Duffy - Cushing Testing

My dog has had IBD for several years...he was diagnosed right around 3 years ago. We have been on the Royal Canin hydrolyzed food for all of that time and it's been great for him. His signs (chronic vomiting) have completely gone away unless he gets into people food somehow. While reading the list of ingredients it may seem 'unhealthy' but the prescription diets have real scientific studies behind them showing they work and dogs do well on them. A dog with IBD basically has an allergic reaction to the food, and usually its the proteins. The hydrolyzed diets are specially processed to make the protein too small for the dog's immune system to recognize (they still digest them normally though) which prevents the inflammation. I was told that Royal Canin deep cleans the entire plant before they make any hydrolyzed food to avoid contaminating it with any other proteins. My internal medicine specialist said the over the counter 'limited ingredient' foods are not processed that carefully and may be contaminated and cause the inflammation. I've never heard of the Petco brand and would need to read more but I am skeptical that it's truly hydrolyzed at the price I see advertised online...that special hydrolyzed processing makes the food very expensive! A similar sized Royal Canin bag costs over $70, and the Hill's is closer to $90. Purina makes a hydrolyzed diet called HA you could look into as well. Luckily my dog is smaller and only eats about 7 lbs a month.

Hi All,

We went to the new Vet recommended to me by my Vet specialist. Blood work taken this week shows Duffy's ALKP jumped all the way to 1,346. (His liver biopsy done in the fall 2018 did not show anything conclusive-no tumors-cancer etc) He continues to drink a lot of water and urinate frequently. When I am home he goes out every couple of hours. At least this week when I wasn't home he made it to the Wee Wee Pads again. He said his Kidney results were fine and he is going to send me a copy so I have the numbers... He reviewed all of Duffy's previous test reports. He said the ACTCH does not always show Cushing's and he wants to do the Low Dose Dexamethasone Suppression test. It is being done Monday. We should have the results by Tuesday. Can anyone tell me the difference between the ACTH test and the Low Dose Dexamethasone Suppression test?

Thanks!

The ACTH is stimulation test that lets us know the amount of cortisol the adrenal glands are holding in reserve. If the amount after stimulation is higher than what would normally be expected, then Cushing's is a consideration.

The LDDS is a suppression test that takes all day and results in 3 figures. This test tells us if the adrenal glands are able to suppress cortisol or not. If they can't, that is another reason to consider Cushing's.

Another test you didn't mention is the abdominal ultrasound which can let us know a great deal like if Cushing's could be present and which form by how the adrenal glands look as well as giving us a peek at the condition of many other organs like the liver, kidneys, etc.

The thing to keep in mind is that none of the tests for Cushing's can 100% diagnose this disease. It is a combination of tests plus the signs and behaviors we observe that give the strongest confirmation for Cushing's.

Here are some links about each of these tests. The HDDS test is rarely used these days since the LDDS is now able to determine which form of Cushing's the pup has, adrenal (ADH) or pituitary (PDH).

ACTH
https://www.idexx.eu/globalassets/do...g-protocol.pdf

http://veterinarynews.dvm360.com/con...drenocorticism

LDDS
https://vcahospitals.com/know-your-p...pression-tests

https://www.idexx.eu/globalassets/do...ssion_test.pdf

Thanks Kellie. I did more research and Wellness has a brand in their Line called "Simple - Salmon and Potatoes". It is for skin/stomach issues. I read the reviews on Chewy.com. There were about 200. A few said their dog were diagnosed with IBD and some said their Vet put them on it after diagnosis and they did very well on it so I will try mixing it in slowly and see how he does..... Almost all the reviewers had diarrhea/vomiting problems. I decided against the Petco Brand and am going to try the Wellness as I use to feed him Wellness before they thought he had Liver Disease and i home cooked Turkey and Oatmeal for the last several years. He did well on it and my Havanese before him did good on Wellness. If that doesn't work I will have no choice but to stick with the Hills as he is doing well on it. My boy use to be 13lbs all of a sudden he is 16.5. I am not giving him anything but strictly Hills Z/D dry/canned mixed and their treats. He only gets a half of a small bone when he goes out to potty in the yard or when we get home from a short walk. Not sure if because there is more calories in this food and I need to feed less than before? I am so confused at this point. After a bad case of diarrhea last month fecal tests showed Clostridium and they put him on Metronidazole for 7 days and the Vet did an ultrasound and said he had thickening of small intestine. The test results from last months blood work when he had the diarrhea showed some elevated numbers and "possible pre or borderline" Cushing's so today he went for the LDDS test. He is almost 11 years old. So we are a month later and his poop has improved a lot but he is drinking so much more and started to have accidents in the house and not using wee wee pads. He is doing better with the accidents and hasn't had an accident in the house in a week but is wanting to go out a lot. I am watching and he is urinating. A urine culture was done- no infection. Now his ALP is up to 1,300 and ALT 300. Unless the ALP went up think of for the ALP due to the Metronidazole. I read online that can affect the liver...... But maybe I need to stop reading so much on the Internet as I am making myself crazy........ Anyway, I will have the results by tomorrow of the LDDS test. I am glad your boy is doing well on Royal Canin. It is so horrible when they are not well. Thanks for your response!

