Needing a second (and third and fourth!) opinion about my dog/testing stage Atypical

[nicolesnickels]

I am so happy to have found this forum....and I am hoping to get your expert opinions about my dog Chester.

Chester is an 8 1/2 year old, male, neutered, shih tzu poodle mix. My other dog is the same age, same mix of breeds, spayed female.

In December the female dog started having urination accidents in the house at night and was treated for a UTI. She did 3 weeks of Clavamox with no response and then 5 weeks of Baytril and has had several clean urinalyses since then. She has no symptoms.

In January Chester started urinating in the house at night. He pees once per night, in one of two areas, at different times (we have a camera). Sometimes he will go 1 hour after he is taken out at night, other times 5 hours, it depends. My regular vet did a urinalysis and found evidence of infection so he too was put on Clavamox for 2 weeks and a new urinalysis showed worse infection so he was switched to Baytril and was on it for approximately 4 weeks. My vet referred me to a local specialist when he saw numerous unrecognizable cells in the urinalysis and thought he might have bladder cancer. I should mention that the regular vet did blood work and his ALP was 132.

We went to the specialist who did a cystocentesis. That came back with USG greater than 1.050, no WBC's, no neoplastic cells, trace RBC's and no casts. The doctor also did an ultrasound which showed nothing remarkable except a slightly thickened urethra. The specialist thought he might have Cushings and told us to stay on the Baytril and made an appointment for a re-check a few weeks later.

At the recheck he did another unremarkable ultrasound and sent the urine out to be cultured. The culture came back negative. He also did an adrenal panel which sent to the Clinical Endocrinology Service at the University of Tennessee.

The first ACTH test was done and the results seemed backwards. The baseline numbers were all higher than the post-stim numbers. The lab comments suggest a potential switch of the test tubes at collection. The test was repeated.

Here are the results:

First test:
Cortisol ng/ml- baseline 161.2 (normal 2.0-56.5), post stim 70.5 (normal 70.6-151.2)
Androstenedione ng/ml - baseline greater than 10 (normal .05-.36), post stim 3.19 (normal .24-2.90)
Estradiol pg/ml - baseline 75.1 (normal 23.1-65.1), post stim 82.2 (normal 23.3-69.4
Progesterone ng/ml - baseline 2.83 (normal .03-.17), post stim .69 (normal .22-1.45)
17 OH Progesterone ng/ml - baseline 3.34 (normal .08-.22), post stim .60 (normal .25-2.63)
Aldosterone pg/ml - baseline 366.8 (normal 11-139.9), post stim 68.0 (normal 72.9-398.5)

Second test:
Cortisol ng/ml- baseline 91.1 (normal 2.0-56.5), post stim 169.6 (normal 70.6-151.2)
Androstenedione ng/ml - baseline 2.43 (normal .05-.36), post stim 7.79 (normal .24-2.90)
Estradiol pg/ml - baseline 89 (normal 23.1-65.1), post stim 88.2 (normal 23.3-69.4
Progesterone ng/ml - baseline 1.17 (normal .03-.17), post stim 2.97 (normal .22-1.45)
17 OH Progesterone ng/ml - baseline .67 (normal .08-.22), post stim 2.90 (normal .25-2.63)
Aldosterone pg/ml - baseline 31.8 (normal 11-139.9), post stim 115.9 (normal 72.9-398.5)

His doppler blood pressure was 140mmHg which was normal.

His symptoms are: 1 accident per night in the house. He is crated during the day and has never once had an accident. He has always been a panter (I expressed concern once to the vet about his panting about 4 years ago). He has a beautiful coat with no hair loss, a normal ALP. He has gained weight steadily over his life but is very active and a happy boy.

The specialist wants to treat right away with Lysodren and I am weary.

His cortisol of 169.2 is just outside of the normal limit of 151.2. His ALP is normal, his SG of the urine is fine (In fact past urinalyses of which he has had many are 1.042, 1.040, 1.055, 1.036, 1.042, 1.040, 1.031. He may be drinking more than usual (it's hard to tell with 2 dogs) but it's not excessive or something we have really noticed.

He obviously has some kind of increased hormonal issue going on but is that necessarily Cushing's? I need a second medical opinion but have no idea who to turn to next. What are your thoughts? What questions should I be asking and are there any other tests that should be run?

Thank you all for your help!

[Simba's Mom]

Welcome to the family, this is an awesome site, lots of info and encouragement. I don't know a lot but others do, so I will just welcome you!

[Harley PoMMom]

Hi and welcome to the forum!

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[Harley PoMMom]

Cushing's is one the most difficult diseases to get a confirmed diagnosis for and it is often misdiagnosed. Other non-adrenal illnesses share some of the same symptoms of Cushing's such as diabetes and thyroid problems, and should be ruled out.

Strong symptoms are a huge part of making the diagnosis and a cushing savvy vet will not initiate any treatment unless there are obvious signs and a confirmed diagnosis.

Cushing's is a slow progressing disease so one does have the time to get their furbaby a confirmed diagnosis.

Since Chester's post cortisol is not very elevated and without obvious clinical symptoms, IMO, I would hold off on any treatment for Cushing's.

Please know we are here to help in any way we can so do not hesitate to ask any and all questions.

