New-Blood tests point to Cushings-Please help!

[RomeotheBoy]

Hello everyone,

My Romeo is a 12 1/2 year old Yorkshire Terrier who I recently brought to the Vet. for what I thought were allergies. He's always had dandruff but a few weeks ago he developed some sores down his back and his chest. None were bothersome to him but I took him to the vet anyway. She suspected Cushings, also due to his pot-belly appearance, and blood test results point to him having it. His cholesterol and triglycerides were high and his urine was diluted as well. In the meantime we have changed his food to Urinary SO Moderate Calorie (he was previously on the full calorie version of this specific food bc it helps to control his kidney stones-hes been on this for many years now and its helped to keep them at bay).

On Saturday I will bring them a urine sample and from there we will determine whether or not to do the LDDS Test.

Other than his skin he doesn't have all the symptoms I've been reading about. I am at work 8 hours a day and at the very end of the 8 hours he gets out of his bed to pee and drink just once. Yes, when I am home he will pee and drink more frequently but manages not to drink or pee when I'm not home so I feel that this doesn't point to excessive thirst/urination. His appetite is fairly normal as well.

I have been reading a lot on the subject of treating vs. not treating and here are my questions.....

-Will the LDDS test tell me how severely his Cushings is if he does in fact have it? If so will that help me to make a decision about treatment?

-Will the LDDS test indicate which type he has (Pituitary dependent vs Adrenal dependent)? Does that info. alone point to treating or not treating?

-In the meantime should I try adding Melatonin/Lignans/etc. to help in any way? Could these be taken if he were to take medicine?


Just like the rest of you-I am in love with my Romeo and I'm sad and worried. The fact that he's aging is sad enough to come to terms with and now this adds a whole new level of worry. Above all I want to do what's right for him to make him comfortable and happy, so I am doing my best to be educated and make the right choices.

Thank you for any and all input you could offer. I look forward to learning more.

[Harley PoMMom]

Hi and welcome to you and Romeo!

I only have a moment to post but I do have a couple of comments.

The ACTH stimulation test measures the cortisol in a dog's system, other things can cause the cortisol to be elevated besides Cushing's, any non-adrenal illness will make the cortisol run higher, so unfortunately the ACTH test will not be able to tell you how severe the Cushing's is.

The ACTH stimulation test can not differentiate between the adrenal or pituitary type, the low dose dexamethasone suppression (LDDS) or an ultrasound have the ability to do that.

Romeo's case does not scream Cushing's to me as he doesn't display the common obvious symptoms such as: excessive drinking/urinating, ravenous appetite, panting, rear leg weakness. Since Cushing's is a slow progressing disease one does not have to start treatment right away.

I'll try to get back later and I'm sure other members will be by to share their thoughts and advice as well.

Hugs, Lori

[RomeotheBoy]

Hi and welcome to you and Romeo!

I only have a moment to post but I do have a couple of comments.

The ACTH stimulation test measures the cortisol in a dog's system, other things can cause the cortisol to be elevated besides Cushing's, any non-adrenal illness will make the cortisol run higher, so unfortunately the ACTH test will not be able to tell you how severe the Cushing's is.

The ACTH stimulation test can not differentiate between the adrenal or pituitary type, the low dose dexamethasone suppression (LDDS) or an ultrasound have the ability to do that.

Romeo's case does not scream Cushing's to me as he doesn't display the common obvious symptoms such as: excessive drinking/urinating, ravenous appetite, panting, rear leg weakness. Since Cushing's is a slow progressing disease one does not have to start treatment right away.

I'll try to get back later and I'm sure other members will be by to share their thoughts and advice as well.

Hugs, Lori



Thank you Lori! Am I able to request the LDDS test instead of the ACTH test? Is it more accurate/specific? My vet mentioned the ACTH test and that's why I was considering it.

[RomeotheBoy]

Hi and welcome to you and Romeo!

I only have a moment to post but I do have a couple of comments.

The ACTH stimulation test measures the cortisol in a dog's system, other things can cause the cortisol to be elevated besides Cushing's, any non-adrenal illness will make the cortisol run higher, so unfortunately the ACTH test will not be able to tell you how severe the Cushing's is.

The ACTH stimulation test can not differentiate between the adrenal or pituitary type, the low dose dexamethasone suppression (LDDS) or an ultrasound have the ability to do that.

Romeo's case does not scream Cushing's to me as he doesn't display the common obvious symptoms such as: excessive drinking/urinating, ravenous appetite, panting, rear leg weakness. Since Cushing's is a slow progressing disease one does not have to start treatment right away.

I'll try to get back later and I'm sure other members will be by to share their thoughts and advice as well.

Hugs, Lori

My apologies Lori-I misspoke-I have so much info. and acronyms in my head and its def. spinning..... the test my vet suggested if we were to move further is the LDDS test-not the ACHT...... I edited the post to reflect that-At least now I have some info. on that test-so sorry!

