New here - Louie age 13 small poodle (mix?) with Cushings

[mojomom77#]

Hi, so glad to find this forum. So Louie is recently diagnosed but the low-dex test came back inconclusive for type (conclusive that he has Cushings; inconclusive if adrenal or pituitary). I don't have any details on his test or bloodwork so please feel free to let me know what info I should be asking for and I'll get it. He has classic symptoms btw - excessive thirst/peeing; hunger, panting, just noisy breathing in general, and starting to get a bit of a pot belly; also hind legs showing some weakness.

He was tested after pre-anesthesia bloodwork for another procedure showed high liver enzymes. The other procedure was to have a skin wart removed that would not stop off and on bleeding for months. Then after the Cushing's diagnosis, he randomly developed a problem in his right eye with blood in the eye. At the same time he had a suspicious lump on top of his head, of course on the right side of his head, but it is unknown if this bump is related to bleeding in the eye. No bumps falls, etc that we know of. The lump was infected and receded with antibiotics. He is seeing a vet opthalmalogist for the eye and it appears now that the retina is detached and he is blind in that eye; he is on steroid eye drops and they seemed to work and the bleeding/redness was gone until it wasn't - it came back while we were out of town (dog sitter) and the vet is keeping him on the eye drops for now. Nobody has expressed any suggestion that this is in any way, shape, or form related to Cushings by the way. So at this point a mystery.

My main question today to start - in order to identify his Cushings type, we can have an expensive ultrasound done. Since 85% of cases seem to be pituitary, is this necessary vs just starting him on the meds? Pros/cons or is this not even a question I should be asking? Thank you!!

[labblab]

Hello and welcome to you and Louie! Before writing a lengthier reply of my own, I have a couple of quick questions to ask you. First, how long ago did you first notice the outward Cushing’s symptoms? Then, how long ago did Louie start taking the steroid eye drops? And finally, was the LDDS (Low Dex) test performed while he’s been taking the steroid drops?

The reason why I ask about the timing of the symptoms, testing, and steroid drops is because supplemental steroids taken for a period of time can cause Cushing’s symptoms in an otherwise normal dog. Supplemental steroids can also skew the diagnostic test results. And for a dog who actually does have naturally-occurring Cushing’s, the addition of a steroid medication will likely make the symptoms even worse because you’re increasing the excessive amount of circulating hormone/steroid even higher.

I know there are times when the benefit of short term steroid treatment outweighs the negatives for a Cushpup, and I’ll assume that Louis’ eye treatment is one of those situations. But as I say, before writing more, knowing the timeline of Louis’ treatment and testing will be helpful to me.

And once again, welcome to you both!
Marianne

[mojomom77#]

Hi and thanks!

Cushings symptoms like more drinking and peeing started last fall/winter and progressed from there. I was thinking maybe diabetes?

Timeline below - note he was diagnosed and symptomatic of Cushings well before the eye bleeding and steroid eye drops.

June 10th -pre-op bloodwork prior to removal of a bleeding wart; vet noticed increase in liver enzymes and we started piecing together Cushings symptoms including increased thirst, peeing, food anxiety/hunger, panting, noisy breathing.

July 1 - Low Dose Dex test
July 24 - Retinal bleed
July 25 - Steroid eye drops started
Aug 9 - follow up with vet opthalmalogist

I did call the vet eye doc last week b/c the retinal bleed continues so she wants him to stay on the eye drops. I asked if there were any concerns with him being on them this long and was told it was necessary to try to save the eye.

[labblab]

Thanks very much for this additional info. It does sound as though this is one of those situations where the importance of giving the steroidal eyedrops outweighs any temporary worsening of the Cushing’s symptoms. And it’s helpful to know that the original testing and symptoms did precede the eyedrops. So we can now move forward under the assumption that the diagnosis is accurate.

As far as sharing test results with us, it would be helpful to see the actual numbers from the LDDS test, along with a listing of any abnormal readings on Louie’s other blood/urine panels. We only need to see values that are too high or too low, along with the lab’s normal reference range. There are certain abnormalities that often occur with Cushing’s, and it helps us to see whether or not Louie’s labs fit within that profile. You’ve already mentioned elevated liver enzymes, for instance, and that is definitely a common Cushing’s abnormality.

