Advice needed please

[Yammersmom]

Hello, all!

My baby Sampson was diagnosed with Cushing's yesterday... :(
I have so many questions to ask all of you.

Firstly I need to decide whether putting him through an ultrasound to try and determine type is worth considering.

He is almost 13 years old and I don't want to put him through anything unnecessary.

I have been of the belief that he had cushings for around 2 years, we did a ACTH set in Oct of 2013 that came back inconclusive. Because at that time and up until fairly recently his symptoms were manageable and not affecting his quality of life we didn't pursue further.

Over the last few months he has become increasingly weaker and weaker in his hind legs. We brought him in a few times and again last week and then on Wed he went in for a LDDST.

Results of this show cushings.
(will post lab results)

Now I'm faced with ultrasound to determine type or to start him on Trilostane which treats both types but will be more costly.

Questions I'm wondering about:
1. trilostane vs mitotane - is there a clear winner between the two for effectiveness/side effects when treating pituitary cushings?

2. is one safer than the other? (worried about my old pup's aging body/mind)

3.The major symptom that I'm wanting to correct being his hind end weakess and muscle deterioration as this is what is affected his quality of life in the most dramatic way- is there one better than the other, had more success?

4. how soon will I see or notice improvements and know if the medication is working?

5. any other advice and incite is greatly appreciated as I am so overwhelmed and worried about my baby!!!

Sampson's liver enzymes have climbed dramatically, I don't what is considered really high but compared to what the norm is they are sky high!

ALP in IU/L - normal range = 5-160
Nov 2012: 591
Oct 2013: 2181
June 2015: 5255

ALT in IU/L - normal range = 18-121
Nov 2012: 99
Oct 2013: 115
June 2015: 589

For some reason I cannot attach files?

So results from ACTH in Oct 2013 are,
Cortisol Pre: 120
Cortisol Post: 579
normal range for pre:0-280 nmol/L
normal for post: 221-650 nmol/L

LDDS: July 2015
Cortisol 0hr : 174 nmol/L
Cortisol 4hr: 152 nmol/L
Cortisol 8hr: 148 nmol/L


Thank you in advance :)

Jo

[Harley PoMMom]

Hi Jo,

Welcome to you and Sampson!! I'm sorry but I have only a moment to post and so I don't lose track I have replied to your questions in blue within the body of your post.


Hello, all!

My baby Sampson was diagnosed with Cushing's yesterday... :(
I have so many questions to ask all of you.

Firstly I need to decide whether putting him through an ultrasound to try and determine type is worth considering.

Those LDDS test results point to the adrenal form of Cushing's, with this type, surgery can be a cure, however an adrenalectomy should only be done by a seasoned surgeon and this surgery sure is costly.

Regarding an ultrasound, if feasible, can be a very useful diagnostic tool as other abnormalities may be found on the internal organs, such as gallbladder mucocele, kidney issues, pancreatitis...etc. However not all ultrasounds are created equal. And yes, they can be quite costly and having them done correctly is important. A good quality ultrasound/interpretation depends on a few things; the tool used, the technician performing it, and the physician interpreting it. Usually a Board Certified Veterinary Specialist is the best choice to perform an ultrasound.

He is almost 13 years old and I don't want to put him through anything unnecessary.

I have been of the belief that he had cushings for around 2 years, we did a ACTH set in Oct of 2013 that came back inconclusive. Because at that time and up until fairly recently his symptoms were manageable and not affecting his quality of life we didn't pursue further.

Over the last few months he has become increasingly weaker and weaker in his hind legs. We brought him in a few times and again last week and then on Wed he went in for a LDDST.

Results of this show cushings.
(will post lab results)

Now I'm faced with ultrasound to determine type or to start him on Trilostane which treats both types but will be more costly.

Questions I'm wondering about:
1. trilostane vs mitotane - is there a clear winner between the two for effectiveness/side effects when treating pituitary cushings?

