Please help!

[tobyfishrap]

We have a 12 year old Akita Shepherd mix recently diagnosed with Cushings. We are doubtful because he doesnt seem to have the major symptoms of Cushings so we are thinking he might have been misdiagnosed or maybe we are just in denial. He doesnt drink excessively-we know for sure because the water bowl (shared with 2 other small dogs) are still almost full when we get home. He doesnt urinate excessively, no accidents whatsoever. Sometimes, he doesn't even urinate when walked in the morning. It is the unnecessary panting and unusual breathing that led him to the test. His hind legs are a little weak when walking sometimes they fall behind coz I can hear his nails against the ground . Hair is a little thin on the thigh area where he sleeps on but he always had this. Appetite is good, always has been and I dont know know if excessive or not. We have no food or garbage lying around so I consider his appetite normal. I will email the test results to whoever wants it. I see urinary cortisol/creatinine ratio is 29, Cortisol Sample 1 is 6.1 (high), Sample 2 Dex is 2.1 (high) Sample 3 Dex is 1.1. My name is Ingrid and our dog is RAP.

[frijole]

Hi! I am at work so can't post a ton. The test that you had done is the low dose dex suppression test and it can have false positives. Not all dogs have all issues - my Haley had the appetite but no drinking issues. She would inhale food and not chew. She lived to eat.

So we will need more info before we can really comment. Given the lack of symptoms I would certainly insist on more testing before giving any treatment.

Did you have any blood panels done prior to the cushing's test? It'd be helpful if you could post any abnormal (high or low) results as well as the range for normal beside each result. That way we can see what they look like.

Two other simple questions - does your dog have a round tummy and is the urine clear or yellow? :)

Kim

[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 to you and Your sweet little fur baby.

Hugs,
Kathy

[addy]

Hi Ingrid,

My pup did not have all the symptoms either, mostly hair/coat skin issues and hind leg problems. The problem with the tests done for Cushings is that they are not perfect so can yield false positives as well as false negatives.. A big part of diagnosis is history and symptoms.

Tell us as much as you can and list all tests showing abnormal values with the lab's normal range as well. Was there only one test done?

Glad you found us!!!:)

[labblab]

I believe the 3-sample test results that you gave us are for a diagnostic LDDS test. However, if so, those results are most likely negative for Cushing's. To know for certain, we need to know the "normal" range for those values. The normal can vary from lab to lab, but normally the cut-off is around 1.4 - 1.5 ug/dl. In order to be positive for Cushing's, the 8-hour result has to exceed that norm. Since your dog's 8-hour result was only 1.1, I can virtually guarantee that it is lower than the cut-off and therefore within the range of a normal dog without Cushing's...

Here is a link that better explains how to interpret the results of an LDDS test.

http://veterinarymedicine.dvm360.com/vetmed/Medicine/ClinQuiz-Interpreting-low-dose-dexamethasone-suppr/ArticleStandard/Article/detail/580093

Marianne

[lulusmom]

Marianne, Ingrid sent the LDDS results to our gmail addy. The reference range is 0.0 - 1.4 ug/dl. I agree with you that this test is not consistent with cushing's.

Ingrid, I am having a hard time reading your vet's notes but it looks like RAP was on prednisone at some point. Can you clarify when that was prescribed, what it was for and how long had he been off of it before the LDDS test was done? What other meds was or is he on?

Glynda

[tobyfishrap]

Hi! I am at work so can't post a ton. The test that you had done is the low dose dex suppression test and it can have false positives. Not all dogs have all issues - my Haley had the appetite but no drinking issues. She would inhale food and not chew. She lived to eat.

So we will need more info before we can really comment. Given the lack of symptoms I would certainly insist on more testing before giving any treatment.

Did you have any blood panels done prior to the cushing's test? It'd be helpful if you could post any abnormal (high or low) results as well as the range for normal beside each result. That way we can see what they look like.

Two other simple questions - does your dog have a round tummy and is the urine clear or yellow? :)

Kim

Hi Kim,

I'm pretty new at this so I am not sure where to reply. In answer to your question, the vet did a few blood work and it showed that his liver enzyme is at 700, then a month later it was at 740, then she put her on prednisone, actigall, flagyll and amoxicillin. His belly was a little round but that was due to him eating a lot maybe, and his urine is almost clear.

[frijole]

OK... thanks for the response. Why did your vet put your dog on those drugs? Is something else going on? Most important a vet wouldn't put a dog with cushing's on prednisone because that would make it worse! Seriously - prednisone is = to cortisol which is what causes cortisol. It is 100% equivalent to giving a diabetic dog a box of sugar to eat. Makes no sense whatsoever.

