New to Group and Cushings

[ILOVEMYPOM]

Hello everyone. I have learned a lot by reading some of your posts. I am hoping you all can help guide me through this process. My pom Teddy who is 5.5 years old and 5.5 lbs began losing his hair in December 2015 on his behind. As of today, he has very little hair on his belly and behind and has lost some hair on his legs and tail. He is thinning everywhere else. After being told it was Alopecia X, my gut told me to get a second opinion.

Teddy was tested two weeks ago and the results were reviewed at the University of Tennessee and tested positive for Cushings (pituitary dependent) :(

His out of range results are as follows:

Baseline Results:
Coritisol 8.8
Androstenedione 1.27
Progesterone .61
17 OH Progesterone

Result:
Progesterone Post ACTH 11.1

Comments: Most of the baseline values are elevated and deviations from reference range vary from mild to significant (androstenedione and progestins). Occasionally, marginal elevation in baseline cortisol concentration may be related, in part, to testing stress. The condition is less serious when only one column is affected. However, elevated baseline are considered to be more "pathogenic" than just post-ACTH elevations, since the body is exposed continuously to hormone excess.
Dexamethasone suppressed normally cortisol and other steroids which indicates a functional negative feedback with the pituitary and also
suggests a a pituitary dependent condition. If indeed, this is the case of HAC. Various treatment options are attached for your consideration, if signs of hyperadrenocorticism and no other concurrent non-adrenal illness are present some veterinarians initially consider the use of
items 2-4 combined (on attached sheet), if symptomatic for hyperadrenocorticism. These results indicate presence of adrenal activity (mild).

I was not given the treatment page yet, but the Vet recommended the following:

Melatonin 3 mg 2 x's per day
HMR Lignans 40 mg 1 per day
Vetroyl 10 mg per day $75.00 from our Vet

I am concerned about the Vetroyl because Teddy is only 5.5 lbs. I saw on a link on a previous thread and went to the manufacturers website and it says they recommended 5mg for Teddy's weight (if I read it correctly).

Sorry for the long post. Hoping someone can let me know their thoughts. I appreciate it :)

[labblab]

Hello and welcome to you and little Teddy! Thank you so much for giving us such a good introduction to your little boy. I do have a remaining question to ask, and that is whether you are seeing any other abnormal overt symptoms in Teddy other than the hair loss? Well, actually two questions: has he exhibited any other lab abnormalities in terms of traditional blood or urine panels?

I must admit that I am somewhat surprised by UTK's write-up of Teddy's results. It would be helpful for us to actually see the complete testing results, including reference ranges. They reference both ACTH results and also dexamethasone suppression, which implies that a combined ACTH stimulation test and Dex Suppression test was performed by your vet. This is possible, but fairly unusual, so it would be helpful to see all the test results.

The part of the write-up that is new to me is this:


Occasionally, marginal elevation in baseline cortisol concentration may be related, in part, to testing stress. The condition is less serious when only one column is affected. However, elevated baseline are considered to be more "pathogenic" than just post-ACTH elevations, since the body is exposed continuously to hormone excess.

In over a decade on the forum and after reading many lab interpretations, I have never seen that statement made before. From what you've written above, it appears as though only progesterone was elevated on the post-ACTH panel. All the other stimulated readings, including cortisol, must have been within normal limits. So it seems as though UTK is basing their treatment recommendation largely on elevated baselines alone. As I say, that's a new one for me, but it must be due to excessively high baseline elevations (that's why seeing the reference range will be helpful for us).

However, here's another question mark. Here's a link to UTK's treatment recommendation page, and as you'll see, items 2-4 relate only to melatonin and lignans. Trilostane treatment is listed as item 7. And actually, historically, we've been more likely to see UTK recommend maintenance doses of Lysodren (item 5) as opposed to trilostane as an "add-on" for treatment of elevated hormones when stimulated cortisol is within normal range.

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

If Teddy's post-ACTH cortisol reading was within normal range and if he isn't exhibiting any symptoms other than hair loss, then I'm wondering how/why trilostane treatment is being initially suggested by your vet. I will add that trilostane has indeed been tried experimentally for treatment of Alopecia X, even when dogs exhibit normal cortisol levels. But from what you've written, I don't see UTK recommending it at this time for Teddy. And yes, as a sidebar, if he were to start taking trilostane in this situation, it absolutely should not exceed 5 mg. (we can supply additional supporting info for that).

