Intro. Kasey- 7 yo Lhasa MX- DX Cushings + Atypical

[KaseyzMom]

Hi Everyone-

Kasey and I are newbies here I have joined this group in hopes of becoming more educated about my Kasey's recent DX of Cushings + Atypical Cushings. We have been testing and retesting for a little over a year now and we finally were able to get a DX from the Univ Tenn adrenal panel we did last month. I will type a little about Kasey's history and the recommendation's from his vet who is an IMS. Right now, I am struggling to understand the vet's recommendations of Trilostane versus Lysodren so therefore we have not started any medications at this point. This is all new to me so I have absolutely no experience with this disease and little education about Cushings other than what I have read on the internet and on other forums such as this one. I am not one to take the advice of a doctor on a whim. I try my best to educate myself before I begin medicating my dog. So this is where I am right now. I will post some of Kasey's history the past year and if this isn't sufficient please let me know and I can post more. I do not know what the rules are on this forum as for posing test results. So please feel free to enlighten me.

If anyone with a similar DX would like to offer suggestions on their exp. with Trilostane versus Lysodren I would appreciate it. This is where my struggle is at the moment. I would also welcome any comments on diet, supplements, further testing, and even vet recommendations if you are in the SW FLorida area. I am considering a second opinion but just a regular vet won't do. Currently, Kasey is seeing an IMS at a local Animal speciality hospital. Thank you in advance for your help and assistance.

Janet and Kasey, Southwest Florida- USA, Lhasa Apso X, M/N, Age 7y 2 mos.30# of LOVE
08/11- routine bloodwork showed elevated kidney values indicating acute or chronic kidney failure further tests needed to DX;
09/11- Further tests kidney values returned to normal (deemed acute KF or lab error);
08/11- shows clinical signs of increased appetite and some increased panting;
09/11- UPC- normal; UCCR elevated- Further testing recommended -LDDS/ACTH;
10/11- Bloodwork Results: All normal except the following:
ALKP HIGH 261 U/L (Ref Range 5-131)
TP HIGH 7.7 g/dL (Ref Range 5.0- 7.4g/dL)
GLOB 3.6 g/dL (Ref Range 1.6-3.6g/dL) **High end of Normal
Anion Gap 32 mEg/LH (Ref Range 8-25mEg/LH)
T4 1.3 ug/dl (Ref Range 1.0 - 4 ug/dl) **Low end of Normal

11/11- Univ. of Mich- LDDS/ACTH Results- **Please note I converted these cortisol values from nmol/L units to ng/ml units for easy comparison to the Adrenal Panels Results at UTK** Conversion Factor 2.759
Cortisol Baseline: 79.376 ng/ml HIGH Ref Range (5.436 - 39.869 ng/ml)
Cortisol Low Dose Dex 4H 6.161 ng/ml Ref Range (0-10.873 ng/ml)
Cortisol Low Dose Dex 8H 7.973 ng/ml Ref Range (0-10.873 ng/ml)
Cortisol 1hr Post ACTH 203.696 ng/ml HIGH Ref Range (79.739 - 199.347 ng/ml)

Comments: "Here is a mixed message with normal suppression of cortisol but a slightly excessive response to ACTH stimulation. One possibility is that this dog does not have hyperadrenocorticism and the elevated results reflect a stress response to non-adrenal illness. Another is that this dog has pituitary dependent hyperadrenocorticism where the primary tumor remains responsive to this dose of dexamethasone. Any decision regarding a DX of hyperadrenocorticism will weigh heavily on the confidence of clinical signs."

