Feeling Conflicted

[beaglepants]

Hello, I am new here, a brief background, i am a registered vet tech but I have been out of the game for a few years now having a baby, and now expecting another. I do locum work and that keeps me in the field.

Maxwell is our 12yr old beagle/basset x that I adopted while I was in tech school. I do regular blood work on all my dogs once they are seniors and his ALKP has been mildly elevated for a couple years (just barely over normal values) This time his value was still just over normal, but his cholesterol was up as well. We checked his thyroid and his t4 was normal, but his TSH was mildly elevated. I took him in because he had a couple urinations in the house but they seemed very strange as they happened at dinner time and under our daughters high chair.

12hr overnight USG was 1.028 so a bit low but normal. He has ALWAYS been a big drinker, we have done water deprivation tests etc in the past to rule out DI and the dr's i used to work with decided it was psychological. There has been no increase in his water consumption, no pot belly, no hairloss, no weight gain. Infact he really doesn't look like a cushingnoid dog at all. We ran a urine cortisol and it came back at 11, one above the reference range, so he went in yesterday for a LDDST.

His results came back today as
resting cortisol : 441 nmol/L (ref 30-300)
4hr post : 220 nmol/l
8hr post: 161 nmol/l

I have asked for his dr to put in a call for a consult with the Lab's clinical pathologist as I am having a hard time deciding if we should treat when he really is Asymptomatic. We have spent a lot of money on maxwell (5K on an MRI and ventral slot procedure for IVDD when he was 9) so we will do what we can for him, I'm wondering if we should go straight to an IM specialist etc. I also feel inadequate as a tech right now because I honestly don't know what to make of his results, if they point towards PDT or ADT, I haven't really had to deal with this in years and my Vet didn't really specify.
Does anyone have any insight or even some encouraging words? I lost my soul dog of 15 years about 4 years ago and I really REALLY don't want to say goodbye to anyone else anytime soon! My first dog had cushings about 20 years ago and the only Tx they did then was prednisone and he ended up addisonian and dying in a matter of 1.5-2yrs post Dx. it was awful.

thanks guys.

[addy]

Hi and Welcome.

I'm not sure I have any words of wisdom for you. My dog was diagnosed when she was about eight years old. I waited a year to treat her as her blood work and symptoms were not bad. I chose Vetoryl because Zoe had inflammatory bowel disease as well. She lived for another 3 years, passing away from a blood clot to her brain. Well, we think that is what happened.

Deciding if and when to treat is a decision everyone makes based on their dog's symptoms and blood work. The goal of treatment is to lessen symptoms that are of concern to you and bothersome to your pup. The drugs we use are powerful and false positives during testing can occur. So we first have to be sure of the diagnosis; history and symptoms play a big role in diagnosis.

Have you had any blood work done?

There is no need to rush into treatment and an experienced vet is really needed. If you have an Internal Medicine Specialist you can consult with who is experienced in dealing with Cushings, it may be the way to go. A lot of things can come up.

Hang in there. Sorry this is so short. Others will be along soon.

Again, welcome!

[Dixie'sMom]

Hi and welcome to the forum. I'm very sorry to hear that Maxwell is having problems. I'm fairly new to being a Cush Mom so I can't be of much help to you except to say that you have come to the right place for help. The folks on this forum have a wealth of real life experience and a ton of knowledge medically in regard to Cushings and all that it brings to the party. I am glad to hear that your boy is experiencing very few Cushing's symptoms other than PU/PD.

The experts should be around soon and can interpret those lab results for you and offer up their thoughts. Again, welcome to you and Maxwell and I look forward to getting to know you both.

(I see that Addy and I were typing at the same time. Help has arrived! )

[molly muffin]

It is very hard with the treatment when they are asymptomatic. The reason for early treatment even when there are no symptoms is to prevent future damage to organs.

The thing is that there can be other reasons for cortisol to be high and without an increase in water consumption, the couple accidents under the highchair could indeed be behavioral. After all, he has been the only baby in the house for a long time.

