New Diagnosis - waiting ACTH results

[TobyMama]

Hi! I'm brand new to this diagnosis and forum.

My 14.5 year old cockapoo Toby has been informally diagnosed with Cushings. He had the ACTH test run yesterday and I'm expecting to hear results today (T, 10/4/16).

I took him to the vet because he was drinking LOTS of water and peed in the house while I was at work... something he hasn't done since he was a puppy.

As I googled his symptoms to see what this might mean, I saw that he had other Cushings symptoms as well - lots of panting, increased hunger in the evening for a few weeks, possible weakness/lethargy (couldn't walk around the block like he used to do), possible pot-belly starting...

Thursday - The vet ran urinalysis and blood work, ruling out diabetes and kidney problems.
Bloodwork:

total protein - 7.5 (5.0-7.4)
ALT - 160 (12-118)
AlkPhos - 475 (5-131)
GGT - 13 (1-12)
Cholesterol - 374 (92-324)
Precision PSL - 185 (24-140)
Platelets - 401 (170-400)
Urinalysis: Spec Grav - 1.014 (dilute) (1.015-1.050)
Microalbuminuria - 9.8 (<2.5).

Friday - X-ray was next - liver enlarged, but larger than vet expected with the "lesser" elevation of liver enzymes/results.

Friday - Ultrasound was next - liver enlarged, one adrenal gland enlarged, no masses seen.

Monday - ACTH test run. Expecting results today (Tuesday).

We had attributed his not walking as much to old age. Also, a few months ago, he suddenly lost his hearing. Since then, he's been sleeping a lot more and a lot more soundly. I chalked this up to him being older and not being able to hear as well.

Toby weighs about 23#. He had peed in the house on Tuesday and Wednesday, and Tuesday night he was just so hungry that I gave in and he ended up eating about 3X what he is usually given. The next morning, he wouldn't eat. Wed evening - very hungry again, gave him 1.5X what he usually gets. Next morning - wouldn't eat. Now, we're back to giving him only what he usually gets, and he's still not eating in the morning - very unusual for him before these symptoms started. It's concerning me.

Anyway... that's all I've got for now. I'll post results as I get them and I welcome and covet your thoughts and advice!!

[TobyMama]

Oops. Forgot to add... Toby had acute pancreatitis several years ago and is now on Royal Canin low fat dry dog food.

His decrease in hunger the last few days is concerning because this was the start of his pancreatitis symptoms..... :P No vomiting or diarrhea at this point.

[DoxieMama]

Welcome to you and Toby. I'm sorry I haven't a lot of time to post right now, but if you can edit your first post and put the reference ranges in for each test result that may be helpful for others to see just how much those results are out of range. Please let us know the results of the ACTH when you get them.

For the hunger, you could add green beans to his meals to help fill him up without a lot of extra calories.

Looking forward to learning more about Toby!

Shana

[TobyMama]

Oops. Didn't mean to post again.

[Harley PoMMom]

Hi and welcome to you and Toby!

I see from his blood work that the Precision PSL - 185 (24-140) is elevated, which is a test for pancreatitis, so the high levels in his liver enzymes could be attributed to an inflamed pancreas. However the enlarged liver and his symptoms of panting, increased hunger/drinking/urination, weakness/lethargy, and a pot-belly are commonly seen in dogs with Cushing's. Also dogs with adrenal-dependent Cushing's (ADH) do have one adrenal gland that is larger than the other so with Toby it's hard to say if these anomalies are due to Cushing's or something else such as pancreatitis. Hopefully once we see those ACTH stimulation test results we can get a clearer picture of what might be going on with your sweet boy.

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

Hugs, Lori

[TobyMama]

Vet just called, and ACTH test was positive for Cushings. I'll try to get copy of results and post numbers for your help.

She wanted to start him on Vetoryl, but when I mentioned his waning appetite the past several days, she's concerned something else might be going on and wants to wait. She definitely doesn't want him on Vetoryl until this other thing is cleared up or figured out.

:/

[judymaggie]

Hi and welcome to you and Toby! I think your vet is making a good decision in holding off on starting Toby on Vetoryl. It does sound as though there is an underlying issue other than Cushing's. The high microalbuminuria is also indicative of something else going on. Please do let us know how your vet is going to proceed.

