Molly, 13 yr, shih tzu - lhasa aspo - Molly has passed

Hi everyone, I'm Sharlene and my lovely dog Molly has been diagnosed with Cushings for 5 days now.
I've been reading over the site and I've cried many tears while reading the various posts. Some tears for you and your loving companions, some for Molly, some if I am honest, for myself.

Molly weights 19.2lbs. She has in the past been prone to crystals forming, so she has been on SO dog food for years. She takes Glucosimine because she has a hip joint that isn't grooved really deep enough and she's had some issues with that in the past. In fact, it was a sore leg and a pot belly that causes her to be tested for cushings 2 years ago, results of which were negative, from a DEXA test. Hence the glucosimine. Her ALP's have been high consistently and we try to balance that using the SO food, that encourages her to drink more water and the crystals not to form. She only had them once, that was enough.

This morning I went and picked up copies of her lab tests going back 2 years.
I'll post any that were off with the appropriate ranges:

2010 physical
ALP 518 (20 - 150)
everything else within normal ranges

2011 physical
Albumin 46.7 (26 - 44)
Protein 78 (51 - 72)
ALP 764 (5 - 151)

2011 DEXA
Cortisol (Base) 82.2 (20 - 300)
Cortisol (DEXA) - 4 hours 28.7
Cortisol (DEXA) - 8 hours 35.1

Not Cushings

2012 March physical
Albumin 44.1 (26 - 44) (barely out of range)
Protein 76 (51 - 72)
ALP 1121 (5 - 141)
ALT 139 (6 - 118)

At my request we redid the ALP and ALT along with the ACTH test a week ago

2012 June tests
ALP 1003 (5 - 141) (this has actually decreased a bit since March)
ALT 152 (6 - 118) (while this has gone up a bit since March)

Cor1 - Cortisol (base) 172 (30 - 300)
Cor 21 - Cortisol (ACTH) - 1 hour 924
Cor 22 - Cortisol (ACTH) - 2 hour 1014

Lab states, that in a normal animal Cortisol will increase above 250 but not above 600.
The results are consistent with Cushings Disease; Pituitary-Dependent Hyperadrenocorticism

okay, so now that is out of the way, my vet, who has been Molly's vet since we brought her home as a rescue baby at 11 months, feels that this has been caught at the very earliest of stages. Her recommendation is to begin treatment with Vetoryl 30 mg. In fact, it is sitting here on my desk right now. It is the monster in the closet, under the bed, or in my case, in front of this computer monitor.

So I asked her why begin treatment now,( actually she has called me once since they told me on Wednesday, to discuss and then we spoke again today, when I went to pick up copies of lab results) and she said, that although it is not clinically necessary to start right now and we can decide when we would want to start medications for the cushings, that her experience is that when treatment is not started, the risk increases greatly for dog to develop diabetes and/or pancreatitis. That she feels and she has had good results with early treatment. I asked also about the Davis study suggesting a lower dose and she said that the Davis study is already out dated compared to more recent studies, from universities around the world. That she has had good luck with this dose for Molly's size. Starting the medicine she said would be followed up with tests at day 10 - 14 (she suggested day 12) after starting treatment and then based upon how molly is doing, either 4 weeks or sooner if she feels that it is needed.

So, that is where we stand. She didn't say start right now, because as she mentioned we might not have tested at all and it wouldn't have been caught until some other time, when I brought her in for a problem of some sort. True enough I suppose. She thinks it is an opportunity to prevent any further complications and to get her sorted out and on the road to a "maintenance" life, which would hopefully be a long one. She also said, that it is possible that once the cortisol levels go down, that we will see some arthritic issues since she had a spell with joint pain last year. She outlined what we'd use to treat that if it does occur, which would be Glucosomine first, pain meds possibly, laser and finally injections if none of the other options work.

I find myself second guessing how well I thought molly was/is. She does lay around more, but has a great time playing when she wants to. She doesn't eat all at once every day, usually she eats maybe half or even less, and then later will finish off (around dinner time). She drinks, but not overly so and we in fact try to encourage her to drink since she had issues with the crystals forming. She does have some times when she doesn't want to jump up or she has to make a running leap for that window seat she loves. And yes, there is the pot belly. (we thought she just really loved those treats a tad bit too much and that is probably still true)

Have I been in denial? Maybe. Yet people on the street can't believe she is 9 years old, thinking her much younger.

Will starting her on the medications sooner rather than later lead to less complications and a better over all life? I don't know that either.

Really, I know a lot and I know nothing. That about sums up the gist of it.

Hi Sharlene and welcome to you and Molly:)

There will be plenty of more knowledgeable members stopping by to say hi and help in any way they can. My confusion or concern is the lack of appetite and thirst. Usually a dog with cushings has a very healthy appetite and can never seem to get enough water to drink.

It is possible to get a false reading on cushings test if the pup is experiencing any other health problems. Has an ACTH stim test been performed, The way I have always understood cushings diagnosis is that no one test is conclusive and cushings can be somewhat difficult to diagnose at times.

Hang in there and check back often, things can be kind of slow on the weekends and close to the holidays.

Oops I see the ACTH has been done so maybe a Low Dex test to confirm.

Hi John,

Yes the ACTH was done, results in first post. Appetite depends, she would woof down a bag of treats like there is no tomorrow if you let her, she loves her can food, but the dry food, some days she will graze at it and others she'll eat it all at breakfast. Water, yea, same concern here, she doesn't overly drink, although she has a bowl of water in the bedroom at night, because she will get up and get drinks during the night most of the time.
I actually had the same concerns and mentioned them today to the vet. She said that not all dogs display the same symptons but that she does feel that the cushings diagnosis is correct.
I don't know if it is or not and that is why I haven't jumped on starting her on medicine. The liver is high, the cortisol is definitely there in the ACTH test.
Weekends are for good times, relaxing and enjoying not having to do the work thing. I hope everyone is enjoying this one. For us, it's a long weekend too. :) Love it!

Hi Sharlene :)

Did they determine which type of cushings it may be? One thing to be aware of, in most cases, treatment is usually used to treat the symptoms, such as excessive hunger, excessive thirst and frequent urination.

In some cases where it's adrenal based, surgery may be possible thereby a cure. The medications Lysodren and Trilostane do not cure cushings, only treats the symptoms.

