Cushings, Diabetes and Liver Issues???

[Kylie's Mom]

Hi All,

My 13 year toy poodle, Kylie, was diagnosed with diabetes in January, 2016 and with Cushing's on April 15, 2016. A few days before the Cushing's diagnosis, Kylie had bloodwork done and she had a number of unusual results:
ALP: 965 (normal is 5-160)
ALT: 942 (normal is 18-121)
AST: 171 (normal is 16-55)
GGT: 23 (normal is 0-13)
Cholesterol: 11.1 (normal is 3.4-8.9)
Triglycerides: 7.53 (normal is 0.23 to 1.71)

We are unsure whether the diabetes/Cushings caused these abnormal blood results or if there may be something else going on, possibly with Kylie's liver. Kylie also had an abdominal ultrasound on April 14, 2016 and the vet noted "the liver is mildly enlarged and diffusely hyperchoic being isoechoic to the spleen". Does anyone else have a dog with Cushings that has had similar bloodwork results? How common are these types of results in Cushings dogs?

By way of background,Kylie's diagnosis has been ongoing for several months. In January, we took Kylie to the vet for housetraining accidents. At that time, our vet thought this could be caused by Cushings so she did bloodwork and also administered a low dose dexmethasone suppression test. Kylie's low dose dexmethasone suppression results were:
0 hours - 69
4 hours - <27
8 hours - 48
However, the bloodwork done at the same as the low dose dexmethasone suppression test showed that Kylie was diabetic so we were unsure whether Kylie actually had Cushings or if her diabetes may have caused had a false positive on this test.

We started treating Kylie's diabetes but have been unable to regulate her diabetes. Her glucose levels are a perfect curve except that the starting and ending points are way too high (>30 mmol/L). Our vet thought we may be having difficulty regulating Kylie's diabetes because of a history of high triglycerides - which is why the bloodwork noted above was completed. Once we saw the results, our vet referred us to an internal medicine vet.

The internal medicine specialist administered an ACTH Stimulation Test and obtained the following results:
Pre Serum Cortisol: 54.9 nmol/L
Post Serum Cortisol: 894.0 nmol/L

Based on these results, the "mildly enlarged adrenal glands" noted on Kylie's abdominal ultrasound and the prior low dose dexmethasone suppression test, the internal medicine specialist diagnosed Kylie with Cushing's.

Any thoughts or suggestions are appreciated. We are very worried about our baby!! Thank you so much!!

[labblab]

Hello and welcome to you and sweet Kylie! I'm so sorry that nobody has yet had a chance to reply to you, and I'm afraid I only have a moment free, myself, right now. But I want to reassure you that you have come to the right place ;), and I'm certain you will soon see some responses. For some reason, this weekend has been very quiet around here. But we are very glad you've found us, and we will look forward to having the chance to discuss Kylie's situation. Thank you so much for all the great info you've already provided.

So stay tuned, and I'm sure you'll get more feedback soon!
Marianne

[molly muffin]

Hello and welcome to the forum.

I too am in Ontario. :)

First, there is always a concern, that if there is another chronic disease, that a false positive with show up on the either the LDDS or the ACTH. Although probably more often on the LDDS, as it is quite likely with any chronic condition that the body is producing excess cortisol in reaction to the disease.

I can see why there is much concern about the Liver possibly being a problem as the first 4 test you listed are liver specific, ALP, ALT, AST and GGT.
If you are not on a liver supplement like milk thistle, sam-e, then that is a possibility to help the liver and you should definitely discuss with your vet.

Normally in cushings, we will see ALP, sometimes Very high and some increase in the ALT. Seeing all four elevated for me, would raise some flags that something is going on that needs to be addressed. I'm not sure if diabetes would cause that increase in the AST and GGT or not, but I think it would be worth asking your IMS about.

Also while on the subject of diabetes, there is a sister site to us for diabetes
www.k9diabtes.com/forum

I would highly suggest registering with them, as they are very knowledgable about diabetes and we have members who are on both forums who are dealing with both disease.

I'm so glad you found us and look forward to getting to know you and Kylie

[Kylie's Mom]

Hi All,

Thank you for your notes - I really appreciate it! The internal medicine specialist told us that on the ultrasound Kylie's liver appeared "normal" for a diabetic dog and attributed her elevated liver values to either untreated Cushing's and/or unregulated diabetes. Has anyone else seen this side effect with their Cushing's dogs?

