12-13 boxer- Cushings? Where to start

[swcruiser]

I have come here probably like many others- Distraught my best friend doesn't seem himself and trying to figure out how I can best help him. Im trying to get some insight and advice from people that have unfortunately found themselves in a similar situation. I want to know as much as possible so I can A. make informed decisions B. assess the capability of the care giver c. know that i did everything i could to make Jakes last years the best possible.

We rescued Jake over 10 years ago and he has been an AMAZING boy. Rowdy like all boxers but very smart, aware and easy to train. He used to love chasing the ball even though he had an ACL surgery and had hip displaysia. While these slowed him down a bit he was still eager to play and always willing to do a little running.

In late October he started slowing down a bit. At the time it seemed like a combination of things. The weather was getting bad-- he wasn't getting as much exercise---> put on some extra weight--> started expecting snacks constantly---> and he was definitely more lethargic.

I tried to walk him more often and was continuuing to feed him snacks as I thought maybe that due to his age he may not be retaining as much of the nutrition .

[swcruiser]

a couple months went by and he continued to be more lethargic and lost interest in chasing the ball. Every now and then he will chase a stick or snowball but he wont pick it up. He seems to be very tired and sometimes drowsy. His stomach has the potbelly look although it has decreased somewhat after he has been on Thyroid medication and a restricted diet (past 2 weeks).

BTW- for the last 9 years jake has strictly eaten home-cooked meals. including meat (elk, deer, beef, lamb, fish) with vegetables, sweet potatoes etc. He eats very well.

when he was initially taken to the vet he had trouble holding urination for more than 6 hours. He went inside a couple of times but his water consumption was normal. He did seem to stare off into space also. Almost like he was daydreaming. His walking also seemed a little wobbly. After taking him to the vet to check on what might be going on ( i wasn't there) they gave him a rabies vaccination and Banamine for any adverse reaction. I was NOT happy about this. They said he need thyroid medication as it was low. He began the thyroid medication and they also gave him a supplement for dimentia (nutria). At any rate a day later he was drinking excessively and urinating every couple of hours throughout the night. He also had bloody stool. I suspected the supplement and quickly discontinued use and also dropped the thryoid to half. The bloody stool resided and he has been back on the thyroid medication. He seems a little more alert but definitely not himself. He still has excessive drinking and urination. When we took him in for the urination and drinking they did bloodwork and the vet said he may have cushings. He said the specific gravity suggested kidney failure. He also did an ultrasound for his kidneys and he said that one he could not find and the other was a strange shape. They also said there was a hard growth on the liver. Cosmetically, Jake looks very healthy for his age. His coat is soft and shiny and no signs of hair loss anywhere. I will post the blood work which shows elevated liver enzymes.

03/13 urinalysis
glucose/ketones/Billirubin- all negative
protein- TR
blood- 250 Ery/uL
pH- 6.5
specific gravity- 1.1
color- light yellow
RBC/WBC/CASTE/Epithelium/Bacteria-- all none seen
crystals- sm amourphous bits

[swcruiser]

GLU 95.0 mg/dl (74-143)
BUN 34.0 mg/dl (7-27) high
CREA 1.3 mg/dl (0.5-1.8)
PHOS 4.8 mg/dl (2.5-6.8)
CA 11.0 mg/dl (7.9-12)
TP 6.4 g/dl (5.2-8.2)
ALB 3.2 g/dl (2.3-4)
GLOB 3.2 g/dl (2.5-4.5)
ALT 242.0 U/L (10-100) HIGH
ALKP 388.00 U/L (23-212) HIGH
TBIL 0.1 mg/dl (0-0.9)
CHOL 207.0 mg/dl (110-320)
AMYL 828 U/L (500-1500)

CCBC TEST RESULTS
RBC 6.39 M/uL (5.5-8.5)
HCT 39.7% (37-55)
HGB 16.7 g/ul (12-18)
MCV 62.1 fl (60-77)
MCH 26.1 pg (18.5-30)
MCHC 0.0 g/dl (30-37.5) LOW
RDW 15.8% (14.7-17.9)
% RETIC 0.6%
RETIC 38.4 K/ul
WBC 9.93 K/ul (5.5-16.9)
% NEU 78.0%
% LYM 14.3%
% MONO 6.8%
% EOS 0.7%
% BASO 0.1%
NEU 7.75 K/ul (2-12)
LYM 1.42 K/ul (0.5-4.9)
MONO 0.67 K/ul (0.3-2)
EOS 0.07 K/ul (0.1-1.49)
BASO 0.01 K/ul (0-0.1)
PLT 398 (175-500)

HIS T4 WAS 1.1 ug/dl (1.1-4) on the low end of scale.

