New member - Bodger tested negative on LDDS, what next?

[Bodgy]

So my 4 year old bull terrier bodger has been gaining weight probably the last 9 months or so and we didn't really notice the other symptoms until reading about Cushing's the last week. About a week and a half ago we brought him in for a blood test thinking it might be a thyroid issue. Thyroid came back good and the vet suspects Cushing's so he had his LDDS test today and well find out the results tmrw. His symptoms are panting, frequent peeing, weight gain, saggy belly, more lazy than normal, skin issues(bug he's a bully and it would be hard to tell which is which from his normal or Cushing's related). He's also been on prednisone the last 2 or 2 and half years but not steady. Hell be on it for about a month or 2 til his skin issues get better than well take him off for a couple months til they return. We never liked using it but we've tried EVERYTHING and tgat was the only thing that really helped completely. He's been off it this time for probably about 5-7 weeks. So my first question is could he have iatrogenic Cushing's from the sprodaic use of the prednisone? Also will they be able to tell after i get the results tmrw if he has iatrogenic, adrenal or pituitary, or will I need an ultrasound? If the ultrasound comes back negative how will they kown if it's iatrogenic or pituitary? I'm going to post Bodger's results tmrw after i get them but what questions do I need to ask the vet tmrw? I have more questions but they are about surgery and medication so il just wait til we kown more tmrw. Thanks allot and any info that I need to know before tmrw be sure to tell me. Bodger thanks u too.

[Harley PoMMom]

Hi and welcome to you and Bodger!

I'm sorry for the reasons that brought you here but sure glad you found us and we will help in any way we can.

I see you posted that Bodger has been off the prednisone for 5-7 weeks, so just to clarify, Bodger wasn't taking the prednisone when the LDDS was performed, correct? If he was, unfortunately the LDDS is not the test of choice because prednsione can cause a false positive result.

And, yes, even short term prednisone use can cause the same symptoms as the naturally-occurring Cushing's. If Iatrogenic is suspected than the ACTH stimulation is the test that is required. I've included an excerpt and the url to a blog on the subject by renown endocrine expert, Dr. Mark Peterson.
[ACTH is the] Best test to diagnose iatrogenic hyperadrenocorticism in dogs. If the dog has clinical and laboratory features consistent with Cushing’s syndrome (e.g., polyuria, polydipsia, polyphagia, pot-belly, truncal hair loss, high serum alkaline phosphatase) but has a recent history of glucocorticoid use, this is the test of choice. If the cortisol response to ACTH stimulation is low-normal or blunted in this dog, the diagnosis would be iatrogenic Cushing’s, rather than the naturally occurring disease. http://www.endocrinevet.info/2011/02/diagnosing-canine-cushings-disease.html

Now, the ACTH stimulation test can determine if the dog has Iatrogenic but can not distinguish between the adrenal (ADH) or pituitary (PDH) form, the LDDS test has the ability to differentiate between PDH and ADH.

So, if Bodger did not receive any prednsione for 5-7 weeks, the LDDS test results will be accurate and could show whether he has ADH or PDH, if the results are positive for Cushing's but inclusive for ADH or PDH I'd personally opt for the ultrasound. If both of the adrenal glands are visualized and abnormalities are found with the adrenal glands, than the type of Cushing's may be determined. Dogs suffering from adrenal Cushing's will typically exhibit only one single enlarged adrenal gland, and a mass or a tumor may be visualized on the one enlarged gland. Both adrenal glands will typically be enlarged in dogs suffering from pituitary Cushing's.

Has Bodger had a CBC/chemistry blood panel done recently, and if so, could you post all abnormalities that are listed along with the reference ranges? If an urinalysis was done could you post those findings too?

One important question I would have for the vet is asking how many of cases of Cushing's he has treated and what is his preference in the medications used for treating Cushing's.

Please know we are here for you and Bodger, and do not hesitate to ask all the questions you have.

Hugs, Lori

[DoxieMama]

Welcome to you and Bodger! You mention that he has gained weight; how much does he weigh now?

[Bodgy]

Great info, thanks Lori. Ive been reading some great reports over at the Yahoo group on iatrogenic and my gut is telling me that is what he has. Yes, he hasn't taken any prednisone or any other internal or topical steroid in 5-7 weeks. Im curious if he has iatrogenic will this LDDS test he just took lead the vet to believe or point to adrenal or pituitary? (Especially if he's not familiar with iatrogenic) So from everything I've read I believe the next step should be the ACTH test to test for iatrogenic. If he's negative should I then have the ultrasound to rule out adrenal or can the vet revert back to the LDDS test to distinguish between if it's adrenal or pituitary? I was a little confused by what u stated above, you were saying that he could have iatrogenic from his use but then you said you would opt for the ultrasound if the LDDS test is incliclusive you would opt for an ultrasound. Shouldn't I now do an atch next though to see if he has iatrogenic? And then an ultrasound?

