New here - suspect Cushing's in 4.5 yr old beagle mix

[JoniMom]

Good morning,

We have a rescue dog, Joni, who is 4.5 yrs old, 47lb (she should be 42lb). She was diagnosed with hypothyroidism about 1.5 years ago and is currently on .3mg levothyroxine twice daily. Initially, she responded well, and many of her clinical symptoms improved for a month or so. Then they started to return. They adjusted her dose from .2 mg to the current .3mg. But little was accomplished. She remains lethargic, irritable, sheds like crazy, licks obsessively and recently - which is what caused us greater concern - has started panting and drinking more than usual. She pants at night after being at rest for some time, and at other intermitten intervals inside our AC house. She is also newly exercise intolerant. She has gained wait and has a strong appetite. To us, her belly looks like it's becoming a pot-belly. She's definitely putting on weight - last weigh in was 47, and she's been 42-43lb consist for the past many years. She's always been incredibly fit, so we notice this right away, but others not so much as she just looks 'normal' to some, but we know she's getting heavy. She's normally an incredibly athletic dog, and now she pants like she ran a marathon if we take her just around two blocks. Usually she is happy to hike and run for hours on end. She also is shaking her head intermittenly - her ears appear clear and no infection. And her licking and shedding have become worse.

The Vet ordered a Cortisol to creatinine urine ratio test that we just an hour ago got the results from:

10.6 ug/dL cortisol
195.4 mg/dL creatinine
17 ratio

We are awaiting official response from our vet, but I take it this rules out Cushing? I can't really find the reference ranges in these values online....

We just know our pup is not happy and not herself. If it's not cushing's, does anyone have other ideas as to what this might be? Any thoughts would be welcome and thank you in advance.

Shelton

[labblab]

Welcome to you and Joni — we’re really glad you’ve found us! Boy, I have to admit that her symptoms are so classic for Cushing’s that it’ll be very surprising if those UC:CR results are indeed within normal range because, if so, that does make Cushing’s quite unlikely. One question, though: was the urine test based on only one sample, and was the sample obtained at home or at the office? (I guess that’s actually two questions ;-) We’ve been told that pooling samples obtained on three successive mornings at home can result in a more accurate picture, since cortisol production can be variable and you also want to eliminate the effect of stress. As far as stress, that could artificially elevate the reading, and that doesn’t seem to be Joni’s issue. But still, I’m curious to know how the sample was obtained.

Also, have there been any other abnormal results on Joni’s lab profiles other than her thyroid? Cushpups commonly exhibit elevations in liver markers and cholesterol, and also sometimes have abnormalities in certain blood cell counts (platelets and white cells). Also urine is typically quite dilute with low specific gravity. Urinary tract infections are also common. If Joni’s blood and urine panels have all been normal, that also makes Cushing’s unlikely. But if she’s had other results that are consistent with Cushing’s, that makes me scratch my head even further and makes me wonder whether you might still want to advance to a more specific diagnostic Cushing’s blood test even in the face of these urine results.

I’ll go ahead and close for now as opposed to peppering you with more questions! But once again, we’re very glad you’ve found us and we hope we’ll be able to help chart the best path forward.

Marianne

[JoniMom]

Hi Marianne,

Wow thank you for the fast reply - I have to say I feel some relief just having someone else thinking on her scenario in such a thoughtful way! I really appreciate it. We went through a string of not so great vets for a number of years chasing the thyroid issue, and finally found one we liked, only for her to leave the practice. Now we’re basically with a new vet every time we go in.... I think they are generally well intended, but I just fatigue of not feeling like we have a partner to really help us figure it all out.

So Joni has always had some irregularities with her lab work. Her most recent physical and full blood panel was done in January of this year, so know that it’s now 7 months ago from whatever is happening today. But here are the ways she was irregular back then - I don’t really know what any of it means, and wasn’t really given an explanation from our vet - my emails weren’t responded to at the time (different vet then who we corresponded with this past week for the urine test, though they are all a part of the same vet practice here in Philly).

Hemoglobin - slightly high outside reference range; 21.0
MCH - slightly high; 26.1
Reticulocytes - high; 129
Glucose - low; 59
Albumin - high; 4.3
Creative Kinase - high; 245

And since you mentioned cholesterol specifically, it was normal but towards the upper limit within the given reference range at 321. All other values were within the reference ranges, but some other values were right at the very top or very bottom of the ranges. Let me know if you want to know those values.

Also, her T4 even on supplementation always remains low - it was at 1.3ug/dL still. I never have understood why we can’t get that to go up more when she’s on .3mg twice daily.... feels like it should be a bit higher. When she was diagnosed, she was at .8, so I guess it is all relative... but feels odd.

Thank you again and please let me know if you have any other questions - I’m grateful to have someone who is thoughtfully interested!

