ACTH Stim Results in desired range--still has signs of CC

[tcc]

My stafforshire terrier Butter was diagnosed with Cushings last fall. In the last few months we were finally able to get his vetoryl figured out, 20mg a day and both of his stim results in the last month showed he is in the right range.

While his Stim results show he is being properly medicated, in the past month he is experiencing calcinosis cutis lesions on his neck and tail, liver enlarged, and his liver tests show elevated levels...all symptoms of a cushinoid dog but the Stim results say it is managed.

Going to see an Internal Medicine Specialist soon but am wondering if anyone has an opinion or information on what might be happening.

Thanks - Ty

IDEXX Services: ACTH Stimulation (One Pre, One Post)-
Endocrinology
7/8/16

Cortisol - Pre ACTH 1.7 ug/dL 2.1
Cortisol - Post ACTH 6.6 ug/dL 6.3

[judymaggie]

Hello and welcome to you and Butter! I have manually approved your membership so now all your posts will be seen right away.

You are correct in that Butter's ACTH test results from 7/18 indicate that his cortisol is in the recommended range. However ... we have seen on this forum that dogs need to have their post number at 5 or below in order to have better control over the calcinosis cutis (CC). Also, an enlarged liver and elevated liver enzymes may take a very long time to change even if cortisol levels are in range. Some enzymes may never get back to normal ranges. This does not mean that the dog is experiencing liver damage or liver disease.

Has your vet done a biopsy of the lesions? This is really the only way to definitively diagnose CC. I am going to take the liberty of adding a reference to the CC in your title so that those members who are dealing with this will know to check out your thread. Here is a link to Renee's thread about her dog, Tobey -- Renee has a vast knowledge about CC:

http://www.k9cushings.com/forum/showthread.php?t=5908&highlight=Renee

In order to fill in the gaps and help us understand Butter's disease process, please post the results of recent lab tests. With regard to blood tests, you need only post the highs and lows along with the stated range. Some urine tests will also have such highs and lows and others will have numbers (such as dilution factor). Please also provide us with the results of any tests that were done to diagnose Cushing's, i.e., ACTH (in addition to the 7/16 results), LDDS, ultrasound.

What symptoms did you or your vet see in Butter that led you to test for Cushing's? Is he being treated for any other conditions? If so, what other medications does he get?

Sorry for all the questions but we can offer our best guidance when we have a complete picture of your pup!

[Harley PoMMom]

Hi and welcome to you and Butter from me as well!

Judy has done a fabulous job with her introduction to you so I really have nothing to add. I just wanted to let you know that I have manually validated your membership so that your posts can now be seen by all members. You can disregard our email asking you to respond. ;)

Once you post Butter's test results and answer those questions that Judy posted it will help us to provide you with more meaningful feedback. ;)

Looking forward in hearing more about your dear boy!

Hugs, Lori

[lulusmom]

Hi and welcome to you and Butter.

I agree with Lori that Judy has done a superb job of covering all the bases. She definitely hit on all of my questions and requests so for a very rare change, my post will be limited to providing feedback on the CC and the stim test results.

According to Dechra, the manufacturer of Vetoryl, the acth stim test results you posted would be considered good if all of Butter's symptoms have resolved. However, Dr. Edward Feldman, a renown and very well published endocrine specialist with massive experience with Vetoryl (trilostane), does not subscribe to Dechra's recommendations and lectures his students and vets attending his lectures that if you are treating with Vetoryl (trilostane) and you want the dog to be as normal as possible, you have to get the pre and post acth stimulated cortisol to be less than 5 ug/dL. I believe that goal is even more important when dealing with CC. To quote Dr. Ellen Behrend, who is also a renown endocrine specialist and contributing author in feline and canine endocrine textbooks in a veterinary textbook; "Calcinosis Cutis does not always resolve with successful treatment of HAC." I believe successful treatment for a dog with CC would be twice daily dosing regimen and consistent pre and post stimulated cortisol at less than 5 ug/dL. As Judy mentioned, Renee is our resident expert on CC. She has been dealing with her precious Tobey's chronic CC and I hope that she will drop in shortly to share her experience with you.

I will be looking forward to your responses and Butter's test results.