Love and hugs,
Lori

[molly muffin]

Hello from me too :) Several of the others have more knowledge about the intermediate hormones and their elevation so I won't even try to figure that one out. :)
I do think though that clinical symptoms need to be there, so you'll have an idea when treatment is working, or in the case say of lysodren, when a dog is loaded. That completely relies on symptoms it seems.
You want to have a clear indication of cushings and what type before you start any treatment. I'm not really sure that you have that yet.
I'm sure some of the others will be along to look over the test results too.
Again, welcome. :)

Sharlene and Molly Muffin

[nicolesnickels]

I would be very interested in hearing some opinions about the other elevated hormonal levels Chester has. His post stim cortisol is just over the normal range but some of his other hormone levels are quite high. Are there diagnoses other than Cushing's when other hormone levels are high like this?

[nicolesnickels]

As I do more research I have a few questions:

1. If a dog has high post stim cortisol and high post stim for the other hormones does he have typical and atypical cushings or does atypical Cushings only happen when cortisol levels are normal but the other hormones are elevated?

2. Chester's results show post stim cortisol only slightly past the normal range (and within the normal range for other labs it seems) so perhaps a diagnosis of atypical cushings is more appropriate?

3. I have been reading about melatonin and lignans to treat atypical as a first treatment. Do melatonin and lignans decrease cortisol at all or do they just decrease the other hormones?

I thank you so much for your help!

[mytil]

I wanted to welcome you as well to our site.

I do not have any direct experience in this, but I am sure others that do will pop in soon. Here is a link to additional information on atypical cushing's (http://www.k9cushings.com/forum/showthread.php?t=198) in case you have not had the chance to go through these as well as this one - http://thehormonelab.com/handbook/adrenocortical-function/adrenal-sex-hormone-imbalance-in-dogs-shap.

Terry

[nicolesnickels]

Thank you for the links! I have been reading for days it seems! I am so happy to have found this forum.

[labblab]

Boy, I have to agree that Chester is a puzzle right now! I wish I had something brilliant to add that would shed some light, but I'm afraid I do not. :o

But in answer to a couple of your questions, technically, Chester's diagnosis would be conventional Cushing's and not "Atypical." As you've already guessed, this is because his cortisol is elevated. When that is the case, the status of the other adrenal hormones doesn't alter the general diagnosis because virtually any dog with elevated cortisol will also exhibit elevation in at least some of the intermediates, as well. Also, no, lignans and melatonin do not have a significant impact on lowering cortisol.

If I am understanding things correctly, though, Chester's other lab results are all normal (his UTI has resolved) and his only overt suspicious symptom is urination at night? If this is all true, I have to agree that I would hold off on beginning any treatment at this time. As is obvious from the UTK testing, "something" is affecting his hormonal profile at this time. But I don't think there is yet sufficient evidence as to what it is. For future reference, if Chester were to become more obviously symptomatic, one option given his profile would be to start him on a "maintenance" program of Lyosdren rather than proceeding with a full "load." What this means is that he would be given smaller doses of Lysodren on a regular basis. Lysodren does lower most all adrenal hormones in additon to cortisol (estradiol is the wildcard since there can be other sources in the body in addition to the adrenals).

However, the big question is what to do now? Truly, I think I would just sit tight for the time being and see what develops. It is obvious that you are monitoring him very closely. I would probably repeat his other labwork within 90 days in order to see whether other abnormalities manifest. And you will certainly notice any other behavioral changes, too. But in the absence of strong symptoms, the majority of experts recommend holding off on medical treatment of Cushing's since the diagnosis always remains suspect in that situation.

Marianne

[nicolesnickels]

Thank you so much for your reply. It had a lot of great info in it.

What do you think about Chester's cortisol level post-stim? 169 with a normal range up to 151. The first test (where it looks like collection tubes were switched) was 161 post stim (it listed as baseline since there was a mixup) with the same normal range. Chester is a very excited and excitable dog, he always has been. Does this small of an outside of normal margin definitively mean Cushings?

I was thinking of asking the vet to try Melatonin and lignans for a few months and repeating the test, would there be any benefit to this? i.e. if the other hormone levels are decreased could the cortisol naturally decrease? I'm not sure what the interplay is between all of the hormones.

In answer to your questions his UTI has resolved (cystocentesis showed no infection) and urine culture came back negative. His overt symptom is the single accident during the night. He is otherwise acting like his normal self though he does have a tendency to pant (since he was young) and will eat all of his food given to him. He does not eat my other dog's food and I wouldn't classify him as ravenous. There are times when he will leave some kibble on his plate and I have read this isn't typical of Cushing's dogs? He doesn't beg for food and I don't think he drinks any more than my other dog. His coat is beautiful and there is no hair loss.

The specialist vet I am seeing wants to load with Lysodren. I would like a second opinion but am not sure how to go about that. I spoke to my regular vet who referred me to the specialist and we don't live in an urban area so that specialist practice is who he always uses.

When you say to repeat other labwork do you mean just the regular blood profile? Do you think I should ask for the UCCR test? Or would that automatically come back positive because of the elevated cortisol? I was thinking perhaps if his elevated cortisol was just due to his excitability and hate for the vet then maybe the UCCR would come back negative and I would have an atypical Cushings diagnosis?

As I can see is the case with most of you, my dogs are so dear to me and there isn't anything I wouldn't do to help Chester. That includes not following a vet's recommendation if I don't think it's what's right for my dog. I am so thankful to have a resource like this available to me. Hope everyone has a nice Sunday.

[addy]

Treatment is for resolution of symptoms that a mom or dad is concerned about. The panel done by UTK used to include treatment options with recommendations to the vet to consider based on symptoms, history, etc.