[Bodgy]

Thanks doxie! Bodger's normal weight is about 64lbs and now he's 72lbs.

[trishlhk]

Hi and welcome! I am a newcomer too! Best of luck on everything.

[Bodgy]

So bodgers test came back negative and the vet tech told me no further recommendations are required except a diet, I tried to speak with the vet but she was extremely busy so she's going to call me back. I'll include the test results from his original CBC blood test and the LDDS results.

CBC test- list the high ranges:

Cholesterol- 327mg/dL. Range-93-324
Triglyceride-377. Range-29-291
Platelet Count 562(10^3/uL). Range-170-400
Platelet est. Increased
Differential. Absolute. %
Neutrophils-11,297. 79%. Range-2060-10,600


LDDS test: Cortisol Serial 3 (Dex)

Sample 1(915 am)-2.1ug/dL. Range1.0-5.0
Sample 2(115 pm)-<1.0. Range-0-.1.4
Sample 3(520pm)- <1.0. Range- 0-1.4


So is it still possible he has iatrogenic with a negative LDDST? Could he have atypical? What about stress giving a false negative? He's an extremely hyper dog when he goes on car rides and to the vet and meets anyone in general. Could that have thrown his cortisol out of whack and given a false negative? Should I do an ACTH test next or how should I proceed? Of course I'm going to talk to my vet but I wasnt sure if I wanted my GP doing this and now after the test complicating matters I'm prob going to end up at an Internal medicine specialist, if I can afford one. Thanks

[Bodgy]

Thank-you Trish. I appreciate it. Just worried and confused now after the test results.

[trishlhk]

Thank-you Trish. I appreciate it. Just worried and confused now after the test results.

I totally understand. My Kody tested "inconclusive/borderline" the vet thinks we might have caught it just as it was emerging. We are watching and waiting at this point. I am sorry I don't have more experience to share for you.

[Harley PoMMom]

Yes, he hasn't taken any prednisone or any other internal or topical steroid in 5-7 weeks. Im curious if he has iatrogenic will this LDDS test he just took lead the vet to believe or point to adrenal or pituitary? (Especially if he's not familiar with iatrogenic)

Since he was off the prednisone for 5-7 weeks those LDDS test results are accurate which means that Bodger does not have the naturally-occurring or iatrogenic type of Cushing's.

Stress and/or prednsione use can cause the LDDS test to be a false positive not negative and as we can see this did not happen.


So from everything I've read I believe the next step should be the ACTH test to test for iatrogenic. If he's negative should I then have the ultrasound to rule out adrenal or can the vet revert back to the LDDS test to distinguish between if it's adrenal or pituitary?

At this point I would be more inclined to have an ultrasound performed to see if there could be something else going on that is attributing to his symptoms.



I was a little confused by what u stated above, you were saying that he could have iatrogenic from his use but then you said you would opt for the ultrasound if the LDDS test is incliclusive you would opt for an ultrasound. Shouldn't I now do an atch next though to see if he has iatrogenic? And then an ultrasound?

Since he did test negative on the LDDS test I wouldn't pursue anymore diagnostic tests for Cushing's, an ultrasound would be my next step.

Hugs, Lori

PS: Some other questions I have, when Bodger was taking the prednisone, what dose was it and for how long "at one sitting" was he taking it?

[labblab]

Hello and welcome from me, too! I wanted to let you know that I retrieved your note requesting a thread title change. I hope the change I've made suits you, but just let me know if you were wanting something different.

Secondly, I am taking a little bit different tack here and am thinking that I might want to proceed with an ACTH stimulation test, after all. I see that Bodger has been "off" the prednisone for over a month, but can you tell us what dose he had been taking and for how long beforehand? Depending upon the dosage and duration, I'm still wondering whether it's possible that his natural adrenal function remains impaired or affected in some way. If he was still taking the prednisone, you already know that the obvious question would be whether or not he suffers from iatrogenic Cushing's. However, it seems remotely possible to me that he might be suffering from the opposite issue: iatrogenic Addison's, or low cortisol production. If Bodger has persistently been dosed with high amounts of prednisone, I am wondering whether his adrenal glands are now slow to shift back to producing sufficient amounts of natural cortisol.

