Newbie - with of course questions

[SusieTaunton]

Hello,
I've been lurking for a little while now and educating myself on Cushings since the vets first indicated that could be the root of Susan's problems. Susan is an 11 yo Wire Fox Terrier - currently weighs 14.2 (last three years she's been between 13-14 lbs)and in the last year we noticed little things - seemed to drink more, skin seemed thinner, walks seemed to be something to just get through rather than enjoy, wanted to get under blankets to sleep (which she had never done before) and she'd had a couple of UTIs Initially we chalked it up to age but by Jan of this year, our fantastic vets (seriously the best!) let us know that they felt something else was going on. We decided to start with her thyroid as tests indicated that was a good place to start. But they also let us know based on what they saw, and from experience, it was possible she had both Hypothyroid and Cushings.
So based on test results, we started with the Thyro-tabs and that has gotten us part way- her skin now heals normally, I was able to strip her for the first time in over a year (which she really enjoyed), the eczema and thin skin cleared up. Polyuria and polydipsia though got worse. So we did the LDD, and the results indicated Cushings. Trilostane will arrive this week (16 mg to start) and we'll get her started and monitor. But what I wanted to know was : is she High-High or High low? The test did not give ranges.
Here is the info I got back:
Item Result Ref Range measure
Baseline 76 15-110 nmol/L
Cortisol LDD 4h 53H 0-30 nmol/L
Cortisol LDD 8h 63H 0-30 nmol/L


And because others have posted and it seems to get asked, here are the tests that got us started
Urinalysis:2/14 & 2/6 all in normal ranges
Specific Gravity on 2/14 was 1.046

Chemistry (first value is from 2/14, second from 2/6, in parens is reference range) These are only the abnormal or close values. Everything else is within range
Glucose 132 109 Mg/dL (70-143mg/dL)
BUN:Creatine Ratio 15 , 10 (no range provided)
WBC 4.68 9.9 K/uL (5.05-16.76)
Lymphocyte 0.76 0.94 (1.05-5.1 K/ul)
Eosinophil 0.02, 0.05 (0.06-1.23 K/ul)
PDW 9.6, 8.2 (9.1-19.4 fL)
MPV 8.3, 7.3 (8.7-13.2 fL)
ALP 140, 83 (23-212U/L)
Cholesterol 416 , no 2/6 value (110-320 mg/dL)
Amylase 329 no 2/6 value (500-1500 U/L)


We ran a T4 in March , TT4 = 1.0 ug/dL Reference range (1.0-4.0) and then again in May TT4 1.7 ug/dL


I'm very comfortable with where the vet is - we are lucky to live hear an excellent Vet school & teaching hospital so our local vets are very well trained and have access to lots of resources and mentors. I just wondered what your experience might tell you.

Thanks for any feedback and thank you for having a forum like this!

[Harley PoMMom]

Hi and welcome to you and Susan!

Dog's with Cushing's very rarely have a normal USG (urine specific gravity) especially such a high number as Susan's. One thing I would recommend is to have her thyroid tested again, I do see that it was checked in May but her level could have become elevated which would cause a dog to drink/urinate more. How is her appetite? Cushdogs generally have a very elevated ALP, on the forum we've seen them in the 1000's and with Susan having 2 endocrine diseases I would think that ALP would be much higher than it is...so that's a bit puzzling to me.

As for her LDDS test, the results do not differentiate between the adrenal or pituitary type, it just shows that she may have Cushing's. The ACTH stimulation test is the one that measures the level of cortisol from the adrenal glands, did she have an ACTH stimulation test performed? An ultrasound would be something I would suggest to have done because if the adrenal glands are visualized a diagnosis of the type of Cushing's could be revealed, another benefit is that it can show any abnormalities with the other internal organs.

The starting dose of 1mg per pound of the dog's weight is what's currently endorsed so since Susan weighs 14.2 lbs than 14 mg of Trilostane is what is recommended but the 16 mg should be ok. However, Hypoadrenocorticism can develop at any dose so keep an eye out for any signs such as lethargy, vomiting, diarrhea, appetite loss, or if Susan just isn't acting herself, if any one of these symptoms are seen than the Trilostane is stopped and an ACTH stimulation test is performed.

Two important rules with Trilostane is that it has to be given with a meal to be properly absorbed and those ACTH stimulation tests have to be performed 4-6 hours post pill. Susan's first ACTH stimulation test should be done 10-14 days after starting the Trilostane and it is also recommended to not change the dose until the dog is on the medication for a month.

I'm so glad you've come out of the shadows and created a thread for Susan, and please know we will help in any way we can.

