Unconfirmed Cushing's, Feeling Hopeless

[Little_Love]

Hi All,

I am new but very thankful that a place like this exists. My 11 year old toy poodle Minnie and I have been going through some tough times. A few months ago, she began having accidents in the house which was uncharacteristic for her so I immediately took her to the vet. The vet stated her hair was quite thin, and then upon giving her history the vet felt like Minnie might have Cushing's. We did a Urine-cortisol ratio test which was super high, so we moved forward with the ACTH test. Minnie has also had elevated liver enzyme levels for the past few years but they were not as high as they are now: ALB 4.5, ALKP 1522, ALT 192. The issue we're facing is her ACTH test came back normal- which I know can occur for a small percentage of cushing's dogs.

My vet wanted to try her on Anipryl (selegiline) since the side effects are low, and there would be no damage to the adrenal gland as with other Cushing's treatment, since we do not have a definitive positive diagnosis. We tried 5mg for 30 days- maybe a 5% improvement, only drinking improved minimally. Vet bumped to 10mg and we're at 15 days on 10mg and I feel like she's worse. The water drinking is more than it was on 5, her appetite is out of control, and now she's starting to show some loss of personality- which she has maintained her puppy like happiness through all of this. I want to call the vet and see about pulling her off the Selegiline...she might tell me to try to hold on for the 30 days.

Anyway, I'm just devastated. I wish we had a clear diagnosis and a way to know for sure what was going on and to treat her. The hungriness makes me feel so sad most often. And at one point in time she was very overweight- about 2 years ago but she's actually lost weight and has been maintaining for about a year now.

All other blood panel results normal, GGT high at 18, CI high at 122.

I appreciate any advice. If anyone has had experience diagnosing or treating not as clear cut Cushing's cases (and really the ACTH test seems to be the only thing not clear but was so vital!). Anything is appreciated. Thank you all so very much <3

[lulusmom]

Hi and welcome to you and Minnie.

I'm sorry for the reasons that brought you here but I'm glad you found us. Minnie's story has been told here before by others who have walked in your shoes. It is a frustrating and scarey disease that becomes less frustrating and scarey as you become more and more knowledgable. You've come to the right place for an education as well as lots of support from some pretty experienced members.

Poodle is a breed that is no stranger to cushing's and that breed is also mentioned in most reference material I've read on adrenal tumors as being a breed at higher risk. Females seem to be at higher risk as well so it is possible that Minnie could be in that small percentage of dogs who have adrenal dependent hyperadrenocorticism. Many endocrine specialists don't like the acth stimulation test for purposes of diagnosing as a good many dogs with cushing's yield false negative results, which is more likely to happen if a dog has an adrenal tumor.

Besides having accidents in the house and thinning coat, was Minnie exhibiting any other symptoms, such increased appetite, panting, muscle weakness? Did your vet do a complete urinalysis, including a culture to rule out a urinary tract infection? Can you please provide the normal references ranges for the abnormal blood values you posted?

If it were me and could afford it, my next move would be to ask the vet to do a low dose dexamethasone suppression test, followed by an abdominal ultrasound.

The more information you can provide us, the better we will be able to provide you with meaningful feedback. I look forward to your responses and any other info you can share.

Glynda

P.S. I have manually validated your membership so there is no need to respond to our email asking you to validate.

[lulusmom]

I have copied and pasted an excerpt below from a renown endocrinologist, Dr. Mark Peterson's, blog that addresses the accuracy of acth stimulation tests for diagnosing cushing's.


But what’s the percentage of dogs with Cushing’s disease that are actually diagnosed with this test? What’s the test sensitivity?

About half of dogs with cortisol-secreting adrenocortical tumors and about 80% of dogs with pituitary-dependent hyperadrenocorticism (PDH) show an exaggerated cortisol response to the ACTH stimulation test.

In clinical practice and reality, however, the sensitivity is actually worse than those statistics reveal. Although it is clear that over 20% of dogs with Cushing's syndrome have post-ACTH cortisol test results within the reference range (< 20 μg/dl for my laboratory), an additional 20-30% of dogs with Cushing's have test results described as "borderline" (serum cortisol concentrations >16 μg/dl but <24 μg/dl).

In effect, that means that only 50-60% of dogs with Cushing's disease will have serum cortisol responses that are clearly abnormal (> 25 μg/dl). In other word, this test is a poorly sensitive diagnostic test for Cushing’s syndrome. In most dogs, it would be more cost effective to turn to another test, such as the low-dose dexamethasone suppression test, as the first-line screening test.