[lulusmom]

Hello and welcome to you and Romeo.

It would be very helpful if you could round up all of the blood and urine labs that were done so far and post the results here. With respect to the blood labs, we need only see the high and low values, and please include the normal reference ranges. Was Romeo fasted for the testing?

With respect to the urine test, I would be most interested in the urine specific gravity (USG). I find it highly unusual that Romeo has diluted urine yet he apparently does not drink and pee excessive amounts. Most cushdogs do have dilute urine because they lose the ability to concentrate their urine. These dogs normally pee great volumes of urine and drink huge amounts of water to stay hydrated. With respect to Romeo's skin problems, did your vet do any scrapings or cultures to identify the type and cause? Is Romeo itchy?

I'm sorry for the reasons that brought you here but I'm glad you found us. I look forward to hearing a lot more about your precious Romeo.

Glynda

[RomeotheBoy]

Thanks so much. I will get the numbers from my vet asap. But what about my questions about those tests? Id love to know some more information and know whats ahead of me.

Thanks again!

[Harley PoMMom]

Thank you Lori! Am I able to request the LDDS test instead of the ACTH test? Is it more accurate/specific? My vet mentioned the ACTH test and that's why I was considering it.

Yes, you can dictate what test is performed. I'm going to elaborate a bit more about the tests that are used for Cushing's. What test should be done is dependent on the dog's symptoms and health issues.

If a dog has very mild symptoms of Cushing's a screening test known as the urine cortisol: creatinine ratio (UC:CR) can be done. The UC:CR is a simple urine test that measures the amount of cortisol in the urine. If the results are normal than the chances of that dog having Cushing's is pretty much zero. Now, if the results do show that a high amount of cortisol is detected than another diagnostic test needs to be performed.

The two diagnostic tests that are generally recommended are the LDDS and/or ACTH stimulation. The LDDS is considered the "gold standard" test for Cushing's, however if a dog does have a non-adrenal health issue or are overly stressed this test can yield a false positive result.

So, if the dog does have obvious symptoms of Cushing's and has an underlying health problem the ACTH stimulation is the better option.

Now, getting back to Romeo, since he is not displaying strong Cushing's clinical signs, if this were me, I would forgo testing for Cushing's at this time. If, however, in the future he would start showing symptoms that are characteristic of Cushing's than the next step would be to have him tested. This is just my opinion and hopefully others will share theirs as well. ;)

I'm going to direct you to our Helpful Resource Forum where we have a wealth of information regarding Cushing's; the medications used and the treatment protocols. It also includes articles written by some of the most renown veterinarians that specialize in endocrinology such as David Bruyette, Mark Peterson, and Edward Feldman. An educated dog owner is a very important factor in treating this disease so please utilize it and if you have any questions do not hesitate to ask them. ;)

Here's that link to our Helpful Resource Forum Helpful Resources for Owners of Cushing's Dogs (http://www.k9cushings.com/forum/forumdisplay.php?f=10)

Hugs, Lori

[lulusmom]

I apologize for not answering the questions you posed in your first post. Please see my responses in blue text below. If there is something you don't understand, please don't hesitate to ask because that is how we learn and become even greater advocates for our dogs.



I have been reading a lot on the subject of treating vs. not treating and here are my questions.....

-Will the LDDS test tell me how severely his Cushings is if he does in fact have it? If so will that help me to make a decision about treatment?

Results of the LDDS test is not reflective of the severity of the disease but if results are consistent with cushing's and a dog presents as cushingoid, has overt symptoms and lab abnormalities consistent with cushings, then a positive result would indicate that the disease has progressed enough to cause a disconnect between the pituitary gland and the adrenal gland. When this happens, the pituitary gland is releasing a constant stream of acth hormone and the pituitary gland responds by releasing excessive amounts of cortisol. The acth stimulation test measures the adrenal glands' response to a synthetic form of acth and dogs with cushing's will have an exaggerated response. This exaggerated response may be a better measurement of disease progression based on the level of post stimulated cortisol; however, I believe it is the symptoms that guides us in our decision to treat. Both of my cushdogs had very overt and problematic symptoms so opting out of conventional treatment was not an option. There are many horror stories on the internet about Lysodren and Vetoryl and I'm here to tell you that after moderating thousands of threads, the vast majority of adverse reaction is due to a vet who is not following protocol and a pet owner who hasn't taken the time to bone up on the disease and the pill or capsule they are putting in their dog's mouth. The welfare of every dog who walks through our door is our primary objective so we will help you learn by sharing our experiences and credible reading material that will help facilitate Romeo's treatment safely and effectively.

-Will the LDDS test indicate which type he has (Pituitary dependent vs Adrenal dependent)? Does that info. alone point to treating or not treating?