It seems that all the tests are showing borderline, with the LDDS showing some loss of control.
Does it have the reference range for the 4 hour and 8 hour on your print out of the results?

mine for instance is
0 hour 28 - 120 nmol
4 hr and 8 hr 220 - 500 nmol

for initial testing and no treatment. It is up to 200 at 4 and 8 hr if dogs are on treatment.

I think though that if you rule out, diabetes, thyroid, kidney as being the culprit, you could go for an ultrasound of the internal organs, liver, spleen, gall bladder, adrenal glands and see if they show any problem areas. Depending on what that shows, you could consider moving forward with treatment. I would likely want an ACTH before any treatment started as a baseline. I like baselines for comparisons and if you do opt for treatment, ACTH is the monitoring test.

Those are my initial thoughs.

Welcome to the forum!!

[labblab]

Hello from me, too. I have only a moment to post right now, but I do want to seek some clarification re: those LDDS test results. As Sharlene says, it will help if you can give us the stated normal range for the 4 and 8 hour results. However, I think they will be different from what Sharlene has given as an example -- I think Sharlene's listed norms are actually for an ACTH test and not the LDDS.

The typical cut-off for an 8-hour LDDS result is approximately 40 nmol/L (either 1.4 or 1.5 ug/dl per the reporting units commonly used in the U.S.). This means that the result for a normal dog at the 8-hour mark will fall below that point -- a higher 8-hour result is diagnostic for Cushing's.

So if we translate Maxwell's results into American units, here is what we have:

resting cortisol : 441 nmol/L (ref 30-300) or approx. 16 ug/dl
4hr post : 220 nmol/l or approx. 8 ug/dl
8hr post: 161 nmol/l or approx. 5.8 ug/dl

Assuming that the lab's norms are consistent with what we usually see, these are quite high readings, all three. I believe this is actually one of the highest baseline readings that I've seen. The 8-hour reading is most definitely higher than the typical diagnostic cut-off, and if so it is consistent with Cushing's. Also, since it is less than 50% of the baseline reading, the overall result is consistent with the pituitary form of the disease.

One cautionary note: I do want to make sure Maxwell's reporting units truly are nmol/L. If they are instead ng/ml, then the results are very different.

Marianne

[molly muffin]

Oh fooey Marianne you are right I was looking at ACTH in nmol. Not the LDDS test.
Baseline is definitely higher than normally seen. I would have still the ultrasound of organs mentioned and ACTH if this is feasibly possible. It can get spendy.

[lulusmom]

Hi and welcome from me too.

Was a urine culture done to rule out a UTI before testing for cushing's? Was Maxwell fasted for the blood chemistry? Was a complete blood count done and if so, any abnormalities? Can you please post the actual abnormal values on the blood chemistry and CBC. It would also be helpful if you would post all results of the thyroid panel?

Even without clarification as to the references ranges for the LDDS, if Maxwell were my dog, I wouldn't treat, primarily because the goal of treatment is to remedy the symptoms and Maxwell has none. There is also no evidence that Maxwell has any problems that would be compounded or exacerbated by high levels of cortisol. Thirdly, the LDDS is highly likely to yield false positive results in the face of non-adrenal illness or marked stress. How is Maxwell's anxiety level at the vet's office? Given that Maxwell's body condition is completely normal, he has no symptoms commonly associated with cushing's and with no ultrasound to validate the LDDS, I personally would not feel comfortable with the diagnosis at this point in time.

If Maxwell has cushing's, he'll become symptomatic at some point and if and when that happens, you won't be in a quandary any longer. Your boy is at the bottom of his life expectancy for his breed(s) so in my opinion, you should enjoy every day with him and revisit cushing's when you feel compelled. That might be if he becomes symptomatic or you may want to have blood drawn again in six months. That's just my two cents worth but I'm providing a link to Dr. Mark Peterson's blog for veterinarians which is a very credible resource. Dr. Peterson is a well published and highly respected endocrine specialist. The link below is to a blog entitled "Working Up the Asymptomatic Dog for Cushing's Disease.

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

We'll all be looking forward to your responses. I apologize for all the questions but the more we know, the better we can provide you with meaningful feedback.

