Trouble understanding test results

[minpinlulu]

Hi,

On October 28 my 9 year old min pin was diagnosed with Cushing's and she started taking 10 mg of Vetoryl. Her symptions were drinking water excessively and therefore not being able to control urinating. She had her second ACTH test on November 11 and the Vetoryl was increased to 30 mg a day. I'm having trouble understanding the test results. She still drank a lot of water after starting the 10 mg but I would like to know if the test showed any improvement. After the second test the Vet was not there to speak with us and I'm starting to wonder if we should get a second opinion. Since being on 30 mg she's not drinking quite as much water but enough that she's still having little accidents in the house. My husband and I are worried because we want her to get better and after about $1200.00 the condition has only slightly improved.
We are also really worried about pancreatitus because she's gained a lot of weight and last year she had surgery due to pancreatitus and up until now we were able to control her weight.

The test report is hard for me to understand so I'm typing directly as it is on the report.

Chemistry Results 10-25-13
ALB = 3.2 g/dL
ALKP = 324 U/L H
ALT = 65 U/L

Hematology Results 10-25-13
HCT = 55.5% H
BASO = 0.03 K/uL

Immunoassay Results 10-28-13
CORT01 = Result 6.1 ug/dL
CORT06 > Result > 30.0 ug/dL H
ACTH Stim (Cushing's selected) < 2 ug/dL - in the presence of supporting clinical signs, results are consistent with Addision's Disease2 - 6 ug/dL - Inconclusive6 - 18 ug/dL - Normal18 - 22 ug/dL - Cushing's Syndrome possible > 22 ug/dL - In the presence of supporting clinical signs, results are consistent with Cushing's SyndromIDEXX offers....

Immunoassay Results 11-11-13
CORT01 = Result 8.1 ug/dL
CORT08 > Result > 10.0 ug/dL H
(then there's information about Theraputic monitoring)

[Squirt's Mom]

Hi and welcome to you and your baby girl! :)

We are gonna flood you with questions at first, so be patient. The more we know about your sweet girl, the better feedback we can offer. ;) We LOVE details, so the more you can tell us about her medical history and the more completely you can answer our questions, the better.

But, before that, I want you to know that you are in great hands now. The people here are amazing, full of knowledge and first-hand experience. In addition, you will not find better support anywhere. So take a deep breath and try to relax a little bit - I know that's tough to do right now but it will get easier.

How much does your baby weigh?

How is her pancreas these days?

Did her appetite increase along with the peeing and drinking? BTW - she wasn't peeing so much because she drank so much. It's actually just the opposite - Cushing's makes these pups pee like mad so they must drink to stay hydrated. Never, ever restrict water for a cush pup - it could be quite risky, especially when the cortisol is not controlled.

Has she had any hair loss?

Does she pant?

Was the ACTH the only test that was done to diagnose Cushing's?

How long after the pancreas surgery was the testing for Cushing's started?

Did she have an ultrasound?

Would you mind posting the normal ranges for the Chemistry and Hemotogy results posted? Different labs use different norms. ;)

I'm sure others will be along soon. We are glad you found us and I want you to know you are family now...and we stick by our family here at K9C. We will be here anytime you need to talk. You are no longer alone on this journey.

Hugs,
Leslie and the gang

[goldengirl88]

Welcome to the forum. Could you please tell us the symptoms your dog is having? What is the weight of your dog? Have you had a urine test, blood panel or ultra sound done? If so could you give us the abnormal results along with the labs normal guide as each is different. Are you suspecting pancreatitis solely based on the weight gain? Is you vet experienced in treating Cushings as 30mg of Trilostane seems like a lot for a small breed like a min pin, that is why we need the weight. Have you had any other testing for thyroid or diabetes? We are here to help you so you aren't alone in this anymore. I know it is scary at first but with proper treatment your dog can possibly live out it's natural life. Blessings
Patti

[Trixie]

I am not an expert evaluating the test results but I will tell you that the symptoms of Cushing's will not disappear that quickly even while on the medication. It takes time and getting the right dosage can be tricky.
How much does your dog weigh?
If I am reading your results correctly it seems your dog's level went up in the 2 weeks since you started the Vetoryl so your vet tripled the dose.
You may just want to be careful going up to a much higher dose that quickly. The recommended dosing is 1mg per pound.

