Almost 8 y.o. recently diagnosed, a few questions

[PaddysPerson]

Hello. My boy, Paddy, was diagnosed with Cushings right before Christmas. He had the ACTH test and results were sample 1 - 11.0 . And sample 2 was 21.2. Is it normal for the first one to be so high?

His ALP has been above normal for a few years now (since 1-2014) but that has been the only thing that was out of range. In the fall of 2013, he had a neck injury and took rimadyl for maybe a week or two, followed by prednisone for 10 days or so (not simultaneously). His vet attributed the elevation to that & prescibed adenosyl/Denamarin. His ALP was 140 previously and 1-2014 it was 449 & ALT was normal at 35. When it was rechecked the following July it had gone down to 301 and down to 278 after that. It would then fluctuate over next few visits. His doc said he was/ is overweight & could be fat deposits elevating ALP. His ALT went up a little but was still in normal range. Last July, ALP was up to 468, ALT 100. I took him to vet in October for not acting "right". ALP was 576 & ALT was up to 166. Referred to internist for an ultrasound. IMS said his liver is small and one side rounded. Didn't mention anything about his adrenal glands but took an aspirate from rounded side. He said it could either be cushings or age related degeneration. I didn't get the ACTH done til December. Vet said it was clearly Cushings. We (vet & I) decided to wait til after holidays to start vetoryl.

Scheduling/family issues (I don't drive & have hard time getting to vet) occurred & just getting ready to start vetoryl tomorrow. He is 23-24 lbs & will be taking 30mg once daily. I read here,though, to start at just 1mg/lb. I e-mailed Dechra & the response I got was 1-3 mg/lb & follow advice of our vet. I'm nervous about it. Paddy's doc works Weds- Fri and alternate weekends. I'm wondering if I should wait til next week when she'll be working more days. Just haven't met the other doctor yet.

The only symptoms I notice are weight gain and panting. He doesn't seem to drink that much & he's still a picky eater. His energy level isn't what it used to be.

Is there any other testing that should be done? Should I wait til next week to start the vetoryl, in case he has any side effects?

Thanks for any advice! I don't really have anyone to talk to about this and am always second-guessing things.

[Whiskey's Mom]

Hi & welcome to you & Paddy! He's such a cutie. :)
The experts will be along soon to answer your questions in more detail. But I wanted to say that I think you should wait to start the Vetoryl until you hear from them. This is based on my own experiences and what I've learned here. The people here are wonderful and very knowledgeable, and they'll be able to give you the best advice on how to proceed in caring for your sweet little guy.
You came to the right place for advice and support!
Annie and Whiskey

[labblab]

Hello, and welcome from me, too! I'm so glad that Annie had a chance to greet you already, because I do share some worries about starting Paddy off with the Vetoryl today, too. Even if the worries are laid to rest, I believe I'd hold off on starting until next week when your own vet will be more readily available in the event of questions or problems.

First of all, I am quite annoyed that Dechra gave you no dosing clarification beyond repeating the published (but outdated!) 1-3 mg. range. They seem to be very leery about stepping on the toes of vets, and since your vet has started you off on 30 mg., apparently they don't want to challenge that. Since Paddy weighs between 20-30 pounds, starting off with 30 mg. is not outlandishly high. But you will want to watch him carefully for any ill effects and be prepared to temporarily discontinue the Vetoryl if he appears unwell. Also, since you say that driving to the vet can be difficult for you, I believe you should ask your vet to provide you with some "rescue" prednisone to have on hand in case an emergency situation arises in which Paddy's cortisol drops too low and he becomes really ill. I would not start treatment without obtaining the prednisone, so that's another reason to wait until next week.

But backing up a bit, I always worry, myself, when dogs are diagnosed with Cushing's but don't exhibit many of the more common outward symptoms. Paddy's picky appetite especially concerns me, because most Cushpups have ravenous appetites. One of the benefits of Vetoryl treatment is to normalize excessive hunger. So in the case of a dog who is picky to begin with, it raises questions about the accuracy of the diagnosis and also the worry that the med may depress a picky appetite even further.

As far as the diagnostics, can you please give us the "normal" range for the ACTH results? For most labs, a post-ACTH of 21.2 is actually not super-highly elevated and might only fall within a borderline range. But the lab that performed Paddy's analysis may have a different range of norms, and it would help us to know what they are. As far as his first reading being high, yes it is high, but stress alone can cause elevations in baseline cortisol. So if Paddy is a dog who gets highly stressed at the vets, that could raise his baseline level, and it can also elevate the second reading as well. That's another reason why I'm wondering how far out of range that second reading actually was.

Also, I'd be very interested in the actual assessment of his adrenal glands on the ultrasound. It is not common for Cushpups to have adrenal glands that look totally normal on the imaging. It can happen, but usually only if the disease is in the very early stages. Typically, Cushpups will exhibit enlargement of the adrenals, and I'd want to know if that's the case for Paddy. It sounds as though the IMS was focused mainly on the liver abnormalities, which he said may -- or may not -- be Cushing's-related.

The bottom line is that it may indeed be the case that Paddy has Cushing's, and it is indeed true that for middle-aged dogs, you are hoping to stave off internal systemic damage that can result from chronic elevation of cortisol. But on the other hand, in the absence of typically observable symptoms such as excessive thirst, urination and hunger, it becomes much harder to monitor the therapeutic effect of the medication. Plus, there are always some question marks as to whether or not Cushing's is actually the culprit since other nonadrenal illnesses can result in "false positives" on the ACTH and also cause lab abnormalities.

I am very sorry if I am adding to your worries :o. But if it were me, I'd hold off on starting the Vetoryl until you've had the chance to talk with your vet further. I would tell her that I've been reading up on Cushing's so that I can be as well informed as possible. Based on what I've read, I'd like to know what the normal range was for the ACTH, and I'd like to know whether the adrenals were of normal size and appearance on the ultrasound. If so, does that not concern her that the diagnosis may be in question, especially since he doesn't exhibit excessive thirst/urination/hunger? Last but not least, if you do go forward with the Vetoryl, I'd basically demand that I be given some prednisone to administer in the event of overdose at a time when I couldn't get Paddy in immediately to be evaluated.

Marianne

[molly muffin]

Hello and welcome. I must say that Paddy is just a cutie pie!