Weight gain is not characteristic of Addison's, but many of Bodger's other symptoms could be shared by both Cushing's and Addison's. I hate to advise you to spend the money unnecessarily, but the possibility might be worth talking over with an internal medicine specialist if you do proceed with that route. The ACTH stimulation test is the only test that can be used to diagnose either iatrogenic Cushing's or Addison's; the LDDS is of no value for either of those conditions.

But before going further with this train of thought, please do let us know what dose of prednisone Bodger has typically been taking, and for how long a time before this most recent break. (Edited to add that I now see Lori and I are both asking these same questions. ;))

Marianne

[Bodgy]

I'm getting told elsewhere that the LDDS can't test for iatrogenic, I have to have an ACTH test, and that he absolutely could have it, the effects lasting up to 6 months. I'm seeing a IMS next month so I'll see what they have to say. Bodger would take the prednisone for a months to 2 months and then stopped for a month or 2. Il keep everyone updated on what happens at the IMS next month. Thank u guys again, Uve been great.

[Bodgy]

Hi Marianne, I just saw ur post. Thanks yeah the title is perfect. I'm not sure at the moment what the dosage was I can post it tmrw. He's usually on prednisone for a month or 2 and then is off for a month or 2 without being weened off. What I believe is going on is that he has iatrogenic and even though he hasn't taken prednisone for over a month his symptoms are still showing and he never got over them the times he was off if it, it wasn't enough time and then we he started it again it just kicked back in. My vet doesn't want to listen to what I have to say so I am seeing a IMS next month and I'm going to discuss it with her if course but the first thing I want to do is get an ACTH test. What I'm wondering is, is iatrogenic still detectable if the prednisone is out of the system for over a month- so we can actually know that is what we are dealing with. And if it's not detectable, dies that not necessarily mean he didn't have it or is just under table and he still has his symptoms playing out up til 6 months. But we'll see what happens, I'm taking him in around the 3rd week in September so I'll keep everyone updated to date. I've learned allot in a shirt time on these forums and I really appreciate everyone's concern and advice. Il post Bodger's prednisone dosage tmrw. Thanks

[lulusmom]

Hi Joe and a belated welcome to you and Bodger.

As promised, I've cut and pasted my response to your post on our fb page below so that everyone in both groups are kept in the loop. Thank you, Leslie, for sending Joe here. I see that Marianne has already given you some excellent information and apologize for any duplication. As you can see, I have a problem with brevity. :D


Hi Joe Warren. If Bodger was on prednisone for more than week, your vet's dosing instructions should have included tapering. i.e. give one pill a day for five days then one pill every other days, etc. It is dangerous to do otherwise. I have seen your thread on k9cushing's and am just now finding the time to weigh in on the symptoms and lab abnormalities. You list his symptoms as weight gain, despite continued exercise and eating less; panting, sagging belly; frequent urination; laziness; callused spots on his skin. The only thing in that list that can't be attributed to obesity is the frequent urination. Dogs with cushing's pee a lot because their kidneys are no longer concentrating their urine. As a result they drink voluminous amounts of water to stay hydrated. To see one listed and not the other is highly unusual. A urinalysis, including a culture, is routinely done as a screening test to rule out a urinary tract infection as well as check urine specific gravity (USG), which is usually very low in a cushdog. I didn't see that you mentioned a urinalysis here or on k9cushings. Can you please let us know if these tests were done?

I also wanted to mention that Bodger's blood lab abnormalities (Cholesterol, Triglycerides, Neutrophils) are commonly seen in dogs with cushing's but they are also to be expected in an overweight dog. Was Bodger fasted for blood draw?

It is possible that what you are seeing could be the lingering effects of the prednisone but unless Bodger is in the very, very small minority of dogs who are missing the genetic marker that triggers a steroid induced isoenzyme of ALKP, I would expect that if the symptoms you are seeing are truly due to long term treatment with prednisone, you would most likely be seeing persistent elevations in ALKP. If a dog is suspected of having iatrogenic cushing's, the LDDS test is not the correct test. Per Dr. Mark Peterson, a recognized and well published endocrine specialist, "Best test to diagnose iatrogenic hyperadrenocorticism in dogs. If the dog has clinical and laboratory features consistent with Cushing’s syndrome (e.g., polyuria, polydipsia, polyphagia, pot-belly, truncal hair loss, high serum alkaline phosphatase) but has a recent history of glucocorticoid use, the ACTH stimulation test is the test of choice. If the cortisol response to ACTH stimulation is low-normal or blunted in this dog, the diagnosis would be iatrogenic Cushing’s, rather than the naturally occurring disease. None of the other pituitary-adrenal function tests can make this differentiation."

