13 year old Yorkshire terrier just diagnosed

[Mrspisc]

Bella is a 12 year old Yorkshire terrier that weighs 9.75lbs. She is a female and is spayed. She is up to date on all her vaccinations.

About two years ago, Bella was put on medication for her thyroid. The first indication was her hair loss and we brought her to the vet for bloodwork that determined she had a thyroid problem. She is on the following:

Levothyroxine Sodium (0.1 mg, per tablet) 1 tablet given by mouth twice daily

Diet: peanut butter with her pill twice daily, dry food at her leisure (hills older dog) throughout the day and rotisserie chicken at night.

A month ago Bella’s hair began to fall out and leave blotches on her back. She also has little spots. Bella lives with two other yorkies and was the dominant one but lately she has no tolerance for them and bites them from across the room for no reason (not even good to guard). She sleeps through the night without having to go to the bathroom and never wets in the crate if she is left for a few hours. She eats and drinks normally. The only clear indication was her hair loss and the vet recommended a complete blood count. They told us that her levels indicate cushings and they recommended a low- dexamethasone suppression test, a fasting test and an ultrasound after both those tests came back. We opted for just the low-dexamethasone suppression test.

Her original bloodwork makes me very nervous. The medications to choose from also make me very uncomfortable simply because of the side effects and the fact that she doesn’t have any symptoms but hair loss right now and I don’t want her feeling sick. I have read that many holistic methods: Lignans and melatonin are highly recommended and I would love to hear from someone that went down that path, if in fact she has cushings.

Total Blood Count Results:
A/G ratio 2.1 (high)
All Phosphatase 418 (high)
BUN/Creatine Ratio 52 (high)
Magnesium 2.9 (high)
Na/K ratio 26 (low)
Cholesterol 329 (high)
Triglycerides 3243 (high)
Precision PSL 163 (high)
Platelet Count 620 (high)
Platelet EST increases
Platelet Count 620 (high)
Neutrophils 59 (low)
T4 <0.5 (low)
Protein 3+ Negative
Blood: Trace high

Dex test:
Cortisol Sample 1: 8 High
Cortisol Sample 2 Dex: 4.6 High
Cortisol Sample 3 Dex: 6 High

I just don’t know where to go from here. The vet would still like to do another test to see if her diet is causing the triglyceride levels. I also don’t know if I should do the ultrasound given her age because if she does have a tumor, we wouldn’t opt for surgery given the statistics and outcomes, but with that said a part of my still wants to know how long I have with my little girl.

We also want to know the best direction to go in for medication. We have heard many bad side effects from the medication to help cushings. We have also heard that diet could make our dog feel better. My last question is how long does my dog have if we don’t give meds vs. meds and if she does have a tumor.

Also has anyone tried holistic approaches?

Thank you so much. I’ve had my little girl since college and she’s been with me through marriage and two kids. I want what’s best for her and for her to be healthy and not sick on medication.

[Harley PoMMom]

Hi and welcome to you and Bella!

I am sorry for the circumstances that brought you here but so glad you found us, and we will do all we can to help you and your sweet girl!

To me, Cushing's is unlikely because Bella does not display the most common symptoms such as excessive drinking/urinating and a ravenous appetite. I do see from her blood work that her T4 is still low which is an indicator of how the thyroid is functioning so the first thing I would try is to up her Levothyroxine medication. Also, a lot of Bella's blood work abnormalities (especially the elevated triglycerides and cholesterol) can be attributed to a low thyroid level so that is another reason to start with getting the thyroid level within normal ranges.

Bella's LDDS test results do indicate Cushing's, however, this test can yield a false positive result if a non-adrenal illness is present such as Hypothyroidism. Another thing, hypothyroidism can also make a dog aggressive which it sounds like what may be going on with Bella.

I take that Bella had an urinalysis done, right? The reason I ask is because on her blood work you have noted that the Protein is 3+ and a trace of blood was found, did the vet mention that she may have an UTI?

Lori

[Squirt's Mom]

I would stop the rotisserie chicken immediately. The ones around here all contain onion in some form or the other and onion is toxic for dogs. I wanted to try it with a pup I had who had stopped eating but every place I talked to either basted with a solution that contained onion or injected the chicken with a solution that contained onion. If you want to feed your baby chicken, get chicken breast and bake it yourself with no seasonings at all. Most of the chickens in the grocery stores have been injected with salts but not onions.

I second what Lori has said - I do not see Cushing's in your description and the LDDS is notorious for false-positives if a non-adrenal illness is present. I would want an abdominal ultrasound performed myself. AND a new test for kidney function called the SDMA. The BUN and CREA were normal...just the ratio was high?

