My havanese pup has been diagnosed with cushings

[Snoop]

Hello everyone, My 9 year old 14 lb havanese pup named snoopy has been diagnosed with cushings disease.

I had a blood test done for him and his ALP was 8877, through the roof as I was told, so they suspected cushings disease.

ALT 618
AST 67
ALP 8877
GGT 156
Creatine Kinase 358

Creatinine was low 29, so they said kidney function was likely good.

So we did the Low Dose Dexamethasone Suppression test and these are the results

Cortisol Baseline 102 nmol/L
Cortisol 4 hr Post 60 nmol/L
Cortisol 8 hr Post 109 nmol/L

He has the clinical signs of cushings, excess water drinking, voracious appetite, loss of hair, face skin darking, when I walk him he walks very slowly and then starts panting after just a few meters. I think his belly is a bit bigger but hard to tell. He's also lost some muscle mass cause I can feel his bones more.

Anyhow, My vet recommend I start him on trilostane 15 mg per day.

Here is my question, Is it normal to have cushings and yet have a baseline cortisol within normal range.
He is not on any kind of medication now and his baseline is 102 nmol/L, which is within normal range. Should I start him on the trilostane or should I get more test done.
My Vet said that the baseline is not what determines if he has cushings but the results of the 3 test is what determines it.
Also, if it is cushings, does the baseline reading give any indication as to the amount of trilostane i should start him on, since its not that high should I start him on a lower dose.

He's also loss a bit of weight, does cushings cause weight loss or is it all due muscle mass loss?

Thinking back, some of these conditions were appearing about 6 months ago, I just though he was aging, I hope I haven't done any damage to him by not getting this looked and earlier.

I'm new to this, trying to learn as much as I can so I can give him the best care as I can, so any input/advice would be appreciated.

Thanks
--Frank

[labblab]

Hello Frank, and welcome to you and little Snoop. I apologize that I have only a few minutes to write this evening, but I wanted to quickly tell you a couple of things. Your vet is correct that it’s the third cortisol reading that determines the overall Cushing’s diagnosis, and not the baseline cortisol level. It is not uncommon for baseline cortisol levels to fall within the normal range even when Cushing’s is present. Also, the initial dose of trilostane is based solely on weight alone — neither the cortisol level nor the severity of symptoms factor into the initial dosing decision. The most widely accepted initial dosing formula is 1 mg. per pound (2.2 mg. per kg.). So a starting dose of 15 mg. for a 14 pound dog does sound appropriate.

Before talking further, can you do us a favor and tell us what the normal lab ranges were for all those liver-related lab results that you listed? It’s the case that astronomically high ALP levels are not uncommon with Cushing’s, along with mild elevations in other liver values. But if all of Snoop’s liver values were severely elevated, I’m thinking you might want to explore the status of his liver a bit further at this stage of the diagnostic process in order to make sure that nothing else is going on with his liver instead of, or in addition to, Cushing’s. So it’ll help us to find out more about those lab ranges to see how far “off” his other liver values actually are.

Thanks so much in advance, and once again, welcome to you and Snoop.
Marianne

[Snoop]

Hi Marianne, thanks for your reply

The normal ranges for the liver-related lab results are

ALT 618 18 - 21 IU/L
AST 67 16 - 55 IU/L
ALP 8877 5 - 160 IU/L
GGT 156 0 - 113 IU/L

Creatinine 29 44 - 133 umol/L

Creatine Kinase 358 10 - 200 IU/L

The report from the lab says that SDMA is within the reference interval and creatinine is low which indicates kidney function is likely good.
The report also says to evaluate a complete urinalysis and confirm there is no other evidence of kidney disease but my Vet didn't suggestion or mention this to me.

Even though he's been drinking a lot more then his usual, almost 300 ml a day, he's not really peeing any more often then usual, he doesn't need to go during the night, I always leave pee pads out for him and he hasn't been using them, although he seems a bit more anxious for me to let him out in the morning.

He only start drinking more water a few weeks ago, but some of his other cushing symptoms started maybe about as much as 6 months ago which I thought were due to aging.

My vet did say that all those values should come down once I start treating him for his cushing, so I assume she thinks those elevated readings are all due to cushings.

Thanks again for your reply, and I'm so grateful to have this forum to help me through this.

--Frank

[labblab]

Hello again, Frank, and thanks for providing those ranges. I must confess that I remain somewhat concerned about these combined elevations across the board in terms of Snoopy’s liver values. I must tell you that I’m not a vet myself, so my own knowledge is limited. But we typically don’t see combined elevations to this extent in the labwork of dogs that come to us here if Cushing’s is the sole issue.