We went down that same diagnostic road with an ultra sound and UTK panel. My pup also had bouts of colitis at the time. Her only symptoms were hair/coat problems and not wanting to jump in the car. Her urine was not dilute and the only abnormal finding in her blood work was higher cholesterol. We started on melatonin and lignans until I could get her colitis under control. That took a year. Zoe's cortisol was much higher than your pup's. I had many emails back and forth to Dr. Oliver, the head of the department. He has since passed away but was always willing to discuss things with us.
For my dog, the melatonin and lignans did bring down her estradiol to normal, decreased her other intermediate hormones but her cortisol went higher.

Part of starting treatment is for you to be comfortable with it. I resisted for a year but then Zoe kept getting a few more symptoms during that year so I finally opted to treat a year later.

Signs of loading can be very slight, a slight pause in eating, a bit of a decrease in water and each dog loads in a different time frame.

Cushings is usually never an emergency to start treatment so you have time to learn, ask questions and observe your dog and without major symptoms it would seem best to wait.

[Squirt's Mom]

Hi and welcome to you and Chester! :)

My Squirt also had elevation in all the intermediate hormones and she was treated with the lignans and melatonin for several years successfully. In the summer of 2011, her cortisol started rising...and there was no question about this based on her signs at that time. When this happened, we added the Lysodren as a maintenance dose only - she did NOT load - and this approach lowered her cortisol back to normal and has maintained it as such, just as it is supposed to. ;)

The combination of lignans and melatonin will work on all those hormones with the exception of the cortisol. The melatonin has the potential to lower the cortisol, but only a tiny bit and not in all dogs. They are a relatively benign treatment, tho the lignans can cause loose stools or diarrhea at first in some pups, and can make existing issues along this line, like IBD, worse until the pup adjusts. The melatonin will make them sleepy at first, but they typically adjust fairly quickly. Squirt has been on them both for five years and has had no problems.

I'm glad you found us and want you to know that you and Chester are no longer alone on this journey. We will be with you all the way. Don't hesitate to ask any questions; we will do our best to help.

Hugs,
Leslie and the gang

[nicolesnickels]

Thanks, Leslie and Addy!

I'm happy to hear you both waited to treat - the vet seems annoyed that I am hesitating. Did you seek second opinions at all? I think I need one.

Do you think I should ask for any other tests? UCCR or LDDS? I want to be as informed as possible but just can't justify loading with Lysodren when we have normal blood work (including ALT and ALP), normal ultrasound, and slightly higher than normal cortisol levels based on what I have read.

What are typical cortisol levels in Cushing's dogs (ng/ml)? Chester's 161 and 169 where normal is 151 seem barely high to me but maybe those numbers are really high? I have no frame of reference.

Do you think trying melatonin and lignans and retesting in 4 months (is 4 months the right timeframe?) is appropriate? If there are any other symptoms in the meantime I would test earlier, I assume. Or should I leave it alone until/if he shows more symptoms?

We appreciate the help! My other dog Cleo had a mass removed from her neck this week and we are waiting for pathology so it has been quite a few months here in our house with our furbabies!

[addy]

Melatonin and lignans can take 3-4 months to work on estradiol and the intermediates so yes, you would need to wait at least that long. I think 4-6 months depending on any increase or new symptoms would be reasonable.

Our first vet, whom was holistic, tried to push me into treatment based on a UC:CR. I made my own appointment without referral with an internal medicine specialist and had the subsequent UTK panel and ultra sound. If any vet is not willing to work as a team and listen to your concerns, it is hard. If this vet seems to be pushing you into something you are not comfortable with, yes, I would seek another opinion or have a frank conversation with the current vet.

Did you tell us if you pup was tested for hypothyroidism?

You are already doing the most important part, learning and asking questions:):):):)

[nicolesnickels]

What is the test for hypothyroidism?

[addy]

http://animalendocrine.blogspot.co.uk/2011/02/how-do-we-confirm-diagnosis-of.html

I just wondered. Some dogs will have hypothyroidism and once their Cushings is controlled, it resolves. It does not seem Chester is currently showing any signs of hypothyroidism, I'm just trying to cov er all bases;)

[nicolesnickels]

I just looked at the lab work he had done. It was done in January and there was no TSH, T4 or T3 testing. Do you think I should request new lab work along with the thyroid testing?

[addy]

It would be a seperate test. I had Zoe's checked about that same time but that was because I knew hers was already alittle low and at the time she seemed more hypothyroid than Cushings.

So, if he is not having any of the symptoms, probably not



http://healthypets.mercola.com/sites/healthypets/archive/2011/07/19/yes-you-can-get-a-oneyear-heads-up-that-your-dog-is-hypothyroid.aspx

[nicolesnickels]

Chester doesn't have any of those symptoms, but maybe it's worth it to test to rule out?

Can anyone give me examples of their pets post stim cortisol on the ACTH test (ng/ml)? Chester's numbers are not that far from normal but I wasn't sure if most Cushings dogs present with numbers like this or if their cortisol levels are greatly increased?

Also, are there any Cushings/endocrinologist specialists out there who would do phone consult after records review?

[Harley PoMMom]

Second test:
Cortisol ng/ml- baseline 91.1 (normal 2.0-56.5), post stim 169.6 (normal 70.6-151.2)


To convert ng/ml into the units of ug/dl, which is what we are used to seeing, just move the decimal point to the left...so 91.1ng/ml = 9.1 ug/dl and 169.6 ng/ml = 16.9 ug/dl.

The labs I have used for my angel boy, Harley, ACTH stim tests had reference ranges of 6ug/dl - 20ug/dl for the post. These post reference ranges are for a healthy dog that does not have Cushing's disease. So, IMO, Chester's post number is within normal limits and treatment should not be given.

