Duffy - Cushing Testing

[ls1012]

Hi All,
My 10 year old Havanese has some of the symptoms of Cushing's. Heavy panting, exercise intolerance (he use to walk with me two miles up to a few months ago) now he can barely do 1/3 mile..... I do not force him and it has been very hot and so now I am just letting him go in the yard to go potty and right back in unless I go swimming in the pool I take him in and that seems to keep him cool for a while.

He also has a dry cough, especial after he barks he will cough. I video'd it and took it to my Vet to see. They said definitely a cough. So we started with X-Ray (Slightly collapsed trachea) followed by an Ultrasound of abdomen and heart. Abdomen shows the same as last few years. Liver is enlarged and heart echo showed slight mitral valve leak with slight thickening. Rest of heart ultrasound is normal. Cardio Vet said Mitral Valve leak to mild to treat at this point- re-check in 6 months. ALT and ALKP have been a little high for a few years. Now they are higher. (359 and 414) Denamarine does not seem to be holding enzymes down as well as it was last few years. Cushing's test on last Friday.

The results from Cortisol Serial 2 ACTH are as follows:
Pre
Post
Cortisol Sample 1 - 11 (High) (Lab comments said it should be between 1 and 5)
Cortisol Sample 2 - 7.5
Which test is the Resting Cortisol? I would think Sample 1 would be but it appears his levels went down if that were the case? Would that make sense?

Also what is IATROGENIC HYPERADRENALCORTICISM? It says it should be between 1 and 5 with little to no increase in post cortisol levels.
HYPOADRENALCORTISM- Resting cortisol is usually sub normal and less than 1. With no increase after ACTH.

Can someone help me with understanding these tests results? My Vet is on vacation and the other Vet in the practice sent me these results. My Vet will not be back until next week and I am a bit nervous until I can speak to her.

We go back this Friday for Bile tests on the Liver.
Any help with understanding this test is appreciated!
Thanks Much,
Lynn

[labblab]

Hello Lynn, and welcome to you and your boy. I apologize that I can’t write as lengthy a reply as I’d like right now, but I can start with a couple of quick thoughts. First, it is very unlikely that an ACTH would give a result where the first (resting) cortisol reading is significantly higher than the second (stimulated) reading. My best guess is that the two test tubes were accidentally reversed and/or mislabeled in conjunction with the lab submission and analysis. The other possibility is that the stimulating agent was ineffective. However, given the two numbers that were listed, I’d guess that the samples were simply reversed. If this were the case, then the result would still be negative for Cushing’s because I feel certain that 11 would fall within the normal range for a diagnostic post-ACTH test.

Iatrogenic Cushing’s refers to development of the syndrome secondary to a dog being given supplemental steroids such as prednisone. Dogs who are given steroids for sufficiently long periods of time can see disruption in their normal adrenal activity, and the development of the same symptoms that result from naturally occurring Cushing’s. The cure is simply to wean the dog off the steroids.

Hypoadrenalcorticism refers to Addison’s Disease, or the situation where the adrenal glands are not producing enough hormones (as opposed to producing too much).

So, turning back to your test results, we’re not exactly sure what happened that led to this odd result. If the samples were simply reversed, it is a negative result for Cushing’s. If the stimulating agent was ineffective, however, then the test was not accurate. Even when conducted correctly, one drawback to the ACTH is that it produces a fair number of “false negatives,” especially in the presence of an adrenal tumor (as opposed to a pituitary tumor). There is another blood test, the LDDS, that is less likely to miss making the diagnosis in a dog who does have the disease. So depending upon the outcome of the bile acid test, one alternative might be to retest with a LDDS. Another, different option might be to conduct an abdominal ultrasound in order to actually view the status of the adrenal glands, as well as the liver and other internal organs. The imaging might help provide additional clues as to what is at the root of your boy’s problems.

Marianne

[ls1012]

Thank you Marianne. I am suspicious as they changed the name of the lab work from another patients name to mine so what you are saying may be exactly right. I am not even sure they have the correct blood work for my dog. I am going to call my Vet's partner who gave me these results today as my Vet is away. I am a bit annoyed as I asked for the LDDS test as that is what the Cardio Vet recommended and for some reason they did not want to give it. Duffy is going back Friday for Liver Bile tests as his Ultrasound shows an enlarged liver and his ALKP and ALT is high again. Denamarine was working well but it seems it is not holding them down as well now (359 and 414). I am sure i will be back tomorrow with more questions after I speak to the Vet. I am learning even with dogs you have to be your own health advocate. Thanks again!

[ls1012]

Hi Marianne,

I am totally confused at this point. From everything i have read online and on this site (such as what you posted) the 1st cortisol level is supposed to be lower than the second cortisol level after they inject him. My Vet's partner is telling me that his level is supposed to go lower and if it went higher it would mean his body can't process the cortisol. I said well why is the pre level highlighted as HIGH (11) when it is supposed to be between 1 and 5? She said it could be high for lots of reasons including stress. OK, great answer. Doesn't solve a darn thing and don't think I even buy in to it.

Evidently there was confusion as to whose blood it was and she also explained to me the names on the vial was the correct name but the names inside the bags were wrong hence the name change on the lab notes. Also, I asked her why the blood work when we did not request it and she said because they made a mistake and did it.... In any case if this is true and it is my dogs blood work it shows his phosphorous is low (probably due to the home cooked diet they had me put him on that they said would help his liver issues but I don't see much of a change after a year or so now)..... However, I did some research and did see low phosphorous can cause breathing problems which could be a part of my boys problem.... In any case they sold me a new supplement vitamin holistic in powder form that should help the low phosphorous.