[TobyMama]

So here are the ACTH results:

Cortisol Sample 1: 6.4 (HIGH) (1.0-5.0)
Cortisol Sample 2: 22.3 (HIGH) (8.0-17.0)

The vet has put Toby on 30mg of Cerenia, once per day, in case his decrease in appetite is from nausea/upset stomach.

We'll see how he does in a few days.

[molly muffin]

If he has pancreas issues starting up again, this can affect the cortisol levels in the body.

I would make sure that his test especially for pancrease get back into normal range, (they did rule out UTI right? I see he had a urinalysis), then see if the other symptoms do or don't subside and go from there.

You definitely wouldn't want to give any vetroyl while not eating.

[TobyMama]

Molly - yes, UTI is ruled out.

Vet is giving him Cerenia (?) once a day because his hunger has gone down from being ravenous! ;)

She's trying to save me the $ of the pancreatitis blood test, but it's only $100 and I'm willing to pay that, now that I know that.

What is the advice of you "experts"? Should I just wait and see how he does with this anti-nausea medication or should I go ahead and get the pancreatitis testing done? Is the pancreatitis blood work absolutely conclusive?

Just looking for some advice here.

He still is not vomiting, that I have found (I'm at work all day)... but when he had pancreatitis last time, he was vomiting quite often and I would have heard it during the evenings and nights.

Thanks for any and all help and advice.

[Harley PoMMom]

What is the advice of you "experts"? Should I just wait and see how he does with this anti-nausea medication or should I go ahead and get the pancreatitis testing done? Is the pancreatitis blood work absolutely conclusive?


Unfortunately there isn't one test that is 100% accurate at diagnosing pancreatitis but the spec cPL has the highest specificity and sensitivity and the specificity for pancreatitis is even higher if the result is >/= 400 ug/L (specificity means that the chance of a positive result is pancreatitis).

It could be that Toby had an acute attack of pancreatitis which does come on suddenly. My Harley had chronic pancreatitis and even though he showed no symptoms his spec cPL results would never fall into the normal ranges.

Since Toby's appetite hasn't increased I believe I would hold off on any testing until that appetite stabilizes...just my two cents worth ;)

Hugs, Lori

[TobyMama]

I'm wondering if perhaps I'm giving the wrong impression to both this site and to my vet regarding Toby's eating.

For 2-3 months prior to his peeing in the house, he was getting so, so hungry at night. Last Tuesday, I gave him 3X what he normally gets at night, and he ate it all and was still hungry.

Wednesday - Wouldn't eat in the morning - ended up eating his "breakfast" in the afternoon when I got home from work. That night, I gave him 2X what he normally gets, and he ate it all and was still hungry.

Thursday, and every morning since, he barely eats anything in the morning. Very unusual. But he has ended up eating his "breakfast" in the afternoon once I'm home from work, and then eats his normal amount of dinner. But hasn't acted hungry after dinner since Thursday.

So.... he's back to eating his normal amount, but isn't acting super-hungry after dinner - a change from the past few months. And he is not eating in the morning - a change from his whole life.

Just wanted to make sure I clarified.

[Joan2517]

Sounds like his internal clock is off.

[judymaggie]

Hi! Not sure if you are still giving Toby cerenia. However, I am wondering if Toby is nauseous in the mornings. It might be worth a trial of pepcid (AC/original, not "complete" version). I give Abbie, who weighs 23 lbs., 5 mg. in the am. Perhaps you could ask your vet about trying this and see if this makes a difference with being interested in the morning.

[TobyMama]

Yes, I am still giving Toby Cerenia... Today is the 2nd day. I don't think he's been nauseous at all. Even though this is an anti-nausea med, I think the vet is just wondering if this might be the issue as to why he's not eating.

Are you suggesting Pepcid if he's still taking Cerenia or if he's not taking Cerenia? :)

[judymaggie]

Hi -- I was thinking pepcid if he was no longer taking cerenia. My vet has prescribed cerenia for acute vomiting but pepcid for chronic issues.

[TobyMama]

I just learned that Toby's pancreatitis test was positive. I don't know the actual test or numbers yet, but :(.

Vet says to continue with Cerenia and maybe add Pepcid. I missed her call tonight but will talk with her tomorrow.