I don't think there is anything that I could possibly add to what Marianne wrote as she covered all the bases of what would be my concern too.

With the cortisol Not being that high, and i'm curious about the range too, I'd personally prefer a low and slow approach, so I'd probably ask to start at a lower dose. I'm a worrier that way though.

[PaddysPerson]

Hi. I posted here about two years ago, after my dog Paddy was originally diagnosed with Cushings - not Atypical then.( I had been concerned about him being given 30mg of vetoryl since at the time he weighed @23 lbs. His vetoryl dosage has since been lowered to 10mg because of lower cortisol levels with ACTH tests.) His ALKP has been elevated since January 2014, thought to be result of having been on Rimadyl (I think that's the one. NSAID for neck pain previous Fall/Winter) and prednisone for a month or so. He started taking Adenosyl/Denamarin after that. At some point, it did lower a bit but went back up. Oct. '16 ALT also was higher than norm (ALKP 576 ALT 166) His doc recommended an ultrasound. The IMS said it could be Cushings. He had the 2 hour ACTH test in Dec. '16/Jan. '17. Pre was 11.0 & Post 21.2. I didn't start him on Vetoryl until late Feb. '17.

His ALT lowered but ALKP continued to go up. GP & IMS said sometimes it just takes awhile for it to go down & in some dogs with cushings, it just stays elevated. Also thought he could have sludge in his gallbladder.

In July '18, his ALKP was 1967. In Jan. '19, ALKP 3288! ALT was 135. So we went back to IMS for another ultrasound (the 3rd or 4th one). He also did another aspirate. IMS said no inflammation of his liver, no sludge in gallbladder. Still looked like "vacuolar hepatopathy." Cytology "suggestive of steroid hepatopathy". He said to do another ACTH test, given IV instead of IM as usual. (Paddy's ACTH test in January was pre 3.1 post 3.1) The results of ACTH in Feb. '19 , given IV, were pre 2.1 post 3.6. IMS suggested to check for Atypical (2nd option was a liver biopsy). So in March, UTK stim test was done.(Vetoryl given w/food @ 4hrs before as norm). We got the results last week. Cortisol is good/optimal. His androstenedione and 17 OHP are both elevated and baseline progesterone also (but not post on that one). IMS said to discontinue vetoryl and to instead give 3mg melatonin twice a day. Then recheck in a couple of months.

Is the melatonin alone enough to lower those two hormones? The IMS had previously also mentioned lignans. And I've also seen that some dogs with atypical are on lysodren ( although I'd prefer not to. I wish I hadn't given vetoryl now) Also, where should I get the melatonin? Any brand that's better quality? Also, what about side effects of melatonin? I think I read it can cause headaches or that there is an issue with giving it during the day..? Is there any interaction with Denamarin or Dasuquin?

Here are the results from UTK (just cortisol & the elevated ones) :

Test.....Baseline...Normal Range....Post....Normal Range

Cortisol ug/dL 3.6 <1.0-5.6 5.1 7.1-15.1
Andro. ng/ml 4.13 0.05-0.36 3.69 0.24-2.90
Progest. ng/ml 0.71 <0.20 1.12 0.22-1.45
17 OHP ng/ml 2.71 0.08-0.22 4.07 0.25-2.63

The ranges of the lab that usually does his ACTH are
baseline 1.000-5.000 ug/dL post 8.000-17.000 ug/dL.

Sorry if I've been long-winded. I also want to apologize for not following up with you all after my first post. I did read your replies & appreciated the advice.

[labblab]

Welcome back to you and Paddy! You’ll see that I’ve combined your new post with your original thread — this way, all of Paddy’s information and history will be consolidated in one place. I’m afraid I’m short of time this morning, so I’ll need to wait until another time to write more. But definitely, we’re glad to see you back and we’ll do our best to try to help some more.

Marianne

[Squirt's Mom]

Atypical Cushing's is a form in which the cortisol is NORMAL but two or more of the intermediate, or sex, hormones are elevated. Since Paddy was taking Vetoryl for Cushing's a normal reading on the UTK test is expected if the drug is prescribed at the right dose and properly given (with food). Studies have shown that Vetoryl CAUSES elevations in some of the intermediates so running the UTK panel at this stage of the game was really a waste of money. Now if the Vetoryl has consistently been causing his cortisol to be TOO low and the original diagnosis of Cushing's was in question, then stopping the drug and then checking the intermediates might have made sense to me. Regardless, you don't stop giving the Vetoryl, or Lysodren, just because there are elevations in those other hormones if the diagnosis of conventional Cushing's, with elevated cortisol, was accurate - you give the melatonin and lignans with the Vetoryl or Lysodren. And it is the combination of melatonin and lignans that work on the intermediates - giving one or the other alone will not work. So I highly question the IMS' understanding of Atypical Cushing's. UTK does not recommend using Vetoryl in Atypical pups but prefers Lysodren because of the studies that show Vetoryl causes those elevations. It is feasible that Lyso also could cause elevations in the intermediates but I don't know of any studies supporting that. So all in all I am confused about what the IMS was hoping to achieve with the UTK panel as well as telling you to stop the Vetoryl and use melatonin only.

[PaddysPerson]

I listened to voice mail from IMS again today & may have misunderstood him. He said it would be the wrong thing to RAISE the vetoryl dose, even though ALKP keeps going up. I'll call tomorrow to be sure..sounds like Paddy should continue with it. I think I've read here and elsewhere that lysodren is better, though, right? But there should be a month off before switching to the other.

Not sure if I need to post these but here are results from his ACTH since he was first tested. Feb. '19 was done IV & rest are IM.
Baseline normal range is 1.000-5.000 ug/dL & post normal range is 8.000-17.000ug/dL

2/19 pre 2.1 post 3.6
1/19 3.1 - ( I think there was no change)
10/18 4.6 5.8
7/18 2.6 3.8
2/18 3.3 4.5
11/17 2.9 4.1
4/17 5.5 6.6
3/17 6.6 8.3
12/16 11.0 21.2

He still doesn't drink alot (I measured within the past month & he drank @ 1 cup, along with eating rice). He lost a few pounds last year but put some back on when I switched to an rx liver diet in July (no longer on that). He doesn't have a pot belly. His fur may be a little thinner o.n his torso, right behind front legs. It's a little thin on his forehead. He does pant alot, but not everyday. I wouldn't call his appetite ravenous...maybe impatient?