It took months for my dog to respond to the medication, though many people will see symptoms start to wane after a few weeks. My dog kept drinking heavily for weeks after we started and we had to keep adjusting the Vetoryl.
You have to be patient, the medication will work once your dog is on the right dosage, it takes time. Continue to observe your dog carefully because now you have a higher dose and you don't want her to go too low. Watch for lethargy, vomiting, diarrhea which would be the symptoms of going too low.
Is she on a low fat diet? I imagine since you have been through Pancreatitis that you already have her on low fat food.
Others will chime in here about your test results...I'm sorry I can't be more helpful with the numbers.

Barbara

[minpinlulu]

Thanks so much for replying.

To answer your questions:

She weighs 15.6 pounds (I don't think her normal weight should be over 12 pounds)

She had pancreatitus September 2012 and at the time she weighed 19 pounds and we didn't realize there was a reason you are not supposed give them table food (we completely blame ourselves).
She has not had any problems since the surgery last year. After her surgery, we changed her eating habits from leaving dry dog food out all day to a scheduled feeding time and limited treats. We make sure the treats are not over 6% fat and she was eating Prescription Diet R/D (wet). She was okay on the R/D (but we had to hand feed her because she would eat so quickly she'd make herself throw up). Since the excessive drinking started she will not eat the R/D, so we are now feeding her Freshpet food from the cold section in the grocery store.

The pancreatitus was Sept. 2012 and the Cushing's was diagnosed Oct. 2013.

I'm not sure if her appetite has increased because we only feed her at a specific time. She's never been one to pass up a treat. The only difference is her refusal of the R/D but we have a Chihuahua that eats the Freshpet so when Lucie was refusing to eat the R/D she would try to eat our Chihuahua's food. We though it was just a coincidence?

We haven't noticed any hair loss.

If she's been curled up in a blanket on the couch for a little while she'll get out from under it panting. She'll usually move to the floor and stretch out. But this is really nothing new, she's done this for years.

The very first visit they did blood work & urinalysis. The next visit they did the ACTH test. No ultrasound.

The notes for the urinalysis states, "urine specific gravity is abnormal today (10-25-13) at 1.010, but she has no signs of kidney disease on blood work. The urine is probably dilute because she is drinking so much water. In addition, one of her liver enzymes, alkaline phosphatase, is slightly increased."

Hematology Results:
Result ; Reference Range
BASO = 0.03 K/uL ; 0.00 – 0.10
EOS = 0.17 k/uL ; 0.10 – 1.49
HCT = 55.5% H ; 37.0 – 55.0
HGB = 17.8 g/Dl ; 12.0 – 18.0
LYMPHS = 1.06K/uL ; 0.50 – 4.90
MCH = 23.7 pg ; 18.5 – 30.0
MCHC = 32.1 g/dL ; 30.0 – 37.5
MCV = 73.8 fL ; 60.0 – 77.0
MONOS = 0.45 K/uL ; 0.30 – 2.00
RBC = 7.52 M/uL ; 5.50 – 8.50
WBC = 7.56 K/uL ; 5.50 – 16.90
NEUT = 5.86 K/uL ; 2.00 – 12.00
%NEUT = 77.4%
%EOS = 2.2%
PLT = 389 K/uL ; 175 – 500
Retics = 79.0 K/uL ; 10.0 – 110.0
%Retics = 1.1%
RDW = 15.1% ; 14.7 – 17.9
MPV = 7.3 fL
PDW = 19.4%
PCT = 0.29%
%LYMPHS = 14.1%
%MONOS = 5.9%
%BASO = 0.3%

Chemistry Results:
Result ; Reference Range
ALB = 3.2 g/dL ; 2.2 – 3.9
ALKP = 324 U/L H ; 23 – 212
ALT = 65 U/L ; 10 -100
BUN/UREA = 7 mg/dL ; 7 – 27
CREA = 0.9 mg/dL ; 0.5 – 1.8
GLU = 114 mg/dL ; 70 – 143
TP = 6.6 g/dL ; 5.2 – 8.2
GLOB = 3.4 g/dL ; 2.5 – 4.5
ALB/GLOB = 0.9
BUN/CREA = 8

Her symptoms are the excessive drinking & urinating, and potbellied appearance.

