Our Mandy Girl

[LizNDale]

My Mandy girl (10 year old, 62lb German Shorthaired Pointer) will be at Vets Monday for an all day Cushings test.

We brought her in 2 weeks ago for excessive drinking/peeing/and occasional incontinence.

At that visit:
Urine-
pH = 7.0
Leu 25 Leu/uL
Specific Gravity 1.006

Blood:
LaserCyte-
HGB High 18.8 g/dl (12.0-18.0)

Catalust Dx-
ALT High 187 U/L (10-100) **2 WEEKS LATER: 212
ALKP High 353 U/L (23-212) **2 WEEKS LATER: 681
GGT High 12 U/L (0-7) **2 WEEKS LATER: 28 Result verified by repeat analysis
CHOL Normal 291mg/dl (110-320) **2 WEEKS LATER: 396

VetStat-
pH(ven) High 7.47 (7.31 - 7.42)
Na High 162.0 mmo/L (144-160)

Abdomen:
Appears Normal. Nonpainful bladder, normal size kidneys.

Body Score 3/5

We treated with 2x225mg Denosyl 2x/day for 15 days.

"Then reschedule liver panel and possibly cortisol suppression test."

Both Dale and I thought she was drinking less water and peeing less, but that may have just been hopeful looking for improvement. We dipsticked every morning first pee, SG always between 1.015 and 1.020, but not sure how accurate these dipsticks are.

She still had incontinence, but that seemed less. No hair loss. Normal appetite. No Potbelly. Active, happy, energetic.

Dale brought her back Monday for follow-up. Vet called me Wednesday, said "not good news". Either Cushings or Liver problem. Leaning towards Cushings. He said something like “If not Cushings, then not sure, as other liver diseases appear to be ruled out by labs.” I asked if that would mean liver cancer and he said ‘perhaps’.

So results from 2 weeks later vs original:
Catalust Dx- 2 weeks Later
ALT High 187 U/L (10-100) 212
ALKP High 353 U/L (23-212) 681
GGT High 12 U/L (0-7) 28
CHOL Normal 291 mg/dl (110-320) 396

Re; 281HEMOLYSIS and 282 LIPEMIA Indexes:
Index of N,+,++ exhibits no significant effect on chemistry values.

BILE ACIDS High 17.9 umol/L (0.0 - 6.9) (This was first Bile test)

So, all you wonderful people out there, any advice for her Monday appointment and what questions we should ask?

Do these labs, particularily the worsening #s in 2 weeks, point to Cushings? Since she is otherwise symptomless, would that imply early stages?

Thank you in advance, I've been reading threads, and am hugely impressed by this forum and its' participants.

Liz

[Harley PoMMom]

Hi Liz,

Welcome to you and Mandy! I'm sorry I have only a minute to post but did want to give you my opinion, although it maybe short :eek:, and to welcome you here.

Dog's with Cushing's almost always have a high elevation in the ALP and sometimes the ALT is mildly elevated, the GGT is usually not high so this makes me think, along with the high bile acid test, that a liver issue could be the culprit for those elevated levels along with the increased drinking/urinating.

Was an ultrasound done to get a good look at the internal organs? If not, that would be my next diagnostic step.

I am sure others will be along to share their advice and support. Please do not hesitate to ask all the questions you want.

Hugs, Lori

[LizNDale]

Thank you Lori, I appreciate the note.

I don't see an ALP result on either of the reports. Is it usually in the same grouping as the ALT, ALKP and GGT?

We have not scheduled an ultrasound, next step is the all day test on Monday. If that is negative, I think that will be our vets next recommendation.

My heart is kinda pounding, I think I am hoping it is Cushings because I am afraid of the alternative. Is that crazy? I mean, I don't want either, and the idea of Cushings scared the heck out of me, but then having read so many of the threads here, while still scarey, is still apparently quite manageable.

[molly muffin]

Hi and welcome. The ALKP is sometimes just called the ALP it's the same thing.

The thing is that the test on monday could be a false positive if something is going on with the liver. Now I know that is a scary thought, but the ultrasound might be the most bang for the buck in light of the results of the GGT being higher and the Bile Acid test, which is liver specific being higher.

If it is something on the liver, then the ultrasound would show you that. Now that is scary of course, but we have our Flynn and he has had two liver surgeries to remove nodules and he is just fine. He's also had an adrenalectomy to remove a tumor. I'm sure Trish will be along once she is back from Flynns play date to give you some insight to that.

Welcome again. Don't panic, whatever it turns out to be, there will be steps that can be taken for your girl.