I am headed out the door so don't have long to post but your dog doesn't have typical cushing's symptoms. A cush dog is ravenous and would eat anything and never leave a kibble EVER. I'm glad you did not start any meds. The world experts all agree you do not treat until there are symptoms even if the dog has cushings. You are right - UC Davis does recommend lower dosing and we have found over the years and experience from many hundreds of people who have come here that starting low is the ONLY way to go.

I want to convert your test results when I return. Are you from outside the US? The numbers are higher than normal and I think it is the unit of measure used by the lab. I'll check in later.

Hang in there and don't fret this diagnosis - Molly will be fine. Kim

John,

The lab said Pituitary-Dependent Cushings, not adrenal based. And they think that the symptoms will start to show that literally it has been caught very early. That the excessive food and thirst will probably be some of the first symptoms that she develops. She has had accidents in the house, but not consistently, so I wouldn't attribute them to cushings.

Kim, I'm in Canada. Not sure what the conversions would be, but have included the lab ranges as given. Yes, my vet acknowledges that there is no cure, only symptom treatment. Her concern is the other possible illness that could occur and might be preventable such as diabetes, which molly currently has no signs of. In fact, molly other than the liver and the cortisol and belly has no signs of cushings. In most cases she wouldn't have probably been tested at all.

Sharlene.

Thanks Sharlene, :)
I am very interested in following yours and Molly's thread.

Shih Tzu's hold a very special place in my heart.;)

I am curious. If this is not cushings, and my vet is adamant that it is, what tests should I ask for? What else could it be. The sudden increase in the ALT's is what is worrying, along with the cortisol going up.

I want to take care of whatever the problem is, I just don't know what to do. Another talk with the vet and she is definite that starting early prior to typical cushings symptoms can help to prevent other organ problems from developing.

I don't know what to do.

The ALT only results are:

54 (10 - 118) 2010
110 (6 - 118) 2011
139 (6 - 118) March 2012
152 (6 - 118) June 2012

As you can see, those numbers are just going up like crazy and pretty quickly too. I was told they really get worried once the number hits (double normal results, which would be 236. Vet thinks Vetoryl will get the cortisol under control so that she won't end up with any major organ damage.

Thoughts?

Hi again Sharlene,

I was just wondering, was a High resolution ultra sound performed? Usually to take a look at the adrenals and other important organs. In many cases one or both adrenals may be enlarged due to the cushings. This is because they are working overtime to produce the cortisol.

I do remember Leslie's story about Squirt and the ultra sound found something wrong with her spleen which in turned caused a high cortisol count. She will probably be around soon to elaborate.

Another question, I see the ACTH test was performed, was there another test like the LDDS, performed after the ACTH test to determine if it is indeed pituitary based.

Hi Sharlene,

I wanted to offer you a belated welcome from me. I also have two Shih Tzus and love the breed!

First, Molly sure is a cutie! My dog, Hannah, also had crystals in her urine and has been on Royal Canin SO food for 8 years. It has helped her out a lot!

Hannah was diagnosed in March of 2011 after routine blood work before a dental. Her Alk Phos level was high and my vet asked about Cushing's symptoms (water increase, urinating more, ravenous eater, etc.) She was drinking and urinating a bit more, but I don't know that I would have contacted the vet about it. He did a LDDS test that day and she did test positive for pituitary Cushing's. We had an ultrasound done a few weeks later just to be sure things were normal there and they were. My vet also felt that we caught it very early and said that for many dogs it takes years for things to progress.

I still have not started treatment on Hannah over a year later. We did try Anipryl for a few months because I knew it worked in some dogs and had basically no side effects and didn't have to be carefully monitored. Her ALKP level did drop, but I didn't notice much of a difference otherwise so we decided to stop the Anipryl. She has now been taking Denamarin, a liver supplement, for about 6 months and her ALKP level returned to normal. It was over 800 when we started and was about 200 a few months ago.

Since I know the main way to determine how she is doing is by monitoring her eating and drinking, I don't feel comfortable starting her on a stronger drug unless I am sure I will be able to see a difference. She definitely gets several drinks a day, but she is not emptying a water bowl and she is not peeing constantly. She does LOVE to eat and does beg me for food sometimes, but it isn't out of control. She has a full coat, no pot belly, no skin issues...just some hind leg weakness. I have decided that until she has more significant symptoms I don't want to treat. My vet strongly supports this, as did the IM vet we saw. I know there could be some damage being done, but I don't feel comfortable risking it with powerful drugs.

I am glad you are taking the time to think about what is best for Molly. I know others will be by to offer more "expert" opinions on what is best for her. I would definitely take some time to think, read, and educate yourself before jumping into anything.

Also, I know ALT and ALKP are different liver enzymes, but the high normal end for ALKP here is 212 and Hannah's was over 1700 when she was diagnosed. I definitely understand your concern, but I don't want you to panic. I wonder if a liver supplement would help Molly as well. I know many people on this forum use one, so that might be something to look into.

Please keep us updated on what you decide and always feel free to ask questions. You have found a wonderful place of helpful, knowledgeable, caring and supportive people!

Julie & Hannah

Hi Sharlene,

Welcome to you and Molly! :)

My Squirt is another one who currently has very high ALP, but her vets aren't worried about it. However, she is actively cushionoid and Molly isn't so that may be why your vet is concerned. It takes more than just the ALP elevation to indicate a real problem - that would show as elevations just about across the board via the liver enzymes. The liver is an amazing organ that can take a whole lot of punishment before it rebels. If you are really concerned about the liver function, a bile acid test may be worth discussing with your vet.

You are wise to wait on treatment as signs are a critical part of not only diagnosing but monitoring treatment. Without strong signs, handling this disease is much more difficult and risky. So take your time - it sounds as it you have plenty of it to learn a lot before you start treatment. ;)

I started to tell you about Squirt's story but since you have been reading for two years I didn't want to repeat something you may well be familiar with. :D If you aren't and would like to hear it, I will be happy to share! In a nutshell, she was diagnosed in '08 and is doing great today at the ripe old age of 14! :):cool:

I'm glad you found us and look forward to learning more as time passes!