There is a particular type of gallbladder issue called a mucocele to which dogs with Cushing’s can be more vulnerable. I do believe that gallbladder problems might contribute to some of the elevations that are present with Snoopy. And if, by chance, he does suffer from a mucocele, that can be a serious problem that requires treatment in its own right, either via medication or surgery.

I regret if I’m adding more worries onto your plate, but if it were me, I’d ask your vet specifically about these elevations and whether any more diagnostics would be helpful — especially in terms of Snoopy’s gallbladder. For instance, an abdominal ultrasound could provide helpful information about all of his internal organs, including his liver, gallbladder and his adrenal glands.

As it turns out, his LDDS results could be associated with a tumor on either his pituitary gland or an adrenal gland since the 4-hour value was not less than 50% of the baseline value. It was very close, but not actually less than 50%. So there could be some value in viewing the adrenals as well as the liver and gallbladder. Surgery does offer a complete cure for adrenal tumors, although it is a very serious and expensive undertaking.

Anyway, these are my continued thoughts about this. Whatever you decide to do, please do keep us updated!
Marianne

[Katy1]

Hi Frank and welcome to the most wonderful place in cyberspace if you have a Cushings pup.

In reading through your thread, I did not read that Snoop had an ultrasound done. I know it’s an extra expense, but I’ve had recent experience with my miniature schnauzer, Annie, who had the gallbladder issue with a huge mucocele which Marianne was talking about.

Annie, who is 9, was diagnosed with Cushings in Feb. of this year. She had been diagnosed with diabetes the previous year. She is currently taking 250mg. of Lysodren twice a week.

On Monday, April 15, Annie ate her breakfast as usual and by noon she was puking pure bile. I called her vet and we took her in right away. They did an ultrasound along with blood work and discovered she had pancreatitis plus the ultrasound showed that her gallbladder was twice it’s normal size plus she also had a huge mucocele inside the gallbladder that was blocking the bile duct. He was able to stabilize her enough by Wednesday so we could make the two hour drive to a specialty clinic in Chicago. She had her gallbladder removed the next morning and she did so well that we were able to bring her home on Easter Sunday. I won’t sugar coat this---it was expensive but we had lost her older sister in January and just couldn’t bare the thought of loosing our last pup while still grieving the loss of her big sis.
I’m not trying to scare you but you might want to consider an ultrasound which will also give your vet a better idea of what might be going on with her adrenal glands.
I apologize if I have been out of line in anyway. It’s just that so much weird stuff has happened with our little girl and I don’t want anyone else to have to go through what we have with Annie.

Anyway, I’m a huge proponent of an ultrasound for Snoop if you can swing it. If I missed the fact that this has already been done, I’m sorry and you can just forget all the above. Otherwise, I offer my Blessings to you and Snoop and wish the best for you both. Karen

[Snoop]

Thank you Marianne and Katy for your response, any information is welcome as all I want is the best for my Snoop.
I will talk to my vet about getting the ultrasound as soon as I can.
Are there any clinical signs that I should look for if he has a gallbladder issues?

Thanks again for all the knowledge.
--Frank

[Snoop]

I looked at his blood work again and see that his Bilirubin - Total was 1.0 and is within range of 0.0 - 5.2 umol/L.
Is this any indication that his gallbladder is ok?

I have stated him on his trilostane, on Friday, 15 mg per day.
So far so good, he seems very relaxed after taking it, just lays there and doesn't want to get up, he's very alert but doesn't seem to want to get up.
He likes to sit at the top of the stairs and look out the window, usually when I walk by he would get up and follow me but after taking the trilostane, he just laid there looks at me when I walk by but doesn't get up to follow.

I will keep everyone update so that everyone can benefit from my experience as I am benefiting from others.
--Frank

[Katy1]

Hi Frank,
I don’t know anything about the effects of trilostaine, I’ll leave that up to the experts here. My concern would be the change in Snoop’s behavior after starting his meds.

I had a scare with Annie today. I’m still learning too and all Cush pups are different. Annie has cataracts and we saw her eye doc last Monday. She said Annie’s eyes were stable but wanted us to start her on Ocu-Glo, which is just a supplement.

Today was her Lysodren day which I gave to her with her breakfast. At supper I gave her the eye med in a piece of food and she immediately threw up. That told me that I can’t overload her little body with stuff on her Lysodren days.

Like I said I have no experience with trilostaine but really keep an eye on Snoop’s behavior and if something doesn’t seem normal to you, have a talk with your vet.