He had back surgery when he was three,surgery for a torn ACL in 2015, and in May 2017 tore another. For the second one, I decided to just do crate rest instead of surgery. He had been taking vetoryl for a few months then & his ALKP was @870, I was afraid for him to have it.

I just wish we could get his ALKP to go down. Everytime he gets bloodwork..can't believe how high it is. How freaked out should I be?

-Jennifer

[Harley PoMMom]

With a post of 3.6 ug/dl you definitely don't want to raise his Vetoryl dose. If the ALT isn't elevated, I wouldn't worry too much about the high ALP, sometimes this enzyme never returns to normal even with treatment. Many of our members use a liver supplementation such as milk thistle, Denosyl, Denamarin, or SAM-e.

Regarding that Lysodren is safer than Vetoryl, that is not true, some dogs just do better with one drug treatment than the other medication. If you do plan on switching, though, there should be a wash-out period of one month.

Hugs, Lori

[molly muffin]

I agree, I wouldn't raise the vetroyl as his cortisol seems to be doing well on that, but his ALKP isn't. Most of the time, yea, they think it is sludge in gallbladder or liver, something else then causing the alkp to keep rising. But seems that you have ruled that out, so maybe the supplement option would help. I tried all of them, and I think did help some. I like the denamarin, as had the sam-e in it also if I remember correctly.

[PaddysPerson]

I heard back from the IMS office today/yesterday. He said to continue with 10mg vetoryl, add 3mg melatonin twice per day. HMR lignans not indicated since estrogen not elevated. At some point, may need to switch to lysodren but at this time that's also not indicated. Recheck cortisol (and ALKP?) in 4-6 weeks.

A few questions about melatonin..will it also lower cortisol? Is there more chance of levels getting too low? I'm still going to give both, but just want to know if I need to keep more of an eye on that. Also, any certain type? The K9 brand of melatonin flavored chewables, are those ok? Do I give at same time with vetoryl?

An ALKP of 3288 doesn't seem too high? Normal range is 23-212 u/L. His ALT was also elevated in January - 135, normal 10-125 u/L. He's been taking adenosyl/Denamarin for 4 years now - 8 hours after eating, 1-2 hours before he eats, I do have to give him a teeny bit of chicken with it, though. IMS has mentioned liver biopsy if ALKP doesn't go down...really don't want to have to do that.

Thank you all so much for your advice so far.

[labblab]

Thanks so much for returning and clarifying the new treatment instructions. As far as melatonin, I don’t have personal experience with it, but these are the only real instructions that I found on UTK’s website in relation to melatonin “type”:


Regular melatonin is usually used rather than rapid release or extended release products.

So hopefully the canine chewable that you’ve found will fit that bill. I believe melatonin does have the ability to modestly lower cortisol. I doubt this will present an issue, but it would be a good question to clarify with the IMS. I’d be interested in hearing his response.

Yes, Paddy’s ALKP is certainly high, but as others have said, we’ve seen very high levels in other Cushpups, too. I know it’s hard to sit by and feel worried about lab abnormalities such as these. So hopefully you may see some improvement soon. Please do keep us updated.

Marianne

[PaddysPerson]

Hi again, everyone.
So..... Paddy is still taking 10mg vetoryl once daily & 3mg melatonin 2x. His ALP is still really high. September 2021 it was around 2500. Last month, it was 3400 (diluted?). He also has had tightness in his tummy. His GP recommended another ultrasound which showed that his liver and prostate are both enlarged. And he's neutered, in case I forgot to mention that earlier. So......I guess I'll try to post results from some of tests. First is the stim test from UTK in 2019 :

TEST - RESULT (Baseline) / Normal Range (Baseline)** / (Post ACTH) / Normal Range** (Baseline Post-ACTH)
Cortisol vg/dL : 3.6 / <1.0-5.6 / 5.1 / 7.1-15.1
Androstenedione ng/ml : 4.13* / 0.05-0.36 / 3.69* / 0.24-2.90
Estradiol pg/ml : 45.7 / 23.1-65.1 / 47.2 / 23.3-69.4
Progesterone ng/ml : 0.71* / <0.20 / 1.12 / 0.22-1.45
OH Progesterone ng/ml : 2.71* / 0.08-0.22 / 4.07* / 0.25-2.63
Testosterone ng/dL : <15.0 / <15.0-24.0 / <15.0 /<15.0-42.0
* Above or below reference range **Mean normal range values for neutered male dogs

"These results:
[x] indicate presence of increased adrenal activity (mild).
[] indicate presence of adrenal hypofunction.
[] are within normal limits.
History: on trilostane; Cushing's is well controlled but liver values>>; Note: If on Trilostane (Vetoryl), suggested post-ACTH cortisol is 1.4-9.1 ug/dl
Comments:
. Five out of twelve values are elevated from marginal to significant. This increase in adrenal
activity indicates a mild hyperadrenocorticism (HAC). This hormonal pattern has been observed after a prolonged therapy with trilostane (Vetoryl). Vetoryl is effective in controlling, however it may cause iatrogenic elevation of some sex steroids (See items 7, 6 and 5 attached sheet)."

Results from first ultrasound aspirate (2017)
DESCRIPTION
Eleven smears made of needle aspirates from the liver of a 7-year old M/C Shih-Tzu. Hx: Presented for increased liver enzymes. On abdominal ultrasound the liver is slightly hyperechoic. No masses noted; remainder of ultrasound is WNL.
The smears have similar findings and contain a varied number of hepatocytes, with many erythrocytes. Most of the hepatocytes are found in large clusters, they are polygonal in shape and have round nuclei with a moderate amount of medium blue cytoplasm that often shows moderate cytoplasmic clearing. Some hepatocytes also have a large cytoplasmic accumulation of dark grey green granular material (bile pigment or lipofuscin). Occasional macrophages are seen that also contain a large amount of this pigmented material. No bile plugs are evident. Neutrophils and small lymphocytes are seen in numbers consistent with blood. A few well-granulated mast cells and rare plasma cells are present. There is a moderately heavy background of proteinaceous material with a moderate number of bare nuclei and scattered bits of particulate material. No infectious organisms are seen.
OPINION
Moderate vacuolar hepatopathy; the appearance of the hepatocytes (cytoplasmic clearing) is consistent with either an intracellular accumulation of glycogen or hydropic degeneration (a nonspecific indicator of cell damage). Biopsy with histopathology is suggested for more information.