So going full circle, if you can give us the complete UTK results, that will be a big help. Instead of typing them all out, if you can take a digital photo of the page/s, you can create a personal photo album here and upload the image to your album. If that's not an option for you, let us know and perhaps we can come up with another approach.

I'm going to close for now (and I hope I haven't overwhelmed you!). But once again, welcome!

Marianne

[ILOVEMYPOM]

Marianne

Thank you so much for getting back to me. I have uploaded his test to my album. However, I was not able to link it to this message. Please let me know if there is something I need to do. Everything I posted for Teddy was out of reference. Sorry for the confusion. I was very concerned in the comments over the wording “pathogenic.”

Thank you for sending the treatment link. I was unable to access it from their website. We have a follow up appointment today, so hopefully I will find out more. I would never give Teddy trilostane for hair loss. Everything I read said if was only Alopecia X, it is purely cosmetic. I would not want to risk larger issues for him to re-grow fur. I love him regardless of his hair :)

We are not seeing any other signs. We have a 3 year old Pom as well and he seems to have the same energy as her. He does seem to pee a lot, but is not having any accidents. As far as the eating and drinking more, again that seems to be normal. We were relying on the tests to give us an answer to why he was losing his hair and this seemed to come from left field. Meaning, I was not expecting it.

As far as other blood work, the abnormalities from 5 months ago are below:
Platelet Count 428 170-400 10^3/mL HIGH
Neutrophils 47 60-77 % LOW
Lymphocytes 40 12-30 % HIGH
BUN/Creatinine Ratio 30 4-27 Ratio HIGH
Phosphorus 1.9 2.5-6.0 mg/dL LOW
Sodium 156 139-154 mEq/L HIGH
T4 <0.5 0.8-3.5 ug/dL LOW

T4 retested – Hypothyroidism
T4 0.6 0.8-3.5 ug/dL Low
TSH 0.04 0.00-0.60 ng/mL NORMAL
Free T4 (Equilibrium Dialysis) 15 8-40 pmol/L NORMAL

Urine
Specific Gravity 1.056 1.015-1.050 HIGH

Thank you so much for taking the time to respond and assist through all of this. I truly appreciate it.

[labblab]

Thank you so much for posting this additional info, as well as the photo of UTK's results. For our registered members, here's a link to the report:

http://www.k9cushings.com/forum/album.php?albumid=1161&pictureid=8742

The report confirms that a combo ACTH/LDDS was run, and the results remain very interesting to me. I see that the word "Cushing's" has been handwritten on the result, but it is actually the case that Teddy did not have a single elevated value consistent with a true Cushing's diagnosis on either the LDDS or post-ACTH panels. The only abnormal on the post-ACTH panel was an abnormally low level of estradiol. With a cortisol level that is within normal range on both the LDDS and the post-ACTH panel, he would not be diagnosed as having conventional Cushing's at this point. And by virtue of non-elevated results for the other hormones on the post-ACTH panel, it appears as though UTK is basing the determination of current "mild" adrenal overactivity solely upon the elevated baselines. Whether this activity is going to broaden or worsen in the future is really anyone's guess, I would think.

Soooo...until or unless Teddy were to exhibit other overt symptoms of elevated hormonal activity, I would see no harm in giving the melatonin and lignans a try. But I remain in the dark about starting up with the trilostane. Given Teddy's currently "normal" LDDS and post-ACTH cortisol responses, I would want to know the justification for treating with trilostane since we have been told repeatedly by experts that a traditional Cushing's diagnosis cannot be based solely upon an elevated baseline cortisol reading.

Marianne

[ILOVEMYPOM]

Marianne:

I just left the Vet. I questioned her wanting to give Teddy the trilostane and sshe stated she called Univ of Tenn and they informed her over to give him the meds. Seems odd to me it would not have been Included in the comments. So, she said I could call Univ Tenn which I already did and left a message. She gave me a prescription for 5mg of trilostane since that is where I wanted to start IF I decide to give him the meds.

PS: Any thoughts on getting trilostane from a compound pharmacy. She quotmed me $75 and my local pharmacy is only $35 with free shipping and can give us a liquid if he doesn't take the capsule. Again, not sure that is what I will do, but wanted your thoughts.

Other than clalling and talking to Univ of Tenn any other suggestions? I can start the Melatonin but can't find the lignan in any store, so I will have to order it online.

Thanks again.