Sharlene and molly muffin

[Harley PoMMom]

I totally agree with Sharlene. The low-dose dexamethasone suppression (LDDS), which does take all day, is known for giving false positive results when an underlying illness is present. If this were me, I would spend the money on an ultrasound instead.

Hugs, Lori

[LizNDale]

Hoo boy, thanks Sharlene. Ok, 1 step at a time. My husband is not keen on spending a lot of money on this, I know ultrasounds are pricey. And cancer treatments and surgeries even more so. I am hoping I can change his mind. He adores Mandy, she is his bird hunting dog, but he says "you can't love a dog." I vehemently disagree. I believe he loves her, but can't admit it. He is a very pragmatic man. I'll post a pic of him and Mandy on our pontoon on my profile page. Her head is on his lap, and the tender look and smile on his face as he pats her sure look like love to me! I had it in my facebook page, and the Wisconsin GSP rescue page used it for their profile picture for Father's Day. My avatar is my favorite picture of her, but she is 10 years older than that now, her face is almost all white.

At any rate, this may be a battle. In more ways than one.

[LizNDale]

Thanks Lori,

I am so glad you posted, because I completely missed that Sharlene was talking about the upcoming test on Monday. Thought she was referring to past Monday's results.

Ok, so I have a lot to think about over the weekend, and some research to do.

Does anyone have a link to documentation that supports high Bile Acid and high GGT not pointing to Cushings?

Are there other tests that are less likely to show false positives? The possibility of pumping those toxic drugs into our girl due to false positive is a non-starter for me. Especially since she has so few Cushing-like symptoms (Drinking, peeing, occassional incontinence - that's it).

Oh, we've got her on that incontinance drug, Proin. Didn't I see some posts from folks indicating it's not a good drug? Edit: **I'm stopping the Proin**

I posted that picture of Dale and Mandy. Tell me that's not love on Dale's face!

Thanks again,

Liz

[Trish]

I agree with the others, will these abnormal liver tests I am another who would go for ultrasound for Mandy. Dr Peterson a renown vet endocrinologist discusses liver tests/cushings in his blogs and here are a couple for you to consider. I hope they help! My dog had abnormal liver tests and had liver tumours that have been successfully removed.. twice! I would have to say abdominal ultrasound was the best test we had done, he did not have cushings.

http://endocrinevet.blogspot.co.nz/2011/02/diagnosing-hyperadrenocorticism.html

http://animalendocrine.blogspot.co.nz/2013/09/working-up-asymptomatic-dog-for.html

[LizNDale]

Thank you Trish. I've read both blogs and posted a comment to Dr. Peterson.

**Edit" Dr. Peterson responded: There are many ways to workup a problem like this, none of them wrong. Based on the clinical signs and low urine specific gravity, I would a certainly do a urine culture as an early step in diagnosis, if not already done.

Doing an ultrasound before a Cushing's test would not be wrong, but it this was terrible liver disease, I would expect your dog to show signs of illness.

I'd consider doing an ultrasound with the plan of collecting a sterile urine sample at the same time. Make sure that they look carefully at the kidneys too (sometimes that is the only way to diagnosis early kidney disease or diagnose pyelonephritis). I'd also consider a liver biopsy at the same time so you get a histopath diagnosis to help figure out the liver values. Finally, they should look carefully at both adrenal glands for an adrenal tumor, which tend to be more common in larger breed, female dogs.

I found this Review 'Interpretation of Laboratory Tests for Canine Cushing’s Syndrome' online at wordpress:

http://actualidadveterinaria.files.wordpress.com/2011/08/interpretation-of-laboratory-tests-for-canine-cushings-syndrome.pdf

In a section on differentiating Liver Disease from Cushings, and labs that overlap the 2, '...hyperbilirubinemia, hypoalbuminemia, microcytosis, or abnormal clotting times should sway the clinician away from screening for HC.'.

Mandy's BIL was negative, her ALB and MCV are Normal. I'm thinking this is why my vet is leaning away from liver disease.

I have a call into the vet to discuss, and to ask if they did a UC/CR test. I don't see anything that looks like results for that on her paperwork. Wouldn't that be an easier way to rule out Cushings? My understanding is that there are few false negatives.

I'm concerned too about Mandy's stress impact on both the UC/CR and LDDST. She gets very anxious at the vets. This review talks about Oral LDDST and UCCR Combination, which is done at home by the owner. I'm going to ask him about that as well.

[molly muffin]

The UC:CR is I believe, a very simple test that can be used to rule Out cushings, it just can't be used to confirm if it is high. Then further testing would be needed.