And here are ultrasound results from a few weeks ago:

SITE COLLECTED? Liver
DESCRIPTION
Five slides of a fine-needle aspirates of the liver from a 12-year-old, MC, Shih Tzu ("Paddy") are examined. Clinical History: "Clinically normal dog long-term, RX for Cushing cortisol levels good not PU/PD but ALP still severely increased, previous FNA liver - vacuolar hepatopathy; abd U/S today - enlarged hyperechoic liver no mass; mild particulate matter in GB; enlarged prostate/LN not previously seen 2x2 cm homogenous".
All the slides have similar findings. There is moderate cellularity and moderate to marked amounts of blood. There are several hepatocytes, occasional macrophages, and occasional lymphocytes (predominantly small and fewer medium-sized). The hepatocytes are seen in variably-sized clusters and occasionally scattered singly. The hepatocytes are polygonal, with moderate amounts of cytoplasm and variably distinct cytoplasmic borders. The cytoplasm is medium blue, with mild to moderate cytoplasmic rarefaction and occasionally contains a few dark blue-black granules (bile and/or lipofuscin). The nucleus is round, measures 1-1.5x the diameter of a neutrophil with coarse chromatin and 1-2 prominent nucleoli. There is mild anisocytosis and anisokaryosis. Occasionally these cells are binucleated. The macrophages are slightly vacuolated and contain a small amount of cellular debris. The background is light blue, proteinaceous, with occasional ruptured/free nuclei and a small amount of blood.
OPINION
1. Moderate vacuolar hepatopathy (glycogen-type) in hepatocytes 2. Mild lymphocytic infiltrate
Cytoplasmic rarefaction can be seen with either endogenous or exogenous increased corticosteroid hormones or hydropic degeneration. The lymphocytic infiltrate could represent a reactive process or could be also seen in older dogs. The number of neutrophils present is subjectively increased. A CBC can be performed for more information.

SITE COLLECTED? Prostate
DESCRIPTION
Five slides of fine-needle aspirate preparations from the prostate of a 12-year-old, MC, Shih Tzu ("Paddy") are examined. Clinical History: "Clinically normal dog long-term, RX for Cushing cortisol levels good not PU/PD but ALP still severely increased, previous FNA liver - vacuolar hepatopathy; abd U/S today - enlarged hyperechoic liver no mass; mild particulate matter in GB; enlarged prostate/LN not previously seen 2x2 cm homogenous".

There are many cells that have a grey-blue cytoplasm and a smudged nucleus. One of the slides contains rare atypical epithelial cells are seen in small accumulations and occasionally scattered singly. These cells are polygonal to oval with small to moderate amount of light blue cytoplasm and variably distinct cytoplasmic borders. The nucleus is round, measures 1-2 x the diameter of a neutrophil with coarse chromatin and occasionally one prominent nucleolus. There is mild to moderate anisocytosis and anisokaryosis. Rare binucleation is noted. The macrophages are slightly vacuolated and contain a small amount of cellular debris present. The background is light to medium blue, necrotic and occasionally contains round colorless vacuoles.
OPINION
probable carcinoma and abundant necrosis.
The presence of cellular atypia and the extensive necrosis in aspirated from a mass is most consistent with a neoplastic process. However, the number of intact cells available for evaluation are too few in number to allow for a more definitive diagnosis. Consider resampling the area surrounding the edge of the mass for cytologic examination, or perform a biopsy with histopathologic evaluation for further information and characterization.

Hopefully, I've copied everything to where it's easy to read. I thought I'd include cytololgy results. Honestly, I don't really understand the descriptions of their findings.....only that "c" word descibing his prostate...

The IM has suggested Finasteride because of Paddy's high androgens? (2019), to shrink the prostate, re-checking in a few months. Getting another ACTH from UTK first, though, just to see his hormone levels. That's happening within next few days.

Any advice you all have would be greatly appreciated. Questions for the IM? Does anyone have any experience with Finasteride - interaction with vetoryl? In my googling I found something about it possibly causing diabetes and/or blood clots? Alot of times the information can be overwhelming & hard for me to understand.

[labblab]

Welcome back to you and Paddy! We’ll definitely be interested in seeing the results of the UTK stim test when you receive them. I’m assuming that he has had intervening monitoring ACTH tests of his cortisol alone since 2019? How have they been looking in terms of his cortisol control? If his cortisol has been running on the higher side, that might explain the continuing increase in his ALP. However, if his cortisol has remained well controlled, then something else may be contributing. As far as the elevations of his other adrenal hormones, we’re indeed aware that Vetoryl can play a part in that. However, after almost 20 years of trilostane treatment with Cushpups, I believe the jury is still out as to whether there’s any genuine issue that may arise from that as opposed to simply being “it is what it is.”

Out of all the helpful information you’ve given us, it sounds to me as though the prostrate condition is the most immediately important, especially in the presence of the cancer cells. However, it doesn’t sound as though your vet is urgently worried about that, so perhaps the type of cancer that’s involved is not particularly aggressive, especially since it doesn’t sound as though he’s suggesting surgical intervention. I’m afraid I’m not very knowledgeable at all about prostate issues, and I’m totally unfamiliar with Finasteride. So you’ll be doing us a service if you help to educate us as you learn more yourself.

I wish I could be more helpful to you right now, but it sounds as though we’re all kind of in a “wait-and-see what the results are” mode. However, as I say, any info about Paddy’s intervening monitoring cortisol tests will be helpful. And also, how’s he been doing in terms of any observable Cushing’s symptoms?

Marianne

[PaddysPerson]

It's taking longer to get results from UTK. As I understand it, there's only one dr who's reading/typing the results. So,.....

The weekend after Paddy had the ultrasound, he did start drinking and peeing alot more. His water bowl is small and he would empty it, I would refill & he'd drink it all again. Before, he'd drink the most after eating. His poop was different, too - some small & thin or just softer than norm. I did start to restrict his water by only filling the bowl 1/3 or 1/2. His poo got more normal looking.

