New-atypical Cushings?

[maria]

Pumphrey is my 9 y/o Beagle who has had symptoms of Cushings for the last 5 years that have gotten progressively worse.
She has a huge pot belly but I can feel her ribs, she is drinks large amounts of water and charges the water bowl in the morning. She is always hungry and has to be fed separately or she will eat everyone's food, she pants a lot, is lethargic, can't jump on bed anymore, has accidents: I let her out in the am, then 2 hours later, then 1 hour later on the way home from the vet she peed in the car . As you can imagine, this has been very frustrating for me because without a diagnosis, I cannot treat. She is having a LDDST on Wed. Since her uriine cortisol has been normal each time it is taken, I am suspecting this test will also be wnl. I think she might have atypical Cushings. Her thyroid is normal. Would an abdominal x-ray be of any value to see what is going on inside her abdomen? Vet said her liver felt enlarged. Any advice appreciated.

Total protein : 7.5 (5-7.4) last year was 7.3

ALP : 510 (5-131) last year was 216

Ca : 12.1 (8.9-11.4) last year was 12.1

Chol : 348 (92-324) last year was 255

Trig : 793 (29-291) last year was 127

Lipase : 1040 (77-695) last year was 828

Platelet : 600 (170-400) last year was 583

Urine Specific gravity : 1.010 (1.015-1.050) last year was wnl

Protein : 2+ (negative) last year was negative

Cortisol/Creatinine ratio 8 - Cushings is highly unlikely in dogs with < 13

Hemolysis 2+ Lipemia 2+ with no significant interference.
Maria

Maria

[Budsters Mom]

Welcome Maria and Pumphrey,
I am sorry for the reason that brought you here, but so glad you found us.;)

You have come to the right place! There are many K9Cushing's angels standing by to help and stay with you every step of the way. They love details, test results, any information you can get your hands on. The more the better. We will do all we can to help. Others will be popping in to welcome you also. Please post the LDDS test results when you get them, as well as any other tests you may have.
So again welcome to you and Pumphrey,

Hugs,
Kathy and Buddy:cool:

[Harley PoMMom]

Hi Maria,

Welcome to you and Pumphrey, what a unique and cute name your girl has!

Pumphrey sure has many of symptoms of Cushing's but with a normal UC:CR...Hmmm, I'm puzzled. Is she taking any other herbs/supplements/medicines? Does she have any other health issues?

An abdominal ultrasound might be more useful as a diagnostic tool that an abdominal X-ray.

I am sure the others will be by soon and will be more helpful than me. Please know we will help in any way we can so do not hesitate to ask any and all questions.

Love and hugs, Lori

[maria]

Thank you both for responding and for the welcome. I will ask about the ultrasound. She is not taking any herbs or supplements. The reason that I think she might have atypical is because of the cortisol/creatinine ratio being normal. I have done so much reading and research I can't find anything other than Cushings that matches her symptoms.

[lulusmom]

Hi, Maria, and welcome to you and your precioui girl, Pumphrey.

It sounds like your girl is a four legged poster child for canine cushings, both clinically and physically. Given the normal UC:CR, I would tend to agree with you about the possibility of atypical cushing's. If Pumphrey were mine, I'd want an abdominal ultrasound to rule out an adrenal mass. These tumors don't always secrete cortisol but can pump out massive amounts of sex hormones which cause the same symptoms and clinical abnormalities we see with excess cortisol, the hallmark of "typical" cushing's. The ultrasound will also give your vet a good look at the surrounding organs to assess their condition as it relates to cushing's and/or other possible causes.

If your vet has not already done a urine culture, I personally would want one done to rule out a urinary tract infection as a contributing factor in Pumphrey's accident. A urine culture will identify the type(s) of bacteria so that appropriate antibiotics can be prescribed.

If one of the normal UC:CR's was done recently, chances are an LDDS will also be normal so you may want to think about doing a full adrenal panel by the University of Tennessee Knoxville. It's not inexpensive but it includes cortisol as well as the sex hormones.

Cushing's is a graded disease that progresses like a snail but I would think after five years of symptoms, which sound to be quite overt now, there's got to be some kind of hyperadrenal activity going on and hopefully your vet will determine the cause.

Glynda

[maria]

Thank you Glynda. She is the poster child for Cushings. That is what is so frustrating. She has all the clinical signs except hair loss. I did take your advice and cancelled the LDDS test tomorrow until I talk to the vet about the full adrenal panel. It did not make sense to me that if her urine cortisol would not be elevated if her circulating cortisol was. So if her urine cortisol is not elevated why would the blood cortisol be?

[lulusmom]

Hi again,

If your vet did a recent UC:CR and it was normal, then you would expect an LDDS test to be normal as well. I have included the url to an article on the UC:CR. Excerpts below from the first two paragraphs of this article sums up why you would expect the LDDS to be normal.

http://veterinarymedicine.dvm360.com/vetmed/Medicine/ArticleStandard/Article/detail/357729


I think that the urine cortisol:creatinine ratio (UC:Cr) serves an invaluable role in ruling out canine Cushing's disease since a dog with a normal UC:Cr almost assuredly does not have Cushing's disease.

Dogs with hypercortisolemia have increased excretion of cortisol in their urine. This excretion can be compared to creatinine excretion, which should be fairly constant in dogs with normal renal function. False-positive elevation of the UC:Cr (i.e. elevation not related to Cushing's disease) can occur in patients with gastrointestinal, renal, lower urinary tract, liver, neurologic, or immune-mediated diseases or congestive heart failure.1 Although the UC:Cr is more frequently elevated than it is normal, when it is normal, you know that your patient does not have Cushing's disease and that you need to look for another possible cause for the patient's clinical signs.

An abdominal ultrasound would be a logical next step to check for an adrenal tumor and if negative, a UTK panel to check for elevations in intermediate hormones.

Glynda

[maria]

Hi Glynda,

Yes, her last cortisol/creat ratio was last week and it was 8.

I cancelled the LDDS test for the reasons. Thanks for the link and the excerpt. She is not doing too well today. Very lethargic. I really need to get some answers. Her abdomen is seeming to get bigger. She gained to pounds this year and weighs 36#. She only eats a cup of dry and some moist per day. :confused:

Which of the panels should I ask for. I need to be really specific. I called around and one vet had never heard of the adrenal panel. My vet has but I want to ask for the right one.

Adrenal Panel - ACTH Stim
Cortisol, progesterone, 17-hydroxyprogesterone, estradiol, androstenedione,
aldosterone in baseline and post-ACTH samples
Canine

Adrenal Panel Combined Dex Supp/ACTH
Cortisol, androstenedione, estradiol, progesterone, 17-hydroxyprogesterone
and aldosterone in baseline, post-dexamethasone and post-ACTH samples
Canine:
Thanks again for all your help.

[lulusmom]

Hi Maria,

I'm sorry to here that Pumphrey is not feeling good today and I know how frustrated and sad you must be that a diagnosis is still up in the air. I am a bit concerned about your vet's experience with cushing's and how the various screening and diagnostic tests work. A lot of us have found that sometimes it is ultimately more cost effective to see a specialist so I'm wondering if that is something you may be willing to consider for Pumphrey. You can search for internal medicine specialists yourself by going to www.acvim.org. If you let us know what city and state you are in, there may be members who can provide a name for you. Most specialist require a referral, which I'm sure your vet would be happy to do.

If you want to proceed with a UTK panel via your vet, it would be the first one you posted. You don't need the combo dex acth. If you are open to a specialist, I would put off the UTK and let the specialist suggest the next step for Pumphrey. I'm not a betting woman but I'd bet that a specialist would definitely want to see an abdominal ultrasound to see what's going on internally.

If you want to continue on with your vet, I still think an abdominal ultrasound would give you more bang for your buck but keep in mind that it should be done on a high resolution machine by an experienced radiologist. Cost wise, it's probably around the same general price as the UTK panel...somewhere in the $400 range. It's been a while since I've had to do either test so prices could have gone up.

[Squirt's Mom]

Hi and welcome to you and Pumphrey! :)

If it were me, I would start with the abdominal ultrasound - asap. My Squirt tested positive on five cush tests but the ultrasound found a tumor on her spleen. Once that was removed, her cortisol returned to normal and remained that way for about four years. If I had started treatment without the US, she could have died when the tumor ruptured. The US is one test that can tell us very much about many things - it is worth every penny in my book. You'll want to ask them to do their best to see both adrenals - sometimes difficult to see - but if there is tumor on one of them that is not associated with cortisol you want to know about that as much as you do one that is associated with cortisol. ;)

Squirt does have elevated intermediate hormones - the hormones involved in Atypical are Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone. These hormones, with the possible exception of Estradiol, can all be controlled with Lysodren. Sometimes Estradiol is produced outside the adrenals where Lyso cannot reach. So the initial treatment is with a combination of flax lignans and melatonin. This combination will typically address estradiol no matter where it is being produced. The lignans and melatonin take several months to work, tho, so patience is required in Atypical treatment. If after several months the hormones are still not in range, then the Lysodren is added as a maintenance dose only - there is no loading phase with Atypical. In my book, if a pup has to have Cushing's Atypical is the one we want because it is so easy to treat and the treatment is quite benign. HOWEVER, be aware that Atypical is often a precursor for true, or conventional, Cushing's with elevated cortisol. ;)

I am a bit concerned with the lethargy you mention. Is this something new? Is she peeing and pooping alright? How's her appetite? She is responsive, right? How is she this morning? Let us hear from you when you can!