11/11 Abdominal Ultrasound - all normal except two nodules on Spleen;
11/11 Splenectomy performed; histology report- Nodules were Benign (Splenic Nodular Lymphoid Hyperplasia- NO evidence of Neoplasia) Also Liver Biopsy- Mild to Moderate Glycogen Accumulation- with mild portal hepatitis- NO Neoplastic changes found in liver;
11/11- Bloodwork all normal except:
ALP 526 U/I HIGH (Ref Range 0-140 U/I)
ALT 255 U/I HIGH (Ref Range 0-120 U/I)
Glucose Mildy 126 mg/dl HIGH (Ref Range 75-125 mg/dl)
Triglycercides 157 mg/dl HIGH (Ref Range 30-130 mg/dl)
RDW 19.7 % HIGH (Ref Range 12-17.5%)
PLT 87 u/l LOW (Ref Range 200-500 10~3/ul
07/12- UT adrenal panel recommended and performed;
07/12- Extensive Bloodwork-
ALT 125 U/L HIGH (Range 12-118 U/L) note lower than 11/11 BW @255
ALP 481 U/L HIGH (Range 5-131 U/L) note lower than 11/11 BW @526
GLU 158 mg/dl HIGH (Range 70-138 mg/dl) note higher than 11/11 BW @126
Calc 11.7 mg/dl HIGH (Range 8.9-11.4 mg/dl)
Platlet Count 444 uL HIGH (Range 170-400 uL)
Lymphocytes 34% HIGH (Range 12-30%)
Neutrophils 58% LOW (Range 60-77%)

Thyroid Panel Normal;
Diagnosis:
08/12- Cushings- due to Significant Increased Adrenal function shown on University of Tenn. Panel
UTK Adrenal Panel Results below:
Cortisol:
Pre 139.20 ng/ml (Normal 2.0-56.5 ng/ml)
Post- 169.3 ng/ml HIGH (Normal 70.6-151.2 ng/ml)

Androstenedione: Pre 3.01 ng/ml (Normal .05-.36 ng/ml)
Post 3.81ng/ml HIGH (Normal .24-2.90 ng/ml)

Estradiol: Pre 59.2 pg/ml (Normal 23.1-65.1 pg/ml)
Post 65.2 pg/ml (Normal 23.3-69.4 pg/ml)
**Note (both pre & post Estradiol is on the high end of normal)

Progesterone: Pre 3.13 ng/ml (Normal .03-.17 ng/ml)
Post 3.50ng/ml HIGH (Normal .22-1.45 ng/ml)

17 OH Progesterone: Pre 1.47 (Normal .08-.22 ng/ml)
Post HIGH (Normal .25-2.63 ng/ml)

Aldosterone: Pre 347.6 pg/ml (Normal 11-139.9 pg/ml)
Post 474.3 pg/ml HIGH (Normal 72.9-398.5 pg/ml)

** Per UTK these results indicate SIGNIFICANT increased adrenal activity

08/12- IMS recommends starting Trilostane- 10 mg 2 x day and ACTH in 10 days after starting, then testing monthly until stable and testing every 3 months going forward. Vet Reasoning- “Lysodren results in the destruction of the adrenal glands and is a higher risk medication"

DIET: Homemade chicken, rice and green beans or mixed veggies, mixed with some dry kibble from time to time, Vit- Pet Tab Plus, treats- such as milkbones, animal crackers, frosty paws, vanilla wafers, ginger snaps

[labblab]

08/12-
Cortisol - 139.20 pre 169.3 post HIGH
Androstenedione- 3.01 pre 3.81 post HIGH
Estradiol- 59.2 pre 65.2 post (both pre & post on the high end of normal)
Progesterone 3.13 pre 3.50 post HIGH
17 OH Progesterone 1.47 pre 1.74 post HIGH
Aldosterone 347.6 pre 474.3 post HIGH
** Per UT these results indicate significant increased adrenal activity

Hello and welcome!

I apologize that I have only a moment to post right now, but can you please give us the units of measurement for the UTK adrenal panel results, and also the "normal" reference ranges?

I am particularly wondering about the cortisol result, because I'm guessing that the "post" number that is listed (169.3) is in a unit of measurement that would translate to 16.93 ug/dl (a unit with which we are more familiar). And if so, that would typically be at the upper end of the normal range rather than abormally high. So I'm curious to see what UTK's listed normal range actually is. I believe that "whether" or "how high" the cortisol is elevated would have a bearing on the treatment recommendations.

