Perplexed on what to do

[Deborah Jane]

Hello everyone, this forum is so informative and I really appreciate all the help you give. Here is my story: My 10 yr. old Brittany Spaniel had lab work done 3/2014 for a dental cleaning. Gabe's ALKP level was elevated, but the ALT was normal, as was all other blood values. ALKP was 274, normal is 23-212. The vet said it wasn't typical of Cushings, so we would retest in a year, unless symptoms developed. Eight months later, Gabe started having severe panic attacks in the car (he was always nervous, but not to this degree). He started drinking excessive amounts of water and urinating a river. She tested his liver enzymes again 12/2014 and the ALKP was 314, ALT, normal. 5 months later 5/2015, his liver enzymes were ALT 203, ALKP 542. He was retested 6/3/2015 and his ALT and ALKP were creeping up again. I wrote them down, but can't find them at the moment. I do remember the ALKP was in the 700's. He had a LDDS test yesterday and the vet called today. The starting cortisol level was 7, normal l-6.
4 hour was .2 normal less than .5 and 8 hr. was 1.7 normal less than 1.5. She said the results were inconclusive, but the 8 hr. result would lean toward Cushings. She called the Dr. at the lab to get his opinion and he said based on the 8 hr. it was indicative of Cushings. My vet said they could start him out at half the dosage of Vetoryl, she doesn't want to push him into Addison's or we could wait and watch him and then medicate if he starts showing more symptoms. He isn't drinking as excessively as he was, but still urinating large volumes. He did have an ultrasound and everything was normal. He does not have extended abdomen, hair loss, or skin infections. He was also diagnosed as hypothyroid 5 weeks ago and started Soloxine and his T4 level is normal now. I am hoping he will be able to lose his excess weight now. I was just wondering what your thoughts are on all of this? My main concern is the extreme anxiety, he pants in excess when stressed and he is taking Klonopin when we go on our 2 hour trips to the cabin. Thanks so much for your time and sorry this was so long.

[labblab]

Hello and welcome to you and Gabe! As you probably already know, Cushing's is a very difficult disease to diagnose definitively because there is no single test that rules it in or out without question. On the face of it, Gabe's LDDS test is indeed "positive" because the 8-hour result is higher than the normal reference range -- but only minimally. If Cushing's is the cause of the elevation, then this result is consistent with the pituitary form of the disease because both subsequent results were less than 50% of the initial baseline draw. But a drawback to the LDDS is that other, nonadrenal diseases or illnesses can also cause an elevated cortisol reading as well. So we need to sift through his symptoms.

Consistent with Cushing's is excessive thirst/urination, elevated liver values, weight gain, low thyroid, and excessive panting. When you say that Gabe is unusually anxious, are you seeing abnormal behavior other than panting? Excessive panting is a common symptom of Cushing's, but it is not necessarily associated with anxiety. So I am just wondering whether you are seeing more than the panting. Cushpups can be especially heat-intolerant, so being confined in a warm area can definitely increase the panting and make them even more restless.

You mention that he's had an ultrasound -- was this performed in your regular vet's office? The reason why I ask is because with pituitary Cushing's, you'd expect to see enlarged adrenal glands and also some characteristic liver changes. This is not always the case, but a totally normal ultrasound is less common. However, the adrenal glands are very difficult to visualize without sophisticated ultrasound equipment that is often available only in specialty practices. So depending upon the quality of the images that were obtained on Gabe, there may be abnormalities present that just were not seen.

So where does this leave you? Unfortunately, with some puzzle pieces that are consistent with Cushing's, but not with a complete picture. I'm assuming that a urinary tract infection has been ruled out as the cause of the thirst/urination? If so and if he were mine, I might wait for another month or so to see whether the normalized thyroid level leads to further improvement across the board. If not, I might consider going ahead and trying trilostane to see whether that leads to positive changes. If you do proceed with trilostane, the recommended initial dose is not to exceed a formula of 1 mg. per pound.

One caution: be sure not to limit his availability to water at all times. If he is peeing excessively, he needs to be able to replenish his system with the fluid he is losing. So that worries me a little bit if he seems to be peeing more although drinking less. Are his kidney values all normal? How about any blood or protein in his urine?

OK, enough questions for you to have to answer! Once again, welcome. We're so glad you're here.

Marianne

[Deborah Jane]

Thank you Marianne for your reply. Gabe's panting from the anxiety results in difficulty breathing, making a high pitch squeal, rims of eyes turning red. He does pant normally also, but this is the extreme when he has ridden in the car. My vet says it is an all out panic attack. When he is medicated for the anxiety, he does fine. As far as the ultrasound, it was done at my vet's office and she showed all the organs and said what she would be looking for if there were abnormalities. She even went so far as to ultrasound the lungs and heart. The vet is hoping also that once the thyroid is balanced out, his anxiety will decrease. She said his endocrine system is going through a lot right now. He was having diarrhea, but that is now cleared up. She told me to continue the Lignans, Melatonin and SamE for right now. Since he isn't into full blown Cushings, she said we have time to see if these make a difference, if not, he will start the meds at half the dose. This is all so nerve wrecking, I just want to do the right thing and get him feeling back to 100%. Thanks so much again for your reply, this group is the best!! :)

[Deborah Jane]

Marianne, just reread your reply and forgot to answer your question regarding kidney values, all was normal. His urine is normal also.

[molly muffin]

I just want to say hello and welcome you to the forum.

I think that over all your vet has a very good plan in place and is the same route that Marianne mentioned, see how he does with the thyroid values normalized and if not treat but start low and work up.

Dogs can do very well on treatment and we've seen them be on medication for years and years just fine, key is starting slow and doing regular testing to make sure everything is fine.

Over all, when things with the endocrine system are more normal, the anxiety might go away too. Well that would be nice but not guarantee.

Glad you found us.