I agree, that definitely looks like some love and bonding happening between Dale and Mandy. It's a wonderful picture, I can see why others would want to use it, especially for Fathers Day, it's perfect. Your Mandy is a lovely lady thats for sure. White face is like grey hair for us humans. She's earned every single one of them, wear it with pride. :)

I a bit more nervous with biopsy's if they aren't needed. Unless something was seen on an ultrasound I wouldn't likely have that done yet. Although I do understand Dr. Petersons reasoning to get stuff done at the same time and start to rule possibilities in and out.

My husband can be pretty pragmatic too, but I know he adores our molly. You do what you can within your financial means and the main thing that any of us are looking for is quality of life. To give them the best life possible for as long as they have left.

Sharlene and molly muffin

[LizNDale]

Thanks Sharlene,

I'll ask the vet if he did the UC:CR when he calls me back, or replies to my email.

Quality of life is also a factor in my husband's thinking. If it's not Cushing's, do we want our currently healthy (seemingly), happy, energetic, active senior puppers to have the stress of vet appointments, poking and prodding, chemo medication that may or may not work, surgery, etc in her last years? If we have decided to not treat cancers that the ultrasound uncovers, should we even have one?

With Dr. Peterson's belief that Mandy would have signs of illness were she afflicted with liver disease, I am thinking we will go ahead with Monday's test and take it from there.

[Harley PoMMom]

I think that the urine culture and sensitivity test, that Dr Peterson mentioned, is a really good idea.

The picture of Dale and Mandy is just beautiful...AWWW!!!

Hugs, Lori

[Trish]

Wow that was good of him to reply so fast!! I was just concerned about the risk of a false-positive on the LDDS if something else was going on. Probably worth mentioning that just before my dog's last bout with liver surgery last November, he appeared to be doing well and was not unduly "sick". But his scan showed a 9cm liver mass, so they do not always show signs of illness with liver disease. But as Dr Peterson wrote there is no right or wrong way to proceed here so I hope you get some answers for Mandy and a plan to keep her feeling well! :)

[LizNDale]

Well, our girl is almost done with the LDDST, Dale will be picking her up shortly.

I had sent an email to my vet, Dr. Pederson, he called me this morning around 7 to address my questions. I had written it before getting Dr. Peterson's response, so I told him some of my questions had self-resolved.

I asked about the Urine Culture, it said he hadn't done one, based on the various labs, but that he would have that done today. He was very thoughtful when he gave his response. I mean 'full of thought', not 'thoughtful = nice'

He also said he hadn't done a UC:CR, believing that based on Mandy's labs the test would not be negative, and the result wouldn't add any info.

I also told him, and I haven't updated it here, that I think this weekend we saw back leg weakness, actually her entire rear end.

This weekend when she peed, she seemed to have shifted so that more weight is on her upper legs, and her back legs quiver. She used to just squat and go, but now it seems like she has to plan her position.

Her favorite place on the pontoon is standing with her elbows hanging over the front corner piece, so she can fish with Dale. This weekend, she was obviously resting more of her weight on the chest, taking the load off her legs.

Her tail (docked) has changed, dramatically. Where it joins her rear, the hair is all fluffy, like she has a Mohawk. Her tail itself seems much fluffier, like it has doubled in diameter.
She has an odd triangular shape when I look at her from the rear, kind of like hip bones are protruding - can't quite explain it.

Still no hair loss, potbelly, or a desperate hunger.

I am feeling more and more that we have a cushy dog.

Ultrasound costs $400 he said, is that an average cost?

Trish, thank you for your note, I am leaning towards having an ultrasound done as well. What was it that made you have one? Was his Cushing test negative? I should read your thread. I've been reading lots of peoples posts. You folks are all amazing.

Lori, thank you for your comment on the pic. I don't care how much Dale denies it, he *loves* our Mandy.

[goldengirl88]

I just wanted to say that that is not too bad for the ultra sound cost. Where are you having it done? You need a high definition machine or do not waste your money, as I made that mistake in the beginning. Blessings
Patti

[LizNDale]

Thank you Patti..

I am in the north woods of Wisconsin, my vet is in a small town of Spooner, Wi. They have the ultrasound machine and can do the test itself, but need to send it our for interpretation. I will find out if it is HD.

Getting so nervous, should find out tomorrow what the results are. I will post them here as soon as I hear, in hopes that folks here can give me some input.

Dale says she was very quiet last night, and hard a hard time getting up into the chair to cuddle. I commute to Houston, TX during the week. If she has Cushings and we have to load, I'll stay home and not travel, so I can watch her.

