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Old 03-05-2011, 11:01 AM
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Default 14 year-old Shih Tzu With Recent Cushing's Diagnosis

Hi,

My Shih Tzu, Hannah, who will be 12 tomorrow, was just diagnosed with Cushing's Disease this week. She went into the vet for her yearly dental cleaning, but her bloodwork was concerning and led my vet to suspect Cushing's, so we postponed the dental procedure and he instead did the low dose dexamethasone suppression test. On her regular blood test, everything was in the normal range except for PLT (which I figured out is platelets, and the vet never mentioned this, so he must not be concerned-should I be?) and ALKP. The normal range for PLT is 175-500 and her reading was 618. The normal range for ALKP is 23-212 and hers was 1770. (Last year it was a bit high at 263, but we let it go).

He told me he suspected Cushing's and asked if I have seen any symptoms. She has maybe had a slight increase in drinking (although I never thought she drank enough compared to other dogs previously) and occasionally seems to urinate more. This seems to come and go. Over the last couple of months I have noticed that she seems to eat more quickly and is more often trying to sneak into my other dog's bowl. I increased her feeding amount a little bit since it is winter here, but also noticed that she has lost some weight. She was 10.8 pounds at the vet this week and was 12 pounds 9 months ago.

These are the results he gave me over the phone on the second test: The level he measured at the start of the test (I didn't write down what level this is as I was writing quickly at work, so hopefully you know) was 3.7. After four hours it was 1.9. After 8 hours it was 5.4. He said this can basically confirm the pituitary form of Cushing's. He told me he thinks she is in the beginning stages, as she is showing no major signs, and that it may be a good idea to just watch and see how she does/progresses for now. The medication he recommends we try first (when/if we decide to) is Anipryl because of the low side effects. If that doesn't work he recommends Trilostane. He said the point is really only to treat symptoms and that nothing will add length to her life, which seems to match up with what I read.

I am wondering if you all agree with this diagnosis, and if you think it is smart for me to wait before trying Anipryl since symptoms seem very slight, or if you would start it now. The only other thing that she has started in the last year or so, but has become more frequent is occasional barking at us like she is trying to tell us something (her tail is wagging and she will paw at us), but we can't figure out what she wants-we try letting her out, playing, petting her,etc. Sometimes I wonder if it is old age, and now if it is connected to this. But it also only happens sometimes. She is also a poop eater-she was rescued from a puppy mill and had many litters, and sometimes I think she just wants to go outside because she will dig around in the snow trying to find poop (even though we pick it up). Sometimes this behavior happens more after she or the other dog have recently pooped.

I do like the idea that if there is any cognitive stuff going on the Anipryl could help that too. She doesn't have any hair loss or the pot belly stomach, and no skin infections. She has had allergies for years, but seems to still lick/itch in the winter, and we thought it might also be nerves/mental, as she is a somewhat nervous dog. I now wonder if this could have anything to do with Cushing's...but again, there are no visible signs of problems in terms of coat/skin.

Any advice/opinions you can share will be greatly appreciated. I love my Hannah very much and she is the sweetest most loyal dog I have even known. I want to make the right decisions, but don't want to jump into anything too quickly. I trust my vet, but would like to hear from others too. Sorry this is so long, but I wanted to share everything.

Thank you for reading!

Hannah's Mom
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Old 03-05-2011, 01:51 PM
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Default Re: 12 year-old Shih Tzu With Recent Cushing's Diagnosis

Welcome to you and Hannah!

You have done a wonderful job of summarizing Hannah's situation and your questions. I can often be pretty long-winded in my replies, but given how well you have laid out Hannah's information, I can pretty much leave it at saying that I believe your vet's current recommendation makes a lot of sense. Given the lack of overt symptoms, I believe that most experts would agree with holding off on treatment for the time being. None of the screening tests for Cushing's are fail-safe (it looks as though your vet performed the LDDS test), and until or unless overt symptoms manifest, I believe that a firm diagnosis always remains somewhat in doubt. If and when you do wish to treat, there is probably no harm in starting off with Anipryl, as long as you recognize that only a small percentage of Cushpups respond favorably to it and most do end up requiring a shift to trilostane or Lysodren for effective control of elevated cortisol.

I would make one departure from your vet's comments, though. And that is to say that our experience here has been that many younger dogs who are effectively treated for Cushing's go on to far outlive that "two-year" life expectency that is often quoted. I think that statistic may result from the fact that so many dogs are already older when they are first diagnosed. But for younger dogs, I cannot help but think that their lifespans are extended if the chronic internal organ damage that can be associated with Cushing's is slowed or halted through effective treatment.

