Alva, 12 yr. old Deaf Sheltie

[DeafSheltieMom]

Hi everyone,
First of all, I am so grateful I found this site. I have learned a lot already, and am now ready to introduce myself and my dog. I apologize for the length of this post. We've had a very, um, interesting (and expensive) few months...

I'm Dayle, mom to Alva, a 12 yr. old born deaf sheltie. He's been with us for his entire life. We've played in Agility most of his life, until diagnosed with shoulder instability at the age of 9, after which we ran ground games (no jumping, weaving or contacts). He is now completely retired.

August of last year, Alva's liver levels were shown to be elevated. My vet recommended an ultrasound, which showed a small mass in the liver. Since it was small, they wanted to watch the mass to see if it grew, or maintained it's size.

We did another ultrasound in January and it showed the mass had grown slightly. They referred me to an internal specialist at a local vet hospital for consult. She recommended a liver lobectomy, since the mass looked like it could easily be removed cleanly. After the mass was surgically removed, the biopsy showed the mass was a well differentiated hepatocellular carcinoma. The surgeon was able to remove the mass completely, and no follow-up chemo was required.

Immediately after the surgery on Feb. 2, Alva experienced acute extreme PD/PU. It has not let up since. We have been back to the hospital to visit the internal med specialist and the surgeon. They were all perplexed by his condition. The surgery site has healed beautifully, he was off the Tramadol a few days after the surgery. The only problem was the excessive drinking and peeing. Just FYI, in the year prior to his liver diagnosis, he was drinking a little more than usual, but did not have the excessive peeing, nor any other symptoms. He has been on Denamarin since September, but no other meds.

Here are his lab numbers from September 2016, when he had his first ultrasound. I hope these are the ones you need. Everything else was in the normal range.

ALT=600 (10-125 U/L) -- High
ALKP=1561 (23-212 U/L) -- High
BUN=19 (7-27 mg/dl)
CREA=1.2 (0.5-1.8 mg/dl)
GLU=93 (70-143 mg/dl)
MCHC=36.0 (32.0-37.9 g/dl)
RETIC=6.9 (10.0-110.0K/ml) -- Low
WBC=4.86 (5.05-16.76 K/ml) -- Low
LYM=1.16 (1.05-5.10 K/ml)

Here are his numbers from January 2017, which lead to the referral to the surgeon:

ALT=810 (10-125 U/L) -- High
ALKP=1777 (23-212 U/L) -- High
GGT=73 (0-11 UL) -- High (note, this was not tested in Sept)
CHOL=520 (110-320 mg/dl) -- High (note, was not tested in Sept)
BUN=20 (7-27 mg/dl)
CREA=1.2 (0.5-1.8 mg/dl)
GLU=55 (70-143 mg/dl) -- Low
MCHC=33.6 (32.0-37.9 g/dl)
RETIC=25.2 (10.0-110.0K/ml)
WBC=4.98 (5.05-16.76 K/ml) -- Low
LYM=1.19 (1.05-5.10 K/ml)

Here are his lab numbers (from the hospital lab) after his surgery
dated Feb 7, 2017, when they were trying to figure out why he was PD/PU:

Urinalysis/Chemistry Panel
WBC=12.3 (4.6-15.5 K/ul)
LYM=13 (5-40)
MCHC=36.6 (32.2-36.4) - High
Comments: WBC-Minimal toxic change; RBC-Mild anisocytosis

GLU=90 (70-125mg/dl)
BUN=21 (7-31mg/dl)
CREA=0.8 (0.7-1.7mg/dl)
AST=182 (5-65 U/L) (not previously tested) - High
ALK PHOS=1592 (5-150 U/L) -- High
ALT=931 (5-110 U/L) -- High
GGT=67 (0-10 U/L) -- High
Chol=682 (114-330 mg/dL) -- High

Specific Gravity=1.005 (1.008-1.060) - Low

The internal med specialist and surgeon originally recommended withholding water overnight (a few days after surgery), since they believed Alva had psychogenic water drinking because the onset of symptoms was acute. However, that was not helpful, and if anything, made things worse. :( That lasted over two weeks, while the surgery site continued to heal.

