13-year-old Lab with probable Cushing's

[MarkP]

Hello all,
I am pleased to have found this support forum, as we have been struggling with what is probably Cushing's for a month or so.

Our 13-year-old brown Lab, Griffin, went in about a month ago for a rabies booster. The the vet decided to give him a more thorough examination because he had not been in for at least a year (he has never had any health issues). We have since had the following three tests performed, which helped rule out some problems, but a definitive diagnosis of Cushing's is still elusive. I will ask the vet clinic to send me the results, and will post them once I receive them.

Geriatric blood panel - high ALP, most everything else normal. T4 was at the end of the low range, which is why the Thyroid panel was performed.
Thyroid panel - endocrinologist indicated there is an underlying problem, but it is not symptomatic of a Thyroid disease.
LDDST - inconclusive

Behavioral symptoms
These started about two months ago. I mistook some as signs for aging. I did notice the excessive peeing and drinking, but thought nothing of it because this summer has been so hot.


His strangest symptom is fur loss on his tail. There is a stripe down the center with no fur. There are other patches without any either.
Increased water consumption: drinks 2-3 times what he used to a day.
Increased urination: No accidents in the house yet, although sometimes I wonder why not given how long he pees when he goes out. He does not drink much after the household goes to bed.
Increased appetite. He seems to be hungry all the time, and his hunger has increased noticeably in the last month.
labored breathing, even when just lying in bed.
Intolerance to exercise. Slow walks are about all he can take, and regardless of the temperature, he is panting for 10 minutes after the walk. I stopped taking him on 0.5 mile walks because his hind quarters would shake sometimes when returning into the house.
Some symmetrical thinning of the coat, although not like in the pictures I have seen online. This could be due to the fact that is coat has always been thin.
Coat is looking dull in places.
Very flaky skin, especially around the areas where fur has thinned significantly.
Lethargic most of the time, although will be interactive when walks/food/company are involved (He tried to run after a squirrel today)
Mental dullness, but his parents experience this too :)


He does NOT have a distended stomach or noticeable loss of muscle yet. His bowels are normal.

Based on what I have read here and elsewhere, I would say overall his symptoms are mild.

The vet suggested another test (maybe ACTH) and then an ultra-sound if needed to confirm a diagnosis, and then described the treatment regimen for Cushing's to us. As mentioend above, a positive diagnosis has still not been confirmed, but the vet is fairly confident it is Cushing's. She has been impressively open and caring, which has been great.

Advice, Please
Given his age and the risks and stresses of pursuing treatment, we are unsure of how to proceed. I would greatly appreciate this community sharing its opinions and observations. I have a few questions that I found difficult to find answers to:


Is there a typical trajectory and what is its time course?

Does treatment, rebalancing of cortisol, simply slow the progression of the disease or stop it? I ask this wondering whether there are conditions related to it to which he will succumb.

Our overriding concerns are mitigating pain and maximizing comfort. The fact that he has been otherwise healthy is a good reason to start treatment, but his age makes me wonder whether it is sensible to do so. Death is a part of life, and medical intervention is not always prudent. He has been an amazing dog. Smart, loyal, loving. We want to ensure the final stage of his life is humane and dignified.

Thank you so much for your time.

[Harley PoMMom]

Hi Mark,

Welcome to you and Griffin! I am sorry for the reasons that brought you here but so glad you found us. Thank you for the through medical history on your boy, we love details as this is very helpful to us in providing meaningful feedback, and once you get those other test results and post them this will give us an even clearer picture.

Although the low dose dexamethasone suppression (LDDS) is the "gold standard" test for diagnosing Cushing's there is a small percentage, 5% to 10%, of dogs that display Cushing's symptoms that have a negative test result but actually do have the pituitary type of Cushing's. In that case another test is needed such as an ACTH stimulation or an ultrasound.

Griffin sure is a handsome fella and the fact that he is 13 years young is quite a testament to what a great job you have done in making the right decisions for him so far. Cushing's is typically a slow progressing disease, and the decision whether to treat or not depends on a number of factors: age of the dog, apparent discomfort, and severity of symptoms (both external and internal).

