Undecided about treatment for Duke 10 1/2 yr. old Bichon

[sheila]

Hi, My name is Sheila and Duke is my 10 1/2 year old Bichon who is believed to have Cushings. We have just had the initial blood test which indicates Cushings and now need to have a urinalysis and another day long blood test. (Forgive me for not knowing all the terms-this is new to us.) Over a year ago, when we had Duke at the Vet for a digestive issue, I asked about his distended belly and constant appetite..which the vet thought was the result of his digestive issues. Those issues cleared up but his appetite, belly distention, constant thirst did not. Six months ago, had him back at the vet for a hot spot and the dr. mentioned Cushings but said they do not usually recommend treatment for a dog as old as Duke. I did a little research and the info I found seemed to support her statement. Well, back to the vet last week for vaccines and saw a different vet (same clinic) who advised us to get Duke tested. Had the initial test and results point to Cushings. The vet called and ran through the next steps (tests) and treatment. I guess my main question is if any dog who has gone through treatment lived very long after that..and at what quality of life? The more I read, the more confused I get. Read a couple articles that said dogs rarely live longer than 2 years after being diagnosed with Cushings -Whether they are treated or not. My biggest concern is quality of life for whatever time Duke has left. I am a realist and I accept that no matter what, the day will come that Duke will leave us (if I don't leave first!) I would really like to hear from anyone on their thoughts and experiences, especially if your dog was diagnosed and began treatment longer than 2 years ago. Thanks

[Harley PoMMom]

Hi Sheila,

Welcome to you and Duke! That 2 year statement is not true, we have many dogs on the forum being treated for Cushing's that have already surpassed that. Cushing's is not a death sentence for a dog, it is a very treatable disease and many dogs can live their normal span with resolution of the symptoms and do have a good quality of life.

Now, if you could get copies of all test/s that were done on Duke and post those abnormal results here that would be a great help to us. We are especially interested in the results of all diagnostic tests that were done to diagnose Duke's Cushing's.

I was wondering if you could tell us more about Duke, such as how much he weighs, and is he taking any other herbs/supplements/medications? Does Duke have any other health issues?

We are here to help in any way we can, so do not hesitate to ask all the questions you want.

Hugs, Lori

[Renee]

I'm also jumping in here to dispel the 2 year life-span myth.

I do believe that 2 year myth is rooted in truth, in that many people choose not to treat cushings, or they find out about it so late in the game that too much damage has been done.

Your little Duke is just 10.5 years, which for a little dog, is really not that old at all. I would completely put the 2 year doomsday out of your head!

Take a stab at answering Lori's questions and we will help you through this journey!

[sheila]

Thanks Renee'! He is going for his acth stimulation test tomorrow and will also have the urine test. Will get and post his initial blood test results tomorrow too. This site has helped us so much more than all of the other research and reading I've done about Cushings...I was getting so confused and conflicted. We are going for it..just wish we would have known about Cushings when his symptoms started 18 months ago..hopefully the disease hasn't done too much damage. Thanks for the encouragement!

[sheila]

Thanks Lori! Duke has had lots of skin and "growth" issues over the years. We've had 3 masses removed-benign and he gets these wart like things that seem to go away on their own. Vet says this is common with white dogs. He weighs 30 lbs now. He has always been large for the breed weighing in at over 20 lbs most of his adult life, but has packed on the last 10 in the last 18 months. We had noticed the distended belly, lethargy, and difficulty getting up stairs then, and mentioned it to the vet. Since he was being treated for a digestive issue she kind of blew it off. He improved but the belly kept growing, he started acting like he was starving all the time, drinking a lot and opting to sleep on the cool bathroom tile floor than the bed, and excessive panting. The first vet that mentioned Cushings about 6 months ago said they do not normally test for or treat dogs as old as Duke due to the cost and side effects of treatment. We just saw another vet last week for his vaccines and she had a totally different attitude. The only test we have had done so far is the initial blood test which indicates he may well have Cushings. Now she recommends we have a urine test and another blood test, where he will stay at the vets all day to be tested periodically after a shot. This is all so new to me. I have to take a urine sample in tomorrow and will pick up the results from his initial blood test then. I can't say money is no object..it is, but more important to me is for Duke to be as comfortable as possible. Duke hates going to the vet and has only been away from us overnight once when he had surgery. When I started reading that dogs didn't live 2 years past diagnosis, I debated about whether we should even have the other tests. The idea of creating so much stress and confusion for him in the last year of his life seemed worse than letting the disease run it's course...to know that there's a possibility of getting it under control and him being comfortable makes a big difference. I will post the results of the initial test when I get them tomorrow. Thank you so much.