Which brings me to my next question. Has anyone here tried the pre-prepared raw diet? Maybe that would be a better solution for him. I am going to have to do some research on that.

I am thoroughly disgusted that my little Havanese is suffering and no one can seem to pinpoint the problem. Apparently who knows if my Vet even got the blood work right.... The cardio doc suggested the LDDS to begin with due to the panting and the ravenous appetite. There is an Emergency/Specialty Hospital by me that is very good. They did minor surgery on Duffy when his anal glands were impacted and also diagnosed a scratched cornea when his old Vet said he did not have one and referred me to an eye specialist who was wonderful. They specialize in oncology etc but do have a general internist on call and they told me I can bring him through ER tonight and they would have to take him. They said they may keep him over night but would work with me to try and find out what is going on. I took some videos of his labored breathing and coughing with my cell phone to show to them.

I am at a loss. I don't know what else to do. We have gone to the cardio doc- my regular vet. Nothing to really explain the breathing problem or the liver problem. As soon as he walks even inside in the AC he breathes heavy. If he gets excited forget it. The breathing and panting is horrendous. (you are talking a dog that walked two miles with me) up to two months ago. Other than that he has vomited twice in the last two days. I am not all that concerned about that as it has been a pattern on and off for several years with him. He sometimes does that on and off and then it stops. Like he hadn't vomited for over a month to Sunday. They attribute it to his high liver enzymes and enlarged liver although we do not know what is causing the enlarged liver. I have a Bile Acid Test scheduled with my Vet this Friday but I think she is about to not be my Vet anymore after todays ordeal. Maybe the specialty clinic can do it.

I am sorry to ramble but I am disgusted and sad.

Any advice or knowledge with any of these issues would be greatly appreciated. I do not know what to do at this point. I think we will pack ourselves up after I am done with work and take him to the ER/Specialty hospital. i called Pet Plan Insurance to see if he would be covered for the same issues and they said as long as it is a covered issue whether it be a 2nd or 3rd opinion he is covered. TG for Pet Plan. I would never be without it again....

Thanks for listening. - Lynn

[labblab]

I’m afraid your vet is flat-out wrong in maintaining that the expectation is for a diagnostic post-ACTH level to be lower than a pre-ACTH, regardless of whether a dog has Cushing’s or not. As you’ll see from the interpretation protocol given by IDEXX labs, for a normal dog without Cushing’s, here are the expected results:

Pre-ACTH: 2 - 6 ug/dL
Post-ACTH: 6 - 18 ug/dL

For a dog with Cushing’s, the expected post-ACTH result is even higher.

http://www.idexx.fi/pdf/en_ie/smallanimal/snap/cortisol/cortisol-acth-stimulation-protocol.pdf

And per noted endocrinologist, Dr. Mark Peterson:


In normal dogs, administration of ACTH produces a rise in serum cortisol to values usually >10 μg/dl (>300 nmol/L). In contrast, dogs with Cushing’s syndrome (because of the increased thickness of the adrenal cortex) tend to have an exaggerated cortisol response to ACTH administration, with post-ACTH serum cortisol rising to concentrations >20 μg/dl (>600 nmol/L).

So, yes, your vet is correct that stress can elevate cortisol levels. But that doesn’t change the nature or expectation of the results from an ACTH stimulation test. It is named a stimulation test for a reason — because the injection stimulates the production of cortisol as opposed to suppressing it. On the other hand, the LDDS is a suppression test, and involves an entirely different physiological mechanism. Perhaps your vet is confusing the two tests, but that’s not a comforting thought. So I still think there was something wrong with your dog’s ACTH test.

I can’t disagree with your desire to get a second opinion from an internist. Cushing’s may still be a possibility, but something else may be involved , too. Aside from the panting, exercise intolerance, and liver abnormalities, does he exhibit any other outward symptoms that are typical of Cushing’s such as excessive thirst and urination, excessive hunger, skin and coat problems, pot belly, seeking cool spots, hindend muscle weakness, etc.?

Marianne

[ls1012]

Thank you Marianne. Yes, he exhibits excessive hunger to the point of crying when it is time to eat and gulps it down and looks for more. He has a slight pot belly and always seeking out cool spots. Either where he can feel the AC in the summer or the tile floors. He will cuddle with me when it is very cold in the winter just for a while and then get up and move. He also has the dark marks on his belly that he did not have. I realize there may be something else wrong and it may or may not be Cushing's but I would like to at least rule out Cushing's as my Cardio Vet said that would be a good place to start because of his panting and excessive hunger etc. Right now all I am getting is - "it could be this and it could be that" but I am just spinning in circles with "maybe" which is not helping my dog or my pocketbook, more importantly my dog..... The only one who seemed to know what he was talking about was the Cardio Vet as after the EKG and Ultrasound diagnosed slight mitral valve thickening and leakage but not severe enough to be treated. (No fluid in abdomen on x-ray) Re-check in 6 months. If it is not Cushing's then we need to move on to the next test. Bronchial scope tests for the breathing was also recommended as a possibility? But I don't want to skip something that is not an invasive test before we move on to more invasive tests. I don't want to miss something because of ignorance or mistakes. If my Vet does not know the difference between an ACTH and LDDS test I do not feel comfortable returning to them......