Glynda

[beaglepants]

Hello everyone and thank you for all your responses.

no the lab did NOT give a ref range for the 4 and 8hr post samples. I am going to see if I can copy and paste all his results...

i only have the results saved and it won't let me copy and paste them...argh.

he isn't pu/pd...someone said he was. He was home for 7.5hrs yesterday with Aspen our other dog. waterbowl was full when I got home and no accidents. He goes all night no problem, always has.

[beaglepants]

 ok so his ALKP result was 202 (ref range 5-141 U/L)
cholesterol was 12.23 (ref range 2.50-9.90 nmol/l)

No other findings. CBC normal, no stress leukogram.

Kidney function normal.

Biochem profile he was not fasted and the sample was lipemic.

LDDS he was 12hr fasted, water only.

Urine Cortisol was 11 x 10(power of 6) it says anything over 10 is positive.

does this help?

[Amanda's Mom]

Hi maxwells mom. I don't know that I can contribute much that is useful as we didnt go through the diagnostic procedures with my 12.8 yr old girl Amanda. I was having ultrasound done every few months of kidneys and bladder and a tiny adrenal node showed up back in June. In Oct it had grown considerably but she really didnt have much in the way of symptoms of Cushings. Her urine was somewhat dilute and she had been having accidents but since we got her a year ago she has always had some issues with urinary incontinence. My concern was a tumor that might be malignant but in any event was growing and would become locally invasive. Amanda has a heart murmur and isn't the best candidate for what her IM said is one of the riskiest procedures they do. Still, it nagged at me for a few days and I finally talked with her again and we agreed, if the tumor invaded the vena cava the surgical risks would escalate and really, her heart would never be better than it was right then. So after consulting with a very good surgeon who had done many adrenalectomies we put her on some pre op medications and a week later Amanda had the surgery. Surgeon said he had to peel the tumor off the vessels as it was wedged so tight. Obviously if we waited much longer the surgery would have been far more difficult. She came thru like a trooper and has done fabulously. Her left adrenal gland is good size and functioning well. She has healed so well there is almost no sign of her incision and she was back to her normal self in only a few days. Tumor was benign and she is "cured". Pathology showed it was a secreting tumor so she would have started showing more symptoms. We just got lucky and caught it early. I would suggest an ultrasound for Maxwell just to see if there is an adrenal tumor. Of course most Cushing results from a pituitary tumor but maybe 20% are adrenal. It's not an invasive test and it shed some light on what's going on.

On a side note, my ten year old bichon who never peed in the house started to so a few months after we took in another senior dog. No physical cause could be found and he seemed to be marking areas where the newer dog would sit as well as corner of our bed. Vet felt it was likely a behavioral/psychological issue. (He also had become more aggressive) three days on prozac and he is his old self and the peeing stopped. We will try to wean him off in another month or so. You mentioned a few accidents under the baby's high chair so I wondered if this was behavioral because of the baby and all the attention to the baby? Just a thought.

I wish you the best as I know what tough decisions you face. I nearly cancelled Amamda's surgery I was so afraid of it. But I felt given the location and potential for local invasion it would become a serious factor eventually, and her health was as good as it was ever going to be so if we were going to do it, this was the optimum time while she was not having symptoms or feeling sick from Cushings. I would definitely talk with a good Internist and or endocrinologist regarding Maxwell. Good luck!

[lulusmom]

Thanks for responding. His alkp is barely over normal and that can be from a non-fasted sample, especially if it's lepemic. The same goes for cholesterol. If your dog was pu/pd, you would know it. He'd most likely be peeing all over the house, you couldn't keep the water bowl full and if you don't have a doggie door, he'd be bugging you to let him out several times during the night. I have not changed my mind about what I would do if Maxwell were my dog.

Glynda

[Dixie'sMom]

I was the one that thought he had pu/pd but he didn't. Sorry if I confused the issue.

[Silliam]

Was recently alerted to the fact that Cushing dogs in something like 80% get high blood pressure before they are symptomatic. So maybe you could check that?
And cushings is notorious for being hard to diagnose
Either way welcome to the forum
There are many way more educated then me who will help I just say hi now and then:p;)

[lulusmom]

Was recently alerted to the fact that Cushing dogs in something like 80% get high blood pressure before they are symptomatic. So maybe you could check that?