I'm really not suspecting pancreatitus, I'm just worried that it will occur because of the weight gain.

They said one of the Vet's at the clinic specialty is Cushing's Disease (though this is not the person she has been seeing). This is also not the clinic that treated her pancreatitus. She's taking two 10mg of Vetoryl in the morning and 10mg at night. The clinic said they are always sold out of the 30mg tablets.

Hope I answered everything. Any other questions, let me know.

Thanks in advance for all of your help.

[goldengirl88]

Hi:
I can see right now that if your dog weighs 15 lbs it is on twice the normal starting amount. I have found thru my dog that starting low and slowly going up if you have to is a much better approach. These are powerful drugs and need close monitoring, they are not to be taken lightly as some vets do. What was the reason for putting the dog on the 30mg? Did the vet give you any prednisone? If not you need to ask for some asap. In the event your dogs cortisol drops too low it will be necessary to give the prednisone. I see the ALKP is up and that is found with Cush dogs. I think you need to call Dechra and start a file on your dog, and explain the mg your dog is on. They have people there that will tell you this dosage is high to start off-866-933-2472. It may not be a bad idea for your vet to talk to them too, as they will tell the vet this dosage is high. I have found it to be much safer to give your dog 1mg per lb to start off with as recommended. This gives the dogs body time to adapt to such a strong drug. Otherwise your dog can crash. Have you had an ACTH test before starting your dog on the 30 mg? Was you dog fasted before the test? If so the results are no good, and your dog could end up being overdosed. The thing that helped me the most was to educate myself on this disease. You are the only advocate for your dog, so you need to know what the right protocol for treating and testing is. Do not put blind faith in anyone even your vet. It will be a mistake you may regret. We will help you thru this journey, you will be hard pressed to find more knowledge on this disease any where else. You can trust the people on here, they know this disease inside and out. First please tell us about the ACTH testing done and the results. Was the dog feed a meal first?? Have you had an Ultra Sound? If so, do they know what type of Cushings your dog has? When using trilostane the dog should be tested every time the dose is changed, but must eat a meal with a little fat as the drug is fat soluble and take the trilostane after or during eating. The test must be completed by 4-6 hours or it is no good either. How long was your dog there after taking the vetoryl and what time was it finished? These drugs have to be monitored closely or bad things can happen. I would have started this dog on 10mg and gone from there. You can have this drug compounded cheaper thru Diamondback Drugs. You could even start with 15mg if you get it from them. Vetoryl is 10mg then goes to 30 mg so if you want an in between dose you have to get it compounded. Blessings
Patti

[minpinlulu]

She did start off on 10mg.

After the first ACTH test she was put on 10mg once a day in the morning and then after the second ACTH test it was increased to 30mg (two pills in the morning and one in the evening).
For the first ACTH test her last meal was the night before at about 7:00pm with a treat or two the morning of the test and for the second ACTH test her meal was that morning (at the same time as the dose of medicine for that day which was about 7:00am). I'm not sure what time of the day the tests were done, we dropped her off at 7:30am and picked her up at 5:00pm.

The vet only gave us the Vetoryl, no prednisone.

She's had no ultrasound and they haven't said which type of Cushings.

Thank you.

[minpinlulu]

I rechecked the vet report and it states "ACTH stim test results are consistent with Cushing's (Hyperadrenocorticism) affects the adrenal glands and causes the body to have excess circulating cortisol, which is a stress hormone."