[labblab]

I will be most interested to hear what UTK tells you about the trilostane. They should have his report in front of them when they talk to you, but do stress that you are aware that Teddy tested within the normal range for cortisol on both the Dex Suppression test and also the post-ACTH panel. Unless they have some persuasive argument to offer, I personally would not give my own non-Cushing's dog a medication as powerful as trilostane solely to treat hair loss.

So until you do hear back from them, I wouldn't move forward with a trilostane purchase. Based on what they tell you, we can then talk more about your options.

As far as lignans, here's a link to UTK's lignans fact sheet. Since you didn't get a copy of the treatment options, I don't know whether you got this fact sheet, either, and it may be helpful to you when ordering.

https://vetmed.tennessee.edu/vmc/dls/endocrinology/Documents/LIGNANS%20INFORMATION.pdf

[ILOVEMYPOM]

This forum has been awesome. Thank you so much for everything. I have been printing everything you have sent.

I decided to email UTK and attach all of Teddy's previous medical records that the Vet we saw today did not have. I'm curious what their response will be. It is VERY concerning that she is recommending trilostane without it being in UTK's comments.

THANK YOU so much for the treatment page as well. She did not want to provide it to me for some unknown reason.

It sucks to feel powerless over a disease, but with all the information I have gathered from your responses and other posts I feel I have knowledge and knowledge equals power and control over making decisions. I am so grateful for the forum :)

[labblab]

You are so welcome! And of course, bear in mind that none of us here are vets, so there is always the chance that we are overlooking some important puzzle pieces, ourselves. There is never a day that passes that I don't feel as though I'm still learning something new. So perhaps talking to UTK directly about this will shed some new light on their recommendations. As I say, I do know that trilostane has been used in some instances solely to treat Alopecia X, so perhaps that may be what is prompting the recommendation here. We shall see!

In the meantime, many kudos to you for being so proactive re: Teddy's care. And by the way, he is sure a cutie-pie!! ;) :) :)

[ILOVEMYPOM]

Thank you. I love him very much.

I posted the Vet recommendations in my album in case there is any interest. There is no need to feel obligated to review them :)

I will keep you updated when I hear back from UTK.

Thanks again.

[labblab]

OK, I'm back one more time because I want you to be as well-armed as possible when you talk to UTK. Now that I've read your vet's summary of Teddy's test results, I do believe she is misinterpreting the results. This is what she's written:


A combination cortisol-low-dose dexamethasone/ACTH stimulation test was performed. Teddy's baseline values were elevated for 4 out of the 6 cortisone and related sex hormones tested. Teddy was diagnosed with Cushing's Syndrome. The test shows that Teddy likely has the pituitary form of the disease.

Ummmm...I don't think that's exactly what UTK said. I must say that their comments section is not written very clearly. But here is their diagnostic impression: "These results indicate presence of increased adrenal activity (mild)."

In our experience with UTK, increased adrenal activity can be associated with a range of findings, including traditional Cushing's (elevated cortisol levels on Low Dose Suppression Test and/or post-ACTH stimulation test), or instead a condition labeled by them as "Atypical Cushing's" (elevations in adrenal hormones other than cortisol). Many other clinicians do not agree that "Atypical Cushing's" constitutes a meaningful diagnosis, but that's beside the point for the moment. This is the UTK sentence that I want to highlight for you (poorly written though it is :rolleyes:):


Dexamethasone suppressed normally cortisol (to < 1 ug/dL) and other steroids which indicates a functional negative feedback with the pituitary and also suggests a pituitary dependent condition if, indeed, this is the case of HAC (my bolding).

What I think they are noting here, first off, is that Teddy's cortisol suppressed normally on the Dex test. This would tend to rule out traditional Cushing's. However, due to the pattern of suppression, if Teddy does indeed suffer from an abnormality otherwise affecting his overall adrenal activity, it is likely due to a pituitary tumor rather than an adrenal tumor. However, with no symptoms other than alopecia, I think a lot of this remains iffy. For instance, UTK themselves note that stress alone at the time of testing can have an impact on elevating baseline cortisol levels. All in all, I really don't think UTK has yet definitely diagnosed Teddy with pituitary Cushing's at this time.

I apologize if what I'm writing here is confusing, and UTK may directly tell you something entirely different, after all. But I just felt bothered about your vet's diagnostic paragraph for the reasons above.

