Trying to find the best way forward

[Vesta]

Hello all and thank you for this forum. I'm hoping to get some opinions and advice about a rather complicated situation.

My 11 year old beagle/spaniel cross, Carter, is displaying the classic symptoms of Cushing's disease (excessive thirst, pot belly, heavy panting, highly increased appetite, high anxiety). He had highly elevated liver enzyme levels that we discovered during a surgery in February to remove a number of small tumors. I don't have the numbers (my apologies) but both the ALT and ALP were extremely high. After a month of antibiotics and Denamarin, the ALT was lower, but the ALP was even more elevated.

He also has muscle weakness, but this is complicated as a symptom as he had a serious spinal injury that caused back leg weakness last summer.

Both my vet and I feel that Cushing's is the most likely situation and his decline in the last 6 weeks has been quite dramatic. Her recommendation is a LDDST and then start him on Vetoryl.

We haven't yet done the Low Dose Dexamethasone Suppression Test (LDDST) that our vet is recommending. Carter experiences extreme anxiety at the vet and I'm struggling with the decision to take on the frequent and prolonged visits for testing (8 hour and 4 hour testing) that are part of the Cushing's testing and treatment protocol with Vetoryl. My primary concern is whether the benefits of the treatment would be enough to put him through the significant stress of the protocol.

I know that every dog responds differently, but I'm wondering how others might have thought through this trade off. My guiding philosophy is to maximize his quality of life--he's truly the sweetest and most loving dog I've ever known and I don't want him to suffer.

Thanks in advance for any ideas you might have.

-Vesta

[DoxieMama]

Welcome to you and Carter, Vesta! I apologize that I don't have a lot of time to respond right now, but I wanted to take a moment to post. It's true that the LDDS test is an 8 hour test, but that only needs to be done once for diagnosis. Once treatment is commenced, the test that is done repeatedly is the ACTH test, which only takes a little over an hour... but I actually have this done in two separate visits. I bring my pup in, they start the test, then I take him home and bring him back about 55 minutes later and they finish the test. Given Carter's anxiety, perhaps that is an option that would be easier on him? Just a thought.

If you have not yet had a UCCR test done, that's another option which doesn't require a vet visit at all. With his symptoms you may not want to do it, but it is an option to consider. If it doesn't rule out Cushing's, then the LDDS would likely still be the next step.

Again, I'm sorry this is rushed (I'm at work and just popped on for a moment). Hopefully others will be by to provide their ideas before too long.

Hugs! Shana

[Harley PoMMom]

Hi Vesta,

I have manually approved your membership so now all your posts will be seen right away. Also, please just disregard the validation email that was sent to you from k9cushings. ;)

Welcome to you and Carter! I certainly understand your dilemma in treating your precious boy especially an elder one because there is a fair amount of testing done to monitor the treatment for Cushing's. However the LDDS test is used as only a diagnostic test for Cushing's, which does take 8 hours to perform, the ACTH stimulation test is the one that is used in monitoring treatment, and depending on the stimulating agent used, this test takes an hour or two to perform.

Since Carter does experience a high degree of stress at the vets I wouldn't recommend the LDDS test because extreme stress can skew those results, instead I suggest an abdominal ultrasound. If the adrenal glands are visualize an ultrasound has the ability to differentiate between the adrenal or pituitary type of Cushing's. It also can give the vet a really good look at the surrounding organs, including the gall bladder, pancreas, liver, etc., to make sure there are no non-adrenal problems that can be contributing to symptoms and lab abnormalities.

I'm including this post from one of our administrators to a member contemplating treatment for their elderly dog:




Lori has already given you some really good information to think about when asking yourself whether to treat or not. I'd like to give you some more info that is straight out of a veterinary textbook that is used in teaching hospitals. I typed this excerpt and saved it for people like you who may be in a quandry whether it be quality of life issues or financial hardship. Both are very much important considerations.


To Treat or Not to Treat

The “urban legend” exists that survival is the same whether or not a dog with HAC is treated. That statement has never been scientifically evaluated. It may be true for some dogs, but likely not all. Importantly, treatment typically greatly improves quality of life for both the owner and dog.