And now, finally turning to your original question: is there value in determining whether Louie has an adrenal tumor vs. a pituitary tumor? You’re correct that the same medication can be used to treat either condition. However, Cushing’s caused by an adrenal tumor can actually be cured by successful tumor removal. This surgery is very expensive and is significantly risky. Depending upon age and general physical condition, not all dogs are even considered to be reasonable candidates for surgery. If surgery is something you would want to consider, though, then an ultrasound would definitely be valuable. Abdominal ultrasounds can also convey useful information about the status of other internal organs in addition to the adrenal glands, such as the liver, kidneys, gallbladder and spleen. We often say here that an ultrasound can offer a lot of bang for your buck. But for many people, those “bucks” can be needed for spending elsewhere. And if adrenal surgery is not a consideration regardless of the presence of a tumor, then there’s also likely less of a need to know whether or not it actually exists.

I personally think that an ultrasound can be a very valuable diagnostic tool, in general. But we certainly have many folks here who undertake treatment without opting for the expense of an ultrasound. So whatever you decide in that regard is really up to you, and we’ll understand whichever route you choose to go.

Marianne

[mojomom77#]

Thank you for the reply. Below are some test results that I have:
LDDS test:
Cortisol baseline: 3.1 - reference value 1.0-6.0 ug/dL
Cortisol - 4 hr post dex - 4.1
Cortisol - 8 hr post dex - 3.7

Bloodwork:
Hemoglobin - 13.1 (Low) (ref 13.4-20.7 g/dL)
Reticulocyte Hemoglobin 22.9 (Low) (ref 24.5-31.8 pg)
WBC - 19.6 (high) (ref 4.9-17.6 K/uL)
Monocytes - 2.293 (high) (ref 0.13-1.15K/uL)
Eosinophils - 1.509 (high) (ref 0.07-1.49K/uL)
Platelets - 78 (low) (ref 143-448 K/uL); with a comment that scanning of the blood film revealed adequate platelet numbers. due to clumping, the aut platelet number cannot be accurately determined)
Potassium - 3.9 (low) (ref 4.0-5.4 mmol/L)
Na: K Ratio - 39 (high) (ref 28-37)
Chloride - 107 (low) (ref 108-119 mmol/L)
ALT - 288 (high) (ref 18-121 U/L)
ALP - 1369 (high) (ref 5-160 U/L)
Triglyceride - 481 (high) (ref 20-150 mg/dL)
Lipase - 351 (high) (ref 0-250 U/L)

Thanks for the info on value of ultrasound. Am leaning towards it. Waiting now on vet trying to talk to eye vet for a consult.

[labblab]

Thanks again for this additional info. I’m definitely not an expert on lab interpretation, but it does look as though Louie shares several abnormalities common to Cushing’s. As you already know, his LDDS results are indeed consistent with Cushing’s, but do not help us to differentiate between pituitary vs. adrenal forms.

Out of his other bloodwork, several of the abnormalities are just slightly out of range so I’m not focusing on them. Of those that are more significantly out of range, the elevations in white blood cells, monocytes, ALT, ALP, and triglycerides are regularly seen with Cushing’s. We do seem to often see higher lipase levels, too, perhaps in conjunction with some inflammation of the pancreas — or perhaps, not.

Anyway, Louie’s overall profile does support the Cushing’s diagnosis. So now I think we’ll all be poised to follow your next steps forward. Please continue to update us!

Marianne

[mojomom77#]

Hi, again - back with update and question on Louie. He did have the ultrasound and it was consistent with Pituitary form of Cushings - increased size in both adrenal glands. Vet wanted to start on Vetoryl last fall but we delayed due to his eye problem - that's been under control now for a while but life just got in the way!

He's going back to the vet this week and will likely get started on the Vetoryl. Just want to be sure I have my ducks in a row - my understanding is he should have the ACTH stim test at 14 days and again at 30 days, but wait until the 30 days to make any dosing change b/c it can take that long to see the effects of the meds? Am I getting that right?

Has anyone had trouble with Addison's disease after starting Vetoryl and what should I be on the watch for? Overall have your dogs managed side effects of the vetoryl well? He has to pee a LOT and drinks a LOT so those are 2 main symptoms we are hoping to improve for him and for us.