[labblab]

FYI, here's a blurb that explains how to interpret a low dose Dex test:


Test interpretation. When interpreting LDDS test results, first evaluate the eight-hour post-dexamethasone administration cortisol concentration. If it is above the reference range, the dog probably has hyperadrenocorticism (false positive results may occur in dogs with nonadrenal illness). If it is within the reference range, either the dog does not have hyperadrenocorticism or there is a 5% to 10% chance that the dog has PDH. (The dog may have early pituitary disease and the pituitary gland is still responding to a pharmacologic dose of dexamethasone by decreasing ACTH production, thereby reducing serum cortisol concentrations.) In those cases, an ACTH stimulation test is warranted.

And that's the thing, Teddy DID have an ACTH stimulation test performed at the very same time -- and it also came out normal.

OK, now I'm going to go work on cleaning my house and I will quit pestering you!! Promise. :o

[ILOVEMYPOM]

Thank you for reviewing the Vet recommendations for me. I am as confused and concerned as you are.

I sent UTK the Vet's recommendations and hopeful they will be able to shed some light on all of this (including their own results). They are very confusing to me (especially the part you highlighted with the big IF...).

I would be willing to put my little guy through this all over again to get further information if needed, and pay the $300 for testing because I do not want to give him medication unless there is a very high percentage that he needs it. I informed UTK in my email I WOULD NOT give him medication just to treat the hair loss alone.

If UTK is unable to put me at ease, I am not sure what to do. The only thing left that I can think of is MRI/CAT scan and I would have to travel for that and who knows how much that will cost. I would drive him to Tennessee if I could get answers. LOL

If only his Cortisol was high in the pre-ACTH I would feel better, but his other hormones were elevated as well. UGH

Again, thank you so much for your time and assistance. I really do appreciate it :)

[labblab]

I know I said I was shutting up, but one more thing...:D

Really, I'm trying to put your mind at ease rather than alarming you. Poms seem to be pretty well known to be vulnerable to hair loss issues, I think, and there really may not be anything very sinister at play for Teddy. I've asked one of other Admins to check in here when she has more time. I believe she has owned and loved more than one hairless Pom, and she may be able to shed much more light on this whole issue for you.

[ILOVEMYPOM]

You are not alarming me :D Weeding through these medical terms is not easy. I always do research, so you have saved me hours of time. I don't think I have stopped researching since we got the results on Wednesday.

I may have a silly question...

The fact that his cortisol levels were elevated prior to dex supp and post ACTH and then normal at 4 hr dex supp, 8 hr dex supp, and post ACTH show that he has Cushings? Shouldn't the levels decrease? I've read a lot of articles and get confused each time. I think my brain is on overload.

He went from 8.8 (High) to <1.0 (normal) <1.0 (normal) 14.2 (normal)

Thanks again :)

[labblab]

That's not a silly question at all. As I said earlier, running a combination LDDS/ACTH test is fairly uncommon, and procedurally, I'm not even sure how it's done. Teddy must have been at the vet's office for about ten hours! But this is the thing: the LDDS is a "suppression" test while the ACTH is a "stimulation" test. The two tests involve assessment of different aspects of adrenal functioning, use two entirely different chemical agents, and the results must be viewed in isolation even though they are listed side-by-side on the UTK report. The only thing they have in common is the initial baseline draw as the starting point. I have to assume that one test must be totally completed before the injection for the other is begun.

So how are they interpreted? I'm not sure if you saw my reply yesterday about interpreting the LDDS, but if not, just scroll back up to the top of this page. But in a nutshell, a normal dog exhibits suppression of cortisol levels at the 8-hour mark, which was the case for Teddy. The notion of a pituitary tumor comes in when the dog does not suppress cortisol as effectively at the 8-hour mark (thus is "positive" for Cushing's), but either the 8 or the 4-hour mark is <50% of the baseline (as opposed to an adrenal tumor that doesn't result in suppression at either time). In honesty, since Teddy's 8-hour result on the test was normal, I don't know why UTK bothered to include that comment about a pituitary tumor at all. In conjunction with his normal ACTH, it seems as though they could have just said that Teddy's Dex test was also normal and leave it at that. But as the blurb in my earlier reply states, there is a 5-10% chance that a dog with a normal 8-hour LDDS (like Teddy) may still have a pituitary tumor. So I guess the point they wanted to make was that, no matter what, an adrenal tumor is unlikely for Teddy due to the suppression pattern on his test.