Love and hugs,
Lori

[nicolesnickels]

Ok...I thought his cortisol number was not that high. I know each lab will have a different cut-off.

So if the cortisol is within normal or close enough to normal then he would have atypical Cushing's based on his other hormones, right?

Also, I read something about when the estradiol is high the cortisol reading not being accurate. Is this correct?

[labblab]

Hi Nicole,

Usually, a basic thyroid measurement is included in a general "chemistry" panel. This is the "T4" level. If Chester's T4 level was normal (which presumably it was, or it would have been pointed out to you), then there is probably no great value to pursuing more involved thyroid testing. The additional testing has value when a dog's T4 level is low, because the additional testing can suggest whether the low T4 is the result of a genuine thyroid issue, or whether it is the result of some other, secondary condition such as Cushing's.

As far as Chester's cortisol level, every lab has their own set of "norms." The lab at UTK has norms for cortisol that are somewhat lower than many other labs that are commonly used for veterinary analysis. To "translate" Chester's cortisol into units with which we are more familiar here in the U.S., his two post-ACTH cortisol results would be 16.1 and 16.9 ug/dl, with the normal "cut-off" set at 15.1 ug/dl. So no, Chester's cortisol was not highly elevated, but it exceeded the lab's norms on both draws so within their frame of reference his cortisol was higher than it "should" have been.

But as other folks have said, hormonal elevation can be associated with illnesses or/and stressors other than Cushing's. So in my own mind, in the absence of typical Cushing's symptoms, the diagnosis remains in question.

Marianne

[nicolesnickels]

Thank you, Marianne! My vet is so quick to load with Lysodren (and he's a specialist!) and I usually go along with recommended treatment but have been second guessing and waffling since he first spoke to me about it. I don't want to make the wrong decision here!

What other illness/stressors should I be looking at? Are there any other tests you think should be run right now?

[labblab]

Nicole, we were writing at the same time. But no, I have never heard that the estradiol level has any bearing on the validity of the cortisol level. And since Chester's cortisol does, in fact, exceed the norm for UTK's cortisol range, I do believe he would fall within a conventional Cushing's diagnosis within their testing framework.

But the "diagnosis" is meaningless without other corroborating data such as consistent symptomology. And I really would not get hung up on the diagnosis per se -- "Atypical" vs. conventional Cushing's. The bottom line is that Chester's entire hormonal profile exhibits elevations. The question is "why?"

[nicolesnickels]

Exactly!

What other tests (if any) should Chester have to help me to get to the why?

[Harley PoMMom]

You are correct , if a dog has elevations in one or more of the adrenal sex hormones AND cortisol is normal then this is known as Atypical Cushing's.

If my memory serves me correctly :eek: I do believe I have read somewhere that elevated estradiol can skew cortisol results BUT as far as I know, there are no scientific/academic studies that back that assumption up.

[labblab]

I really cannot think of other tests that I would run right now, in the face of a normal ultrasound and the absence of both overt and laboratory abnormalities other than the adrenal profile. That's why I would just watch Chester carefully for the time being, and repeat his basic blood/urine panels in about 90 days unless something changes beforehand.

[nicolesnickels]

Thank you both for your help! I really appreciate it. I am going to speak to the specialist tomorrow and back him off the Lysodren loading. Do you all think I should go to melatonin and lignans or hold off until we have repeat testing and/or additional symptoms?

It's a good thing we live in Florida and the house is tile because I have wiped up more pee in the past 3 months than when my dogs were puppies and being house trained!

[Harley PoMMom]

Here's a abstract that I find interesting; it is about the findings of elevated estradiol in healthy dogs: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-3164.2010.00896.x/abstract

Let me know what you think. ;)

[nicolesnickels]

Hmm, not sure how to interpret that article!

I will be speaking to the specialist today but want a second opinion. Are there any Cushings/endo specialists who would do a phone consult after reviewing Chester's records?

[molly muffin]

Dr. Peterson is one on the leading endo specialists in cushings and I believe that he will do a phone consultation after reviewing records. I know that some of the others have done this with him, but I'm not sure on what steps you take to get this done. I'm sure one of the others here have used him and hopefully they can stop in and tell you what steps to take to set one up.

Sharlene and Molly Muffin

[nicolesnickels]

Oh that sounds great. I would love more information on how to set up a phone consult with Dr. Peterson.

[nicolesnickels]

Sharlene I see you also have a shih tzu mix that is baffling you!

[labblab]

It is possible that Dr. Mark Peterson would be willing to do so, but I'm guessing the consult would be expensive. Dr. Peterson is a highly respected endocrinologist in New York who lectures, writes, maintains an internet blog, and serves as a consultant to Dechra (manufacturer of Vetoryl, brandname trilostane). Here is a link to his personal website. And even though he says on his website that he cannot offer advice without personally examining a dog, I do believe he has performed record reviews for a couple of our members including Addy. When she stops back by here, she can let you know whether or not I am correct. In the meantime, here's that link:

http://www.drmarkepeterson.com/

Another suggestion I would make which may or may not be possible for you is to consider a consultation at a university veterinary school if there is one anywhere near you. This would not be just a review of records, but a full consultation if Chester's case remains as puzzling a bit further down the line. Surprisingly, pricing at vet schools can often be less than that at private specialty practices. Plus, the entire range of specialty services is represented along with the chance for internal consultation among the vets/professors/researchers who are typically up-to-date on current trends and studies. Just a thought to throw out. As I say, not necessarily now but perhaps later on if a lot of question marks linger.

