Help & advice

[treecott]

Hi, I am new to this forum, and live in the UK, so hope it is ok to post on here. I have a shih tzu, called Murphy, he is approx 10lbs in weight, and the vet believes he has cushings disease. He does not have many symptoms of the disease, really only hair loss, and lethargy and weakness in his back left leg. In Dec last year, the vet thought he had arthritis in his back leg, as he was not managing to walk as far on his daily walks. He was put on Metacam, and had some blood work done. At the time, he had started to lose some of his fur, and his tail was very sparse. We mentioned cushings then, or hypothyroidism, but our fears were dismissed.

In february of this year, he was checked over by a different vet, who said that he had the beginnings of Degenerative neuropathy, and that he would eventually become paralysed in his back legs, and also she found a testicular tumour. He had the tumour removed and he recovered well from the op. We settled ourselves to the fact he had this degenerative disease. In June, we took him back to get his 6 month bloodwork done again, and his liver enzymes were high. The vet said from these she thought it was cushings, and wanted to do an ACTH test. We had this done, and he has tested positive for Cushings.
Even the vet has said he doesnt have many of the cushings symptoms, but it is according to her a definitive diagnosis, and se wants to start Vetoryl. I will try and post his results here if I can - so bear with me being new.

My problem is his liver enzymes are quite high, and to buy some time, and give us time to think what to do, we have put him on Denamarin for a month, and will have another blood test done to see if the liver enzymes have come down. It seems a bit of a chicken and egg, is his liver enzymes high because of cushings, or is the liver damaged.

I know the way we measure in the UK is different to other countries, so I hope you can make some sense of the results. Any advice would be much appreciated, as I dont want to start vetoryl if something else is affecting his liver, and it is giving a false ACTH reading. I have read that Metacam can cause liver damage, and he was first put on that in December, and that is the only thing that he has had which may affect his liver other than Cushings. Incidentally, since I started the Denamarin, I took him off the Metacam, and he has been off that just over a fortnight, and he seems much more alert, Thanks in advance

[treecott]

I have tried to upload the test results, but cannot find out how to do this, so I will detail the results which were classed as high.
Dec 2016.
ALP - 52 U/l (ref 12.00-83.00)
ALT - 210 U/l (ref 13.00-78.00) high
Gamma GT - 16.0 U/l (ref 6.00-14.00) High
Cholesterol - 8.8 mmol/l (ref 2.80-8.30) High

June 2017
ALP- 144 U/l (ref 12,00-83.00) HIGH
ALT - 822 U/l (ref 13.00-78.00) HIGH
Gamma GT - 78.0 U/l (ref 1.00-14.00) HIGH
Urea - 8.1 mmol/l (ref 1.70-7.40) HIGH)
Cholesterol - >11.64 mmol/l (ref 2.80-8.30) HIGH

everything else was normal.

His v-T4 thyroid was 14.2 nmol/L (15.00 - 55.00 ) LOW

I dont know why his ALT has gone up so much since December, I can only think it has to do with the Metacam, his ALP is high, but having read some posts on here, it is not that high.

ACTH test results June 2017

Cortisol Pre (C) 208 nmol/L (ref 50.00-250.00
Cortisol Post 692 nmol/L
Post ACTH values greater than 600 nmol/l - suspicious for HAC
Post ACTH values 500 - 600 nmol/l - Equivocal
Post ACTH values less than 500 nmol/l - suggest normal adrenal function but do not exclude HAC

Hope someone can make some sense of these results. Thanks in advance.

[Squirt's Mom]

Hi and welcome to you and Murphy! :)

I have a couple of questions about the results you posted. In Dec. you say his ALP was listed as high but according to what you typed it is not, it is within range -


ALP - 52 U/l (ref 12.00-83.00)

Is this a typo?

Also you say the T4 was high but based on the numbers posted it is not low but actually HIGH - typo?

[quote]His v-T4 thyroid was 14.2 nmol/L (ref 2.00-6.30) LOW

I wanted to get clarification on these values then members can start replying to you. ;) I'm glad you found us and look forward to learning more about you and Murphy as time passes!