Turning to the ACTH, a stimulating agent is injected in order to "wring out" the adrenal glands in order to see how much cortisol they've been holding in reserve. Interpretation of the test is very simple. If the post-ACTH result is higher than than the normal range, the result is consistent with a dog who has Cushing's. However, once again Teddy's result was within the normal range for that test. So on both the two different tests for traditional Cushing's, he tested normally.

So that leaves us solely with the baseline elevations. I can't speak knowledgeably about elevations in other baseline adrenal hormones, but as I wrote earlier, I have never seen elevated baseline cortisol treated as a valid diagnostic indicator of Cushing's. Any formal interpretation of the ACTH that I've seen disregards the baseline value entirely. And in terms of the LDDS, the only real significance of the baseline is in terms of comparison purposes to the subsequent readings (the 50% thing I was talking about before). I can tell you that we've seen many dogs over the years with baseline cortisol values as high as Teddy's, some of whom test positive for Cushing's and some of whom do not. So I'll be very interested to find out how UTK elaborates on these baseline results for Teddy.

All in all, bear in mind that, no matter what, UTK is characterizing Teddy's situation as a mild case of adrenal overactivity. Under these circumstances where hair loss is his only issue and given his entirely normal result on both the LDDS and ACTH, I would surely not pursue any aggressive diagnostics such as an MRI or CT of the head if he were mine. I would probably just give the melatonin and lignans a try to see whether they help. Over time, they just may do so.

Marianne

[ILOVEMYPOM]

He was at the Vet for 9 hours. He has a long day. Luckily, my husband took food for him. Something I would not have thought to do.

I reread your post on his results and found the site you referenced.

Test interpretation. When interpreting LDDS test results, first evaluate the eight-hour post-dexamethasone administration cortisol concentration. If it is above the reference range, the dog probably has hyperadrenocorticism (false positive results may occur in dogs with nonadrenal illness). If it is within the reference range, either the dog does not have hyperadrenocorticism or there is a 5% to 10% chance that the dog has PDH. (The dog may have early pituitary disease and the pituitary gland is still responding to a pharmacologic dose of dexamethasone by decreasing ACTH production, thereby reducing serum cortisol concentrations.) In those cases, an ACTH stimulation test is warranted.

5%to 10% is pretty low and like you said ACTH was normal.

I guess the question remains on why his baseline results were so high.

I hope I hear from UTX tomorrow. I'm not sure how they will respond since I am an owner. Has anyone had luck talking to them that you are aware of?

I've done a lot of reading and I just want an answer. I started Melatonin and I'm waiting to order the Lignans because I think 40 MG may be too much for my little man.

Thanks again. I was able to read things over and it is much more clear.

[labblab]

At the risk of causing even more head-scratching for you :o, I'm going to include a link to an article that discusses some of the question marks that surround the clinical significance of elevated adrenal hormones other than cortisol. UTK has been an institution that has had a special interest in this area and that is why they are one of the few veterinary labs worldwide that even perform analysis of complete adrenal panels. However, having said that, I must tell you that there remains a fair amount of controversy among non-UTK clinicians as to what, if any, conclusions to draw from an "abnormal" adrenal panel. I do, personally, respect the efforts that UTK has put into researching this area. But I'm also aware that there is yet a lot to be determined about the subject.

Of particular note is that every related article that I've seen thus far discusses only the potential significance of post-stimulated elevations. I have never seen diagnostic determinations made as a result of elevated baselines alone, perhaps since even stress alone can cause at least some degree of baseline elevation, as UTK did indeed note in their report. That is why I'm surprised that they are emphasizing the elevated baselines on Teddy's panel. At any rate, here is a quote from the article I am giving you.


For the diagnosis of standard HAC, determination of basal cortisol concentration is not reliable and never used by itself. No evidence has shown that measurement of basal serum sex hormone concentrations are any more reliable for diagnosis of adrenal dysfunction; thus, the following discussion will focus on ACTH-stimulated concentrations, which are a measure of adrenal reserve.

http://www.2ndchance.info/cushingsbehrend2010.pdf

I am suspecting that there may not be a clear-cut explanation for Teddy's hair loss. Hormonal abnormalities may play a role, but the exact mechanism may not be known. As you'll see from the article, trilostane treatment has been helpful in treating hair loss in some Poms, but not for others. So as much as you want a definitive answer right now, unfortunately it just may not be there.

[ILOVEMYPOM]

Marianne:

I can't say enough how helpful you have been. All of the information you provided assisted me in getting answers for my little guy.