Hugs,
Leslie and the gang

PS. On the normal ranges you added for the LDDS...(20 - 300)...is that the range for all three values - base, 4, and 8 hour?

Hi Sharlene.

I’ve fallen behind in reading everybody’s threads so I apologize for just now getting around to welcoming you and your precious Molly Muffin. I’d like to make some observations and maybe ask some more questions and the easiest way tie my questions to the information you’ve provided is to type my stuff in blue text within the body of your post. Please see below.

Quote:

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Originally Posted by molly muffin

Her ALP's have been high consistently and we try to balance that using the SO food, that encourages her to drink more water and the crystals not to form. She only had them once, that was enough.

If Molly has cushing’s, it is highly unlikely that prescription or nonprescription food will have any effect on ALP.

2012 June tests
ALP 1003 (5 - 141) (this has actually decreased a bit since March)
ALT 152 (6 - 118) (while this has gone up a bit since March)

In subsequent posts I noted that you are very concerned about the progressive increase in ALT. 152 would be considered a mild elevation, which is the norm for a dog with cushing’s. This doesn’t mean a dog’s liver is being damaged but rather is being overworked from the effects of high cortisol. It also should not be the primary factor in determining whether a dog should start treatment.

Cor1 - Cortisol (base) 172 (30 - 300)
Cor 21 - Cortisol (ACTH) - 1 hour 924
Cor 22 - Cortisol (ACTH) - 2 hour 1014

Lab states, that in a normal animal Cortisol will increase above 250 but not above 600.
The results are consistent with Cushings Disease; Pituitary-Dependent Hyperadrenocorticism

This appears to be an acth stimulation test, probably using an acthar gel, with peak concentration occurings two hours after stimulation, thus the two post blood draws. Here in the states most vets prefer to use cortrosyn as the stimulating agent, with peak concentrations occurring 1 hour after stimulation, requiring only one post blood draw. Regardless of which stimulating agent is used, an acth stimulation test does not differentiate between pituitary and adrenal based disease. Could you please recheck your paperwork to make sure you aren’t missing some text.

okay, so now that is out of the way, my vet, who has been Molly's vet since we brought her home as a rescue baby at 11 months, feels that this has been caught at the very earliest of stages. Her recommendation is to begin treatment with Vetoryl 30 mg. In fact, it is sitting here on my desk right now. It is the monster in the closet, under the bed, or in my case, in front of this computer monitor.

So I asked her why begin treatment now,( actually she has called me once since they told me on Wednesday, to discuss and then we spoke again today, when I went to pick up copies of lab results) and she said, that although it is not clinically necessary to start right now and we can decide when we would want to start medications for the cushings, that her experience is that when treatment is not started, the risk increases greatly for dog to develop diabetes and/or pancreatitis. That she feels and she has had good results with early treatment.

Symptoms are a big components of a diagnosis and a cushing’s savvy vet would not confirm a diagnosis and launch into treatment in the absence of overt symptoms. The primary goal of treatment is not to cure the disease but rather to eliminate clinical signs. If there are no overt clinical signs, there is no need to jump into treatment. As a matter of fact, I would be hesitant to start treatment without validating the ACTH stimulation test and determining which form of the disease Molly has.

I asked also about the Davis study suggesting a lower dose and she said that the Davis study is already out dated compared to more recent studies, from universities around the world.

The UC Davis protocol was established as a result of their extensive experience with Trilostane. Based on the 100’s of threads here, I believe UC Davis protocol is much safer than the dosing recommended by Dechra, the manufacturer of Vetoryl. One of our administrators was actually told by an internal medicine specialist on staff with Dechra that they are verbally recommending to vets that they use the very lowest end of the range for dosing but they have not yet published a revision to packaging inserts.

That she has had good luck with this dose for Molly's size. Starting the medicine she said would be followed up with tests at day 10 - 14 (she suggested day 12) after starting treatment and then based upon how molly is doing, either 4 weeks or sooner if she feels that it is needed.

Proper protocol dictates that an acth stimulation test be done at 10 to 14 days and again at 30 days. I would recommend that if and when you start treatment, your vet should follow proper protocol, especially in the first 30 days of treatment.

I find myself second guessing how well I thought molly was/is. She does lay around more, but has a great time playing when she wants to. She doesn't eat all at once every day, usually she eats maybe half or even less, and then later will finish off (around dinner time). She drinks, but not overly so and we in fact try to encourage her to drink since she had issues with the crystals forming. She does have some times when she doesn't want to jump up or she has to make a running leap for that window seat she loves. And yes, there is the pot belly. (we thought she just really loved those treats a tad bit too much and that is probably still true)

With symptoms being limited to a pot belly, I absolutely would not start treatment until symptoms became apparent. I would, however, want an abdominal ultrasound done to make sure there is not some other problem going on. A very small number of dogs have cushing’s caused by tumors outside the pituitary and adrenal glands that secrete acth, so having a look at internal organs is a really good idea. In these cases the treatment of choice would be to remove the tumor. One of our moderators has a dog who had elevated cortisol but it was later discovered, via an abdominal ultrasound and subsequent surgery, that the cause for the elevated cortisol was a tumor on the spleen. Once removed, cortisol levels fell. Oddly enough, these dogs usually have higher levels of circulating cortisol, like Molly. With just an acth stimulation test and no symptoms, how does your vet know what she is truly dealing with?

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Quote:

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Originally Posted by molly muffin

I actually had the same concerns and mentioned them today to the vet. She said that not all dogs display the same symptons but that she does feel that the cushings diagnosis is correct. I don't know if it is or not and that is why I haven't jumped on starting her on medicine. The liver is high, the cortisol is definitely there in the ACTH test.

For what it’s worth, you’re conclusion is the same as mine so I’m glad you have not rushed into treatment. Based on the information you have provided thus far, your vet has determined that Molly has elevated cortisol via an acth stimulation test. Absent further testing to validate and differentiate, I personally wouldn’t assume the diagnosis is correct.

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Quote:

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Originally Posted by molly muffin

John,

The lab said Pituitary-Dependent Cushings, not adrenal based.

As I mentioned previously, I have no idea how the lab can make this determination.
And they think that the symptoms will start to show that literally it has been caught very early.

That’s possible but I’m not sure what constitutes catching the disease early with no clinical signs of the disease.

