Is it cushings or not with our blue - Blue has passed

so to summarize Blue's visit with the doctor....he was diagnosed with cushings.
He had substantial weight gain since oct 2017 at 98 lbs -he's close to 110 lbs now. His appetite is so ravenous, polyphagia, excessive thirst and urination, polyuria/polydipsia, he hasn't grown his hair back from his ultrasound last summer, alopecia, and now the scabbing, thickening calluses on his elbows, and skin bumps on his back, calcinosis cutis. (not to mention his "mopey, sad, lazy, crotchety, old man " mood/behavior as I like to call it.)
His lddst test run last summer was indicative of Cushings, and I did ask about his baseline and she said "4" so ...but...the ultrasound ruled out adrenal tumors, making it more likely pituitary dependent cushings.
She would like to start him on Vetoryl, but is awaiting results of his thyroid function test and serum chemistry and urinalysis to determine the best treatment plan.
so...i'll keep you posted, thanks so much. I sincerely hope its smooth sailing on this medication. after a month, they said they will blood test him to see how he's doing on it. do you think that would sound about right then? thanks!

There is a strict protocol to follow with Vetoryl and based on that protocol the first test is 2 weeks after starting treatment. You also need to make sure his vet knows that the new starting dose is 1mg/lb NOT 3mg/lb as it was when Vetoryl was first released in the US. You can find all this info and much more here (and I would share this with his vet just to make sure they know how to handle this very powerful drug) - http://www.k9cushings.com/forum/show...-and-Resources

btw - that link is from our Helpful Resource section where you will find a great deal of beneficial info. ;)

It is also important that you know in order to get the CC under control his post ACTH after starting treatment must be at optimal range - around 2.5-3.5 ug/dl. The CC will get worse before it gets better even with treatment so don't get discourage. You can read about a successful journey with CC on Tobey's thread. Sadly, she has passed but her story continues to help babies with CC like Blue.

http://www.k9cushings.com/forum/show...Renee%2C+Tobey

hello again...so the vet called last night, and had a change in plans. she is taking baby steps, and doesn't want to start the vetoryl just yet. she is prescribing thyro tabs .8 mg - she said his liver tests were high (she said should be 100's and is in upper 600's?) and his cholesterol is way high. she is still awaiting the urinalysis results. she will email me the numbers but...she is thinking perhaps he can benefit from thyroid meds. in a month she will do blood work to see how he's responding. so I guess I need a crash course in thyroid disorders? I know its probably still cushings, but...and I was thinking back and realized a couple years ago he wasn't making tears, and was put on some eye drops. I wonder if that had anything to do with this at all. or if it was a symptom of cushings we didn't realize? oh and the CC's on his elbows and back are being treated with medicated shampoo and mousse. so he gets a spa treatment at home a couple times a week now! :) hope it works! thanks-I'll keep you posted.

It is not uncommon for dogs with Cushing’s to register low thyroid results. Sometimes dogs suffer from both conditions truly independently — Cushing’s and “primary” hypothyroidism. However, low thyroid readings can often be secondary to Cushing’s and end up resolving all by themselves once the Cushing’s itself is treated.

I am guessing your vet may be basing the decision to start thyroid supplementation based on a low T4 reading on the general lab panel. The thing is, more specialized thyroid testing can help interpret whether low T4 readings are likely to be secondary to another condition, such as Cushing’s. If so, it’s very unlikely that thyroid supplementation alone will solve the problems.

Based on my personal experience with my own Cushpup, I would ask your vet to first draw blood to be sent off for a complete thyroid panel prior to starting the thyroid meds. This is because any thyroid test result will be skewed once the meds are in the system. My own dog was diagnosed as being hypothyroid in conjunction with a low T4, but in the presence of many Cushing’s symptoms. We gave him thyroid supplementation for several months but his condition steadily worsened. When we finally tested for Cushing’s, his cortisol level was highly elevated and it became clear that he had Cushing’s that needed to be treated. We had lost a lot of time and a lot of his strength in the process.