Hugs,
Leslie and the gang

EDITED TO ADD - I agree wholeheartedly with Glynda's suggestion of an IMS.

[maria]

Thank you both for the great advice. One reason I was wanting to do the adrenal panel with my reg vet is that it is about 100 less expensive but I have put a call into the internist. He is out of the office until Mon but they have an ultrasound service that comes every Thursday so I am going to talk to him first to see if we can do it all in one visit. He is about 2hrs from me given traffic in LA.

Sorry your dog has atypical but I am relieved to here if one has to have Cushings it is the best to have. I really appreciate the info on the treatment. Natural is so much better than prescription but at least the prescription option is there if we need it as well. The ultrasound is 400-500 and the endocrine panel is 450. My reg vet is 320 for the panel and 45 for the office call.

Pumphrey slept all day yesterday. Normally she sleeps a lot but follows me from room to room and lies down next to me. She charged the water bowl this am so she has some energy. She has 3 siblings -2 rescue Chihuahuas and a Standard Poodle. I also have a horse with metabolic disorder. Kind of like diabetes in humans. We thought she might have Cushings as well but so far that lab was negative. In horses the opposite is true about the coat. They grow a really long, wavy coat if they have Cushings.

[maria]

Pumphrey looks like she swallowed a beach ball. Her abdomen is huge! I get an appt with the IMS on Tuesday. His name is Dr. Richard Martin. When I lived in Venice CA in the 1970s and 80s he and Dr. Olds (surgeon) were my regular vets. Since I moved to OC, I see them only as specialists since the drive is so far. He is on the link you sent of approved Vets.

[lulusmom]

Hi Maria.

I'm so glad you have booked an appointment to see Dr. Martin. Unlike most of us, you are very fortunate to already know and trust an internal medicine specialist. I also live in So Cal and drive 50 miles to Fountain Valley to see our IMS. 50 miles in So Cal might as well be 100 miles on any day of the week. :mad: Hopefully Dr. Martin can sort things out and finally confirm a diagnosis.

For sake of clarification for members, k9cushing's does not have an approved list of vets or specialist. The www.acvim.org is a non profit organization with membership being limited to board certified internal medicine specialists. If you use their "search for specialist" feature, you will only see a listing of their members. If a pet owner can't find an IMS in their state/city on the acvim site, googling "veterinary internal medicine specialists" almost always yields a few names.

Looking forward to hearing how the appointment goes.

Glynda

[maria]

Thanks for the clarification about the specialists.

Yes, 50 miles in LA might as well be 100. Glad you have someone in Fountain Valley. I used to live in Huntington Beach and took my dogs to All Care Animal Referral in FV when I had an emergency.

[lulusmom]

It's a small world. My first cushdog was diagnosed at VCA All Care and Dr. Moore and his staff of specialists continued to direct her treatment until she passed in January. My second cushdog, a shelter rescue, was diagnosed elsewhere but Dr. Moore and his staff directed his treatment too until he passed last June.

[maria]

Sorry for your loss of your shelter dog. They are the best! I don't know Dr. Moore but then I only went there for emergencies and was too worried to really pay attention to who was treating them. I did have a rat euthanized and I remember the dr was very compassionate.

Pumphrey also has a perminantly luxated patella that I just found out about so I am not sure if it is that or the Cushings that is making her struggle a bit to get up from a sitting position. Her belly is so large that could also be a factor.

[maria]

Spoke with our regular vet. She is going to run a complete adrenal panel on Monday. We spoke about the ultrasound and after we get the results, that is the next thing on the books. Rather than go locally, I am going to see Pumphrey's IMS for a check-up and ultrasound. They have a company that comes every Thurs to do their ultrasounds. Hopefully, we will have more definitive answers as a result. She expects the test to be back by the end of the week. She has personal experience with atypical Cushings as a close family member's dog had it and she ultimately dxd it and has had some others in her practice with it.

[Trixie]

Hope you can get some answers about Pumphery's condition soon!
Barbara

[Squirt's Mom]

MODERATOR NOTE: I have merged your post about the update into Pumphrey’s original thread. We normally like to keep all posts about each pup in a single thread as it makes it easier for members to refer back to the pup's history when needed. Thanks!

[maria]

Thank you, I will post as soon as I get results

[doxiesrock912]

You're ahead of the game with the IMS!

We discovered that Daisy had Cushings when she was diagnosed by the third vet that we saw and I'm 99.9% sure that she's had it undiagnosed for at least a year!
The IMS specialist at Cornell was wonderful and her knowledge extensive and accurate.

The ultrasound is so important in order to know exactly what is going on with Pumphrey just in case there is more than Cushings at work.

[maria]

It is frustrating when you know something is wrong but it doesn't fit into a neat little syndrome until the symptoms get really bad. At least that has been my experience. I think Pumphrey has had this (whatever this is at this point) for at least 5 years. Partly my fault as I did not decide to go through the expense of Cushings testing if she was too young to have it. Also her urine cortisol was wnl except one time when it was taken at the vet's then it was 75 (not sure of the units) which is way over 13. The vet said it was probably just due to the stress of being at the vet. Yet another vet told me that was over what would be expected from stress. That was the only elevated urine cortisol she has had. SHe has also had elevated blood glucose which have been normal the last few blood tests.

I am glad you finally got your dx so you were finally able to treat Daisy. You are very fortunate to have such a prestigious hospital to take her to. How is Daisy doing now? When my horse was dxd with Equine Metabolic Disorder and insulin resistance, the labs were sent to Cornell.

[molly muffin]

Hello and welcome to you and Pumphrey.
I don't have a lot to add in addition to what the others have told you, other than to agree it is hard to get a diagnosis with cushings. So many other things can cause cortisol to go up. It's good to have a good vet and an IMS to work with though. It can make a world of difference.
Again, welcome to the forum,
Sharlene and Molly Muffin

[maria]

Thank you for the welcome! Having had the time to read through some of the posts I do see that it can be difficult to diagnose. I thought it was just Pumphrey because her urine cortisol was normal.

I called the IMS' office yesterday and they put me in the books for a US on Thursday. I am going to ask for one and I am sure he will agree so she thought it best to get the appt before they fill up. She has her adrenal panel in the am tomorrow so hopefully but the end of this week or first of next, I will have some answers.

Has anyone else's dog had a normal cortisol/creat ratio but still been dxd with Cushings? Everything I have read says if the ratio is <13 the dog does not have Cushings. I did read one article ( can't find it now of course) that stated there were false negatives.

[molly muffin]

I do not recall that there are false positives on the UC:CR. If it is negative then that normally rules cushings out as the culprit. If it is positive then you do further tests, because other things could cause it to be positive than just cushings.
I'm pretty sure that negative UC:CR rules cushings out.

hugs,
Sharlene and Molly Muffin

[maria]

Here is a really good article on atypical Cushings if anyone is interested. Serum cortisol levels are normal in some of these dogs so I think that would also mean normal urine/creatinine ratio as well.

http://veterinarynews.dvm360.com/dvm/article/articleDetail.jsp?id=485128

[Harley PoMMom]

That also can be found in our Resource Thread, there is a wealth of information there plus articles regarding Atypical Cushing's, here's a handy link: Congenital adrenal hyperplasia-like syndrome/ Hyperestrinism/ "atypical Cushing's" (http://www.k9cushings.com/forum/showthread.php?t=198) :)

[maria]

Thank you for the link. I did not know you had a resource thread!

[Harley PoMMom]

OMG, I am so sorry! Yes we do have a Resource Thread and it has loads of information, here's a link: Helpful Resources for Owners of Cushing's Dogs (http://www.k9cushings.com/forum/forumdisplay.php?f=10) Grap a cup of coffee!!! It has a lot of info!!! ;):D

[molly muffin]

Yea, there is no high cortisol usually with atypical, but the only way to really determine that is the panel being sent to UofT. I think they are still the only ones that are doing it.

Sharlene and Molly Muffin

[frijole]

Actually you don't have to do the UT panel to determine if there is high cortisol - you could have done a normal acth test and if there is high cortisol it is normal cushings and not atypical. Atypical cushings is when other sex hormones are elevated and that is what is measured (in addition to regular cortisol) in that panel.

Atypical cushings is not treated with traditional cushings meds because there is no cortisol to lower.

I would say that if you ruled out cushings with the urine test you can pretty much count on normal cortisol levels. Kim

[maria]

Thanks for the info. I thought the newer drug worked on atypical. The lab panel she had today tests for the precursor hormones involved in atypical with an ACTH included.