I'd never heard this and would be very interested in learning more. Can you provide a link to any information on this?

[labblab]

I was wondering about this myself, so started Googling a bit this morning and this is a 2012 quote I found from Dr. Peterson. It doesn't specify the presence or absence of other overt symptoms, but this statistic is pretty shocking...:eek:


Over 75% of dogs with untreated Cushing’s syndrome have systemic arterial hypertension and half have proteinuria. Unfortunately, both hypertension and proteinuria may persist despite successful treatment of the hypercortisolemia.

http://endocrinevet.blogspot.com/2012/06/hypertension-and-proteinuria-frequent.html

I had no idea the percentage was that high! The rest of this article is a very interesting read in terms of the possible significance/ramifications of these findings.

Marianne

[lulusmom]

Dr. Peterson's blog came up on my search too and I also found that it didn't really serve as support for a statement that 80% of dogs with cushing's have hypertension before they become symptomatic. It was some interesting reading though, so thanks for posting the link, Marianne.

Feeling Conflicted, two of us have provided you with links to two blogs on Dr. Peterson's site. That site has a wealth of information and I heartily recommend that all members check it out. I subscribe to his blog to keep abreast of the latest developments as well as follow his responses to veterinarians who go there to learn. There is always something to learn.

Glynda

[labblab]

I'll keep noodling around, myself, to see what more I can find. Although that specific statistic may be hard to document, I think it reflects a general ongoing question as to whether or not it is wise to treat dogs for Cushing's in the presence of certain lab abnormalities but in the absence of overt symptoms. In "Feeling Conflicted's" case, there really aren't even significant lab abnormalities other than the highly elevated LDDS. So I dunno what you'd opt to do if hypertension was discovered, as well. When abnormal labwork points to Cushing's, some experts say they'd go ahead and treat for Cushing's in the presence of hypertension and/or significant proteinuria, even in the absence of overt symptoms. I've read others who say not so fast. So I think this remains an unsettled area of conversation at the moment.

Having said all that, I agree it might not be a bad idea for "Feeling Conflicted" to have a blood pressure check, regardless of anything else. If it is high, then direct treatment of the blood pressure may be in order, and the info can also be filed away as additional support of a possible Cushing's diagnosis in the future if not right now.

Marianne

[Silliam]

Was recently alerted to the fact that Cushing dogs in something like 80% get high blood pressure before they are symptomatic.

What I think I was trying to say is that
Around 80% of dogs with Cushings and even some other endocrine disorders show abnormal blood pressure readings.This can occur before other symptoms so it is handy to check.
If blood pressure is up it means something is causing it and if your dog is already leaning towards cushings then it is probably worth seeing if the rise in blood pressure is caused by the excess cortisol. I guess it would be a diagnosis of exclusion
Sadly we don't check our dogs BP enough at routine check ups to know what percentage showed BP changes before other symptoms. It is also non invasive using the Doppler method and isn't a huge expense.
Now this part is just my personal opinion:
I just think if you're border line Cushings but not sure if your dog needs treatment yet, knowing if the cortisol has pushed up the BP would let you know internally how things are going as high BP is a risk for a lot of damage. So it might give me some more info before I decided. Like gathering clues or something.
Sorry for the confusion.

[Squirt's Mom]

"Gathering clues" - that's exactly what diagnosing Cushing's is like! :D

[molly muffin]

We should all have detective licenses by now!

[Dixie'sMom]

I wonder why a routine BP check isn't done at all vet visits right along with the temperature and exam. It sounds like it could be an early warning signal for a lot of things. hmmmm...

[molly muffin]

One reason is probably because it is so hard to get accurate readings and you need to do curves, like with blood sugar. So you take a few readings, discard the highest and lowest and average the rest. Often the highest will be the first. Plus as I discovered, many GP vets don't have BP machines! Isn't that ridiculous. I really do think that BP is a good indicator of things going wrong, but it should be done along with bloods urinalysis, etc Sometimes BP doesn't go up till there are already major problems to be addressed. :(