Help needed with Cushings test requested by Vet

Hello! My name is Debbie and I am new to this group. This forum was recommended to me by a member of I Heart Senior Dogs. My fur baby is Sophie and she will be 14 in January. She is a Cocker Spaniel and Jack Russell mix and is a sweetheart. When we had her teeth cleaned this past summer the vet noted from her blood work that her liver enzmes were high. I do not have the test result but she said they were in the 900 range. She started Sophie on the Denamarin Advanced tablets. We gave her those for 3 months and went back for another blood test last week. The vet said her levels had come down slightly. They are now around 800, which she deemed way too high. She said the next step was a test for Cushings. I've read some negative things about how stressful this test can be for dogs and can result in positive results just because of the stress level they are under when tested. I want to do what is best for my puppy and I've heard this disease can be fatal if not treated. The main reason for the test is the high level enzymes. Sophie has had some nights when she gets up and wanders around the house, but those are far apart. She was panting a great deal but that seems to have greatly improved since she is on the Denamarin. She is not exhibiting excessive thirst and there has not been any change in her bathroom habits. She does have several skin tags now, but is not loosing hair. Help! I just want to do what is best for Sophie. If the test needs to be completed we will gladly have it done. Thanks so much for your help. It's just so difficult being entirely dependent upon your vet.

Hello, and welcome to you and sweet Sophie! I’m so sorry you have any reason to be concerned about her right now, but I’m very glad you’ve found us. Before addressing Sophie’s specific situation, I’m going to recopy a message that I recently posted to another member who was debating treatment for her senior dog. Then I’ll talk a little more about Sophie.

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Given her age, Gidget has now entered her senior years. That being the case, there may be pros-and-cons to Cushing's treatment that you'd want to think over. In my own mind, the decision whether or not to treat any dog depends on a number of factors: age of the dog, apparent discomfort, severity of symptoms (both external and internal), etc. Cushing's is typically a slowly developing syndrome, and the decision to actively treat may come sooner or later in the process. The primary goals of treament are to control the troublesome observable symptoms (things like excessive thirst, urination, hunger, panting, muscle wasting), and also to halt/delay silent internal damage. Untreated Cushing's can make dogs more vulnerable to things like high blood pressure, high cholesterol, protein-losing kidney disease, blindness (as a result of high blood pressure), pancreatitis, ligament damage and slow healing, chronic infections and skin issues, GI disturbance, etc. Not every dog will suffer from all or even many of these issues, but the disease can make them happen. For a younger dog, I would want to provide as many quality years of life that I could, and that would mean putting a stop to the development of the internal systemic damage as well as relieving the uncomfortable outward problems.

However, since the damage usually occurs over time, my own opinion is that I don't worry so much about the "silent" damage in a dog who is already elderly. Instead, my biggest concern for a senior dog is immediate quality of life. So if the overt symptoms are making the senior dog uncomfortable, I would treat. Otherwise, I might choose not to treat, especially if my senior dog suffers from inflammatory conditions like arthritis that may actually be soothed by the elevated cortisol level of Cushing's. Treatment also involves frequent vet visits and blood draws, especially at the beginning. So again, if vet visits are really stressful for a senior dog, I'd also factor that into my treatment decision.

Marianne

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OK, so in terms of Sophie’s presentation, the only real “red flag” right now is the elevated liver enzymes. One question I have for you is whether the main elevation is in her Alkaline Phosphatase (noted on printouts as ALKP or ALP). This is the enzyme that is most commonly elevated in Cushpups, although other conditions can elevate this enzyme as well.

If so, and in the absence of bothersome observable symptoms, you may want to discuss in greater detail with your vet what the actual goal of treatment would be for a dog of Sophie’s age right now, even if she were to test positive. Even in younger dogs, many specialists delay treatment if the only symptom is the lab abnormality of elevated liver enzymes. This is partly due to the fact that, in the absence of consistent observable symptoms, a Cushing’s diagnosis remains suspect if those lab values are the only abnormality. Also, liver elevations that are truly secondary to the high circulating steroids of Cushing’s don’t necessarily herald actual damage to the functioning of the liver. Finally, in the absence of observable symptoms, it makes it much more difficult to monitor the appropriate dose of the Cushing’s medication. Re: the ramifications of the elevated liver enzymes, here’s a statement made a few years ago by Dr. Mark Peterson, a nationally-known Cushing’s specialist.

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I am not a proponent of treating dogs with asymtomatic Cushing's disease, unless they have secondary hypertension or proteinuria...

...In general, most dogs with Cushing's syndrome develop a high alkaline phosphatase, with is "induced" to rise because of the cortisol excess. In other words, the fact that this liver (and bone) enzyme is high only means that it is a marker for Cushing's and does not reflect liver damage. So to me, that is not a reason to treat, especially since this value rarely normalizes after successful treatment with trilostane or mitotane.

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So to sum things up, for a dog of Sophie’s age, I’d personally be reluctant to launch into Cushing’s testing and treatment unless she suffered from symptoms that were making her uncomfortable. That time may come, but it doesn’t appear to be right now. Again, I’d ask your vet what the actual goal of treatment would be at this stage. If your vet is most worried about Sophie’s liver, I might opt instead for some actual liver function testing which is different than checking the enzyme levels. If Sophie’s liver function has not been compromised, then I’d likely put Cushing’s on the back burner for now.

Marianne

Thanks so much for all the advice and help. You have certainly presented information in a way I can understand and appreciate your concern for a pup Sophie’s age. I have read so much and read so many opinions from dog parents with diagnosed cushings. It’s so easy to get confused with all the different viewpoints on treatment options and dosing. I do have one other question. Is it reasonable to ask for an ultra sound at this point? Thank you again for taking so much time to respond. Sophie and I appreciate all the help! ��

Welcome back to you and Sophie! In general, I consider abdominal ultrasounds to be an excellent diagnostic choice because they can deliver helpful information about all of the major internal organs. In terms of Cushing’s, the appearance of the adrenal glands and the liver can be very helpful in terms of identifying abnormalities that are consistent with the disease. For that reason, I would never tell anybody it’s a bad idea to have the imaging done. However, when Cushing’s is suspected, I’ll add the cautionary note that you really want the ultrasound to be performed on state-of-the-art equipment and the interpretation to be done by a well-trained professional. This is because the adrenal glands can be very hard to see and/or their appearance correctly analyzed. Many general vet offices don’t have this capability with their equipment and staff. So if you choose to proceed with an ultrasound, you might wish to ask for a referral to a specialist to have it done.

In Sophie’s case, you might find some alternative explanation for the elevated ALP. However, if the internal images are consistent with Cushing’s, obviously you’d have more reason to proceed with diagnostic blood testing. However, if that’s the case, in my own mind you’d still be left with the question as to whether or not to proceed with treatment, regardless, in the absence of observable symptoms. But that’s a bridge you can cross later on, depending on all the information you gather.

Marianne