Thank you Marianne for looking at the cushings test results. I thought it was questionable but didn't have time to look at work. So the test for cushings is negative.

In short - your dog doesn't have cushings. But I still want to know why your vet gave you those drugs to give. Scratching my head.

Oh and you answered me just fine! Good job mom! Kim

[tobyfishrap]

Marianne, Ingrid sent the LDDS results to our gmail addy. The reference range is 0.0 - 1.4 ug/dl. I agree with you that this test is not consistent with cushing's.

Ingrid, I am having a hard time reading your vet's notes but it looks like RAP was on prednisone at some point. Can you clarify when that was prescribed, what it was for and how long had he been off of it before the LDDS test was done? What other meds was or is he on?

Glynda

Hi Glynda,
I am going to get all of his medical records. Hopefully you will be able to read them. I am very hesitant to give him the Trilosane that she prescribed Rap.

[tobyfishrap]

Hi Kim,

I'm pretty new at this so I am not sure where to reply. In answer to your question, the vet did a few blood work and it showed that his liver enzyme is at 700, then a month later it was at 740, then she put her on prednisone, actigall, flagyll and amoxicillin. His belly was a little round but that was due to him eating a lot maybe, and his urine is almost clear.

A week after him taking the pred, she took some blood work again and it showed that his live enzymes was 1700 something.

[frijole]

Is your dog still on prednisone? Kim

[tobyfishrap]

OK... thanks for the response. Why did your vet put your dog on those drugs? Is something else going on? Most important a vet wouldn't put a dog with cushing's on prednisone because that would make it worse! Seriously - prednisone is = to cortisol which is what causes cortisol. It is 100% equivalent to giving a diabetic dog a box of sugar to eat. Makes no sense whatsoever.

Thank you Marianne for looking at the cushings test results. I thought it was questionable but didn't have time to look at work. So the test for cushings is negative.

In short - your dog doesn't have cushings. But I still want to know why your vet gave you those drugs to give. Scratching my head.

Oh and you answered me just fine! Good job mom! Kim

I don't know but she told me that she doesn't know what's going on with Rap becuase as I mentioned it started out with his panting and restlessness. His dosage of the pred was 2 20mg twice a day for five days, then 1 20mg twice a day for five days then half a tab every other day until gone. Along with that was actigall twice a day, flagyll once a day adn amoxicillin twice a day (500mg each) for 14 days. On the third day of the 2 20mg twice a day we thought we were going to lose Rap.. No sleep the whole night, he panting like there is no tomorrow and drinking water like there's no tomorrow. I just slowly taper it down.. Stopped the actigall and the flagyll. I could not bear seing our dog like that.. Looking back if Rap died, I killed him following doctors orders.

[frijole]

Your vet is clueless. Google it. Prednisone causes the thirst and the panting and the restlessness. I can't believe they gave you prednisone. At least they knew to taper it. YOu can' just quit giving it after you've been on it a while - it's too hard on them.

Please no more of that stuff. I have to leave and will be gone for a couple hours - I will check back in then. I do not think your dog has cushings at all.

Please write us a detailed story of when the 'illness' started and what the symptoms were. If this is because of the high alk phos/liver enzymes that could have been from anything. Anyway, the more info the better - we'll do our best to help lots of great people here. Kim

[molly muffin]

Okay, I'll be here off and on and will check for updates.

Prednisone can cause the same symptoms as cushings. There are only a few very special circumstances where you would give it to a dog With cushings, none of which have been mentioned here and which would be in very small amount, nothing like what your vet put Rap on.

Without knowing much more like the full story of why Rap was put onto this medication and what sort of values were abnormal, it is hard to really have the full picture of what is going on and what your next step should be.

Lets go over those items. You can get copies of all the testing? and post here. Do you know WHY Rap was put on these medications, what they were for?

sharlene and molly muffin

[tobyfishrap]

Is your dog still on prednisone? Kim

Not anymore Kim

[molly muffin]

How long ago did you stop the prednisone? and how long after the prednisone was stopped was the blood work where the enzymes were higher and cushings (cortisol) test done?

Sharlene and molly muffin

[tobyfishrap]

Marianne, Ingrid sent the LDDS results to our gmail addy. The reference range is 0.0 - 1.4 ug/dl. I agree with you that this test is not consistent with cushing's.

Ingrid, I am having a hard time reading your vet's notes but it looks like RAP was on prednisone at some point. Can you clarify when that was prescribed, what it was for and how long had he been off of it before the LDDS test was done? What other meds was or is he on?