At Hannah's age, though, I know her comfort and quality of life are your highest priorities. So I know you will monitor her very closely for the increase in symptoms that would prompt further intervention (or even alternative diagnostics if any problems were not consistent with Cushing's). One additional test that you might wish to consider, now or later, is an abdominal ultrasound. Visualization of the adrenal glands can lend helpful support to a Cushing's diagnosis. And visualization of the other internal organs can help identify any other disease processes that may be going on in addition to, or instead of, the Cushing's.

In the meantime, you may want to consider giving her some benign supplements that support liver function. If others don't beat me to it, I'll stop back by with info in that regard that you can discuss further with your vet.

Marianne

Last edited by labblab; 03-05-2011 at 02:00 PM. Reason: To add something.
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Old 03-05-2011, 03:26 PM
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Default Re: 12 year-old Shih Tzu With Recent Cushing's Diagnosis

Hi and welcome from me as well. I agree with Marianne - it doesn't appear that there is a need to rush in treating as there are no problematic symptoms. My girl Haley was diagnosed at 12 1/2 and treated for over 4 yrs... she passed in May of 2010 but not from cushing's. We used lysodren.

The other thing I disagree with your vet on is anipryl. There are pluses and minuses to all drugs but it really hasn't been used much in years because it does not work for most dogs. I would read up on it before going there. Most now use trilostane or lysodren. They work differently but seem to be equally effective.

But for now I'd just take it slow because you really don't have any symptoms to treat. You could use milk thistle to help with the alk phos/liver enzymes. It brought Haley's numbers down from 2000 to 700's. Cush dogs typically don't have normal liver enzymes even after treatment.

Glad you found us. Keep us posted on whatever you decide and feel free to ask questions. Kim
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Old 03-05-2011, 05:05 PM
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Default Re: 12 year-old Shih Tzu With Recent Cushing's Diagnosis

Hi and welcome from me and my boy, Harley.

An increase in drinking, urinating more frequently, and weight loss even though one has been feeding more, can be symptoms of diabetes in a dog. Was an Urinalysis done too? If so, were ketones or glucose found in Hannah's urine?

Lori
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Old 03-05-2011, 05:55 PM
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Default Re: 12 year-old Shih Tzu With Recent Cushing's Diagnosis

Hello All-

Thank you so much for your replies. I REALLY appreciate the advice and support of others who have been through this, or are familiar with what we are going through.

I do think I will wait to see what happens before moving forward with any treatment. I also talked with my vet about doing a urinalysis on Hannah, since she has a history of problems with crystals in her urine and has been on a prescription food (Royal Canin Urinary SO) for several years to control the issues, and I would like to see if she is doing okay in that area since now I may not notice problems if she is urinating more often due to Cushing's. Hopefully doing that will also show if there is anything else going on with Diabetes? I don't know if anything in the blood test he did pre-dental would show up if Diabetes was an issue?

My vet does not seem to use Lysodern at all. From what I have read, I have to say I would be a complete nervous wreck about trying it as well. Also, I am gone several hours each day at work (I am a teacher) and I would worry about missing concerning symptoms. I do know his other choice is Trilostane, but he seemed to think trying Anipryl first, to see if it did work in her case, would be less risky. I have to say I agree. I feel very nervous about adverse reactions and these Addisonian issues; however, if Anipryl didn't work, and her symptoms were there, I would try the Trilostane.

Where do I find the milk thistle? I think I ready other information about people trying supplements with some success and I would be open to that as well.

My vet said that Cushing's varies with each dog and each case is different, which makes sense to me. My parents' collie had Cushing's and had to be put to sleep when she could no longer get up and was leaking urine almost constantly. She went very quickly from the time of diagnosis-didn't even make it 6 months, but they determined she had a tumor on her adrenal glands which metastasized to her liver. To say the least, when I heard Hannah's diagnosis, I didn't have very high expectations. After being reassured by my mom and my vet, I realized that Hannah's situation is not as bad. My parents dog was drinking a bucket of water, panting constantly, leaking urine, having trouble with her back legs/end, etc. and everything progressed quickly. Anyway, I asked my vet to give me his best guess on how long Hannah might make it, as I was wondering if she even has a year. He guessed two to three. Does anyone else have any idea, based on her limited symptoms at this point? My concern is that it could progress really quickly, even though she doesn't seem too bad now.