Pumphrey is not doing well and is limping. I think it is a result of muscle wasting and her luxated patella. It seems she has gone downhill in the last month. I am concerned that when we get the Cushings under control, her pain is going to get worse. Is it contraindicated to give them NSAIDS or opiates when treating for Cushings with Lysodren and the one that begins with a T ?

[frijole]

Read Glynda and Marianne's posts on this subject right here about pain management drugs and cushing's:

http://www.k9cushings.com/forum/showthread.php?p=27331

[maria]

Thank you. That makes sense. I wonder if synthetic opiates would also be contraindicated? Her pain is coming from her knee that is now permanently dislocated.

Love your little doggies. Are they Schnauzers? A dear friend had a lovely little Schnauzer who had Cushings as well. When my daughter is older, I was telling her a Schnauzer would be the perfect dog for her.

[frijole]

Thanks those are my girls Annie and Haley. Yes, schnauzers - one was white, the other silver. They are both angels now. They lived to be elderly and had wonderful lives. I used tramadol. It is pretty potent stuff and I recommend starting at 1/2 of the normal recommended dose. A number of us all experienced this about the same time. For some reason the normal dosing was just too much - not sure if it was the cushings or the fact they are elderly.

[maria]

For the last few days Pumphrey has gotten more and more lethargic. She is not on any meds (well at least until an hour ago when I gave her a tramadol for a torn cruciate ligament I was told she had yesterday) The IMS is certain she has Cushings. We are having an ultrasound tomorrow and the results of the adrenal panel are 7-19 days away. She seems to have a really hard time getting her back end up. She acts as if she is starving all the time but could not even get it up to get some yogurt I gave her and had to slide the bowl to her as she was in a sitting position kind of back on her but ( not a normal sitting position) and obviously did not want to get up. I know her stifle hurts her but it seems more than that. Is this the hind-end weakness that comes from Cushings?

[molly muffin]

Did the vet look at the back problem? Along with the torn ligament, this might be what is causing this rather than pure muscle wastage. I'm thinking disc problem possibility.

Sharlene and Molly Muffin

[maria]

Hi Sharlene,

No, her back is fine. She seems a little more animated now. Perhaps the tramadol is kicking in. But you could just look at her eyes and tell she was not feeling well. You know that look, head hanging etc.

I just realized your Molly does not really have a diagnosis either from your signature line. I wonder how many others there are like this and if this is a syndrome that has not been discovered yet.

[maria]

Pumphrey had her ultrasound on Thursday. Her adrenals were normal but her liver was mild to moderately enlarged. He labs were drawn on May 29 to go to University of Tennessee but because of the holiday weekend, they are not being run until today so I have to wait 10 more days to get any answers. Meanwhile, she is not feeling well. Her limping is worse in her right leg due to the cruciate ligament tear. She is on tramadol for that but it seems to make her pant so I don't like giving it. She has been lethargic and has not been dumping trash cans, opening my cabinets and stealing dirty clothes like she does when she is feeling well. So frustrated having to wait like this knowing there is a treatment to help her feel better.

[maria]

Sorry. should have said labs were drawn on May 20

[molly muffin]

Waiting is the hardest part. Sometimes it seems that we are either in full steam ahead mode, or wait, wait, wait, with no happy inbetween. It's not true, of course, often we are just carrying on, but when one or the other strikes, go or stop, it seems so much more profound than the normal stuff.
Hopefully Pumphrey will start to feel better and you'll get those answers back soon.

Sharlene and Molly Muffin

[maria]

Thanks, Sharlene. I know you understand.

[maria]

After 15 days of waiting, the adrenal panel from UT is finally in and our vet is out with the flu. Results as follows:

cortisol ng/ml baseline : 58.5 - normal :2.1-58.8
cortisol ng/ml post ACTH -99.2 - normal : 65 - 174.6

Androstenedione ng/ml : .60 - normal : 0.5-.57
Androstenedioine ng/mg post ACTH : 2.09 - normal : .27-3.97

Estradiol pg/ml : 114.9 - normal : 30.8-69.9
Estradiol pg/ml post ACTH : 113.9 - normal : 27.9-69.2

Progesterone ng/ml : .44 - normal : .03-.49
Progesterone ng/ml post ACTH :1.37 - normal : .10-1.50

17 OH Progesterone ng/ml : .21 - normal : .08 - .77
17 OH Progesterone ng/ml post ACTH : .95 - normal : .40 - 1.62

Aldosterone pg/ml : 72.4 - normal : 11 - 139.9
Aldesterone pg/ml post ACTH - 546.5 - normal 72.9 -398.5

Comments-estradiol may contribute to clinical signs but not a good indicator of adrenal activity because it is secreted by adrenal tissue.
(?) these results indicate presence of increased adrenal activite ( marginal)

So Pumphrey is very symptomatic, I will recap her symptoms and labs below. Her cortisol level was in the high normal range at baseline. Androstehedione elevated baseline. Estradiol elevated baseline and post ACTH. Aldosterone elevated post ACTH.

Her symptoms are getting worse. Both the IMS and reg vet are convinced she has Cushings based on clinical presentation. What do the above results mean? Is she a candidate for some type of t reatment? Lab says if clinical consider Melatonin implant and Lignan. Her labs don't seem to match the severity of her symptoms. I am confused.

Pumphrey is my 9 y/o Beagle who has had symptoms of Cushings for the last 5 years that have gotten progressively worse.
She has a huge pot belly but I can feel her ribs, she is drinks large amounts of water and charges the water bowl in the morning. She is always hungry and has to be fed separately or she will eat everyone's food, she pants a lot, is lethargic, can't jump on bed anymore, has accidents: I let her out in the am, then 2 hours later, then 1 hour later on the way home from the vet she peed in the car . As you can imagine, this has been very frustrating for me because without a diagnosis, I cannot treat. She is having a LDDST on Wed. Since her uriine cortisol has been normal each time it is taken, I am suspecting this test will also be wnl. I think she might have atypical Cushings. Her thyroid is normal. Would an abdominal x-ray be of any value to see what is going on inside her abdomen? Vet said her liver felt enlarged. Any advice appreciated.

Total protein : 7.5 (5-7.4) last year was 7.3

ALP : 510 (5-131) last year was 216

Ca : 12.1 (8.9-11.4) last year was 12.1

Chol : 348 (92-324) last year was 255

Trig : 793 (29-291) last year was 127

Lipase : 1040 (77-695) last year was 828

Platelet : 600 (170-400) last year was 583

Urine Specific gravity : 1.010 (1.015-1.050) last year was wnl

Protein : 2+ (negative) last year was negative

Cortisol/Creatinine ratio 8 - Cushings is highly unlikely in dogs with < 13

Hemolysis 2+ Lipemia 2+ with no significant interference.
Maria

[Harley PoMMom]

Since her other intermediate hormones are elevated and she is displaying obvious Cushing's symptoms, you can add just a maintenance dose of Lysodren (low dose) along with the melatonin and lignans, even though her cortisol is within the normal ranges. I would talk to your vet about this.

Love and hugs, Lori

[maria]

I will ask. Thanks!! It just seemed to me the melatonin and lignin's won't be enough. She charged the water bowl again and had an accident in the house the other night that was so much I thought we had a pipe leak!

[frijole]

I think getting an ultrasound is a good idea because you can get a look at the organs just in case something else is going on. A good look at the adrenals can give you a clue as to whether you are in the early stages of cushings. Otherwise things to rule out (if you haven't already) are hypothyroidism, diabetes (insipidus and mellitus), SARDS.

Kim

[maria]

her ultrasound showed mild to moderate liver enlargement and normal sized adrenals. I used to think she had diabetes insipidus but that is kind of a diagnoses of rule everything else out first. Doesn't explain the huge pot belly. You can easily feel her ribs too.

[Boober]

Marie all that sounds like what Boober was like. I finally had to demand a U of Tenn Adrenal panel and her results came back like Pumphreys. For the past year she has been on melatonin and spruce lignans and the symptoms have lessened especially the water drinking. I started using flax lignans but read that spruce were more effective. For her incontenience I'm using Cornsilk (up to 6 capsules daily) and it has worked amazing to stop the incontience to almost nothing. She has that muscle wasting in her one back leg and I've noticed over the year that it's gotten worse and she also developed an on again off again limp in her front leg that seems more on again than off. Unfortunatly in May she was diagnosed with nasal carcinoma so now were dealing with that also. I hope Pumphrey feels better soon.
Sue and Boober

[maria]

Oh dear! I am so sorry to hear about the nasal carcinoma. Thank you for taking the time to respond to my relatively minor problems when you have that going on. Are you perusing chemo, surgery or radiation? I had a friend with a silky terrier who had it and now her sister's maltipoo has it as well. I will be praying for your baby for healing and to give her doctors wisdom to treat her.

It really helps when someone has been/is in your position...especially with a syndrome like atypical cushings which is even more difficult to diagnose than regular Cushings. I am not sure if all the precursor hormones need to be elevated to diagnose this or just one. Also, I am unclear of the significance of the normal baseline aldosterone and elevated post ACTH result.

Good to know the melatonin and lignins helped. It was mentioned here and I also read Lysodren can help with this too. I have not heard of corn silk. Where do you get it and how do you give it?