[goldengirl88]

What we want to know is the numbers form the two ACTH's done. That is so irresponsible of that vet not to tell you about the cortisol possibly going low and giving you no prednisone, there is no excuse for that. Please call that office and get prednisone asap. You should never be without it. I take mine everywhere I take my dog. Blessings
Patti

[minpinlulu]

The ACTH information on the history report is:

Oct. 28 (first ACTH test)
CORT01 = 6.1 ug/dL
CORT06 > > 30.0 ug/dL H

Nov. 11 (second ACTH test)
CORT01 = 8.1 ug/dL
CORT08 > > 10.0 ug/dL H

There's no reference range listed.

I just scheduled an appointment with the specialists she saw for the pancreatitis last year. It's a further drive but I think it will be worth it. We just don't feel very confortable with the current vet.

[goldengirl88]

Good idea, but did you get the prednisone? That is the important right now. Are you saying that after you started treating you dog that the cortisol went higher on the pre number on the subsequent testing??

[minpinlulu]

I will call and ask the vet for prednisone. What would this be used for?
Her only symptoms are the increased water consumption/urination & potbelly.

If you are referring to the 6.1 on the first test and the 8.1 on the second test, then yes. I am completely clueless. Is a higher number better or worse?
6.1 & 30.0 was before treatment, 8.1 and 10.0 was after treatment started.

[goldengirl88]

You will need the prednisone if you see vomiting, diarrhea, lethargy, if the dog cannot get up and stand, or won't eat. Do not give any trilostane if you see this as it can be life threatening. You will have to then go to the vets and have your dogs electrolytes checked asap. If any of the above things happen you need to give a tablet of the prednisone and go to the vets. Yes a lower number is preferred , as long as your dog is not showing any clinical signs of Cushings the number may be ok. If the dog is still having symptoms then you may need to change the dosage. You have to pay attention to all the clinical signs, like panting, drinking too much, really hungry. If these are still gong on then the dog is not controlled. How long has the dog been on 30mg? Maybe it has not been long enough yet. You will need to get the dog rechecked with another ACTH test 30 days after a new dosage. You need to make sure the vet is following the correct protocol when testing. It has to be finished 4-6 hours after starting. Make sure you get some prednisone so you don't get into an emergency situation with no vet open. Blessings
Patti

[Harley PoMMom]

Hi and welcome to you and your girl from me as well!

Sorry for the circumstances that brought you here but so glad you found us.

Cushing's can be a difficult disease to get a confirmed diagnosis for because not one test is 100% accurate at diagnosing it and other non-adrenal illnesses share many of the same symptoms as Cushing's.

Was an ultrasound or LDDS test performed to validate a Cushing's diagnosis? Has a spec cPL test been done to make sure the pancreatitis is under control? My boy, Harley, was diagnosed with pancreatitis and never showed any symptoms of this disease, so the only way to monitor the pancreatitis was with a spec cPL test.

An ACTH stimulation test is used for monitoring and can be used as an diagnostic test for Cushing's. The ACTH stimulation test measures cortisol in a dog's body. There are two blood draws done, the first is the pre number and is really not significant unless one is wanting to rule out Addison's, the second draw is the post and shows how much cortisol the adrenal glands have in reserve, the post number is very important. I see that your girl's post ACTH number has dropped significantly from 30 ug/dl to 10 ug/dl in less than a month on the 10 mg of Vetoryl so I am a bit concerned with the increase of her Vetoryl dosage to 30 mg. We've actually seen some dogs continue to drop through the 30 day mark while on the same dose. Please watch out for signs of her cortisol going too low which can be: lethargy, vomiting, diarrhea, or your girl just not acting herself. If she displays any one of these symptoms stop the Vetoryl immediately and call the vet, prednisone is usually given when a dog's cortisol has gotten too low.

Here's a couple of handy links for you: Links to Cushings Websites (especially helpful for new members!) (http://www.k9cushings.com/forum/showthread.php?t=180) and Trilostane/Vetoryl Information and Resources (http://www.k9cushings.com/forum/showthread.php?t=185)

If you have any questions please do not hesitate to ask them and remember we are here to help in any way we can.

Hugs, Lori

[minpinlulu]

Thanks everyone.

She's been on 30mg since Tuesday November 12.

Thanks for all the information.

[goldengirl88]

I still think the 30mg is too much for her, please keep close watch and get your prednisone ready. Blessings
Patti

[molly muffin]

Hello and welcome to the forum.