Here are some other questions I have:
-Should I move forward with a dental? He said they can still do one when we are ready. I know Cushing's dogs can be more prone to infection, but I also don't want to spend tons of money not knowing what other treatment, procedures she may need. She doesn't have great teeth, but has had many pulled, and has had yearly dentals as long as I have had her (the past 8 years).
-Does it make sense that she is eating more and losing weight? She is 10.8 lbs. now and was 12.3 in June. (I am wondering if this could be due to muscle loss).
-Do Cushing's dogs lick/itch a lot, even without any visible skin conditions? This seems to be worse this winter (when her allergies have normally subsided in winter). And is the random, but somewhat incessant barking and pawing at us when we have no idea what she wants, something that could be part of Cushings?
-Do you think the LDDS test with the 4 and 8 hour checks does clearly indicate the pituitary form of the disease?
-Would the abdominal ultrasound show anything other than enlarged adrenal glands to show more evidence? Or were you thinking it might show a tumor there, which would mean it is not a pituitary issue?
-Is there any "typical" progression with this disease? Like how long it might be before Hannah shows worse symptoms? I realize all pets are different, but my vet said it is typically slow, and my only experience is my parents' dog, which was VERY quick.

I will definitely be following up with my vet with all of my questions and concerns to make sure I do the right thing for Hannah. I just don't have tons of money to do everything (my husband and I are both teachers) and want to make sure I prioritize my issues and only test what is necessary at this point...as I also still need to figure out if she will get a dental and I have another Shih Tzu to take care of as well. They are both due for their exams and vaccines in April. That is why I thought the urinalysis might be good and not too expensive.

Again, thank you SO much for your help and suggestions. I will check back often and keep you updated.

Hannah's "mom", Julie
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Old 03-05-2011, 09:59 PM
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Default Re: 12 year-old Shih Tzu With Recent Cushing's Diagnosis

Welcome Julie.

Sorry to hear that your baby is having problems.
Hanna may have a while to go. Shih Tzus live long. My Shih Tzu Cushing girl lived to be 15.

Mine had more Thyroid symptoms than Cushings. She never drank a lot or peed a lot (it was only a little bit more), even before diagnosis. She was hungrier and gained weight... In retrospect, I felt that mine had Cushings for a few years before the diagnosis. There was some panting when I walked her for 3-4 years. Basically, I noticed that she was "getting older" and stopped more often during her walks and had some panthing, and hing legs shaking. That's when I took her in for bloodwork. She was diagnosed with Hypothyroid. Her liver enzymes were elevated, Cholesterol and Triglycerides. Then we did the ACTH and it was Cushings. Mine did very well on Trilostane once the adjustment period was done with (approx 4 weeks). Mine had the additional Thyroid which made things a bit tricky loading the Trilo and Soloxine at the same time. It doesn't mean that yours will be the same as any of ours, but you may see some similar symptoms and/or behaviors in Hanna.

Cushings is not a death sentence, but it complicates things; it mimics many other things going on. Many times the dog will have Cushings/Diabetes/Thyroid combos, two or only one of the three. Once the dog gets diagnosed with Cushings many times Vets think that Cushing is responsible for all of it's ills. Sometimes that's true, and other times it's not.

-Anipryl did not work well on my sisters' dog.
-if your Vet starts Hanna on the lowest dose of Trilostane 1mg/lb it may not be so bad. Check ACTH 14 days later to see if an increase is necessary...
-As far as Hanna pawing and barking...is she maybe begging for more food? That may be her new Cushings hunger call?
-Ultrasound will show if there is an adrenal tumor (I don't think LDDS is conclusive for deferentiating tumors. Sometimes there is tumor on the adrenals and pituitary-rare),and other organs like the condition of the Liver, and the bladder stones...
-Dogs need a dental because bad teeth can affect their Liver, kidneys etc. Cushings can affect those organs. In fact, from now on you will probably see some blood work adjustments.
-actually she shouldn't itch with Cushings because the extra cortisol pumped out should keep allergies in check, unless something else is going on...
-typical progression is what I've decribed with my Shih Tzu above. It may not bother some people, but the panting and stopping bothered me. As I said, a few years earlier she had 'some' panting, but that didn't bother me, until she had that depressed, oldish look, and walk. A Shih Tzu should not look or act old at 12. Mine was diagnosed at 13and was full of life until 15....and got cancer.
-IMO, a full chemistry profile, CBC, T4, UA and an Ultrasound is a good idea. You do what's comfortable for you.