My poor guy! No wonder he sometimes eats a lot and sometimes doesn't...his poor body doesn't know WHAT to feel.

[molly muffin]

Oh your poor boy. Yea that will do it alright. Hopefully he'll feel better soon.

[TobyMama]

Just came from vet. Toby is eating better with combo of Cerenia and Pepcid, so we will continue thoseand add 30mg Vetoryl to start combatting the Cushings. Toby weighs 27.8 pounds. Prayers this does the trick. We go back in 2 weeks to test.

[judymaggie]

Hi! I am glad to read that Toby's appetite has picked up. Curious ... did the vet do a repeat cPL to make certain that the pancreatitis has cleared up? Sharlene had mentioned a while back that it would be important to have the pancreatitis gone before starting Vetoryl and I would agree.

[TobyMama]

No, we did not repeat the pancreatitis test. The vet mentioned, and I had seen in other places on the internet, that Cushings can actually push a pancreatitis-prone dog INTO pancreatitis. So the vet felt that we needed to address the Cushings along with the pancreatitis, since his eating has improved (back to normal amount daily) and he's showing no other physical/outward symptoms of pancreatitis.

We're going to watch him very closely and call the vet with any changes. I'm hoping we're doing the best thing for him.

[Harley PoMMom]

Since he does have pancreatitis it may be beneficial to start him on a low-fat diet. With pancreatitis those low-fat meals (3-4) should be small and fed throughout the day. You definitely want to keep him hydrated, and this disease can be painful so giving a pain med, such as tramadol, will help.

Hugs, Lori

[molly muffin]

So glad that he is doing better.
He's had pancreatitis before right?

Hopefully he keeps improving.

[TobyMama]

Yes, he had a severe bout with pancreatitis in July 2012, and he has been on low fat dog food ever since.

Thanks for the tips about smaller meals throughout the day and about making sure he's drinking enough. Drinking water has not been a problem yet...he's still got that Cushings' thirst!! 😉

[TobyMama]

Toby has been on 30mg Vetoryl for 5 days, and over the past couple of days, his appetite has slowly decreased. Today he would eat only from my hand.

He just had a bout of diarrhea.... so of course stopping the Vetoryl. He's still been taking the Pepcid and Cerenia daily.

Just posting in case there's wisdom to be shared about this. The vet will check-in Saturday morning to see how he is doing.

Thanks!

[Harley PoMMom]

Yep, stopping the Vetoryl was the correct thing to do, great job Mom! Vetoryl leaves the system rather quickly so hopefully Toby will be feeling better soon but if by tomorrow he still having the inappetance and diarrhea than he should probably be seen by the vet. Did the vet prescribe any prednisone for his to keep on hand?

Hugs, Lori

[TobyMama]

No, the vet did not order prednisone. What would that be for?

I'm wondering if there is a section in this group/forum that I haven't read that kind of explains stuff like this?? I simply jumped in once I found you! :o

[Harley PoMMom]

When a dog's cortisol drops too low they are given some kind of a glucocorticoid replacement, such as prednisone. The body reacts to prednsione like it does to the cortisol.

We have a wealth of information regarding Cushing's; the medications used, and treatment protocols, which can be found in our Helpful Resource thread and it also includes articles written by some of the most renown veterinarians that specialize in endocrinology such as David Bruyette, Mark Peterson, and Edward Feldman. So please feel free to utilize it and if you have any questions do not hesitate to ask them. Here's a link to our Helpful Resource thread: Helpful Resources for Owners of Cushing's Dogs (http://www.k9cushings.com/forum/forumdisplay.php?f=10)

Hugs, Lori

[TobyMama]

Thanks! I tried looking through it and got overwhelmed. Between his having both Cushings and Pancreatitis, I'm in over my head and will just have to trust our vet.

Toby ended up going out 14 times during the evening and night with diarrhea, toward the end having bloody stools. Went to vet in the mornings no and he got a shot for the diarrhea as well as flagyl and another anti-diarrheal. Vet also took a blood sample to test for cortisol levels to see if that's the cause. Poor boy. He's been kinda miserable the last couple of days, but has perked up this evening! Diarrhea has stopped.

We'll get blood test results on Monday.

[molly muffin]

So they did the ACTH test to check and see how toby's levels are and if they are low and causing the diarrhea?