Glynda
Yes Glynda he was on pred, actigall, flagyll and amoxicillin. He was off pred for a week then he had blood work. His liver enzyme read 1730. A week after that blood test they did the 8 hour blood abd urine test for cushings.

[molly muffin]

I am pretty sure that having a blood test a week after being on that much prednisone, that it is not unexpected that the liver enzymes would have increased. That is to be expected when taking prednisone. Also, 2 weeks later doing a cushings test after being on prednisone is too soon for any valid result. I am not sure if the minimum is 30 days - 45 days to wait or if it is even longer based on the amount of prednisone taken and the length of time taken for.
However, what I do know, is that higher liver enzymes and the cushings test have little meaning based on that scenerio.
Prednisone is a steroid that acts in the same was as cortisol, you can think of it as a synthetic cortisol in fact as it works in the same way and does the same thing.
Sharlene and Molly Muffin

[frijole]

I don't understand why your dog was put on the two antibiotics either. Was something else going on? Two antibiotics, a drug for gall stones and prednisone. There's got to be more to this story. Tell us as much as you can please. Thanks. Kim

[tobyfishrap]

I don't understand why your dog was put on the two antibiotics either. Was something else going on? Two antibiotics, a drug for gall stones and prednisone. There's got to be more to this story. Tell us as much as you can please. Thanks. Kim

Here is the story of Rap!! Back in 2010, Rap was in for his regular checks. He had blood work done, liver enzyme was at 700, vet said that it is a little high but other wise he is in good health. 2011, he had another lab done, his liver enzyme was 640. Vet said better that the previous lab. 2012, liver enzyme 740. Later part of 2012 (Nov), he was chewing his rear, came to find out his anal glands were infected. Got cleaned, and vet put him on antibiotic, rechecked after finishing antibiotic, but infection was not cleared, vet prescribed another antibiotic, eventually cleared. 1/13 rechecked anal glands checked still cleared. 4/13 anal glands cleaned again, per tech it was half full. Later part of April, he started panting off and on until one day when I was monitoring them from work that rap jumped up on the couch and being restless. Took him to the vet. Vet could not diagnose him, sent home some calming natural supplement. It helped a little but started panting again this time it was pretty often. Vet took some blood work, his liver count was 1000. This is where vet put him on pred, actigall, flagyll and amoxicillin. She said that he might have some kind of an infection that is causing the panting and the live count to go up. She said that if it did not work she might have to do x-rays and ultra sound. She said that after finishing up the meds she will do the lab work again. As mentioned earlier, rap had to take pred 2 20mg twice a day for five days, then 1 20mg twice a day and half tab every other day until gone. The actigall was twice a day for 10 days, the flagyll once a day for 10 days and amoxicillin twice a day for 14 days. I only gave rap 2 20mgtwice a day for 3 days, 1 20mg twice a day for two days, half tab every other day for 5 days and 1/4 tab every other day for 5 days. The actigall I gave it him for 6 days same with flagyll and amoxicillin. On may 20, vet took blood work his lever count went up to ALP 1730, ALT 202, BUN 10, CRE 0.8, GLU 116 and TP 8.0. On 6/1/13 he was there for 8 hours for the cushings test. On 6/6/13 vet put him on Trislostane 60mg 1 cap per day.

I have not given him any Trislostane as I do not trust giving him any of the medications. I would like to give him natural stuff.

Since beginning of this year, Rap has been hacking off and on and when he barks he has that hoarse sound. He still pants but not as bad as he did before.

I am giving him some Milk Thistle and Adrenal supplement and Agile Joint from PetWellBeing. I have read the review from their website and they have good reviews with these products. I feel safe giving natural stuff to him that what the vet is prescribing.

[frijole]

The cushings test was June 6th - when was the last day you gave the predinsone? Thanks. Kim

PS I think you did the right thing holding off on the trilostane. Not because it doesn't work in cushings dogs but rather the test results do not support cushings.

[labblab]

OK, just read your most recent reply with Rap's more complete history, and this is what I'm making of it. He was given the prednisone before the vet suspected Cushing's, and alongside several other meds that were presumably being aimed at treating some unidentified infection/inflammation that might have been causing the panting and restlessness. The prednisone was tapered and he finished the courses of the other meds but the symptoms remained alongside elevated liver values when blood was rechecked and the vet decided to run the LDDS.

Here's my take on things. First, absolutely do not give Rap the trilostane. His LDDS was negative for Cushing's, and it looks as though your vet totally misinterpreted the LDDS test results. I took a look at the lab sheet you sent to our gmailbox, and the IDEXX test result very clearly states that an 8-hour test result lower than 1.4 is negative for Cushing's (Rap's result was 1.1). Yet somebody, presumably your vet, has handwritten the note "PDH - Pituitary Cushing's." That person did not accurately read the interpretation instructions printed on the form.