You could ask your Vet for a copy of Hannas bloodwork so you have a file for future comparison.
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Old 03-05-2011, 10:45 PM
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Default Re: 12 year-old Shih Tzu With Recent Cushing's Diagnosis

Julie,

I too am confused about the weight loss as it is the opposite of what you see with cushings. I would want to rule out diabetes. You should have a glucose reading from the blood panel if they did a complete one. If not I would go there next to be safe. Diabetes and cushings have similar symptoms.

I wish I could say that there is a natural progression with cushings but I've been here for 6 yrs now and there really isn't. The leading experts in the field all agree that it is not necessary to treat if the symptoms aren't there so I wouldn't start anything at this point in time. You will know if you see an increase in urination, etc.

You can buy milk thistle capsules at any health food/vitamin store. I just poured half a capsule over food in the a.m. and the other half at night.

Cush dogs do tend to lick alot and can have skin issues. (this is all covered in our important info section in great detail) Your friend's dog that passed had an adrenal tumor and sometimes they grow quickly which might be what happened. Your LDDS test result is indicative of pituitary cushings. It is the most common.

I would double check on the blood test to rule out diabetes. The LDDS test is not fool proof. My dog had a false positive on it and four false positive ACTH tests. Cushings can be tough to diagnose so you can't really feel comfy with only one test.

Hope this helps. Kim
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Old 03-06-2011, 08:01 AM
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Default Re: 12 year-old Shih Tzu With Recent Cushing's Diagnosis

I see you've already gotten some great information from others. Here's a few more thoughts from me:

Quote:
Originally Posted by jmac View Post
Hopefully doing that will also show if there is anything else going on with Diabetes? I don't know if anything in the blood test he did pre-dental would show up if Diabetes was an issue?

I'm guessing that Hannah's blood glucose level was part of the pre-dental labwork, and that it was normal. If that value had been elevated, your vet would have suspected diabetes. But you can double-check with him as to what Hannah's glucose level was on that test.

Where do I find the milk thistle? I think I ready other information about people trying supplements with some success and I would be open to that as well.

As Kim said above, you can buy milk thistle in health food stores. SAM-e is another supplement that is often recommended for liver support. Here's a link that gives more info about both these supplements:

http://www.k9cushings.com/forum/showthread.php?t=192

I would not waste my money on other supplements advertised on the internet as specifically "curing" or controlling Cushing's. There is no scientific evidence that they help.


-Should I move forward with a dental? He said they can still do one when we are ready. I know Cushing's dogs can be more prone to infection, but I also don't want to spend tons of money not knowing what other treatment, procedures she may need. She doesn't have great teeth, but has had many pulled, and has had yearly dentals as long as I have had her (the past 8 years).

As has already been said, you don't want infections to get out of control in Cushpups. The one reservation that I would have about a dental is the fact that most anesthetics can be hard on the liver, and we know from her lab results that Hannah does have some liver involvement going on. So in my mind, performing the dental would involve the judgement call as to whether her teeth are currently in a state where it is worth burdening her liver with the anesthetic. Again, something to discuss further with your vet.

-Does it make sense that she is eating more and losing weight? She is 10.8 lbs. now and was 12.3 in June. (I am wondering if this could be due to muscle loss).

While it is true that most Cushpups gain weight rather than lose it, my own boy also lost weight prior to diagnosis even though we even switched to a higher-caloric food in order to try to "beef him up." So I do know that weight loss is possible. He definitely did lose muscle mass during the pretreatment period.


-Do Cushing's dogs lick/itch a lot, even without any visible skin conditions? This seems to be worse this winter (when her allergies have normally subsided in winter). And is the random, but somewhat incessant barking and pawing at us when we have no idea what she wants, something that could be part of Cushings?

Again, while it's true that steroids can aid in controlling the manifestation of allergies in many dogs, my Cushpup was also a "weirdo" in this regard and licked his front paws incessantly for a long, long time prior to diagnosis at a time when his cortisol level was very high. As soon as his cortisol level was controlled with trilostane, the licking magically ceased. I have no explanation for what was going on, but it was a clear and definite change for him.

-Do you think the LDDS test with the 4 and 8 hour checks does clearly indicate the pituitary form of the disease?

