8 yr old Akita diagnosed with Atypical Cushings

[Miko's Dad]

Hello all, and ty for having this website.
I have a 8yr old female spayed Akita that was just diagnosed with atypical cushings. The vet wants to start her on Lysodren with 6mg
of Melatonin. She has had hair loss on her back for about 3 yrs but her cortisal lvls have always been in the normal range.
She is a female spayed Akita with no other issues other than she seemed a little less active than normal, huge appetite and large water consumption over the last 3-4 weeks. She weighs 114 lbs and we have ran tests to make sure that she had no issues with parasites etc..


Here are the test results from UTK that where just done.

Cortisal (base) 55.8 of 2.1-58.8 range
Cortisal (post acth) 129.4 of 65.-174.6
Androstendione (base) 0.35 of 0.05-0.57 range
Androstendione ( post acth) 0.80 of 0.27-3.97
Estradiol (base) 50.2 of 30.8-69.9 range
Estradiol (post acth) 45.5 of 27.9-69.2
Progesterone (base) 0.59 of 0.03-0.49 range
Progesterone ( post acth) 2.40 of 0.10-1.50
17OH Progest (base) 0.71 of 0.08-0.77 range
17OH Progest ( post acth) 2.76 of 0.40-1.62
Aldosterone (base) 259.5 of 11-139.9 range
Aldosterone (post acth) 400.3 of 72.9-398.5

Her ultrasound found no abnormalities on the adrenal glads or any other of her organs.
What concerns me is the Vet is prescribing a loading dose of (25mg/kg/twice daily) for up to 8days before testing, then a maintenance dosage of (50mg/kg/twice weekly) and tests at 1 month and every 3-4 months.
This seems like a very high dosage for atypical cushings.
Would love to hear thoughts on this.
kris

[Harley PoMMom]

Hi Kris,

Welcome to you and Miko! Glad you found us and we will help in any way we can.

The lab from UTK sends a treatment option sheet along with the test results, do you have this sheet? If not, I will provide a link to this documentation, and I am including this excerpt:
5) 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. Treatment Option Considerations (https://vetmed.tennessee.edu/vmc/dls/endocrinology/Documents/Treatment%20Info%2c%20Atypical%20Cushing%27s%20rev ised%20June%202011.pdf)

An induction or loading phase with Lysodren is done only for dogs with elevated cortisol, since Miko's cortisol is within the normal ranges only a maintenance dose of Lysodren is given.

You are right to be concerned with the vets treatment plan. The usual treatment that is started first for Atypical Cushing's is melatonin along with lignans. It can take 4-6 months to see improvements with this type of treatment. If no improvements are seen than a maintenance dose of Lysodren can be added.

I am also including a link from our Resource thread that has info regarding Atypical Cushing's: "Atypical Cushing's"/Congenital adrenal hyperplasia-like syndrome/ Hyperestrinism (http://www.k9cushings.com/forum/showthread.php?t=198)

If you have any questions please do not hesitate to ask them. ;)

Hugs, Lori

[Squirt's Mom]

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

Ditto to what Lori said - a minimum of 4-6 months on melatonin and lignans only THEN if no improvement a maintenance dose of Lysodren is added. There is NO loading phase for Atypical pups. (Loading is when the med is given twice a day for a short period.) The dosing formula is ok, within range, but the loading is not appropriate unless the cortisol is elevated.

Were any other tests given? The LDDS? What about labs that show things like BUN, CHOL, ALPK, etc? Would you mind post the abnormal, too low or too high, values from that test along with the little letters that follow and the normal ranges? It would look something like this -

BUN 11ug/dl 5-15 (EXAMPLE)

Glad you found us and look forward to getting to know you both better as time passes.
Hugs,
Leslie and the gang

[lulusmom]

Hi and welcome to the forum.

Dealing with Atypical Cushing's can be beyond frustrating because the efficacy of any of the treatment options is an iffy proposition and no all vets agree on treatment protocol. I'll mention more about that in my comments in blue text within the body of your original post below:



I have a 8yr old female spayed Akita that was just diagnosed with atypical cushings.

Akita's are one of the plush coated Northern Breeds that seem to have a genetic predisposition to alopecia X. Most of these dogs are asymptomatic and have normal labs. Your vet should have done a senior screening which includes blood chemistry, cbc and urinalysis. Can you please post the abnormal values on the chemistry and cbc and please include normal reference ranges. Also, please post the results of any urine tests. I would most interested in the urine specific gravity and the results of urine culture.