[TobyMama]

I don't know if it's the ACTH test. He hadn't taken anymore Vetoryl since his diarrhea started up, and the vet tech said it was a "cortisol" blood test... I think she called it a "resting" test. I'm pretty sure it's to see if the cortisol levels had dropped too low and were causing the diarrhea.

[molly muffin]

Yep that is what the ACTH test will tell you. There will be a pre and a post number. You don't want them to be under 1.5 post.

[labblab]

I don't know if it's the ACTH test. He hadn't taken anymore Vetoryl since his diarrhea started up, and the vet tech said it was a "cortisol" blood test... I think she called it a "resting" test. I'm pretty sure it's to see if the cortisol levels had dropped too low and were causing the diarrhea.
From what you've written, I'm guessing the vet truly may have just tested Toby's resting cortisol alone. The ACTH stimulation test involves two blood draws rather than just one: a resting (or "baseline" cortisol), and then a second blood draw one hour after a stimulating agent has been injected. The full ACTH gives the most complete picture of the adrenal function, but as long as the resting cortisol is higher than around 2.0 ug/dL, low cortisol is less likely to be the problem. Since Toby had only been taking the trilostane for five days, perhaps your vet wanted to hold off on performing the full monitoring ACTH test, especially since it is much costlier for the patient. Either way, when you can find out the exact number for the test result, it will help guide us forward.

Marianne

[Harley PoMMom]

Thanks! I tried looking through it and got overwhelmed. Between his having both Cushings and Pancreatitis, I'm in over my head and will just have to trust our vet.



I know that overwhelming feeling so I totally understand, please do not hesitate to ask any and all questions that you may have and we will do our very best to answer them, ok? ;)

Hugs, Lori

[TobyMama]

It has been a while since I posted. We tried 3 separate times to give Toby Vetoryl, but every time he ends up with diarrhea and greatly reduced appetite. The vet feels the Vetoryl is causing the problem. So we're now trying Anipryl. Any advice or things to watch out for? Thanks in advance for any help!

[molly muffin]

With Anipryl there should be no risk to low cortisol, which is what normally causes the loss of appetite.

I should say that anipryl doesn't work in all dogs on some and you don't need to do ACTH tests when on it, so that is a plus.

If he doesn't respond to the anipryl, and cortisol levels remain too high with symptoms remaining, then lysodren is an alternate possibility.

[TobyMama]

Thank you!! Any side effects anyone is aware of?

[Squirt's Mom]

Yes - Anipryl can cause some tummy upset so you will want to have some Pepcid AC (ONLY the AC form) on hand. That or some Tagamet. The generics of those are fine to use. ;) It can also cause some restlessness and anxious behavior in the beginning but most pups adjust quickly and that goes away.

Bear in mind, Anipryl works ONLY on dog with the pituitary form, it will not work at all on a dog with the adrenal based form. In order for it to work on the pituitary form, the tumor MUST be in the pars intermedia portion of that gland. To give you an idea of it's efficacy - 85% of cush pups have the pituitary (PDH) form and of that 85% only about 20-25% have the tumor in the pars intermedia so that means a very small population of our cush babies will benefit from Anipryl....and even then it usually works only for a short time. ;)

(and yes, unless it is Iatrogenic, which is caused by exposure to steroids, all cush pups have a tumor either on the pituitary or adrenal gland(s) )

Look into Lysodren so you are prepared if the Anipryl does not help. I am the odd man out in treatment for canine Cushing's and prefer Lysodren to Vetoryl. I am in the process of testing another of my babies to see if she has Cushing's and if she does I will go with Lyso if at all possible. ;) I don't care for "new and improved" - it rarely is in my book. :)

Hugs,
Leslie and the gang

[TobyMama]

Thanks, Leslie! I just now saw your response.

According to the various tests Toby had done, it looks like it is a pituitary tumor. And the Anipryl seems to be helping. Toby has been on Pepcid AC daily since the Cushings pushed his pancreatitis up.

I will look into Lysodren for the time Anipryl stops working. I really appreciate your insight and response!!

[Squirt's Mom]

I'm glad to hear the Anipryl is helping! Hopefully you will have the same luck with it that Squirt did and Toby will do well on it for several months to come.