I'm not sure where to start,but his teeth are not in good condition (my fault) and last week his appetite wasn't as good. It got to where the last few days, I could barely get him to eat anything - not even rotisserie chicken. I tried to inspect his mouth & was pretty sure he had/has a sore on his inner cheek so made an appointment with his regular vet for yesterday. They couldn't get a good look at the sore but said he would probably need to to go to the dentist & have a few teeth pulled :( . He was given an antibiotic shot, Covenia, & an appetite stimulant, Mirtazapine. Because he's been so thirsty lately & his eyes IMO look to be more cloudy recently, I asked what they would have to do to check for diabetes. They did a quick test ( & also took a urine sample to be sent to lab) Well his glucose was 445.000 mg/dl (Lab range 70.000 - 143.000 mg/dl) It was 137 in mid March.

They showed me how to give him an insulin shot, that he has to have food first, and after week he will have to go back to be tested throughout the day.
I wasn't able to give Paddy the shot when we got home because of the eating problem ( & I'd like to give it earlier while the vet is still open). He got the Mirtazapine & I waited a couple of hours before trying to feed him (We got 2 rx foods. One is for diabetes & the other is Royal Canin recovery) Tried just a few spoonfuls of the recovery one and he ate it right away. I was so relieved that I brought him some more, but he wouldn't eat it. Several hours later, tried again & he still wasn't having it (he did eat a teeny bit of a chicken nugget,though). To "remind" him that it tasted good, I just put some food in his mouth a couple of times & he did eat all of it (only 1/8c because I'm afraid after not eating anything & then getting antibiotic, he'll have diarrhea).

I'm worried I won't be able to get him to eat enough to give the insulin shot today though, especially since the appetite stimulant wasn't given until late afternoon yesterday (if that makes sense?) And should I give the recovery or diabetic food?
Nothing can be done about his teeth until the diabetes is under control or whatever. Not that I really wanted Paddy to have to go through that, I just want him to feel better & to feel like eating. I just........ :(

Should I have asked for a pain med for his mouth? Is the antibiotic enough for right now?
I'm also wondering how I should schedule his other meds around the insulin - melatonin (2x) & vetoryl (1x). I usually feed him 3 smaller meals per day. And still waiting to hear from IMS about UTK results & figure out prostate and Finasteride.

[Squirt's Mom]

I wish I could help but I am not familiar enough with diabetes to be comfortable in commenting. I do know it is important that they eat in order to get the shot. Since he is not feeling well that may be more difficult than normal. I am going to give you a link to our sister site, K9Diabetes and want you to go talk to them. The forum may not be very active but they have tons of info on their site and if you are on Facebook they have a group there I can give you the link to. Here is the link to the forum:

https://www.k9diabetes.com/forum/

Here is the link to the K9diabetes FB group:

https://www.facebook.com/groups/CanineDiabetesSupportandInformation

Please jump on over there and start talking. They are the experts in canine diabetes.

Please do let us know how things are going with your precious Paddy.
Hugs,
Leslie

[labblab]

Hello again from me, too! I’m afraid, though, that I’m in the same boat alongside Leslie — I don’t have enough knowledge about diabetes to offer you advice about that. I’m sooooooooo glad she gave you the links to the canine diabetes groups, though, and I’m hopeful you’ll be able to get some helpful support from the folks there.

I’m so sorry that Paddy had these added issues to deal with. They’ve got to be hard for both of you to handle! Even though we may not be able to offer much advice about the diabetes, we’ll still be anxious to get updates on how you’re doing. So please do let us know.

Best wishes,
Marianne

[PaddysPerson]

Update on Paddy- Paddy is scheduled to have teeth extractions tomorrow. His diabetes and insulin have been my main concern. But is there anything I need to keep in mind in regards to Cushings? He had a CBC done this past week. His ALP that had been in the 3000's in March is now down to 1144. He also had a stim test done - sample 1 was 4.4 & sample 2 was 4.7 (also, I don't think it was timed as usual. It wasn't planned for that day.) I guess I'm just posting results of his bloodwork here in case anything stands out as an issue. His vet did give an rx for Clindamycin for his mouth/teeth.

ALB/Glob Unknown 0.500 0 - 0
Albumin (ALB) Normal 2.500 g/dL 2.200 - 3.900 g/dL
Alkaline Phosphatase (ALKP) Above Normal 1144.000 U/L 23.000 - 212.000 U/L
ALT/SGPT (ALT) Normal 88.000 U/L 10.000 - 125.000 U/L
Basophil Normal 0.060 10^9/l 0.000 - 0.400 10^9/l
Basophil, % Above Normal 1.200 % 0.000 - 1.100 %
Bilirubin, Total (TBIL) Normal 0.300 mg/dL 0.000 - 0.900 mg/dL
BUN (Blood Urea Nitrogen) Normal 23.000 mg/dL 7.000 - 27.000 mg/dL
BUN/Crea Unknown 39.000 0 - 0
Calcium (CA) Normal 9.800 mg/dL 7.900 - 12.000 mg/dL
Chloride (CL-) Normal 112.000 mmol/L 109.000 - 122.000 mmol/L
Cholesterol (CHOL) Normal 319.000 mg/dL 110.000 - 320.000 mg/dL
Creatinine (CREA) Normal 0.600 mg/dL 0.500 - 1.800 mg/dL
Eosinophil Normal 0.170 10^9/l 0.000 - 0.800 10^9/l
Eosinophil, % Normal 3.700 % 1.000 - 18.000 %
Gamma Glutamyl Transferase (GGT) Normal 0.000 U/L 0.000 - 11.000 U/L
Globulin (GLOB) Above Normal 4.800 g/dL 2.500 - 4.500 g/dL
Glucose (GLU) Above Normal 583.000 mg/dL 70.000 - 143.000 mg/dL
Hematocrit (HCT) Normal 39.850 % 37.000 - 55.000 %
Hemoglobin (HGB) Below Normal 11.100 g/dl 12.000 - 18.000 g/dl
Lymphocyte Below Normal 0.470 10^9/l 1.000 - 4.800 10^9/l
Lymphocyte, % Normal 10.000 % 9.000 - 47.000 %
MCH Below Normal 19.400 pg 19.500 - 24.500 pg
MCHC Below Normal 27.900 g/dl 31.000 - 39.000 g/dl
MCV Normal 69.000 fl 60.000 - 77.000 fl
Monocyte Normal 0.240 10^9/l 0.200 - 1.500 10^9/l
Monocyte, % Normal 5.100 % 2.000 - 12.000 %
MPV Above Normal 12.000 fl 3.900 - 11.100 fl
Na+/K+ Unknown 25.000 0 - 0
Neutrophil Normal 3.760 10^9/l 3.000 - 12.000 10^9/l
Neutrophil, % Normal 80.000 % 42.000 - 84.000 %
Osmolality Unknown 315.000 mmol/kg 0 - 0 mmol/kg
PCT Normal 0.320 % 0.150 - 0.390 %
Phosphorus (PHOS) Normal 4.800 mg/dL 2.500 - 6.800 mg/dL
Platelet Count (PLT) Normal 267.000 10^9/l 165.000 - 500.000 10^9/l
Potassium (K+) Normal 5.800 mmol/L 3.500 - 5.800 mmol/L
Protein, Total (TP) Normal 7.400 g/dL 5.200 - 8.200 g/dL
RBC Count (RBC) Normal 5.750 10^12/l 5.500 - 8.500 10^12/l
RDW Normal 18.800 % 14.000 - 20.000 %
Sodium (Na+) Below Normal 142.000 mmol/L 144.000 - 160.000 mmol/L
WBC Below Normal 4.700 10^9/l 6.000 - 17.000 10^9/l