The vet wants to start her on Lysodren with 10mg
of Melatonin. She has had hair loss on her back for about 3 yrs but her cortisal lvls have always been in the normal range.
She is a female spayed Akita with no other issues other than she seemed a little less active than normal, huge appetite and large water consumption over the last 3-4 weeks.

When you say your dog has become less active than normal, what have you noticed in that regard? Is she sleeping a lot more? Is she exercise intolerant? Has she gained weight?

Has your dog always had a good appetite or has the appetite increased over a period of time? If the latter, when did you notice the difference? Does your dog beg for food, forage for food, clean her bowl as well as the best brand name dishwasher?

Dogs with hyperadrenal activity that affects the kidney's ability to concentrate urine, pee lakes. They drink buckets to keep up with huge volume of peeing. Is your girl peeing a lot and having lots of accidents in the house?

She weighs 114 lbs and we have ran tests to make sure that she had no issues with parasites etc..

Here are the test results from UTK that where just done.

Cortisal (base) 55.8 of 2.1-58.8 range
Cortisal (post acth) 129.4 of 65.-174.6
Androstendione (base) 0.35 of 0.05-0.57 range
Androstendione ( post acth) 0.80 of 0.27-3.97
Estradiol (base) 50.2 of 30.8-69.9 range
Estradiol (post acth) 45.5 of 27.9-69.2
Progesterone (base) 0.59 of 0.03-0.49 range
Progesterone ( post acth) 2.40 of 0.10-1.50
17OH Progest (base) 0.71 of 0.08-0.77 range
17OH Progest ( post acth) 2.76 of 0.40-1.62
Aldosterone (base) 259.5 of 11-139.9 range
Aldosterone (post acth) 400.3 of 72.9-398.5

Her ultrasound found no abnormalities on the adrenal glads or any other of her organs.

So the ultrasound was completely normal? Just a note here...dogs with atypical most often have the same organ abnormalities that dogs with typical cushing's have, specifically enlarged liver and adrenal glands.

What concerns me is the Vet is prescribing a loading dose of (25mg/kg/twice daily) for up to 8days before testing, then a maintenance dosage of (50mg/kg/twice weekly) and tests at 1 month and every 3-4 months.
This seems like a very high dosage for atypical cushings.

What concerns me is that it sounds as though the problematic symptom for you appears to be the hair loss which has been present for the last three years and that the appetite and increased drinking is secondary. If the appetite and increased drinking are not really clinical conditions (polyphagia and polyuria/polydipsia) caused by elevated levels of sex hormones, your girl could have alopecia X, which is more a cosmetic issue than a medical one.

Is your vet an internal medicine specialist or a general practitioner? With respect to treatment with Lysodren, the University of Tennessee recommends a three to four months of treatment with melatonin to see if that works before they recommend a maintenance dose of Lysodren. Many specialists understand that melatonin is only effective 30% to 50% of the time so they do recommend concurrent dosing of melatonin with low loading doses (25mg/kg) of lysodren anywhere from 4 to 7 days and then to a weekly maintenance dose of 25mg to 50mg/kg.

I have included links to some very good reading on atypical cushing's and it's various treatments. Some of it is pretty technical but I think you will understand most of it.

http://www.2ndchance.info/cushingsbehrend2010.pdf

http://www.ivis.org/proceedings/navc/2005/SAE/091.pdf?LA=1

http://www.vmsg.com/files/Case_Report_Atypical_Hyperadrenocorticism.pdf


Would love to hear thoughts on this.
kris

I'll be looking forward to your responses.