As far as the gallbladder goes, it’s only the ultrasound that willl let you and your vet know what’s going on inside your boy. I think the liver can be affected by the gallbladder and that may throw the blood results off a bit. But like I said, listen to the the experts here, I’m just a Cushpup mom with a lot of passion. Blessings to you and your boy. Karen

[Harley PoMMom]

I looked at his blood work again and see that his Bilirubin - Total was 1.0 and is within range of 0.0 - 5.2 umol/L.
Is this any indication that his gallbladder is ok?



According to this article titled: "Gall Bladder Mucoceles: An Emerging Disease Syndrome in the Dog," only about 50% of dogs have elevated bilirubin.


Many dogs with gallbladder mucoceles have inflammatory leukograms. About 75% of dogs have elevated ALP, ALT and GGT however only about 50% of dogs have elevated bilirubin. It is important to note that a recent paper described 5 cases of gallbladder rupture in dogs with bilirubin levels that were within reference range. All 5 of these dogs had abdominal pain and some amount of abdominal effusion.8

Link to the article: https://www.mspca.org/angell_services/gall-bladder-mucoceles-an-emerging-disease-syndrome-in-the-dog/

I believe an ultrasound is the best way to diagnose it.

Lori

[Snoop]

Thanks everyone for the informative feedback.

And I agree, an abdominal ultrasound is probably the best way to go, and on the plus side as Marianne said I will get more information about his other internal organs.

I will talk to my vet and arrange for this and keep everyone informed.

--Frank

[Squirt's Mom]

Hi and welcome to you and Snoopy!

It's been a few days now and I am curious if Snoop is still showing the same reaction following the Vetoryl? And - have you seen any loose stools or diarrhea, signs of nausea or vomiting? Is his appetite still good?

I'm glad you found us and look forward to hearing about that ultrasound! That test gives us the biggest bang for the buck because not only can it go a long way in diagnosing Cushing's, and telling us which type, it lets us have a look at many other organs to boot! ;)

Hugs,
Leslie

[Snoop]

Hi Leslie,

Sorry for the late reply.

Snoopy is doing fine, other then that first hour or so when he started the Vetoryl where he looked very relaxed and not wanting to get up to follow me like he normally does, he has shown no other reaction to the Vetoryl, it's only been a week but he is already drinking less water, pretty much back to what he was drinking before the cushings, is this normal for his drinking to return to normal in just one week? His appetite has not changed though. I have been feeding him lots of steamed vegetables to satisfy his hunger without giving him too many calories, he seems to like it.

My Vet doesn't have an ultrasound machine on site, so we had to schedule for a specialist to come in with the ultrasound equipment.
His ultrasound is scheduled for this Tuesday.

Hoping for the best and will update when I get the results.

Thanks

[Harley PoMMom]

It usually takes around 2 weeks to see improvements in thirst and hunger, but all dogs react differently so the decrease in drinking in one week wouldn't worry me too much. Glad he likes those steamed vegs, that ravenous appetite sure can get out of control!

Good luck with the ultrasound and let us know the findings, please.

Lori

[labblab]

Good luck with the ultrasound from me, too! Also, my Cushing’s boy was one who showed improvement in his thirst/urination within just 2-3 days of starting the trilostane. So I know from personal experience that it’s possible to see changes within a very short amount of time ;-).

We’ll be watching for your further updates,
Marianne

[Snoop]

Hi All,

I got good news to report, ultrasound results came looking positive for my little guy.

The following is the ultrasound report for him

Diagnostic Imaging Report Findings

29 still B-mode and colour Doppler ultrasound images as well as 3 video clips are provided for evaluation.

Liver/GB: The liver is subjectively increased in echogenicity. No abnormalities are detected.
The gallbladder is mildly to moderately distended with small, hyperechoic foci adhered to the ventral gallbladder mucosa.
The small foci are most consistent with mineralized sediment. Gallbladder wall thickness is normal.

Spleen: Normal echogenicity and echotexture. No abnormalities seen.

Left kidney: Measures slightly small right kidney 4.32 cm in length. No pylectasia, mineralization or other abnormalities are detected.

Left adrenal: Mildly, uniformly enlarged for the size of the patient, measuring 7.1-7.4 mm. No nodules or masses are seen.

Urinary bladder: No abnormal findings.

Right kidney: No abnormal findings. 5.25 cm in length.

Right adrenal: Mildly enlarged caudal pole, measuring 7.2-7.4 mm in thickness. No nodules or masses are seen.

Stomach: No abnormal findings.

Pancreas: No abnormal findings in the region of the right pancreas.

Small intestines: Normal wall layering and thickness (3.7-3.8 mm for jejunum and 4.3 mm for duodenum). No abnormal findings.

Colon: Normal wall layering and thickness (1.2 mm). No abnormal findings.