As long as you monitor her closely and stop the medication if you see anything like what Patti mentioned, vomiting, diarrhea, lethargy, not eating, etc, you should be alright. Splitting the dose sometimes helps when symptoms are not controlled all day long.

I would rather see what the actual numbers are for the post than to see the >>10. As that doesn't tell us quite enough, for instance, if symptoms are all controlled, then a post of say 9.0 can be fine, but if not you want to get down to around 5.0, so I hope that once the cortisol is just a tad lower they give Actual results.

The pre you don't want to get to low either, not below 1.45 ever. (some vets let it go lower but Dechra the maker of vetroyl doesn't recommend this).

Welcome again to the forum
Sharlene and Molly Muffin

[Skye]

hello!!!! i am a minpin parent!!! welcome! you have found the most amazing group here!!!!
I would like to ask is this a board certified Internal Medicine vet? or a general vet that enjoys internal medicine? HUGE difference, and I would VERY strongly suggest to see a Internal Medicine Vet. Request a high definition ultra sound, if you havent had a UPC, UCCR (creatatine and cortisal level ratio) (i believe that is what the test is called?) and you can have your Vet call the predisone in at walgreens or perhaps any pharmacy, and you should be able to pick it up there.
your in the right place amongst all these amazing people, lots of knowledge, experience and support.

[goldengirl88]

Hope you were able to get your prednisone and that things are well with your baby. Blessings
Patti

[minpinlulu]

I called the vet and asked about Prednisone in case she develops the symptoms mentioned above (vomiting, diarrhea, lethargy). They told me Prednisone is a very strong medication and they don't recommend it.

She's been seeing a general vet but we have an appointment next week with the Internal Vet Specialist (board certified).

[addy]

Just a side note here:

Not all specialist or vets will dispense prednisone when treating with Trilostane. Ours would not and other members have had the same issue.

[Trixie]

My vet does not like to give out the Prednisone either, luckily I live across the street from the vet and a 5 minutes away from a 24 hour emergency animal hospital. The Prednisone would be what you would use to help your dog out of an emergency situation...if the dog went too low you would administer the Predinsone.
The most important thing is to carefully observe your dog, especially now that your dose was tripled. The medication can take the cortisol level down to nothing and the dog needs cortisol to live...of course with Cushings the cortisol is too high but you can not let the level go too low ...that's the danger everyone here is posting about and it can easily happen. This is the difficulty with the drug you have to strike a safe balance..it doesn't happen overnight.
If you see the slightest change in her appetite, poop quality, energy level then you don't give the next pill and call your vet, it doesn't hurt to miss the dose if you see something in your dog that just seems off. Better safe than sorry.
If you notice an even more serious change...perhaps the inability of the dog to move or get up then you have to get to a vet at once.

I don't think I would want to go from 10mg to 30mg that quickly, your dog only weighs 15 pounds..you should be between 15mg-20mg to feel like you're giving a safe dose, even if the symptoms are still apparent. You might want to ask your vet about being a bit more conservative in the increase of the dose...your vet said Prednisone is a strong med but so is Vetoryl.

Believe me I had the same thing going on with my dog...we started the Vetoryl and there was NO change at all...drinking, peeing, eating etc...it actually got a bit worse and here we were now giving medication. It just takes time and patience. Going up 3 times the original dose is a little risky.
If it were me I think I would try going 10mg in the morning and 10mg in the evening and see how that goes. You'd be doubling the dose for the day but not giving so much at one time. You may want to discuss the triple increase...and in the meantime watch your dog like a hawk now that there is a lot more Vetoryl going in.

Barbara

[goldengirl88]

I just think the vets that do not give prednisone are setting people up for disaster. If you have an Addison's crisis and your dogs life hangs in the balance what the hey does it matter if prednisone is a strong drug or not?? It's better than your dog dying right?? I simply would not put up with not having the proper emergency meds to give if I had a life threatening situation with Tipper. Sorry, but that is the way I feel, I am always prepared when it comes to my dog as her life depends upon it. Blessings
Patti