Almost 8 y.o. recently diagnosed, a few questions

Hello. My boy, Paddy, was diagnosed with Cushings right before Christmas. He had the ACTH test and results were sample 1 - 11.0 . And sample 2 was 21.2. Is it normal for the first one to be so high?

His ALP has been above normal for a few years now (since 1-2014) but that has been the only thing that was out of range. In the fall of 2013, he had a neck injury and took rimadyl for maybe a week or two, followed by prednisone for 10 days or so (not simultaneously). His vet attributed the elevation to that & prescibed adenosyl/Denamarin. His ALP was 140 previously and 1-2014 it was 449 & ALT was normal at 35. When it was rechecked the following July it had gone down to 301 and down to 278 after that. It would then fluctuate over next few visits. His doc said he was/ is overweight & could be fat deposits elevating ALP. His ALT went up a little but was still in normal range. Last July, ALP was up to 468, ALT 100. I took him to vet in October for not acting "right". ALP was 576 & ALT was up to 166. Referred to internist for an ultrasound. IMS said his liver is small and one side rounded. Didn't mention anything about his adrenal glands but took an aspirate from rounded side. He said it could either be cushings or age related degeneration. I didn't get the ACTH done til December. Vet said it was clearly Cushings. We (vet & I) decided to wait til after holidays to start vetoryl.

Scheduling/family issues (I don't drive & have hard time getting to vet) occurred & just getting ready to start vetoryl tomorrow. He is 23-24 lbs & will be taking 30mg once daily. I read here,though, to start at just 1mg/lb. I e-mailed Dechra & the response I got was 1-3 mg/lb & follow advice of our vet. I'm nervous about it. Paddy's doc works Weds- Fri and alternate weekends. I'm wondering if I should wait til next week when she'll be working more days. Just haven't met the other doctor yet.

The only symptoms I notice are weight gain and panting. He doesn't seem to drink that much & he's still a picky eater. His energy level isn't what it used to be.

Is there any other testing that should be done? Should I wait til next week to start the vetoryl, in case he has any side effects?

Thanks for any advice! I don't really have anyone to talk to about this and am always second-guessing things.

Hi & welcome to you & Paddy! He's such a cutie. :)
The experts will be along soon to answer your questions in more detail. But I wanted to say that I think you should wait to start the Vetoryl until you hear from them. This is based on my own experiences and what I've learned here. The people here are wonderful and very knowledgeable, and they'll be able to give you the best advice on how to proceed in caring for your sweet little guy.
You came to the right place for advice and support!
Annie and Whiskey

Hello, and welcome from me, too! I'm so glad that Annie had a chance to greet you already, because I do share some worries about starting Paddy off with the Vetoryl today, too. Even if the worries are laid to rest, I believe I'd hold off on starting until next week when your own vet will be more readily available in the event of questions or problems.

First of all, I am quite annoyed that Dechra gave you no dosing clarification beyond repeating the published (but outdated!) 1-3 mg. range. They seem to be very leery about stepping on the toes of vets, and since your vet has started you off on 30 mg., apparently they don't want to challenge that. Since Paddy weighs between 20-30 pounds, starting off with 30 mg. is not outlandishly high. But you will want to watch him carefully for any ill effects and be prepared to temporarily discontinue the Vetoryl if he appears unwell. Also, since you say that driving to the vet can be difficult for you, I believe you should ask your vet to provide you with some "rescue" prednisone to have on hand in case an emergency situation arises in which Paddy's cortisol drops too low and he becomes really ill. I would not start treatment without obtaining the prednisone, so that's another reason to wait until next week.

But backing up a bit, I always worry, myself, when dogs are diagnosed with Cushing's but don't exhibit many of the more common outward symptoms. Paddy's picky appetite especially concerns me, because most Cushpups have ravenous appetites. One of the benefits of Vetoryl treatment is to normalize excessive hunger. So in the case of a dog who is picky to begin with, it raises questions about the accuracy of the diagnosis and also the worry that the med may depress a picky appetite even further.

As far as the diagnostics, can you please give us the "normal" range for the ACTH results? For most labs, a post-ACTH of 21.2 is actually not super-highly elevated and might only fall within a borderline range. But the lab that performed Paddy's analysis may have a different range of norms, and it would help us to know what they are. As far as his first reading being high, yes it is high, but stress alone can cause elevations in baseline cortisol. So if Paddy is a dog who gets highly stressed at the vets, that could raise his baseline level, and it can also elevate the second reading as well. That's another reason why I'm wondering how far out of range that second reading actually was.

