Questions...Could it be Atypical Cushings?

[Mld0917]

We have had a very rough year. First we lost our 15 year old cat to cancer last October, then our 14 year old dog to kidney failure in July. Now my 11 year old dog, Sadie, is having issues.

In June, 2013 our dog needed a teeth cleaning. The pre op blood work was completely normal. Her ALKP was 100. A few months later, she started dribbling urine and gaining weight. I took her in and the doctor put her on Proin. She has since started panting a lot and had anxiety so I took her in again and the blood work done in June 2014 showed an elevated ALKP of 1119. She was then tested for Cushings using the low dose dexamethasone test and they said it was completely normal. She was put on Denamarin for 1 month and we just did a retest. Her ALKP was 1050 and her T4 had dropped from a normal value of 1.4 to 0.4. All other values are normal. He said the ALKP value should have dropped much more after a month on Denamarin.

I asked the vet if she could have atypical cushings and he said the last 2 conferences he went to said it was not a real disease. He also said she was most likely not hypothyroid but it was probably due to something else with the liver. He had no idea what it could be, but suggested X-ray, referral for ultrasounds and possible biopsy. All costing a lot of money. He said those tests may not give us any answers either. We have had some major health issues in our home, plus the expenses from my other pet's illness and recent testing of Sadie.

I told him I would speak to my husband and call back tomorrow. I am hoping one of the other vets is on duty. Does anyone have suggestions as to what I should be asking? Can I treat atypical cushings on my own with Flaxseed, Lingans, Melatonin? He said he did not think Denamarin would help. I am really lost as to what I should do.

[lulusmom]

Hi and welcome to the forum.

I am so sorry that you have not received a response yet and I will do my best to be helpful. First let me say how sorry I am that you lost your beloved kitty and pup. I know how horrible is to lose two in such a short period of time so my heart goes out to you.

Now lets see how we can help you and your precious Sadie. In order to provide you with meaningful information, we'll need you to provide additional information. In order to keep myself on track and make sure you know why I'm asking the question, I've typed my questions and comments in blue text within the body of your post below.



In June, 2013 our dog needed a teeth cleaning. The pre op blood work was completely normal. Her ALKP was 100. A few months later, she started dribbling urine and gaining weight. I took her in and the doctor put her on Proin.

I just wanted to comment here that dribbling urine doesn't really describe the excess peeing a drinking that cushdogs have. Did your vet do a urinalysis, including a culture and sediment to rule out a urinary tract infection. If so, can you please post the results for us?

She has since started panting a lot and had anxiety so I took her in again and the blood work done in June 2014 showed an elevated ALKP of 1119.

Were there any other abnormalities on the blood chemistry and complete blood count (if done)? If so, can you please post just the highs and lows, and please include the normal reference ranges. Panting can be a sign of many things. Has your vet ruled out arthritis, spine/disc problems? Have you noticed that Sadie seeks out cool places, like tile, to lie down? Can you tell us what you mean by anxiety? Is she restless, whiney and if so, is it worse during a specific part of the day or all the time?

She was then tested for Cushings using the low dose dexamethasone test and they said it was completely normal. She was put on Denamarin for 1 month and we just did a retest. Her ALKP was 1050 and her T4 had dropped from a normal value of 1.4 to 0.4. All other values are normal. He said the ALKP value should have dropped much more after a month on Denamarin.

80% or 90% of dogs have a steroid induced isoenzyme of ALKP so if one of those dogs has cushing's, you are gonna see anywhere from a mild to severe increase in ALKP. These increases are not because the excess steroids are killing liver cells, it's because the steroids are causing an abnormal accumulation of fat in the liver and it is having to work a bit harder. Denamarin does not reduce cortisol so unless a dog is also receiving treatment to reduce cortisol, I wouldn't expect to see any improvement on Denamarin alone.

I asked the vet if she could have atypical cushings and he said the last 2 conferences he went to said it was not a real disease.