The pattern of Hannah's LDDS test is consistent with pituitary Cushing's (suppression at the 4-hour mark with "escape" at the 8-hour mark). In terms of the numbers themselves, she is right at the borderline, because vets are generally looking for either a 4 or 8-hour result that is less than 50% of the baseline cortisol level. So with a baseline of 3.7 and a four-hour level of 1.9, she is hovering right there at the 50% mark that would be diagnostic of PDH. Here is a link to a thread that will give you more info about interpreting LDDS tests:

http://veterinarymedicine.dvm360.com.../detail/580093


-Would the abdominal ultrasound show anything other than enlarged adrenal glands to show more evidence? Or were you thinking it might show a tumor there, which would mean it is not a pituitary issue?

Yes, exactly right, the appearance of the adrenals could give further support for either the pituitary or adrenal form of the disease. But in the absence of overt Cushing's symptoms in Hannah, I was also thinking as much along the lines of making sure that there is nothing strikingly abnormal about her liver (other than the changes that are typical of Cushing's) or other internal organs that might account for her test elevations.

-Is there any "typical" progression with this disease? Like how long it might be before Hannah shows worse symptoms? I realize all pets are different, but my vet said it is typically slow, and my only experience is my parents' dog, which was VERY quick.

I agree with your vet's assessment that Cushing's is generally a slowly progressing disease in the absence of aggressive tumors, which are the exception rather than the rule.
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Old 03-06-2011, 10:43 AM
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Default Re: 12 year-old Shih Tzu With Recent Cushing's Diagnosis

Thank you all again for your helpful responses. I have done a lot of reading since Thurs. afternoon when I got this news. I was able to find information on the LDDS test and do feel better that Hannah's test is suggestive of PDH. Even though my vet explained it to me it took reading much more on the internet to understand it better.

She did have a CBC done and her glucose levels were normal. I have decided to have a UA done on her this week to make sure there is not a UTI. Also, her cholesterol was normal, as well as her BUN. (I read on some site that those levels typically are involved in Cushing's too; I believe it was high cholesterol and lower BUN). Her other liver level (ALT) was also normal. Everything was in the normal range other than her platelets and her ALKP. Should I post the complete result (I have a copy), or would it not help anything if the other levels are normal?

I will look more at the links you provided (I looked through them yesterday) to find out more info. about milk thistle. I'm hoping it would also tell me the dosage.

I have really paid attention over the weekend and am starting to feel that there are enough symptoms there-the increase in water intake and an increase in the amount of time she pees, as well as the crazy appetite-for me to do something. (I think I mentioned before that Hannah didn't seem to drink/urinate enough in my opinion, compared to other dogs, and it has definitely increased). Therefore, I think I am going to start with the Anipryl first to see if it does anything. I have read a lot and know that only 20-40% of people feel it is really effective, but with low risks, I would like to start there. Then if after that two to three month period it hasn't done anything I will move onto the Trilostane, my vet's other recommendation. Does that make sense to the rest of you, or do you still think I should wait until things get worse? I don't want to wait until she is peeing all over the place if I notice SOME changes. My vet said they have two doxies who are being very successfully treated with Trilostane right now. Is it correct that the main period you have to really be careful/watch your dog closely is that initial "loading" period the first few weeks (when you also get the blood tests done, etc.)?

I don't feel that she really shows any of the other symptoms of liver disease and assume that since her glucose is normal now and if her UA is done we should also be able to rule out diabetes and see if a UTI is present. I think I will talk with my vet about the dental and will maybe wait a little while before doing that. I always got nervous having her anesthetized anyway, and right now I know I would be worse. I feel like I am still a bit skeptical about her diagnosis, but at the same time, many pieces seem to fit at this point, and it sounds like each dog is different.

On a side note, today is Hannah's 12th birthday, so I'm going to spoil her like crazy and try not to think about Cushing's all day. I just want to be educated and make the best decisions for her. . I don't want to ignore the symptoms/changes I have seen, but I don't want to dive into anything either. That balance is tough, so I appreciate your advice.

Thank you again for your help! I GREATLY appreciate it!

Julie
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Old 03-06-2011, 10:54 AM
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Default Re: 12 year-old Shih Tzu With Recent Cushing's Diagnosis

Oh Julie, Happy Birthday to sweet Hannah!!!!!!!!!!!!

I think you're absolutely right to take this day "off" from worrying and instead to totally focus on celebrating with your girl!

But as far as beginning the Anipryl, if your vet agrees, I don't see any harm in going ahead and giving it a try at this early stage. If Hannah's symptoms do continue to increase and you move on to trilostane down the road, ongoing monitoring via blood testing will continue for as long as she remains on the medication. However, once dogs are stabilized on an effective dose, the testing can become much less frequent.

Marianne
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