Vet asked if I wanted to test for Cushings? (15 y/o cairn terrier) Hamish has passed

[mcdavis]

Sorry for the long post but I took a look through some others and see that people like an intro / detail so they can provide the best advice. Also I tend to waffle when I'm worried / scared so I have bolded my questions in case it helps.

I have a 15 year old cairn terrier, Hamish, who suffered some stomach upsets at the beginning of the year (caused by Blue Buffalo food). The vet prescribed RC Sensitivity and we didn't realise just how low calorie it was - result was that Hamish lost quite a bit of weight however he was still healthy and walked 3-4 miles most days.

The vet noticed the weight loss and suggested we do a blood panel (his first ever) to check his kidneys - they came back fine, however his liver values (ALT / ALKP) were elevated. The vet prescribed a course of Milk Thistle and Zentonil Advanced then retested 2 weeks later at which point the results were higher. By this point he had started to regain weight thanks to the introduction of Fromm Gold.

That was back in July and, after continuing with the Milk Thistle plus SAMe, we had another liver panel done today. His ALKP was unchanged whilst the ALT had dropped slightly but was still higher than it should be. Here is the history of the liver values:

early Jul late Jul mid Aug today
ALT 206 382 337 215
ALKP 317 412 434 416

She said his BUN was also high (10.9 when range is 2.5 - 8.9) but other kidney values OK and thought it might be high protein in his food. She said I should stop feeding the Fromm but it's only 23% protein (RC is over 21%) and I prefer him to have some good quality food (it's around 20% of the food I give him).

She then asked if I wanted to get him tested for Cushings using the ACTH test and this is where I really wanted to get some advice. There are a lot of symptoms that he has to a greater or lesser extent that seem to indicate Cushings but can also be caused by something else, plus I realise that he will not exhibit all of them, and some may or may not be normal for a dog of his age:

- there have been 3 or 4 instances where he's pee'd indoors / could not hold it

- we feed him 3 meals a day with the majority of the food in the evening and he drinks quite a bit in the evening but barely anything throughout the day

- he loves his food and went through a period of inhaling it (until we got him a slow feed bowl), and when he was 10 we tried feeding him senior dog food which made him ravenous (too low protein / calorie) so we went back to adult food and all was fine

- in the Summer it was very hot so walking for more than 10 minutes caused him to pant, however since it has cooled down he will walk 2+ miles and no panting, however he will only walk if there are things to sniff, etc. If there is nothing of interest he will trail behind and try to go home.

- he sleeps a lot during the day, but then he has always slept if there's nothing much going on

- the vet said he had a pot belly look, however I'm not entirely sure what this means, and it probably isn't helped by the fact that he has 2 large fatty lumps on his abdomen (he has had them for 5+ years and they have been checked out)

- his weight fluctuates slightly but he is back to the normal range (6.5 - 7kgs)

- his fur has thinned out but still grows quite fast

- last Winter he suffered from arthritis and weakness in the back legs however he's currently not showing any signs of arthritis (cortizol dulling the pain?)

I think I should get him tested but wondered if it should be the ACTH or LDDS? Also having read about the need to watch him very closely when first introducing meds I need to delay treatment until Jan so should I delay the test until Jan so that the vet has the most up to date info?

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[jmac]

Welcome to you and Hamish!

I am sorry for the circumstances that brought you here, but you have found a wonderful group! We were all scared and worried when we came here, so we totally understand how you're feeling. I am so glad you found us because you will get wonderful advice and support!

First, thanks for giving us so much info. about your dog. If you could also post the normal reference range for the ALKP and ALT, that would be great. Cushing's is difficult to diagnose and often requires more than one test. There are some symptoms that many Cushing's dogs have, such as increased drinking and urinating (sometimes leading to accidents in the house), ravenous eating, usually they gain weight, they frequently have a pot belly, are often hot/pant a lot, have thin hair or hair loss and slow regrowth, and rear leg weakness;however, not all cases are the same.

Others will be along soon to advise you and answer your questions. In the meantime, please take a look at the resources section of the website to learn more about Cushing's.

Again, I'm so glad you found this site. W are here to help, so please don't hesitate to ask questions.

Julie & Hannah

[frijole]

I can tell you've done some homework. YOu are right, there are potential cushings symptoms but they can also be signs of other issues which is why getting a true diagnosis usually takes multiple tests.

The liver enzymes you posted, particularly the alk phos are signs of cushings but they really aren't that high. cush dogs often have alk phos between 1000 and 2000. That said, better safe than sorry.