At this point I have been reading up a lot on Cushings and trying to decide where to start. Should I wait to do more tests after another week to see if the thyroid medication helps? Do I start the Cushings specific tests now? The VET says his kidneys are basically gone but Im a little confused on this because his specific gravity is actually showing concentrated urine. Anyone has similar experiences? Any insight would be greatly appreciated. Im just not sure how to start and also trying to find a respected dr. who has a lot of experience with Cushings in the NYC or catskills area. Thank You!

[Harley PoMMom]

Hi and welcome to you and Jake,

Cushing's is a slow progressive disease, and because it does move a snail's pace clinical symptoms also proceed slowly and generally are not noticed until they are very symptomatic. There are other conditions that have overlapping symptoms with Cushing's, such as hypothyroidism and diabetes. Has Jake's thyroid levels been checked recently? The reason I am asking is because too much of the thyroid supplementation can cause increases in drinking/urination.

The common clinical symptoms seen in dogs with Cushing's are: excessive drinking and peeing, I mean peeing rivers and drinking buckets upon buckets of water; voracious appetite, they are like little hoover vacuum cleaners looking for any crumb they can find; panting; loss or thinning of coat; skin issues; muscle wasting; muscle weakness, especially in the hind quarters; exercise intolerant; difficulty or unable to go up steps or jump on furniture. Besides the increased drinking/urinating does Jake display any of those other symptoms?

Unfortunately Cushing's is one of the most difficult canine diseases to diagnose, which makes it one of the most misdiagnosed. One of the things that makes Cushing's so challenging to diagnose is because there is not a test that can 100% accurately identify it, so vets have to perform multiple tests to validate a Cushing's diagnosis.

If you would get copies of all tests that were performed on your boy and post those values that are abnormal that would be great...e.g...ALT 150 U/L (5-50)...thanks!

Low specific gravity does not necessarily mean kidney failure, did the vet mention performing any other tests to check the function of the kidneys?

I see that an ultrasound was done, were the adrenal glands visualized?

If Jake does indeed have Cushing's I want you to know that it is a treatable disease, however success in treatment does depend on a few things; keen owner observation, a pet parent willing to educate themselves about Cushing's, and a vet/IMS that has experience treating Cushing's and is knowledgeable about the protocols for Cushing's.

We have a wealth of information regarding Cushing's in our Resource thread, so I am providing a link to it, feel free to print anything out and if you have any questions do not hesitate to ask them.

Helpful Resources for Owners of Cushing's Dogs (http://www.k9cushings.com/forum/forumdisplay.php?f=10)

Hugs, Lori

PS I posted my reply just after you added the blood panel results so I'll continue here. I have had 2 boys that had kidney failure and Jake's blood work does not say kidney failure to me. When the kidneys do not work as efficiently as they did there are elevations in the creatinine, phosphorus, and potassium. I see none of those in Jake's chemistry panel.

[swcruiser]

Hi Lori,
Thank You for the information. Jake does have some of those symptoms. He was on the low range of thyroid and is now taking medication.

Peeing every 2-3 hours started after the vaccination and thyroid meds- he definitely drinks a lot more than normal. He will drink a lot then lay down and then needs to urinated in a couple hours. He holds it late at night for 4-5 hours but as soon as i open the door he goes.

his appetite has always been good. We cut back his food a little bit and removed snacks as he was overweight. He will eat most of his bowl but he will still leave a little bit of it and come back to eat a little later. so I would say he is not a hoover.

muscle waisting and weakness are apparent and he doesn't seem interested in exercise.

As for the kidney disease I was a little surprised myself. He has peed in doors a few times in the last few months but this really only happened if he didn't get out within 6 hours. I figured it was related to age and not being able to control his bladder as well. It wasn't until meds came in did he really drink and urinate a lot.

[Squirt's Mom]

Hi and welcome!