Atypical cushing is controversial and had your vet gone to another conference, he may have heard from keynote speakers who feel that atypical cushing's is real, or at least has been labeled as a condition that is not very well understood. I've been researching canine cushing's since 2005 and I've probably changed my mind a few times about atypical cushing's over the years. I'm not a huge believer because there is no concrete, scientific evidence that proves it exists nor an explanation as to why it exists. We know what causes typical cushing's but not atypical. I do know, however, that we have a few members who had luck with the melatonin and lignan treatment regimen but again but in my opinion, I'm not convinced the symptoms didn't get better on their own. However, if I were in your shoes, I wouildn't hesitate to try melatonin and lignans as they are very, very benign in comparison to Lysodren or Trilostane. I am hoping that Leslie chimes in and shares her experience with atypical cushing's and it's treatment.

He also said she was most likely not hypothyroid but it was probably due to something else with the liver.

It's impossible to tell for sure whether Sadie has true low thyroid or whether the T4 is being transiently lowered by a non-thyroidal condition, such as cushing's. Your vet would have to do a full thryoid panel to make that determination. What is Sadie's breeding?

He had no idea what it could be, but suggested X-ray, referral for ultrasounds and possible biopsy. All costing a lot of money. He said those tests may not give us any answers either. We have had some major health issues in our home, plus the expenses from my other pet's illness and recent testing of Sadie.

From what you've posted so far, I don't know if your vet has done sufficient testing to rule out other causes before incurring the expense of an ultrasound. If that's where you are in the process, I personally think an abdominal ultrasound would be the way to go. Your responses will help us understand your vet's rationale, including why he may be considering a liver biopsy, especially if ALKP is the only abnormality.

I told him I would speak to my husband and call back tomorrow. I am hoping one of the other vets is on duty. Does anyone have suggestions as to what I should be asking? Can I treat atypical cushings on my own with Flaxseed, Lingans, Melatonin? He said he did not think Denamarin would help. I am really lost as to what I should do.

It is difficult to provide you with appropriate questions and why you should ask them without knowing more about Sadie's diagnostic history. I can tell you however, that you can treat on your own with melatonin and lignans. It's been awhile so I have forgotten what type of lignans you need to purchase but I can get back to you on that. Melatonin should be just the plain stuff, not rapid release or extended release. There is not need to give Flaxseed as it is the lignans from flax hulls that you need to buy.

I'll be looking forward to hearing a lot more about Sadie. There is no such thing as too much info so lay it on us. :D

Glynda

[molly muffin]

Hello and welcome to the forum. You certainly have had a rough go of it lately. Poor dear, losing both your cat and dog. That is horrible. I had one of those years and don't wish them on anyone.

Now dear Sadie. Well, lignans you can get either flaxseed hull or HDR which is a spruce type. Melatonin you will want plain melatonin, not rapid release or any other enhanced type.

This is a link to treatment for atypical instructions:

https://vetmed.tennessee.edu/vmc/dls/endocrinology/Documents/Treatment%20Info,%20Atypical%20Cushing%27s%20revis ed%20June%202011.pdf

You said the LDDS was negative, do you know if he did an ACTH to check for high cortisol?

Cushings is very hard to diagnose and a thyroid problem can have some of the same symptoms. I know he doesn't think that is what the problem is, but it is a thought to be looked into fairly easily with a thyroid panel.

If you could let us know about the test and abnormal results and whether or not they did a urine culture, that would be helpful.

Also, is Sadie still on proin? Also, Denamarin is beneficial over all supplement for the liver so I would keep Sadie on it.

Sharlene and molly muffin

[Mld0917]

Thank you so much for your responses. I do not have a copy of the most recent blood work since I was called with the results, but they said they would have a copy for me Thursday. I will also pick up the LDDS test results so I have the exact numbers. It is my understanding they did not do an ACTH test.

When I took her in for the dribbling/peeing issue last fall, the vet did a culture and said it was negative.