Kim, I'm in Canada. Not sure what the conversions would be, but have included the lab ranges as given.

If the acth stimulation test is in nmol, you would convert to ug/dl by dividing the results of each draw by 27.59. Conversion of Molly’s acth stim test is

Cor1 - Cortisol (base) 6.23
Cor 21 - Cortisol (ACTH) - 1 hour 33.4
Cor 22 - Cortisol (ACTH) - 2 hour 36.75

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Quote:

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Originally Posted by molly muffin

Vet thinks Vetoryl will get the cortisol under control so that she won't end up with any major organ damage.

Cushing’s is a very graded disease, progressing at a snail’s pace and it takes a very, very long time to do any internal organ damage. Thanks to my ignorant gp vet, my dog was overtly symptomatic for almost two years before an internal medicine specialist finally diagnosed her. If any dog with cushing’s was going to have internal organ damage from long term excess cortisol, it would have been my Lulu but she is fine. I just had a senior panel done and her kidney levels and liver enzymes are perfectly normal.

Just to validate what I have been saying about not treating in the absence of symptoms, here are some excerpts from reference material published by renown and well published endocrine specialists as well as a much utilized veterinary text book. You should share these with your vet and ask her why she disagrees with the experts.

Excerpt from reference paper written by Dr. Mark Peterson, entitled Cushing’s Disease in Dogs: Recommended Diagnostic Protocol and Treatment Options.

Quote:

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False positive results are common in dogs suffering from non adrenal disease. Because such false-positive test results occur for all of the commonly employed screening tests (ACTH stimulation), low-dose dexamethasone suppression, urinary cortisol: creatinine ratio), the definitive diagnosis of hyperadrenocorticism should never be made purely on the basis of results of one or more of these screening tests, especially in dogs without classic signs of hyperadrenocorticism or in dogs with known non-adrenal disease. If a dog has no clinical signs of Cushing’s syndrome, we do not recommend treatment.

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Excerpt from Dr. Rhett Nichols, entitled Canine Cushing’s Syndrome: Diagnosis and Treatment (Part 1: Typical, Atypical, and Pseudo-Cushing’s Disease.

Quote:

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Based on the lab tests, does the dog have Cushing’s syndrome:

The most important criteria for making a diagnosis of Cushing’s syndrome or hyperadrenocorticism (HAC) is the patient must have signs and symptoms consistent with the disorder. The importance of signalment, history, and physical examination finding cannot be overstated.

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Excerpt from Merck Veterinary Manual:

Quote:

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Diagnosis can be challenging; it should be based on clinical signs and laboratory abnormalities and confirmed via an appropriate screening test for hyperadrenocorticism. If results of screening tests are inconclusive or if laboratory abnormalities associated with hyperadrenocorticism are noted in a dog without clinical signs, the dog should be retested 3-6 mo later.

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Whew, that was a novel and I commend you if you are still with me. I've been typing this off and on since early this morning but have been interrupted a number of times. I hate it when work gets in the way. :D I see that others have posted since I started this epic saga so please excuse any duplication.

Glynda

I am absolutely with you still! Thank you all so much for your very informative information and for calming my up and down panic attacks.

Okay, to answer John, no they didn't do the LDDS after the ACTH test. That is the one with DEXA right? They did this 2 years ago in May 2010, with negative results.

So it sounds like a high density ultrasound is the best option at the moment. It is possible that a liver supplement might help her liver values come down. I'll ask the vet about that. Also, a confirmation with a follow up Low Dose DEXA test.

I have asked the vet about these tests since her determination that Molly had Cushings and she said that I pay her to know what tests are needed and what are not. She didn't feel a follow up is needed, that I'd be wasting money.

Her values from this lab are in nmol/L for the ACTH test.

Glynda I am going to type out exactly what it says within the text for results on the ACTH test. Keeping in mind that their text recommendations will be based upon the nmol/L ratios.
(thank you for taking the time to type all that out btw! wow!)

Cor1 - Cortisol (base) 172 (30 - 300)
Cor 21 - Cortisol (ACTH) - 1 hour 924
Cor 22 - Cortisol (ACTH) - 2 hour 1014

TEXT: RESULT INTERPRETATIONS

Normal animals: Cortisol will increase above 250nmol/L, but not above 600nmol/l.

Primary Hypoadrenocorticism (Addisons disease; Adrenocortical insufficiency); Pre-ACTH concentration is below the reference value (often undetectable) or low normal. Post-ACTH concentration does not differ from the pre-ACTH concentration or changes very little.

Secondary Hypoadrenocorticism: Pre-ACTH concentration of cortisol is below the reference value (sometimes undetectable) or low normal. Post-ACTH concentration is elevated 3 to 5 times above the Pre-ACTH concentration.

Primary Hyperadrenocorticism (Adrencortical tumor); Pre-ACTH concentration of cortisol is usually above the reference value . However, because of the sporadic pattern of cortisol secretion, it's concentration may be within the reference value, even low. Post-ACTH concentration may be within the reference value, above the reference value, or unchanged from pre-ACTH conecntration. No change from pre-ACTH concentration is an excellent indication of a tumor. If the post-ACTH concentration is within or above the reference falue, additional testing (e.g., dexamethason suppression) is recommended.

Secondary Hyperadrenocorticism (Cushings disease; Pitutary-Dependent Hyperadrenocorticism): Pre-ACTH concentration of cortisol is usually above the reference value. However, because of the sporadic pattern of cortisol secretion, its concentration may be within the reference value, even low. Post-ACTH concentration of cortisol usually is far above the reference value because of functional adrenocortical hyperplasia: serum cortisol will increase to >600 nmol/L. (This is the one I typed out earlier as it seems to be consistent with Molly's results)

latrogenic Cushings Syndrome: Pre_ACTH concentration of cortisol is below the reference value (often undetectable) or low normal. After long-term treatement with corticosteroids, post-ACTH concentration does not differ from pre_ACTH concentration or changes very little.

I've been watching Molly like a hawk the last couple days. (poor thing probably has a complex by now!) and to me, she seems a bit more lethargic than normal, but it is hot out, although not inside. She isn't panting at all (unless out in the heat, then we both pant together). She is drinking her normal amount of water, not exceslys (even with the heat) and eating the same, (when she wants but not all at once). I think she is above the same as Hannah. I know the vet goes on about the pot belly, but Molly has had that belly since she was about 5 maybe. I'm telling you she gets Good treats! So I'm not convinced about that either.