I have to keep focusing on results and numbers and facts and figures, otherwise I want to give in to tears.

[molly muffin]

Good lord, you're in Wisconsin and have to commute to Houston during the week. Yowser! That's a haul for sure.

You don't technically load with trilostane, is that what you'd be using? You just sort of settle in and find the dose that works best for her. If you are using lysodren, then you load and go to maintenance.

Might need to get a ramp to the couch? I had to get step to my window seat for my molly. Just to help her get up there?

Deep Breaths. :)

Sharlene and molly muffin

[LizNDale]

Sharlene,

You know, I am really getting ahead of myself! She hasn't even been diagnosed yet and we haven't talked yet about treatment choices.

The ramp is a great idea. Dale will have to build one for her.

Breathing deep. :o

LizNDaleNMandy

[goldengirl88]

Liz:
I love Wisconsin, went there as a child with my father. I remember a big wooden carving of an Indian somewhere and had my picture taken with it. I hope you baby does well. Tipper will be on Vetoryl 2 years in August. Such a beautiful girl Mandy is. Blessings
Patti

[LizNDale]

Ok, so Dr. Pederson called with the LDDST results:

Pre: 3.4 mg/dl
4 hours 1.0 mg/dl
8 hours 2.6 mg/dl

Has diagnosed Cushings, Pituitary based. Recommends starting her on Trilistine. I agreed.

Urine culture was negative.

I can't tell you how much I hate being so far away from her, that it will be 34 hours before I see her. Found an empty conference room to take the call from Dr. Pederson, call Dale and tell him, and get some crying out of my system.

I will work from home next week so I can keep a 24 hour eye on her.

I know she'll be ok, I knew this was coming, but still the shock of it all is hard to deal with.

I'd appreciate any advice you have, and feedback on what these #s meant, if you all agree with his diagnosis.

Hugs to my dog, and to all of your furbabies too.

LizNDaleNMandy

[molly muffin]

Okay, so no more than 1mg/1lb, give with food in the morning. If they are doing a split dose, where you give say 25 mg am and 25mg pm (as an example). Then give both with foods. ACTH is done to check levels 4 - 6 hours after the morning dose given with food. First ACTH will be around 14 days after beginning meds. I notice that usually when starting, you'll start to see real results at about 10 days after beginning.

I know it is scary when starting out, but the key is take start low and work up as needed. You'll be just fine!

hugs
Sharlene and molly muffin

[LizNDale]

Thanks so much Sharlene!

In terms of staying with Mandy every day, during the day, is 1 week enough? If I only have one week, which would be the best week for me to be home, the first or second?

Thanks,

Liz

[goldengirl88]

If it were me I would go for the first week, as that is when the cortisol will start really going down and their body will be adjusting to a lack of high cortisol, and to a new drug they have never been on. Blessings
Patti

[LizNDale]

Thank you Patti, makes sense. That is what I'll do.

[molly muffin]

It's tough to call that one, as you want to know how it is going when you start a new medication, but then want to be see how it is going at around the 10 - 14 day mark too.

If you start on a saturday, are home all week, then Sunday would be the 9 day point and could schedule the ACTH for the end of that second week.

Just let Dale know everything to look for or keep an eye on for the second week and he will hopefully feel comfortable enough by that point to do so.

It should be okay. You aren't starting her too high for her weight, so maybe it'll just be easy peasy. Many don't have any problems at all.

hugs
Sharlene and molly muffin

[Trish]

Trish, thank you for your note, I am leaning towards having an ultrasound done as well. What was it that made you have one? Was his Cushing test negative? I should read your thread. I've been reading lots of peoples posts. You folks are all amazing.


Gosh, sorry I missed this. Yes I would get the ultrasound done, very good test to have done if cushings is considered, it gives a good view of all those internal organs including adrenal glands that can help confirm cushings diagnosis in conjunction with the other tests. Plus a good view of the liver and I think it would be worth doing for that reason in Mandy's case. Flynn's first brush with illness was with a liver tumour, he had it removed in late 2011. Never got back to 100%, so his vets were querying cushings but he never had the more obvious symptoms like PU/PD. Over the next year he had various tests including LDDS which was normal. Subsquent ultrasound picked up an adrenal tumour that he had removed a year following his liver resection. He did have repeat LDDS and ACTH, both remained normal. His adrenal tumour turned out to be one that does not cause cushings. His liver tests have never normalised and then another year down the track he had another liver op to remove a 9cm mass. Luckily his liver tumours are not the real nasty malignant ones, they just grow so big but we have been able to keep on top of them with the surgery. His last op was 6 months ago now and he is doing really well and his check ultrasound last month showed no major new lesions!