I may be missing the boat and your vet may have included more involved thyroid testing in the panel that was already performed. But I would want to explicitly know if that was the case. If it wasn’t done, waiting a couple of months more to start Cushing’s treatment, if appropriate, is not a big issue for many dogs. But CC can be the huge game-changer. If it starts to worsen during the interim, I would rapidly advance to Cushing’s treatment. We have seen the condition explode here, and sadly, some dogs have even needed to be euthanized because of the massive discomfort. I don’t mean to tell you this to scare you, but I do want you to be aware of the big picture when CC is genuinely present.

Marianne

I’m back with some quotations from the diagnostic test lab at Michigan State’s vet school. They are nationally known for their thyroid analysis, and blood can be sent to them for performance of a complete thyroid profile.

https://animalhealth.msu.edu/section...oid_Canine.php

Quote:

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How do I interpret MSU's thyroid profile?

In addition to testing for serum levels of total thyroxine (TT4), total tri-iodothyronine (TT3), free thyroxine (FT4), and free tri-iodothyronine (FT3), this profile tests for T4 antibodies (T4AA), T3 antibodies (T3AA), canine thyrotropin (cTSH; thyroid stimulating hormone), and thyroglobulin antibodies (TgAA). The cTSH test provides much needed information in any attempt to diagnose hypothyroidism. Many non-thyroidal factors can cause decreases of TT4, TT3, FT4, and FT3 into the hypothyroid range in a dog with normal thyroid function making it difficult to differentiate sick-but-euthyroid animals from those with hypothyroidism. When thyroid hormone levels are low due to primary hypothyroidism, most (around 85%) animals will have abnormally high cTSH levels...

Non-thyroidal illness (sick euthyroid). It is well known that thyroid hormone concentrations can decrease as part of a metabolic response to non-thyroidal illness. This decrease occurs in part from changes in thyroid hormone production, characteristics of serum binding, and metabolism of thyroid hormones. In these circumstances, measurement of free T4 in the direct-serum analog assay (standard profile) may underestimate the true circulating concentration of free T4 and give a falsely low result. Free T4 by equilibrium dialysis gives a more accurate result and so will more correctly identify normal free T4 concentrations in sick animals, allowing for better identification of animals that are not hypothyroid...

My patient has low thyroid hormone concentrations, but thyroid stimulating hormone is not elevated. What does this mean?

Depending on the clinical presentation, one of two main possibilities is likely.

The more common explanation is that T4 values often decline in animals with non-thyroidal illness and in animals receiving certain drug therapies (some glucocorticoids or anticonvulsants). Non-thyroidal illness may suppress TSH release from the pituitary via glucocorticoid-mediated inhibition or lower T4 concentrations by altering serum protein binding affinities...

With this pattern of test results, a trial with T4 supplementation is suggested only if there is a strong clinical presentation consistent with hypothyroidism and if no non-thyroidal illness can be detected. An objective case review should be conducted after 6-8 weeks of therapy for evidence of clinical improvement. Thyroid supplementation can be discontinued if no improvement has occurred in that time, and the diagnosis reconsidered. A therapeutic monitoring sample taken during treatment should help confirm whether adequate amounts of thyroid medication were being absorbed. Even when there is clinical improvement, strictly speaking, therapy should be discontinued to see if the original clinical signs return in the absence of medication. Admittedly, this latter protocol is rarely followed in clinical practice.

While the administration of thyroid hormone to animals which do not have hypothyroidism is generally considered to have minimal risk, large scale studies in human medicine have shown detrimental effects of such treatment in patients that have decreases in serum thyroid hormone concentrations due to non thyroidal illness. (Brent GA and Hershman JM. Thyroxine therapy in patients with severe non-thyroidal illness and low serum thyroxine concentrations. J Clin Endocrinology and Metabolism. 1986, 63:1)

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And here’s why blood for complete thyroid testing must be drawn prior to beginning supplementation:

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Once an animal is receiving thyroid hormone medication, thyroid testing can only tell if that medication appears to be well absorbed. No comment can be made about the patient’s endogenous thyroid functional status. Because of the suppressive effects of thyroid medication on the endogenous thyroid in normal dogs, a withdrawal period of 6-weeks is recommended before a diagnostic sample can be taken with which the dogs' endogenous thyroid status can be assessed free from interference by the thyroid medication.