[labblab]

I can only imagine how frustrating and upsetting this is for you! Out of curiosity, did the vet explain why they ran an ACTH instead of the LDDS that you requested? That really doesn’t make any sense to me because the stimulating agent for the ACTH can sometimes be hard to acquire and is quite expensive. Cynical person that I am, I wonder if they had some of that agent left over from another dog and wanted to go ahead and use it and bill for it. I know it’s all water under the bridge now, but there’s a lot that’s puzzling about how they handled things.

One thing you might do is just book a regular appointment with an internist as opposed to going through the ER approach which would likely be a lot more expensive than just an office visit. You may need a referral for the internist, but your regular vet ought to be bending over backwards to help you get some answers right now. Perhaps the cardio vet could recommend an internist to you?

I totally understand and agree that you’d like to start with the less invasive stuff first, and a LDDS might be a good first step. I feel like your old practice owes you that test since that’s what you requested. But heck, who knows if they’d mess that up, too. So maybe it would be worth it to have a preliminary consultation with an internist and arrange a LDDS through him/her if they agree that it’s a reasonable place to start.

Marianne

[Joan2517]

What about just testing his cortisol level like we did with Gable? That gave us the diagnosis after years of trying to find it.

[labblab]

Hey Joan, in quickly looking back, it was an ACTH stimulation test that ended up diagnosing Gable:


Okay, well Gable's ACTH results are in:

Cortisol Sample 1: 5.1 HIGH / ref range: 1.0 - 5.0
Cortisol Sample 2: 23.8 HIGH / ref range: 8.0 - 17.0

So his result demonstrated the pattern we’d expect from a Cushing’s dog. His post-ACTH was elevated above the range we would have expected for a dog without the disease. I sure wish I thought that Lynn’s little boy’s ACTH was conducted properly, but I just don’t know. Plus, if I’m recalling correctly, Gable had tested negative on LDDS tests prior to finally getting this positive on the ACTH. So it just goes to show that sometimes multiple testing is necessary to finally get to the bottom of things.

Marianne

[Joan2517]

You're right, Marianne. We did it before he started the Vetoryl. I mixed it up with the pre-pill testing. And yes, Gable tested negative on two LDDS tests prior.

[ls1012]

Hi All,

I am new here and trying to seek out some help.

My dogs liver ALT and ALKP have always fluctuated all of his life. His liver biopsy did not show anything conclusive and they do not believe he has liver disease.

Last summer he had increased drinking and heavy panting with exercise intolerance. They did an ACTH test which came back normal. He was recently diagnosed with a slight leak in Mitral Valve with no treatment needed at this time. He was also diagnosed with Partial Laryngeal Paralysis and is on Doxepin which he is doing well on.

He had a bad episode of diarrhea and vomiting so I took him to my Vet who did a whole slew of tests as I told him he has increased thirst and urination also. He is also having accidents in house and has to go out in middle of night. He was always 13lbs and now up to 16lbs. He will eat anything at this point if i let him.

His blood work including kidney tests came back normal. SDMA test came back normal also.

I ended up taking him to the VCA ER in the middle of the night two days later as he stopped eating and started vomiting worse. They kept him overnight and took an ultrasound the following AM which showed slight thickening in small intestine wall and was diagnosed with IBD. They put him on Hills Z/D. I am in the process of trying to get him off of. It worked well but the ingredients are so unhealthy and it is not even FDA approved.

I received the last blood work test back from my Vet. His profile came back with "indicative presence of adrenal activity" "4 out of 12 values are elevated ranging from mild to significant".

The increased levels were:
Androstenedione-Pre ACTH - .63 (Normal- .05 to .36)
Progesterone - Pre ACTH - 3.39 (Normal -.34 to 2.90)
Progesterone - Pre ACTH - .31 ( should be less than .25)
Progesterone - Post ACTH - 1.94 (Normal- .0.22 to 1.45)
The labs were done by University of Tennessee

They state these values are indicative of early stage hyperadrenocorticism. They also state that the "Steroid profiles Diagnosis of Atypical Cushing's". They recommend Ultrasound or Endogenous ACTH. Endogenous ACTH was also done in blood work which had a result of .28 The panel states if Cushing is diagnosed over .15 is consistent with PDH. First treatment they want to do is Melatonin.

My problem is my Specialty Vet who did the liver biopsy, scope for bronchial disease and last month ultrasound and diagnosed IBD says he does not need treatment for this and my regular Vet says he does. I am in the process of making an appointment with a recommended Vet for a third opinion.

Do any of you have an experience like this or with what they are labeling "Atypical Cushing's" ?

Any help is much appreciated!

Thanks!
Lynn

[Squirt's Mom]

I am headed out the door shortly but wanted to let you know I have merged this latest post with your baby boys' original thread. We like to keep all info about each pup on one place so it is easier to look back thru the history if needed. ;)

Very quickly - treatment for Atypical Cushing's (in which 2 or more of the intermediate hormones you have listed are elevated but the cortisol is NORMAL) is the combination of melatonin and lignans from either flax or spruce. This can take a minimum of 4 months to show changes so patience is required with this form of Cushing's. Some vets do not believe in Atypical, some believe it is a precursor to conventional Cushing's with elevated cortisol. My Squirt started out Atypical and did become true Cushingoid over about 3 years at which point we added Lysodren to her lignans and melatonin. UTK does not recommend Vetoryl for Atypical pups because it has been proven to cause elevations in the intermediate hormones.