I'm glad you found us and look forward to more info soon!
Hugs,
Leslie

[Mrspisc]

I would stop the rotisserie chicken immediately. The ones around here all contain onion in some form or the other and onion is toxic for dogs. I wanted to try it with a pup I had who had stopped eating but every place I talked to either basted with a solution that contained onion or injected the chicken with a solution that contained onion. If you want to feed your baby chicken, get chicken breast and bake it yourself with no seasonings at all. Most of the chickens in the grocery stores have been injected with salts but not onions.

I second what Lori has said - I do not see Cushing's in your description and the LDDS is notorious for false-positives if a non-adrenal illness is present. I would want an abdominal ultrasound performed myself. AND a new test for kidney function called the SDMA. The BUN and CREA were normal...just the ratio was high?

I'm glad you found us and look forward to more info soon!
Hugs,
Leslie

The bun/creatine ratio was high at 52. Normal is 4-27.

Through all my research I thought she had a hyperactive thyroid and needed higher doses of medication. I would like to know why her triglycerides are so high.

I just want to make sure I am going down the right path for her. We’ve already done a lot of testing. I did not want to have to put her on these medications for cushings which seem very strong and the weekly/ monthly tests are extreme.

I would like to see how she responds to a higher dose of her meds. I just wonder how to approach this with my vet.

[Harley PoMMom]

Levothyroxine sodium is generally used to treat a low thyroid level.

Regarding the elevated cholesterol
and triglycerides: From googling I found that
Adequate levels of thyroid hormone, especially the active form of the thyroid hormone, T3, are essential for the metabolism of cholesterol.

Because hypothyroidism reduces the rate at which your body uses calories for fuel and slows hormone production, your triglycerides are more likely to remain in your fat cells.

I definitely ask the vet that if she is taking a thyroid supplementation than why is her T4 low because it shouldn't be if the dose is correct.

[Mrspisc]

Levothyroxine sodium is generally used to treat a low thyroid level.

Regarding the elevated cholesterol
and triglycerides: From googling I found that

I definitely ask the vet that if she is taking a thyroid supplementation than why is her T4 low because it shouldn't be if the dose is correct.

According to the vet, the cushings disease could be throwing her levels off to make the levels lower??

[Harley PoMMom]

According to the vet, the cushings disease could be throwing her levels off to make the levels lower??

Yes, this is known as sick euthyroid syndrome and a better assessment of thyroid status is having a Free T4 by equilibrium dialysis done, this test is the one recommended when trying to confirm a dog is euthyroid when it is receiving thyroid hormone supplementation...so this would be the first thing I would do.

[labblab]

Hello, and welcome from me, too. I have to agree that Bella’s symptom presentation is a bit of a puzzle. As you already know, some of her lab abnormalities are consistent with Cushing’s, but some point elsewhere. From your listings, we can’t tell how far her readings fall outside of normal ranges, so some of the abnormalities may be negligible. However, elevated ALKP, cholesterol, triglycerides, and platelets are often found in Cushpups. On the other hand, Cushing’s often increases neutrophils rather than lowering them. Also, I notice an elevated Precision PSL which is associated with pancreatitis. Cushing’s can cause kidney changes that result in increased levels of protein being released into the urine, but there can be other causes of proteinuria, as well. And last but not least, your vet is right that Cushing’s can skew diagnostic thyroid testing results downward. However, now that Bella is receiving supplementation, I would have expected to see her thyroid levels increasing, regardless. So I’m not sure what’s up with that.

As far as initial diagnostic thyroid testing, Lori is absolutely right that Free T4 by equilibrium dialysis, along with testing of TSH levels, is the best indicator as to whether low thyroid levels are genuine, or instead secondary to another condition such as Cushing’s. However, once thyroid supplementation has been started, I don’t believe you can make this determination any longer. That’s why it’s wise to ask for complete thyroid panels to be performed prior to beginning supplementation, and perhaps your vet did exactly that. Otherwise, per Michigan State’s veterinary thyroid testing service, this is the issue:


Once an animal is receiving thyroid hormone medication, thyroid testing can only tell if that medication appears to be well absorbed. No comment can be made about the patient’s endogenous thyroid functional status. Because of the suppressive effects of thyroid medication on endogenous thyroid hormone production in normal dogs, a withdrawal period of 6 weeks with no thyroid supplement is recommended before a diagnostic sample can be taken. After 6 weeks of no thyroid supplement, the dogs' endogenous thyroid status can be assessed, and is free from interference by thyroid medication.

Given all these question marks, if Bella was mine, I do believe I’d opt for the abdominal ultrasound in order to get a clearer picture as to the status of all her internal organs. Her LDDS results could result from either a pituitary or adrenal tumor, but more frequently in conjunction with an adrenal tumor. Even if you would not consider surgery, I do think it would be helpful to know whether an adrenal tumor is present. If for no other reason, at least you’d know that the Cushing’s diagnosis is indeed accurate. But the ultrasound could also reveal other poossible abnormalities in her kidneys, pancreas, liver, etc. that could account for some of the problems you’re experiencing. The ultrasound is not an invasive test, and can provide a lot of helpful information. If you decide to have one done, it may be best to request a referral to a specialist who has state-of-the-art imaging equipment. The adrenal glands can be very hard to view accurately, otherwise.