The goal of treatment is to control the troublesome symptoms (things like excessive thirst, urination, hunger, panting) and since the damage of untreated Cushing's usually occurs over time, my own opinion is that I don't worry so much about the "silent" damage in a dog who is already elderly and my primary concern for a senior dog is immediate quality of life. So if the overt symptoms are making the senior dog uncomfortable, I would treat. Otherwise, I probably wouldn't. Another reason that makes it difficult in deciding to treat is that it's not pleasant for any dog to go through the trauma of multiple vet visits and the many monitoring tests that are required for treatment and for a senior dog it can be worse. Also, if a dog is already suffering from arthritis, Cushing's treatment may cause more discomfort as that elevated cortisol does have anti-inflammatory properties.

My Pomeranian boy, Harley, was around 12 years old when I started treatment for his Cushing's and unfortunately it unmasked kidney disease, his vet and I decided to stop treatment and focus on his kidneys instead. That elevated cortisol eventually did irrevocable damage to his heart, liver, and kidneys. And at 14 years old he received his angel wings.

I don't tell us this to discourage you from treating your precious boy, only you know Griffin best and I have no doubt that you will choose the right path for your sweet boy.

Hugs, Lori

[MarkP]

Hi Harley,
Thank you so much for responding so quickly, especially on a holiday. I appreciate your frankness and sharing your opinion. It is helpful to hear your perspective and insight having dealt with it yourself. This is just want I want to learn.

Griff was his normal self in May, at least outwardly. Now he is often, though not always, withdrawn, ravenous, and his coat is not looking too good. I should have the test results later this week.

[Harley PoMMom]

My boy, Harley, had a lot going on medically, he also had chronic pancreatitis which we could never get control of, than the kidney disease came into the picture. The decision to stop treatment for the Cushing's was a difficult one, and to be completely honest, one that I sometimes do regret but one can not change the past.

Cushing's is most commonly present in middle-aged or older pets and because the symptoms occur so gradually, the changes are often attributed to "old age" so many dogs with Cushing's go undiagnosed for years. We have many members here who are having success in treating their dogs for Cushing's and some of them precious furbabies are older dogs.

Hugs, Lori

[Little_Love]

Hi Mark,

I send my best wishes for what I know is an incredibly scary and frustrating time. My senior dog went without Cushing's meds for 2 years although symptomatic due to blood results that always had her as A-typical Cushing's. She had a little 'buddha' belly and the hair thinning along with increased thirst, ravenous appetite, etc. Her liver enzymes were also elevated. I was okay with not treating her, however her Cushing's progressed to the point that she had complications that gave rise to Diabetes (a common co-occurring disease with Cushings). It's incredibly hard to treat diabetes with Cushing's so she was retested for Cushings this year and her levels were very high, making her eligible for medication.

I decided to treat her with Vetoryl. She responds very well to the medication and it has helped managed her diabetes. So it was a necessary choice for me. That being said, she's about to turn 14 (granted she is a small dog) but lived 2 years with no Cushing's treatment just fine. It was mostly me who had to adjust- she peed a lot more, and I was willing to make that sacrifice and work around her issues (thank you non-carpeted apartment).

Let us know how your ACTH comes back! That will really help to decide a lot (or at least it did for me).

~Mandy

[MarkP]

Good Evening all,
Griff made a few trips to the vet this week. On Wednesday we had the ACTH test and today a urine test, which had not been done. We learned a lot, but still no firm diagnosis. As the doctor who summarized the thyroid panel said, "we have a diagnostic dilemma." Here are a few test results. If you would like me to post more, just say so.

Below are the results of the Geriatric panel that yielded the initial cause for concern a month ago.

https://drive.google.com/open?id=0BwRDhH42kT_lb3daTmhhZktjbm8


The ATCH test turned out to be negative, which I take as good news, but we still do not know what he has.
Pre-ACTH cortisol: 2.8 ug/dL
Post-ACTH cortisol: 7.8 ug/dL

The urine test showed no sign of infection, but the urine was diluted to such an extent it was almost water (specific gravity = 1.008).