[labblab]

Welcome back, and good luck to you guys today! Thanks for posting all this info, and unless I’m missing something, I don’t see anything of significance on the Cushing’s front. His ACTH stimulation test results look very good. So I surely hope that all will go well with his extractions today. I know you’ll be glad once that’s behind you.

Best wishes,
Marianne

[PaddysPerson]

Hi. Just to update re Paddy's teeth extractions - it went well.He had 9 teeth extracted on his left side and was scheduled to have seven more removed from right side a month later. That didn't happen,though, because Paddy had an issue urinating, not wanting to eat, and had to stay at ER for a few days. I posted more details on diabetes site. The IMS at the ER looked at results from stim test from April (showed atypical cushing's) and discontinued the vetoryl . So Paddy has been off that for about a month now. I'm not sure if the plan is to start him on lysodren or not.Are lignans and melatonin an alternative for atypical? We see the IMS this week to have a sensor put on for Paddy's diabetes. I'm not sure if the cushing's is something that's being addressed then... we've also seen an oncologist recently and are trying to decide about treatment for his prostate.

[labblab]

Welcome back to you and Paddy. I’m very relieved to hear that the extractions went well. But I’ve just now read your updates on the diabetes forum, and I’m sorry to see that the cancer issue is an increasing concern for you two. Given all of Paddy’s recent problems including his lack of appetite and difficulty urinating, I can’t argue with the decision by the IMS to at least temporarily discontinue Paddy’s Vetoryl. As far as giving lignans and melatonin for the elevations in Paddy’s other adrenal hormones, I doubt that lignans will be recommended since Paddy’s estradiol was still within normal range last April. That’s the hormone that lignans is most useful for. The IMS may continue with the melatonin for the other elevations. My understanding is that melatonin may also have a mild effect in lowering cortisol, although nowhere as great as the effect of Vetoryl.

I’ll be very interested in finding out what the IMS recommends on this next followup visit. Until then, please give Paddy a big hug from his friends here, and I surely hope he starts feeling better!

Marianne

[Squirt's Mom]

I haven't read your posts on the diabetes site but am familiar with Atypical Cushing's. That is what my Squirt started out with. Atypical is a form in which the cortisol is NORMAL but 2 or more of the intermediate hormones are elevated. The only place I know of that tests for this form is the University of Tennessee in Knoxville so if labs weren't run by them there can be no diagnosis of Atypical. The cortisol is the key - if it is elevated then the dog has conventional Cushing's, not Atypical. The intermediate hormones will be elevated in most cush pups so they aren't diagnostic in and of themselves for Atypical

UTK used to say that they preferred Lysodren for Atypical pups if the cortisol did start to rise. This is because Vetoryl/Trilostane has been shown to cause elevations in these other hormones while Lysodren controls them with the possible exception of estradiol. Estradiol can be produced in some odd places like hair follicles and Lyso works ONLY on the adrenal glands. So if this hormone is elevated then the only thing that reach it is the combination of lignans and melatonin. One or the other won't help.

I will be interested in hearing what the IMS plans for Paddy. I am very glad the extractions went well!
Hugs,
Leslie

[PaddysPerson]

I just realized I never posted the results of Paddy's last UTK stim test (from April). It took nearly a month to get them.

TEST - RESULT (Baseline) / Normal Range (Baseline)** / (Post ACTH) / Normal Range** (Baseline Post-ACTH)
Cortisol (C) ug/dL : 6.7* / <1.0-5.6 / 7.8 / 7.1-15.1
Androstenedione (A) ng/mL : 2.48* / 0.05-0.36 / 3.74* / 0.24-2.90
Estradiol (E) pg/mL : 59.7 / 23.1-65.1 / 56.2 / 23.3-69.4
Progesterone (P) ng/mL : 1.22* / <0.20 / 1.99* / 0.22-1.45
17-OH-Progesterone (17OHP) ng/mL : 5.11* / 0.08-0.22 / 6.94* / 0.25-2.63
Testosterone (T) ng/dL : <15.0 / <15.0-24.0 / <15.0 /<15.0-42.0
* Above or below reference range **Mean normal range values for neutered male dogs

Paddy isn't taking anything for his cushings since the vetoryl was discontinued in December.The internist who is handling his diabetes now says that he needs to see someone for his cushings since that could be contributing to his high glucose. The only option is Lysodren, right? I'm still trying to decide if we should do chemo for Paddy's prostate (oncologist recommended vinblastine). I don't think radiation is an option as Paddy would have to be sedated every day for five days, staying at the hospital.. and the cost also seems to make it out of reach. The only treatment he's getting for his prostate right now is an nsaid (piroxicam) and a supplement someone recommended (turkey tail mushroom). He's lost alot of weight since the spring. How worried should I be about starting lysodren and chemo so close to the same time? I'll be calling the oncologist this week to ask about his cushings (that's what our regular vet instructed) and will also need to discuss chemo again before I make a decision about that.

I'm not sure if Paddy's cushings could've been atypical from the beginning or if it was caused by the vetoryl..? I think the first time the UTK test was done was in 2019. One of the IMS told me to discontinue the melatonin in June or July because of possibly preventing insulin from working.

