann

[Sushi-Q]

Mary Ann, I Do know Dr Leibel from Hermosa Animal Hospital because my boss uses him! She loves him, and the only reason I have not used him is because he is a bit out of my way, but not by much. I suppose 30 min away vs 10 min is minor, except when you need to go frequently, then it would be an hour round trip and I work, so...but again, I wouldn't mind if its for my dogs. I will call this week and find out more, thanks!

I'd like to hear from anyone who had the ultrasound done on their dogs, what is the approx price range so that I can be prepared when I ask? Esp since I fear my current vet is just too pricey. From what I've gathered so far, this seems to be the next step for PB, if I'm reading it right.

Thanks for reading this folks.

Suzie & PB (that's stands for Pretty Boy BTW, cuz he's just so gorgeous. I don't think I'm biased;) )

[Harley PoMMom]

I took Harley to the School of Veterinary Medicine at the University of Pennsylvania. The ultrasound there cost around $400.

Not all ultrasounds are created equal. A good quality ultrasound/interpretation depends on a few things; the tool used, the technician performing it, and the physician interpreting it. There is a great difference in the quality of U/S machines. Is it a human grade (Phillips, GE, Siemens) My gen vet had an old (? brand) that just doesn't have the power to capture crisp, high-resolution images.

The technician, most likely, will perform their own and therefore, it should those most experienced with capturing good windows and images. That would be a board cert. radiologist or board cert. Internal Med Spec. Likewise the one interpreting it should be the most experienced as well, and that's one of the 2 above. In addition, you could get a copy on disk and always have it over-read by another. Just my opinion.

Love and hugs,
Lori

[Sushi-Q]

Lori, thanks for that advice, very wise words indeed. I never would've thought about not all ultrasounds being equal. So, do I outright ask vets or their receptionists what type of machines they have?
I am in the process of looking for another vet practice. I have a lot of things to consider before I make my decision. Sometimes I am discouraged after reading some of the posts; some pets and their owner/parents go thru so much heartache, so much pain, and not all ends well. It's just so scary to face. Like I've mentioned before, when do I seek treatment? I am told Cushing's is slow-moving, but when will I know now is the time to start? That's my main worry right now. I don't want my dog to suffer because I'm clueless...

Suzie

[addy]

Hi Susie,

Each dog is different, different symptoms, perhaps different health problems so it is hard to have a tailor made answer for when to start treatment. I have even had difference of opinions between vets.

I know how hard it is to consider. Usually, treatment is begun to alleviate symptoms that are worrisome and/or concerning to the "owner" (I prefer the word parent:) )

Have you read through this link? Maybe that will give you more insight.

http://www.k9cushings.com/forum/showthread.php?t=2231


Hang in there. Many of us struggled with the same question.

[Harley PoMMom]

Lori, thanks for that advice, very wise words indeed. I never would've thought about not all ultrasounds being equal. So, do I outright ask vets or their receptionists what type of machines they have?SuzieWhen I inquired Univ. of Penn. about their ultrasound machine, they informed me that they use not a high resolution machine per se, but a "state-of-the-art" machine with all the bells and whistles!

My gen. vet told me that their ultrasound could not capture images as clear as Univ. of Penn., and the cost was around the same. I figured if I was going to spend that kind of money I wanted those u/s images to be as clear as they could be. In fact, Harley's pancreatitis was diagnosed from his first u/s done at Univ. of Penn. Harley never displayed any symptoms of pancreatitis.



I am in the process of looking for another vet practice. I have a lot of things to consider before I make my decision. Sometimes I am discouraged after reading some of the posts; some pets and their owner/parents go thru so much heartache, so much pain, and not all ends well. It's just so scary to face. Like I've mentioned before, when do I seek treatment? I am told Cushing's is slow-moving, but when will I know now is the time to start? That's my main worry right now. I don't want my dog to suffer because I'm clueless...

Suzie

I truly believe you will know when the time is to start treatment, plus we are here to help, and yes, Cushing's is a slow progressing disease.

Love and hugs,
Lori

[Sushi-Q]

Thanks Lori for letting me know about the ultrasound cost in your area. I figure $400 in PA will probably translate to $500-600 here in So. CA. I have since done more research, and a vet practice where I got my baby doxie girl spayed actually lists their prices on most of their services. They have their own lab and ultrasound machine, and said their ultrasound starts at $320. I will ask them, and a specialist (VERY pricey) place, what types of machines they have. I have used the specialist before, their consults are over $150.

I will also contact Hermosa Animal Clinic for prices. Bottom line, though, is I want a dr who is familiar with Cushings. But I want you all to know, with all you experts out there, your opinions are what I trust the most!:) Yes, I am still not confident but feel better that one day I will "just know" when to start my PB on treatment.

[frijole]

Sometimes the law of supply and demand lowers the price and I'd think there'd be a greater supply of high res machines in CA. Also teaching hospitals can sometimes save you money. I paid $500 in Omaha (was referred to them) and they didn't find a tumor. A month later I went to the K State Univ Vet Hospital and paid $150 for a much more comprehensive set of films and they found the tumor. Not only did they have better eqpt, they had better people reading and taking the film. It was worth the 10 hrs of driving. Kim