With respect to Bodger's skin issues, if he truly has naturally occurring cushing's which is the only reason to continue to pursue a diagnosis for pituitary or adrenal dependent cushing's, he would not need prednisone as he would be self medicating with the high levels of cortisol. The fact that he needed steroids just a few months ago tells me that it is highly unlikely that he all of sudden has elevated cortisol from a pituitary or adrenal tumor that is now causing the symptoms you listed. If that is the case, you probably won't be seeing any more skin problems. Has your vet ever prescribed Apoquel for Bodger's chronic skin problems? This is a fairly new FDA approved drug that has proven to be a Godsend for dogs who suffer with chronic, insanely itchy skin. If not, I highly recommend that you talk to your vet about it instead of steroids for Bodger. I've included a url to the manufacturer's press release that provides a lot of information about it's efficacy.

Lastly, I wanted to talk about Bodger's weight. Low thyroid is a much more likely to make a dog fat than cushing's. As a matter of fact, weight gain is not a symptom of cushing's and studies have shown that cushdogs who eat their normal food intake, do not gain weight. My first cushdog got fat because I free fed and she simply ate too much. That was many, many years ago and I've not fed my dogs kibble since then. You mentioned that low thyroid has been ruled out. Did your vet do a full thyroid panel or did he rule it out based on T4 results that are usually included in the blood chemistry. Can you share the results of whatever thyroid hormones were tested? I have seen multiple overweight dogs misdiagnosed with cushing's so if Bodger were mine, I would be focusing on weight loss. What steps have you and your vet agreed on to achieve that goal? Any change in diet? Increased exercise?

I will be copying and pasting this post on your thread on k9cushings so that everyone on both groups are kept in the loop.

https://www.zoetisus.com/.../study-shows-apoquel...

[Bodgy]

Hi Lulu, thank-you. Some excellent points. I just recently realized he was suppose to be tapered off and chewed the vet out for not telling us, on the bottle it just says to taper on not off.

I didn't list it but yes very frequent drinking as well. No we haven't done a urine test, the vet didn't say anything about it. In fact she says nothing is wrong with him and doesn't recommend any further treatment. I've already scheduled an appointment with a IMS and dermatologist. We will 'most likely be switching vets...again. I will definitely bring up the urine sample/culture/gravity..is that all one test? Different from the UCcR as well?

Bodger was fasted for blood draw for 12 hours, nothing but water. Also I really dont see how he can be overweight. He eats less food than he use to because until recently we thought feeding less would lead to weight loss, than we thought of the thyroid issue and now Cushing's. He also gets the same exercise maybe more than he always has.

Yes I actually read that article and was told about this after Bodger had his LDDST. She didn't specifically think he had iatrogenic cushings so that's why she did the LDDST test, and I brought this point up to her after word
s, she just kind of fumbled around with the answer.

Yes we have tried apiquel and it didn't do one thing to improve his condition. He took it for 3 weeks which should have been plenty time. His skin problems don't really cause itching though either. We are going to get a skin allergy test at the dermatologist plus what ever else she might recommend.

No I don't believe he did have a full adrenal unless it was part of the CBC blood test. I will ask the IMS about that as well. That's interesting about the weight gain not being a Cushing's symptom he definitely doesn't eat more, he eats less. He's gained 7 pounds in the last 9 months from 65 to 72. What is the thyroid heading under in the CBC blood test and I will post it here. Can I post a picture attachment here, I don't see an option?

Thanks for all your ideas, you've given me some more stuff to think about and talk with the IMS about.

Edit: Another thing I wanted to add- it's not hard evidence in the way of science but it goes a long way with me. Right before these symptoms started happening Kristi(bodgys mommy) told me that she has mothers Intuitionn and she thinks there's something wrong with him and she's told me this several times in the last 9 months. But me being a guy I just blew her off. Sometimes u just gotta with ur gut huh.

[labblab]

Hi again, just wanted to add a quick comment about weight gain/loss. Many of our members do report weight gain in their Cushpups prior to starting treatment, but I am guessing this is due to owners overfeeding in response to the ravenous appetite that has developed in their dogs. When dogs constantly beg for food, I think a lot of folks break down and give extra treats or bigger food portions in response. Plus, if untreated dogs become more lethargic or suffer from loss of muscle mass in their hindquarters, they may not get as much exercise as previously and, as a result, burn off less calories.