Also, aside from some increased appetite and panting, does Kasey exhibit other overt Cushing's symptoms? Has the appetite/panting increased over time, or stayed about the same?

Thanks in advance for your answers!
Marianne

[KaseyzMom]

Thanks Marianne
I have updated Kasey's Adrenal tests to show UM and Normal ranges per the UT report. The cortisol is listed in UM ng/ml and the normal range for Post is 70.6-151.2 ng/ml...Kasey's post result is 169.3 ng/ml so they flagged it as being HIGH.

The only clinicial signs Kasey exhibits at this time is the heavy panting but it is not constant and he has shown no increase in panting in the last 12 months when we started all of the testing, Kasey has always been a hearty eater and some of this is my fault so there is no increase over the last 12 months. We have been trying to get his weight down so he is eating less now and fewer treats. There has been a very slight increase in water intake and potty but he does not get us up in the middle of the night and we have not seen any evidence of accidents in the house. My hubby is home with him and our other dog all day long so he is closely monitored. He does seem to retain fluid in the abdomen area but he is also overweight so it's hard to say that it is 100% attributable to Cushings, no hair loss to report, he is groomed every 5-6 weeks, he does chew at his paws on occasion esp. when the hair starts to grow out and we have to keep ear drops in his ears regularly due to his long floppy ears retaining moisture and water after baths but we use the no steroid label of course.

Thank you for your time.

Janet and Kasey

Hello and welcome!

I apologize that I have only a moment to post right now, but can you please give us the units of measurement for the UTK adrenal panel results, and also the "normal" reference ranges?

I am particularly wondering about the cortisol result, because I'm guessing that the "post" number that is listed (169.3) is in a unit of measurement that would translate to 16.93 ug/dl (a unit with which we are more familiar). And if so, that would typically be at the upper end of the normal range rather than abormally high. So I'm curious to see what UTK's listed normal range actually is. I believe that "whether" or "how high" the cortisol is elevated would have a bearing on the treatment recommendations.

Also, aside from some increased appetite and panting, does Kasey exhibit other overt Cushing's symptoms? Has the appetite/panting increased over time, or stayed about the same?

Thanks in advance for your answers!
Marianne

[Squirt's Mom]

Hi Janet and welcome to you and Casey!

My Squirt is Atypical and we are a Lyso house. There is a fair amount of controversy about the use of Trilo vs Lyso for Atypical pups. Studies have shown that most dogs with Cushing's will have elevations in the intermediates along with the elevated cortisol. Studies by UTK have also shown that Trilo will cause further elevations in the intermediates while Lyso doesn't.

It might help to understand the distinction between Atypical and true, or conventional, Cushing's. In Atypical only the intermediates, some of all, are elevated BUT the cortisol is normal. If the cortisol is also elevated, then the pup is considered to have true Cushing's, not Atypical, even if some or all of the intermediates are also elevated. The key is the cortisol. Normal cortisol means Atypical; elevated cortisol means conventional Cushing's. Since Roxy's cortisol appears to be elevated, she would be considered to have true Cushing's, not Atypical.

If the cortisol is elevated then that becomes the prime focus of treatment and many vets simply prefer Trilostane (Vetoryl), period. The reasoning behind this is sometimes faulty. Trilo has the reputation of being "safe" - it is no safer nor more risky than Lysodren. They both have the exact same potential risk factors and the exact same possible negative side-effects. You vet telling you that Lyso will destroy the adrenal but Trilo won't, is simply incorrect. Trilostane can and does cause complete adrenal necrosis just as Lyso can (reading the manufacturer, Dechra's, brochure will show that clearly). Both are very powerful drugs and protocols need to be followed closely. What makes Trilo seem safer is the very short life in the body. Trilo is leaving the system in 2-12 hours while Lyso is just reaching it's peak at 48 hours. So IF there is a problem, the Trilo is out of the body much sooner than the Lyso...but the risks are the same for both drugs.