I do adore out little molly. Before her I had a golden retreiver that I'd had since a baby. She was on prednisone from the time she was 2 for severe allergies. I am convinced that she died due to not being diagnosed with lastogenic Cushings. She had the severe hair loss, horrible skin condition, went to the bathroom in the house, drank as much as she could, weakness in her hind legs especially and yet, I never heard a word about cushings or that she could be treated for what she did have. That just makes me ticked off big time.

Molly was the rescue baby I got a year after Tasha (my golden) when I could no longer stand the silence in the house. We lost one of our cats that had been Tashas constant companion since babyhood 3 months before we lost Tasha. The silence was unbearable. Molly was meant to be in our home and I want to shake my fist at fate and say, how dare you give Molly a disease of any kind.

Okay I too cannot keep things short it seems. Sorry.

No I haven't been on here for 2 years, that was one of the other newbies. I have however, been reading through everyone's threads, at least some of them, there are a lot more to still get through. I found this actually as a link under VeterinaryPartner.com as a recommended link. That link I got from a friend who is a vet in Maine.

Hugs to everyone. Some moments I feel fine, and others I feel like crying and panicing a the mere thought of anything happening to molly.

HUGS and Belly rubs to all those faithful companions of ours.

I'm going to throw this out there because it really is upsetting me and I feel totally disloyal for these thoughts. I admit that I thought them as soon as my vet said she wanted to test for Cushings bakc in March when we got the first high ALT results.

Why the heck does she keep pushing cushings disease, when all molly had was a pot belly 2 years ago, she pushed this and the results were negative. This time it was because of the liver and I feel like, gee she finally got the results she's been looking for. It kind of pissed me off at the time. Now I feel the same about pushing meds that I don't want to have her on yet if not needed.

It makes me wonder how many dogs she has put on these meds and do they really need them, what are their life expectancies with the meds. Would I be in fact hurting molly to put her on them now or would I be hurting her more if I don't put her on them and the vet is right and she wouldn't develop diabetes or some other disease.

The vet even told me I shouldn't be reading so much stuff on the internet, it would just confuse me. (again, way to piss me off)

I do try to remember that she is the only vet that has ever treated molly in her life and that I know she loves her too. (molly boards with the vet and often hangs out in the vets office with her instead of in the "cage" area) So I don't doubt that she cares for her, but it still is bothering me. I just want to scream sometimes in frustration. :(

Okay so got that out of my system. Thanks for letting me rant. I guess I'm like the angry mom whose kid had been diagnosed with some horrible, non-curable disease and want to blame someone for it. :(

Hi there,

I would be upset if that was the response I got from my vet as well. I understand that they are the experts, yes, but they don't know everything and they certainly aren't experts in everything. My vet thought it was good that I was reading about Cushing's and also felt good about me wanting to take her to an IM specialist; he gave me a recommendation for who to see.

Also, reading and researching is what a GOOD owner WOULD and SHOULD do, so that would tick me off too! You should be sure you know what you are dealing with before you give your dog any medication, and many, many, many vets would recommend against treating when you aren't seeing symptoms. How does she expect you to know how Molly is doing if the main thing you are supposed to watch for is a decrease in drinking and ravenous eating?! That is the main reason I will not treat Hannah yet. It would be too hard to watch for.

I am glad you are not giving meds yet. If I were you, I would push for the LDDS test and the ultrasound, if you can afford it. I would also see if there is an internal medicine specialist vet you could see in your area for a second opinion. I think your vet needs to understand that you are a concerned and proactive pet owner, who loves her pet deeply. She should not be making you feel this way.

Keep us updated on what you decide!

Julie & Hannah

Hi Sharlene,

My HUGE mistake....:o:o:o:o

I'm glad you are considering an ultrasound, tho. I am also very glad that you are not letting your vet push anything on you or Molly until you are ready. That pressure can make us feel like CRAP! I know....I refused to be pushed and was told point blank I was killing my dog because I didn't start treatment immediately (not here, on another cushing's forum)...and that was the mildest thing they said. :mad:

When Squirt was first diagnosed, we had a great vet who took a very conservative and thorough approach to testing. Squirt had the LDDS, HDDS, ACTH, UTK panel and two ultrasounds - all positive for PDH. After the second U/S, they told me about a tumor on her spleen. In Sept of '08 that tumor and half her spleen were removed. Her cortisol returned to normal as a result. That tumor was causing her internal stress and her body responded just as it was supposed to - by releasing excess hormones including cortisol which caused all those test to be positive when they really weren't. They were all false-positive because of that tumor.

This sort of experience like Squirt had is only one of the reasons Cushing's is so very hard to diagnose. Cortisol is one of the bodies natural responses to stress of any kind - internal or external. So just because one or even two of the cush test come back positive, that does not mean you have a confirmed diagnosis in every case - like Squirt's. FIVE tests said she had PDH in 2008 - all five were wrong. In addition, the cush signs are shared with many other conditions like liver or kidney diseases, hypothyroidism, diabetes to name a few. Diagnosing Cushing's is as much a process of ruling out all other possibilities as it is getting positives on the testing. ;)

So if your vet isn't willing to listen to you, to work with you as a team, then it may be worth looking into a different vet to handle the Cushing's - an IMS is a good idea. For one thing, they have more education and experience in things like Cushing's and for another, you vet might not feel as slighted if you see someone who specializes VS another GP vet. ;) They may even be willing to work with an IMS.

Hugs,
Leslie and the gang

Just a quick note. I emailed using the "contact us" Dechra site, to try to get something in writing about going with a lower dose in dogs vs the higher one in their insert and got the response that they cannot give advice to pet owners, but if you send them your vets info, they will contact That vet.

Well, I already gave my Vet a speech about drug representatives vs other clinical studies, so I know she is in contact with the drug rep already. She told me she was. Anyway, this is just to let you know, emailing them using the form doesn't appear to do any good.

grrrrrrr

Just like in human medicine, a doctor should NEVER bully a client. You have a right and responsibility to be an informed client. I am currently in the process of trying to get my fur baby into a specialist at Cornell for a second opinion because I think my vet is rushing into Cushings and ignoring the fact that the testing is negative and he is asymptomatic.