No there is not, what works for one dog may not work another. With either drug, side effects are minimal if the proper protocols are followed.

2. is one safer than the other? (worried about my old pup's aging body/mind)

As for deciding which medication to use, it depends on the vets knowledge, experience and familiarity with the drug they use, how comfortable the pet owner is with the treatment plan, and the dog's general health. Vetoryl/Trilostane is no safer than Lysodren/Mitotane, and vice versa. Cushing's is a treatable disease, however for the treatment to work safely and successfully it requires an educated pet owner along with an experienced vet.

3.The major symptom that I'm wanting to correct being his hind end weakess and muscle deterioration as this is what is affected his quality of life in the most dramatic way- is there one better than the other, had more success?

Unfortunately, no, improvement in muscle weakness takes a while.

4. how soon will I see or notice improvementes and know if the medication is working?

The increased thirst/urination/appetite usually takes about 2 weeks to subside. With both medications, ACTH stimulation testing is needed to monitor the effectiveness of the drug.

5. any other advice and incite is greatly appreciated as I am so overwhelmed and worried about my baby!!!

Sampson's liver enzymes have climbed dramatically, I don't what is considered really high but compared to what the norm is they are sky high!

ALP in IU/L
Nov 2012: 591
Oct 2013: 2181
June 2015: 5255

Those liver enzyme values are quite high even for a dog with Cushing's, I'd be more inclined to think that there might be a liver issue attributing to those elevations other than Cushing's

ALT in IU/L
Nov 2012: 99
Oct 2013: 115
June 2015: 589

For some reason I cannot attach files?

So results from ACTH in Oct 2013 are,
Cortisol Pre: 120
Cortisol Post: 579
normal range for pre:0-280 nmol/L
normal for post: 221-650 nmol/L

LDDS: July 2015
Cortisol 0hr : 174 nmol/L
Cortisol 4hr: 152 nmol/L
Cortisol 8hr: 148 nmol/L


Thank you in advance :)

Jo

The best advice I can give you is to do your research on Cushing's, the treatment protocols, and how it is diagnosed. I am providing a link to our Resource forum which has a wealth of information regarding Cushing's and also includes articles written by some of the most renown veterinarians that specialize in endocrinology http://www.k9cushings.com/forum/forumdisplay.php?f=10

Please know we are here to help in any way we can, and remember you are not alone on this journey.

Hugs, Lori

[Yammersmom]

Hi Lori,

Thank you for your response. Do you think then if signs point to Adrenal I should just forgo the costly and somewhat invasive ultrasound and just start on the Trilostane as the Mitotane only treats pituitary?

I don't think that surgery would be a viable option for us if it is adreanal so...?

[Squirt's Mom]

With those liver values - ALP and ALT - I would forget about Cushing's myself and pursue the liver. It is possible he has liver disease or something going on with the gall bladder and does not have Cushing's at all. So tell the vet you want to look at the liver and gall bladder before anything else is done concerning Cushing's. I would NOT start either Vetoryl or Lysodren until those two organs have been checked out thoroughly. ;)

[lulusmom]

Hi and welcome to you and Sampson.

First let me say that you avatar is awesome. Sampson is so cute. Talk about a big, contagious smile. :D What is Sampson's breeding? This answer is important for more than just my curiosity. Some breeds seem to be predisposed to cushing's and other breeds are predisposed to conditions that may share same of the same symptoms that are associated with cushing's.

Like Lori and Leslie, I too am not accustomed to seeing ALKP and ALT so high, specifically the ALT. This liver enzyme is usually only mildly elevated. While not having the benefit of the normal reference range, I would still have to assume that an ALT of 589 is at least a four to five fold increase using reference ranges for any labs. With liver enzymes that high, I would have to assume there are other abnormalities on both the blood chemistry and the cbc. Can you please post just the highs and lows and please include the normal reference ranges? These addition results can give us clues as to whether you may be dealing with something more than or other than cushings.