Hopefully others will be along soon to chat with you!

[Harley PoMMom]

Hi Lynn,

Sorry that Duffy is having some problems on top of the health issues he already has :( In all honestly, with all that is going on with Duffy I really wouldn't try the treatment (melatonin & lignans) for Atypical Cushing's. This type of Cushing's is really debated among the top veterinarian endocrinologists because they have found that dogs with non-adrenal illnesses can have elevated adrenal hormones and according to one study high estradiol levels were noted in healthy dogs.

Regarding the increased drinking/urinating; was his urine cultured to make sure that an UTI is not brewing?

Lori

[ls1012]

Thanks John. I made an appointment for Thursday night with a new Vet. Hopefully we can get to the bottom of what is going on.

[ls1012]

Hi Lori,

I made an appt. with a new Vet on Thursday night who came recommended to me.

They took a urine test by Cystocentesis. The IDEXX SDMA came back normal at 7. Here is what the rest of the urine report reads as:
Color: Dark Yellow (but it has been looking more clear since all of this water drinking)
Clarity: Cloudy
Specific Gravity: 1.035
PH: 6.5
Urine Protein: Negative
Glucose: Negative
Ketones: Negative
Blood/Hemoglobin: Negative
Bilirubin: Negative
Urobilinogen: Normal
White Blood Cells: 0-2
Red Blood Cells: 0-2
Bacteria: None Seen
Epithlial Cells: None Seen
Mucus: None Seen
Casts: None Seen
Crystals: None Seen

I am assuming if no bacteria was seen there was a culture taken? I don't really know the answer to that?

The results look pretty normal and the Vet said the slight blood in urine is probably due to taking it with a needle?
Maybe I should have the test repeated by the new Vet?

Usually he goes to his Wee Wee Pads if he has to go. Now he is just peeing on my area rug even when I am home. He is drinking tons of water. They switched me over to the Hills Food Z/D and I am mixing it with new food now to see if I can get him off of it with no diarrhea. So far he is doing good with that. I am wondering if the change from a home cooked turkey and oatmeal food for the Liver (which we no longer think is the problem and he was taken off of due to the diarrhea) to a dry food is part of the problem?

I feel like I am spinning my head but worst of all I feel bad for my happy little boy. :(

Thanks for any help!
Lynn

[ls1012]

Lori,

One more question:

I understand how a UTI can cause the excessive urinating but would a UTI cause the excessive drinking?

Thanks!
Lynn

[Harley PoMMom]

An UTI will absolutely cause a dog to drink more. And if the urine is dilute than a regular urinalysis may not pick up bacteria that is in the urine which is why an urine culture and sensitivity test is recommended.

When Duffy pees, is it coming out in a strong stream or does it seem to dribble out?

I just did a quick Google search about the Hills Food Z/D and it seems that increased drinking in the dog is a complaint.

Normal water intake for dogs is 1 ounce per pound, how many ounces is Duffy drinking and how much does he weigh? Also, dry dog food can increase a dog's thirst because of the lack of moisture.

[ls1012]

Hi Lori,

I just walked him and he appears to be peeing normally but now when I clean it up it is not so yellow. I have read that about Hills Z/D also and have read the same thing. One of the many reasons I am trying to get him off of it. I have him half way converted. Today I worked from home and gave him only the other food at lunch and he didn't have diarrhea but had lots of stomach noise and soft stool but far from diarrhea. I may have to experiment with the food but don't want to upset his stomach to much. I will wait until he sees the Vet Thursday night but that food is horrible. Although the Vets love to give it out and I can't argue it worked but to what extent of lack of nutrition/and or damage am I doing to my dog? But that is a discussion for another day.

Duffy is 16lbs (gained 3lbs in last few months) has always been about 13lbs.

He is drinking about 23oz of water a day. I have been filling up a 16oz water bottle and putting it in to his bowl.

My major concern is the peeing where not appropriate. He is not even using the wee wee pads which is just not him. Maybe from the large amount of water he is drinking he just can't control it.

Do any of you have dogs with IBD or Colitis or Sensitive Stomach? What food do you feed them?

I always fed Duffy Wellness Core but my Vet switched him to home cooked turkey and oatmeal due to what they believed was liver disease altho after liver biopsy it appears that the liver is not the reason ALT/ALKP is going up........

Thanks,
Lynn

[Joan2517]

I always fed my dogs the Wellness Original formula and my Gable always had diarrhea or pudding poops. My vet recommended Hills w/d formula and the next day he was pooping normal and has been since. His drinking did increase with this food, but he hasn't had an accident.

[ls1012]

Thanks Joan! Glad to hear that Hills W/D is working good for you. I will say it did stop the diarrhea but I would rather find something else if I can as the ingredients in Z/D are not good in my opinion and the peeing and drinking is excessive, especially with the accidents.... Right now I am mixing it with Petco Whole Hearted Grain Free Salmon as it is the only hydrolyzed food with decent ingredients I can find other than Royal Canine and Hills Z/D.....