[molly muffin]

Yes, I think starting with the melatonin and lignans is a good regime and then lysodren if needed too. Remember though it does take time for sympoms to subside on this regime, but with normal cortisol levels, even if at the high end, you aren't looking at treating with normal vetoryl or lysodren alone.

Have a chat with your vet and see what he thinks.

Hang in there.
Sharlene and Molly Muffin

[Boober]

Marie the only option for nasal carcinoma is radiation and with Boober being 12.5 with highly elevated liver enzymes and a cost of $10,000 I wasn't going to but her thru that as there is no cure and no guarantee that it will give more time. Plus the side effects of the radiation can be very bad and don't show up for months after. I have her on some very good cancer fighting supplements and so far she has no symptoms anymore so were taking it one day at a time.

They say that it takes about 4 months before you seen any changes with the lignans and the melatonin. I've certainly noticed the sympton changes since this all began a couple years ago.

The incontinence as you know is a nightmare and so frustrating so doing research I came upon corn silk. It's a diuretic and used for bladder issues. Honestly its been a miracle, we've gone from many accidents a day to weeks without any. I give 2 capsules at breakfast, one a lunch, 2 at supper and 2 around 9pm so about 6-7 a day. You an give more if needed or less if needed. I also make sure that Boober goes out for a pee regularly. I buy Natures Way brand and there fairly inexpensive. I open the capsules and put the powder mixed into her food or wrapped in sardine at night.

[maria]

My friend and her sister did not treat either. Yes, one day at a time. I have had several dogs with cancer. The all of them had surgery and the cancer came back. We tried homeopathy and a very good diet to give her quality of life and toward the end, hospice at home. Just enjoy each day with her. I know you will pamper and spoil her. Each day is a gift. Toward the end my spitz would only eat orange chicken from the Chinese take-out and that is exactly what she got.

Do you mind my asking where you get the spruce lignins and corn silk? I have seen it several places but not all are of the same quality.
Poor Pumphrey just sleeps all day like an old dog. She looks today as if she as swallowed a beach ball. I just called the IMS to see about getting an appointment for the melatonin implant since my reg vet is out today and they don't do it. He is going to be gone next week so more waiting!

[molly muffin]

hi Maria,

You don't think that you would want to just try giving the melatonin? That way you wouldn't have to wait. I'm sure some of the others on here have used it with the lignans and just given it so you can control the dosage?

hugs,
Sharlene and Molly Muffin

[Boober]

I think you could probably also start the melatonin and lignans. I buy Natures Way corn silk either from Swanson Vitamins in the US when I'm ordering a lot of supplements or in town if I run out. $3.00+ at Swanson. I got the spruce lignans (Swanson Ultra 7-HMRlignans 60 caps from Swanson also, 40mg and I give Boober 2 at breakfast. I give her 2 melatonin a day 12 hours apart 3 mg. I take it myself at night to help me sleep.
Sue and Boober

[maria]

thank you both for the advice. I spoke with the IMS who told me the estradiol was the only significant abnormality but dxd her with atypical cushings. Later, my dear regular vet called me even though she was sick with the flu to give me the results. She also dxd atypical cushings and even though the other abnormalities were not that high, she things Pumphrey could be overly sensitive to them. She told me i could use the regular melatonin and lignans that I could get from a health food store as you both are suggesting. She said to wait at least 4 months to see if they are going to help with the symptoms. If not, she would recommend Vetyoryl in addition to them. She has atypical Cushings patients and even though it is proported to elevate estradiol, she has had good results with it. I am going to get the nature's way. Pumphrey weighs 35 #. I wrote down the dose of each but can't find my note pad.

[molly muffin]

hmmmm, definitely give it a minimum of 4 months to see if it works. Some of the others will know better than I, but I'm pretty sure the recommendation from the UTenn where Atypical Cushings was first diagnosed and treatments for it determined. (thank you to the late Dr. Oliver and a huge supporter of K9cushings), I'm pretty sure that they recommend using lysodren in addition to the lignans and melatonin and I thought there was a specific reason to Not use vetoryl with this combination.
Like I said, I'm sure some of the others will know for sure about that.

It's good to have a plan!!
hugs,
Sharlene and Molly Muffin

[Boober]

The U of Tenn just told me to use the lignans and melatonin. Most of the tested sex hormones were elevated in Boober's Adrenal panel. I did notice some changes before the 4 months but that's how long they suggest it might take. I did notice that Boobers nails grew alot faster probably due to the lignans.

[frijole]

Sharlene is correct - in some cases lysodren is prescribed as it helps lower sex hormones. It is a different type of dosing than regular cushings as there is no load period - it's a lower dose strictly to lower those hormones. Kim

[maria]

I came across this limited study and at read, it seemed to be counter-productive. However, the results seemed promising. Please let me know your thoughts.

http://www.petcarebooks.com/pdf/Atypical-Cushings-treatment.pdf

[labblab]

Hi Maria,

As you can see, I've merged your question about Caroline Levin's work into your original thread. This is so our readers will have the context for your question.

I apologize that I don't have time to write more now, but I will come back later on to add some thoughts and links. But just wanted you to know that this research has indeed been discussed on other threads in the past. I personally have strong concerns about Ms. Levin's treatment recommendations. So I'll come back to talk more about that.

Marianne

[maria]

I just started Pumphrey on Melatonin 6mg/twice daily and HMR Lignan 40mg/d. I know it takes at least 4mths to see any improvement. The drugs for regular Cushings are so strong, I am wondering if these relatively benign supplements really work? If so, what kind of improvements in symptoms (pot belly, ravenous appetite, excessive thirst and lethargy) and to what degree have people experienced? Has there been a complete remission of symptoms or is it typically just mild improvement. Pumphrey's culprit is hyperestrinism. Do the liver function tests and other abnormal chemistries normalize as well?
Pumphrey-8 year-old Beagle with atypical cushings diagnosed 1 month ago.

[Budsters Mom]

Hello and welcome:)
I am sorry for the reason that brought you here, but so glad you found us. You have come to the right place! There are many K9Cushing's angels standing by to help and stay with you every step of the way. They love details, test results, any information you can get your hands on. The more the better. We will do all we can to help. Others will be popping in to welcome you also. So again welcome Maria and Pumphrey.:)

Hugs,
Kathy

[Trish]

HI Maria and Pumphrey too!

Just wanted to pop in and welcome you. There are some on here who use those meds, I am sure they will be in here when they wake up and can offer you more advice. I know if it is truly atypical those supplements can be helpful. Sorry I am not more up to date with that.

As Kathy said if you can round up Pumphreys results and post them all, the members here will be able to better advise you. I do know they like to see the results from University of Tennesee for the atypical cush pups as from what I understand that is the only lab that specifically tests for atypical.

Glad you found us, you have landed in with a hugely knowledgeable group of people, so stand by for more questions from them!

Trish :)

[Mel-Tia]

I am sure pumphrey already has a thread.... Probably on page 10 or something. Mods are sleeping as its the wee hours for them...

Maria, I am sorry I do not know anything about atypical but I am sure folks will be in a bit later.

Hope you are both doing well

Hugs.

Mel
Xxxx

[labblab]

I am sure pumphrey already has a thread.... Probably on page 10 or something. Mods are sleeping as its the wee hours for them...

Maria, I am sorry I do not know anything about atypical but I am sure folks will be in a bit later.

Hope you are both doing well

Hugs.

Mel
Xxxx
Mel, you are absolutely right about Pumphrey's original thread, so I have now merged everything together into one spot. ;)

Marianne

[Squirt's Mom]

Hi,

My Squirt was on melatonin and lignans for several years and they did help with signs. Squirt had mild signs to start with, mostly panting, lethargy, and hiding instead of interacting. I don't remember what, if any, changes occurred in her blood work. Since moving last year, my filing system has become a large plastic tote that papers are simply tossed into then covered up with the lid or I could pull her file and find out. :o:D

It does take time so be patient. Something I noticed with Squirt and the melatonin - it made her nails grow very fast and very thick so keep an eye on them as you may need to trim them more often. The melatonin may also make Pumphrey sleepy for a few days until he adjusts to it but he should be back to normal soon. Watch the stools with the lignans as they can cause some loose stools / diarrhea as they adjust to increased fiber.

How much does Pumphrey weigh? 6mg twice a day sounds like a dose for a large dog so I wanted to check the dose. ;) (Squirt weighs 14lbs and took 3mg twice a day.) You are using just plain melatonin, right? Not extended release, time released, etc - just plain ole melatonin.