Thanks, Marianne & Leslie, for your help. I get really confused & overwhelmed trying to figure all of this out.

[Harley PoMMom]

How is Paddy's appetite? Lysodren is only recommended for cushdogs that have a ravenous appetite because the dog has to go through a loading phase, and the one of the most important things to watch out for when loading with Lysodren is a change in that hunger. Maybe a lose dose of Vetoryl could be an option, however, right now I believe that keeping him off all Cushing's medications would be better since Paddy may be starting Vinblastine, which I see that gastrointestinal problems are an ill side effect and those cushing medications can cause the same issue.

I'd definitely discuss all your worries and questions with the oncologist and please do let us know what is said, thanks! Give some gentle hugs to Paddy from me and there are huge loving hugs for you as well.

More hugs, Lori

[labblab]

Lori has asked the first question I have on my mind, too -- has Paddy's appetite normalized again yet? And how about his ability to produce urine? I realize his situation is really complicated, and you are having to balance a lot of considerations. It would be hard for any of us to figure out the best path forward right now! But it also seems to me that if the specialists think the Cushing's medication needs to be restarted, that going back on the Vetoryl would be the preferred choice for him right now. It's true that Vetoryl can cause elevations in adrenal hormones other than cortisol, but I don't believe it's been established that those elevations necessarily cause genuine problems for all dogs, as long as elevated cortisol is under control. And given Paddy's current situation, I think resuming his Vetoryl would be the preferred medication choice over Lysodren.

Having said that, I would think there would be reservations about giving *either* Vetoryl or Lysodren to a dog that is observably unwell -- not eating and not urinating properly. I realize that controlling his glucose level is super important, but if Paddy is not eating or urinating properly, there could be dangers in giving him any additional meds right now, especially in conjunction with the chemo. So I do think it'll be important to find out what the oncologist has to say about all this. And we'll be very anxious to find out right alongside you.

Marianne

[Squirt's Mom]

Another thought is that any testing for Cushing's would not be reliable in my opinion. This is because everything sweet Paddy has going on is causing stress in the body. Any time the body is stressed the cortisol rises in a natural response to the stressor to help the body cope. So it is very likely that any test for Cushing's will come back positive but is that result trustworthy? I have had 2 dogs misdiagnosed with Cushing's because they both had other health issues going on at the time of testing. One did eventually develop Cushing's but the necropsy on the second one proved she never had it...her adrenal glands were perfectly normal even tho she had not had treatment for some time.

And I agree with Marianne and Lori...the appetite and urination are important in both diagnosing and treating Cushing's. The medication chosen could cause more problems than it helps. I wish I knew the magic solution to offer but I simply don't. Lori has it right...I would discuss everything with Paddy's oncologist and let him/her direct you.

We are with you no matter what path you choose.
Hugs,
Leslie

[PaddysPerson]

I haven'y spoken with the oncologist yet... I feel like when I do I'll have to also make a decision about the chemo but I'll call them before weekend. They're at Auburn U. as that is the closest one. Also trying to find holistic vet for herbs,etc...maybe accupuncture?
Paddy's appetite has been better - knock on wood - since having those teeth extracted.He had sores on his inner cheeks from rubbing his face and the tarter :( . Now, he'll bark at me sometimes if I take too long getting his food ready. He does strain when he pees, though. And some days he poops alot (like, 7 or 8 times). I'm not sure what to do about the weight loss. I don't know how to help him gain weight since the food he's on is rx/ low carb etc for diabetes. I've spoken to Paddy's gp vet and the IMS he's seeing now & no one really has answers or they tell me to talk to one of the other vets. No nutrionist at Auburn either but I'll ask them again about his diet & weight.
Does anyone feed their pup Dr. Harvey's? I'm trying to give Paddy that along with his regular food (supposed to be good for diabetes & cancer). Instructions are to add oil along with choice of protein. I've read that krill and fish oil are blood thinning,though, same thing for digestive enzymes. Worries me...
I really do appreciate all of your kindness and help.

[Harley PoMMom]

There are people known as veterinary diet nutritionist who specialize in canine nutrition. I used Monica Segal but there are others such as Dr. Rebecca Remillard.

Dr. Remillard also has a website http://www.petdiets.com (http://www.petdiets.com/) where she does offer consultations and formulation of diets for pets with medical conditions.


Monica Segal:
Monica Segal is certified in Animal Health Care through the University of Guelph with studies in animal nutrition,physiology, diseases and parasites, as well as pet care.
She writes featured articles in many publications throughout North America. Monica conducts seminars and workshops by invitation, hosts an Internet discussion group at K9Kitchen, and authored a book called "K9 Kitchen, Your Dogs' Diet: The Truth Behind The Hype," published in June 2002. Her second book, "Optimal Nutrition" inlcudes a foreword wrtten by Ana Hill DVM, PhD and was published in 2007. Monica lives in Toronto, Canada, with her husband Morley and dogs, Cassie and Tori.

http://www.monicasegal.com/

Monica is also an administrator of a facebook group that deals with canine nutrition : https://www.facebook.com/groups/K9Kitchen/

Leslie, Squirt's Mom, has had diets formulated for her furbabies as well and I'm hoping she will be along to advise you too.

Love and hugs,
Lori

[Harley PoMMom]

I'm trying to give Paddy that along with his regular food (supposed to be good for diabetes & cancer). Instructions are to add oil along with choice of protein. I've read that krill and fish oil are blood thinning,though, same thing for digestive enzymes. Worries me...
I really do appreciate all of your kindness and help.

Oil alternatives could be flaxseed, coconut, or avocado?

[Squirt's Mom]

I highly recommend Monica and her protege', Jody Zesko. Monica isn't taking as many new clients as she used to but was still taking some last I talked to her about a year ago. Jody has formulated the diet I'm feeding my Tilly. Jody's business is called Spot On Nutrition and her website is-

https://www.spotoncaninenutrition.com/

Both Jody and Monica design the diet for YOUR dog...it's not a general diet but specific based on your dog's lab work, breed, age, etc. Both do home cooked, mixed (commercial with toppings/additions), and raw diets...but I am not a fan of raw ESPECIALLY in any dog whose health is compromised in any way but many think it is the only way to go. You can't go wrong with either of these ladies. There is one person I will tell you to stay away from. She is knowledgeable but extremely unreliable...that is Cat Lane with The Possible Canine. I studied under her for several years and know her well. ;)

As for adding oil....I think I would wait until I knew more about what the future held before I took that step. Most oils are beneficial but as you have learned some do have some effects that can be worrisome with certain health conditions.