BUN 34.0 mg/dl (7-27) high
CREA 1.3 mg/dl (0.5-1.8)

The BUN can be elevated for many reasons and return to normal on its own. The creatinine (CREA) is the value that really tells us there could be a serious problem that needs to be looked into. As you can see, Jake's CREA is normal. I don't see any indicators there that he has a serious kidney issue - BUT I am not a vet. I adopted a pup about 4 years ago and I was told she was in kidney failure based on these two values - BUN and CREA. Both values were elevated in Trinket. However but have come back to normal range so that diagnosis of kidney failure was proven wrong. So even when both of these values are elevated, we still can't jump to kidney disease. I would demand my vet tell me where he got this idea and back it up with test results beyond this one. ;)

[swcruiser]

I agree with you on this as well. The kidney issue was not mentioned after seeing the test results but after hearing about the excessive urination and the specific gravity test. I wasn't there during the appt. but from what I understand the specific gravity should be lower than normal with kidney problem. Jakes value was actually 1.1. The vet also mentioned that one kidney could not be found during ultrasound and the other had a highly irregular shape. This led him to suggest kidney failure. Im going to setup another blood and urine test next week along with the thyroid to see if anything else is changing.

Thank you!

[molly muffin]

Hello and welcome from me too.

Lori and Leslie have definitely covered all the bases, so I'll just say welcome and that I think a recheck is a good idea, also a check of the thyroid levels as being on medicine a swing either way can cause some of the symptoms.

[swcruiser]

Molly, Lori, Leslie,
Thank you for the insight. I will be getting follow up testing done this week and will see a vet experienced with Cushings.

[molly muffin]

Let us know how things are going and what the vet says.

[swcruiser]

So Jake seems to be a little better but still not as energetic as he used to be. Since the first appt. on the 14th of March he has lost about 10 lbs. Mostly due to reduction in snacks and more walks. He still has rear leg weakness and stumbles occasionally. The frequent urination has reduced a little bit but I think it might be due to high thyroid levels and/or trying to find the right amount to give him. his new T4 levels came out 6.6 ug/dl with 1.6-5.0 ug/dl as the normal level. An updated urinalysis showed the following:

ph 7.0
LEU neg.
PRO neg.
GLU neg.
KET neg.
UBG normal
BIL neg.
BLD 250 Ery/ul
S.G. = 1.012

so it looks like he doesn't have kidney problems. Still waiting on the Cushings test and will also do bloodwork later this week.

[swcruiser]

I just received the ACTH test results and it looks like Jake is positive.

Cortisol sample 1 4.7 (1.0-5.0)
Cortisol sample 2 23.2 (8-17) HIGH

The Dr. spoke with a specialist at Cornell that recommended a high sensitivity ultrasound to determine how the Adrenal Glands look. I guess they were wanting to check to see if 1 or both are abnormal size. The specialist also recommend a HDDS. Recommendations on next steps anyone?

[labblab]

I think an ultrasound is an excellent idea. Not only does it give you important information about the adrenals, it also gives you insight into the status of other important internal organs: liver, kidneys, spleen, gallbladder.

If you proceed with an ultrasound, though, I don't see much usefulness in also performing a HDDS test since actually viewing the adrenals should provide the same info (pituitary Cushing's vs. adrenal Cushing's) but even in a more comprehensive way. Maybe the specialist was talking about either/or?

Marianne

[swcruiser]

Marianne,
Thanks for the input. I think he said it would be best to start with the ultrasound and then consider the HDDS if there were still questions. The vet spoke with the specialist so I haven't had a chance to speak directly with them yet.

[molly muffin]

Do you have the ultrasound scheduled?

I agree that is an excellent tool and good bang for the buck so to speak.

Let us know how that goes and excellent that no kidney problems!

[LtlBtyRam]

My heart goes out to you. We have all been there trying to figure out what is going on with our fur kids. Keep us posted.

[swcruiser]

So Jake went in for an additional ultrasound and it looks like everything is normal! Kidneys are fine. Adrenals are normal size and Liver does not have any abnormal growths as originally reported. I had a feeling the first doc was incorrect about the kidney issues and liver... anyway he is on trilostane 30mg once a day. He is 75 lbs. . A very low dose. Does this seem to low? The Doctor thought we should go higher but I insisted on half the normal. Boxers tend to have sensitive stomachs and I didn't want to start high and go backward.