Sadie's issue can best be described as dribbling with a few days here and there of breakthrough urinating. I would say a day or two every couple months. When she leaks, she constantly licks, so it is hard to tell how much is coming out. It is not like her to go in the house when she does, it is a lot of urine. She has done it again the past couple days since I took her to the vet so I increased the proin because she was on the lower range of the dose they allowed. I bumped her from 1/4 pill twice daily to 1/2 pill twice daily. She also takes a half of a trazodone twice daily for anxiety that can best be described as jumpiness. She has always been a timid dog. Our other dog was the boss, even though she was a tiny little Shih-tzu mix. If one of us gets up to quickly Sadie jumps, and paces sometimes at night. No whining when we are at home, but when I would leave, I would hear her barking and whining. The trazodone has helped with the anxiety.

Sadie goes through 2 bowls of water a day. The bowls are about 32 oz. There is usually some left at the end of the day.

She eats Blue Buffalo senior. I give her the recommended amount of dry/can mix, but she always seems hungry. However, she does not always eat all her food. She does a lot more begging for treats and while we eat.

Sadie does prefer to lie on the tile floor. She pants a lot and I notice she breathes heavily sometimes when sleeping. She does have periods of normal breathing.

Her belly is bloated. The doctor said he did not feel any organ enlargement, but the ultrasound would show that if there was any. He has ruled out arthritis and disk issues. He also said she does not have jaundice, gum color is good and heart sounds good.

I should mention that most of her life, she has run with my husband. Generally 3-5 miles a day about 5 days a week. She hasn't run for close to a year due to my husband having knee and back issues. She does get walks, but has gained nearly 10 pounds in the past year. These symptoms have coincided with her decrease in activity, but the vet does not think it's related. I notice sometimes when I walk her, she seems to stumble but my husband has not noticed that and it may be that I don't walk fast enough.

Sadie is a mixed breed Border collie, English Springer Spaniel, husky mix. She looks quite a bit like a small English Setter.

Here are the prior blood test results (highs and lows)

7/6/13

WBC. Low. 5.0
MCHC. High. 37
CK. High. 329

T4 was normal at 2.0
ALKP was normal at 100


6/3/14

ALKP. High. 1119
Bicarb. High. 29
AST. Low. 15
TRIG. High. 213

Updated: I was able to get the additional results faxed to me today.

Bloodwork on 9/13/14 Everything was within normal range except:

ALKP High 1050
TRIG High 205
T4 Low 0.4


This is the results of the LDDS done on 8/7/14

Pre-Dex 2.5
4 Post Dex 0.8
8 Post Dex 0.5

Some other thoughts. I'm sorry I may be grasping at straws, but it is worth mentioning. Could they have given her steroids during her teeth cleaning that could have had an effect?

I also have her a few doses of Trifexis at the same time until I read some of the issues people were having. Could this have harmed her liver?

Thanks again for your help. I think I may try the lignans and melatonin. The doctor did not seem to think the Denamarin would do anything and is costly, but said I could try Sam e in the same dosage and that would be more cost effective.

[bgdavis]

Doesn't the University of Tenn. do full adrendal panels anymore? My Criss Ann may have been the first dog on this forum to have been diagnosed by that test back in 2004. She was put on Lysodren and survived with her 'atypical Cushings', diabetes, and lupus until March of 2009.

It took two years and trips to 2 vet schools before the UofT diagnosed her and she got help. You can read about her history and see before and after pictures of her here: http://www.k9diabetes.com/forum/showthread.php?t=83

https://vetmed.tennessee.edu/vmc/dls/endocrinology/Pages/default.aspx

Bonnie and Angel Crissy Ann

[Mld0917]

Thank you for the links. I will check that out.

I forgot to mention another strange symptom. Recently Sadie has been pulling my purse under the bed at night and eating my entire pack of gum. It happened 3 times, so I have stopped keeping gum in my purse. She has never done this before.

[Squirt's Mom]

OMG! Some gums contain Xilitol which is very toxic to dogs. Please be extra careful with gums around dogs.

[Mld0917]

Yes, it scared me and I checked the label when it happened. Thankfully my gum does not contain xylitol. I only found out the second time because she pulled my purse under the bed and I found a pack that had previously gone missing. I thought it was a fluke, but when she did it again, I stopped keeping gum in my purse. I don't want to take any chances. It is strange though, that she would start doing this at 11 years old.