[TobyMama]

My initial post was on 10/4/16, and here we are at 7/31/17. :)
Toby was diagnosed with kidneys beginning to fail in early February 2017. With "doggy dialysis" (subcutaneous saline) and continuing on Anipryl (and... flagyl, mirtazapine, Pepcid AC, and centrine), he has been doing so well!! ...until about a week ago.

His thirst has greatly increased, and the last couple of days, his afternoon and evening appetite is through the roof again. I'm thinking that the Anipryl has stopped its effectiveness. He also shows some signs of increased weakness, at times.

I'm writing to see if there are any specific signs to look for that pertain to a Cushing's dog specifically as I think he's deteriorating.

just heard from the vet... she's going to get his weight on Wednesday and run a blood panel. Possibly adjusting Anipryl. :)

thanks!

[molly muffin]

I think the blood panel is your best bet to find out what is going on. You want to check for diabetes, low or high cortisol, deteriorating kidneys.

[TobyMama]

I am SO grateful for every day I've had with my sweet boy since his diagnosis of Cushings and of kidneys beginning to fail... the vet gave him only a couple of months if the dialysis hadn't worked!! :)

Toby has continued on the Anipryl (15mg) (and the host of other meds to manage nausea and appetite). I was correct back in July that his increased thirst/appetite were symptoms of Cushings not being managed well-enough anymore on the Anipryl. Vet suggested added 50mg of Ketoconazole every other day, while monitoring for vomiting/nausea. He was doing better with that addition until mid-December. I increased his 50mg of Ketoconazole to 2 days on, 1 day off, and he was doing better until maybe 1 week ago. He's panting, ravenously hungry, gained some weight...

I have a call into the vet as to whether or not going to 2 days on/1 day off was acceptable (I just did it on my own, I'm embarrassed to say), and if we can go to once a day with it.

I hope this doesn't sound too morbid, but what does Cushing's do that causes death for a dog? Is it that they seem so uncomfortable that you put him down? Does is destroy/effect organs? Is there an article or post somewhere that I can read about the cause of death from Cushings? Thanks.

[labblab]

We’re so glad to hear back from you, and especially to know that you’ve been graced with these additional months with Toby. I’ll be keeping all fingers crossed that the trend continues!

As far as end-of-life issues associated with Cushing’s, they really can be quite variable as you probably already suspect. Cushing’s can cause problems on its own, or worsen pre-existing vulnerabilities, in organs such as the kidneys, heart, and liver. Not every dog will suffer serious organ damage, but that can be one serious outcome. Uncontrolled Cushing’s can leave dogs more vulnerable to infections of all sorts, so that can be another serious issue. Apparently a greater risk of blood clots can be associated with Cushing’s, so that can be a serious and even lethal problem. Muscle wasting and vulnerability to ligament damage can seriously impair a dog’s mobility. These are just examples, but the take-away is that there are a number of different kinds of problems that can afflict dogs who suffer from extended periods of elevated cortisol. And it may be one single serious problem, or a combination.

With my own Cushpup, prior to beginning treatment, he didn’t suffer from any one single “big” problem, but a whole host of different issues had completely compromised his quality of life. The excessive thirst/urination/hunger, extreme muscle wasting such that he couldn’t jump or climb, constant panting, flopping down continually on hardwood or tile to cool himself off, lethargy — all these things had left him just a shell of his former self. Honestly, if we had not started treatment, we probably would have released him at that point because his life just seemed so miserable. So it can be a lot of different things that can force an owner’s sad decision.

I don’t know if this helps answer your question. If not, please tell us more as to what you’re wondering about, OK? And in the meantime, please give Toby a big hug for me! He’s already dodged one huge bullet, and we’ll surely be hoping you can keep him stabilized so as to enjoy yet more time together.

Marianne

[TobyMama]

Marianne....

Thank you! That's exactly what I was looking for. He has dodged a big bullet... several, actually. His pancreatitis flared up at one point, then the kidney failure issue... I look at our trips to get "doggy dialysis" 3 times a week as an adventure for him! I always let him stick his head out the window... even in below-freezing weather (thanks to my heated seats and blanket for me!)

<3 <3 I will certainly hug Toby for you!!

Blessings to all who struggle with this for their dear pups!!

[molly muffin]

That is wonderful idea making the trips for dialysis an adventure. :) I love his avatar photo.