John,

He just had a ultrasound last month for severe diarrhea and they diagnosed IBD slight small intestine thickening. He was put on Hills z/d and it has stopped.

The results read the liver was normal to very mildly enlarged. The kidney, adrenal and stomach were all within normal size limits.

September 2018 he had a liver biopsy done. They didn't find much and here is the result:

Vacuolar hepatopathy (VH) is a fairly nonspecific reaction to
various conditions or diseases occurring either within or outside of
the liver. VH is also often accompanied by mildly to moderately
increased alkaline phosphatase (ALKP). Roughly half of these cases
have an identifiable source of glucocorticoid, either endogenous
(Cushing's disease) or exogenous (steroid therapy). Many cases have no
identifiable source; in these cases, VH is associated with a wide
variety of conditions (non-hepatic organ disease, systemic disease).
Occasionally, VH results from drug metabolism, especially drugs known
to induce ALKP (ex: phenobarbital). If this biopsy is representative
of the liver as a whole, then the prognosis is good as there is NO
significant inflammation, necrosis, or fibrosis noted in the H&E
sections. No evidence of portal hypoperfusion was seen, however
portal hypoperfusion (especially microvascular dysplasia) can affect
some areas of the liver and not others.

He has a collapsed trachea (Grade 2) and partial Laryngeal Paralysis diagnosed at same time as liver biopsy from bronchial scope. He is on Doxepin as it helps some Lar Par dogs and he seems to be doing decent on it.

His ALP went from 354 to 1,200 since last month's ultrasound and blood work. Unless it was from the Metronidazole given to him for the IBD episode last month. I read that could affect the liver online.....

I read that IBD can make liver enzymes rise also but they were only 300 ALT and 354 ALP last month when he was diagnosed....

I don't think that the Doxepin would all of a sudden make his liver enzymes go that high as he has been on it since last summer.......

He also has a slight Mitral Valve Leakage- no meds required at this time. I don't think that would make ALP go that high either as he has had it since at least last summer but he goes back for his 6 month check up next Wed so will ask Cardio Vet.

Last month his
pre ACTH was 28
post ACTH was 5.5
His Androstenedione: pre .63
Post: 3.39

Progesterone:
Pre: .31
Post: 1.94

We did an LDDS test today and I will have the results tomorrow. I will read the links you sent me.

Thanks for your response!
Lynn

Hi All,

We finally got an LDDS that Duffy's cardiologist Vet recommended in July when his heart was ok and he had signs of severe panting and increased thirst etc. My old Vet gave me the ACTH test as she said they had good results with that and they mixed up the tubes and then said that the numbers were off because of stress.

Lately his symptoms became worse (drinking and getting me up to let him out a lot and even sometimes at night) and his liver ALP went from 300 to 1,200 and he went from 13 to 16.5 lb. So I brought him to a new Vet.

Results from LDDS:
Tube labeled pre - 9:45am
Tube labeled post1- 1:45pm
Tuble labeled post2- 5:45pm
Cortisol Sample 1 - 12.0 (HIGH) Ref Range 1.0 to 5.0
Cortisol Sample 2 Dex- 1.0 Ref Range 00 to 1.4
Cortisol Sample 3 Dex - 2.7 (High) Reference Range 00-1.4

My Vet said this is indicative of Pituitary dependent Cushing's (PDH)
He said he would treat him with Vetoryl (Spelling)?

For this week I have to track as close as possible how much water he is drinking a day. Is this to base the med dose on?

He had an ultrasound last month of his kidneys, liver, adrenal glands, intestine and stomach when he had an IBD flare-up. Everything was in normal range except the Small Intestine showed some thickening. They did not see any tumors.