My Vet called today and stated UTK contacted her regarding my email and "they" decided to start with Melatonin and Lignans. I asked why the change from "her" treatment plan and I got the run around and then she said due to "my concern." She stated UTK recommended Lysodren if we do not see any results from the natural remedies. I questioned her decision to give Teddy 40 mg of Lignans and she had to contact UTK AGAIN and they recommended 10 mg. She stated UTK asked if they should contact me or if she would convey the information and she stated she would provide the information to me. Umm....NO. I told her I wanted to speak to UTK myself and here is that update.

Dr. Giori spent 31 minutes talking to me about Teddy. He inadvertently stated UTK NEVER recommended Vetoryl. (He thinks she recommended Vetoryl because Teddy tried Melatonin in the past for hair growth and it was not successful. However, he was on a smaller dose and it was not combined with the lignans.)

He stated we should try Melatonin and Lignan for 4 to 6 months and see if there is an improvement in his coat/hair loss. He stated this is what he would do if Teddy were his dog. We discussed Teddy's results and he acknowledged that Poms are in their own category when it comes to sex hormones, etc. He stated we should be watchful of signs of Cushings, and should retest in 4-6 months if we do not see any improvement. The results do not prove that Teddy has Cushings. He stated we could do an ultrasound. He stated the ultrasound could show if it was pituitary HAC because the adrenal glands would be plump and then we could also see if there were any tumors on the adrenals. Any idea of what this should cost or if this would be worth it? First thing on my agenda is finding a new Vet.

I started the Melatonin and ordered the HMR Lignans.

Even though we do not have a definitive answer I am relieved that he does not recommend medication at this time. I didn't want to "not give" Teddy medication due to my "concern." I wanted a medical opinion on what to do which UNK provided. Dr. Giori provided me with his phone and email should I have any further questions. He was AWESOME and was very patient and very detailed.

The article you provided this morning really solidified that POMs have their own genetic issues which Dr. Giori also acknowledged. I am planning on emailing Teddy's breeder to see if there have been any similar health concerns.

So, what are your thoughts?

Again, without your knowledge and assistance I probably would not have questioned the Vet's decision to start Vetoryl (especially since the Vet would not provide me with the Treatment Options page). I am so grateful to you and this forum. It may have saved Teddy from receiving medication he does not need and crossing my fingers may never need (I know I am being extremely hopeful). So, again, know how much I appreciate what you are doing :)

[labblab]

Whew, I'm so glad you've had the chance to talk to UTK directly! I've been holding my breath because, as you know, I did not see how a Cushing's diagnosis could be derived from Teddy's current adrenal testing results. So I'm relieved that UTK agrees, but I remain quite distressed that your vet misinterpreted the results so significantly. This does not bode well for her other potential Cushing's patients. :(

As far as next steps, I don't believe I'd yet bother with an ultrasound, myself. Teddy's suppression pattern on the LDDS makes a cortisol-secreting adrenal tumor unlikely. And again, in my own estimation, his adrenal panel results are not so highly irregular as to warrant a lot of additional investigation right now. If he were to subsequently develop additional clinical symptoms of abnormal adrenal activity such as excessive thirst, urination, appetite, etc., then I'd be more interested in retesting in the future. But if poor coat remains his only overt symptom, I believe I'd just give the melatonin/lignans a try for now.

[lulusmom]

Hi and a belated welcome to you and Teddy.

I am the admin Marianne mentioned as having bald Pomeranians. That's a claim to fame I'm darn proud of. I am very glad and not surprised that Marianne has done a great job of providing you with valuable information as well as asking very legitimate questions about the reasons for your vet's decision to treat with Vetoryl. There is at least one peer reviewed study conducted involving trilostane (active ingredient in Vetoryl) in the treatment of alopecia x. As I recall, most of the subjects were Pomeranians and trilostane actually grew hair for most of them. One of my tiny Pom cushdogs was bald and ultimately diagnosed with pituitary dependent cushing's. She was diagnosed with hypothyroidism at two years old and cushing's at three years old. She lost her coat rather early in life and never regained it with, melatonin, trilostane of mitotane. Her torso was bald and her skin was as black as coal. After much research, I finally followed the advice of Dr. David Bruyette. He claimed that he could probably grow hair but his first line of treatment for alopecia x is a sweater. Dr. Bruyette is a renown endocrine specialist so that statement validated studies I've read that dogs with alopecia x are simply bald and otherwise healthy. I rescued two little male bald Pomeranians who also wore sweaters in colder temps.

