Great insight! Appreciated!! This has been so helpful!
I do trust our Internist. I feel that are top notch. We have others that drive from other parts of our state to be seen there. They are a great specialty group!
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Great insight! Appreciated!! This has been so helpful!
I do trust our Internist. I feel that are top notch. We have others that drive from other parts of our state to be seen there. They are a great specialty group!
We went in for Max's ACTH test today and his vein blew. We have set up a new test for Wednesday. My poor boy has rolling old veins...He was very well behaved and seems excited this morning as he knew I put his car towel down in the car last night. They discussed maybe inserting a catheter to help when they redo the test! :(
I would appreciate help with Max's ACTH results and where to go from here! Please read the email from his vet. My head is spinning a bit and I am a little scared to start treatment without doing an LDDS test again...I do not even know what to think! He did eat the morning of the ACTH test....I replied to her and asked some questions and that was one of my main ones. Please see her email below...I appreciate your advise on this!
Hi Elizabeth,
I am out of the office on vacation the rest of the week, but wanted to give you this information.
Maximus' ACTH stimulation cortisol is considered normal at 11.8. To diagnose Cushing's disease, we would want the level to be >22. I went back to look at his LDDS test results from June 2020 and they were very consistent with Cushing's disease. Generally, once you have Cushing's disease, it doesn't go away. The ACTH stimulation test can look normal in about 20% of dogs that actually have Cushing's disease, so it is not the most sensitive test. That being said, if we treat him with medication and he actually doesn't have Cushing's disease (let's say the adrenal glands have necrosed/died some), we couldm make him sick.
We have some options on how to proceed:
1. Repeat the LDDS test. This is the most sensitive test for diagnosing and if it remains abnormal, we can feel good about treating. The downside is that this is the 8 hour test.
2. Start treatment with a very low dose of trilostane (as we had planned to do anyway) and monitor him very closely.
I think with his history, his clinical signs and his bloodwork changes, it makes sense that he does have Cushing's disease and it is reasonable tto try treatment, but I want you to have all the information to make an informed decision moving forward.
I will be back in the office on Monday!
Let me know if you have further questions!
Regards,
Vanessa Von Hendy-Willson, DVM, MS, DACVIM (SAIM)
reply e-mail: DrV@upstatevet.com
Dear Elizabeth,
I surely understand why these results are throwing a bit of a “monkey wrench into the machinery.” I appreciate the fact that your internist has broken out many of the pros-and-cons about the situation. At this point, I just have a few other thoughts to add. First, it has always been my understanding, as well, that the ACTH is more likely than the LDDS to give a “false negative” in a dog that truly has Cushing’s. This failure seems to be even more likely for dogs who suffer from adrenal vs. pituitary tumors. I can’t remember whether Max’s original LDDS results pointed towards one type of tumor as opposed to the other. If not, you’d be be left with considering an abdominal ultrasound to actually view the adrenals, but I know that’s not an attractive option at this point.
Going back to the differential test results, the “flip side” of the equation is that the LDDS is more likely than the ACTH to return a “false positive” if a dog is suffering from an alternative nonadrenal illness or physical stress. Since Max’s LDDS was performed almost three years ago, you’ll know much better than I whether he was ill in any other way that might have skewed the test results at that time.
I know your decision about treatment would be much easier if this ACTH testing had also been consistent with a Cushing’s diagnosis. I think it’s very good that your internist is trying to provide as much information as possible for you to consider. Unfortunately, though, it doesn’t sound as though there is a definitive answer and you and your vet will have to go ahead and roll the dice, one way or the other. I know it’s a lot to consider, and we’ll remain here to help you brainstorm with your own thoughts about this.
Best wishes no matter what you decide,
Marianne
Yes, his LDDS test in 2020 was consistent with Pituitary. I believe the results are on page 1 or 2 of this thread. I guess there’s a lot of what if’s for me, but I try to just think about facts to help feel less worried. I just don’t feel comfortable giving Vetoryl unless we know for sure. I’m wondering if a retest LDDS would help. He has all the markers for Cushing’s.
My big question is: if the ACTH test is used to monitor medication, how do they do that if it can be incorrect in 20% of dogs? If his test was 11, is that pretty accurate? How would they make sure it’s accurate on Vetoryl? I may be missing something.