A negative result on the LDDS is usually very trustworthy -- it is an accurate finding in 90% of dogs who are tested. And you don't need to worry about the prednisone having skewed the test, because your worry in that vein is if a test comes out "positive" -- you wonder whether the prednisone caused the positive result instead of Cushing's.

Bottom line, I believe Rap needs further diagnostics to find out what is at the bottom of his unresolved cough, panting, and abnormal test values. I do not believe it is Cushing's, and I am sorry to tell you that I would have little/no confidence in a vet who starts trilostane treatment after mis-interpreting the diagnostic test. Or for that matter, seemingly just throwing everything except the kitchen sink to clear an unidentified supposed infection. If Rap were my dog, I would want a second opinion as to what is going on with him. Do you have other vets in your area? We can help you with a search if you are not sure.

Marianne

P.S. Just to clarify re: the LDDS results: had Rap's 8-hour result been higher than 1.4 and therefore consistent with Cushing's, THEN you would look at the 4-hour number. In Rap's case, the 4-hour result would indeed have been consistent with the pituitary form of the disease, but only if the 8-hour result was "positive" to begin with.

[molly muffin]

Kim, I think it was about 2 weeks earlier that the prednisone was stopped.
Is that right Ingrid?

Sharlene and Molly Muffin

[tobyfishrap]

Kim, I think it was about 2 weeks earlier that the prednisone was stopped.
Is that right Ingrid?

Sharlene and Molly Muffin

Hello Sharlene and Molly,
It was only a week after he was off prednisone when they did his blood work and then 11 days later the cushings test.

[tobyfishrap]

OK, just read your most recent reply with Rap's more complete history, and this is what I'm making of it. He was given the prednisone before the vet suspected Cushing's, and alongside several other meds that were presumably being aimed at treating some unidentified infection/inflammation that might have been causing the panting and restlessness. The prednisone was tapered and he finished the courses of the other meds but the symptoms remained alongside elevated liver values when blood was rechecked and the vet decided to run the LDDS.

Here's my take on things. First, absolutely do not give Rap the trilostane. His LDDS was negative for Cushing's, and it looks as though your vet totally misinterpreted the LDDS test results. I took a look at the lab sheet you sent to our gmailbox, and the IDEXX test result very clearly states that an 8-hour test result lower than 1.4 is negative for Cushing's (Rap's result was 1.1). Yet somebody, presumably your vet, has handwritten the note "PDH - Pituitary Cushing's." That person did not accurately read the interpretation instructions printed on the form.

A negative result on the LDDS is usually very trustworthy -- it is an accurate finding in 90% of dogs who are tested. And you don't need to worry about the prednisone having skewed the test, because your worry in that vein is if a test comes out "positive" -- you wonder whether the prednisone caused the positive result instead of Cushing's.

Bottom line, I believe Rap needs further diagnostics to find out what is at the bottom of his unresolved cough, panting, and abnormal test values. I do not believe it is Cushing's, and I am sorry to tell you that I would have little/no confidence in a vet who starts trilostane treatment after mis-interpreting the diagnostic test. Or for that matter, seemingly just throwing everything except the kitchen sink to clear an unidentified supposed infection. If Rap were my dog, I would want a second opinion as to what is going on with him. Do you have other vets in your area? We can help you with a search if you are not sure.

Marianne

P.S. Just to clarify re: the LDDS results: had Rap's 8-hour result been higher than 1.4 and therefore consistent with Cushing's, THEN you would look at the 4-hour number. In Rap's case, the 4-hour result would indeed have been consistent with the pituitary form of the disease, but only if the 8-hour result was "positive" to begin with.

Hello Marianne,
Thank you for responding. The "P.D.H Pituitary Cushings" was the vets handwritting.
Thank you for such a clear explanation. Yes we will have a second opinion on Rap. We are changing vets.. I am so glad that we followed our intuition on this meds that the vet gave him.
I will appreciate it if you can help us find a most trusted vet.