You mentioned that you suspected cushing's for two years and that up until recently Samson's symptoms were being managed and not effecting his quality of life. What symptoms has he had for two years that were manageable but made you think he had cushing's? You also mentioned that your biggest concern is the weakness in Samson's legs. Cushingoid dogs with advanced disease, which you believe to be the case, "usually" have some very problematic symptoms that become unmanageable well before the dog's mobility is compromised by severe muscle wasting. Drinking buckets and peeing lakes, begging and constantly foraging for food are the most problematic. Other symptoms are panting, loss or thinning of coat, skin problems and change in skin pigmentation. Which one of these symptoms did Samson have before his hind legs became noticably weak?

You've given us a good start with the information but it falls way short of support for a cushing's diagnosis so providing you with information about effective treatments feels a be premature to me. However, I would definitely recommend using the link to some excellent reference material that Lori provided. I can tell you that there is no clear winner between Trilostane and Mitotane for the treatment of pituitary dependent disease. Both are very effective and both can have side effects and both have their own worrisome "what if" scenarios that reading clinical studies may raise for geeks like me. However, if knowing that most experts choose Trilostane as their first choice makes a difference, then you should know that they do. Most experts also choose Trilostane as their first choice to treat adrenal tumors.

We'll be looking forward to you providing more information on test results and symptoms.

Glynda

P.S. Do you know how much experience your vet has with cushing's? Is s/he a general practitioner or an internal medicine specialist?

[Yammersmom]

Sampson is a mixed breed but when we got him almost 13 years ago form SPCA they said he was Husky/Akita.

The normal reference range says:
ALT: 18-121
ALP: 5-160.

I wanted to try to post his labs but I cannot attach files? How do I do this?

Symptoms he has include pretty much everything.
excessive thirst, excessive urination, increased hunger, dry scaly coat/skin, skin pigmentation, has basically no fur left on his tail, slow to heal, panting, pot belly (but spine and hips are bony)

Our vet is Dr Eliot Kaplan, this is his bio,

http://trilake.ca/meet-the-team/veterinarians/

He has a great reputation but I'm not sure what I should be looking for with regards to a specialist. He is board certified and I believe the only one that is anywhere near here.

I'm starting to think then an ultrasound is probably what we should be doing...
This is all so hard, I just want my Sammy back. It breaks my heart :(

Thank you all, your words of wisdom are so appreciated!

Jo & Sammy

[lulusmom]

Hi Jo,

I know it's easier said than done but try to relax. You've just taken a lot of concern away relating the diagnosis by sharing on of those symptoms. I would still like to see the other abnormal lab results and I'm sorry about your inability to upload the actual document. Unfortunately spammers force us to limit uploads to jpeg format. You only need to type the high and low values and the normal range for each. Are there a lot of abnormalities other than the ALT and ALP?

Glynda

[Yammersmom]

Hi Glynda,

Not a lot of other abnormal values.
AST:85 normal: 16-55
GGT:40 NORMAL:0-13
CK 205: NORMAL:10-200

comments say
cl: loss
albumin:hemoconcentration
ALT,AST,ALP,GGT: rule out cushing's, biliary-oriented hepatopathy +/- pancreatitis next test depends on clinical signs.

Sampson has hypothyroidism as well and has been on thyrotabs for quite a few years

[Yammersmom]

Day one of vetoryl for my boy today. In peoples experience, how soon should I expect to see any differences?

[molly muffin]

That is quite dependent on the dog. In general starting at the 1mg/1lb you notice a change within 10 days. Urinating and appetite usually. Sometimes energy levels.

That is just one of those things noticed on here as an average, we've had people notice a change in a matter of days and if the cortisol isn't coming down enough, then it can take longer.

[Squirt's Mom]

Was this ruled out as suggested on the lab or did the vet stop at Cushing's?


...biliary-oriented hepatopathy

These liver values are concerning to me but I tend to worry when others don't. ;)

[molly muffin]

How is Sampson doing on the vetroyl?