On the other hand, not all dogs with positive tests for HAC need to be treated and the decision should be made on a case-by-case basis. In deciding when to treat, consideration should be given to the dog, quality of life, the owner, and clinical signs. None of the drugs are cheap and neither mitotane nor trilostane are benign; therefore, treatment is not to be taken lightly. If the only clinical sign is a benign clinicopathologic finding (e.g. elevated serum ALP activity) treatment is not warranted (neither is testing). If the issue is only cosmetic (e.g., poor hair) or very mild (e.g., slight increase in thirst and urination), a frank discussion should be had with the owner of the risks and benefits. In making the decision, further questioning of the owner on issues that might relate to clinical signs (e.g., the dog has stopped jumping on furniture –a sign of possible muscle weakness) can be helpful, as well as seeking evidence of clinical signs that the owner might not note (e.g., serial evaluation of urine samples collected at home for consistent suggestion of polyuria/polysipsia). It is also important to test for proteinuria by measurement of a UPCR and for hypertension by measurement of blood pressure. Both can damage the body; so if either or both are present and due to HAC, treatment may be more imperative. On the other hand, clinical signs may be recognized in retrospect; for example, an owner attributes decreased playing to old age, but when HAC is treated, the activity increases. Treatment of HAC can unmask diseases that may be inapparent due to the anti-inflammatory effects of hypercortisolemia. For example, clinical signs of atopy or degenerative joint disease may develop with treatment of HAC as cortisol concentrations decrease.

Therapy without knowing whether AT or PT
At times the differentiation between PDH and AT is not possible due to such issues as owner financial constraints or inconclusive or conflicting results on differentiating tests. In such a situation, given that the vast majority of dogs have PDH, therapy can be initiated accordingly. However, the owners should understand that an accurate prognosis cannot be given and that attempting to differentiate between the forms once therapy is started is quite difficult, if not impossible.

The textbook from which I copied the above text is not used to school general practitioner vets so you may want to share this with your vet so that you are both on the same page on your decision to treat as well as being informed of those things that should be monitored if no treatment is ultimately decided...

Glynda



Now, I have just a couple of questions before I end my novel here! :o Could you get copies of all the tests that were done on Carter and post those results for us? With respect to the blood chemistry and complete blood count (CBC), you need only post the highs and lows and please include the normal reference ranges. How much does Carter weigh? What is the dosage of Vetoryl the vet wants him to start on? Was an urinalysis done and what were those findings?

Please know we are here to help in any way we can and we will walk this journey with you and Carter.

Hugs, Lori

[Iluvhannah]

I'm still very new to be giving any advice so you have been warned, the others will know a lot more than I do, at this stage.
I would agree that a ultrasound might be the best option since Carter doesn't enjoy the vet. My girl hates the vets office and gets all stressed out. When she was being tested they offered to let me take her home and bring her back throughout the day for the blood work. If you live relatively close and Carter doesn't stress over going for car rides this might be an option.
Another one that my vet offered was to allow me to stay with my dog, since she does better with me their, than alone. They offered to let me come on a day when one of the vets was on Vacation and just hang out with her in there. This option might not be best for your situation or available at your vets office but worth a thought.

The only question I have that isn't important test related but you were asking about if you should seek treatment to make him comfortable.
Early in the post you said Carter's situation declined rapidly, do you think he is okay now? Hopefully that came out and made sense. I'm not insinuating he would be in pain without treatment. Just asking if he is continuing to get worse.

I have experienced the help from this forums members, you are going to be in good hands and they have a wealthy of information and insight to share.

It sounds like you are a wonderful mother to Carter. Nice to meet you.

[Vesta]

Thanks everyone for your ideas and your concern for my little guy.

It is great to know that taking him home between the testing intervals might be an option, I will ask my vet about that possibility as soon as I can.

Carter is currently 38.8 pounds which is definitely overweight for his frame, but he's been stable at that weight for about a year. The change is in the body shape, with the pot belly becoming visible only a few weeks ago.

In terms of his current situation, I would say he is continuing to decline, which is another reason I'm uncertain about what is best. The rapid symptom progression seems unusual, and my vet was startled by how much he had physically changed since she saw him in May. His anxiety is also getting a lot worse. He used to be a very laid back dog, but now he's anxious to the point where he almost starts to panic if his routine is disrupted.

I have a message into my vet and hopefully she'll be able to call me back soon and I'll ask about the testing options.

Thanks again,

-Vesta

[AvileeG]

Hi Vesta,

What jumped out at me from this was the phrase "his decline in the last 6 weeks has been quite dramatic." I may be wrong (and if so there are many more experienced folks here who could correct me), but my understanding is that Cushing's generally progresses quite slowly -- so the rapid decline would lead me to question whether there may be something else (possibly as serious as Cushing's) going on. Knowing that trilostane is not benign in itself, I would be very careful about treating with Vetoryl without a fair amount of further testing -- both for Cushing's and for anything else that could be causing those symptoms.

Good luck,
Avilee

[dsbailey]

I do the same thing as Shana "DoxieMama" except we go somewhere enjoyable for an hour during ACTH Tests, grandma's house, home depot, the park ... Also for the LDDS test I was able to take her home between blood draws.

Darrell and Lolita