Marianne

[Harley PoMMom]

Regarding testing to confirm a dog is euthyroid when it is receiving thyroid hormone supplementation, according to this 2017 published article in dvm360 from Dr. David Bruyette, titled: Canine hypothyroidism: Supplementation and monitoring updates:
So, is there a way to confirm a dog is euthyroid when it is receiving thyroid hormone supplementation? There are two options: thyroid-stimulating hormone (TSH) measurements or free T4 by equilibrium dialysis (fT4 by EqD). If the TSH is normal, the dog is euthyroid. If the TSH is high, it needs more thyroid hormone; if it’s low, the dog is getting too much of the hormone.

But if you read the companion article “Canine hypothyroidism: Shield your patients from overdiagnosis,” you may have already spotted the problem with this option. In that article, we stated that with the TSH assay, 25% of hypothyroid dogs have a normal TSH concentration to start with (because the assay does not work well). Therefore, to use TSH assays to monitor a dog on hormone replacement therapy, you must have had a pre-treatment TSH result that was high. Without that, you simply can’t interpret what the TSH concentration means now.

The other option is to measure fT4. After two weeks of thyroid hormone supplementation, fT4 concentrations over a 24-hour period are constant. With the fT4 by EqD test, it doesn’t matter what time of day or when in relation to the pill administration you collect the blood sample, because the concentrations don’t fluctuate. http://veterinarymedicine.dvm360.com/canine-hypothyroidism-supplementation-and-monitoring-updates?pageID=2

So I believe running the fT4 would be the best option.

Lori

[labblab]

That’s really interesting, Lori, and thanks so much for the citation. Michigan State still has their caveat listed on their 2018 listing of thyroid testing FAQs, so perhaps there’s not total agreement about this.

https://animalhealth.msu.edu/sections/endocrinology/Thyroid_Canine.php

I do think that, ideally, vets should perform full diagnostic thyroid panels before beginning supplementation in any dog. But if that hasn’t been done, it sounds as though the free T4 by equilibrium is the best option.

Marianne

[Mrspisc]

Thank you so much everyone.

Lori, her blood panel did make mention under her T4 results, that if the total result is less than 1.0 mcg/dL. A free-T4 by equilibrium dialysis may be helpful in supporting the diagnosis of hypothyroidism in patients demonstrating clinical signs compatible with hypothyroidism.

The vet also wanted us to perform an ACTH stem test.

[Mrspisc]

That’s really interesting, Lori, and thanks so much for the citation. Michigan State still has their caveat listed on their 2018 listing of thyroid testing FAQs, so perhaps there’s not total agreement about this.

https://animalhealth.msu.edu/sections/endocrinology/Thyroid_Canine.php

I do think that, ideally, vets should perform full diagnostic thyroid panels before beginning supplementation in any dog. But if that hasn’t been done, it sounds as though the free T4 by equilibrium is the best option.

Marianne

Would you recommend the ACTH stem test?

I’m also worried that continuing to give her her thyroid meds is doing her more harm then good.

[labblab]

In Bella’s case, if I were to pursue additional diagnostics, the first thing I’d probably do is request an abdominal ultrasound. As I mentioned earlier, this may require referral to a specialty vet’s practice.


Given all these question marks, if Bella was mine, I do believe I’d opt for the abdominal ultrasound in order to get a clearer picture as to the status of all her internal organs. Her LDDS results could result from either a pituitary or adrenal tumor, but more frequently in conjunction with an adrenal tumor. Even if you would not consider surgery, I do think it would be helpful to know whether an adrenal tumor is present. If for no other reason, at least you’d know that the Cushing’s diagnosis is indeed accurate. But the ultrasound could also reveal other poossible abnormalities in her kidneys, pancreas, liver, etc. that could account for some of the problems you’re experiencing. The ultrasound is not an invasive test, and can provide a lot of helpful information. If you decide to have one done, it may be best to request a referral to a specialist who has state-of-the-art imaging equipment. The adrenal glands can be very hard to view accurately, otherwise.

The reason why I’d put money towards the ultrasound as opposed to the ACTH is because the ACTH is especially vulnerable to returning “false negatives” for dogs who suffer from adrenal tumors. This means that the test frequently comes back within the normal range when an adrenal tumor (as opposed to a pituitary tumor) is the source of the problem. Since Bella’s LDDS pattern did not rule out the possibility of an adrenal tumor, I believe I’d feel more comfortable if I actually had the opportunity to directly view her adrenal glands, as well as her other internal organs.