Sublumbar region: No abnormal findings.

Other: A solitary long access view of the heart is provided. No abnormalities are seen.

Opinion & Recommendation
Mild bilateral adrenomegaly. No adrenal nodules or masses are seen. Primary consideration is given to pituitary dependent hyperadrenocorticism given the bilateral adrenal changes.

Mildly, diffusely hyperechoic liver, likely secondary to hyperadrenocorticism in light of the history. Other differentials including hepatopathies or hepatitis may be less likely.

Left kidney measuring slightly smaller than the right kidney could be an incidental finding in the absence of elevated renal values on bloodwork. No pylectasia, mineralization or other evidence of renal disease is detected.

Suspected mild mineralized gallbladder sediment adhered to the ventral gallbladder mucosa. This could be an incidental finding in the absence of gallbladder wall thickening or secondary to cholestasis.

No additional abnormalities detected.

My Vet believe that the abnormalities found are due to his cushings and don't believe he has any other conditions.
I will be seeing my Vet next week for his first ACTH test, if anyone sees anything in his ultrasound report that I should ask my Vet about please let me know.

Thanks
--Frank

[Harley PoMMom]

The enlargement of the adrenal glands could be due to just the use of the Trilostane as it is known to have that effect on them.

[Katy1]

Hi Frank,
I know how much better you must feel since the ultrasound! As a pup mom who has been through two pups with gallbladder problems, I would recommend you ask your vet about “sludge” in the gallbladder. My angel schnauzer, Gracie, was diagnosed with a sludgy gallbladder when she was only seven and we managed it until her death in January of this year.

Fast forward, now we have Annie who had an enlarged gallbladder with a complete mucocele blocking her bile duct which resulted in us rushing her to Chicago for emergency surgery in April. I’m not trying to scare you with Snoop—-please trust me.

In June we had to take Annie to her eye doctor two hours away. She has cataracts which are stable at this point. However, in talking about Annie’s journey to this point, she made the comment “ I think gallbladder problems in dogs are under-diagnosed and mostly overlooked by most regular vets.”

You might want to ask more questions about Snoops gallbladder numbers, ask about sludge, and anything else. I”m so thankful you were able to get this done for your boy. Blessings to you and Snoop. Karen

[Snoop]

Thanks for the suggestion Karen, I will ask my Vet what the findings about snoopy's gallbladder mean.
My Vet spoke to me about the ultrasound results before she sent me the report, so I didn't get a chance to see the report before speaking with her.
Snoopy is scheduled for his first ACTH test this week so I will be seeing her this week.

Frank

[Snoop]

Hi All,

Got the results for my snoops ACTH test

Pre 31 nmol/L
Post 81 nmol/L

My vet said snoops looks to be doing very well on his current treatment and suggest I can wait 60 days before his next test.
Before the test my vet said 30 days but seeing that he's doing well, she said I can probably wait 60 days, Is that a good idea to wait that long considering where his current readings are?

Also, he does have some sediment in his gallbladder, my Vet said its a small amount and that there is no blockage or anything like that and that it should clear up over time.
If his blood test later on shows any abnormalities then we can look at it again at that time.

[labblab]

Hello again, and thanks so much for all the additional info you’ve been giving us. Regarding the ACTH results, for the benefit of some of our other readers, I’m converting Snoopy’s results into the units that are most commonly reported here in the U.S.:

Pre-ACTH: 1.12 ug/dL

Post-ACTH: 2.93 ug/dL

The “pre” number is just a hair low, but the “post” number is squarely within the desired therapeutic range for a dog taking trilostane, so that’s indeed great since that’s the primary number upon which dosing decisions are made. Since you’re asking our opinion about retesting, though, I’d advocate for testing again in another 30 days. In looking back through your thread, I’m thinking that this first monitoring test was taken after three weeks of treatment? If so, we still might expect that his cortisol level could continue to drift downward a bit more while still taking this same dose. For safety’s sake, I believe I’d want to see where it has “landed” by another month from now. If everything is still A-OK then, I’d think you could follow Dechra’s protocol and finally make the leap to wait for three months before testing again :-).

Whatever you decide, please keep us in the loop. And congrats on all these good test results ;-).

Marianne

[Snoop]

Hi Marianne, thanks for the suggestion and converting the units for me. I'm in Canada so that is how the units are reported for me, I will try and convert them the next time.


Yes, I don't think I want to wait 60 days to get his next test, I'll get him test in about 30 days from now, in the meantime I will keep a very close eye on him.

Thanks for your input.
--Frank

[Katy1]

Hi Frank,

Just consider me a curious neighbor—how is Snoop doing? Blessings, Karen