You should share this with your vet. You can read the entire blog here: http://endocrinevet.blogspot.com/2011/02/diagnosing-canine-cushings-disease.html

Glynda

P.S. Can you please share the results of Minnie's acth stimulation test?

[Little_Love]

Thanks so much for the reply :)

Minnie's symptoms are as follows:
Increased appetite- extreme
Increased drinking- almost as extreme as the appetite
Some periods of heavy panting, especially at night
According to the vet her hair is thin, you can see her little pink skin so I suppose I would agree
Occasional accidents
Elevated liver enzymes
Weakness in back legs- they shake/quiver at times, with increased frequency when she's being held despite the fact I'm supporting them

She is a toy, so only 11lbs-it's hard to see if she has the 'pot-bellied' look of Cushing's.

I have done an ultrasound and her glands were the normal little peanut shapes. They did not see anything abnormal during ultrasound. The vet said maybe we're catching it early so that could be why or it could be another form. With the urine test, she did have increased bacteria so we treated her for a UTI and the vet said UTIs are common among Cushing's dogs.

As for blood tests: ALB: Normal is 2.2-3.9 and she is at 4.5
ALKP 23-212 and she is at 1522
ALT 10-100 and she is at 192
Those are all her liver enzymes.

Other elevated levels were GGT (0-7) she's at 18. CI (109-122) she's at 122. Vet didn't mention anything about this, and I've researched them and it appears they could be elevated due to the liver (?).

I can't find her ACTH results but as soon as I do I will get them posted.

Thank you so much <3

[Budsters Mom]

Hello and welcome from me too.:)

First of all, Cushing's is not hopeless. Many of our Cush babies live out their normal lifespan with proper treatment. It is all pretty overwhelming and terrifying at first.:eek::eek: We've all been there at one time or another. The more that you learn and we'll help you, the better you will feel about the whole ordeal. Cushing's sucks. :(That is true. But it's not the end of the world. You are off to a great start with Glynda. I'm looking forward to learning more about your sweet girl. Others will be dropping by to welcome you also. We ask tons of questions because the more we know, the better we will be able to help you both. Hugs,

Kathy

[Little_Love]

Thank you :)

I know we can have a good prognosis and good life with Cushing's. My hopeless feeling stems from the fact Minnie remains with an unconfirmed diagnosis. I'm looking for guidance on what steps we should take next as the Anipryl is not having an effect and the vet does not want to try another medication until we have a confirmed diagnosis.

We have lots of blood tests, urine-cortisol ratio test, an ultrasound and ACTH test at this point. I've also taken her to a small animal internal medicine specialist but they wanted to biopsy her liver and I just wasn't ready for something so invasive.

Wondering what we should try next...

I called the vet as I can't find her ACTH #s and they are mailing them- my Dr wasn't there and the tech wouldn't read them to me over the phone.

[molly muffin]

The only other thing I can think of that you haven't done is the LDDS test.

In our case I have a positive ACTH and a negative LDDS. Repeatedly in fact.

So, if the LDDS is positive, then that might give you more to go on.

hugs,
Sharlene and Molly Muffin

[Little_Love]

So I got the ACTH results in the mail today (since I couldn't get them on the phone!)

resting= 2.9
4hr dex= < 0.7
8hr dex= 1.0

It seems like it's consistent with Iatrogenic cushings but that is caused by steroid use from what I'm reading? I'm trying to gain access to this article as the abstract describes Minnie quite well, I bolded the matching characteristics. I don't understand how this could fit so well, as she's not an any meds (until the Cushing's one that is)

Iatrogenic hyperadrenocorticism in 28 dogs.
Huang HP, Yang HL, Liang SL, Lien YH, Chen KY.
Source
Department of Veterinary Medicine, National Taiwan University, Taipei.
Abstract
Twenty-eight dogs with iatrogenic hyperadrenocorticism were studied. The most common clinical signs were cutaneous lesions (27/28), polydipsia (21/28), polyuria (19/28), and lethargy (16/28). The most predominant findings on biochemical profile were elevated alkaline phosphatase (ALP, 15/28) and alanine transferase (ALT, 14/28); hypercholesterolemia (14/28); elevated aspartate transferase (AST, 12/28); and elevated triglycerides (12/18). Baseline cortisol levels of all 28 dogs were at the lower end of the referencerange and exhibited suppressed or no response to adrenocorticotropic hormone (ACTH) stimulation. The mean time for each dog to show initial improvement of clinical signs after corticosteroid withdrawal was six weeks, with another mean time of 12 weeks to demonstrate complete remission.