[Budsters Mom]

I'm relieved that you're changing vets.:) Frankly, the one you have now scares me!:eek:

Hugs,
Kathy

[labblab]

In a situation where a dog's symptoms are complicated or puzzling, we have learned that it can be helpful to ask for a consultation with an internal medicine specialist (or IMS). These are vets who have had additional training beyond regular vet school. They may be somewhat more expensive on the front end, but we have found that you can end up saving money in the long run by getting an accurate diagnosis in shorter order. IMS vets are affiliated with vet school hospitals and also local specialty/emergency practices. In order to find out if there is one in your area, you can first check this website. You will be clicking the box for "SAIM" (Small animal internal medicine), and you can search by state or by zip code. However, not all IMSs are listed on this website. So if you don't find someone here, you can also google for an internal medicine specialist in your state or area. You will usually need a referral to see an IMS, but your current vet should certainly be willing to make the referral once you point out that the LDDS result was misinterpreted!

http://www.acvim.org/PetOwners/FindaSpecialist.aspx

Depending upon whether you can find an IMS near you and also what Rap's actual diagnosis may turn out to be, it sounds as though you may be in the market for a new GP vet altogether. Often, specialty vets turn the animal's care back over to a GP vet once the problem has been identified and a course of treatment established. So that will involve searching for a qualified GP vet in your area. Do you have other friends with pets? That can sometimes be a good place to start -- just word-of-mouth recommendations Or again, you can also Google vets in your area and take a look at on-line reviews, etc. But let's look and see first if there is an IMS that might be available to you. By any chance, are you near a university vet school? They are great resources and actually often charge very reasonable prices for their consultation services after a referral as been made to them by a GP vet.

Marianne

[tobyfishrap]

I'm relieved that you're changing vets.:) Frankly, the one you have now scares me!:eek:

Hugs,
Kathy

Thank you Kathy. When we change vet, we don't plan on telling the vet what the other vet diagnosed him with. Instead to have him checked and his current panting, hacking and hoarse bark. We'll see what the new vet have to say. For sure though Rap needs to be checked because his panting really concerns me.
Again, thank you very much.

[labblab]

We were posting at exactly the same time -- just wanted to make sure you see my reply right before your new one.

[tobyfishrap]

In a situation where a dog's symptoms are complicated or puzzling, we have learned that it can be helpful to ask for a consultation with an internal medicine specialist (or IMS). These are vets who have had additional training beyond regular vet school. They may be somewhat more expensive on the front end, but we have found that you can end up saving money in the long run by getting an accurate diagnosis in shorter order. IMS vets are affiliated with vet school hospitals and also local specialty/emergency practices. In order to find out if there is one in your area, you can first check this website. You will be clicking the box for "SAIM" (Small animal internal medicine), and you can search by state or by zip code. However, not all IMSs are listed on this website. So if you don't find someone here, you can also google for an internal medicine specialist in your state or area. You will usually need a referral to see an IMS, but your current vet should certainly be willing to make the referral once you point out that the LDDS result was misinterpreted!

http://www.acvim.org/PetOwners/FindaSpecialist.aspx

Depending upon whether you can find an IMS near you and also what Rap's actual diagnosis may turn out to be, it sounds as though you may be in the market for a new GP vet altogether. Often, specialty vets turn the animal's care back over to a GP vet once the problem has been identified and a course of treatment established. So that will involve searching for a qualified GP vet in your area. Do you have other friends with pets? That can sometimes be a good place to start -- just word-of-mouth recommendations Or again, you can also Google vets in your area and take a look at on-line reviews, etc. But let's look and see first if there is an IMS that might be available to you. By any chance, are you near a university vet school? They are great resources and actually often charge very reasonable prices for their consultation services after a referral as been made to them by a GP vet.

Marianne

Thank you very much for your advise Marianne. We will be looking around for a new vet. I really don't want to bring Rap back to his vet now. I am pretty upset with the whole situation right now. Whatever we have spent is not the question but the way Rap was diagnosed and made us believe that he has cushings and to top it off giving him medication for that. We would have killed Rap..

[tobyfishrap]

Thank you very much for your advise Marianne. We will be looking around for a new vet. I really don't want to bring Rap back to his vet now. I am pretty upset with the whole situation right now. Whatever we have spent is not the question but the way Rap was diagnosed and made us believe that he has cushings and to top it off giving him medication for that. We would have killed Rap..

Hello, how long will take for all those meds that Rap took to be clear from his body before I can schedule him to be checked by another vet?
Thank you.

[frijole]

When was the last dose of all these meds? Here's what I found online - I can't vouch for it's authenticity but it seems right:


The half life of prednisone is about 36 hours. That means 36 hours after the last dose, half of it is still in the system. 36 hours after that, 1/4 of it is left, 36 hours later, 1/8, etc. Within a few weeks, it'll all be gone.

I would be searching in earnest for a new vet and not really a cushing's specialist - just a regular vet that has experience and paid attention in school. As my brother always said "Kim remember 1/2 of all doctors graduated in the bottom 1/2 of their class". :D Kim