Thank you for advice and support!

[Joan2517]

Hi, again - back with update and question on Louie. He did have the ultrasound and it was consistent with Pituitary form of Cushings - increased size in both adrenal glands. Vet wanted to start on Vetoryl last fall but we delayed due to his eye problem - that's been under control now for a while but life just got in the way!

He's going back to the vet this week and will likely get started on the Vetoryl. Just want to be sure I have my ducks in a row - my understanding is he should have the ACTH stim test at 14 days and again at 30 days, but wait until the 30 days to make any dosing change b/c it can take that long to see the effects of the meds? Am I getting that right?

Has anyone had trouble with Addison's disease after starting Vetoryl and what should I be on the watch for? Overall have your dogs managed side effects of the vetoryl well? He has to pee a LOT and drinks a LOT so those are 2 main symptoms we are hoping to improve for him and for us.

Thank you for advice and support!

This is exactly correct. My Gable was very sensitive to Vetoryl and started at 40mg (he was close to 80lbs.), but ended up on only 5mg twice a day. The symptoms are tricky to notice, but NO appetite is the biggest. He never really stopped eating, but started drinking and peeing more again, which made us think he needed a higher dose, but thankfully we did the ACTH and found his numbers way too low and we stopped the meds until his adrenals rebounded. We had to do that a few times before ending up on the 5mg.

[labblab]

Welcome back to you and Louie from me, as well! I agree with Joan that your understanding of things seems to be spot on :-). In case it’s additionally helpful to you, though, here’s a link to a thread on our “Resouces” forum that offers an informative set of guidelines associated with Vetoryl (trilostane) treatment.

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

You’ll see that two important recommendations are that initial daily dosing not exceed a formula of 1 mg. per pound, and that the medication always be given alongside a meal in order to be metabolized most efficiently.

I know you’ll be watching Louis like a hawk, so if you should see any indication that he’s reacting poorly to the medication (e.g., loss of appetite, vomiting, diarrhea, general lethargy, etc.), you’ll know to stop the Vetoryl and to contact your vet. Sometimes dogs who have been overdosed require some supplemental prednisone while their adrenals rebound. But most often, just discontinuing the medication for a while and then subsequently lowering the dose will be the solution. You’ll find more info about all this in that link that I’ve given you above. If you’ve not already seen it, do look it over and feel free to ask us any questions.

Please give Louis a hug for us, and good luck to you both!
Marianne

[mojomom77#]

Thank you!

[mojomom77#]

Hi, again,

Well Lucky is still not on the Vetoryl after having blood work done last week, the vet called to say the following about his bloodwork compared to @ 6 months ago:
1) Liver values elevated (perhaps not surprising?)
2) Platelet count low
3) Kidney values elevated
4) Anemia - perhaps due to some internal bleeding, bone marrow not producing enough red blood cells, or intestinal parasites - unclear the why but is concerned about the anemia and would like to do additional workup for anemia and kidneys before starting vetoryl.

This was all on a voicemail so including this info now while I concurrently try to reach the vet to discuss.
He is definitely low, low energy most of the day, but especially in the morning. Whereas he used to be hungry all the time and eat the food as soon as put down, now he eats most of his breakfast closer to lunchtime. Does a belly splat on the floor often times when he does the 'doggy shake', and having trouble getting up the one step from our garage, so definitely his hind legs at least giving out/struggling.

Focus for us is on quality of life at this point but any ideas on the anemia, etc. welcome :-)

[labblab]

Hello again, and welcome back, although I’m surely sorry to hear that Lucky is having these additional problems. I absolutely agree with your vet’s decision to further pursue the kidney/anemia issues before introducing any Vetoryl. There are specific warnings about the use of Vetoryl in dogs suffering from kidney dysfunction, so that will be an important puzzle piece to investigate. I believe kidney dysfunction can also be responsible for anemia, so perhaps there’s a linkage between those two issues. Please continue giving us updates. And definitely please give Lucky a big hug from his family here. And the same to you, as well — I know these new developments have to be very stressful for you, too.

Sending healing wishes to sweet Lucky, and my warm thoughts to you.
Marianne

[mojomom77#]

Thank you Marianne, appreciate the kind thoughts and advice. Haven't heard back from vet yet so will wait to find out more.