[WinstonTheWestie]

My dog has had IBD for several years...he was diagnosed right around 3 years ago. We have been on the Royal Canin hydrolyzed food for all of that time and it's been great for him. His signs (chronic vomiting) have completely gone away unless he gets into people food somehow. While reading the list of ingredients it may seem 'unhealthy' but the prescription diets have real scientific studies behind them showing they work and dogs do well on them. A dog with IBD basically has an allergic reaction to the food, and usually its the proteins. The hydrolyzed diets are specially processed to make the protein too small for the dog's immune system to recognize (they still digest them normally though) which prevents the inflammation. I was told that Royal Canin deep cleans the entire plant before they make any hydrolyzed food to avoid contaminating it with any other proteins. My internal medicine specialist said the over the counter 'limited ingredient' foods are not processed that carefully and may be contaminated and cause the inflammation. I've never heard of the Petco brand and would need to read more but I am skeptical that it's truly hydrolyzed at the price I see advertised online...that special hydrolyzed processing makes the food very expensive! A similar sized Royal Canin bag costs over $70, and the Hill's is closer to $90. Purina makes a hydrolyzed diet called HA you could look into as well. Luckily my dog is smaller and only eats about 7 lbs a month.

[ls1012]

Hi All,

We went to the new Vet recommended to me by my Vet specialist. Blood work taken this week shows Duffy's ALKP jumped all the way to 1,346. (His liver biopsy done in the fall 2018 did not show anything conclusive-no tumors-cancer etc) He continues to drink a lot of water and urinate frequently. When I am home he goes out every couple of hours. At least this week when I wasn't home he made it to the Wee Wee Pads again. He said his Kidney results were fine and he is going to send me a copy so I have the numbers... He reviewed all of Duffy's previous test reports. He said the ACTCH does not always show Cushing's and he wants to do the Low Dose Dexamethasone Suppression test. It is being done Monday. We should have the results by Tuesday. Can anyone tell me the difference between the ACTH test and the Low Dose Dexamethasone Suppression test?

Thanks!

[Squirt's Mom]

The ACTH is stimulation test that lets us know the amount of cortisol the adrenal glands are holding in reserve. If the amount after stimulation is higher than what would normally be expected, then Cushing's is a consideration.

The LDDS is a suppression test that takes all day and results in 3 figures. This test tells us if the adrenal glands are able to suppress cortisol or not. If they can't, that is another reason to consider Cushing's.

Another test you didn't mention is the abdominal ultrasound which can let us know a great deal like if Cushing's could be present and which form by how the adrenal glands look as well as giving us a peek at the condition of many other organs like the liver, kidneys, etc.

The thing to keep in mind is that none of the tests for Cushing's can 100% diagnose this disease. It is a combination of tests plus the signs and behaviors we observe that give the strongest confirmation for Cushing's.

Here are some links about each of these tests. The HDDS test is rarely used these days since the LDDS is now able to determine which form of Cushing's the pup has, adrenal (ADH) or pituitary (PDH).

ACTH
https://www.idexx.eu/globalassets/documents/reference-laboratory/protocols/canine-acth-stimulation-testing-protocol.pdf

http://veterinarynews.dvm360.com/consider-acth-stimulation-test-when-you-suspect-canine-hyperadrenocorticism

LDDS
https://vcahospitals.com/know-your-pet/dexamethasone-suppression-tests

https://www.idexx.eu/globalassets/documents/reference-laboratory/protocols/low_dose_dexamethasone_suppression_test.pdf

[ls1012]

Thanks Kellie. I did more research and Wellness has a brand in their Line called "Simple - Salmon and Potatoes". It is for skin/stomach issues. I read the reviews on Chewy.com. There were about 200. A few said their dog were diagnosed with IBD and some said their Vet put them on it after diagnosis and they did very well on it so I will try mixing it in slowly and see how he does..... Almost all the reviewers had diarrhea/vomiting problems. I decided against the Petco Brand and am going to try the Wellness as I use to feed him Wellness before they thought he had Liver Disease and i home cooked Turkey and Oatmeal for the last several years. He did well on it and my Havanese before him did good on Wellness. If that doesn't work I will have no choice but to stick with the Hills as he is doing well on it. My boy use to be 13lbs all of a sudden he is 16.5. I am not giving him anything but strictly Hills Z/D dry/canned mixed and their treats. He only gets a half of a small bone when he goes out to potty in the yard or when we get home from a short walk. Not sure if because there is more calories in this food and I need to feed less than before? I am so confused at this point. After a bad case of diarrhea last month fecal tests showed Clostridium and they put him on Metronidazole for 7 days and the Vet did an ultrasound and said he had thickening of small intestine. The test results from last months blood work when he had the diarrhea showed some elevated numbers and "possible pre or borderline" Cushing's so today he went for the LDDS test. He is almost 11 years old. So we are a month later and his poop has improved a lot but he is drinking so much more and started to have accidents in the house and not using wee wee pads. He is doing better with the accidents and hasn't had an accident in the house in a week but is wanting to go out a lot. I am watching and he is urinating. A urine culture was done- no infection. Now his ALP is up to 1,300 and ALT 300. Unless the ALP went up think of for the ALP due to the Metronidazole. I read online that can affect the liver...... But maybe I need to stop reading so much on the Internet as I am making myself crazy........ Anyway, I will have the results by tomorrow of the LDDS test. I am glad your boy is doing well on Royal Canin. It is so horrible when they are not well. Thanks for your response!

[ls1012]

John,

He just had a ultrasound last month for severe diarrhea and they diagnosed IBD slight small intestine thickening. He was put on Hills z/d and it has stopped.