Marianne

P.S. I see that Sharlene and I were writing at the same time. :)

[nicolesnickels]

Thanks, Marianne!

I am in Florida, I think the only vet school here is at the University of Florida in Gainesville. That's about 3 and a half hours - doable but not ideal. I will keep that in mind though.

I found two other small animal internal medicine specialists that are within 45 minutes and am thinking of making an appointment with one of them since my current specialist wants to load Chester with Lysodren asap. Is it common practice to let your vet know you are seeking a second opinion or just best for me to go to the other vet without saying anything?

[molly muffin]

I sent Patti a msg, I think she consulted with Dr. Peterson for Tipper.

Oh, you know Florida has some really good vet hospitals. Isn't that were they did the trials and the surgery on Doc for removal of the tumor and radiation therapy. Have to go back through and check that out.

Yes, my molly has continued to baffle me. She is a shih tzu/llahso mix.

Sharlene and Molly Muffin

[labblab]

Many specialty vets require a referral from your regular vet. But even if not, if it were me, I'd probably talk it over with my regular vet anyway -- especially to get his/her input if I was trying to choose between specialists whom I didn't really know. Since Chester's case is not straightforward, you really want to make sure you're seeing somebody with specific expertise in endocrinological issues. But I have a lengthy and really supportive relationship with my regular vet. He knows how obsessive I am and that I will go to all lengths to gather info. ;)

[nicolesnickels]

We are currently seeing a specialist. The hospital has an ACVIM guy and we are seeing one of the other doctors but my regular vet assures me that every case goes through the ACVIM guy. My regular vet referred us when the UTI wasn't clearing up and they saw some strange cells and thought it was bladder cancer. Since the specialist is literally 2 miles away my regular vet refers all Cushings cases to the specialist. I asked my regular vet who he would send me to for a second opinion and he acted really surprised and said the hospital he referred me to was excellent. I will call him again today and see where it goes.

[labblab]

So what is the specialty of the "other doctor" whom you are actually seeing face-to-face at the hospital? Is it him or the ACVIM who has recommended the Lysodren load? Although I guess what you are saying is that, supposedly, the ACVIM approved the recommendation, regardless.

[nicolesnickels]

I haven't ever met with the ACVIM at the hospital. When my regular vet referred us there I have only had one of the other doctors. He is a DVM ( am looking at his bio right now online) and has completed a residency in Internal Medicine Training and is an associate vet at the hospital (there are several). My regular vet assures me that every case is discussed with the ACVIM but I haven't received confirmation of this in Chester's case.

[labblab]

Just wanted to add that you could consider performing a LDDS test, and perhaps another specialist would suggest that. But in my mind, I'm not sure how valuable that info would be right at the moment. The LDDS is even more prone to "false positives" than is the ACTH. So even if it also comes back positive, you're still left with a dog who lacks other corroborative symptomology. And if the LDDS comes back negative, you're still left with a dog who has unexplained hormonal elevations.

For these reasons, I would not proceed with any further testing or consultation right now unless you know you are talking to someone who is highly knowlegeable about endocrinological issues. Otherwise, I think you are wasting your time and money.

[goldengirl88]

Sharlene:
You are right I did have a consultation with Dr. Peterson. I just want to say right up front it was not cheap. I called his clinic in New York and left a message. His secretary called me back and we got the ball rolling. Be fore warned he will not do any consult or talk to your Vet without the fee being paid in advance. It cost me 400.00. I am now not so sure the money was spent wisely as I got much better help on here. When you are scared to death you do anything in an attempt to save your dog. My personal opinion is an IMS would be just as good, unless there are a lot of problems. Hope this helps. God Bless Us All and all our babies.

[addy]

Hi,

My experience with Dr. Peterson:

I had sent a few email questions to Dr. Peterson through his blog and he answered me. I then called his office to inquire about a telephone consultation. I told his office I had email contact with Dr. Peterson. We scheduled a telephone time, I gave her my credit card, the charge two years ago was $150 or $200. I dont rememebr which. I gathered all test copies and records, wrote a history for him and faxed all. I made a list of questions and he called me at the specified time and we had a lengthy conversation. I too questioned Zoe's diagnosis, just to be clear for his opinion.

She had had her second UTK panel, six months after the first and I was seeing a few more symptoms, although mild. I had wanted to continue to wait to treat and he advised me to start treatment with Vetoryl. He was not concerned about her blood work not showing all of the normal high abnormalities. I specifically asked him about that.

I do remember another member who's vet consulted with Dr. Peterson. I think it was $150 every time the vet consulted. In my case, I had direct consultation. My original emails to him voiced my concern about loading Zoe with her colitis, per my IMS recommendations, Zoe had just been through a bad flare up that lasted 3 months and was on a daily dose of metronidazole.

I found him patient, supportive and knowledgeable although he did take the lead with asking me questions so some of mine ended off topic and not being asked:o

I then went back to my IMS and told her what I had done. She was a bit shocked but by then she knew I had emails to Dr. Oliver directly at UTK and she knew I would go to the source whenever I could. So she tolerated it, was not happy, but tolerated it.

You have nothing to lose but a phone call to ask if he will do a consult with you or your vet (not the specialist) . I called the Bedford Hills office, not the NYC office.

[nicolesnickels]

I just called Dr. Peterson's office and they advised me that he no longer does phone consultations. I have had a crazy day at work and haven't had the chance to call the specialist or my regular vet yet.