Since there was no improvement (and Alva began to be incontinent), I went back to the internist to specifically treat this issue. I was already suspecting Cushing's all along, but the internist did not until I went in and had a long discussion with her about Alva's history. Originally, everything was based on his liver mass/surgery. They did another specific gravity test, and a cortisol/creatinine ratio test, which was abnormal. So yesterday, Alva went in for the LDDS test. I do not have the numbers for these current tests yet, I will get them either today or tomorrow. The internist has not gotten back to me about the results of the LDDS test yet. I expect to hear from her today or tomorrow.

Obviously, this has been a quite a roller coaster. And to top it all, sleep deprivation is kinda driving me batty :eek: But I am getting really good at hearing dog nail pitter patter in the middle of the night.

Any thoughts or support is greatly appreciated. Thanks for being here for all of us newbies to Cushings.
-dayle (and Alva, who just wants to cuddle)

[Harley PoMMom]

Hi Dayle,

Welcome to you and Alva, and what a beautiful boy he is!! I am so glad you came out from the shadows and started a thread about your sweet boy!

I apologize in advance, I'm at work so this post will be short:( but I'm sure our other members will be by soon to welcome you and to share their thoughts as well.

One note I did want to mention is that cushdogs generally do have high elevations in the ALP because 80-90% of dogs have a cortisol induced isoenzymes and in a dog with Cushing's the chances of a very high ALP is very commonly seen. However, you usually do not see high levels in the other liver enzymes such as the ALT, GGT, AST. This makes me believe that the increased urination and drinking is probably due to a liver issue and not from Cushing's.

And thank you so much for your detailed post, the more information we know the better our feedback can be, so no need to apologize.

Gotta run....

Hugs, Lori

[DeafSheltieMom]

Thank you, Lori. I appreciate your feedback.

The extremely high liver levels is what made the internist not suspect Cushing's in the first place, but he did just have a cancerous tumor removed via a liver lobectomy. He had an abdominal CT Scan immediately prior to his surgery, in case it showed that surgery would not be effective (i.e., tumors spread in other organs, the liver tumor more embedded in the liver than originally suspected, etc.). The CT Scan was clean, except for the one liver mass that was removed in surgery. That includes the kidneys and adrenal glands. I'm not sure if they looked at the size of the adrenals, or was just looking for masses.

They are confused about the liver levels, but they wanted to wait the full 5-6 weeks it takes a dog to fully heal from a liver lobectomy before doing another blood test.

This is all very perplexing to me... Can't wait for the internist to get back to me about the results of the LDDS test, and the urine culture. I'm guessing the full blood panel test is next in his future...

-dayle and alva

[Harley PoMMom]

Alva's case sure has me scratching my head :confused: And I do look forward into hearing what the internist thinks.

I'm including two articles (don't know how much help they will be) that elaborate more about diagnosing PU/PD in a dog: http://veterinarycalendar.dvm360.com/diagnostic-approach-polyuria-and-polydipsia-proceedings-0 and http://www.endocrinevet.info/2011/01/diagnostic-approach-to-pupd-urine.html

Hugs, Lori

[DeafSheltieMom]

Thanks for the articles, Lori. They were very interesting. I was reading them while waiting for the internist. It's hard because the only symptoms he has are the extreme PD/PU (and incontinence), and hunger. His poop is normal (although he does look like he is constipated when he does poop). He doesn't pant, he does shed, but no more than usual. He has, however, lost a little weight over the last few months, and he feels gaunt. He does not have the pot belly or bad skin issues. I do believe he has lost some muscle mass, because he is having difficulties jumping up on the couch and bed.