Glynda

[Miko's Dad]

Hello everyone and thanks for the quick responses.
Yes a senior wellness test were given. Here are the abnormal lvls noted (both Low and High )

Chem 27 results
Creatine kinase:High 208 of ( 10- 200) u/l
Lipase:Low 133 of ( 138-755) u/l
BUN:Low 6 of ( 9-31) mg/dl
Glucose:High 123 of (63-114) mg/dl
Potassium:High 6.8 of (4.0-5.4) mmol/l
NA/K :Low 21 of (28-37)

CBC Comprehensive results
HGB:Low 11.6 of ( 13.4-20.7) g/dl
MCH:Low 18.7 of (21.9-26.1) pg
HCHC: low 28.9 of ( 32.6-39.2) g/dl

Urinalysis results
color : yellow
clarity: clear
Specific gravity: 1.012
glucose: negative
bilirubin: negative
keytones: negative
blood: negative
PH: 8.5
protein: negative
WBC:0-2
RBC: none seen
Bacteria: none seen
EPI cell: none seen
Mucus: none seen
Casts: none seen
Crystals: none seen
Urobilinogen: normal

T4 results
T4: 1.3 of (1.4-4.0) normal

Lab4DX plus results
Heartworm: negative
Ehrlichia canis/ewing II : negative
Lyme: negative
A. Phagocytophilum/Platys: negitve

Coccidiodies screen + Titer results
IGG antibody: negative
IGM antibody: negative
Immunodiffustion Titer: not indicated

Fecal O&P + Giardia results
OVA & Parasites: NO OVA or Parasites seen
Giardia: negative

Ok now to answer some of the other questions, Miko's Dr is a DVM and licensed surgeon, but not a IMS. He consulted with the Dr that performed the ultra sound that is a DVM who's practice is limited to Internal Medicine.
The ultra sound results where not in her file as of yet when I picked them up ( they have been specifically requested as well the notes from the consultation with the DR at UTK )
But if memory serves me correctly, her adrenals where slightly enlarged, but no mention of her liver or any other organs where mentioned.
Thank you for the all the links. (one of them I had not read yet)
but please keep them coming, I really want to be able to read as much as I can.
The change in her demeanor is more something that the owner just knows, she still looks forward to her walk everyday. Sleeping has increased but I feel that has been much due to the melatonin as anything else. She has shown signs of PU/PD only a cpl of accidents in the house which is was out of character for her. I say " showed signs" above because yesterday and today here PU/PD habits are much more in line with her brother. I did change yesterday the type of Melatonin I was giving her to a non fast release or extended release type.
I had not noticed her eating being more ravenous until I started watching her eat, and that she was pushing her brother out of the way to help him finish his food when she was done with hers.
Both have always been free feed 4 cups each once a day.

So in conclusion my concerns are all of it, her hair loss is on there but at the bottom of the list ( just concerned with it as a sign of something not that she has it ).
More currently focused at the course of action the Dr has prescribed for her and the amounts, I feel they are out of balance with her signs and requested a consultation with him to let him argue his case (sort to speak) with me, before we go down that road. I am also writing up my assessment of all her labs and symptoms and my recommendation on a course of action for her and would like this to be ran by a consulting DR at the UTK facility for his input, during a conference call that I am present at.

kris

[Miko's Dad]

Update:
Well I never got a return Call From Miko's vet, so I wrote him a letter about my concerns with doing a loading with Lsyodren of 25mg/kg twice daily and a Maintenance dose of 50mg/kg twice weekly for an "atypical" cushings dog. He response was a little unsettling, which was that he was not, nor was the consulting Doctor comfortable treating a dog who's owner was in his words Micro managing the treatment, and that I should seek a second opinion with a IMS doctor elsewhere.

[Dixie'sMom]

I just wanted to drop in and say hello to you and Miko. I've read your story and can be of absolutely no help to you as far as advice goes, but I'm sure some of the experts will be along shortly. I'm new to having a Cushing's baby myself and especially with Atypical Cushing's, I believe things get much more tricky. With that said, I do, however, have over 30 years of experience working on a daily basis with physicans with huge egos and honey, you just bumped up against two of them. Your requests were not out of line, in my opinion, but your delivery may have hit them where it hurts. You see, they want to call the shots, even tho they are working for YOU. And they want their subjects (patients) to blindly follow. If I were you, I'd gather up all of Miko's records and continue the search for a suitable vet and IMS who is willing to work with you. It sounds like she is stable so you've got time. I'll continue to follow and best of luck to you and sweet Miko.