Lori

[labblab]

Hello, and welcome from me, too! I’m so glad that Lori has had the chance to reply, because I am also finding some aspects of Susan’s profile a bit puzzling. I “second” Lori’s questioning of the high specific gravity of the urine and also the normal ALP. Both of those findings are very uncommon with Cushing’s dogs. And although a couple of Susan’s blood cell counts are consistent with Cushing’s, a couple others are not. The low Eosinophils and Lymphocytes are consistent with what is called a “stress leukogram,” but the low overall white blood cell count and platelet count is atypical. Those two cell counts are often elevated in Cushpups. I am not a vet, and certainly no expert in hematology, but I’d be wondering about all those inconsistencies.

You’ve asked about Susan’s LDDS results. For our U.S. members, the 8-hour reading translates into around 2.3 ug/dL (the more commonly reported unit here). So that’s not a super high level, but high enough to be consistent with Cushing’s. One issue, though, is that the LDDS is vulnerable to showing elevated cortisol levels and therefore “false positives” in the presence of other nonadrenal illnesses that are stressing the body. There are just enough irregularities in Susan’s profile to make me pause and wonder whether Cushing’s is actually the accurate diagnosis here. Just what you need, right? For us to interject some confusion right when you’re poised to start treatment!?

As Lori has suggested, an abdominal ultrasound might be a very helpful diagnostic tool. As she has noted, Susan’s LDDS result could occur in the presence of either a pituitary or adrenal tumor. If it is the case that Susan has an adrenal mass, then surgery might offer a permanent cure. But whether you opt for an ultrasound or not, you may want to ask your vets to clarify these somewhat contradictory lab findings because they really are not typical of the dogs who come to us here with Cushing’s diagnoses. After having said all this, I hope you won’t be sorry you’ve joined us!

Marianne

[SusieTaunton]

Thanks to both Marianne and Lori-
Actually it was the lab work that made me lurk so long. Nothing seemed very "Cushings" indicative and without more tests I was mostly just trying to understand how Susan did or did not fit the profile. When the test came back it, did note that it does not make a distinction as to location of the problem.
The current course of action is to start the Trilosane, then run a stim test. Depending on that we may or may not do an ultrasound.
Susan has a normal appetite for her. If there is food in the offing, she's going to hang around to see if she gets some. However, our IG/MinPin can push her off her dinner if we aren't watching and she doesn't seem to care that much. And as a terrier that defends lots of other things its just not a huge issue for her. Certainly she isn't ravenous when she does eat. Her weight is normal and fairly stable, and she doesn't seem to be gaining, no sign of a pot-belly or anything like that.

She has had recurrent UTI's, but they only see them if they do a hand-spin. The usual machine type didn't show anything. Other than that, no illness or anything. The last one they put her on a months worth of antibiotics which seems to have finally knocked it out.
She has been on a grain-free dog food since we got her from the shelter 6 years ago.
Sounds like maybe I need to do a little digging. Luckily my vets know I like to ask questions and they don't mind at all.
Thanks so much for your responses and welcoming me to the community!
Heather

[labblab]

Hmmm...so Susan’s only outward Cushing’s symptoms are excessive thirst and urination, in conjunction with recurrent UTIs? Since excessive thirst/urination are symptoms of unresolved UTIs, I guess I’m wondering whether a still unresolved underlying infection isn’t a more likely cause than is Cushing’s. With improving skin/coat, no excessive appetite, stable weight, no pot belly, initially seeking warmth (Cushpups seek cool spots)...honestly, I’m seeing neither typical Cushing’s symptoms nor a consistent lab profile. If Susan was truly peeing that profusely, you’d expect an abnormally low specific gravity which just isn’t present. Have you measured the amount of water that she actually drinks in a day? Is it genuinely excessive? Since you have another dog, as well, I’m assuming they probably drink out of the same bowl so that does make it hard to measure Susan’s individual intake. But by how much would you estimate you’re having to add to the water bowl daily in comparison to during the spring?

In that vein, is there any symptom you’re trying to treat with the trilostane other than the thirst/urination? If you’re not seeing any other symptoms that require resolution, I’m honestly not even sure how you’ll judge the performance of the trilostane. A less desirable outcome may even be a decrease in appetite for her. I dunno. I am scratching my head here, as you can see. Is the polydypsia/polyuria problematic for you? If not, I’m still thinking you might want to hold off on starting treatment in order to see whether any other Cushing’s abnormalities manifest. If Susan was mine, I might even request another thyroid test first, just to make sure she’s not being oversupplemented at this point since hyperthyroidism could account for an increase in thirst/urination.