Also, I'd be very interested in the actual assessment of his adrenal glands on the ultrasound. It is not common for Cushpups to have adrenal glands that look totally normal on the imaging. It can happen, but usually only if the disease is in the very early stages. Typically, Cushpups will exhibit enlargement of the adrenals, and I'd want to know if that's the case for Paddy. It sounds as though the IMS was focused mainly on the liver abnormalities, which he said may -- or may not -- be Cushing's-related.

The bottom line is that it may indeed be the case that Paddy has Cushing's, and it is indeed true that for middle-aged dogs, you are hoping to stave off internal systemic damage that can result from chronic elevation of cortisol. But on the other hand, in the absence of typically observable symptoms such as excessive thirst, urination and hunger, it becomes much harder to monitor the therapeutic effect of the medication. Plus, there are always some question marks as to whether or not Cushing's is actually the culprit since other nonadrenal illnesses can result in "false positives" on the ACTH and also cause lab abnormalities.

I am very sorry if I am adding to your worries :o. But if it were me, I'd hold off on starting the Vetoryl until you've had the chance to talk with your vet further. I would tell her that I've been reading up on Cushing's so that I can be as well informed as possible. Based on what I've read, I'd like to know what the normal range was for the ACTH, and I'd like to know whether the adrenals were of normal size and appearance on the ultrasound. If so, does that not concern her that the diagnosis may be in question, especially since he doesn't exhibit excessive thirst/urination/hunger? Last but not least, if you do go forward with the Vetoryl, I'd basically demand that I be given some prednisone to administer in the event of overdose at a time when I couldn't get Paddy in immediately to be evaluated.

Marianne

Hello and welcome. I must say that Paddy is just a cutie pie!

I don't think there is anything that I could possibly add to what Marianne wrote as she covered all the bases of what would be my concern too.

With the cortisol Not being that high, and i'm curious about the range too, I'd personally prefer a low and slow approach, so I'd probably ask to start at a lower dose. I'm a worrier that way though.

Hi. I posted here about two years ago, after my dog Paddy was originally diagnosed with Cushings - not Atypical then.( I had been concerned about him being given 30mg of vetoryl since at the time he weighed @23 lbs. His vetoryl dosage has since been lowered to 10mg because of lower cortisol levels with ACTH tests.) His ALKP has been elevated since January 2014, thought to be result of having been on Rimadyl (I think that's the one. NSAID for neck pain previous Fall/Winter) and prednisone for a month or so. He started taking Adenosyl/Denamarin after that. At some point, it did lower a bit but went back up. Oct. '16 ALT also was higher than norm (ALKP 576 ALT 166) His doc recommended an ultrasound. The IMS said it could be Cushings. He had the 2 hour ACTH test in Dec. '16/Jan. '17. Pre was 11.0 & Post 21.2. I didn't start him on Vetoryl until late Feb. '17.

His ALT lowered but ALKP continued to go up. GP & IMS said sometimes it just takes awhile for it to go down & in some dogs with cushings, it just stays elevated. Also thought he could have sludge in his gallbladder.

In July '18, his ALKP was 1967. In Jan. '19, ALKP 3288! ALT was 135. So we went back to IMS for another ultrasound (the 3rd or 4th one). He also did another aspirate. IMS said no inflammation of his liver, no sludge in gallbladder. Still looked like "vacuolar hepatopathy." Cytology "suggestive of steroid hepatopathy". He said to do another ACTH test, given IV instead of IM as usual. (Paddy's ACTH test in January was pre 3.1 post 3.1) The results of ACTH in Feb. '19 , given IV, were pre 2.1 post 3.6. IMS suggested to check for Atypical (2nd option was a liver biopsy). So in March, UTK stim test was done.(Vetoryl given w/food @ 4hrs before as norm). We got the results last week. Cortisol is good/optimal. His androstenedione and 17 OHP are both elevated and baseline progesterone also (but not post on that one). IMS said to discontinue vetoryl and to instead give 3mg melatonin twice a day. Then recheck in a couple of months.

Is the melatonin alone enough to lower those two hormones? The IMS had previously also mentioned lignans. And I've also seen that some dogs with atypical are on lysodren ( although I'd prefer not to. I wish I hadn't given vetoryl now) Also, where should I get the melatonin? Any brand that's better quality? Also, what about side effects of melatonin? I think I read it can cause headaches or that there is an issue with giving it during the day..? Is there any interaction with Denamarin or Dasuquin?