I hope the HMR (Spruce lignans) works better for Pumphrey than it did for Squirt. I started her on the flax lignans (SDG) and her hormones came down. Then I switched to the HMR when they came out because that meant I could give her one capsule VS 3 - but we lost control of the hormones on the HRM. So she was put back on the flax lignans. I've seen several reports of the HMR working just fine for other pups, tho. They just didn't work well for my Squirty - which is typical! If there's a hard way, that's the way Squirt will take me! :D

Please keep in touch and let us know how he is doing!
Hugs,
Leslie and the gang

[maria]

Pumphrey has Atypical Cushings and she started melatonin and lignans about a month ago with no improvement yet. We also discovered a very painful area in the upper flap of her hear. She had it drained and is on antibiotics but it is not getting better. Vet wants to put her under general so he can cut it open to see what is going on. Her liver is enlarged, her alk phos was ~520, spec gravity 1.010 which IMS said was indicative of kidney disease which takes longer to show in the blood chemistry. I am concerned about putting her under and was wondering if anyone has put a older dog (8) under general and how safe is it considering their special issues? Was presedation used or is it better to just use general? Are they still using Iso?

Thanks.

[Roxee's Dad]

Hi Maria,

Surgery is always a tough choice even in a healthy dog. Our Rozee had a dental which required anesthesia at 16 years old. But even our vet agreed we should take her to a specialist that had the knowledge and equipment to take care of her properly.


Moderators note: I have merged your threads to keep all your information in one thread so members can readily access Pumphrey's history. You can have the title changed anytime you's like by just asking any of the admins or mods :)

[maria]

Thanks John. I also have a 10 year-old Standard Poodle desperately in need of a dental to have teeth pulled but I am scared to do that as well. What kind of specialist does one see for dental ?

'Glad the surgery went well for your furbaby. I know what an agonizing decision it can be. You feel darned if you do and darned if you don't. A friend just placed a rescue dog with no apparent issues and the dog had surgery for a herniated disc and died right after coming out of anesthesia so this is weighing on my mind.

[maria]

Sorry to Squirt's mom. I just realized I did not reply to you. Thank you for sharing your experience with Atypical. There don't seem to be many on here with experience with it. Everything you describe is happening to Pumphrey. She is sleeping all the time and has loose stools. If you have better luck with the flax lignans. I might just get them next time to mix it up. I read where the spruce are absorbed better which is why I tried them first.

I am glad Squirt ( that would be a perfect name for my Chiuhahua) got some improvement with his symptoms. I don't know if there is a next step if this doesn't work because her only really elevated hormone is estradiol and that does not seem to be helped by Lysodren and can be exacerbated by Vetoryl. If nothing works, what ultimately ends up killing the dog? Liver failure, PTS for suffering? What is it that causes the suffering? I can live with cleaning up pee. I had a dog in a wheel chair and a completely paralyzed on so I don't mind caring for a special needs dog. I guess I am just wondering the course this typically takes?

[Squirt's Mom]

My Squirt had a tumor and half her spleen removed at the age of 10. She had one of her back legs redone (both pinned and screwed together since about the age of 2) when she was around 13. She is now 15 and desperately needs a dental but I won't put her under again. She's been under 5-6+ times in her short life and that's enough. ;)

Other than an acute pancreatic attack following the spleen surgery, she did fine both times. I was absolutely terrified, tho...as is evident on her thread. :p:o So I fully understand where you're coming from.

However, 8 isn't that old- just barely over the line to be considered "senior". So as long as she is in otherwise pretty good health and the pre-surgery labs are ok, if the vet was comfortable I'd sure think about it. Also, specific gravity can't really tell whether kidney disease is present or not to my understanding. The values on the blood work called BUN, CREA, and the BUN/CREA ratio tell much more. The specific gravity tells how well the kidneys are concentrating urine - and cush pups can't concentrate their urine when things are out of whack, especially the cortisol. Untreated cush pups will have nearly clear pee. ;) I would ask for clarification on his statement before I got too worried.

The treatment for Atypical can take several months before you see signs of improvement and the hormones are back in range....sometimes 4 months or more. Patience is vital with Atypical. ;) Just keep doing what you are doing and believing it will work its magic. If you start to see signs that the cortisol is rising, then you would want to have that checked again but you would continue with the melatonin and lignans. Squirt uses them and Lyso now but didn't need the Lyso for several years, being controlled on the melatonin and lignans. ;)

You're doing a good job of watching her. Keep up the good work! And stay in touch.
Hugs,
Leslie and the gang

[Roxee's Dad]

Hi Maria,
We used a dental specialist :) Actually we have a Veterinary Specialist facility here that covers just about everything from heart specialist, oncology, dermatology, dental, ophthalmology, internal medicine, etc... We are quite lucky to have this facility in the Phoenix area.

[Squirt's Mom]

I don't know if there is a next step if this doesn't work because her only really elevated hormone is estradiol and that does not seem to be helped by Lysodren and can be exacerbated by Vetoryl. If nothing works, what ultimately ends up killing the dog? Liver failure, PTS for suffering? What is it that causes the suffering? I can live with cleaning up pee. I had a dog in a wheel chair and a completely paralyzed on so I don't mind caring for a special needs dog. I guess I am just wondering the course this typically takes?

Estradiol is the weird hormone in Atypical. It can be produced outside the adrenal glands where Lyso can't reach it. But the lignans and melatonin can reach it anywhere. If this is the only elevation, Lyso could still be tried if that approach didn't work well enough. So there is still that option open to her. ;)

Here is a link on Hyperestrinisim, which is what elevated Estradiol is called, and Atypical from the Helpful Resource section.

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

The vet who was leading the research in this area passed away a couple of years ago, leaving much still unknown about Atypical. It doesn't seem to be a high priority for others in the field at the moment as few if any advances have been made...but lots of controversy abounds. ;) I have chosen from the time I knew Squirt was Atypical to look at it as if it were true Cushing's with all the possible ramification that could mean. That has worked for us so far...tho I did miss when her cortisol started to rise. duh :rolleyes:

Hope this helps! I think we were posting at the same time a minute ago...and you got a bit of a repeat post! :D
Hugs,
Leslie and the gang

[maria]

I have been slacking off in giving Pumphrey her morning does of melatonin for the last 3 weeks. Overwhelmed her but not a valid excuse. I am going to rededicate myself to making sure she gets her am dose. Her stomach seems to have gotten even bigger these last few days. I measured it and it is 29.5 inches around. I thought I could keep track of how she is doing by measuring her stomach. The accidents are getting worse as well. I am afraid this is not going to work and by the time we switch to something else, it will be too late.
Is Lysodren an option for estradiol induced atypical? If so, what is the typical protocol? Is it daily doses of the medication, weekly? My vet is unfamiliar with this disease and is doing his own research but I want to be able to be informed as well to help if needed. Thanks.

[Junior's Mom]

Hi Maria. Squirts Mom posted a link just above for you to read about atypical. I am of no help on this. Have you been giving the lignans as well?

[molly muffin]

Hi Maria,

I think that if the melatonin and lignans don't work by themselves then they can introduce a maintenance dose of lysodren.
One of the others who have used this, I think Leslie, can confirm.

hugs,
Sharlene and Molly Muffin

[maria]

Thank you both for the help. I hope Leslie can get back to me because my vet is not that familiar with atypical.

[Squirt's Mom]

It is the combination of melatonin and lignans that works in Atypical. One or the other alone will not help. So if she has been off the melatonin for 3 weeks, she hasn't been getting treatment for Atypical, just some extra fiber from the lignans for the most part. ;)

To repeat part of my earlier post here -
Sometimes Estradiol is produced outside the adrenals where Lyso cannot reach. So the initial treatment is with a combination of flax lignans and melatonin. This combination will typically address estradiol no matter where it is being produced. The lignans and melatonin take several months to work, tho, so patience is required in Atypical treatment.

So, if the estradiol is being produced outside the adrenals and elevated estradiol is her only issue, adding the Lysodren probably won't help. The melatonin and lignan combination is what can reach the estradiol no matter where it is being made in the body.

When you say "it overwhelmed her" do you mean it made her sleepy? That is to be expected but most pups adjust pretty quickly. What dose were you giving? Did you get plain melatonin and not time released, extended wear, etc.? Use the plain form only.

Here is the link about Hyperestrinism again. You might share this with your vet if he hasn't read on UTK's website about this.

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

Are you seeing any signs that the cortisol may be rising? This seems to be the progression of many Atypical pups - they become true cush pups after a time. Was she ever seen by an IMS?

Hugs,
Leslie and the gang

[maria]

The vet is going to put Pumphrey on Trilostane in 2 weeks when we have our appointment. She is not going to repeat any labs. Pumphrey is doing worse and looks depressed. I am hoping this can help her. If not, I guess it is on to Mitotane. She was dxd with Atypical in June. The vet said she has a had luck giving this to her atypical patients even though it is not recommended for atypical. The only really elevated hormone she had was estradiol. Can someone tell me what the typical dose is for trilostane and how much it costs and where to get it cheaply? ALso, do I need emergency predinisone around and how long should it take to see results. Thanks
Maria

[molly muffin]

I've moved your post over into Pumphrey's thread.

You said the vet wasn't going to do any more labs. When was the last ACTH test and what was the result of it? This is very important, since Trilostane is a drug that will lower the cortisol levels and since with Atypical they are not already high, you want to know what you are starting with.