For me, the choice was simple. I trust the experts at UTK. They are the world leaders in research on Atypical. They prefer Lysodren for Atypical pups so that is what I chose. For about three years, Squirt was on only the melatonin and lignan treatment recommended by UTK and her intermediate levels steadily came down. Last summer her cortisol started to rise as well so we put her on a maintenance dose of Lyso. She has done well on this until recently and her latest UTK panel shows some increases so her regime will be changed.

I hope this has helped a bit and not caused further confusion for you!

I'm glad you found us and look forward to learning more as time passes!
Hugs,
Leslie and the gang

[labblab]

Hi again, Janet.

Thanks so much for the additional info. If I can trouble you one more time, by any chance do you have the actual numerical results for the ACTH/LDDS testing performed back last fall? You've described the results as being "mixed," and I'm curious as to how they turned out, and also I'm curious to compare Kasey's newest ACTH cortisol response to the test performed last fall.

As Leslie has said above, if a dog exhibits abnormally elevated cortisol, the conventional diagnosis is simply "Cushing's" regardless of the status of the other intermediate adrenal hormones. "Atypical" is reserved for situations where the cortisol is normal but other intermediate hormones are elevated. In Kasey's case, the elevated cortisol per UTK's "normal" range places her outside the category of "Atypical."

In fact, from what I have read, virtually ALL dogs who exhibit elevated cortisol will also exhibit elevations in other adrenal hormones as well. So to that extent, I think my own concern about Kasey's situation differs somewhat from that of Leslie. If Kasey does truly suffer from elevated cortisol secondary to Cushing's, I would shift my focus away from the intermediates altogether and I would feel comfortable with treatment using either trilostane or Lysodren. I do think there are genuine differences beteen the two drugs, and I can come back and elaborate on that at another time. But the bottom line is that I think that trilostane would be an appropriate treatment for Kasey, and it sounds as though your IMS is following one of the newest trilostane treatment protocols: twice-daily, low-dose. Here's a research study that discusses possible benefits of dosing in this manner:

http://www.k9cushings.com/forum/showthread.php?t=4442

Having said all that, my greater reservation relates to the true source of the adrenal elevations -- do they really stem from Cushing's at all? Although above the norm, Kasey's cortisol shows only a minor elevation. The only overt symptoms are some panting and hearty appetite. The liver enzymes have all actually decreased without any treatment whatsoever. They are still abnormal, but why have they come down all on their own if Cushing's is the culprit? So to summarize, I'm not troubled by the intention to treat using trilostane if Kasey truly has Cushing's. But I am troubled by the question marks in her symptom profile. Are there enough legitimate symptoms to validate a Cushing' diagnosis? That's one of the reasons why I'm really interested to see those earlier test results and to compare any changes.

Marianne

[molly muffin]

Hi Janet,

I just wanted to stop in and say hello and welcome to the forum. Marianne and Glynda are much more knowledgeable when it comes to the lab tests, their meanings and treatment than myself.

Personally I'm still in the diagnosis phase of trying to figure out what is going on too. Positive one test, negative another test, ALT's, ALP's up and down. It's all very frustrating, so I can very much relate to what you are going through trying to figure this out and learn as much as you can.

You have probably found yourself up late into the night reading everything you can find about anything that might relate to what Kasey is going through. I know, I have and do the same thing.
I sincerely applaud endeavors to Know in order to make the best decisions possible.

Again, welcome to you and Kasey
hugs,
Sharlene and Molly Muffin

[KaseyzMom]

Hi again, Janet.

Thanks so much for the additional info. If I can trouble you one more time, by any chance do you have the actual numerical results for the ACTH/LDDS testing performed back last fall? You've described the results as being "mixed," and I'm curious as to how they turned out, and also I'm curious to compare Kasey's newest ACTH cortisol response to the test performed last fall.