Here are the results from UTK (just cortisol & the elevated ones) :

Test.....Baseline...Normal Range....Post....Normal Range

Cortisol ug/dL 3.6 <1.0-5.6 5.1 7.1-15.1
Andro. ng/ml 4.13 0.05-0.36 3.69 0.24-2.90
Progest. ng/ml 0.71 <0.20 1.12 0.22-1.45
17 OHP ng/ml 2.71 0.08-0.22 4.07 0.25-2.63

The ranges of the lab that usually does his ACTH are
baseline 1.000-5.000 ug/dL post 8.000-17.000 ug/dL.

Sorry if I've been long-winded. I also want to apologize for not following up with you all after my first post. I did read your replies & appreciated the advice.

Welcome back to you and Paddy! You’ll see that I’ve combined your new post with your original thread — this way, all of Paddy’s information and history will be consolidated in one place. I’m afraid I’m short of time this morning, so I’ll need to wait until another time to write more. But definitely, we’re glad to see you back and we’ll do our best to try to help some more.

Marianne

Atypical Cushing's is a form in which the cortisol is NORMAL but two or more of the intermediate, or sex, hormones are elevated. Since Paddy was taking Vetoryl for Cushing's a normal reading on the UTK test is expected if the drug is prescribed at the right dose and properly given (with food). Studies have shown that Vetoryl CAUSES elevations in some of the intermediates so running the UTK panel at this stage of the game was really a waste of money. Now if the Vetoryl has consistently been causing his cortisol to be TOO low and the original diagnosis of Cushing's was in question, then stopping the drug and then checking the intermediates might have made sense to me. Regardless, you don't stop giving the Vetoryl, or Lysodren, just because there are elevations in those other hormones if the diagnosis of conventional Cushing's, with elevated cortisol, was accurate - you give the melatonin and lignans with the Vetoryl or Lysodren. And it is the combination of melatonin and lignans that work on the intermediates - giving one or the other alone will not work. So I highly question the IMS' understanding of Atypical Cushing's. UTK does not recommend using Vetoryl in Atypical pups but prefers Lysodren because of the studies that show Vetoryl causes those elevations. It is feasible that Lyso also could cause elevations in the intermediates but I don't know of any studies supporting that. So all in all I am confused about what the IMS was hoping to achieve with the UTK panel as well as telling you to stop the Vetoryl and use melatonin only.

I listened to voice mail from IMS again today & may have misunderstood him. He said it would be the wrong thing to RAISE the vetoryl dose, even though ALKP keeps going up. I'll call tomorrow to be sure..sounds like Paddy should continue with it. I think I've read here and elsewhere that lysodren is better, though, right? But there should be a month off before switching to the other.

Not sure if I need to post these but here are results from his ACTH since he was first tested. Feb. '19 was done IV & rest are IM.
Baseline normal range is 1.000-5.000 ug/dL & post normal range is 8.000-17.000ug/dL

2/19 pre 2.1 post 3.6
1/19 3.1 - ( I think there was no change)
10/18 4.6 5.8
7/18 2.6 3.8
2/18 3.3 4.5
11/17 2.9 4.1
4/17 5.5 6.6
3/17 6.6 8.3
12/16 11.0 21.2

He still doesn't drink alot (I measured within the past month & he drank @ 1 cup, along with eating rice). He lost a few pounds last year but put some back on when I switched to an rx liver diet in July (no longer on that). He doesn't have a pot belly. His fur may be a little thinner o.n his torso, right behind front legs. It's a little thin on his forehead. He does pant alot, but not everyday. I wouldn't call his appetite ravenous...maybe impatient?

He had back surgery when he was three,surgery for a torn ACL in 2015, and in May 2017 tore another. For the second one, I decided to just do crate rest instead of surgery. He had been taking vetoryl for a few months then & his ALKP was @870, I was afraid for him to have it.

I just wish we could get his ALKP to go down. Everytime he gets bloodwork..can't believe how high it is. How freaked out should I be?

-Jennifer

With a post of 3.6 ug/dl you definitely don't want to raise his Vetoryl dose. If the ALT isn't elevated, I wouldn't worry too much about the high ALP, sometimes this enzyme never returns to normal even with treatment. Many of our members use a liver supplementation such as milk thistle, Denosyl, Denamarin, or SAM-e.

Regarding that Lysodren is safer than Vetoryl, that is not true, some dogs just do better with one drug treatment than the other medication. If you do plan on switching, though, there should be a wash-out period of one month.

Hugs, Lori

I agree, I wouldn't raise the vetroyl as his cortisol seems to be doing well on that, but his ALKP isn't. Most of the time, yea, they think it is sludge in gallbladder or liver, something else then causing the alkp to keep rising. But seems that you have ruled that out, so maybe the supplement option would help. I tried all of them, and I think did help some. I like the denamarin, as had the sam-e in it also if I remember correctly.