Normally per Dechra, 1mg/1lb would be low in, Davis suggest 1mg/1kg of dog weight. I'd think you would want to start low.
Many use compounded trilostane and buy from Diamondback pharmacy online, which your vet can fax a prescription to or call in. Some other compounding pharmacies are also used by various members. I'd definitely use a recommended pharmacy.
I think you can buy vetroyl online too, with a prescription and maybe some of the others can tell you which ones they use.
Costs depends on how much you need monthly.

Happy Thanksgiving,
Sharlene and Molly Muffin

[gpgscott]

Hi Maria,

I have just seen your thread.

It has been a while for me so I cannot quote exact numbers and the like but it is the component of flax lignans, (sdg) which is important not the amount of lignin itself.

I am not a doctor but would question a doctor who would prescribe trilo for hyper-estrinism. Trilo will affect all of the adrenal hormones.

The combo of melatonin/sdg takes time but has been proven effective for dogs with estradiol issues.

Scott

[Harley PoMMom]

I believe a low dose of Mitotane/Lysodren would be a better option for dog's with Atypical Cushing's. If I remember correctly, a low dose of Mitotane/Lysodren would be around 25mg per kg of the dog's weight split and given 2-3 times a week.

Hugs, Lori

[maria]

Pumphrey had been on melatonin and flax hulls for her atypical Cushing's. Since it had little to no effect after 4 months we switched to Vetoryl. Same problem-did not work and her symptoms seemed a bit worse. Now the vet and I decided to try Lysodren. Problem is the vet has her on a loading does of 750mg until I see a marked improvement in her symptoms or 7 days max. I remember that a loading dose is not used in dogs with atypical and I am concered for her. The vet feels because her symptoms are worse ( no hair on her back anymore) increased accidents, lethargy ect, that she also has regular Cushings now. What is the protocol for treating Atypical with Lysodren? Thanks.

[Harley PoMMom]

Hi and welcome to you and Pumphrey,

When a dog is diagnosed with Atypical Cushing's this means that one or more of the intermediate hormones are elevated but the cortisol is not. The treatment for Atypical Cushing's is melatonin along with lignans, and sometimes a low dose of Lysodren is also recommended. Loading a dog with Lysodren is only done when the cortisol production is excessive, NOT for Atypical Cushing's as you have mentioned.

This excerpt is from the UTK treatment option sheet
Maintenance dose of LysodrenTM. Often useful in combination with melatonin and lignan to help lower sex steroid levels other than estradiol, along with suppressive effect on cortisol level. NOTE: MONITOR CORTISOL LEVELS AS FOR TYPICAL CUSHING’S TREATMENT. Link to UTK Option Sheet: http://www.vet.utk.edu/diagnostic/endocrinology/pdf/TreatmentInfoAtypicalCushings201107.pdf

I do have some questions, ok? Could you get your hands on copies of the results from the UTK adrenal panel and post any abnormal results? Where any other Cushing's diagnostic tests done? Was a chemistry/CBC blood panel done recently, and if so, could you post any abnormalities that are listed? How much does Pumphrey weigh? Does she have a ravenous appetite? Any other health issues?

Lysodren treatment for Aypical Cushing's is usually around 25mg per kg of the dog's weight, split and given 2-3 times a week.

Please know we will help in any way we can so do not hesitate to ask all the questions you have.

Hugs, Lori

[Squirt's Mom]

Did the vet do an ACTH before starting the Lyso?

[maria]

yes. it was right after being on Vetoryl for 2 weeks.

[maria]

results were:Pre- 2.9 range 1-5 Pos-5.3 range 8-17

[maria]

Pumphrey labs:
Pumphrey 9 year-old Beagle

Symptoms for 6 years.polydipsia, polyuria, huge pot belly, ravenous appetite, hind-end weakness, depression.

Diagnosed with atypical Cushings June 2013

Treatment-3mg melatonin 2/d with 40mg lignans 1/d

Labs- Calcium-:12.2(8.9-11.4)chol 348(92-324) trig-794(20-291), lipase-1040(77-695) platelet-600 (170-400) specific gravity 1.010 (1.015-1.050) estradiol 113 post 114 (27-68,2)cortisol baseline-58 (2.1-58.8) aldosterone post-546.5 (72.9-398.5)Ultrasound-normal adrenals mild to moderately enlarged liver

[Harley PoMMom]

After 15 days of waiting, the adrenal panel from UT is finally in and our vet is out with the flu. Results as follows:

cortisol ng/ml baseline : 58.5 - normal :2.1-58.8
cortisol ng/ml post ACTH -99.2 - normal : 65 - 174.6

Androstenedione ng/ml : .60 - normal : 0.5-.57
Androstenedioine ng/mg post ACTH : 2.09 - normal : .27-3.97

Estradiol pg/ml : 114.9 - normal : 30.8-69.9
Estradiol pg/ml post ACTH : 113.9 - normal : 27.9-69.2

Progesterone ng/ml : .44 - normal : .03-.49
Progesterone ng/ml post ACTH :1.37 - normal : .10-1.50

17 OH Progesterone ng/ml : .21 - normal : .08 - .77
17 OH Progesterone ng/ml post ACTH : .95 - normal : .40 - 1.62

Aldosterone pg/ml : 72.4 - normal : 11 - 139.9
Aldesterone pg/ml post ACTH - 546.5 - normal 72.9 -398.5

Comments-estradiol may contribute to clinical signs but not a good indicator of adrenal activity because it is secreted by adrenal tissue.
(?) these results indicate presence of increased adrenal activite ( marginal)



I have inserted a post from you with UTK results from 6/7/13, are these the most recent ones?

Hugs, Lori

[maria]

yes. thanks for your help.

[Harley PoMMom]

Has Pumphrey's symptoms decreased at all?

[maria]

No, they have gotten worse. She is more weak, lethargic, hungry, thirsty, having more accidents. She always had a beautiful hair coat which is why nobody suspected Cushings but I shaved her last summer and the hair is not growing back on he her back. Just her legs and her tails is loosing hair. Her abdomen has gotten more pendulous and she is gaining weight. She is panting more too. I forgot to post her Alk Phos was 560 last test.

[Harley PoMMom]

I believe stopping the Vetoryl is correct, but since Pumphrey has been on Vetoryl a wash-out period needs to be done before switching to Lysodren.

Usually the wash-out period is at least 30 days. Although she is displaying symptoms, if this were me, I would want to see an increase in her cortisol to at least 9 ug/dl.

Now, I forget how much she weighs, can you refresh my memory?

[maria]

She weighs 39 pounds. It has been 30 days since she has been off the Vetoryl. I am not sure I understand about her cortisol being 9ug/dl. Her cortisol has (so far) not been elevated. We are just trying the Lysodren to see if it helps her Atypical since nothing else has worked. She is going downhill pretty rapidly these last few months.

[Squirt's Mom]

My word! her cortisol has been normal all this time but the vet put her on Vetoryl?! :eek:

[maria]

Yes because the lignans and melatonin weren't working. We have nothing else to try to treat her with now other than the

[bgdavis]

Maria,

I've been gone from this forum for a number of years, but Pumphrey's condition sounds so much like that of my Criss Ann's that I thought you might like to read her story. Criss ended up with both Atypical Cushings and diabetes, so her story is on the sister forum of here.

http://www.k9diabetes.com/forum/showthread.php?t=83

Bonnie and Angel Criss Ann

[maria]

Thanks so much for the link. Sorry you had to go through this too.

[Harley PoMMom]

She weighs 39 pounds. It has been 30 days since she has been off the Vetoryl. I am not sure I understand about her cortisol being 9ug/dl. Her cortisol has (so far) not been elevated. We are just trying the Lysodren to see if it helps her Atypical since nothing else has worked. She is going downhill pretty rapidly these last few months.

Since Pumphrey's cortisol has never been elevated and with the Vetoryl bringing it down to 5.3 ug/dl, it concerns me. When switching from one drug to another a 30 day wash-out period is recommended, which you mentioned has been done, but they also suggest the cortisol be equal or higher than 9 ug/dl.

So with her weight being 39 lbs which = 17.7 kg, her Lysodren dose, at 25 mg per kg, should not be more than 443 mg, being split and given 2-3 times a week.

[maria]

Thanks so much for the link. Sorry you had to go through this too.

[maria]

Just read Chissy's story. What a special dog. Your Eskies are cute but there is just something about Crissy that draws my eyes to her. I can tell why she was very special to you. I am sorry for your loss. I have had to euthanize every one of my dogs. Being in rescue, that has been quite a large number. I asked God with Sam, my 17 year-old labx to please take her so I don't have to do it with her. It happened that she seemed to go into a come and I rushed her to the vet and she was unconscious by the time we got there. He did help he cross but I did not have to agonize over should I or shouldn't I or is it time yet or not.

Crissy was even pretty before she was treated and I love her little ear but like Pumphrey, she has had issues since she was very young. Pumphrey started having abnormal labs when she was 2.5 years old.

I did not see what treatment protocol you used for Crissy. Did I miss it?

Thanks for sharing your story.

Maria

[bgdavis]

Criss was very special to me. I actually got her when she was just 5 weeks old and I think she thought I was her mother.