He said he would need to have an MRI to see if there was a pituitary tumor and generally they do not do that. I don't want him under anesthesia anyway due to his breathing issues from the laryngeal paralysis either.

The Vet did say that some of the heavy breathing could be from Cushing's also and wants me to bring the results to the Cardiologist Vet when we go for his 6 month check-up next week. (He has slight Mitral thickening but needs no treatment so far).

I also tend to notice that it appears he often drinks more in the afternoon/evening. Is this typical of Cushing's?

Does this sound on track to the experts out there?

Any help is appreciated!
Thanks!
Lynn & Duffy

I have merged your latest post into Duffy's original thread. We like to keep all posts about each pup in one thread so it is easier to keep up with the history. I have also changed the title of his thread to include his name so it will be easier for you to find it and post here from now on. :)

Hello again, Lynn, and thanks so much for this update. Duffy’s LDDS results are indeed consistent with the pituitary form of Cushing’s, and Vetoryl is one of the two effective medications for treatment. So far, so good! You’ve not mentioned the proposed starting dose of Vetoryl, but given Duffy’s weight of 16.5 pounds, I’m hoping the vet will limit the dose to no more than 15 mg. daily, or certainly no more than 20 mg. Initial dosing recommendations have significantly lowered during the years that Vetoryl has been in use, and the majority of researchers and specialized clinicians worldwide now recommend a starting dose that does not exceed 1 mg. per pound. If your vet suggests a higher dose, please let us know so that we can arm you with important supporting documentation to pass on to your vet.

Other helpful tips: Vetoryl should always be given alongside a full meal for proper absorption. Also, your vet ought to schedule a monitoring blood test after two weeks of Vetoryl treatment in order to assess the medication’s affect on cortisol production. Excessive thirst and urination ought to come under better control as cortisol levels lower, but actual blood levels are also essential monitoring tools.

Speaking of thirst, no, the amount of water that Duffy drinks should have no bearing on the initial medication dose. Initial dosing formulas are based strictly on weight. But I’m assuming your vet is interested in guaging how much his symptoms show improvement once treatment actually begins. FYI, here’s a link that contains a lot of helpful info re: Vetoryl treatment:

https://www.k9cushings.com/forum/sho...l-(trilostane)

So good luck yo you both, and don’t hesitate to ask us any additional questions along the way.

Marianne

Hi Marianne,

I will read your link. Thank you for sending it to me!

I have read in a few places that if you put a dog on Vetoryl and they do not really have Cushing's it can do much harm.

I am a bit nervous as I now have three tests with three different results. ACTH showed no Cushing's, 2nd opinion Vet test done which I do not know the name of the test but tested a lot of different hormones. It showed 4 hormones (Androatenedione, and Progesterone both pre and post high) of 8 elevated and results read possible early or beginning of Cushing's. This Vet wanted to treat Duffy with Melatonin. We finally got the LDDS as everyone said that is the "Gold Star" for Cushing's and I posted the results that you read.

Just to be on the safe side I made an appointment with a Internal Medical Doctor for Feb 27 in NYC at the Animal Medical Center. He specializes in endocrinology. Duffy has several medical issues ranging from IBD to partial Laryngeal Paralysis and I am afraid to give him something if not needed.

I have three more questions that you may be able to help me with.

1. I stopped feeding him mostly dry food and am giving him mostly canned mixed with a little dry because its first ingredient is water and so he doesn't drink as much from the bowl as when it is all dry food. This of course lowers the consumption of actual water he is now drinking from the bowl. Before he was drinking about 21 oz or so a day when fed mostly dry. Now about 15 oz a day. The reason I don't want him drinking a lot of water from his bowl is he drinks it so fast and then burps and smacks his lips etc. upsetting his stomach. Not sure how to measure the water intake now. Any suggestions?

2. The third opinion Vet that did the LDDS test said since he had an ultrasound last month with his IBD flare-up and the adrenal glands were viewed and no tumor shown he does not need another one. He also said that they don't generally do tests on the Pituitary Gland. Is this true?

3. When the medication is balanced will it help is ALKP go back to normal?

Your help is much appreciated.

Thanks,
Lynn

Hi Lynn. I've just read your thread and have a few things I wanted to share with you. You can find my comments in red text below. Hopefully I have answered some of your questions.

Quote:

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Originally Posted by ls1012

Hi Marianne,

I will read your link. Thank you for sending it to me!