When we go for Kylie's follow up ACTH stimulation test this weekend, i may ask them to run the blood panel again. I am just worried that we might be missing something.

Thanks again!

[labblab]

Hello again from me! Yes, elevated liver enzymes are common in Cushpups. As Sharlene has said, we more often see elevations in the ALKP and ALT as opposed to additional elevations in the AST and GGT. However, since the IMS has performed an ultrasound and has seen no sinister irregularities in Kylie's liver, I'd differ to his judgement that it may be the combo of diseases that is responsible for the lab abnormalities.

For the benefit of our U.S. readers, I've converted Kyle's post-ACTH into the units with which we are most familiar: 34.4 ug/dL. That is indeed consistent with Cushing's, so I cannot disagree with your IMS's diagnosis at this point. You mention returning for a repeat ACTH this weekend: has Kylie already started taking trilostane, and is the testing for monitoring purposes?

Marianne

[Kylie's Mom]

Thank you for your comments! Yes, Kylie started Trilostane last Wednesday, April 20. Kylie weights 10 lbs and she gets 5 mg twice a day. This weekend is her first check up.

Kylie is still having some housetraining accidents. They are pretty large puddles and sometimes there is more than one. It's not every day and we can't figure out why sometimes she can go all day/night without an accident and the next day there will be multiple puddles. (Oddly enough, we have not noticed Kylie drinking more than usual - even though she is clearly peeing more than usual.)

Do these accidents usually stop after she has been on Trilostane for a while? I know it has only been a few days that she has been on the Trilostane - does it take a while before it works?

[Kylie's Mom]

Sharlene - Thank you for the milk thistle suggestion. I will speak with my vet about that this weekend when Kylie goes in for her check up!

[DoxieMama]

From what I understand, once the cortisol is under control, drinking and peeing less are the first symptoms that are alleviated. My dog (a miniature dachshund weighing about 11 pounds) is on 11 mg Trilostane once per day. By the time of his first ACTH test, he was drinking much less and had stopped having accidents in the house. It was also about that time that he started sleeping mostly through the night, though he still occasionally wakes in the middle of the night to go out. Of course, not all dogs behave the same and some may take longer than others to show results.

[Kylie's Mom]

Hi All,

Kylie started Trilostane about a month ago. Since then she has had 2 follow up ACTH stimulation tests - the last one today - and both times she is a mess after the tests. She is restless and starving. Has anyone else found their dog to be really uncomfortable after an ACTH stimulation test? Perhaps it has something to do with her diabetes?

[DoxieMama]

I haven't really noticed a difference yet, but I know that others have said the same things about their dogs. (And I haven't been home for the whole day to really see how he reacts.) I think Sharlene even has a term for it... which escapes me at the moment. But I think it's not uncommon.

How is Kylie doing, otherwise?

[molly muffin]

I call it the 48 hour spazz as that is about how long it lasts in Molly. Having the ACTH test is like squeezing a sponge and all that extra cortisol dumps into their body (this is the post acth test number) and it takes awhile for it to leave their system.

[Kylie's Mom]

Thank you so much for your feedback - I am really relieved to hear that other dogs have the 48 hour spazz as well!! We have been very worried about it.

The biggest problem we have with Kylie right now is her diabetic cataracts. She can only see in bright light and she has not been adjusting to blindness very well. She walks into doors and walls. It really breaks my heart. We have been referred to an ophthalmologist but she won't be a candidate for cataract surgery until we can regulate her diabetes - and we can't stabilize her diabetes until we get her Cushings under control. We are waiting to hear from the internal medicine specialist but, based on her last ACTH test, our regular vet thinks her dose of trilostane needs to increase from 5mg twice a day to 7.5 mg twice a day.

I am very hopeful that everything will eventually balance out and I know I just need to be patient but it is so hard to see her struggling!!

[Harley PoMMom]

Could you post those ACTH stim test results for us? Thanks!

Hugs, Lori

[Kylie's Mom]

I just got Kylie's ACTH stimulation test results from our vet. Her pre level was 76 nmol/L and her post was 417 nmol/L. Our internal medicine specialist has recommended an increase in her Trilostane to 7.5 mg twice a day. He is also concerned that she may have some insulin resistance resulting from Cushings. This is so frustrating!!

[Harley PoMMom]

Given her high post number it does warrant a dosage increase, for those of us used to seeing ug/dl: pre -76 nmol/L = 2.75 ug/dl and post 417 nmol/L = 15.12 ug/dl. How are her symptoms?