Thanks for your advice!
Starting with your last question first, I guess we have to assume that the 11 ug/dL was an accurate measure of Max’s stimulated cortisol level at the time of the test. The goal with Vetoryl treatment is to reduce stimulated cortisol levels to at least 9, and even lower than that — to no more than 5 if symptoms are still remaining at that higher level. However, I must confess that I can’t recall ever starting a dog on Vetoryl who has registered a diagnostic ACTH of only 11 since that is indeed squarely within “normal” results for a dog without Cushing’s and clearly you wouldn’t want to be lowering his stimulated cortisol a whole lot further with treatment.
One question I would have for your vet is whether there was any possibility that there could have been some problem with the efficacy of the stimulating agent or with the delivery of it. You mentioned that the test had to be repeated using a catheter since a vein was blown the first time. If the stimulating agent didn’t function properly, then that could explain the lower cortisol level. By the way, do you know what Max’s baseline cortisol level was prior to the injection of the stimulating agent? Normally we don’t care much about the baseline level, but in this case I’d be curious to know how close it was to the second cortisol reading.
I surely understand why you’re wanting more confirmation at this point. I’m going to throw an idea out there that your vet may think is nuts. But prior to subjecting Max to another 8-hour LDDS, would there be any point in going back to the beginning, in a way, and repeating a simple creatinine to cortisol ratio test of his urine (UC:CR). I looked back in your thread, and Max had one of these performed initially, but perhaps there’d be some value in repeating it. To recap, we’ve been told the best way to perform this test is for the owner to catch a urine sample at home (low stress environment) on three successive mornings. The samples are pooled and taken to the vet for analysis. An elevated result (like Max had before) is consistent with Cushing’s, but can’t confirm it. That’s when you need to move on to the ACTH and/or LDDS. But here’s the key — a normal result on this test essentially totally rules out Cushing’s. So if Max were to have a normal result on both a UC:CR in addition to this ACTH, I’d be very hesitant to proceed with treatment myself. As I say, just a thought that your vet may not think is helpful, but I wanted to throw it out anyway since it would be a lot less stressful for Max than a repeat LDDS.
Marianne
They did not use a catheter like I thought. They did get the samples and injection without it! :) She did not tell me the baseline and I was curious about that. This was not his first morning urine, but a sample I got at the vet as I took him for a walk outside. I have all of his papers and bloodwork over the years and can go back and look. I will definitely ask about a new UC:CR...won't hurt to go back over things!!! His initial ratio was 93.
You’re right that the UPCR is something different, but here’s a quote from when Max was first diagnosed, and it looks like the UCCR was done at that time. I don’t know what the conditions were when he was tested back then, but from the looks of it, the test may have been done on a urine sample that was drawn by the vet or while at the vet visit. If so, the elevated result may well have been inaccurate. For this test, the dog absolutely needs to be calm and not stressed at the time you get the urine sample. Also, the pooling off samples taken on three successive days also helps to boost the accuracy of the test.Quote:
Originally Posted by Elizabeth513
P.S. I see that you’ve just now edited your previous post, and we’re on the same page ;-).
Yes, I did bring up that concern initially with my home vet. Our old internist agreed that he could have been stressed. I will discuss that possibility of running a new one. I realized after I put those results that it was his protein ration not UCCR! :) Lots to sift through, but I know eventually we will get there. My main concern is the anemia we are seeing. With the occult fecal test positive the internist felt like it was increased cortisol and the combo of galliprant causing an oozy gi tract. I have decreased his galliprant and he is no longer getting 100mg. He was getting 1 day 100 mg and the next day 50mg. I am now doing 2 days at 50 mg followed by a day off. He actually seems to be tolerating it and his arthritis seems just fine.
My boy is definitely a tough one to figure out. I am so so appreciative for just good conversations and others helping me talk through ideas. I want to keep him happy with all the time we get with him.
I've been doing some research with the correlation between Cushing's and anemia and found that generally this is found only in males mainly because of Hypogonadism, a condition where the gonads fail to function properly leading to reduced or no sex hormones. Is Max neutered? If not, then I would consider having a full sex hormone adrenal panel performed or at least checking his testosterone level to see if it is low...just a thought!
Hugs, Lori