I am thinking of either holding off completely on any treatment and seeing what happens or starting melatonin and lignans and retesting in 6 months unless new symptoms develop. He does have elevated hormones even if his cortisol is not super high and perhaps the melatonin and lignans will cause the cortisol to come down a little as I have read can happen. Thoughts?

[addy]

Info I saved from emails UTK remember Zoe's cortisol was much higher than Chester's.

Maybe it will help you to read, not sure:


I refer back to my Lhasa’s adrenal panel referenced above. We have had her on melatonin and lignans after trying to stabilize her chronic diarrhea. We had hoped we could keep her stable and run another full adrenal panel this month but she ended up having a bad colitis flare which started the end of October.
>>>The hormone levels were very elevated across the board, and melatonin and lignans may not control the elevated hormones. Most likely you’ll have to add in a maintenance dose of Lysodren to get the hormones back to normal.



I did consider maintenance dose of lysodren rather than loading with lysodren to see if she can tolerate it. I am worried it will cause Zoe diarrhea as she has such a touchy system.
>>>With the high hormone levels, you probably will need something in addition to melatonin and lignan, and maintenance Lysodren is probably best.
>>>Just an aside, are you by chance using a hormone cream? The high estradiol levels and high progestin levels are commonly seen when hormone creams are used. The hormones readily cross over the skin of dogs into the system.

With cortisol as high as Zoe's in your experience, is a non loading lysodren maintenance dose a viable option?
>>>It certainly would be. There would be two approaches here; 1) you could do a more conservative treatment by continuing the melatonin and lignans, and add maintenance Lysodren; or, 2) you could do the traditional approach where cortisol is very elevated and load the dog to get the hormone levels under control, and then go to maintenance Lysodren.

Is it at all possible elevations in the hormones we associate with Atypical be caused by chronic stress from non-adrenal illnesses?
>>>>I wouldn’t expect hormone levels this high with a non-adrenal illness, and before testing for Cushing’s, you should have some of the clinical signs typically associated with Cushing’s.

Could Zoe's chronic colitis cause the cortisol to continue to rise yet she not have PDH/ADH? In short, could her chronic condition be at the root of all these abnormalities on her adrenal panel?
>>>I don’t think so. You might get some increase from the colitis, but these are pretty high levels. I think hyperadrenocorticism is definitely present.

She does not have exposure to hormone cream but she chews every day on a rubber "Extreme Kong". Could repeated exposure to any type of chemical raise cortisol?
>>>I’ve not heard of any association with chemicals and adrenal hormone levels.

Her symptoms remain: thin coat, rat's tail,increased appetite and her hind leg weakness now includes refusal to jump on the sofa. Previously, it was the bed and car, increased desire to lick and chew which results in increased water consumption.
>>>These signs are typical of Cushing’s disease, so I think that is definitely what you’re dealing with.

Positive changes are in her mood, she is more social with the family and not hiding as much and is not seeking out cold services to lie on, though it is winter in Wisconsin :)
>>>This may relate to estradiol levels coming down. Estradiol can affect behavior, and it seems to cause signs in some dogs similar to “hot flashes” in women; thus the seeking out of cool surfaces.





Melatonin. Results of in vitro cell culture (human H295R adrenocortical carcinoma cells) studies in our lab55 revealed that both 21-hydroxylase and aromatase enzymes were inhibited by melatonin. Also, in dogs with adrenal disease that are treated with melatonin, and repeat adrenal steroid panels are done, cortisol levels are consistently reduced, and estradiol levels are variably reduced.29 Inhibition of the 21-hydroxylase enzyme would lower cortisol levels, and inhibition of the aromatase enzyme would lower estradiol levels. Estradiol levels were decreased in a prior study of dogs treated with melatonin.31 Results of in vitro studies with human MCF-7 breast cancer cells also revealed that melatonin inhibited aromatase enzyme, which resulted in reduced estradiol levels.56 Melatonin treatment for cases of mild adrenal disease in dogs may be effective, and particularly in cases where sex steroids are increased.

[nicolesnickels]

Yes this information definitely helps! It gives me hope that the melatonin can bring down the cortisol as well as the other hormones. It also give me hope that Chester doesn't need to load with Lysodren and could do maintenance if needed.

I think the big question for me right now is whether to treat with melatonin and lignans or hold off. Thoughts?

[molly muffin]

Treating with melatonin and lignan will not hurt. So if you want to give that a shot, I'd do so.
I'll let the others who have used those methods talk about dosage and what type to buy.
Addy and Leslie have both used them.

hugs,
Sharlene and Molly Muffin

[nicolesnickels]

Thanks, Sharlene!

[nicolesnickels]

Just wondering where to get the melatonin and lignans and dosing information.

[molly muffin]

Hopefully either Leslie or Addy who have both used melatonin and lignans will post about that today.
They know more about that than I do. I think you can get it at the health food store but there is specifics to the lignans that you'll need to know, such as what type to get, etc.

I've sent out a message so, cross fingers. :)

hugs,
Sharlene and Molly muffin

[addy]

Hi Nicole,

Unniversity of Tennessee Knoxville has all info on their website. Here is their link to lignans:


http://www.vet.utk.edu/diagnostic/endocrinology/pdf/20120316-LIGNAN-Write-Up-Revision02.pdf


melatonin can be purchased at Walgreens. Do not get time release just pure melatonin. I used Nature's Bounty. If your pup is about 20 pounds, 3mgs twice a day, twelve hours apart.

sorry, gotta run late this morning. I used the SDG lignans I purchased on line. So does Leslie. I have not purchases them in awhile so if Leslie does not come on, I'll look for the link at lunch.