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Thanks...blues urinalysis wasn't what she wanted to see, a bad thing I guess so the vet ordered a different urine test to measure creatine, cortisol? She will call me tomorrow.

I wonder if the test your vet is ordering is instead a UPC (Urine Protein to Creatinine Ratio). Performing a UC:CR (Urine Cortisol to Creatinine Ratio) wouldn’t seem to make a whole lot of sense at this late date, since it is typically an initial “gateway” test which, if elevated, would lead you to a specialized diagnostic Cushing’s blood test such as the LDDS, which has already been performed for Blue.

The UPC is ordered if a dog’s general urine test indicates that an excessive amount of protein is present in the urine sample that was collected. There can be several different causes for excessive protein in the urine, but one cause can be abnormal kidney funtion. Going one step further — and this can be significant in Blue’s case — untreated Cushing’s is a disorder that can cause the type of kidney changes that result in proteinuria. We’ve had a number of dogs here who have exhibited excessive protein loss secondary to their Cushing’s. Depending upon the persistence and severity of the loss (you want to perform multiple UPC tests over time to make the disgnosis) there are specific treatment measures that may be recommended such as moderate restriction of dietary protein along with medication. But if Cushing’s is the underlying culprit, it is also necessary to lower the excessive cortisol production that is leading to the kidney impairment in the first place. So this may end up being the trigger to start the Vetoryl, after all.

After having written all of this, if your vet is instead planning to perform a UC:CR test, I confess I will be pretty much baffled and very interested to find out why.

Marianne

To diagnose urine protein loss you need to have 3 consecutive blood draws showing protein loss, and I'm trying to remember, but needs to I believe be at least 2 - 3 weeks apart. I went through that with my dog who had cushings and kidney issues.

I do agree that I would want a complete thyroid panel before starting the thyroid meds to see if it is primary or secondary. As Marianne mentioned, it isn't uncommon to have a thyroid be out of range if there is cushings involved also.

Spa days are great days. :) My dog always pranced a bit after her spa days.

thanks guys...this is all so confusing. I'm trying to grasp how this all works. its seems so complicated. so the vet replied today from the urinalysis completion, urine cortisol:creatine ratio test...Blue's urine cortisol creatinine is highly elevated, which indicates clinical Cushing's disease is still on the list of differential diagnoses. (the test results are hard for me to understand really, but would urine cortisol result of 15.9 ug/dl and urine creatine 48.9 mg/dl and cortisol;creatinine ratio 101 mean anything?) This means they will run the proposed ACTH stim test in a month when he is scheduled for his T4 check . This test does not require fasting and we will need Blue for two consecutive blood samples one hour apart. For the thyroid aspect of the testing we need to ensure that blood sample is taken 6 - 8 hours after he takes his thyroid medications.
so I guess we will keep doing the thyroid meds am and pm until then. so far so good with that. he's doing ok. it just baffles me the timeline and tests. she must have her reasons? lets hope the month goes well. I just worry. watching him like a hawk. not knowing what to expect. or what might happen. when I hear liver, kidney, I get scared. should I be worried? do you think the vet is wanting to confirm for sure before she starts cushings meds? I know its hard to confirm at times. and I know the meds can help or hurt. ugh. what do you do.

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Originally Posted by Larinda

so the vet replied today from the urinalysis completion, urine cortisol:creatine ratio test...Blue's urine cortisol creatinine is highly elevated, which indicates clinical Cushing's disease is still on the list of differential diagnoses. (the test results are hard for me to understand really, but would urine cortisol result of 15.9 ug/dl and urine creatine 48.9 mg/dl and cortisol;creatinine ratio 101 mean anything?) This means they will run the proposed ACTH stim test in a month when he is scheduled for his T4 check .

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I am still so puzzled as to why the UC:CR test was done when Blue already had the LDDS test performed which we're assuming was positive (we do really need to see that baseline draw for the LDDS test to make an accurate interpretation), the UC:CR is only a screening test as it can not aid in the diagnosis for Cushing's. If this were me, I would have a biopsy done on those skin bumps to see if it is calcinosis cutaneous and if the result is positive I would start treatment for Cushing's.

Lori