[camval1]

I don't think the 2 year thing is true.

I've read many stories of Cushing's dogs living to their normal age range.

The urine test they want you to do is probably the Urine Cortisol Creatinine Ratio test (UCCR for short). This will tell the vet if there is an excessive amount of cortisol in the dog's system, which is what Cushing's is.
The UCCR test will NOT specify what is happening or why. Other tests will need to be done to answer those questions.
They're looking for a number that is less than 32 or 36 (can't remember the exact number). Anything over that and they'll want to do more tests.

If the UCCR is high, then the next test is the Low Dose Dexamethasone Suppression test, or LDDS. This is the all day test. They'll take a blood sample in the morning when you drop him off. Then they give a shot of dexamethasone. At the 4 hour mark, they'll take a blood sample & measure cortisol levels. And they'll take another blood sample at the 8 hour mark and measure cortisol levels again. In a normal dog, the cortisol levels should be high at the 4 hour mark but back to normal at the 8 hour mark. If it's high at the 8 hour mark, then you'll get an official diagnosis of Cushing's.

The next test will probably be an ultrasound of the adrenal glands & liver. They're looking for tumors or growths on the adrenal glands and size of them as well. This test will help them determine if it's adrenal dependent hypercorticism (ADH) or pituitary dependent hypercorticism (PDH).
Tumors or growths on the adrenals = ADH. No tumors or growths on the adrenals = PDH.
In some cases, ADH can be treated with surgery and the dog is cured. But, according to my research, it's a rarer cause of Cushing's.

Much more common is the PDH. PDH can only be treated by medication. It can't be cured. PDH is caused by a micro adenoma on the pituitary gland. These little micro-tumors on the pituitary gland are typically not malignant.

Once they do the ultrasound, they'll know exactly what they're dealing with.

I would ask that you have them run an ACTH Stim test on him before you start treatment. You want, more like, NEED, a baseline for comparisons sake as you begin treatment.
An ACTH Stim test stimulates the adrenals to release their cortisol. They measure the amount of cortisol before the stimulating medication and after.

Then you'll have your choice of 2 different treatment meds. Either mitotane (Lysodren) or trilostane (Vetoryl). Mitotane will require a large loading dose up front and then a reduction to a maintenance dose once the cortisol levels are in control.
Trilostane doesn't work like that. You start off on a dose (no more than 1 mg per pound to start; find another vet if he/she says otherwise) and then adjust up or down based on subsequent ACTH Stim test results. Once the optimum dose is found, your dog will stay on that dose unless symptoms reappear or a future Stim test suggests a change is needed.

I hope this helps.
I just went thru all this with my Airedale. He was diagnosed this past November, started treatment at the beginning of December, and just had his 2nd Stim test, which resulted in great numbers.
In 2 months time, I went from clueless on the subject to an expert. I bet I know more than a lot of vets about the topic now. Not that I ever wanted to.

Good luck & let us know how his tests go.

[Harley PoMMom]

If that urine test is the UC:CR, than I would not have this test done, all this test does is look to see if excess cortisol is spilling into the urine, if there is than another diagnostic test, such as the ACTH stimulation or LDDS, needs to be done. The UC:CR is generally used as an initial test, if the results show that no excess cortisol is in the urine, Cushing's is very unlikely and other causes need to be looked at for the dog's clinical signs.

Also with the UC:CR, 3 urine samples should be taken and pooled together so the accuracy of the test can be higher.