Criss was successfully treated with Lysodren for her atypical Cushings. The pictures show the improvement in her coat and weight. Of course, she was on insulin for the diabetes. She also had lupus on her poor nose, which used to crack and bleed.

Yesterday was her birthday and I think about her every day. I will always miss her.

Bonnie and Angel Criss

[maria]

Pumphrey was on 750mg loading dose for Atypical Cushings for 3 days. ACTH results from yesterday are : 2.9ug/dl (1-5) and 6.4ug/dl(8-17) One month ago we tried Vetoryl for 2 weeks and the results of the ACTH Stim test then were 2.9 and 5.3. Vet is not in today to go over results. Not sure what this means with regard to treatment and how we proceed. Pumphrey's symptoms for Cushings are getting worse.

[lulusmom]

Your Pumphrey is certainly an anomaly and I'm completely perplexed. It strikes me as being very odd that a dog who has been showing signs associated with hyperadrenal issues for six years should have normal sized adrenal glands, and an adrenal panel that shows little to no hyperadrenal activity and no coat or skin problems. I have to question whether Pumphreys problems are adrenal related at all. Estradiol seems to be the only adrenal steroid that is elevated and according to Dr. Mark Peterson:


In the intact male, estradiol is also present, being produced as an active metabolic product of testosterone. In neutered dogs, the adrenal glands do not secrete estradiol directly but do normally secrete adrenal androgens (i.e., androstenedione and testosterone), even in the neutered dogs. A fraction of these adrenal androgens undergoes conversion to estradiol by an enzyme called aromatase in peripheral tissues (especially fat cells). So the source of the circulating estradiol that you are measuring could indirectly be the adrenal glands, but whether or not the high value found in this dog is clinically significant is difficult to know. These adrenal panels are difficult to interpret, and they are often abnormal in dogs even without clear evidence of typical or atypical Cushing's syndrome.

In a recent study of normal dogs published out of the University of Tennessee, they showed that the there was a wide range of variability in estradiol concentration both within and between the dogs (3). In addition, they reported that these estradiol concentrations often exceed the normal ranges established by the laboratory! This may account for why most of the adrenal panels I see have an abnormal serum estradiol concentration.

That excerpt can be found on one of Dr. Peterson's blogs where he is answering a vet's question about a patient. You can read the entire blog here: http://endocrinevet.blogspot.com/2011/08/q-high-serum-estradiol-in-neutered-male.html

I have bolded the text regarding estradiol in an intact male. Is Pumphrey intact? Estradiol is found outside the adrenal glands, especially in the testicles, so if Pumphrey still has his testicles, this could be the source of estradiol. The only way to figure that out if this is causing the problems is to have him castrated and see if symptoms resolve. If it is, neither Vetoryl or Lysodren will help if the source of the estradiol is not adrenal based. If Pumphrey is already castrated, that doesn't leave many options so what I would suggest is that your vet might consider either presenting Pumphrey's case to Dr. Peterson via his blog or post a comment to the existing blog I have referenced above. At this point, you have nothing to lose and Dr. Peterson's time is free on his blog.

Glynda

[maria]

Thank you for the information and the link. Pumphrey was spayed so she doesn't have her ovaries. Yes, she is a perplexing case. I never believed that the elevated estrogen was causing her problems for the reasons stated. I latched onto it because I had nothing else. She began having abnormal labs when she was 2,5 years old and symptoms getting progressively worse. Her glucose has been elevated though not now. Vet said 140 wasn't high enough to say she had diabetes because she was not spilling it into her urine. Her platelests and lipids have been elevated as is her calcium. She is a metabolic mess without a real diagnosis. She is the poster child for Cushings. The only symptom of the list she doesn't have yet are the plaques.

[lulusmom]

Oh my gosh, Pumphrey, I'm so sorry I called you a boy. :o:o:o

I would still talk to the vet about presenting Pumphrey's case to Dr. Peterson. Very few have his credentials and if you can get his opinion for free, then I say go for it.

[molly muffin]

I thought I'd check in on you and see how Pumphrey is doing? Are you continuing on the lysodren and has it made any difference in how she seems to be reacting? I do hope that lysodren is going to be the answer, so life can get back to something resembling normalcy. :) (whatever that is LOL )

Sharlene and Molly Muffin

[pumphrey]

Edited to add: "pumphrey" and "maria" are one and the same, and from this point onward, "maria" will resume posting. ;)

Hello,

I am back. Pumphrey was diagnosed with atypical Cushings ~ 2 years ago. We tried flax and melatonin for 4 months and it did not relieve her symptoms. We then tried Lysodren and loaded her twice. The second time her symptoms improved dramatically for 3 weeks after she loaded and was put on a maintenance dose but then there was not a dramatic improvement so I kind of gave up and quit all meds. Over the last 5 months her symptoms have gotten much worse. Also, she has a huge lipoma that needs to be removed but I am afraid for the surgery because of her labs. The vet now wants to try Ketoconizole but I am thinking of trying Lysodren again because at least she was better than she is now when she was on it.. I do not want ot use Keto because of its effects on the liver.Here are her most recent abnormal labs.
ACTH Stim 4.6 , 14.2 normal range 1.0-5.0 and 8.0-17.0 the vet tells me she does not have typical but her post seems in the high normal range and to me, might indicate typical cushings. What are your thoughts. Could the be typical Cushings?
ALP-1100 normal range 5 -131
BUN -38 normal range 4-27
Ca - 11.7 normal range 8.9-11.4
Chol - 372 normal range 92-324
Trigyl - 1250 normal range 29-291
Lipase - 1548 normal range 77-695
Specific gravite - 1.010 normal range 1.015 - 1.050

[labblab]

Hello Maria and Pumphrey, and welcome back (although I am sorry that you are still having a tough time!)

I haven't yet had the chance to read back through your whole thread, but just from this page alone, it sounds as though Pumphrey is a bit of a mystery :o. No, in honesty, given that ACTH cortisol value, Pumphrey still would not fit the criteria for conventional Cushing's. Have you had her other adrenal hormones tested at all recently? It sounds as though only estradiol was elevated the last time around, and I am just wondering whether there have been any other changes in her overall profile.

I would tend to agree with you -- if you got a good result before with Lysodren, I believe I would repeat it rather than shifting to keto. But just as soon as I have a chance to review your thread in total, I'll come back again and add any additional thoughts.

Marianne

[maria]

Thanks so much Maryanne. Her symptoms are quite severe now. She awakens me at 3-4 in the morning to let her out. From what I have read, is the common Lysodren protocol to give the dog 25mg/kg for 3-4 days then wait 2 days and give the low-dose maintanence dose of 25mg/kg divided in 3 doses weekly? Last time my vet induced her as one would a dog with regular Cushings. I want to tell her the more conventional protocol for dogs with atypical.

Maria

[Harley PoMMom]

Hi Maria,

I just did a quick scan of your thread and found these results from Pumphrey's UTK adrenal panel which shows that her cortisol was NOT elevated, also I saw that her UC:CR results were not consistent for a dog with high cortisol. Since her cortisol did fall within the ranges for a dog without Cushing's a loading dose of Lysodren should of never been tried, only a maintenance dose of Lysodren is recommended.

I have only a moment to post, and I will try to get back later on with more thoughts of mine.

Hugs, Lori



After 15 days of waiting, the adrenal panel from UT is finally in and our vet is out with the flu. Results as follows:

cortisol ng/ml baseline : 58.5 - normal :2.1-58.8
cortisol ng/ml post ACTH -99.2 - normal : 65 - 174.6

Androstenedione ng/ml : .60 - normal : 0.5-.57
Androstenedioine ng/mg post ACTH : 2.09 - normal : .27-3.97

Estradiol pg/ml : 114.9 - normal : 30.8-69.9
Estradiol pg/ml post ACTH : 113.9 - normal : 27.9-69.2

Progesterone ng/ml : .44 - normal : .03-.49
Progesterone ng/ml post ACTH :1.37 - normal : .10-1.50

17 OH Progesterone ng/ml : .21 - normal : .08 - .77
17 OH Progesterone ng/ml post ACTH : .95 - normal : .40 - 1.62

Aldosterone pg/ml : 72.4 - normal : 11 - 139.9
Aldesterone pg/ml post ACTH - 546.5 - normal 72.9 -398.5

Comments-estradiol may contribute to clinical signs but not a good indicator of adrenal activity because it is secreted by adrenal tissue.
(?) these results indicate presence of increased adrenal activite ( marginal)

So Pumphrey is very symptomatic, I will recap her symptoms and labs below. Her cortisol level was in the high normal range at baseline. Androstehedione elevated baseline. Estradiol elevated baseline and post ACTH. Aldosterone elevated post ACTH.

Her symptoms are getting worse. Both the IMS and reg vet are convinced she has Cushings based on clinical presentation. What do the above results mean? Is she a candidate for some type of t reatment? Lab says if clinical consider Melatonin implant and Lignan. Her labs don't seem to match the severity of her symptoms. I am confused.