The internist finally called me tonight with the results. She said there is no doubt Alva has Cushing's. Here are his numbers:

Urine cortisol/Creatinine ratio: (tested 2/22/17)
urine cortisol = 5.3
urine creatinine = 6.00
urine cortisol/creatinine ratio = 275.8 (1-19) -- High

LDDSt (tested 2/25/17)
Cortisol (baseline) = 8.5 ug/dL (2.0-6.0) -- High
4 hour post = 7.0 ug/dL (0.0-1.5) -- High
8 hour post = 6.8 ug/dL (0.0-1.5) -- High

His urine culture initially reported negative, but they have another day or so of culturing before they are sure he doesn't have an infection.

She recommends we start Vetoryl. The hospital is going to call into Costco to start the prescription tomorrow. She said she is starting on a very low dose, but I neglected to ask her what that dosage is. Alva weighed 9.5Kg (20.94lbs) on the day of his LDDS test. What would be the standard starting dosage for his weight?

I did ask her about his very high liver levels. She said since he just had a liver lobectomy, he probably was still generating high levels while his liver is healing and regenerating. She also said he may have some build up of ??? in his liver (not sure what it was she said) that can cause high liver results. She also said he may have high levels for the rest of his life, but they should not be so skyrocketing high.

So now what? Are there any dietary restrictions for a Cushing's dog? Anything else I should be looking for?

Once he starts Vetoryl, he is to go back and get tested in 10-14 days. About how long does it take to start to see any alleviation in symptoms, or side effects (if any)?

Thanks again for all of your help and support. We will continue to monitor both the Cushing's and the liver.

[labblab]

Hello Dayle, and welcome to you and Alva. Regarding your question about Vetoryl dosage, current recommendations are to begin treatment at a dose no larger than 1 mg. per pound. So if Alva's Rx is for 20 mg. or less, that would be considered a low dose.

Before going further, I do want to mention one consideration -- not to worry you unduly, but just because I think it should be pointed out. The pattern of Alva's LDDS test results can sometimes occur in the presence of a pituitary tumor, but it occurs more often in the presence of an adrenal tumor. I know you've reported that his presurgical CT didn't show any adrenal tumors, and therefore it makes sense to conclude that the Cushing's symptoms are pituitary in origin. However, I just have a little niggling question mark in the back of my head -- was Alva's cancerous liver tumor of a type that might also make him more vulnerable to the development of an adrenal tumor? I don't know the answer, but it's a question you might want to clarify with the internist in the event that re-imaging of his adrenals might be called for under these circumstances.

As far as dietary guidelines for Cushpups, we generally just recommend moderate levels of good quality protein, and perhaps also lower levels of fat due to a possibly increased vulnerability to pancreatitis (mixed research re: that linkage).

Please do keep us in the loop as you move further down the treatment path, OK?

Marianne

[DeafSheltieMom]

Thanks for all of the info, Marianne. Alva's liver tumor is usually one that develops in the liver first (not metastasized from another site).

Here is what I found on the type of liver cancer Alva had (most easily readable, for general public):

(link: https://www.vetary.com/dog/condition/liver-cancer-hepatocellular-carcinoma)

"Primary liver cancer accounts for less than 1.5% of all tumors in dogs. The most common type of cancer to originate in the liver is hepatocellular carcinoma. This cancer is believed to form on stem cells in the liver and it can grow to be quite large. It is responsible for about 50% of the liver tumors found in dogs. In some cases, the tumor can be identified as a palpable mass in a dog’s stomach. Often dogs present the typical symptoms of liver disease, but some tumors can be non-symptomatic for quite some time. Eventually, the tumor will cause serious abdominal hemorrhage. This type of cancer is slow growing; however, left untreated, it will cause cell death and cirrhosis of the liver and eventually lead to end-stage liver disease. It can metastasize to other areas of the body, most commonly to other organs in the abdomen, but this is less likely than with more aggressive forms of cancer. Surgery is possible with many tumors, and dogs have a good chance of recovery as long as the entire mass is removed. More diffuse tumors, including several lobes or even the entire liver, are much harder to treat. Cancers on the left lobe usually have a better chance of being successfully removed. This type of cancer is more common in older dogs, around 10-12 years of age."