The results read the liver was normal to very mildly enlarged. The kidney, adrenal and stomach were all within normal size limits.

September 2018 he had a liver biopsy done. They didn't find much and here is the result:

Vacuolar hepatopathy (VH) is a fairly nonspecific reaction to
various conditions or diseases occurring either within or outside of
the liver. VH is also often accompanied by mildly to moderately
increased alkaline phosphatase (ALKP). Roughly half of these cases
have an identifiable source of glucocorticoid, either endogenous
(Cushing's disease) or exogenous (steroid therapy). Many cases have no
identifiable source; in these cases, VH is associated with a wide
variety of conditions (non-hepatic organ disease, systemic disease).
Occasionally, VH results from drug metabolism, especially drugs known
to induce ALKP (ex: phenobarbital). If this biopsy is representative
of the liver as a whole, then the prognosis is good as there is NO
significant inflammation, necrosis, or fibrosis noted in the H&E
sections. No evidence of portal hypoperfusion was seen, however
portal hypoperfusion (especially microvascular dysplasia) can affect
some areas of the liver and not others.

He has a collapsed trachea (Grade 2) and partial Laryngeal Paralysis diagnosed at same time as liver biopsy from bronchial scope. He is on Doxepin as it helps some Lar Par dogs and he seems to be doing decent on it.

His ALP went from 354 to 1,200 since last month's ultrasound and blood work. Unless it was from the Metronidazole given to him for the IBD episode last month. I read that could affect the liver online.....

I read that IBD can make liver enzymes rise also but they were only 300 ALT and 354 ALP last month when he was diagnosed....

I don't think that the Doxepin would all of a sudden make his liver enzymes go that high as he has been on it since last summer.......

He also has a slight Mitral Valve Leakage- no meds required at this time. I don't think that would make ALP go that high either as he has had it since at least last summer but he goes back for his 6 month check up next Wed so will ask Cardio Vet.

Last month his
pre ACTH was 28
post ACTH was 5.5
His Androstenedione: pre .63
Post: 3.39

Progesterone:
Pre: .31
Post: 1.94

We did an LDDS test today and I will have the results tomorrow. I will read the links you sent me.

Thanks for your response!
Lynn

[ls1012]

Hi All,

We finally got an LDDS that Duffy's cardiologist Vet recommended in July when his heart was ok and he had signs of severe panting and increased thirst etc. My old Vet gave me the ACTH test as she said they had good results with that and they mixed up the tubes and then said that the numbers were off because of stress.

Lately his symptoms became worse (drinking and getting me up to let him out a lot and even sometimes at night) and his liver ALP went from 300 to 1,200 and he went from 13 to 16.5 lb. So I brought him to a new Vet.

Results from LDDS:
Tube labeled pre - 9:45am
Tube labeled post1- 1:45pm
Tuble labeled post2- 5:45pm
Cortisol Sample 1 - 12.0 (HIGH) Ref Range 1.0 to 5.0
Cortisol Sample 2 Dex- 1.0 Ref Range 00 to 1.4
Cortisol Sample 3 Dex - 2.7 (High) Reference Range 00-1.4

My Vet said this is indicative of Pituitary dependent Cushing's (PDH)
He said he would treat him with Vetoryl (Spelling)?

For this week I have to track as close as possible how much water he is drinking a day. Is this to base the med dose on?

He had an ultrasound last month of his kidneys, liver, adrenal glands, intestine and stomach when he had an IBD flare-up. Everything was in normal range except the Small Intestine showed some thickening. They did not see any tumors.

He said he would need to have an MRI to see if there was a pituitary tumor and generally they do not do that. I don't want him under anesthesia anyway due to his breathing issues from the laryngeal paralysis either.

The Vet did say that some of the heavy breathing could be from Cushing's also and wants me to bring the results to the Cardiologist Vet when we go for his 6 month check-up next week. (He has slight Mitral thickening but needs no treatment so far).

I also tend to notice that it appears he often drinks more in the afternoon/evening. Is this typical of Cushing's?

Does this sound on track to the experts out there?

Any help is appreciated!
Thanks!
Lynn & Duffy

[Squirt's Mom]

I have merged your latest post into Duffy's original thread. We like to keep all posts about each pup in one thread so it is easier to keep up with the history. I have also changed the title of his thread to include his name so it will be easier for you to find it and post here from now on. :)

[labblab]

Hello again, Lynn, and thanks so much for this update. Duffy’s LDDS results are indeed consistent with the pituitary form of Cushing’s, and Vetoryl is one of the two effective medications for treatment. So far, so good! You’ve not mentioned the proposed starting dose of Vetoryl, but given Duffy’s weight of 16.5 pounds, I’m hoping the vet will limit the dose to no more than 15 mg. daily, or certainly no more than 20 mg. Initial dosing recommendations have significantly lowered during the years that Vetoryl has been in use, and the majority of researchers and specialized clinicians worldwide now recommend a starting dose that does not exceed 1 mg. per pound. If your vet suggests a higher dose, please let us know so that we can arm you with important supporting documentation to pass on to your vet.

Other helpful tips: Vetoryl should always be given alongside a full meal for proper absorption. Also, your vet ought to schedule a monitoring blood test after two weeks of Vetoryl treatment in order to assess the medication’s affect on cortisol production. Excessive thirst and urination ought to come under better control as cortisol levels lower, but actual blood levels are also essential monitoring tools.