Pumphrey is my 9 y/o Beagle who has had symptoms of Cushings for the last 5 years that have gotten progressively worse.
She has a huge pot belly but I can feel her ribs, she is drinks large amounts of water and charges the water bowl in the morning. She is always hungry and has to be fed separately or she will eat everyone's food, she pants a lot, is lethargic, can't jump on bed anymore, has accidents: I let her out in the am, then 2 hours later, then 1 hour later on the way home from the vet she peed in the car . As you can imagine, this has been very frustrating for me because without a diagnosis, I cannot treat. She is having a LDDST on Wed. Since her uriine cortisol has been normal each time it is taken, I am suspecting this test will also be wnl. I think she might have atypical Cushings. Her thyroid is normal. Would an abdominal x-ray be of any value to see what is going on inside her abdomen? Vet said her liver felt enlarged. Any advice appreciated.

Total protein : 7.5 (5-7.4) last year was 7.3

ALP : 510 (5-131) last year was 216

Ca : 12.1 (8.9-11.4) last year was 12.1

Chol : 348 (92-324) last year was 255

Trig : 793 (29-291) last year was 127

Lipase : 1040 (77-695) last year was 828

Platelet : 600 (170-400) last year was 583

Urine Specific gravity : 1.010 (1.015-1.050) last year was wnl

Protein : 2+ (negative) last year was negative

Cortisol/Creatinine ratio 8 - Cushings is highly unlikely in dogs with < 13

Hemolysis 2+ Lipemia 2+ with no significant interference.
Maria

[labblab]

Maria, I think that original UTK panel listed above was performed in June of 2013? Have you ever had a follow-up done? Just curious.

Just wanted to add that it looks as though you also tried Vetoryl for a short while, but not with a good result?

Marianne

[Squirt's Mom]

A dog with Atypical is NOT loaded at all, they simply start on a maintenance dose, 2-4 times a week. ;)

[maria]

Thank you for reposting those labs and for trying to make sense out of this. Okay, so if I understand this correctly, she is not typical. She should not be given a loading dose. She should be maintained on 25/mg/kg divided into 3-4 doses per week? For example, Pumphrey has ballooned up to 45 pounds so her weekly dose should be ~ 500mg divided into 4 doses...is that correct? I am going to tell the vet when she calls today that this is how I want to proceed in addition to the lignans and melatonin I started her on last week.

Maria

[maria]

I forgot to add her BUN is now 38 (it was normal before) and she had 1+ RBC and protein in her urine but no WBC.

[Squirt's Mom]

If the lab work from UTK is the latest ACTH Pumphrey has had, that is the first thing that needs to be done to make sure cortisol has not risen in the meantime. Most Atypical pups do become conventional with elevated cortisol so you'll want to see how it looks first. ;) Just the regular ACTH thru your vet's normal lab is fine - no need to rerun the full adrenal panel unless you or the vet want to see the other hormones. If you can afford it, the full panel would be best but the regular ACTH will tell the tale on the cortisol and that is most important right now. You can check the full panel later.

[maria]

No, we haven't had a new U of T panel. Too many vet expenses this year. I know it would be good to do but Pumphrey is going to need surgery for a large lipoma soon. No the Vetoryl did not work at all.
Thanks for asking and for your help.

Maria

[labblab]

Here are her most recent abnormal labs.
ACTH Stim 4.6 , 14.2 normal range 1.0-5.0 and 8.0-17.0 the vet tells me she does not have typical but her post seems in the high normal range and to me, might indicate typical cushings. What are your thoughts. Could the be typical Cushings?
Maria, I was assuming this was a more recent ACTH test for cortisol? Can you tell us when this test was done?

Marianne

[maria]

Yes, 2 weeks ago. She has not been on any medication for about 8 months.

[Squirt's Mom]

Oh good, I didn't use my good eye to see the results from the new ACTH. :D So the post is still normal which means she is still Atypical so I would not load but start on maintenance.

[maria]

Thank you Squirt's mom. This helps a lot.

[Harley PoMMom]

Okay, so if I understand this correctly, she is not typical.

Correct, she is still Atypical since her cortisol is not elevated.


She should not be given a loading dose. She should be maintained on 25/mg/kg divided into 3-4 doses per week?

Yep, no loading lose of Lysodren, only a maintenance Lysodren dose and that 25mg/kg is usually what is recommended for Atypical.


For example, Pumphrey has ballooned up to 45 pounds so her weekly dose should be ~ 500mg divided into 4 doses...is that correct? I am going to tell the vet when she calls today that this is how I want to proceed in addition to the lignans and melatonin I started her on last week.


For her weight of 45 lbs, which is 20.45 kg, and at 25mg/kg, that comes out to 511.25 mg of Lysodren, which rounded out would be 500mg divided and given 3-4 times in one week, so you are correct in all aspects!!!

Good for you for telling her vet the way Pumphrey should be dosed, you're doing an excellent job being her voice and advocate.

Hugs, Lori

[maria]

Hi Lori,

Thank you for the support. I just spoke to the vet and she agreed to give Pumphrey the Lysodren low dose maintanence dose so she will be taking 500mg/wk. I am wondering how soon should I start to see some improvement? I know the melatonin/lignans take about 4mths but what about the Lysodren? When she was induced last time, I saw improvement after 7 days. I imagine this will take considerably longer.

Maria

[Harley PoMMom]

I would give the maintenance dosing at least a month to see improvements, and then I would have an ACTH stim test done to see where her numbers are....just my two cents worth :D Hopefully others will share their opinions as well.

[Squirt's Mom]

Squirt's response was almost immediate if memory serves. She took 125mg 2x a week at first and her appetite, which had SOARED, came back to her normal Miss Piggy state very quickly. ;)

[judymaggie]

Maria--congrats on managing Pumphrey's way through the atypical maze. My first Cush pup, Maggie, was diagnosed with atypical which we treated with melatonin implants and lignans. By the time she showed elevated cortisol she had serious liver disease so we couldn't add the Lysodren maintenance. I am so glad that you were able to get Pumphrey diagnosed early in the process. The melatonin implant does allow for a quicker, more consistent dose so you might want to ask your vet about it. My Maggie was my vet's first dog to get an implant although he had used them in ferrets for a while.

I totally agree with Lori's recommendations re waiting the month to do the ACTH.

[maria]

Pumphrey has atypical. About 3 weeks ago I resumed lysodren maintenance with melatonin and lignans. Pumphrey had large tumor on her leg which had been there for a while. It was very vascular. The vet did an aspirate and believed it to me a lipoma and we were going to try to get her Cushings under control before the surgery. Well, 3 days ago, she banged the tumor and opened a tiny lesion that squirted blood such that my home, car and yard looked like a crime scene. I am still cleaning blood. But I had to take he in for emergency surgery. All went well. They treated her with dexamethasone prior to surgery because of the lysodren. The strange thing is, for the first 24 hours she was home, her Cushings symptoms were gone. Even today, they are much improved. I read a study about actually treating atypical Cushings with low does steroids which showed improvement in secondary sex hormones. Any thoughts?

Maria

[maria]

Pumphrey has atypical cushings. Her last ACTH was at 14.8. I have not been treating her for over a year because nothing really seemed to work. Her symptoms have gotten much worse. We tried lysodren which worked right after loading then stopped. We tried vetoryl ( compounding pharmacy) didn't work. Lignans and melatonin did not help either. The question I have is that she was so bad yesterday, I started to give her the maintenance dose of lysodren (250) I was going to give her the other 250 later in the week but the vet wants to try her on Vetoryl using the brand name instead of compounding pharmacy to make sure it is standardized. So do I have to wait 2 weeks to try the Vetoryl since she only had 1/2 of the maintenance dose yesterday or can I start her now?

[labblab]

Hi Maria, sorry I have only a moment to post right now, but I wanted you to know I've merged your new reply into your original thread so that all of Pumphrey's treatment history will be consolidated in one place. ;)

Marianne

[molly muffin]

I would wait a couple days then try the brand name vetroyl.

[maria]

I am supposed to be starting Pumphrey on Vetoryl but she hurt her leg so I am having to give her tramadol. Could the side-effects of the tramadol ( tired, lethargic, sleeping all the time etc) mask the beginnings of an Addisonian crisis? Should I wait to start the Vetoryl until she is off the tramadol?

Maria

[Harley PoMMom]

I don't believe that tramadol would mask the symptoms of Addison's. But I also would not initiate the use of Vetoryl when Pumphrey is just starting the tramadol because if any ill effects, such as diarrhea or vomiting, would occur it would be hard to know if it was from the Vetoryl or tramadol.

Hug, Lori

[maria]

Thanks. I will wait. The strangest thing is that since she has been on the Tramadol, her symptoms are gone...well except for the pot belly and hair loss but she isn't panting nor drinking excess water. This happened once before. All of a sudden her symptoms stopped. I correlated it at the time to the melatonin. When I stopped it, she seemed to stop panting. Since Tramadol is contraindicated with melatonin (serotonine symdrome potential) I quit giving it to her. Though I started the melatonin again because she was having symptoms. It is strange.

[Harley PoMMom]

Pain can make a dog pant and drink more water, so now that she is taking the tramadol she may be more comfortable. Keep us updated!

Hugs, Lori