Marianne

[labblab]

One more question occurs to me. At the time that Susan was first diagnosed as being hypothyroid, do you know whether that was based on T4 level alone, or was a more complete thyroid panel analyzed? Comprehensive thyroid panels can sometimes provide information that either points to a primary thyroid problem in its own right, as opposed to a thyroid problem that is likely secondary to a different disorder (such as Cushing’s). Now that she’s started thyroid supplementation, I don’t think that testing can still be performed. But I’m just curious about the type of thyroid work-up she had in the beginning.

[labblab]

And...it’s me back again. Can you tell I’m ruminating over Susan????

But I wanted to add another thought about the ultrasound. If you’re considering an ultrasound at all, it seems to me as though it would be more useful to do it now, before starting the trilostane. A hallmark of pituitary Cushing’s is enlargement of both adrenal glands with an absence of adrenal masses. Enlargement of only a single gland with a visualized mass or tumor would imply adrenal Cushing’s. But this is the thing — trilostane treatment itself causes enlargement of both adrenal glands. So if you wait until after treatment has started before imaging, you lose some diagnostic usefulness. In other words, you won’t know whether it was pre-existing pituitary Cushing’s that caused bilateral adrenal enlargement, or whether it’s just an effect of the medication.

Also, since Susan’s only observable symptom is excessive thirst/urination, prior to beginning treatment I’d think you’d want to make sure there is no other obvious organ abnormality that might be causing the problem as opposed to Cushing’s. So one more question I’d ask the vet is, what is the value that is seen in waiting to perform an ultrasound? Why would you start treatment first, and then perform the ultrasound afterward?

[Harley PoMMom]

I definitely recommend having an urine culture and sensitivity test performed to rule out any UTI, and the added benefit with this is that it can identify the specific bacteria and then the appropriate antibiotic can be prescribed.

[SusieTaunton]

Lots to think about and investigate! Thank you for that because I want to do what is best for Susan. UTI's and heat-seeking are apparently hallmarks of hypothyroidism. Its one of the things that put the vet onto it for her and made them lean that way rather than Cushings. We did a urinalysis when we did the cortisol test and they said everything was normal on it - I got that and the specific gravity on 7/12 was 1.024. All other items- Pro, Glu, Ket, BLD, BIL were negative with UBG - norm, LEU - neg. Also from the same day- Bact Cocci - none to rare, Bact rods- none to rare, WBC was <1 HPF and RBC 2/HPF. So I think from the UTI perspective we are good. The Endocrine Interpretation MSU states "There is failure of appropriate cortisol suppression in response to low-dose dexamethasone administration. This supports the presence of hyperadrenocorticism, although this pattern of results does not differentiate between pituitary-dependent and adrenal dependent hypercorticism. " There is a bit more suggesting additional testing for the locating the exact type (HDD, endogenous adrecocorticotropic hormone concentration and abdominal ultrasound exam) and a warning that non-adrenal disease can confound test results. One of the reasons the vets suggested we do the Cushings test is that they were not satisfied with the response to the thyroid tabs. When we brought her in initially, three vets looked at her and all felt it was endocrine in nature, all felt that thyroid should be done first (its cheaper for one) but two felt that based on symptoms and observation, we were probably looking at more than one issue and one vet leaned more heavily to Cushings being the problem rather than thyroid. One vet is newer to the practice so the others consult regularly with her when she wants second or third opinion. In this case it didn't feel like too many cooks since they are all in agreement in general.
Its not so much that I mind the polydipsia or polyuria, its that Susan is starting to mind. She can't settle for more than about 15 minutes. That said, she does manage to go most of the day in her kennel with out any problem, but if we are home - like on the weekend & evening, she prefers to be let out, and if we aren't fast enough she will pee on the floor.- which she never used to do. At night she is getting up earlier and earlier. She used to be able sleep from about 10 PM (she's very routine oriented) to around 6:00. But in the last 6 months she started getting up at about 5:30 (I never even need an alarm clock now) to now when its 4 or 4:30 and again at 5:30 and from then on about every 15-20 minutes until we leave for work at 7. Also, she used to really love to go for walks, but now, you can tell its a chore. She'll do it, but it seems like a lot of work and she pants even after a short walk. The other dog doesn't but its hard to compare as they are different types of dogs. Susan is definitely more chill than she used to be, but anyone else might think she is excessively energetic (she's a true terrier, need I say more?) Its more that for us. That things she used to enjoy seem to be a work rather than play. She used to love to play ägility - go over a couple of jumps, do the table, sort of do the weaves.. now she doesn't want to do any of it. Still, if the gate gets left open, she enjoys a good run, just doesn't go as far. I'm hoping the Trilosane will restore some of that joy. - sorry for the long post!

One other thing we noticed when she started getting her fur back- in some places it changed color. Areas that used to be white have turned red where she had some skin damage and areas that used to be red (her whole ear) have become white halfway up- even where there was no skin damage.