Speaking of thirst, no, the amount of water that Duffy drinks should have no bearing on the initial medication dose. Initial dosing formulas are based strictly on weight. But I’m assuming your vet is interested in guaging how much his symptoms show improvement once treatment actually begins. FYI, here’s a link that contains a lot of helpful info re: Vetoryl treatment:

https://www.k9cushings.com/forum/showthread.php?8925-GENERAL-GUIDELINES-for-Dosing-and-Monitoring-Treatment-with-Vetoryl-(trilostane)

So good luck yo you both, and don’t hesitate to ask us any additional questions along the way.

Marianne

[ls1012]

Hi Marianne,

I will read your link. Thank you for sending it to me!

I have read in a few places that if you put a dog on Vetoryl and they do not really have Cushing's it can do much harm.

I am a bit nervous as I now have three tests with three different results. ACTH showed no Cushing's, 2nd opinion Vet test done which I do not know the name of the test but tested a lot of different hormones. It showed 4 hormones (Androatenedione, and Progesterone both pre and post high) of 8 elevated and results read possible early or beginning of Cushing's. This Vet wanted to treat Duffy with Melatonin. We finally got the LDDS as everyone said that is the "Gold Star" for Cushing's and I posted the results that you read.

Just to be on the safe side I made an appointment with a Internal Medical Doctor for Feb 27 in NYC at the Animal Medical Center. He specializes in endocrinology. Duffy has several medical issues ranging from IBD to partial Laryngeal Paralysis and I am afraid to give him something if not needed.

I have three more questions that you may be able to help me with.

1. I stopped feeding him mostly dry food and am giving him mostly canned mixed with a little dry because its first ingredient is water and so he doesn't drink as much from the bowl as when it is all dry food. This of course lowers the consumption of actual water he is now drinking from the bowl. Before he was drinking about 21 oz or so a day when fed mostly dry. Now about 15 oz a day. The reason I don't want him drinking a lot of water from his bowl is he drinks it so fast and then burps and smacks his lips etc. upsetting his stomach. Not sure how to measure the water intake now. Any suggestions?

2. The third opinion Vet that did the LDDS test said since he had an ultrasound last month with his IBD flare-up and the adrenal glands were viewed and no tumor shown he does not need another one. He also said that they don't generally do tests on the Pituitary Gland. Is this true?

3. When the medication is balanced will it help is ALKP go back to normal?

Your help is much appreciated.

Thanks,
Lynn

[lulusmom]

Hi Lynn. I've just read your thread and have a few things I wanted to share with you. You can find my comments in red text below. Hopefully I have answered some of your questions.


Hi Marianne,

I will read your link. Thank you for sending it to me!

I have read in a few places that if you put a dog on Vetoryl and they do not really have Cushing's it can do much harm.

I am a bit nervous as I now have three tests with three different results. ACTH showed no Cushing's, 2nd opinion Vet test done which I do not know the name of the test but tested a lot of different hormones. It showed 4 hormones (Androatenedione, and Progesterone both pre and post high) of 8 elevated and results read possible early or beginning of Cushing's. This Vet wanted to treat Duffy with Melatonin. We finally got the LDDS as everyone said that is the "Gold Star" for Cushing's and I posted the results that you read.

The hormones you mention are part of an adrenal panel done by the University of Tennessee Knoxville. The post stimulated cortisol in this test was actually below the normal range which is not consistent with cushing's. This test can yield false negative post stimulated cortisol results in dogs who do have cushing's but in my experience, most false negatives are most likely to happen in dogs with functional adrenal tumors. The abdominal ultrasound results indicated adrenal glands were normal so that would rule out an adrenal tumor. The elevations in the hormones in the adrenal panel can be due to early cushing's disease but they can also be due to non-adrenal illness which is a definite possibility as your dog appears to have chronic IBD. I am a skeptic when it comes to the usefulness of the UTK adrenal panel. In my opinion, it's a last ditch effort to come up with a diagnosis in a dog who presents physically and clinically as cushingoid yet adrenal function tests are negative. What you read is correct; elevations in these adrenal hormones can be an indication that a dog is in early stage of cushing's and at some point, cortisol will eventually be well above normal. If the elevations are caused by non-adrenal illness such as IBD, they will improve with resolution and/or good control of IBD.



Just to be on the safe side I made an appointment with a Internal Medical Doctor for Feb 27 in NYC at the Animal Medical Center. He specializes in endocrinology. Duffy has several medical issues ranging from IBD to partial Laryngeal Paralysis and I am afraid to give him something if not needed.

I think this is a great decision on your part and I will be most interested to hear about your appointment. I can understand why your are concerned about accepting the results of the LDDS test being definitive for cushing's as there is a lot of conflicting stuff going one. You have mentioned your dog's increase in drinking many times but the results of the urine test shows that urine is very concentrated which would rule out polyuria (peeing too much) an polydipsia (drinking to much) as a clinical symptom of cushing's. It appears the ALKP has not been consistently rising but rather going up and down. There are three or four ALKP isoenzymes, one of which comes from the gut so a dog with IBD flares would see the ALKP increase as well as the ALT. The ALKP that increases with cushing's is a steroid induced isoenzyme which does not kill or injure liver cells so if cushing's is causing the elevations in ALKP, you can stop worrying yourself sick. We've seen dogs with ALKP in the 5,000's so what you are seeing is not alarming at all. Treatment The low dose dexamethasone suppression test is an extremely sensitive test which is why it is the gold standard in cushing's diagnostics; however, it is not the gold standard if a dog has a concurrent non-adrenal illness that could cause a false positive result.