You should not feel bad for questioning your doctor's opinion. You are protecting your loved one and seeking the best possible treatment. I say a good doctor empowers you to have confidence in a diagnosis by supporting thier hypothesis with clinical symptoms and solid conclusive diagnostic testing. Good for you for loving Molly so much and wanting the best for her! Are there other vets near you that you could take her to for a second opinion?

what are some good omega 3 supplements or treats/food to give molly? I read that omega 3 is good for helping to naturally lower cortisol levels? Not sure if that is true or what, but figured this is the group to ask.

I think my next course of action will be getting the ultrasound done. After that, we'll see, but I'm think about the 1st part of August to ask for an LDDS test too.

Thoughts? I did have a couple things I thought of over the last couple days. On the morning of her test I actually gave her the revolution skin treatment. I didn't get the phone message that she should be fasting either, so she did have breakfast that morning. She does exhibit stress when going anywhere, but especially vet. She was being boarded and I asked them to do the test that day and they said they did.
I don't know if any of this would actually affect the ACTH test or not of course. Probably and most likely, not, but still...
So for the moment, my thought is what about the supplement idea. I spoke with a friend who is involved in pet rescue, and she suggested 2 other vets in the area, if I want a second opinion. My main thing right now, is that I want any other possibilities ruled out. It may turn out that my vet is correct and she does have Cushings, but I want to eliminate liver disease, thyroid, etc. Diabetes has already been ruled out. Anything else that would cause her cortisols to rise, other than cushings?

Thanks Sharlene and Molly

Hi Sharlene,

Yes, stress will affect the cush tests. Cortisol will naturally rise in the body, human and canine, when it is under any sort of stress, whether that stress comes from the outside - as a vet visit or change in their environment, or from the inside - as in as illness. So there are literally millions of things that can cause the cortisol to rise that have absolutely nothing to do with Cushing's. Elevated cortisol in an of itself is not a problem nor considered an illness/disease/condition. It is when the body is not able to stop releasing the cortisol even when there are no stressors in play that Cushing's becomes a possiblity.

Hope this helps you understand a bit better. We have members who will take their babies in for the testing but not leave them between blood draws. They will take them home if they live close enough, out to a park, or just sit in the car with them to try to lower the natural stress of being at the vets. Not all pups have a problem going to the vet and do just fine being left for the duration of the test. We each have to decide what is best for our baby and what will provide the most accurate results on the tests.

Hugs,
Leslie and the gang

Hi Sharlene,

Just stopping by to say thank you for always checking in on us.

It took me a year to start Zoe on treatment. Her symptoms were not that strong. Take a day at a time. Enojy your Molly. Your avatar is so beautiful of that little girl:):):)

I think my vet has scared the bejebees out of me. She is basically saying that if we don't start treatment that the other cushings symptoms are going to show up and by the time they do that she will have other problems. She is very much an advocate of starting medication early to bring the cortisol levels under control and prevent them from causing any other organ damage. She thinks that this is the best option for giving molly as normal of a life span as possible and said that yes she would always be under treatment for the cortisol.

Gee Addy, look whose talking Zoe and Kodo are freakin adorable. :) :) So many absolutely darlin companions on this site and so sad to think of even one of them having health problems to deal with.
I'll add some pictures of molly to an album when I get a chance.

I'm still not sure when I'll start molly on treatment or when I'll get the ultrasound done. I'm just not ready to have another chat with the vet and molly is okay for the moment.

Hope Zoe's eyes start to get better soon! Poor baby.

Hi Sharlene,

Is Molly showing more or stronger signs lately? I am just really, really uncomfortable treating a pup who isn't showing pretty strong signs since the signs are critical, vital, to monitoring treatment. If there are no signs, how will you know if it is even working much less have any indication that she is over dosed?

And I would want the U/S before starting as well...but that's just me. ;)

You are doing a great job of educating yourself and keeping a hawk's eye on your sweet Molly girl!

Hugs,
Leslie and the gang

Quote:

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Originally Posted by molly muffin

I think my vet has scared the bejebees out of me. She is basically saying that if we don't start treatment that the other cushings symptoms are going to show up and by the time they do that she will have other problems. She is very much an advocate of starting medication early to bring the cortisol levels under control and prevent them from causing any other organ damage. She thinks that this is the best option for giving molly as normal of a life span as possible and said that yes she would always be under treatment for the cortisol.

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Your vet sure scares the bejebees out of me too. I don't want to sound like a broken record but the goal of treatment is to remedy symptoms and if a dog is asymptomatic, treatment should not be prescribed. I believe I provided you with some validating excerpts from some of the worlds most noted endocrine experts. Did you share these with your vet and ask her why her opinion is in direct conflict with them?

If what your vet says is true, almost every dog here would be diabetic and would have suffered with pancreatitis because they were not diagnosed and treated until they were overtly symptomatic. The majority of dogs diagnosed with cushing's are not diabetic nor have they had chronic pancreatitis. The only thing I can figure is that your vet has had minimal exposure to cushing's and the cases she's had were complicated by companion conditions such as diabetes. :confused:

I am pretty sure that you are feeling torn right now because your vet is telling you one thing and we're telling you another. My best advice to you is to not place your faith in anybody to know what is best for Molly. The best and only way you can do that is by educating yourself. We can only provide you with our own experience and point you to excellent reading material. You are Molly's only voice so make it heard. If you have questions, ask them and we'll try to answer as best we can, as well as provide you with links to reading material on the subject.

I don't think Molly is showing any more signs of cushings than she ever has.

It's like my vet could Hear us talking about Molly today. I got a call from the vet's office this morning after I posted here actually, asking how she was doing. I said, fine and that I hadn't started her on the Vetoryl yet. Which seemed to surprise them but I'm not sure why since I said I hadn't decided anything yet.

So I reiterated that point and said I won't do anything till she has an ultrasound to rule out tumors or any other disease. Since they don't do that at the vets office, she has to be referred to the Vet Emergency Hospital, so that is what they have done. Wow, 75 bucks for the referral.