It is a bit tricky on the lignans to figure out but this link is good.

Hang on, will be back when I can

[Squirt's Mom]

Mornin',

The lignans can be ordered online or at places like Whole Foods. I had no luck with places like GNC, tho. They would have products that contained flax but not plain flax lignans. You do NOT want to use flax oil to get the lignans since our cush babies are prone to pancreatitis and the oil has too many fats. You can find the lignans at VitaCost, iHerb, and Lucky Vitamin to name the companies I use and trust. You want plain flax lignans in a capsule. Most of them come in 40 mg capsules standardized to 20% - which means that 20% of those 40mg contain lignans. That means that there are only 8mg of lignans in each 40mg capsule.

40 mg capsule standardized to 20% = 20% lignans
20% is 1/5 of 100 (100 divided by 20 = 5)
40 mg divided by 5 = 8 mg lignans
Each 40 mg capsule contains 8 mg lignans

UTK (University of Tennessee in Knoxville) recommends 1mg / lb / day of the lignans. In skimming back through your thread, I didn't see a weight for Buddy so if you can share that, I'll be happy to help you with the dose. My Squirt has weighed between 13 and 15 lbs and at that weight, she takes 3 capsules a day.

The melatonin you can get just about anywhere - grocery store, WalMart, etc. The thing to remember with melatonin is to get the plain variety...not time released, extended wear, etc, or mixed with other goodies. Just plain melatonin in 3mg doses. UTK recommends 3mg of melatonin twice a day, morning and evening for pups under 30 lbs.


Typically, a dose of 3 mg is given q12hrs (BID) for dogs <30 lbs; a dose of 6 mg is given q12hrs (BID) for dogs > 30 lbs.

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

This treatment protocol is fairly benign and is worth a shot in my mind to start him on. It does take 3-4 months for full effect so patience is required. This combination worked very well for Squirt, lowering all her intermediates.

Hugs,
Leslie and the gang

[nicolesnickels]

Great information.

Chester weighs between 21-24 lbs.

Are there any side effects of the melatonin or lignans?

Also, are there any brands you recommend? I know the supplement industry is largely unregulated and there are large variations in products.

[Squirt's Mom]

I use the VitaCost brand at the moment for both the lignans and the melatonin. Squirt just will not take pill so I use capsules that I can mix in her food and that works fine for her. Look for products that contain LinumLife® lignans and you will be fine.

Buddy will take the same amount as Squirt - 3 40mg capsules of lignans a day which will give him 24mg of SDG, the active ingredient in the lignans that helps our babies. Give the lignans in the mornings along with one 3mg melatonin, then give one 3mg melatonin at night.

There is another form of lignans that is suggested for the intermediates that come from spruce not flax. It has HMR lignans as opposed to the SDG lignans in flax. It takes fewer capsules of the HRM than the SDG to get the same effect supposedly. Since using the HMR meant fewer stuff in her food, I switched Squirt to the HMR over a year ago and she was on it for a while when we had the UTK panel run again. She had lost control of the intermediates on the HMR so her IMS said to put her back on the SDG. I did and the intermediates went back down. So in Squirt's case, the HMR (spruce) lignans did NOT work as well as the SDG (flax) lignans do. If you want to try the HMR, you can get them from Swanson - http://www.swansonvitamins.com/swanson-ultra-7-hmrlignans-from-norwegian-spruce-tree-40-mg-60-caps

Hugs,
Leslie and the gang

[nicolesnickels]

I just spoke to the specialist. He seemed ok with all of my questions but recommends we try the melatonin implant since you can't be sure what your dog is getting otherwise. Does anyone here have any experience with the melatonin implant? Pros? Cons? Side effects?

[Squirt's Mom]

I prefer to have control and regulate the dose of meds my dogs get. I don't trust the implant to give consistent dosing and you don't know when it is out and has to be replaced. An implant also means more vet visits to have it put in and replaced as needed. So for these reasons, I chose not to use an implant. Seems we did have some who went that route but I can't remember who or how it worked out for them. You can use the "search" feature at the top of the page and look for melatonin implant.

[nicolesnickels]

I totally agree with what you are saying. The vet said he would replace the implant at 3-3.5 months. I asked about how to know when the implant is no longer effective and he said that he hasn't had any issues with any of the dogs he has treated. I worry about it both ways - I know the supplement industry is unregulated and you can't ever be sure you are giving your dog what it says on the bottle but the implant is a little scary too. I tried searching the posts with "melatonin implant" - doesn't seem like anyone is currently using one. The vet also suggested flaxhulls.com to buy them - has anyone used this site?

[Squirt's Mom]

Yeah, me again. :p I tried the hulls and they were less than satisfactory for us. They are messy, hard to get accurate measures on, and didn't set well for Squirt's tummy, plus they are much more expensive to use. I think others tried them as well and went back to the capsule form.

[addy]

I'm back too :)

Here is the thing, some dogs get really tired from melatonin and some do not. When I started Zoe on it I had to start her at 1mg twice a dayand build up to the 3mgs per day over the course of a few weeks.

I do remember reading 3 years ago about the implant and if I remember correctly it was mixed reviews.

It is your call, you know your dog best. In Zoe's case, I would not have wanted her almost comatose for 2-3 months, but that is my pup and I always have to be worried about doses for her.

Also, the SDG lignans Leslie told you about IMO, are about the best out there. I did have to switch to a powder since Zoe ended up with issues from the capsuls, I cant say the powder form of it worked as well as the capsuls. I eventually took her off of all of it because of her colitis.