Lori's post is rather prophetic, as the vet now suspects diabetes insipidus, which we will explore next week. She is also wanting an ultrasound to explore the health of the kidneys and liver.

So there you have it.

[Harley PoMMom]

Was the urine sent out to a lab to be cultured? If not, than I would have this done, when a dog has diluted urine a regular urinalysis is not sensitive enough to pick up the bacteria and an urine culture and sensitivity test is done. The urine culture and sensitivity test will show exactly what the bacteria is and what antibiotic is needed.

Hugs, Lori

[MarkP]

Most likely it was not. I will talk with the vet about this next week. She wants him to come in for water-deprivation urine test. Perhaps they can use the same sample for a more extensive one as well. Thank you for the advice.

Keep on wagging!

[labblab]

Mark, I am not a vet and don't mean to be second-guessing yours, but it is our understanding that the water deprivation test can be physiologically very stressful on a dog. For that reason, many of the dogs on our forum for whom Diabetes Insipidus is being considered are first simply given some trial doses of the treatment drug.


Sometimes veterinarians do a desmopressin stimulation test. Desmopressin is the drug used to treat DI. If an animal has a positive response to the drug, it’s a good indicator the problem is truly diabetes insipidus.

A water deprivation test may provide more complete info regarding a possible diagnosis, and your vet may have specific reasons for going that route. But I just wanted to mention this alternative to you in the event you wanted to discuss it as a first step. Given Griff's age, I just hate to think of him being stressed any more than necessary by additional testing. :o

Marianne

[Squirt's Mom]

I agree with Marianne and would just start treatment for DI - if it works, there's the diagnosis without putting your sweet boy at risk and under added stress. ;)

[Tina]

Hi Mark,

Just chiming in to also voice my agreement with Marianne. I have some experience with this situation, as there was a time when the vet suspected that my boy might have Diabetes Insipidus.

I remember her saying that the water deprivation test was used for diagnostic purposes in the past but was rarely used now due to the safety risk and how hard it is on the dog. She said that kidney damage can occur, especially if there is any type of kidney abnormality already present. She indicated that a desmopressin trial is a safer method for diagnosing DI. It sure would be worth discussing with your vet.

Tina

[MarkP]

Hi all,
Thank you Marianne and Tina for your input. The week has been crazy and I am only now getting back to the forum.

My use of the term "water deprivation" might have overstated the situation. Griff does not drink too much at night, maybe one trip to the bowl, but that said, I have estimated that he drinks just under three quarts of water a day, maybe slightly more, which is huge for a dog that in the past was rarely seen at the water bowl.

What I did, following instructions from the vet, was to withhold his water at night, because of what I say above. So around 10pm I put the water on the counter, and when I fed him around 5:30 or 6 he had his water back. The idea was to get the first evacuation of the day and determine if the specific gravity was still low. If so, then it would be at least some confirmation of DI. Griff was fine in the morning. I really appreciate you concern and apologize if I alarmed you.

The test showed that his urine was still diluted, so I thought this would lead to DI diagnosis and treatment. I agree with the approach suggested by Marianne and Tina. It makes sense, but a long conversation with the vet convinced me that we need to get an ultrasound next to eliminate other possibilities and garner enough new information to be more confident in a diagnosis. There could be other underlying problems was the take-away for me.

So, Griff goes in next week for an ultrasound. I will update this thread once I get the results. We sure hope this puts some closure on his condition, health, and prognosis. He is such a great companion.

Thank you all so very much for your concern.

[MarkP]

On Tuesday Griffin had an ultrasound. Kidneys had an age-appropriate look. The liver was difficult to image because the rib cage was in the way, but the doctor did not see anything abnormal. Griff does have a tumor on his adrenal gland. I forget which side. My vet is out of town until next week, so we will not be able to speak until then about options.