[Trish]

Oh dear, well they have made it easy to go and find someone that does not mind the pet's owner being involved in the care planning!! I was fired by own of our vets once :eek:, I think they get a bit intimidated sometimes. But I am not embarrassed to say I micro manage, he is my dog and ain't no way anyone is going to do anything to him without my full knowledge and consent. We are their No. 1 advocate so any vet that does not want to work with that can go jump in the lake as far as I am concerned. I do not worry about their ego's and boy some do have them, I worry about my dog getting the best care possible!! Most vets like owners who are actively involved, so good luck in finding the next one and don't take it personally. :)

[Squirt's Mom]

Well, Kris, this vet just did you a huge favor tho I know it doesn't feel like it at the moment. But vets with that attitude are the most dangerous and pose the most risk to our babies in dealing with this disease. An arrogant vet unwilling to work with you as team is indeed dangerous and risky....and this vet just proved he and his partners fall into that group. It is much better that he showed his true colors BEFORE starting treatment on your baby. So be grateful they never got the chance to put your sweet girl in danger with an uncooperative, uncommunicative attitude. RUN, Kris, RUN to a new vet! ;)

[lulusmom]

Hi Kris,

Your vet was following a protocol that many specialist follow and it is highly possible that it wasn't his idea but rather his consulting vet's, who is probably an internal medicine specialist. Regardless, your vet's attitude is uncalled for and you should send him a letter back that goes something like this.....


Dear Dr. ______

I appreciate your prompt response to my written communication but would have appreciated the courtesy of a return phone call so that we could discuss my concerns about your proposed Lysodren loading. It is beyond comprehension that you should accuse me of micro managing simply because I have concerns about a drug that is a derivative of DDT and known to cause serious side effects, including death if not administered and monitored according to protocol. I am a proactive advocate for my dog and refuse to place blind faith in anybody to act in her best interest, especially when it comes to a serious disease which requires putting a toxic chemo drug in her mouth.

Lysodren loading protocol dictates that the pet owner has a key role in properly administering and monitoring the drug that you have prescribed so as to avoid serious side effects. Protocol also dictates that you provide comprehensive counseling to me on this very serious drug. I therefore find it very troubling that instead of you counseling me on a very valid concern, you accuse me of micromanaging. It is abundantly clear you place your ego above my dog's welfare and that sir is an egregious breach of protocol and professionalism. Shame, shame on you.

I will be seeking the services of a specialist for a second opinion and I will also be asking that specialist for a referral to a knowledgable general practitioner who respects and appreciates pet owners who are proactive advocates in their pet's care. In other words, Dr. ____, you are fired!

[Squirt's Mom]

BRAVO!!! Great letter, Glynda! Copy and paste, Kris, copy and paste! :D

[My sweet Ginger]

Yup. Do just that.:D

[Dixie'sMom]

Oh yes! That letter is spot on. Do it Kris.

[Miko's Dad]

@LulusMom your assessment of this is spot on, that was in fact the case, I spoke with the Medical Director at the facility on the subject of Protocol and Professionalism yesterday. I then recieved an email late last night from her DVM, explaining that he did not mean for his email to come off as being overly critical and that he would be calling me in the morning to address and answer any and all questions I had, the best that he could.

I did in fact speak with him this morning and he was very professional and did answer all my questions, and he spoke very highly of the IMS that I had researched ( "Atypical" experience was a prerequisite) and scheduled with, she will be seeing Miko on Tuesday morning so I can get her assessment and recommendations on Miko.

Thank you all, I will be posting an update on Tuesday letting you know how the meeting went with the new IMS.

Kris

PS : My wife now feels like she is living with a medical student. :)

[lulusmom]

Kris, good for you for not accepting this behavior. You are an awesome advocate! I'd like to add that critical comments are statements that emphasize the importance of a point and your dvm didn't have a point.... he merely wanted to put you in your place. He leveled an unfounded accusation which could only be interpreted as being arrogant, rude and self serving. I'm not sure how he could possibly say that he didn't mean to come across as being critical. Really? He must think you just stepped off the banana boat. :mad:

Glynda

[Squirt's Mom]

Poor old vet just didn't know you now have a whole army behind you! ;)

[Dixie'sMom]

He did not willingly retract his statements... he was forced to by management. Proceed with caution.

[molly muffin]

hmm, I agree with Suzie, he didn't do this willingly and he still started out by not following correct protocol for treatment. That makes me worry and this guy would have to bend over backwards and Swear to follow proper protocols If I even went with him. I'd be looking for someone else personally.

LOL funny about the medical student, I'm pretty sure we all became medical students pretty quickly once we heard the word cushings!