I have three more questions that you may be able to help me with.

1. I stopped feeding him mostly dry food and am giving him mostly canned mixed with a little dry because its first ingredient is water and so he doesn't drink as much from the bowl as when it is all dry food. This of course lowers the consumption of actual water he is now drinking from the bowl. Before he was drinking about 21 oz or so a day when fed mostly dry. Now about 15 oz a day. The reason I don't want him drinking a lot of water from his bowl is he drinks it so fast and then burps and smacks his lips etc. upsetting his stomach. Not sure how to measure the water intake now. Any suggestions?

What is the purpose of measuring his water intake?

2. The third opinion Vet that did the LDDS test said since he had an ultrasound last month with his IBD flare-up and the adrenal glands were viewed and no tumor shown he does not need another one. He also said that they don't generally do tests on the Pituitary Gland. Is this true?

That is true, it is rare that an MRI is done to visualize the pituitary gland unless a very large macro tumor is suspected as causing neurological symptoms and the owner can afford the MRI.

3. When the medication is balanced will it help is ALKP go back to normal?

Effective treatments for cushing's can improve the ALKP but it does not always return to normal. Denamarin and other liver support supplements may not improve ALKP but they still support good liver health. Many members give their dogs liver support supplements. Again, if ALKP is being caused by cushing's, the liver cells are not being killed or harmed. What happens is that high levels of cortisol mess with fat metabolism and causes the liver to over accumulate a fat called glycogen. This is what causes the liver to enlarge.

Your help is much appreciated.

Thanks,
Lynn

[ls1012]

Hi LuLu's Mom,

Thank you so much for answering my questions! I do not know the meaning of measuring the water intake. It is what my "new" Vet asked me to do and he is away until Monday so I can't even ask him. I have a feeling he will not be my "new" Vet for long as he told me he had great news for me when Duffy tested positive for Cushing's which was a bizarre statement to me! He thought it was great news as he said it explained the ALKP. Which as you pointed out we do not know for sure as so many things are going on right now! I believe he just did not want to be bothered getting in to it any further and it was an easy solution to the ALKP problem too..... I have already cancelled my follow-up appointment with him next week and I will take him to the Medical Center and if we need anything in between will take him to VCA Emergency where my Internal Medicine Vet Specialist is who is wonderful but only does tests and procedures.....she is who diagnosed the Partial Laryngeal Paralysis after I brought her a video of him coughing after barking. She did a scope and at the same time she did a Liver Biopsy. She also diagnosed the IBD. I believe IBD can raise Liver Enzymes also. I so wish she practiced general medicine as she is wonderful.

I did read that Metronidazole that Duffy was on for the diarrhea can affect the liver so I am wondering if that made the ALKP go up as it was never even close to that high before (never higher than 400 before).... The ALT was always high but fluctuates up and down.

Duffy was on Denamarin but was taken off and put on Standard Process Hepato Support which I temporarily stopped due to the IBD flare up and also TruBenefits Hepato Support which he is still getting as that helps bring the enzymes down. The Internal Medicine Specialist Vet who diagnosed the IBD believes his IBD is food related as she she sees it a lot in Havanese and it is usually related to Food Sensitivities so we are doing the Hills Z/D prescription dog food test. It cleared the diarrhea right up and it is now 5 weeks later and he is still good so I am currently trying to get him off of the Z/D with "Wellness Simple" if he can tolerate it. It has only been 3 days of mixing the food together but so far so good. I am not a big fan of Hills prescription Z/D but if he has to stay on it so be it! However, I am going to at least try what I have researched........

I will keep you posted to anything new and I will definitely keep you posted as to what the specialist at the Animal Medical Center has to say. I am very grateful I purchased Insurance for him as a puppy. With the amazing Medical Advances for dogs I would never be without it again. I honestly don't know what i would have done without it the last few years.

Thanks Again!
Lynn & Duffy

[Squirt's Mom]

Here is a link to keep up with water intake, which simply means how much water a dog is drinking over a 24-hour period.

https://www.k9cushings.com/forum/showthread.php?3583-Spreadsheet-for-Logging-Your-Dog-s-Water-Intake

I understand what your vet was saying when he said it was good luck to find Cushing's....MANY things are MUCH worse than Cushing's. I work with special needs and hospice dogs in rescue and have had several special needs babies of my own and I can tell you without blinking an eye that I wished a million times several of them only had Cushing's to deal with. Cushing's is a condition that can be treated and the pup live out their normal life-span, even beyond because of the excellent care we give them. So many things cannot be treated or not easily treated and leave the dog with a much shortened life full of pain and loss of joy regardless of our best efforts and the best efforts of their vets. For the majority of cush pups that is simply not the case. So as strange as it may seem, yes, a Cushing's diagnosis can be good news.

[ls1012]

Thanks! Your response is much appreciated. I understand the comment better now. He does have several other health issues so I will still keep my appointment with the Internal Medical Vet in NYC at the Animal Medical Center for a 2nd opinion since all three of the Cushing's Tests had different results...... Maybe he will want to test something else, or one of them over, or go with the LDDS test. We shall see.....

I will read the link you sent me! Your help is appreciated!

Thanks!
Lynn