Sometimes the results of an LDDS will tell us if the dog has PDH. If you share Romeo's results with us, we can make that determination and explain it in more detail. If the elevations in the 4 and 8 hour draw are not consistent with PDH, a validating and differentiation test is needed. Most of us agree that the abdominal ultrasound is well worth the money as it not only makes that differentiation but also gives the vet a good look for the usual adrenal gland and liver abnormalities seen in cushing's as well as get a good look at surrounding organs for possible nonadrenal problems that could be contributing to symptoms. I personally would choose the ab ultrasound because if my dog had an adrenal tumor, I would want to know because 1) surgery may be an option and a complete cure and 2) there is a 50% chance of malignancy in adrenal tumors which can cut a dog's life short. I would definitely want to know what my dog and I are dealing with.

-In the meantime should I try adding Melatonin/Lignans/etc. to help in any way? Could these be taken if he were to take medicine?

The goal of treatment is to remedy problematic symptoms, which are most often more of a problem for a pet owner than the dog. If Romeo's symptoms are problematic and your vet has done an adequate job of testing to confirm the diagnosis, then treatment with one of the two effective drugs, Vetoryl or Lysodren, would be best. Melatonin and Lignans is prescribed for dogs with atypical cushing's, which means the dog has normal cortisol but one or more of the other adrenal intermediate hormones is causing symptoms. The efficacy of this regimen is not that great and it will not effectively reduce cortisol.

Since you are at a crossroads of whether or not to treat with Vetoryl or Lysodren, I've cut and pasted an excerpt from a Canine and Feline Endocrinology veterinary textbook that can help guide you if and when you and your vet discuss an appropriate treatment for your dog.


To Treat or Not to Treat

The “urban legend” exists that survival is the same whether or not a dog with HAC is treated. That statement has never been scientifically evaluated. It may be true for some dogs, but likely not all. Importantly, treatment typically greatly improves quality of life for both the owner and dog.

On the other hand, not all dogs with positive tests for HAC need to be treated and the decision should be made on a case-by-case basis. In deciding when to treat, consideration should be given to the dog, quality of life, the owner, and clinical signs. None of the drugs are cheap and neither mitotane nor trilostane are benign; therefore, treatment is not to be taken lightly. If the only clinical sign is a benign clinicopathologic finding (e.g. elevated serum ALP activity) treatment is not warranted (neither is testing). If the issue is only cosmetic (e.g., poor hair) or very mild (e.g., slight increase in thirst and urination), a frank discussion should be had with the owner of the risks and benefits. In making the decision, further questioning of the owner on issues that might relate to clinical signs (e.g., the dog has stopped jumping on furniture –a sign of possible muscle weakness) can be helpful, as well as seeking evidence of clinical signs that the owner might not note (e.g., serial evaluation of urine samples collected at home for consistent suggestion of polyuria/polysipsia). It is also important to test for proteinuria by measurement of a UPCR and for hypertension by measurement of blood pressure. Both can damage the body; so if either or both are present and due to HAC, treatment may be more imperative. On the other hand, clinical signs may be recognized in retrospect; for example, an owner attributes decreased playing to old age, but when HAC is treated, the activity increases. Treatment of HAC can unmask diseases that may be inapparent due to the anti-inflammatory effects of hypercortisolemia. For example, clinical signs of atopy or degenerative joint disease may develop with treatment of HAC as cortisol concentrations decrease.

Therapy without knowing whether AT or PT
At times the differentiation between PDH and AT is not possible due to such issues as owner financial constraints or inconclusive or conflicting results on differentiating tests. In such a situation, given that the vast majority of dogs have PDH, therapy can be initiated accordingly. However, the owners should understand that an accurate prognosis cannot be given and that attempting to differentiate between the forms once therapy is started is quite difficult, if not impossible.

[RomeotheBoy]

THANK YOU! I can't tell you how much I appreciate help and guidance. The past few days have been so stressful with trying to read and understand to just do what's best.

The vet called me today and his thyroid numbers were low which they told me points to Cushings. I am doing the urine test that you mentioned on Saturday. I have also started keeping a log of his drinking and peeing. I want to share this with others because maybe I am so used to it that it doesn't seem abnormal to me?

I really appreciate your input. Most of all right now I feel sad. Of course this goes without saying but sadness mixed with confusion is way worse. Thank you for helping with the latter....

[DoxieMama]

Hello and welcome from me too. Did the vet mention any other abnormal values in the bloodwork? Low thyroid points to a thyroid issue to me, unless there are also other indications of Cushing's. I highly recommend you obtain copies of the test results themselves, so you can see the numbers (and share them here :)) --- and so you have them on hand if you ever need them for an emergency.