Sharlene and molly muffin

[lulusmom]

Hi Kris. I just wanted to mention a few things about the labs you posted. I am certainly not a vet professional in any way shape or form and any of my opinions are coming straight from a layperson's mouth who has learned some things over the years reading labs for members as well as those of my special needs rescue dogs. I've reposted the abnormal results and typed my comments next to them in blue below:



Chem 27 results
Creatine kinase:High 208 of ( 10- 200) u/l This would seem to be a mild elevation which could be caused by cushing's, low thyroid and high potassium.
Lipase:Low 133 of ( 138-755) u/l
BUN:Low 6 of ( 9-31) mg/dl This is a common finding in dogs with cushing's who have polyuria/polydipsia
Glucose:High 123 of (63-114) mg/dl Can be due to cushing's or stress.
Potassium:High 6.8 of (4.0-5.4) mmol/l Apparently some Akitas have an inherited blood abnormality called microcytosis. Here is an excerpt from an interesting article which can be found at http://www.akitaclub.org/health/health/blood1.html

*An unusual feature of the blood that is seen in some Akitas is microcytosis, the presence of abnormally small red blood cells and a high potassium level. No correlation between high potassium levels and microcytosis has been found, and not all Akitas show these traits. The presence of microcytosis in the Akita has not been associated with any physical problem, though microcytosis, in general, is associated with certain anemias. Other Japanese breeds may also show microcytosis.

NA/K :Low 21 of (28-37) This is a ratio of potassium to sodium. Result is abnormal due to high potassium.

CBC Comprehensive results
HGB:Low 11.6 of ( 13.4-20.7) g/dl
MCH:Low 18.7 of (21.9-26.1) pg
HCHC: low 28.9 of ( 32.6-39.2) g/dl These results would indicate some level of anemia going on. I'm wondering if this could be the result of the microcytosis mentioned in my comments for potassium. I would ask the vet.

Urinalysis results
color : yellow
clarity: clear
Specific gravity: 1.012 This is definitely low but we've seen a lot worse. My own cushdog's USG was 1.008 which remained a chronic problem as he was ultimately diagnosed with diabetes insipidus which did not respond to treatment.
PH: 8.5 This is very alkaline urine which is common in dogs with urinary tract infections. The urinalysis showed no bacteria but bacteria in dilute urine doesn't always show up on a standard urine test. For this reason a culture is usually ordered. Did your vet do a culture? Grain ladened kibble can also increase urine PH. I can attest to that as two of my dogs had very high urine ph and oxalate bladder stones which I believe to have been caused by crappy kibble.
protein: negative This is good news as most dogs with cushing's do have anywhere from 1+ to 3+ protein in their urine.

T4 results
T4: 1.3 of (1.4-4.0) normal I've read that as much as 70% to 90% of Akitas are diagnosed with hypothyroidism at some point in their lives. This low T-4 result would definitely prompt me to do a full thyroid panel. If Miko does have true hypothyroidism, that could explain the behavioral changes. However, dogs with hypothyroidism do not have polyuria/polydipsia so thyroid supplementation would not remedy Miko's excessive drinking and peeing. My first cushdog was also diagnosed with hypothyroidism so it is not unusual to see concurrent conditions.

I would definitely be interested to hear what the IMS has to say about any of Miko's genetic predisposition to those conditions I mentioned in my comments above. I think we'll all be staying tuned for your update on Miko's consult with the IMS.

Glynda

[Miko's Dad]

Hello everyone,
Well we went to the IMS yesterday, was a very good and informative
visit.

We are starting Miko on Lysodren but at a much lower dose and with no loading.
We also are treating her for High blood pressure, as well as retesting her for a bladder infection. it was a good day and we will be back to her new Dr. on tuesday for a blood pressure retest and will go over the results of the Urinalysis- culture and protein/creatinine test that we did yesterday.

[molly muffin]

How is Miko doing? What dosage of lysodren did you start on?

Sharlene and molly muffin

[Miko's Dad]

She is doing a little better, the dosage for the Lysodren is 5mg/kg twice weekly.

[Squirt's Mom]

5 mg or 50 mg?

[Miko's Dad]

Just 5mg. The doctor felt that her cortisol levels where in the normal range so the larger dosage was not required at this time.

[Squirt's Mom]

That is a very, very small maintenance dose even for a true Atypical pup. The maintenance dose is typically 25-50mg/kg given 2-4 times a week. ;)