Hugs,
Leslie and the gang

[treecott]

Hi Squirt's mum, and thanks for the reply. Firstly, Regarding the ALP in December, I am sorry I added this with the other readings which were (high), but I thought if I added it in, even though I know it is within limits, it would give an idea what it was in December, compared to June. Sorry for the confusion.

Also, regarding the T4 in June, my apologies, that was a typo error. I read the limits for the one above by mistake, sorry. It should read
v-T4 - 14.2 nmol/L (15,00 - 55.00 ) LOW.

I apologise for my errors, and hope that helps you, and any others who may wish to offer advice. Thanks in advance.

[Squirt's Mom]

Thanks! I corrected your original post to reflect the correct range for the T4.

As for being from the UK, that's ok, we forgive you. :D:p:D:p Actually we have members from all over the world and we are very glad to have you with us regardless of where you may come from! :):):)

Did the vet say Murphy has degenerative neuropathy or degenerative myelopathy? Degenerative myelopathy is a condition in dogs that causes paralysis. Here is a link about that so to help you decide if that is what the vet meant - http://www.caninegeneticdiseases.net/DM/basicDM.htm

With all that Murphy has going on it is no surprise his cortisol is elevated. This is one of the things that makes this disease so very hard to correctly diagnose - other illnesses can cause false-positives on the Cushing's tests. I know the Metacam will affect the liver enzymes but I'm not sure if the degenerative process he is dealing with will also have an affect on them or not. I would want to ask the IMS about that just for my own peace of mind. Cushing's can certainly cause changes there but many other things can as well. Fun, huh? :p

Murphy has arthritis; be aware that in lowering the cortisol the arthritis is likely to get worse. The cortisol acts a sort of "natural" treatment for inflammatory processes like arthritis, allergies, etc. and when it is lowered back to a more normal range those conditions come roaring to the forefront.

I think for now I would continue with the Denamarin and see if there is another anti-inflammatory that might be a bit easier on the liver than Metacam. Then if the values don't come down and you start to see more cush sign look at Cushing's again. Just me but I think that's what I would do right now.

Others will be along soon to chat with you I'm sure! So hang on!
Hugs,
Leslie and the gang

[treecott]

Hi Squirt's Mom, thanks for amending my original post, and for accepting me from the UK, someone has to live there!!!. The vets originally said his back hind leg was arthritis, then changed it to degenerative neuropathy, but now has said could be caused by Cushings, or the degenerative neuropathy, she doesn't know for sure, and has suggested using Vetoryl for a month or two to see if helps his back leg, however, this is a bit too vague for me, I would like to know one way or the other, and because of his age, she is reluctant to do further testing for Degenerative neuropathy as it is rather invasive. I personally feel it could be something to do with his thyroid, but the vet is leaning more to cushings, but I dont know whether the liver enzymes are giving false positives in the ACTH test, as they are quite high, especially the ALT. I would prefer to keep him on the Denamarin for a little while longer to see if his liver enzymes come down He seems to be managing quite well without the metacam, and I want to keep him off his meds until he has this next blood test so nothing else skews the results. Obviously, if he has a problem with pain, I will ask for something for him. We are just hanging in there hoping and praying his enzymes comes down to a more normal level. Thanks for your advice.

[molly muffin]

Hello and welcome from me to. I'm in Canada! :)

So, okay, I wouldn't really go down the degenerative neuropathy yet.
Ask about tramadol for pain management over metacam that isn't has hard on liver and isn't as bad with high cortisol as metacam is.

Denamarin is a good help for the liver, and hopefully you'll get that to come down but I think you'll want off the metacam too. Then see if it resolves or not.

What was the ACTH result numbers? We use the same units here in Canada as the UK, and we've had quite a few UK, Canadian, Aussie members, so are use to doing the conversions. no worries there.

But that would be my plan for the moment, switch pain management. (adequan also might work for possible arthristis) water therapy is good for the legs too. see how the denamarin does and retest, go from there

Also it is very possible that the high cortisol is causing the back leg problem, we see back leg weakness often with high cortisol (cushings) so that is possible. The fur loss can be from the low thyroid or from the high cortisol.