[molly muffin]

Hello and welcome from me too. Glynda, Lori and Shana have covered everything I could possibly think of I'm sure. :)

I will say that if Only the thyroid value is out of order, that does point more to thyroid than cushings. A skin scraping to determine what the sores are is important too I think, along with the UC:CR, which is a good place to start when symptoms aren't present.

So, baby steps and lets see what the UC:CR shows, I'd also get that skin scraping over if you really want to know for sure, ask them to biopsy one of the sores. If it is calicinosis cutis, then this is almost always due to high cortisol levels, usually caused by cushings.
In the mean time I'd use an antibiotic spray to make sure they don't get any infections and to try and clear them up. Cutting away any hair that can get matted in the sores and allow them some space to try and heal.

[RomeotheBoy]

Ok so here are his numbers-I will post the abnormal ones....

ALT (SGPT) 148 Normal-12-118 IU/L
ALK Phosphate 1524 Normal-5-131 IU/L
Cholesterol 675 Normal-92-325 mg/dl
Triglyceride 1218 Normal-29-291 mg/dl
PrecisionPSL 541 Normal-24-140 U/L

T4 0.8-3.5mg/dl <0


I dropped off his urine on Saturday and will get results tomorrow. I am so nervous. I've logged how much he drinks and goes to the bathroom and it's more than I realized. However, he doesn't do either one all day while I am at work and his water bowl and wee wee pad are both accessible to him. I'm not even sure what to think. I guess I will see what the results are tomorrow and go from there.

[DoxieMama]

Thanks for posting those results. I'm sure that others with more experience and knowledge than I will have more to say about them, but I would be asking about the thyroid and pancreatitis with those results!

[Harley PoMMom]

T4 0.8-3.5mg/dl <0

The T4 is for the thyroid and measures the total amount of T4 [thyroxine] hormone circulating in the blood. If I'm seeing this correctly Romeo's T4 was <0, is that right?

If so, I would want either a full thyroid panel done or at the very least a measure of the free T4 which represents the tiny fraction (< 0.1%) of thyroxine hormone.



Ok so here are his numbers-I will post the abnormal ones....

ALT (SGPT) 148 Normal-12-118 IU/L
ALK Phosphate 1524 Normal-5-131 IU/L
Cholesterol 675 Normal-92-325 mg/dl
Triglyceride 1218 Normal-29-291 mg/dl
PrecisionPSL 541 Normal-24-140 U/L

All of these abnormal blood chemistry levels are found in dogs with hypothyroidism, so my recommendation would be to rule out any thyroid issue.



I dropped off his urine on Saturday and will get results tomorrow. I am so nervous. I've logged how much he drinks and goes to the bathroom and it's more than I realized. However, he doesn't do either one all day while I am at work and his water bowl and wee wee pad are both accessible to him. I'm not even sure what to think. I guess I will see what the results are tomorrow and go from there.

I'm assuming since a urine sample was dropped off that the vet is having the UC:CR test performed. If Romeo does indeed have a thyroid problem this can cause high cortisol levels and the UC:CR test results may reflect that.

So if Romeo's UC:CR result is high other diagnostic tests will need to be done and if his T4 count is less than 0, I think, a thyroid panel would be the next test to have done.

Hugs, Lori

[molly muffin]

yes I'd check thyroid fully next, I'd do a UC:CR (urine creatinine/cortisol) it can rule out cushings, but not confirm it. But that thyroid result is even lower than we normally see with cushing dogs.
Also, implement a low fat diet, and give smaller meals several times a day, as that pancrease results are elevated, but perhaps can head that off, and the trig are very high so need to get that down.

[RomeotheBoy]

He is on Urinary SO14-moderate calorie... He was previously eating the regular calorie. He had a problem with stones so that is why he needs this specific food. I hope that will help.


I got his UC:CR results back tonight and his level was 29-The vet said normally below 13 points to no Cushings so obviously 29 says otherwise = (

I forgot to ask her but is 29 very high for the Cortisol level? What have you guys seen?

I brought Romeo in for a skin thing he had going on. He does urinate frequently, as well as drink, but it is not problematic and it's been this way for a while. He doesn't pant. Yes some other numbers are high/low that could be because of the Cushings. She suggested taking his blood pressure next to see where that stands and then possibly go through with the LDDST.

[molly muffin]

It's high but it doesn't mean for sure cushings, as other things can cause an increase in cortisol. Pancreatis for instance, etc. Thyroid has the same symptoms as cushings so that is why I'd go for the full thyroid panel. As getting that sorted might make the symptoms go away. Then once that is done, you have a normal thyroid test, of course depending on what the full panel says but we know it is already way low, after you get that done, then I'd redo the UC:CR to see if cortisol is still elevated.

yes I am familiar with the SO food as my dog was on it for crystals too. Did the vet talk to you about that? A vet dietician might be able to give some recomendations for food to get trigs down and still have a food that would be good to help prevent the stones.