I would appreciate hearing opinions on surgery, especially for a 13-year-old Lab. I have found some good information online, and it seems with or without surgery, life is not going to be that great. Surgery has significant risks, and the benefits of surgery depend critically on what is found during surgery. Although Griff has been healthy all his life, I am doubtful he has the stamina for it. He is not frail, but he no longer chases squirrels or birds out of the yard, and walks are more of a stroll.

-Mark

[MarkP]

Hello all,
I am surprised to see it has been almost six weeks since I posted last. Work and Griff's care are rather consuming. After many additional tests, including an ultrasound and most recently an adrenal panel from University of Tennessee, Griffin appears to have atypical Cushing's. He has a tumor on his adrenal gland (right side) and the adrenal panel came back with only progesterone elevated by about 2.5 times above the end of the defined range.

Following the treatment guidelines from Tennessee, he started Melatonin about 2 weeks ago. I decided to start him on lignans about a week ago. There are no changes in his observable symptoms thus far, but of course we pray for a change soon. The vet specialist suggested we stay on this regimen for a month before considering other drugs.

His symptoms are a bit worse. There is more hair loss and he cannot hold his bladder as long. Water consumption is about the same. The cooler weather is more agreeable than summer.

Thanks for your past support.

[labblab]

Hi Mark, and welcome back to you and Griff! Please do keep us updated re: his progress, and we will definitely be hoping that the melatonin/lignans combo will help things. Unfortunately, it's true that patience is a virtue in that regard since it can take some time for that regimen to spark improvement, sometimes even several months. But given Griff's age, I surely understand why you wish to start off with a noninvasive treatment that has the least chance of producing ill effects. Has there been any more discussion by your vet, though, about the possibility of giving the Diabetes Insipidus drops a trial run further down the road?

Please give your boy a big pat for us, and as I say, please do continue to update us as time allows.

Best wishes to you both,
Marianne

[Squirt's Mom]

Hi Mark,

First, I want to apologize for the lack of replies to your previous posts. I can offer many excuses but the bottom line is we simply failed to reply. It doesn't happen often but it does happen.

I am very curious about the Atypical diagnosis in the face of an adrenal tumor. Did they say anything about whether or not this tumor is secreting cortisol? I assume the cortisol was normal on the UTK adrenal panel since you posted that the only thing elevated was the progesterone. Typically it takes elevations in at least 2 of the 5 intermediate hormones with normal cortisol level to assign the diagnosis of Atypical. So at this point I am wondering about the diagnosis.

FYI - the treatment for Atypical, the combination of melatonin and lignans, takes at least 4 months to show results. So patience is the key with this form. ;)

Referring back to your question about surgery for Griffin. With this confusing diagnosis, I would want to talk to the vet about the possibility of another kind of adrenal tumor called a pheochromocytoma. These tumors do not secret cortisol but can cause some signs in common with Cushing's and can impact the cush testing. They are treated completely differently from Cushing's so if's important to know what you are dealing with. (This may have already been mentioned to you - I didn't read back thru your thread....I'm being lazy again. :D )

When faced with the possibility of surgery it is usually best to talk directly with the surgeon as they are the one most likely to be able to tell us if our babies are in fact candidates for that surgery. Our GP vets may know but the surgeon WILL know. ;) One of our members, whose baby had a pheo, came up with this list of questions:


Questions to consider and ask the surgeon when facing an adrenalectomy
Part I - Questions to ask when considering if surgery is an option for your dog’s adrenal tumour:

1. What type of tumour do you suspect? functional? non-functional, pheochromocytoma, benign, metastatic
2. Expected life span for my dog in a normal situation. If your dog is close to, at or past his expected lifespan for his breed is surgery going to be of any benefit?
3. Prognosis for my dog if we treated medically i.e. with Cushing’s medications. AND if we do not proceed with surgery how long do you think it would be before the tumour started adversely affecting his quality of life?
4. If he is miserable now, does the benefit of potentially risky surgery outweigh his current quality of life?
5. Are there any other health problems that could impact on a positive surgical outcome, for example: if your dog is overweight or has heart, BP, liver, kidney or lung conditions
6. Is there any sign of tumour spread – imaging should be done, including ultrasound and on advice of specialists either CT or MRI to check whether there is local invasion around the tumour, into blood vessels including vena cava or spread further away in the body to lungs etc
7. Surgeon recommendations – would he/she do it for their own dog?
8. Psychological impact for the owner: It is important to understand this is risky surgery, sadly current guidelines indicate 1:5 dogs do not make it, and some recommendations are not even that high. Can you accept it if your dogs dies during or in the postoperative recovery period surgery? This is where it is important to weigh up whether the benefit of your dog being fully cured is worth the risk of possibly losing him.
9. Financially – can you afford it? Find out estimate of costs.
10. Hopefully this will not happen, but if your dog collapses, e.g his heart stops either during his surgery or afterwards what emergency measures should be undertaken, do you want your dog to have CPR, how far are you (the owner) willing to go for your dog to be saved in such circumstances


Part II - Surgery has been recommended as treatment for your dog’s adrenal tumour, here are a few suggestions on what questions you should ask your surgeon:

1. Are you board certified? How many operations of this type have you done? What complications have you experienced? What were the outcomes?
2. Please explain to me how you will do the surgery, which part would likely give you the most trouble? Will you be doing the actual surgery or a resident in a teaching situation? If so, is their close supervision?
3. Will there be a specialist anesthetist available for the surgery?
4. If it hasn’t been done, do we need a CT/MRI scan to look at the tumour more closely to check for vena cava involvement or any other tumour spread?
5. What are the risks associated with this surgery, including
• Bleeding (including trauma to blood vessels or other organs during surgery)
• clots
• Blood pressure or heart problems such as arrhythmias
• pancreatitis
• pneumonia
• kidney failure
• infection
• wound problems
• bowel problems
• anesthetic risks
• adrenal insufficiency or electrolyte abnormalities
• death (sorry but you have to ask that risk too)
6. If we proceed with surgery does my dog need preoperative treatment with Cushing’s meds, antihypertensive if high blood pressure is a problem – phenoxybenzamine recommended preoperatively for dogs with pheochromocytoma, anticoagulants or anything else?
7. How will you treat to prevent clots postoperatively?
8. What would you do if you found anything else during the surgery i.e. nodules in other organs e.g. spleen, opposite adrenal, liver, kidney. Would you remove them and what are the risks associated when doing additional abdominal surgery together with adrenalectomy
9. How long will it take and when will you contact me so I know all is OK, when can I visit after surgery?
10. How will the postoperative period go, how long would you anticipate he would need to stay in hospital? How will we manage pain?
11. What monitoring would be needed, e.g. heart monitoring, oxygen levels in the postoperative period
12. If your dog has an adrenocortical tumour affecting cortisol production will he need to be on steroids following surgery and for how long?
13. If there are problems when I take him home, who do I contact? Hopefully the surgical team until all is stable.

I hope this helps a little bit. And again I am sorry we did not reply to you sooner. :( We DO care about Griffin and you, I promise.

Hugs,
Leslie and the gang

[MarkP]

Marianne and Leslie,
Thank you for your replies and information. I sincerely appreciate the work your group does, providing support and information. There is no need to apologize for not replying immediate. If I needed an urgent reply, I would have asked for one.

I was intrigued to learn about Pheochromocytoma, and just emailed the specialist for his opinion on the likelihood of Griff having it. I should note that Griff probably does not have high blood pressure, but do not recall ever discussing blood pressure with anyone. Below are some test results and a few condensed summaries describing Griff's current condition. Any opinions are appreciated.

I am nervous about subjecting him to surgery given his age, success rates, and his condition. Although sometimes he seems his normal self, he is somewhat fragile. The colder weather is a plus, but even a very leisurely 0.5-mile walk seemed to push it at the end, with his hind legs trembling. He returns home zonked and goes right to sleep. Maybe this is what a lab his age is supposed to do.