Pomeranians and other northern breeds are genetically predisposed to alopecia x which is not really well understood nor is their any compelling evidence that hormonal imbalances cause any other clinical signs. To be perfectly honest, Teddy does not fit the profile of a dog who would be an appropriate candidate for a UTK adrenal panel nor an LDDS. Aside from hair loss, he is otherwise asymptomatic nor does he have lab abnormalities seen in dogs with atypical or typical cushing's. I'm therefore not surprised that Teddy's results were about as benign as I've ever seen over the years. Was loss of coat the only reason for all of the expensive testing or are there other symptoms and lab markers associated with cushing's that prompted your vet to pursue a cushing's diagnosis?

With respect to treatment, melatonin is the first choice for hair loss and it's efficacy is a crap shoot at best. Lignans are usually added to to the regimen when estradiol is elevated as this is the only intermediate steroid that is found outside of the adrenal glands. It is found in adipose (fatty) tissue and gonads in unaltered males is a likely place for estradiol to hang out. :) That's all interesting information but it doesn't apply to Teddy because his baseline estradiol is normal and his post stimulated estradiol is actually low. I am therefore not sure why lignans were even recommended. Has Teddy been neutered?

I am very glad that you were afraid to treat with Vetoryl because based on what you've shared with us, I'd say chances are good that Teddy has alopecia x, and if melatonin doesn't work, sweaters will do the job. I personally would not give Vetoryl to a dog with normal circulating cortisol for the sole purpose of growing hair. I have to be honest with you here and tell you that my Lulu was 4 lbs of adorable with an amazing coat and when she lost her coat, she was still 4 lbs of adorable and she could have cared less about being bald. It was "my" vanity that drove me to leave no stone unturned to regain her coat and it was my obsessive research on the subject that made me realize that her baldness was cosmetic only and was a much bigger problem for me that was for her. :o If you're looking for a reason why Teddy is losing his beautiful black coat, you can test til the cows come home and may never get an answer. The good news is that in my experience, balding is not fatal for Pomeranians.

The only recommendation that I would make at this point is that you may want to share the results of Teddy's thyroid hormones with Dr. Jean Dodds. Dr. Dodds is considered an expert in hypothyroidism and she feels that some dogs with low and low normal T4 and Free T4, like Teddy, can benefit from thyroid supplementation. Dr. Dodds uses a formula to establish the 50% mark of normal range to determine whether she feels supplementation would help. The formula for Teddy would be as follows:

T4: 0.8 + 3.5 = 4.3/2 = 2.15
Free T4: 18 + 40 = 58/2 = 29

As you can see, Teddy's values are way, way below those 50% marks. Dr. Dodds feels that small breeds may actually do well with values higher than 50% so who knows, she might recommend supplementation, depending on test results. She also may ask you to submit a fresh blood specimen for the Hemopet full thyroid panel which is much more comprehensive. I've included a link below to the Hemopet site which has their contact information. You can call and ask for guidance.

http://www.hemopet.org/hemolife-diagnostics/veterinary-thyroid-testing.html

I have also included a link to a white paper entitled "CONTROVERSIES IN CANINE CUSHING’S SYNDROME" authored by Dr. Ellen Behrend, a well published endocrine specialist who wrote the proverbial book on hyperadrenocortism in the latest endocrinology veterinary teaching textbook used by up and coming veterinary internal medicine specialists. You will see Pomeranians mentioned and you will see that Dr. Behrend "believes the relationship between elevated serum sex hormone concentrations and disease is unclear". It's an interesting read that might be a bit confusing for you but I think you will gain some insight nonetheless.

https://ams.aaha.org/eweb/images/AAHAnet/phoenix2009proceedings/pdfs/01_scientific/044_CONTROVERSIES%20IN%20CANINE.pdf

I am sure sorry for the reasons that brought you to us but I'm super happy that you made your way here. I know from my own experience with three bald Poms the frustrations that come with no answers or resolutions. I'm not sure if anyone has mentioned this but results with melatonin are not seen right away. It can take three or four months and if you don't notice any improvement in that time, it's doubtful that longer term treatment will work. Patience is a virtue with cushing's but believe me, it's more so when you are trying to grow hair. :D We'll be keeping fingers and paws crossed that the melatonin brings some improvement in Teddy's coat. He is such a cutie patooty!