This excerpt is from Dr Bruyette, who is considered an expert in canine Cushing's:

Yes. The same would apply when looking at urine cortisols in the initial diagnosis of Cushings. Ideally 3 morning pooled urine samples collected by the owner at home and refrigerated
Dave

Now, if that urine test is an urinalysis, then yes, I would have that done. Most dogs with Cushing's have diluted urine (low specific gravity), which will show up on an urinalysis. UTI's are common in dogs with Cushing's, however, when a dog does have a low specific gravity a regular urinalysis may not be sensitive enough to pick up any bacteria, so an urine culture and sensitivity test is needed. The urine culture and sensitivity test will show exactly what bacteria is growing in the urine and than the appropriate antibiotic can be prescribed.

A confirmed diagnosis for Cushing's can be challenging, that is why multiple tests are done to validate a Cushing's diagnosis. The LDDS, ACTH stimulation, and/or ultrasound are the usual tests performed to diagnose Cushing's.

The LDDS is an eight hour test whereas the ACTH stimulation takes no more than 2 hours to perform. Now the pros/cons to the LDDS and ACTH as diagnostic tests, which I think Marianne explains so well:

You've asked about advantages/disadvantages to the LDDS and ACTH as diagnostic tests. As others have already said, the ACTH is the only one of the two to be used for monitoring purposes once drug treatment is started. However, either of the tests can be used to initially diagnose Cushing's -- each with it's own pros-and-cons. The ACTH is a more "specific" test for Cushing's; the LDDS is a more "sensitive" test for Cushing's. I'll try to explain what that means below.

As Sharlene has said, one benefit of the LDDS is that, depending on the numerical result, the test can point to the pituitary rather than the adrenal form of the disease. 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 more likely to return a normal result even if a dog 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 :
Marianne

Also, strong obvious symptoms do play a huge part in the diagnosis for Cushing's and it does seem that Duke does display many of the common Cushing's symptoms, so if this were me, I would have the ACTH stimulation or LDDS test done, and if feasible, probably an ultrasound.

Hugs, Lori

[Renee]

Jumping in to say -- if you have the funds, there is nothing wrong with running both the ACTH and LDDS and imaging. I did both the ACTH and LDDS when in the diagnostic phase and followed up a few months later with imaging.

Part of the reason I did both tests was because 1. I like to know everything available, and 2. I didn't want to spend any time wondering if I should have done this or that test over the other.

[sheila]

Duke is having the low dose suppression test and 2 urine tests today, the cortisol/creatinine and a urinalysis. Not sure what numbers on his initial blood test are pertinent so I will post the ones that were way out of whack. The vet there treats with Trilostane.
ALT (SGPT) 150 range 12-118,
Alk Phosphatase 747 range 5-131
GGT 13 range 1-12
BUN/Creatinine Ratio 34 Range 4-27
Cholesterol 373 range 92-324
Triglyceride 399 range 29-291
Platelet Count 458 range 170-400
Neutrophilis 11627 range 2060-106000
All of the other numbers were within normal range. How soon should after starting treatment should he be checked by the vet again? The receptionist said she thought it was 4 weeks, but that seemed like a long time to me. We will be meeting with the vet tonight when we pick Duke up. Any questions you can think of that I need to ask? I feel like my brain has stopped working! Thank you all so much!

[Harley PoMMom]

Thanks for posting those abnormal levels, and most of them can be attributed to Cushing's.

According to Dechra a recheck needs to done 10-14 days after treatment has started. Just wanted you to be aware that if Duke's ACTH stim results at that 2 week mark are higher than Dechra's published reference range, which are 1.5 ug/dl - 5.4 ug/dl, that a dosage increase is usually not done because a dog's cortisol can continue to drift downward during the first 30 days of treatment.

What is the dosage of Vetoryl/Trilostane that the vet prescribing? Dechra has recently revised their initial dosing protocol and they now recommend a starting dose of 2 mg/kg, which when converted to pounds is 1mg per pound of a dog's weight. So for Duke's weight of 30lbs, he should be started at a dose no higher than 30mg. Some vets are not aware of this new dosing protocol so here's a link to that article: http://www.vetsonline.com/news/produ...r-vetoryl.html

Also I'm including a link from our Resource thread with information about Vetoryl/Trilostane: Trilostane/Vetoryl Information and Resources

Please do keep us updated.

Hugs, Lori