Flynny's thread is huge, but there is not a lot of cushings info in there as we did not have to go down that path. But if you are interested in adrenal tumours or liver tumours there is a lot of that in there!

Good Luck with Mandy! :)

[LizNDale]

Thank you Sharlene and Trish,

I think at this point we'll hold off on the ultrasound and see what happens with the Trilistine.

If we do 3x day, Dale will find someone to give her the middle dose, as his shifts are 12 hours. (neighbors let her out for potty, I just hate putting the medication responsibility on them.) I just may have to work from home for 2 weeks. I wish I could all the time, but that is not an option. However, it is also not an option for me personally to not be home with her during critical times, and so if that's what best, what's what I'll do.

Dr. Pederson is creating an account for me at Wedgewood Pharmacy to help us control the cost. I really like Dr. Pederson. He listens, explains, never rushes us. He just recently returned to Spooner after spending some years in Honduras on a veterinary mission.

[LizNDale]

Holy cow, Wedgewood just called me, and they were going to send me 100mg capsules! That would be 3.5mg/kg, or 1.6mg/lb, right? Isn't that too much? :eek:

I asked them to hold off, and I've got a call into Dr. Pederson to talk about the dosage and if we should split it.

What is the consensus here, 1 full dose per day or 2 half dose per day? :confused:

**EDIT** Dechra's online table 1 indicated starting daily dose of 120mg for dogs >44 to <88 lbs. While they would not discuss specific dosage with me, not being a vet, they did tell me that their Table 1 is current. (I read it to him, to make sure we were talking about the same table). So based on Dechra, 100mg for 62lb Mandy is not excessive. What to do?

[Harley PoMMom]

Starting low, I believe, is better because we see less adverse side effects when a dog is started at the low end of the dosage scale.

Here's an excerpt from Dr Peterson, who is a world-renowned veterinarian that specializes in canine/feline endocrinology:

Initial daily dosage of trilostane

When this drug was first used in Europe over a decade ago, the original starting dose was 4-10 mg/kg/day (7-12). However, as experience with the drug grew, it became apparent that these doses were too high in many dogs and lower doses were needed. Accordingly, the dosing recommendation on the US package insert states that an initial daily dose of 2.2-6.7 mg/kg is recommended (4).

My recommended starting dose is either 2 mg/kg given once daily or 1 mg/kg given twice daily. This is similar to the doses used in this study by Feldman (13), where the mean trilostane dose administered to his dogs was 0.86 mg/kg, twice daily (or a mean total daily dose of 1.72 mg/kg). Like Feldman, I feel that it is best to start with a daily dose that is at the low end or even lower than that recommended in the package insert. I would never start a dog on a dose at the higher end of the recommended dosage range (4-7 mg/kg), although some dogs with Cushing’s disease will eventually require daily doses that may be this high or even higher (1,14)...

You can read the full article, which I recommend, on Dr Peterson's blog: Low-Dose, Twice-Daily Trilostane Treatment for Dogs with Hyperadrenocorticism (http://endocrinevet.blogspot.com/2012/12/low-dose-twice-daily-trilostane.html)

One other thing I want to mention, Dr Peterson is a contributor to Dechra's continuing education site.

[Junior's Mom]

Welcome to the forum. I'm confused. You are planning on dosing 3 times a day? Did I read that wrong?
Some members do once a day, and have been fine with that. Others had to switch to twice a day.
I started Junior at twice a day, and only 0.4mg/lb.
No more than 1mg/lb to start with is safest.
It must be given with food, immediately after the meal is best.
Tracey

[LizNDale]

Sorry, no, not 3x, I was mistaken.

[molly muffin]

Once or twice and no more than 1mg/1lb at most to start with. If Dechra is saying that is current, then I believe they are mistaken, as the insert hasn't been updated in ages, and they have said to start at the low end for safety reasons.

Reasons were that too many dogs were getting in trouble starting at higher levels and then crashing. Always error on the side of caution till you know how she'll react to any medication.

If she has a lot of symptoms in the evening, then splitting 30mg am and 30mg pm might work better than one 60mg. Or you could start with one dose and then move to two. 3 is usually way too hard on people to do and very seldom done by anyone. I think we've had maybe one or two on the fourm.

You'll be okay as long as you start at the low end.

you're doing fine!
Sharlene and molly muffin

[goldengirl88]

How is beautiful Mandy doing? How is it going with her treatment? Hope everything is going well. Blessings
Patti