Glynda

[molly muffin]

You could add in a 5mg that Dechra makes now for 25mg a day and see if that doesn't bring the post acth result under 5.0. With cc, we tend to see a better result under 5.
Also with cc, it gets worse before better. A good antibiotic spray to keep the areas from getting infected wouldn't hurt either as they are prone to bacterial infections.

Trichlor spray is one that I think is recommended and made by Dechra (same manufacturer as for vetroyl)

[tcc]

Hi everyone -

Thank you all for the help so far!! I've uploaded all of Butter's tests results over the past year - ACTH, Bloodwork, Ultrasound, Cardiology into an album in my profile called Tests at:

http://www.k9cushings.com/forum/album.php?albumid=1109

I am guessing this was the best way to do so as I wasn't able to add any attachments. I had to break down the PDF of his test results into individual photos so hoping it works.

Thanks!

Ty

[randomguy]

Also with cc, it gets worse before better.

May I ask what you mean about this? My dog just got diagnosed with cushings and my vet never told me anything about this and now I'm kinda worried. :(

[Renee]

May I ask what you mean about this? My dog just got diagnosed with cushings and my vet never told me anything about this and now I'm kinda worried. :(

This is in regards to CC -- calcinosis cutis, a condition that a small number of cushings dogs develop.

[lulusmom]

Ty, thank you so much for posting all of Butter's test results! Wow, what was going on with Butters when the blood labs were done on 6/14/16? His liver enzymes, ALT and GGT were off the charts. It is not uncommon for dogs with cushing's to have ALKP off the charts but Butters was not until this last blood chemistry. From September to December 2015, Butter's liver enzymes improved greatly. The ALKP which I would have expected to continue to rise was only a hair above normal and ALT was normal. From December to June 2016 all heck broke loose and all liver enzymes were greatly elevated which is certainly not what I would have expected in a dog with great result on the an acth stim test done on the same day. Pre 2.1 and post 6.3 are pretty good numbers. Hopefully whatever was going on back in June has resolved and Butters ALT and GGT have dropped significantly. Did your vet mention anything about this and is s/he going to recheck the liver values in a month or so? Honestly, I don't ever recall seeing liver values being pushed that high due to calcinosis cutis but Renee may have more information on that.

When did you start Butter on treatment? I ask because results of an LDDS done 9/15/15 are consistent with cushing's but results of an acth stimulation test done four months later on 1/15/16 shows a post stimulated cortisol of 19.7 ug/dL which is not consistent with cushing's. Was this acth stim test done after you started treatment? If so that would explain the conflict.

Again, thank you so much for the comprehensive job of sharing results with us. I look forward to your updates.

[Renee]

I want to jump in here and second Glynda with my concern about the massive jump in the liver values, not just the ALP.

Can you give us a history and timeline of the cushings and CC? When was cushings diagnosed? When was the first CC lesion seen?

We know that CC is often presumptive for cushings, but we are also learning that other factors can lead to it's presentment. I really wonder if something primary is going on with the liver, which has spiked the CC to develop. Only a very early hypothesis though. It would be incredibly helpful to have a timeline of the cushings and the CC development.

[tcc]

Hi Glenda and Carla! Thanks so much for the input. Butter was diagnosed in October of 2015 and we started him with 50mg of Vetoryl immediately after, and have slowly been moving him down until we found out that 20mg is the proper dosage in around May/June 2016. I took him off the vetoryl in January 2015 for just over a month because he had to have a tooth removed and was having some nerve issues. He went back on following his surgery in February 2015.

My vet is concerned because as you both mentioned his ACTH test results show that his cushings is controlled, but his liver results are off the chart. I had them do a biopsy of his liver and an ultrasound and they saw no signs of cancer, but apparently it is only around 20% accurate. Hoping to get an appointment with an internal medicine specialist soon to figure out what the issue is with his liver.

[molly muffin]

I think seeing an IMS is a good option as those liver enzymes are worrying just because they are so high. It's not unusual to see high enzymes in a cushings dog but not normally as high as that.
Having said that, every dog is different too, and if the biopsy showed nothing and the ultrasound showed nothing, then I think I'd ask if something else could be causing those enzymes to go up. Not that I have any idea what it might be but it's a question to ask. Pancreas, gall bladder, where those looked at on the ultrasound? Anything off with the lymph nodes, any infections from anything anywhere, etc. Just keep plugging at it. Having the cortisol controlled is good though.
What about supplements for liver support like Sam-e, milk thistle, viatmin e, omega 3's.