Other things of importance:
He started stumbling before the meds and continues to stumble.
Very tired looking. Almost exhausted looking. He seems to get worn out with very little exercise and has trouble getting up. He needs a second to balance himself when first getting up but then seems ok altough wobbly! I don't think its gotten worse with the meds but I was out of town prior to starting the meds and my sister said he had fallen a couple of times.

Other than that he has a healthy appetite and is very alert when food is mentioned...:D. He eats normally and his excessive drinking and urination are gone. The new doc thinks he didn't need the thyroid as he was borderline. This seems to have caused the excessive drinking.
he drinks normally now but has a hard time standing to reach his bowl. How long does the trilostane typically take to show positive signs?

[molly muffin]

Every dog is different so there is no standard time to see a difference. With a low dose, lower than the 1mg/1lb I don't know how long it will take.

Do you have access to a vet hospital that can do a neurological consult? To see if they have some thoughts about the stumbling, and other issues?

[swcruiser]

yes I do. Just not sure who I trust. Do u think it might be neurological? He just seems overly exhausted. the mornings he is better and at night he is very tired until he eats something. He seems to Regain strength after eating.

[molly muffin]

Neurological, as just a possibility. With cushings in play, the question is whether or not there is a tumor of the pituitary gland putting pressure on the brain. So it is just an option to have if needed.

It also could be normal muscle weakness from cushings too. When do you do a follow up ACTH test?

[swcruiser]

He is due in at the end of the week or early next week. How bad does the normal muscle weekness actually get with Cushings? Does it get to the point of being debilitating? His rear legs seem to be giving him the most trouble early on but now it seems like his rear is stable but weak and his front legs are causing him to stumble....

[molly muffin]

Usually it is the back legs that get weak from cushings. High cortisol causes a weakening of the tendons and ligaments.
They can get pretty bad, sometimes though they improve when the cortisol comes down into therapeutic ranges, but you never know for sure if they will or not.

[swcruiser]

So Jake received is ACTH after being on 30 mg per day of Trilostane. The tests show this dosage to be good for controlling cortisol. Unfortunately, his ability to stand and getup has deteriorated. He needs to be helped to his feet and he wobbles a lot. They suspect he has a brain tumor so we are looking into seeing a neurologist. Does anyone have a recommendation in the tristate area?

[molly muffin]

Can you tell us what the actual numbers where on the ACTH test please?

Tri-state area as in?? I think there is a east coast and a west coast area considered tri-state? Sorry I am in Canada and not a lot of help for you, but others might have an idea.

I use the same specialist that are at the hospital where my Internal Medicine specialist is at.

[Squirt's Mom]

To me, the "tristate area" is the ARKLATEX - Arkansas, Louisiana and Texas. ;) BUT you can use this link to find vets in your area, including specialists -

From the Helpful Resource section - http://www.k9cushings.com/forum/showthread.php?t=182

[swcruiser]

Sorry.. tri state meaning NYC, PA, NJ. :) His stim tests results are below:

sample 1 1.7 1.0-5.0 ug/dl
sample 2 4.5 8-17 ug/dl


I used the search but Id rather have a direct referral. Its hard to assess these things over the internet.

[Harley PoMMom]

Those are excellent ACTH stim numbers, just a FYI, those reference ranges that are listed ( 1.0-5.0 ug/dl; 4.5 8-17 ug/dl) are for a dog that is not being treated with Vetoryl. The therapeutic ranges for Trilostane/Vetoryl are 1.5ug/dl - 5.5ug/dl with a post as high as 9.1ug/dl as long as the symptoms are controlled.

If you are looking for a reference for an IMS in PA, I strongly recommend going to Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania in Philadelphia, PA, its address is: 3800 Spruce Street - Philadelphia, PA 19104. I took my boy, Harley, there and was very impressed. The IMS that Harley saw was Dr. O'Neill.

http://www.vet.upenn.edu/

I have also used Chesapeake Veterinary Surgical Specialists in Maryland, it's only an one hour drive for me, it is located at 1209 Cromwell Bridge Road, Towson MD, 21286.

Dr. Brendan B. Anders and Dr. Petrus were the 2 IMS' that treated my dogs.

Their website: http://cvssvets.com/

Hugs, Lori

[Squirt's Mom]

If I were within driving distance I would go to Penn State, no question.