[treecott]

Hi Molly Muffin, thanks for your reply and advice. I personally dont think it is Degenerative neuropathy, I think from Dec to now I would have seen a lot more degeneration than I have. Will ask the vet about Tramadol, thanks for the info on that. He has been off the Metacam now for nearly 3 weeks, and on Denamarin for 2 weeks, and already I am seeing an improvement in his alertness, and he seems to be managing pain wise as far as I can tell. I posted the ACTH result numbes in my original post, but for ease, I am listing them again. Cortisol Pre (c) 208 nmol/L (ref 50.00-250.00) and Cortisol Post 692 nmol/L. The vet said it was definitive, but like I have said, the only symptoms he has are loss of hair, rear end weakness, and lethargy. I do believe the Metacam has affected the ACTH results, and once he has his liver test results soon, I am really hoping being off the metacam will bring these down along with using the Denamarin.

My dilemma really is if it is cushings, is it that which is causing the liver enzymes to rise, or has it been the Metacam which has caused the liver enzymes to rise, thus giving a possible false positive on the ACTH test. I guess time will tell when we get the next set of blood work done to see if things have changed very much. I am going to get a cbc and a complete thyroid test done as well, and depending on cost, possibly an ultrasound of his liver to see if there is a problem there if the enzymes dont come down. Any suggestions on my thoughts for course of action. Thanks

[molly muffin]

He was on the metacam when the ACTH was done I take it?

Those numbers definitely signify high cortisol and we often see high liver numbers in cushings, but how much was from metacam and how much from another cause is unknown until you can test later on. We even see thyroid affected which can even out if caused by cushings and once on medication for it. If things are still high when you next test, I would probably go ahead and start a low dose of cushing med vetroyl to get the cortisol down a bit, but not too much to make things uncomfortable.

[treecott]

Yes he was on Metacam when he had the ACTH done. The next test will be done on 27th July, as that will be a month on Denamarin. Keeping fingers crossed for him. He does definitely seem brighter off the Metacam, but will keep you posted about the results, and what we are going to do. Thanks for the advice though its much appreciated.

[molly muffin]

Thanks for letting us know. Hoping the numbers have come down with the denamarin when they test.
My dog ran in the 800's on ALKP for a long time before it went up any further.
It is very common in dogs with cushings for the liver ALKP to be raised significantly and the ALT some also.

Treatment for cushings can help to bring those numbers down in some dogs. Not all. We never got my molly's ALKP down much further.

[treecott]

Thanks for your reply. We were at the vets yesterday with one of our other dogs who had a UTI, and we spoke to her about Murphy. She was pleased that he is improving on Denamarin, and we said we would come in on 27th for a blood test, and asked about getting an ultrasound on his abdomen, to show the liver and other organs to see if everything is "normal", or not, to see what we are dealing with. She gave us an idea on price, which was less than we expected, so we may know more then. The vet did say that Metacam does affect the liver, so hopefully, keeping fingers crossed that the liver enzymes come down with him being off it now.

Do you knowwhich liver enzyme was the one which reflected the high level of cortisol, was it the ALKP, or the ALT, because Murphys ALT is a lot higher than the ALKP one, or does it affect both. Thanks Will keep you posted when we get the results.

[molly muffin]

ALKP is more likely to be increased with cushings, although there is always a few who don't follow that pattern and have no increase in liver enzymes.

You can't use liver enzymes to diagnose cushings, as ALKP can raise due to other things too.

[labblab]

Yes, as Sharlene says, high elevations in ALKP are common with Cushing's. Other liver markers such as ALT may also show elevation, but typically it is the ALKP that is the most extreme.

Marianne

[treecott]

Thanks for the information on which liver enzyme is high for suggested Cushings. My murphy's ALKP was 144, and his ALT was 822. We are getting another blood test done on 27th July after a month on Denamarin, and 6 weeks off Metacam, and hope it brings them down. I must confess, he seems to have more symptoms of hypothyrodism than Cushings, and as the ACTH test was just over borderline, I am wondering if the Metacam has affected the results of the blood tests, which maybe has created a false positive for cushings on the ACTH test - not sure how all this works, but hoping for the best but expecting the worst. Thanks to Molly Muffin, and Labblab for your help in trying to get me to understand. Wendy x Will keep you up to date when I get the next results.

[molly muffin]

With the ALT being the really high one and liver specific I'm hoping that with the metacam stopped that you will see that number come down. Keep in mind, I'm looking for even a bit of movement downwards as it can take a bit of time for the liver to recover, but we know that with time, a liver who can make a good recovery. So I'm hoping and even inclined toward there being something that affected the liver.