Assessment by Specialist
Abdominal Ultrasound - The right adrenal gland is en larged (3. I cm shorl axis), rounded in
contour and has irregular echogenicit;- and texture. Invasion into the caudal vena cava cannot be completely assessed due to poor
patient compliance. A uniform hyperechoic nodule ( L36 cm short axis) is identified at the cranial aspect ofthe left adrenal gland. The
caudal aspect ofthe left adrenal gland is reduced in size (0.47 cm). Both kidneys are normal in size but have hyperechoic cortices and
flattened to concave areas at their caudal poles. Bilateral renal cofiices are hyperechoic. The liver is difficult to image due to patient
conformation and gas filled stomach but appears normal in size, echogenicity and texture. No abnormalities are noted at the
gallbladder. The spleen and urinary bladder are normal. Impression: Right adrenal tumor. Left adrenal nodule, likely benign.

Assessment:
Griffin's history of polyuria/polydipsia, increased lethargy, and loss ofmuscle strength along with his clinical signs ofbilaterally
synmetrical alopecia, increased ALP, and a pendulous abdomen are all consistent with a diagnosis ofCushing's disease.
Ultrasonographic evidence of a right adrenal tumor also supports this diagnosis directly. The only potentially confusing diagnostic
result was the lack of evidence of Cushing's disease on the standard screening tests peformed by your family veterinarian: ACTH
Stimulation Test, the low-doese Dexamethasone Suprression Test. These tests showed that Griffin is not producing abnormal
levels ofcortisol. Therefore the most likely diagnosis at this point is Atypical Cushing's disease, which is a condition where one or both
ofthe adrenal glands are producing abnormal levels of other hormones that are not measured by the standard screening tests. To test
for these hormones (including estradiol, androstenedione, I 7-hydroxyprogesterone, progesterone and aldosterone).


Adrenal Panel Results
1 CORTISOL (baseline) 1.6 <1.0‐5.6

2 CORTISOL (post ACTH) 7.5 7.1‐15.1

3 ANDROSTENEDIONE baseline 0.09 0.05‐0.36

4 ANDROSTENEDIONE (post ACTH) 0.09 0.05‐0.36

5 ESTRADIOL (baseline) 0.31 0.24‐2.90

6 ESTRADIOL (post ACTH) 57.9 23.1‐65.1

7 PROGESTERONE (baseline) 0.40 < 0.20

8 PROGESTERONE (post ACTH) 2.37 0.22‐1.45

9 17 OH PROGEST (baseline) 0.08
17 OH PROGEST (post ACTH) 0.59 0.08‐0.22

TESTOSTERONE (baseline) <15.0
TESTOSTERONE (post ACTH) <15.0


Normal Ranges:
1. <1.0‐5.6

2. 7.1‐15.1

3. 0.05‐0.36

4. 0.05‐0.36

5. 0.24‐2.90

6. 23.1‐65.1

7. < 0.20

8. 0.22‐1.45

9. 0.08‐0.22

[Squirt's Mom]

Did the vet talk to you about the treatment for Atypical? It is a pretty benign treatment - melatonin and lignans. It is the combination of these supplements that does the work so both must be given. It takes at least 4 months to see any improvement in most pups on this treatment. My Squirt started out Atypical then in time became true cushinoid with elevated cortisol. This is the pattern most Atypical pups follow - most do develop conventional Cushing's. ;) Here is the treatment sheet from UTK where the Atypical testing was performed. If you need help determining the dose of melatonin or lignans after reading, let us know and we will be happy to help.

https://vetmed.tennessee.edu/vmc/dls/Endocrinology/Documents/Treatment%20Considerations.pdf

Understand...these supplements will NOT address the adrenal tumor. They can help with the signs and they can help lower those intermediate, or sex, hormones that are elevated in Griffin - like the progesterone.

Hugs,
Leslie and the gang

[molly muffin]

I certainly don't think it would hurt to try the melatonin and lignans to see if that helps him at all.
A pheo is a possibility I'd think with the ultrasound results. What did the vet say about that?