Not sure if your dog still suffers from weight loss but that isn't a sign of cushings - our dogs are plump. They inhale food, drink BUCKETS not lots of water.

Rather than spend money on the ACTH or LDDS tests I'd start out with a urine test called UC:CR. It can rule OUT cushings with a degree of certainty and its' cheap and fast!

Note that vets no longer treat cushings unless the symptoms are pretty blatent so there is no rush to treat.. and therefore no rush to test unless you want to rule it out.

Regarding the tests - the LDDS is typically a starting point as it can tell you if it's cushings and sometimes what type of cushings. The problem is that it can also yield false positives when other non adrenal illnesses are present... happened to one of my dogs. I'd still start there and if it was positive I'd still do the acth test or an abdominal ultrasound to get a good look at what's going on. That's my 2 cents! Kim

[labblab]

Welcome from me, too!

I want to "second" Kim's suggestion that your best first step may be the UC:CR urine test. As she says, it cannot provide a definitive diagnosis, but it can help rule out Cushing's before you get involved in more expensive testing. If you do proceed with blood testing, I believe I would indeed wait until January since you know you would not be starting treatment until then, regardless.

As far as which blood test to request, there are pros-and-cons to both the ACTH and the LDDS. As Kim says, a benefit of the LDDS is that a positive result can also sometimes help differentiate between the two forms of Cushing's. The ACTH cannot do that. On the other hand, the ACTH is less likely to return a "false positive" if a dog is suffering from a different illness other than Cushing's. So for a dog with questionable symptoms for whom you'd prefer to err on the side of caution before beginning treatment, the ACTH may be the preferable test. The downside, though, is that the ACTH is also more likely to miss properly identifying a dog who truly does have Cushing's. So the ACTH is the more "specific" test (less likely to give a false positive), while the LDDS is the more "sensitive" test (less likely to give a false negative). Confusing enough??

For what it's worth, here's a decision-making chart that I've always found helpful in deciding which test to start off with. It is a set of testing recommendations given by Dr. Rhett Nichols :

Final screening recommendations

What if the patient has only biochemical changes and no or mild clinical signs suggestive of Cushing’s syndrome?
The ACTH response test may be the preferred test. In these patients, it may be better to miss a diagnosis of HAC [Cushing's] in early stages by using a test with lower sensitivity than falsely diagnose HAC by using a test with lower specificity.

Is nonadrenal illness present?
The LDDS and ACTH response tests can give false positive results in the face of nonadrenal illness, but the LDDST is more likely to do so. Thus, the ACTH response test is recommended when nonadrenal illness is present.

What if the patient has moderate to severe clinical signs of HAC and has no known nonadrenal illness?
The LDDST is preferred as the initial screening test. This test has a higher sensitivity as compared to the ACTH response test.

Is an AT [adrenal tumor] suspected?
The LDDST is recommended because the sensitivity of the ACTH response test for HAC caused by an AT is only 62%.

Has the Cushing’s syndrome suspect been treated with a cortisone
preparation?
The ACTH response test is the preferred test if an animal has a definitive or questionable history of receiving exogenouscorticosteroids and has signs compatible with HAC...

Since Hamish does not seem to have symptoms that are "screaming" Cushing's, I might choose to start off with the ACTH myself. If it comes up "positive," that would be a more reliable indicator than a positive on the LDDS that he really does have Cushing's. Plus, if you do plan to start treatment, you would probably want an ACTH beforehand, anyway, as a frame of reference for the subsequent monitoring of the drug's effectiveness. An abdominal ultrasound is also an excellent diagnostic tool when used in conjunction with either blood test. If you proceed with the ACTH, the ultrasound can be helpful in differentiating the type of Cushing's since the blood test alone cannot provide that info.

Marianne

[mcdavis]

Wow. First of all Thank You for the information - it sounds like starting the testing process in January is the way to go, however I'm trying to research as much as possible as my vet's approach is 'I will make suggestions but you need to tell me what you want to do'. Whilst this may not work for everyone it does actually work for me because I prefer to understand the options and be involved in the decisions about Hamish's care.

To answer your questions:

The reference range for the ALT is 10-118 (Hamish currently 215) and ALP is 20-150 (Hamish currently 415).

He has gained some weight since the stomach upsets earlier in the year but that was because I was deliberately giving him extra food however we are now back to normal portions and his weight is just fluctuating slightly (up and down) which I think may depend on when we weigh him (we have been using the WiiFit so we have some history).

When I was brushing him this morning I noticed that his fur was a bit dull, however I can't work out if I'm trying to play down the symptoms because I want him to be OK or if I'm exaggerating them because I don't want to neglect him / not treat him if he is ill. It's kind of frustrating isn't it.