His tumor was in the left lobe, and was fully removed. I have confidence the cancer did not metastasize, but it is a possibility. I will email my internist about what you said regarding the adrenal tumor possibility. She's been extremely helpful and open to conversation and questions. I'm quite pleased with her level of care and knowledge.

If a tumor (in either the pituitary or adrenal glands) is causing the glands to overwork, obviously the only "cure" is to remove the tumor, but will Vetoryl help with the symptoms if surgery is not possible?

Btw, just got a call (literally while I was typing) that Alva's prescription has been ordered. It is for 10mg 2x/day, the low dosage you mentioned.

I'll be picking it up after work, and start his first dose tonight at dinner time. I was told he should take the med with food.

Thanks again. I'll keep you all updated on his progress.
-dayle and alva

[DeafSheltieMom]

Before going further, I do want to mention one consideration -- not to worry you unduly, but just because I think it should be pointed out. The pattern of Alva's LDDS test results can sometimes occur in the presence of a pituitary tumor, but it occurs more often in the presence of an adrenal tumor. I know you've reported that his presurgical CT didn't show any adrenal tumors, and therefore it makes sense to conclude that the Cushing's symptoms are pituitary in origin. However, I just have a little niggling question mark in the back of my head -- was Alva's cancerous liver tumor of a type that might also make him more vulnerable to the development of an adrenal tumor? I don't know the answer, but it's a question you might want to clarify with the internist in the event that re-imaging of his adrenals might be called for under these circumstances.

Marianne

Hi Marianne,
I just heard back from Dr. DeBerry. Here is what she said:

"That is correct, however there are about 12% of PDH dogs that will not suppress on any dose of dexamethasone (even with the high dose dex!). The ACTH stim test is even less reliable for adrenal tumors and does not differentiate adrenal from PDH. Endogenous ACTH can, although it may be harder to interpret if he is on Vetoryl. (In suppressing cortisol, the ATCH production is stimulated due to loss of negative feedback.)

His adrenals were well imaged at CT, so unless one of them is over secreting but not enlarged (which would be unusual). If it was an adrenal tumor, the Vetoryl would still treat it, but you might want to consider having it removed surgically. Both the CT and Dr. Jackson’s direct imaging of the adrenals was normal a month ago. Theoretically a very aggressive tumor could advance in this time frame, this is just not how the adrenal tumors usually work."


So, I guess Alva is just special ;) He probably is in that 12% of PDH dogs who does not suppress dexamethasone.

Now the waiting and seeing and hoping...
-dayle

[Harley PoMMom]

About how long does it take to start to see any alleviation in symptoms, or side effects (if any)?


Decreases in hunger, drinking, and urination are commonly seen within 2 weeks of treatment. Side effects can happen at any time while the dog is on the Vetoryl which is why a low starting dose is recommended, and I see that Alva's initial Vetoryl dose, for his weight, is well within the guidelines that are now published.

You're doing a great job and remember we are here for you and Alva.

Hugs, Lori

[molly muffin]

I just want to say hello and welcome to the forum. What a beautiful boy Alva is.

Hoping you see a clear up in symptoms soon.

i can't really add more to what the others have already told you, so for the moment I'll stick to saying hi and welcome. :)

[DeafSheltieMom]

Hi everyone,
Thanks again for being here and being a great support group for us Cushing's newbies... it really is comforting knowing so many people have our backs!

I took Alva in for his follow-up ACTH test for having been on 10mg/2x day of Vetoryl. They also did a specific gravity test, which was closer to normal than it was before :)

Here are the results:
Cortisol (baseline) <1.0 L 2.0 - 6.0 ug/dL
1 hour post 4.2 L 6.0 - 18.0 ug/dL

Interpretation Guidlines (Canine):
Pre-ACTH (resting) cortisol: 2-6 ug/dL
Post-ACTH cortisol: 6-18 ug/dL
Equivocal post-ACTH cortisol: 18-22 ug/dL
Post-ACTH cortisol consistent with hyperadrenocorticism: > 22 ug/dL
Post-ACTH cortisol consistent with hypoadrenocorticism: < 2 ug/dL
Desired pre- and post-ACTH cortisol for dogs on Trilostane (or Lysodren) therapy: Both pre and post samples between 1.0 & 5.0 ug/dL