It is almost backwards of what we expect to see in liver results with cushings. You'd expect the ALKP to be much higher and the ALT to be slightly elevated.

[treecott]

Thanks , I too am hoping to see better results, especially the ALT. Having read up a lot on Cushings, and with the help of people on here, I agree, you normally see the ALKP go up, more than the ALT, so if it is liver specific, and we are having an abdominal ultrasound done, then we may get some answers, (hopefully). Will post the results when I get them, but thanks for your information, it has been great.

[treecott]

Hi everyone, sorry for the delay in posting, just got the results back from Murphy's bloodwork yesterday. Good & not so good news though. Results are as follows:
ALP - in June 144 U/L - July 160 U/l - Ref 12 -83
ALT - in June 822 U/l - July 452 U/l - Ref 13 - 78
GGT - June 78 U/l - July 86 - Ref 1.0 - 14.0
Urea - June 8.1 mmol/l - July 9.0 mmol/l - Ref 1.7 - 7.4
Cholesterol June >11.64 - July >11.64 - Ref 2.8 - 8.3

The abdominal ultrasound showed nothing of note according to the vet. There were no masses, no gallstones/sludge, no liver size change, the spleen was ok, kidneys ok, stomach ok, and the intestines ok. No other information other than that. I am still awaiting the complete thyroid panel results, which had to be sent away, and the results will be back by mid next week, so will post them when I get them.

Overall, we are pleased the ALT has come down, quite significantly, but with the ALT & the GGT going up, the vet still believes it is Cushings, can I ask what are your thoughts on this? Thanks in advance

[treecott]

Hi, can anyone give me any thoughts on the above results please. Help needed as to what to do next. Thanks

[labblab]

Welcome back again, and I'm sorry we've been so slow to offer you any feedback :o.

However, in honesty, I remain somewhat stumped by Murphy's testing profile and am uncertain as to what to recommend right now. Please do let us know what the full thyroid panel looks like. If he is diagnosed with primary hypothyroidism, then I believe I'd solely launch into treatment for that right now, especially since it is so simple and inexpensive. In another couple of months, I would probably then retest again with a full blood chemistry panel in order to see where things stand.

If the thyroid panel instead points to hypothyroidism secondary to some other condition, then Cushing's again gets thrown into the mix. As you know, though, Murphy's liver results are not what we typically expect to see with Cushing's -- the really high ALT and much lower ALKP. However, the Metcam may indeed have been a confounding variable in that sense, and his ALT may continue to lower as more time passes with him off the NSAID. In other words, over additional time, the liver elevations may start to more closely mirror the profile with which we're most familiar.

However, time after time, we have been cautioned by experts that it is not usually prudent to begin Cushing's treatment in dogs who basically exhibit only liver enzyme abnormalities in the absence of observable clinical symptoms that are consistent with the disease. In the absence of typical symptoms, the diagnosis always remains suspect. And if I'm understanding things correctly, Murphy's chief observable complaint is the hind leg issue, which may not be Cushing's-related at all.

I don't think we've yet been told how old Murphy is. His age might really be a factor here in terms of treatment decisions, as well. As has been mentioned earlier, certain issues such as arthritis may actually worsen as cortisol levels are lowered.

So once again, I apologize for feeling a bit befuddled, myself. But I do think I'd await those thyroid results before making any other decisions. Please do let us know how they turn out, OK?

Marianne

[molly muffin]

Well I agree that it is a bit confusing to see the GGT and the ALKP come up but this could be in response to the ALT still being elevated and that has an effect on the liver. The good news is that the ALT is coming down so it could be possible that the GGT and the ALKP will come back down especially if the ALT comes back to at least close to normal range.
I am with Marianne that I wouldn't start cushing treatment solely based on liver enzymes though. And I don't think until we see how things are going to go with the ALT going forward, that we have a complete picture.

Being off metacam the ALT almost came down 50% so I think we can say that the medication has been the culprit of that particular liver enzyme increasing. This I am hoping will continue to come down even more

How are his back legs doing now?