Keep reading and researching, asking questions so you are comfortable with whatever you choose. What works for one dog may not work for the next dog.:):)

Forgot an aside- I checked with a pharmacy about melatonin and dry eye disease. There should not be a connection but melatonin definetly affects Zoe's dry eye disease.

[molly muffin]

Ha! I knew these two would show up and as always be brilliant. :D

I have to say I'd trust their personal experience completely as far as what works and how and what to give. They've already paved the road so to speak and tried the various types and means of delivery for you.

I know that you know what is would be best for your baby. This is good stuff though and I think I'll just bookmark this thread as far as a source for lignans and melatonin treatment. :p

Hugs,
Sharlene and Molly Muffin

[nicolesnickels]

Thank you all so much! You two are a wealth of information and I really appreciate it.

The specialist was nice enough on the phone today but seemed almost dismissive of how I wanted to treat. He just seems so sure that the melatonin and lignans won't work, maintenance Lysodren won't work and Chester will need to be loaded. Is it bad that I would love to prove him wrong?

I am still thinking of going 40 minutes south for a second opinion from another ACVIM. My current specialist is 30 minutes north so it's not much further and probably worth it to have someone whose philosophy is more in line with mine.

[molly muffin]

Nothing wrong with wanting to prove a vet wrong. We don't know that it won't work. Maybe he would just need a maintenance dose of lysodren added at some point. Then again, maybe not and you won't know till you try.
You can always try a second opinion. That doesn't hurt either and if it ends up being someone you are more comfortable with that is willing to work with you with a treatment plan you are comfortable with, then so much the better. If you don't feel as good about the second one, then you can always go with the first still.

Just having someone who will work with you, if a bonus in my opinion. My vet has given up on arguing with me at this point and asks what I want to do, then I ask what she thinks and back and forth. There is of course Molly's IMS now always waiting in the wings too. :) It's gotten almost comical at times. Although it is really not funny at all, sometimes you have to look for the humor to stay sane and not lose it.

Sharlene and Molly Muffin

[nicolesnickels]

Hi Sharlene:

I hear ya! I'm just happy Chester finally went on the pee pee pad last night.

[nicolesnickels]

So....since my last post I saw an ACVIM about 40 minutes south for a second opinion and he think that treating with melatonin and lignans is the right course and said he would definitely NOT induce with Lysodren right now. It felt good to have someone agree with me! My regular vet was impressed with the report from the second opinion doctor and is on board too. So now I need to get the melatonin and lignans.

What brand of melatonin do you all use?

[molly muffin]

I'm so glad that you found a vet who actually agreed with you!! :) And now your vet is on board too. Just a bit of a nudge it seems to make things go the way you needed them to go. Now they'll both be on board going forward hopefully too.
I'll let the ones who are actually using melatonin speak up as to what brand to use. :)

Glad to see you again. How is Chester doing? Still using the pee pad I hope.

hugs,
Sharlene and Molly Muffin

[Harley PoMMom]

So now I need to get the melatonin and lignans.

What brand of melatonin do you all use?

Regarding the melatonin, you want the regular kind not the fast-acting, rapid releasing or extended release products. I was using "The Vitamin Shoppe" brand, here is a link: http://www.vitaminshoppe.com/store/en/browse/sku_detail.jsp?id=VS-1335#.UXNe_kopXFw

For lignan information, scroll to the bottom of this link here: Congenital adrenal hyperplasia-like syndrome/ Hyperestrinism/ "atypical Cushing's" (http://www.k9cushings.com/forum/showthread.php?t=198)

Hope this helps.

Love and hugs,
Lori

[nicolesnickels]

I ordered melatonin and lignans from Vitacost last night. They are a local south Florida company so hopefully it won't take too long to get here.

Yes, he is still using the pee pee pads but last night there were some poop remnants which is not what I wanted to see! Chester had a tendency as a puppy to "clean up" any messes made in the house. I'll put the pad down again tonight and if it happens again will have to reconsider!

[molly muffin]

ACK. You'll have to let Chester know that some thing you just don't need any help cleaning up! LOL
Hope the lignans and melatonin get there soon and you'll start to see improvements in that over all.

hugs,
Sharlene and Molly Muffin

[nicolesnickels]

Hopefully! Thanks!

[Doccy]

Oh, you know Florida has some really good vet hospitals. Isn't that were they did the trials and the surgery on Doc for removal of the tumor and radiation therapy. Have to go back through and check that out.



HI,
Just wanted to clarify...Yes, I took Doc to UF for his radiation treatment. He's done really well and they are really good to work with. Even if you only have your vet consult with them, it may be well worth it. If you do end up going and need to spend the night, most hotels in the area offer discounts if you are visiting the vet hospital, they can give you a list of those hotels. If you have any specific questions, just msg. me.

Jessica and Doc

Jessica

[nicolesnickels]

Thank you for the info! I called a couple weeks ago to see if they would review records and they said I had to bring Chester in. I'll see how he does these next few months!

[Simba's Mom]

So you have alittle poo eater too, aren't our pups something else? Anyways, hope Chester continues having good days!!!

[nicolesnickels]

Yes, it's so gross. He will only eat Cleo's and only if it's fresh and done in the house. Thankfully that almost never happens (or at least didn't until the pee pee pad went down at night). Nasty.

[Simba's Mom]

Simba likes his as poosicles, so hopefully when the weather warms up, he will be over it :rolleyes:

[nicolesnickels]

Ew yuck! Chester likes his before they hit the floor....