Glynda

[ILOVEMYPOM]

Marianne:

I was very impressed and relieved to talk to UTK. I think I will take Teddy to University of Florida should he need any further testing or follow up.

I too am distressed with the Vet. I think she is new to the field, but in my opinion that is not an excuse. She was solely prescribing Vetoryl on her own accord. Not acceptable.

I will be keeping an eye out for other symptoms, but the hair loss is the only one thus far.

Thanks again for everything. I appreciate it.

I'm dissecting the article you sent Atypical Cushing’s Syndrome in Dogs: Arguments For and Against. I really wish I pursued my childhood dream of being a Veterinarian aka doggie doctor. LOL It would have really come in handy lately.

Do you have dogs with cushings?

I had a 16/17 year old Australian Sheppard mix we had to let go in May who had kidney issues. I made her dog food for six months and may do some research to see if this is something I should start doing again for Teddy and Missy (his 3 y/o sister - not blood related). I think nutrition can really assist in disease if we know what to feed and what not to feed.

[ILOVEMYPOM]

Hi Glynda:

Thank you for the welcome. Marianne has done a great job of providing me with vital information throughout this week of hell. LOL

I would only want to use Vetoryl if Teddy 100% had Cushings. I have read a little bit about Alopecia X and saw that it bothers the humans more than the dogs. I had tried DermaMagic Skin Rescue prior to the testing, but he ran away from me when I tried to put the lotion on him, so after a week or so, I gave up. I really liked the shampoo bar, but now I am using Dermabenz3. After the DermaMagic his skin started to flake. I'm not sure if that was a coincidence or not.

I'm sorry to hear about your cushdog. That is really young for both hypothyroidism and cushings. Did she live a normal lifespan? That was a concern I had about Teddy only being 5.

Teddy's only symptom was hair loss. He had some abnormalities in his blood work, but they were not consistent with Cushings. He also had his T4 retested, but they said it was "fine." The UTK panel was due to me seeking a second opinion since my previous Vet was trying to get me to go to his private practice (bill me $150 for a consultation) and sell me standard process supplements. I'm not against holistic treatment, but I didn't like his approach (trying to poach me from the medical practice) and wanted to be sure there was not a medical reason for his hair loss. His hair loss has been gradual since December 2016. It started on his butt and now his tummy is almost bald and so are part of his legs. His penis has hair which is somewhat annoying :D

We did try melatonin for a month at a very low dose. I think we gave 3 mg a day. We were told to give 6 mg now.

Teddy has been neutered.

UTK did recommend the lignans.

I told my Vet and the Assistant Director at UTK that I would rather love my naked boy who is healthy vs my furry unhealthy boy. His fur growing is not worth the risk. We live in Florida so he doesn't even need a sweater. Just a t-shirt if he is out in the sun too long :)

I will definitely look into Dr. Dodds information and the paper by Dr. Behrend. I really feel information is power and can help guide us in making tough decisions. I haven't read so many articles since Grad school at least my research classes are coming in handy even if I am a little rusty :)

Thanks again. You and Marianne have been awesome. This forum prevented me from giving my little guy medication he didn't need :eek:

[molly muffin]

I just want to say hello. Boy oh boy what a situation. I've read through the whole thread and was super glad that Marianne and Glynda where able tojump in on the vetroyl situation. I know I've had the UTK test done and was surprised to see anything about vetroyl being mentioned in association with it as that isn't their normal protocol at all. And never for a dog with normal cortisol levels. Wow.
Hopefully when your vet talked to them they explained why they don't do that for dogs with normal cortisol, so your concerns puti, no way, that was all on her..
Alopecia X isnt life threatening so that is good and Glyndas little girl Lulu was a testament to that.
Let us know how things are going. We'll all be interested in keeping up with your Teddy. He sure is a cutie!

[ILOVEMYPOM]

Thank you for the reply. It really has been a crazy situation. I'm still uneasy about the whole thing.

I have been reading and researching Alopecia X which can be endocrine related.

We are giving Teddy the Lignans and Melatonin and will try that for six months and then probably retest.

I'm considering researching more on nutrition for Cushings just to be on the safe side.

Without a true diagnosis, it is difficult to move forward.

[molly muffin]

Usually when it comes to food for cushings, it is really no different than what you would expect a good quality protein, moderate fat as dogs with cushings can be prone to pancreatis.

However that works out, dry, wet, raw, home cooked doesn't matter as much as that it's a good quality.