My own Cushpup was an exception in that he actually lost weight prior to diagnosis. He did exhibit excessive hunger, but we did not feed any extra treats or larger meals until we realized he was actually losing weight. So that just goes to show that not every dog presents in exactly the same way.

Also, I am still interested in learning Bodger's weight and also the dose of prednisone that he's been receiving. I've still not given up on the thought that his natural adrenal function may now be too low instead of too high. Again, this is not very likely. But I do see that his resting cortisol on the LDDS was around 2.0 and if his stimulated level on an ACTH is not much higher, then it may be the case that his adrenals are suffering from some degree of lingering "under functioning" as a result of extended periodic prednisone use without the benefit of tapering off doses.

Marianne

[lulusmom]

Hi again.

Moms always know best and her gut instincts are usually right so not a good idea to ignore them. There is a reason why mother hen and not father rooster was chosen to describe a person who cares for the needs of others (especially in an overprotective or interfering way). :D Having said that, I think you are an awesome guy for being Bodger's advocate. You have the tough job of learning about the disease which your gut nor mom's can help much. We're your gut instincts here until the light bulb goes on at some point in the future. Nobody is an instant canine cushing's Einstein and if you were, I would bowing to you right now. :D

I would like to apologize for asking you if you had a full adrenal panel done. That was incorrect. What I meant to ask is if your vet did a thyroid panel which includes multiple thyroid hormones. Most blood chemistry results we see include the T4 thyroid hormone so that is what you want to look for on your test results. Please include the normal reference range as well.

Glynda

[Bodgy]

Thank-you. So under the main section 40 or so test results is another section and it says total T4 - 1.6/. Range. .8-3.5 ug/dL -. So it's in the range.

I'm not sure if it lists any if the T4 chemicals above that individually or not. I wouldn't know what to look for. It's pretty much all jibberish to me.

[Bodgy]

Hi Marianne, thanks for the info. il find out today about his prednisone dose he was taking and post it.

[lulusmom]

Thanks for posting the T4 results. I wanted to see just how normal it was. Some dogs with very low normal results can be symptomatic and can benefit from thyroid supplementation That isn't the case with Bodger. By the way, a good number of dogs with naturally occurring cushing's have a low T4 at diagnosis. This is usually a transient decrease caused by chronically high levels of cortisol in the blood, which returns to normal once cushing's treatment has effectively reduced cortisol. I'm not seeing that either so that's another piece of the cushing's puzzle that doesn't fit.

Glynda

[Bodgy]

Hi Marianne, Bodger's prednisone dose was 20mg. I dint remember the exact instructions I believe he was weened in at half a pill for a few days before taking the whole pill.

[labblab]

How much does Bodger weigh?

Marianne

[Bodgy]

How much does Bodger weigh?

Marianne
Currently 72, normal is 65

[labblab]

OK, thanks. I am far from being very knowledgeable about iatrogenic Addison's (adrenal insufficiency caused by steroid use). But I do think Blodger should always have been tapered off a daily 20 mg. dose. The reasoning for this is to prod his adrenal glands into once again producing natural cortisol as the external steroid dose is reduced.

I've had Labs who weigh around the same amount as Blodger, and they have been dosed with 20 mg. daily for short periods of time in order to treat inflammatory conditions. Even after only a 7-10 day course, we've always been instructed to taper down before discontinuing. In reality, I'm also puzzled as to why you would taper "up" the dose. In addition to dogs, I've also had several relatives who have been treated temporarily with steroids for various conditions. And usually you want to start out with a "bang" -- the full dose immediately in order to quickly tamp down the inflammatory issue. It's as though your vet is doing things backwards...:confused:

Anyway, I may be barking up the wrong tree entirely, but I'll be curious to see whether the IMS thinks there is usefulness in performing an ACTH in order to evaluate Blodger's current adrenal response.

Marianne

[Bodgy]

I completely agree about the taper, but we weren't informed to do so, I wish we were, I just recently learned this was the case. I'm curious to find out if this has any impact on his current issue. It also could be the other way around about the prednisone, il have to ask Kristi. She mainly dealt with that. Yeah I'm curious too about the usefulness in an ACTH, in my mind it seems like the next logical step but I could be way off base too. Well just have to wait and see, I'm anxious to find out.