[molly muffin]

Yes the University of Tennessee still does adrenal panels. I just had one done for my dog earlier this year.

Sharlene and molly muffin

[lulusmom]

At this point, if Sadie were my girl, I would probably ask the vet to rule out hypothyroidism via a full thyroid panel before I incurred the cost of a UTK full adrenal panel.

Was Sadie put on Trazodone before or after Proin?

[Mld0917]

Thank you. I will ask about the thyroid panel. She was put on the trazodone after the proin.

[molly muffin]

Love her pictures. What a sweet face she has.

Sharlene and molly muffin

[Mld0917]

Hello again,

I am at my wits end here. I had asked for a call back from the vet. I never received one, so called again. I finally spoke to the same vet as last time. He basically said there is no such thing as atypical cushings, her thyroid is probably sick thyroid and that I could do ultrasound, biopsy along with some other things, or just try some sam e and come back in 3 months. I wish I could afford to try random tests to figure out what is wrong, but still recouping from my other dog that passed and some family health expenses. If I felt I had direction from him, I would feel more comfortable.

I thought in the meantime I would try to treat for atypical on my own with the information provided in an earlier thread. Her main symptom is the weight gain and constant panting/heavy breathing and more urine and water than usual (although not as excessive as I have seen others report).

What I want to make sure is that I am not doing more harm than good by trying this route. She is on proin and trazodone twice per day. How can I find out about interactions with melatonin and lignans? Should I add sam e as well? My hope is to try this and when I go back for the repeat blood work to see some change. If not, hopefully I will be able to see another vet in the practice that can provide me a little more direction.

Thanks again for any input.

[Squirt's Mom]

Glynda is right - Atypical is controversial...still. But unlike Glynda, I have always believed it to be a real condition. Why? Because my pup, Squirt, tested positive for it and the treatment helped lower all her intermediate hormones.

I took Squirt for pre-dental lab work and it came back with elevated cortisol. After 5 tests - LDDS, HDDS, ACTH, UTK panel, and 2 ultrasounds she was diagnosed with PDH. However, after the second US I was told about a tumor on her spleen. Once the tumor and half her spleen were removed, her cortisol returned to normal - meaning she did NOT have PHD but her intermediates were elevated.

For the next several years, Squirt's treatment consisted of lignans and melatonin and her testing showed they were working as did her signs, which in her case were mild. In time, she did become true cushionoid and we added a maintenance dose of Lyso to the lignans and melatonin.

It bothers me that your vet is so close minded. That does not speak well of his ability to play well with others....ie to work with you as a team. HE works for YOU; YOU pay HIM. If you want the UTK panel done, he should be happy to perform that for you. If he is not, I would be looking for another vet asap. ;)

Hugs,
Leslie and the gang

[labblab]

If you look at this reply posted on our "Resouces" forum, you will find info from U of Tenn re: dosing for lignans and melatonin. The lignans info is in the first link; the melatonin info is under the "Treatment info" heading of the second link.

http://www.k9cushings.com/forum/showthread.php?p=157508#post157508

Marianne

[molly muffin]

I would go ahead and add in sam-e too with milk thistle, as that is a good liver support.

It should not hurt to try lignans and melatonin with her and see how she responds to it. Be aware that it can take 4 months or so to see results, although some have seen results earlier.

While atypical is controversial to some, my specialist was not adverse to testing for it, as high sex hormones can cause the same type of symptoms that you see with normal cushings, you just don't have the high cortisol.

Sharlene and molly muffin

[Mld0917]

Thank you so much. I think I will order melatonin, lignans, milk thistle and same-e from lignans.net. I will get her used to the sam-e and milk thistle for a couple weeks to make sure it all agrees with her tummy before adding the others. I was concerned the melatonin might interact with her trazodone or proin, but have not found anything to suggest that.

When I go in for repeat bloodwork, I will try to get the appointment scheduled with a different vet in the practice. I have never seen this particular person until the latest bloodwork and he is not the one that ran the LDDS test, but he is the one that keeps calling me back.