I don’t believe her thyroid supplementation is likely harming her, but for many reasons, it would be good to see what else may or may not be going on internally.

Marianne

[Mrspisc]

In Bella’s case, if I were to pursue additional diagnostics, the first thing I’d probably do is request an abdominal ultrasound. As I mentioned earlier, this may require referral to a specialty vet’s practice.



The reason why I’d put money towards the ultrasound as opposed to the ACTH is because the ACTH is especially vulnerable to returning “false negatives” for dogs who suffer from adrenal tumors. This means that the test frequently comes back within the normal range when an adrenal tumor (as opposed to a pituitary tumor) is the source of the problem. Since Bella’s LDDS pattern did not rule out the possibility of an adrenal tumor, I believe I’d feel more comfortable if I actually had the opportunity to directly view her adrenal glands, as well as her other internal organs.

I don’t believe her thyroid supplementation is likely harming her, but for many reasons, it would be good to see what else may or may not be going on internally.

Marianne

Thank you so much Marianne. I couldn’t agree more. I really appreciate all of your time, especially because I am so unfamiliar with all of this. It means a lot to me.

[Mrspisc]

In Bella’s case, if I were to pursue additional diagnostics, the first thing I’d probably do is request an abdominal ultrasound. As I mentioned earlier, this may require referral to a specialty vet’s practice.



The reason why I’d put money towards the ultrasound as opposed to the ACTH is because the ACTH is especially vulnerable to returning “false negatives” for dogs who suffer from adrenal tumors. This means that the test frequently comes back within the normal range when an adrenal tumor (as opposed to a pituitary tumor) is the source of the problem. Since Bella’s LDDS pattern did not rule out the possibility of an adrenal tumor, I believe I’d feel more comfortable if I actually had the opportunity to directly view her adrenal glands, as well as her other internal organs.

I don’t believe her thyroid supplementation is likely harming her, but for many reasons, it would be good to see what else may or may not be going on internally.

Marianne

The vet let me know that the ultrasound is $385 low end and high end $450 depending on if she needs to be sedated. I am wondering what route there would be to go in depending on her results. If she does have a tumor, she would need monthly medication and routine weekly and monthly bloodwork. I don’t know I could financially make this happen. Is there any alternatives to this? I don’t want to put a price tag on my dog but I wouldn’t be able to live myself with these expenses. I really don’t know what to do.

[labblab]

The Cushing’s medication treatment/monitoring costs are the same, regardless of whether the tumor is pituitary or adrenal in origin. So if you doubt that you’ll be treating the Cushing’s regardless of type, then there would be less value in pursuing the ultrasound. I was thinking you were considering Cushing’s treatment, but wanted to feel more certain about the accuracy of the diagnosis prior to proceeding with medication. In that event, the actual appearance of the adrenal glands could provide helpful diagnostic information to either support or challenge the overall Cushing’s diagnosis, as well as the specific type.

But since Bella is not suffering from some of the more classic Cushing’s symptoms, you may want to hold off on any additional Cushing’s diagnostics right now. And that kind of brings us full circle: as you and Lori have both suggested, before plunging onward, you may want to focus instead on seeing if changes in her thyroid protocol might help improve her existing symptoms.

Marianne

[Mrspisc]

The Cushing’s medication treatment/monitoring costs are the same, regardless of whether the tumor is pituitary or adrenal in origin. So if you doubt that you’ll be treating the Cushing’s regardless of type, then there would be less value in pursuing the ultrasound. I was thinking you were considering Cushing’s treatment, but wanted to feel more certain about the accuracy of the diagnosis prior to proceeding with medication. In that event, the actual appearance of the adrenal glands could provide helpful diagnostic information to either support or challenge the overall Cushing’s diagnosis, as well as the specific type.

But since Bella is not suffering from some of the more classic Cushing’s symptoms, you may want to hold off on any additional Cushing’s diagnostics right now. And that kind of brings us full circle: as you and Lori have both suggested, before plunging onward, you may want to focus instead on seeing if changes in her thyroid protocol might help improve her existing symptoms.

Marianne

I just got off the phone with the vet. The technician I spoke with said that the cushings is secondary to her hypothyroidism. They think her results are the way they are because of the cushings, which is why they aren’t recommending the free t4. I am not sure if there is another question I should be asking. The technician kept pushing back telling me that that ultrasound is necessary as cushings was the indicator after the dex test.

[Harley PoMMom]

The technician I spoke with said that the cushings is secondary to her hypothyroidism. They think her results are the way they are because of the cushings, which is why they aren’t recommending the free t4.

And this could be true BUT it has been recommended by veterinarians specializing in endocrinology that any non-adrenal illness be ruled out before any testing for Cushing's be performed. Since it is already known that Bella may have a thyroid issue this should be the first thing that is ruled out, a FreeT4 by ED would be the test I would want to have done...just my opinion :)

Lori