Best wishes,

Shelton

[labblab]

Thanks so much for all this additional information! Joni’s situation definitely remains perplexing :-(((. I’m not sure what to make, if anything, of the particular abnormalities that you’ve noted. They are not lab values that we commonly see associated with Cushing’s. The liver markers that I was talking about previously are the ALKP (or sometimes noted as ALP) and ALT. Elevated levels of ALKP (sometimes exceedingly high) are very typical of Cushing’s, as are moderate elevations in ALT. If those values were both normal for Joni, then her clinical picture is definitely odd: observable symptoms that are very common with Cushing’s, but lab values that are not really consistent at all.

I wish I was more knowledgeable about thyroid abnormalities, but I know only enough to be dangerous, as they say. Low thyroid can be a primary problem in a dog, but it also can be secondary to other conditions, of which Cushing’s is one. My own Cushpup was initially diagnosed with hypothyroidism based on low T4 readings, but when his symptoms did not resolve with supplementation, we proceeded with further diagnostics and found that he indeed suffered from Cushing’s, as well. I’ve since learned that it’s probably best to perform a more complete thyroid panel prior to beginning thyroid supplementation, as opposed to simply relying on basic T4 levels. More complete thyroid analysis can help guide supplementation decisions— sometimes supplementation is necessary and sometimes it’s not, especially if the low readings are due to another condition. Unfortunately, the difficult part is that if owners want to retrace their steps and have a complete thyroid workup done, the dog has to be removed from supplementation for several weeks in order for new diagnostic testing to be accurate. As an example as to how complex thyroid testing can be, here’s a link to an informational page about thyroid testing found on the website for Michigan State’s Veterinary Endocrinology service:

https://cvm.msu.edu/vdl/laboratory-s...nction-in-dogs

I know I’ve probably gone overboard here with my thyroid discussion, but it just caught my attention since Joni has not been responding to her supplementation in the way you would have hoped or might have expected. In honesty, Joni’s situation is puzzling enough to me that unless your local vet comes up with some reasonable diagnostic suggestions, I’d encourage you to request a referral for a consultation with an internal medicine specialist. I’m sure there are many private specialty practices in the Philly area, but if I’m not mistaken, you’ve got one of the premiere veterinary schools of the nation located there : UPenn. I’m confident they’ve likely got an outpatient clinic there that accepts patients for diagnostic consultation. Either way — UPenn or a private specialty practice — you may find that your money would be well spent to get the opinion of an endocrinological expert. Clearly, something has changed significantly for Joni, and it may take some searching to figure out exactly what’s gone wrong. But specialized professionals may be able to help you find the answers more quickly.

I’m so sorry that I don’t have more immediate answers for you, but please do feel free to continue asking more questions and discussing more options, OK?

Marianne

[JoniMom]

Thank you Marianne! I very much appreciate your thoughts and the links. We're going to follow-up with the vet again tomorrow - it seems since it has been 7 months since we ran a complete blood work on her, maybe it's time to recheck. And maybe that will give us some new insight of something has shifted / changed more recently. Just because you inquired, the ALKP markers were within normal range back in January. And though I'm also no expert on the thyroid issues, I will share when she was diagnosed we did have a full panel with free T4 and T3 and the thyroid stimulating hormone as well - but I agree, it is still puzzling to us that she hasn't responded quite the way we thought she would on supplementation.

Once we have some new markers to go on I will write back in, but thank you again for your support! It means a lot just to have someone else consider all this.

Best wishes,

Shelton and Joni

[labblab]

Dear Shelton, just a quick note to let you know that I’ve moved your thread here, to our main Questions and Discussion subforum. When I replied to you earlier, I hadn’t noticed that your thread was located on one of our subforums that receives less “traffic.” Hopefully more folks will see our conversation here, and join in alongside us ;-).

Marianne

[Harley PoMMom]

The pituitary form of Cushing's is from a tumor on the pituitary gland, usually benign, however a small percentage, around 15%, do grow to be a macroadenoma. The only way to visualize the pituitary tumor is with a computed tomography (CT) or magnetic resonance imaging (MRI).

I do want you to be aware that studies have found that dogs weighing over 40 pounds are sensitive to Trilostane and therefore need smaller doses than the 1 mg per pound that is recommended. If this were me, I would not start Joni on a dose higher than 20 mg. Also, it is vital that the medication be given with a meal so that it is properly absorbed, generally it is administered in the morning with a meal.

The monitoring tests for Cushing's are the ACTH stimulation and this test is conducted 4-6 hours after the dose of Trilostane is given with a meal. For the first 30 days of treatment no upward adjustments to the Trilostane dose should be carried out because cortisol can continue to drift downward during the first 30 days of treatment.

If you have any more questions, please do not hesitate to ask them!