I have read in a few places that if you put a dog on Vetoryl and they do not really have Cushing's it can do much harm.

I am a bit nervous as I now have three tests with three different results. ACTH showed no Cushing's, 2nd opinion Vet test done which I do not know the name of the test but tested a lot of different hormones. It showed 4 hormones (Androatenedione, and Progesterone both pre and post high) of 8 elevated and results read possible early or beginning of Cushing's. This Vet wanted to treat Duffy with Melatonin. We finally got the LDDS as everyone said that is the "Gold Star" for Cushing's and I posted the results that you read.

The hormones you mention are part of an adrenal panel done by the University of Tennessee Knoxville. The post stimulated cortisol in this test was actually below the normal range which is not consistent with cushing's. This test can yield false negative post stimulated cortisol results in dogs who do have cushing's but in my experience, most false negatives are most likely to happen in dogs with functional adrenal tumors. The abdominal ultrasound results indicated adrenal glands were normal so that would rule out an adrenal tumor. The elevations in the hormones in the adrenal panel can be due to early cushing's disease but they can also be due to non-adrenal illness which is a definite possibility as your dog appears to have chronic IBD. I am a skeptic when it comes to the usefulness of the UTK adrenal panel. In my opinion, it's a last ditch effort to come up with a diagnosis in a dog who presents physically and clinically as cushingoid yet adrenal function tests are negative. What you read is correct; elevations in these adrenal hormones can be an indication that a dog is in early stage of cushing's and at some point, cortisol will eventually be well above normal. If the elevations are caused by non-adrenal illness such as IBD, they will improve with resolution and/or good control of IBD.



Just to be on the safe side I made an appointment with a Internal Medical Doctor for Feb 27 in NYC at the Animal Medical Center. He specializes in endocrinology. Duffy has several medical issues ranging from IBD to partial Laryngeal Paralysis and I am afraid to give him something if not needed.

I think this is a great decision on your part and I will be most interested to hear about your appointment. I can understand why your are concerned about accepting the results of the LDDS test being definitive for cushing's as there is a lot of conflicting stuff going one. You have mentioned your dog's increase in drinking many times but the results of the urine test shows that urine is very concentrated which would rule out polyuria (peeing too much) an polydipsia (drinking to much) as a clinical symptom of cushing's. It appears the ALKP has not been consistently rising but rather going up and down. There are three or four ALKP isoenzymes, one of which comes from the gut so a dog with IBD flares would see the ALKP increase as well as the ALT. The ALKP that increases with cushing's is a steroid induced isoenzyme which does not kill or injure liver cells so if cushing's is causing the elevations in ALKP, you can stop worrying yourself sick. We've seen dogs with ALKP in the 5,000's so what you are seeing is not alarming at all. Treatment The low dose dexamethasone suppression test is an extremely sensitive test which is why it is the gold standard in cushing's diagnostics; however, it is not the gold standard if a dog has a concurrent non-adrenal illness that could cause a false positive result.

I have three more questions that you may be able to help me with.

1. I stopped feeding him mostly dry food and am giving him mostly canned mixed with a little dry because its first ingredient is water and so he doesn't drink as much from the bowl as when it is all dry food. This of course lowers the consumption of actual water he is now drinking from the bowl. Before he was drinking about 21 oz or so a day when fed mostly dry. Now about 15 oz a day. The reason I don't want him drinking a lot of water from his bowl is he drinks it so fast and then burps and smacks his lips etc. upsetting his stomach. Not sure how to measure the water intake now. Any suggestions?

What is the purpose of measuring his water intake?

2. The third opinion Vet that did the LDDS test said since he had an ultrasound last month with his IBD flare-up and the adrenal glands were viewed and no tumor shown he does not need another one. He also said that they don't generally do tests on the Pituitary Gland. Is this true?

That is true, it is rare that an MRI is done to visualize the pituitary gland unless a very large macro tumor is suspected as causing neurological symptoms and the owner can afford the MRI.

3. When the medication is balanced will it help is ALKP go back to normal?

Effective treatments for cushing's can improve the ALKP but it does not always return to normal. Denamarin and other liver support supplements may not improve ALKP but they still support good liver health. Many members give their dogs liver support supplements. Again, if ALKP is being caused by cushing's, the liver cells are not being killed or harmed. What happens is that high levels of cortisol mess with fat metabolism and causes the liver to over accumulate a fat called glycogen. This is what causes the liver to enlarge.

Your help is much appreciated.

Thanks,
Lynn

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