[Harley PoMMom]

So I got the ACTH results in the mail today (since I couldn't get them on the phone!)

resting= 2.9
4hr dex= < 0.7
8hr dex= 1.0


Those results look more like a LDDS test than an ACTH stim test. With a LDDS ( low-dose dexamethasone suppression ) there are 3 draws; a pre, a 4 hour, and an 8 hour. When a ACTH stimulation test is done a pre and a post value are given.

So, if indeed those are LDDS test results, they do not indicate Cushing's.

I believe, if this were me, since her liver values are elevated I would look into having a bile acid test done to see how her liver is functioning...just my 2 cents worth!

Hugs, Lori

[Little_Love]

Thank you!!! My vet has never mentioned this but a specialist wanted me to do a liver biopsy and from what I just read about the bile acid test it seems like a lot safer way to see if there is something going on with her liver. She's 11 and I don't like putting her under-plus it's just so invasive so if it can be avoided.

I'm definitely going to look into this! Came home tonight to find a backpack break in...apparently I had the audacity to leave peanuts in my backpack and Minnie's polyphagia had plans for it! She's sitting her unable to touch her back legs together because her belly is so bloated- *sigh*.

I appreciate this so much- it's time to google the night away!! :D Very excited.

[Little_Love]

Hi all,

The forum has helped me get through so much during the 3 year battle with Minnie's (14yr old toy poodle) Cushings. After being a-typical for so long, this year she was retested and found to have results consistent enough to allow her to start Vetoryl (10mg). Pre-Vetoryl she became diabetic and receives 2 injections daily of Vetsulin (11 units total 6/5). She has been receiving shots since April of 2014. On Vetoryl since March of 2016.

Recently she has become very aggressive towards her 'dad' in particular, but also me. It happens most often in the evening but she can go 'feral' in the middle of the day sometimes. She will be cuddling with me, in my arms or laying on the couch on her own and if we go to pet her she gets INTENSELY aggressive. To say she goes 'feral' is not an understatement. She tries to bite us, growls, etc. She cannot be touched or picked up. She calms down from these 'attacks' anywhere from 2-5 minutes. Then she wants to go right back to cuddling or put her paws up to be picked up as if she never tried to just kill you. :confused:

Only other facts I can think to mention are that she has pretty bad cataracts due to the diabetes, so she is mostly blind. She has never been like this before, it started about a month ago occurring only once or twice a week but now it is becoming almost a daily occurrence.

Has anyone had any sudden aggression in their Cushing or Diabetic loves?

Many thanks for reading and commenting.

[Harley PoMMom]

I have merged your latest post with your original thread so as to keep all of Minnie's history in one place. Sometimes it's difficult to find our threads when they aren't showing on the first few pages so I will be sending you a message with a link to your thread so that you can bookmark it or just keep it in your inbox for ready reference. ;)

I am sorry to hear that Minnie is having aggression issues. Sudden aggressive behavior can be a symptom of hypothyroidism, has her thyroid levels been checked recently?

Is her diabetes under control? And how about her Cushing's, has she had an ACTH stimulation test done recently, and if so, could you post those results for us?

Hugs, Lori

[Little_Love]

Hi Lori,

Thanks for the reply. She had her cortisol re-checked as well as a glucose curve within the past 3 weeks- both came back "perfect" according to the vet. Her internal medicine specialist and regular vet conferred and both were over the moon with how perfect the results were. I don't have the exact cortisol results though. The diabetes curve had her lowest at around 120. She gets a curve every month or so just to make sure she's in check.

I have a full blood panel from 7/31. Granted she had pancreatitis at the time, so I'm unsure if any indicators of hypothyroidism would be apparent. However I don't see T4 listed :confused:

Friends have mentioned doggie dementia as a possibility- but she doesn't have any other symptoms that I notice.

Thank you,

Mandy

[DoxieMama]

Hi Mandy,

Did the vet or IMS have any suggestions for what may be causing Minnie's aggression?

Shana

[Wylie]

I am a newbie here. I would also suggest getting the thyroid checked. One of our past dogs suffered from low thyroid, and the only time he was ever aggressive or growled at us was before he was diagnosed and treated.