So, Molly is booked to see an Internal Medicine Specialist and have an Ultrasound Friday morning.
I just spoke with the Vet Hospital and confirmed that this specialist has lots of experience with dogs with cushings or maybe having cushings and told them I'd bring her test results with me and that I'm concerned because of no real clinical signs of cushings. I want all other possibilities to be ruled out.

We'll see what happens on Friday and what the specialist says.

I did tell my vet about other findings, and the response was that I shouldn't be reading so much on the internet (that is the short basic version anyway).

I certainly appreciate all the valuable information that you are all willing to share with me. If not for this forum I probably would have just started her on the meds without any further testing or the ultrasound, thinking I was doing what was best for her and not even realizing the possibilities of something else. :(

:D Don't worry... many of us have been down this same path with vets. There is garbage on the web no doubt... but if you go to the links that Glynda referred to you will find that we are providing you with info that vets pay MONEY to learn in classes! These are the recommendations of world renown specialists in treating Cushing's.

Tell the IMS (or your regular vet) you have been reading articles written by Dr Feldman. If they have never heard of him then they know very little about cushings (its a way to screen ;0) Feldman (among other specialists) makes it very clear that we should not treat until there are symptoms.

Like I said - many of us have been in the same boat - myself included. You want to trust your vet because you have to be able to trust them... then along comes this site with conflicting info. It happened to me 7+ yrs ago. Obviously I stuck with the site and canned the vet. :D And I have no regrets. These people saved my dog's life and my sanity.

Hang in there and all will be just fine. Kim

Quote:

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Originally Posted by molly muffin

I did tell my vet about other findings, and the response was that I shouldn't be reading so much on the internet (that is the short basic version anyway).

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Oh my gosh, deja vu. The new gp vet I took my Lulu 10 days ago too told me exactly the same thing and that I shouldn't believe everything I read on the internet. I asked her if I should disregard all those peer reviewed studies in the veterinary journals and clinical trials submitted to the FDA for drug approval or the numerous audios of lectures I've purchased on how to diagnose and treat cushing's given by Dr. Edward Feldman, Dr. Mark Peterson, Dr. David Tweedt or Dr. David Bruyette, all considered experts in their field. I then told her that in my experience, more than few general practitioner vets need to sit their butts in front of a computer and start educating themselves. Keep in mind, this is the same woman who thought a dog diagnosed 7 years ago should have an ldds test done to obtain a baseline cortisol and that a post stimulated cortisol of 8.4 ug/dl is not only acceptable but normal for a cushdog being treated with Lysodren. The vet literally stammered then and I suspect she'll do the same when we finally connect to discuss Lulu's stim test, hopefully today. I will be offering up a copy of the Lysodren Loading Instructions and related tips in our Helpful Resources forum. These instructions are taken directly from a chapter in a veterinary textbook contributed by Drs. Steven Ettinger and Edward Feldman. I hope she won't be insulted because it will help her treat future patients effectively. Besides, I certainly wasn't insulted when she immediately assumed that I am an ignorant layperson who believes everything I read on the internet. :D

Hi Sharlene,
Just wanted to add that I have had the same experiences. Some with cushings and with ear medications. My vet at the time applied Gentamicin Otic ear drops in Rozee's ears before I could tell him no. I explained that one of the side effects is loss of hearing. He told me I read too much on the internet. I insisted he change medications while he was insisting that is what he used on the local police dept canines. He went back and read the warning lables then came back and apologized, adding that he was going to change the meds for the police canines. Rozee did lose her hearing, but I'll never know if that was the reason.

I was new to the site and with the wonderful help of the members here, I was able to have a knowledgeable discussion on cushings and the treatment with our vet at the time.... we didn't always agree, but I insisted to go with the successful and cautious experiences I have gained here.

Thanks everyone.

It is hearing of your experiences on the board, that makes all the difference in the world when it comes to these one on ones with the vets. Peterson and Feldman are now staples of conversations involving cushings treatments with the vet. To think I'd never heard of either prior to this.

Wow John. You made a difference in a whole community of canines! Way to go! I couldn't be more proud.

Glynda, had to laugh at the thought of you marching in to the new GP vet armed with reams of material to explain very calmly how the vet is wrong. Road trip to Canada? :)

Interesting. I'm speaking with an acquaintance in Penn, who was told her dog must have cushings because the liver enzymes went up. Turned out after an ultrasound to be a large tumor on the liver, which was benign, has now been removed and her dog is fine.

Dear Sharlene
Thank you for the kind words.
I am originally from Toronto, Ontario, Canada. Now in San Diego , Ca.
I tried a lot of things for almost a year, and waited a few months after Apollo's diagnos to research what treatment to do. Apollo is 4.9 kilos(10.75lb) and is on 10 mg. Trilostane. I started very low with him. I listened to my instincts and not the vets often. Question everything if you are not sure. Keep copies of all of Molly's lab's , take notes and write it down for future reference.
Each dog is different and treatment is different.
Below are some links about cushing and some references.
http://www.kateconnick.com/library/cushingsdisease.htm
references to internal medicine vets, just pu in the city and province.
http://www.acvim.org/websites/acvim/index.php?p=3
http://www.acvim.org/websites/acvim/index.php?p=3
You are not alone.
You and your sweet Molly are in our thoughts.
HUgs Sonja and Apollo

We are back from having the ultrasound today and meeting with the Internal Medicine Specialist.

Good news is that she doesn't have any tumors anywhere. Her adrenal glands are slightly on the large size, and liver a tad large. No sign of liver disease, gall bladder, anything that I asked would cause her ALP's and ALT's to be raised. The IMS, told me that looking at the results and all her other tests (that I have posted here) that Molly does indeed have cushings.

Her recommendation is that another LDDS test (we had the last one two years ago, negative) and see what those results are. If they clearly show cushings, on top of the ACTH showing cushings, then we would start her on low dose, 5 or 10 mg of trilostane. She said that was the low end, and that she is of the mindset that you start low and go up, rather than high and go down and that is what she would advise my vet. (I'll be returning the 30mg box of vetoryl)

If the LDDS is low, borderline, not clearly showing cushings, we'd wait and then retest in about 3 months. She also recommended another full blood panel workup and urine workup, prior to starting molly on any medication. So, if the LDDS is high, we'll move to doing the full blood and urine panels.