Hugs, Lori

[Harley PoMMom]

Please forget that 2 year life expectancy, Cushing's is a treatable disease and with treatment dogs with Cushing's can have a good quality of life and there is every reason to believe that they can live out their normal life span. However, for the treatment to work safely and successfully it requires an educated pet owner along with an experienced vet as adverse side effects are mostly only seen when the proper protocols are not followed.

One remark I do want to address, cortisol levels can only be checked with an ACTH stimulation test, so if the vet is stating that her level is low judging solely from those LDDS test results, that's a mistake.

How much does Joni weigh? And what dose of Trilostane is being prescribed?

I'm providing a link to a thread with cost saving ideas: https://www.k9cushings.com/forum/sho...ushingoid-Dogs

Hugs, Lori

[Squirt's Mom]

Hi Shelton,

Welcome to you and Joni!

I wanted to talk to you about that 2-year myth....yes, myth. That is exactly what that claim is. Maybe, MAYBE, many years ago that was seen as fact but today it certainly is not and because of changes in the Cushing’s world that 2-year survival claim qualifies as a myth.

Years ago most dogs were not seen as family nor kept inside. They were working animals and seen more as livestock. As a result when a dog got sick it was the norm to let them go on as long as they could then simply put them down when they could no longer do their job. Very rarely were they treated for any diseases. But today that is not the case. Our babies are part of our family and most of them live inside with us. So when we see them changing we take them to the vet just as we would take a human child to the doctor. And, just like with our human children, when we are told our furbabies have a disease, we treat that disease if at all possible.

Even tho most cush pups are diagnosed when older with most of their lifespan behind them more often than not they still outlive that 2-year claim. This is due to several reasons. For one thing, that fact that most of our babies live with us, sharing our spaces which allows us to notice quickly when they aren’t their usual selves. Even those working dogs who do live outside are held in higher esteem today than they used to be and we are more apt to treat them than our ancestors were. In addition, there have been advances in the diagnosing and treatment of Cushing’s. For another we, as parents, demand more from their vets and ourselves. We demand their vets keep up with the advancements in Cushing’s and we demand of ourselves that we learn all we can to help our babies live their best life possible with the disease. For these reasons that 2-year myth has been busted to smithereens. Barring one of the rare complications with Cushing’s, most cush pups live out their normal lifespan and beyond simply because of the attention and care they receive from their loving and attentive parents who want to the best thing for their furbabies.

Unfortunately, there are some factors that can make that myth a fact. The two most dangerous things for a dog with Cushing’s are 1) a vet who doesn’t understand the disease nor the treatments used to manage it, who don’t keep up with advances, who won’t listen when confronted with their mistakes or advances they may have missed, and who refuse to follow specific protocols for the drugs they prescribe; and 2) parents who won’t take the time to learn about the disease, the drugs used to treat it and the signs associated with low cortisol, who blindly follow anything the vet says even when what they are saying and doing is not correct, and who will not listen when they are presented with sound, scientific proof that their baby is not being properly cared for by their vet. In these cases, that 2-year lifespan might be sadly generous.

You are here, asking questions, trying to learn how to best help your sweet girl so that puts you in the category of those parents who do go that extra mile. Just try to put what you are reading on the web away and don't think on it any more.

Hugs,
Leslie

[JoniMom]

Thank you Leslie and Lori for the resources and also candor about prognosis! It definitely makes us feel better! I am wondering - the complications you mention, and I've read that sometimes the tumors can be more aggressive - how do you know if this is the case or not with your dog? I asked our vet about Joni's outlook. She said it was largely dependent on her response to the medication overtime, and repeat testing. Regarding her weight - she is overweight just now, and is just over 50lb. At her healthy weight she is closer to 43lb. The vet said the typical starting dose was 1 (mg? I forget the unit) per lb, and that Joni would be started using that. Rechecked in 10 days, then on day 30, then at 3 months, then at 6 months. She said the 10 day or 30 day checks demonstrated an adjustment to the dose was needed, then the process would repeat (10 day after adjustment, day 30, 3 month etc). Regarding the ACTH - I am unsure if they performed that test or not. I will ask. I did ask for the results of the LDDS intending to share here, but I didn't ask / didn't know to ask about ACTH. We go this afternoon to pick up the trilostane and start her (I guess today or tomorrow? Unsure if it's given morning or night, with / without food?).

Is there any reason to be concerned that given Joni's younger age she might have a more aggressive / complicated form? Does concurrent hypothyroidism (which was also early onset - diagnosed at approx 2 years of age) raise any flags?

Thank you for the resources regarding the meds. My thought at the moment is to use the vet's own pharmacy until we get her dose right / stable, and then maybe look to source it on a longer term maintenance basis through a cheaper supplier, assuming that makes sense.

Thanks again!