It was low, but my internist was pleased with the results. Alva has greatly improved his peeing/drinking. He still drinks a lot when he drinks, but he doesn't drink as often as he had before the Vetoryl. And his peeing is pretty much back to normal. He does still seem very stiff and his muscles are not back to where they were before. He hunches his back like something hurts. But he is back to barking when my hubby comes home from work, and trotting in circles barking like a silly dog when he wants to play (not often, but much more so than pre-Vetoryl!).

My vet wants to do another ACTH follow-up 30 days from now to make sure his levels are okay.

Are the numbers too low? My vet said not to worry about the pre-levels being really low. She said they are more concerned about the post levels. He had the test started a little over 4 hours after his breakfast Vetoryl. Thanks for the input... still trying to figure all of this out.
-dayle and alva, who charmed the scrubs off the vet hospital staff yesterday! :cool:

[DoxieMama]

So it's been about 2 weeks since starting Vetoryl, right? I think those numbers are good. You do want to stay vigilant for any signs that Alva's cortisol drops too low, because it is typical for it to drop in the first 30 days of a dose.

You're both doing great!!

[DeafSheltieMom]

Yes, it has been 2 weeks. Sorry, I forgot to add that in the post. I was a little concerned it dropped too much, since it will probably continue to drop. But Alva is starting to put weight back on (he was really gaunt), so that may affect his dosage as well. He is not ravenous anymore, just normal "Sheltie is starving" sad sack stuff :rolleyes:

I'm really grateful he is reacting well to the drug. He hasn't had any of the side effects except for one loose poopy day early on.

I'll keep an eye on him during these 30 days and take him in earlier if needed. Thank you!
-dayle

[Harley PoMMom]

I took Alva in for his follow-up ACTH test for having been on 10mg/2x day of Vetoryl. They also did a specific gravity test, which was closer to normal than it was before :)

Here are the results:
Cortisol (baseline) <1.0 L 2.0 - 6.0 ug/dL
1 hour post 4.2 L 6.0 - 18.0 ug/dL


Desired pre- and post-ACTH cortisol for dogs on Trilostane (or Lysodren) therapy: Both pre and post samples between 1.0 & 5.0 ug/dL

It was low, but my internist was pleased with the results.

That post number is great and is not too low. The reference ranges that are used for Trilostane are 1.5 ug/dl - 5.4 ug/dl and if symptoms are controlled that post number can be as high as 9.1 ug/dl...so Alva's post result is prefect.


He hunches his back like something hurts.

Hunching of the back is something a dog with pancreatitis will do, I'd keep an eye out for any more of this stance and if he starts to lose his appetite, have diarrhea, or vomiting, he needs to be seen right away.


My vet wants to do another ACTH follow-up 30 days from now to make sure his levels are okay.

Are the numbers too low? My vet said not to worry about the pre-levels being really low. She said they are more concerned about the post levels. He had the test started a little over 4 hours after his breakfast Vetoryl. Thanks for the input... still trying to figure all of this out.
-dayle and alva, who charmed the scrubs off the vet hospital staff yesterday! :cool:

Aww, I bet Alva charmed them, he is such a handsome boy!!! The next ACTH stimulation test is usually performed 30 days after treatment was started because a dog's cortisol can drift downward during the first month of treatment, so if you notice any signs of cortisol going too low an ACTH stimulation test may be needed.

Hugs, Lori

[molly muffin]

I too was always told not to worry too much about the pre level that it is the post level that is most important. If you think of the ACTH as a sponge test, the pre is what is in his body just at any given moment and when the shot is given, it causes the adrenal gland to dump in the body whatever is being held in the adrenal gland, and then test that. He has 6.0 which is just fine and his adrenal gland is making enough cortisol.