[treecott]

Hi Marianne & Sharlene, thanks for the information, as always good advice. Marianne, Murphy is 13 years and 3 months, and very much loved. His only symptoms are loss of coat/thining coat, lethargy, and rear end weakness. The lethargy has improved quite a bit since he came off the Metacam. His rear leg is still weak, but has got no worse since the diagnosis of degenerative neuropathy in February, which makes me think it is not related to that. He manages to walk about ok, but is slow (mind I would be if I was that old).

My personal belief it that the vet doesnt know what it is - but because his liver enzymes are up, she is attributing it to Cushings. He was on Metacam at the time of his ACTH test, which was 692 nmol/l which is over to 600 to confirm Cushings, but I cant help wondering if the Metacam had affected that result when I see the liver ALT coming down by almost 50% in a month. We get the results of the Thyroid panel in the middle of this week sometime, and I will let you know what they are - good or bad, but my inclination is the same as you both, not to start Vetoryl until we know for definite that he has Cushings. It is so good to have someone to bounce things off, as the vet doesnt always have time to answer all the questions. Could I ask either of you, are there any other things to look out for on the bloodwork which could point towards Cushings. I have only been given copies of the biochemistry results, and the ALP ALT, GGT & Cholesterol are high, as you know, but it would be helpful to know what else to look for.

In the meantime, he is still on Denamarin we are now into the second month with these, and vit e, ginkgo biloba, and glucosamine & chondroitin for his arthritis in his leg. Will let you know as soon as I get the thyroid results. Thank you both very much for your advice and information.

[molly muffin]

Blood work wise, it is Usually the ALKP that really goes up with cushings and the ALT a smaller amount.

Generally you look for symptoms like starving for food all the time, drinking and peeing excessively, hair loss down the back and tail, thinning skin, back leg weakness.

Thyroid problems can present the same sort of symptoms though.

[treecott]

Thanks for that information. Still waiting for the Thyroid results, will post when I get them. Wendy

[treecott]

Hi everyone, got Murphy's Thyroid results, and unfortunately he is not Hypothyroid. So we are back to the Cushings diagnosis, with the back to front liver enzymes. We have decided at this stage, not to treat Murphy with Vetoryl, we are going to keep him on Denamarin, and monitor his enzymes for another couple of months to see where we are then, and then have more blood tests, and perhaps another ACTH test done to see if the levels have altered at all. Obviously if there is any change for the worse, we will not hesitate to then start Vetoryl. Thank you everyone for your advice and help.

[labblab]

Hi again, Wendy. Well darn, I was kind of hoping Murphy's thyroid results would come back low -- that is just such an easy condition to treat. But under these circumstances, I think I'd do exactly what you're planning to do, too. It seems like a reasonable course of action, and with a bit more time, perhaps a different treatment decision will become more obvious.

Please keep us updated as to how Murphy is doing, though, OK?

Best wishes to you both,
Marianne

[treecott]

Hi Marianne, yes, we were also hoping Murphys thyroid result would come back low, as I was so sure that was what it was - not my luck - or his unfortunately. Its nice to know that you agree with our course of action, as we are just struggling with this diagnosis, as he doesnt fit the symptoms, and his results dont either, so we are hoping that by doing what we are doing, he may get better results next time. As for how he is doing, he is quite well in himself, his rear leg is not too good but he manages to get about ok. Has his days when he does drag his foot a bit, but with rest, he picks back up again. If nothing else he is a fighter, with a great spirit, and I know he wont give in until the end, but in the meantime, he will be given lots of love, and support, and we will keep getting his bloods tested and treat accordingly, if necessary. Thank you all for your help and support, its lovely to have people who are actually going through Cushings, or have been through it, as it would appear our vet doesnt have much experience of Cushings - she even said that he may have Atypical Cushings - so it shows how much she knows, as Atypical as you know the Cortisol does not increase, so thats what we are up against. Thanks again and I promise I will keep you all up to date on how Murphy is doing.

[molly muffin]

I have my fingers crossed that his bloodwork will continue to improve and no need to treat.

There are a lot of vets out there that don't have the experience with cushings. As long as they are willing to learn the protocols and what tests mean in relations to cushings, it can work out fine. Just have to educate them. Get the printer stocked up on ink and paper. I think I printed out a book to take to my vet at the beginning. :)