Having said all that, my greater reservation relates to the true source of the adrenal elevations -- do they really stem from Cushing's at all? Although above the norm, Kasey's cortisol shows only a minor elevation. The only overt symptoms are some panting and hearty appetite. The liver enzymes have all actually decreased without any treatment whatsoever. They are still abnormal, but why have they come down all on their own if Cushing's is the culprit? So to summarize, I'm not troubled by the intention to treat using trilostane if Kasey truly has Cushing's. But I am troubled by the question marks in her symptom profile. Are there enough legitimate symptoms to validate a Cushing' diagnosis? That's one of the reasons why I'm really interested to see those earlier test results and to compare any changes.

Marianne

Hi Marianne-

Thank you for your replies. I have edited my initial post to include the LDDS/ACTH test results from Univ. of Michigan performed 11/2011. I also added LOW and HIGH results to Kasey's bloodwork for dates 10/11, 11/11 (pre surgery) and the most recent done on 7/12.

You are correct by noticing that some of Kasey's liver values seemed to have dropped on their own. I am not sure how or why but I can only note that since the 11/11 blood work was done we had the spleen removed, and we changed most of his diet to homemade and trying to feed him less commercial dog treats. I spoke to the IMS again yesterday evening and I asked her why would we only treat cortisol and not the other sex hormones and her reply was that there is no hard medical evidence that the elevated hormones can be tied to a medical problem or a disease. I also expressed my concern that some of the other levels might increase with the use of the Trilostane and again she said that is no real hard evidence that this would cause any real issues. I guess I am just nervous about starting to medicate my baby who for the most part seems pretty healthy on the outside for a 7 year old.

Can you suggest any supplements for Kasey. We only give him the Pet Tab Plus at this time. Is this enough? What about homemade treats? I forgot to ask her if we should still continue Kasey on a weightloss diet. He isn't really losing any weight and I am concerned about trying to reduce his portions any further. I am hoping that once we start treatment that he will lose some of the excess pounds?

Thanks-
Janet and Kasey

[KaseyzMom]

Hi Molly Muffin and Squirt's mom, thanks for the warm welcome and your replies. I will keep everyone posted once we decide on a treatment plan. I hope you and your kiddo's are doing well.

Janet and Kasey

[KaseyzMom]

Hi All-

We are in the process of getting Kasey started on the Trilostane as recommended by his IMS. The initial dosage will be 10 mg/ 2x day for 10 days and ACTH test to follow.

Does anyone have any suggestions on purchasing the initial dose local verus online? The vet price is quite expensive and obviously we need to be sure that this med is going to work for our pumpkin...Any ideas or suggestions would be appreciated.

Also, the vet and I didn't discuss this-- but I have seen some postings recommending having Prednisone on hand in case of over control?

Thanks for helping us get started. I am not looking forward to this....(Momma is a bit worried)..


Hugs,

Janet and Kasey
SW Florida
7yo Lhasa Mix, Male/N 30#
8/12- Dx Cushings

MODERATOR NOTE: Your post concerning purchasing Trilostane has been merged with Kasey's original thread. We like to keep all the info about each pup in their own thread. That way it is easy to look back through the history if needed. Thanks!

[lulusmom]

Hi Janet and a belated welcome to you and Kasey,

I did a quick scan of the test results you posted and you can disregard everything you saw prior to the splenectomy, including the low dose dex test. The only diagnostic test I see after that is the UTK panel and in my opinion, cortisol is below borderline for purposes of diagnosing typical cushing's. With panting being Kasey's only symptoms, I absolutely would not initiate treatment of trilostane or lysodren. I personally wouldn't choose to treat with anything but if there were more symptoms, I'd probably give melatonin and lignans a try.

Internal medicine specialists are the most knowledgable veterinary professionals but unless you have not provided us with everything, I have real reservations about your IMS. What is it about Kasey that your IMS feels an urgency to treat in the absence of the usual symptoms and borderline cortisol? Maybe I'm missing something here and if I am, I'm sure somebody will let me know.

Glynda