I am so much more comfortable with this IMS. I did say I was fine with the vet doing the LDDS, as long as she (the IMS) is consulted. If I feel at any time that my vet isn't on board with the treatment, then I'd rather see her directly. She was fine with whatever I decide.

Interesting, my vet told her in her faxed notes, that I had "read on the internet, much information, that made me wary of treatment" pffffft and hmmmmph

This doctor was fine with my reading up and had just recently attended a conference by the vet association. She said, they compile information from all studies done in the US and I want to say UK too, and then issue statements regarding treatment based upon these findings. She said there would be either a statement or a paper issued soon, a new one I mean, she doesn't think it's been released yet, regarding Cushings treatment. One thing will be not waiting for clinical signs to start low dose treatment if all testing indicates cushings and all other diseases or possible issues ruled out.

She has heard Feldman speak several times she said, after I mentioned papers written by Feldman and Peterson. (she said on you are familiar with the big names in this area and laughed) She said they both are doing excellent work, along with U of Tenn regarding this disease that is so hard to diagnose and hard to treat.

So, in essence, I feel comfortable with her prognosis and her plan at this point and hope my vet can get on board with what we want to do.

Sonja, I'm in Mississauga, but only a stones throw across the creek into Toronto. :)

I've been reading up as much as I can on Cushings, Medicine, treatments, when to treat, when not to treat. It's a big swirly mass of information right now, that doesn't always make much sense. Thanks for the links :)

Quote:

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Originally Posted by molly muffin

This doctor was fine with my reading up and had just recently attended a conference by the vet association. She said, they compile information from all studies done in the US and I want to say UK too, and then issue statements regarding treatment based upon these findings. She said there would be either a statement or a paper issued soon, a new one I mean, she doesn't think it's been released yet, regarding Cushings treatment. One thing will be not waiting for clinical signs to start low dose treatment if all testing indicates cushings and all other diseases or possible issues ruled out.

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Wow, this is huge news and I'm dying of curosity. Is there any way you could find out who the speaker was?

Hi there!

I'm so glad your visit went well today and that you like this vet. Certainly that is a good feeling after your recent experiences with your other vet.

I don't have any input or advice to offer you, but I'm glad you have a vet that respects your thoughts and supports you educating yourself. :)

Julie & Hannah

I don't know who the speaker was, if I missed her saying or what. She seemed to be saying that this would be a new release based upon the compilation of many studies that have been conducted over the last 2 years. (she was explicit that it was based upon many peoples research, mentioned west coast specifically also) She said she had heard Feldman speak a couple times, but didn't say if he is who presented this or if it was a panel discussion or what. She did take one look at molly and say 5 - 10mg to start we can adjust up if it is needed and not risk overdosing, which she felt would be a more dangerous situation.

She said, that she was aware of only 2 cases of adrenal damage to the point of Addisons caused by Trisolane, and that neither had occurred under her or at this hospital. Not 2 world wide or ever, just two that she had been aware of personally.

I looked to see if her email was on her business card but it wasn't, only the general hospital's email.

Next I speak to her I will ask her about who the speaker was. I did mention this board and that everyone here has in the past or is now dealing with Cushings and that all official release of statements or papers are followed carefully so that we will all be watching for that release.

It sounds like you are in good hands and the important thing is you feel you can relate to her and she has experience.

I am so glad you had the appointment!!!!

Oh, this is exciting! New research on our babies disease! I am sure Glynda will be all over this release and bring us all up to date. It is nice to have a resident Cushing's Guru! :D And now they are thinking to start low-dose treatment even with no signs, or mild signs, present, huh? Interesting....

It sounds like you have found a great IMS! I remember how wonderful it felt to find Dr. S in TN after our run in with an IMS or two who were awful so I am very happy for you.

Let us know how things go and what you decide to do!
Hugs,
Leslie and the gang

Thanks gang. I do feel good with this IMS who not only seems to be on board with the same things that I am, low dosing and exhaustive testing to verify results and rule out other possibilities.

Early treatment but Only if positive this what is causing the problems and the levels of all testing should be showing on the high side of cortisol rising, then treatment. At least that is what I understood her to be saying. I wish I knew who was issuing and when and where the statement/report. I'm sure when it does come out, Glynda will be all over it. :)

I found an upcoming continuing education lecture being offered by Dechra that may cover the information on treating without symptoms. This lecture is given by a veterinary dermatologist husband and an IMS wife team, entitled Cushing's Disease: Inside and Out. It's not available to us laymen and I can't see the five modules but they are entitled, 1) Perspectives, 2) Diagnostic Considerations 3) Treatment Options - What We Knew Then 4) Treatment Options - What We Know Now and 5) An Option for Managing Canine Hyperadrenocorticism. The what we knew then and what we know now sounds very interesting. The fact that a dermatologist is contributing is interesting because a lot of dogs with cushing's have severe skin and coat issues with few other symptoms. Even more interesting is that the husband dermatologist's practice is in Pasadena, CA. I had a little Shih Tzu foster dog who had horrific skin problems and few other symptoms, who was ultimately diagnosed and prescribed Vetoryl by another derm vet in that practice. Hmmm?

I have been able to find some of the older Dechra continuing educational material sessions so hopefully, I can find this one at some point. It'll drive me crazy until I find it and I suspect Marianne will be very interested too. Oh how I wish I had a veterinary friend. :(

Glynda

P.S. Sharlene, ask your vet if the names Rhonda Schulman, DVM, DACVIM and/or John Angus, DVM, DACVD sound familiar. One or both may have lectured at the veterinary conference your vet attended.

I'll make a note of that Glynda. I'm not sure when I'll be seeing the specialist again that I had this discussion with. Next I see my regular vet who will be the one to administer the LDDS test and follow up. She is suppose to consult with the specialist at this point. Well, unless she gives me any grief about starting Molly at the lower dose of Trilo, in which case, we could be seeing that specialist a lot sooner than expected. LOL

I'm thinking maybe keep an eye on that Journal of Vet Internal Medicine for any articles too.

I wonder about asking Dr. Peterson or Feldman if they know of anything coming out that will be different than their original recommendations of waiting on treatment. Have you emailed either of them before? Peterson I think has a web blog, not positive.

Sharlene

Sharlene