I'm glad he's eating better! A bad tooth can sure take their appetite away. Maybe that's what I need???? LOL

Hugs,
Leslie

[PaddysPerson]

Hi everyone. I just wanted to post the results of Paddy's last UTK stim test that was done at the beginning of March.

TEST - RESULT (Baseline) / Normal Range (Baseline)** / (Post ACTH) / Normal Range** (Baseline Post-ACTH)
Cortisol (C) ug/dL : 5.9* / <1.0-5.6 / 18.1 / 7.1-15.1
Androstenedione (A) ng/mL : 0.24 / 0.05-0.36 / 1.83 / 0.24-2.90
Estradiol (E) pg/mL : 45.7 / 23.1-65.1 / 42.9 / 23.3-69.4
Progesterone (P) ng/mL : <0.20 / <0.20 / 2.31* / 0.22-1.45
17-OH-Progesterone (17OHP) ng/mL : 0.84* / 0.08-0.22 / 12.46* / 0.25-2.63
Testosterone (T) ng/dL : <15.0 / <15.0-24.0 / <15.0 /<15.0-42.0
* Above or below reference range **Mean normal range values for neutered male dogs

In the notes from UTK, they say to consider a combo of lignans and melatonin and starting on the maintenance dose of lysodren. Our IMS has been waiting to discuss this until after Paddy's oncology appointment, which was last week. I'm not sure what he's going to recommend. A question I have,though, is choosing between the two types og lignans, HMR would be better because of having no fiber...? I'm leaning towards that one, I think.

Paddy has gained a little weight since the beginning of January. He'd been down to 13.2 -ish and is now around 14lbs. I've just been feeding him some rx food along with Dr Harvey's paradigm (his least favorite is the diabetic one - glyco balance - especially when his mouth is bothering him).

The oncology appointment seemed to go well last week. They didn't find any evidence of it spreading. The next day, though, he seemed uncomfortable when it was time for bed (groaning/grunting). He was sedated for xrays so I thought maybe it was from anesthesia or the long day he'd had (also saw a holistic vet on the way home). He started being extra picky about eating and I saw blood in his mouth on the side that did not get extractions. We got antibiotics from our regular vet for that yesterday and an appetite stimulant.Then today, he had blood in his urine :( . I contacted the oncologist who said to monitor for him having to strain more than usual or not being able to go. She said it could be a UTI or secondary from his prostate... :( and to have his regular vet or specialist nearby do a urine culture. So, if we can get through tonight, that's something that will happen at the IMS appointment tomorrow (going to have his glucose sensor changed).

[Harley PoMMom]

Oh, poor Paddy and poor you, I am so sorry you both are going through so much right now. On a bright note, I'm glad to read that he's gained some weight!

Regarding the lignans, I'm not sure which I'd suggest, I believe if this were me I'd print out the information sheet that UTK has and take that into the doc office and discuss it with the IMS and see what they recommend. Here's a link to that information sheet: https://vetmed.tennessee.edu/wp-content/uploads/sites/4/LIGNANS-INFORMATION.pdf

Please do let us know how the appointment goes and wishing you both the best of luck.

Hugs to you both, Lori

[Squirt's Mom]

I do hope Paddy is feeling better by now. I, too, am glad he was able to gain a little weight and hope his appetite stays steady.

I used the combo of lignans and melatonin with my Squirt for a while when she was first diagnosed. Her cortisol was normal but more than 2 of her intermediates were elevated so that is the treatment recommended. When we started the only lignans available were the SDG, or flax, lignans. When the HMR, or spruce, lignans came out I thought it was worth a try to switch. When we did we lost control of the hormones so we switched back to the SDG and remained with them for the duration. When her cortisol started to rise we used a maintenance dose of Lysodren and just skipped the loading phase. This worked for her but has not worked for all pups who started out Atypical then developed conventional Cushing's (with elevated cortisol). Many many dogs do very well with the HMR so it is definitely worth a shot to start out with them vs the SDG.

I am a Lyso girl through and through UNLESS the dog has the adrenal form of Cushing's then Vetoryl is best because of the need for steadily increasing doses as time goes by (high doses of Lyso can be very very hard on the digestive system). Otherwise, I will always choose Lysodren over Vetoryl. And yes, I am an oddball. :D

Looking forward to the next update on our sweet boy!
Hugs,
Leslie

[PaddysPerson]

Paddy's urine was back to "normal" after a few days on the clindamycin (prescribed for his mouth). At IMS appointment, they couldn't do a urine culture or anything because of the antibiotics. So at that time, we held off on re-starting cushing's treatment again (his urine was still kool-aid red then). After he finished 2 weeks of antibiotic, the bloody urine returned, not as red & not consistent (ok so far today). He's been very picky about eating this past week & I've been giving an appetite stimulant - mirtazapine. His teeth are still an issue. I need to go ahead with the rest of his extractions, but...
We saw the IMS the other day & he said Paddy could start lignans and melatonin but waiting on lysodren. I was going to give Paddy HMR because I was worried about him getting too much fiber, however I read that flax lignans have more antioxidants so maybe they might help his other big issue... (also the IMS had dosage of 65mg-250mg for HMR and 15mg for SDG but then I read online 10-40mg HMR for small to large dogs. Have to ask him about that.)
Paddy already gets a probiotic - Visbiome- once a day mixed with a tsp of baby food. I also give him a tsp - tbsp pumpkin with each of 2 meals. Somewhere online I saw that the lignans could be mixed with a little yogurt (to help it absorb better?...:confused: ).
Any suggestions on how to give them? TIA

[Harley PoMMom]

So sorry to hear that Paddy's appetite has decreased, believe me I know how worrisome that can be, hopefully it'll pick up.

Regarding the melatonin and lignans; you want to make sure that the melatonin is the plain kind not the fast-acting or slow releasing type. With the lignans what is very important to know is the standardized percentage of SDG or HMR in the product you are giving. I do believe they produce a liquid form of lignans, that may be easier to give. With my Harley I used the powder form of lignans and just stirred it into his wet food.

Hugs, Lori