[molly muffin]

Hi and welcome. Isn't that just the cutest picture of Hammish!

I'd definitely do the UC:CR.
As for the others, everyone has the tests that they like to do. If it came to starting Hammish on medicine, you'd definitely want an ACTH test first, so you have a baseline. I like the LDDS because we've had positive tests on the ACTH and then complete suppression on the LDDS. (negative) I don't think we are even close to being the norm though, so in the end, before starting anything, I'd probably do both and that is what I did. The UC:CR though is easy to do, and it Can rule out cushings, it just can't definitely confirm it, so if that came back positive then you'd move on to another test.
The ultimate before doing anything is an ultrasound if possible as that can show you what is going on inside him.
So, for the moment and you can do this any time really, no need to wait till January, since if the UC:CR came back positive you'd want to be ready to do another test in January anyway and this one won't break the bank so to speak.
Reading up on everyone's stories is good and going through the fact pages.
Cushings is horribly hard to diagnose as the others have said, and it requires multiple tests to make sure you have the right diagnosis too. Other problems can cause false positives, so you have to be aware of that and ready to do a process of elimination.

Sharlene and Molly Muffin

[mcdavis]

So from everything I've read it sounds like I should have the UC:CR done first, instead of jumping straight into the more major testing.

I'm just wondering why my vet didn't suggest it as an opportunity to say No or Maybe to Cushings that doesn't cost much seems like a very good first step

I was also interested to read about any history of treatment with cortisone - Hamish had a single injection around March this year to help his arthritis - would I be correct in thinking that this would be unlikely to have any long term impact?

[labblab]

You are correct that a single steroid injection in March would not be responsible for Cushing's symptoms now.

As far as the UC:CR, we've been told by at least one endocinological specialist that a test run on only a single urine sample may have questionable validity. He suggests that owners obtain a sample on three successive mornings, and that the pooled sample then be analyzed. You want to collect the samples at home, where your dog will not be stressed. It should be the first pee of the morning, and the pooled sample should be refrigerated until it is taken in for analysis. It isn't always easy for owners to collect urine samples from their own dogs, but if you're willing and able to collect the urine it is a reasonable test with which to begin the diagnostics.

Marianne

[cheydogger]

Hi There-

I am not an expert on Cushing's yet, but as Marianne said, Hammish is not screaming Cushing's like most of the pups you read about on this forum. He does have a few minor symptoms and blood results. I would have to agree with the majority to start off with the UC:CR. the other tests tend to get quite expensive especially since more than one is often needed, plus ultrasound, etc. if he does test positive on the UC:CR, then I would do the ACTH or LDDST closer to the time you would treat him to have a more accurate starting point.

Did the vet do a urinalysis to check for UTI?

I am truly impressed that Hammish can still walk 3 miles at 15 years of age!!. Yay Hammish! This again isn't typical for a full blown Cush dog. They can be very exercise intolerant

You are part of Hammish's treatment team, so your vet should take your input and recommendations into consideration.

I will be interested to see what the vet says or what his results are of whichever test/s he has done.

Good luck!

Ro and Chey

[mcdavis]

Thanks for all of the replies and information and sorry for not replying sooner - I've been reading as much as I can on the forum to learn more about symptoms and possible tests. I feel bad that it's so one-sided at the moment and I can't offer any help to other posters.

Based on what I've learnt I'm a bit concerned that my vet's approach has been 'dog has higher than normal ALKP so we'll assume Cushings and start running expensive tests'.

Ideally I would like her to run through the Cushings symptoms and understand if he is experiencing them, then discuss possible causes (Cushings or ???) based on that information and which tests should be run to rule out or identify / confirm those causes.
If Cushings is likely then I will insist we start with the UC:CR test, instead of jumping straight to the ACTH (which they tell me will cost $300 - $400 - does that sound right??).

So, I have started a spreadsheet to track his daily water consumption (currently around 10-12oz - he is around 14lbs and I read 0.5-1 ounce/lb is normal) and once he's been to the groomers I'm going to take some pics of his tummy to see if he really does have a potbelly (or if it's his fatty lumps).
I'll ask the groomer what she thinks of his fur / skin - she did comment that his fur was thin last time but implied it was an age thing, so I will ask her how it compares to other dogs his age.
I'm also using the WiiFit to track his weight and I'm logging his daily exercise and continuing to give him Milk Thistle and SAMe.

I'd really appreciate your thoughts on whether or the above sounds like a reasonable plan? Have I missed anything really obvious?