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

  1. #11

    Default Re: Almost 8 y.o. recently diagnosed, a few questions

    I heard back from the IMS office today/yesterday. He said to continue with 10mg vetoryl, add 3mg melatonin twice per day. HMR lignans not indicated since estrogen not elevated. At some point, may need to switch to lysodren but at this time that's also not indicated. Recheck cortisol (and ALKP?) in 4-6 weeks.

    A few questions about melatonin..will it also lower cortisol? Is there more chance of levels getting too low? I'm still going to give both, but just want to know if I need to keep more of an eye on that. Also, any certain type? The K9 brand of melatonin flavored chewables, are those ok? Do I give at same time with vetoryl?

    An ALKP of 3288 doesn't seem too high? Normal range is 23-212 u/L. His ALT was also elevated in January - 135, normal 10-125 u/L. He's been taking adenosyl/Denamarin for 4 years now - 8 hours after eating, 1-2 hours before he eats, I do have to give him a teeny bit of chicken with it, though. IMS has mentioned liver biopsy if ALKP doesn't go down...really don't want to have to do that.

    Thank you all so much for your advice so far.

  2. #12
    Join Date
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    Default Re: Almost 8 y.o. recently diagnosed, a few questions

    Thanks so much for returning and clarifying the new treatment instructions. As far as melatonin, I don’t have personal experience with it, but these are the only real instructions that I found on UTK’s website in relation to melatonin “type”:

    Regular melatonin is usually used rather than rapid release or extended release products.
    So hopefully the canine chewable that you’ve found will fit that bill. I believe melatonin does have the ability to modestly lower cortisol. I doubt this will present an issue, but it would be a good question to clarify with the IMS. I’d be interested in hearing his response.

    Yes, Paddy’s ALKP is certainly high, but as others have said, we’ve seen very high levels in other Cushpups, too. I know it’s hard to sit by and feel worried about lab abnormalities such as these. So hopefully you may see some improvement soon. Please do keep us updated.

    Marianne

  3. #13

    Default Re: Almost 8 y.o. recently diagnosed, a few questions

    Hi again, everyone.
    So..... Paddy is still taking 10mg vetoryl once daily & 3mg melatonin 2x. His ALP is still really high. September 2021 it was around 2500. Last month, it was 3400 (diluted?). He also has had tightness in his tummy. His GP recommended another ultrasound which showed that his liver and prostate are both enlarged. And he's neutered, in case I forgot to mention that earlier. So......I guess I'll try to post results from some of tests. First is the stim test from UTK in 2019 :

    TEST - RESULT (Baseline) / Normal Range (Baseline)** / (Post ACTH) / Normal Range** (Baseline Post-ACTH)
    Cortisol vg/dL : 3.6 / <1.0-5.6 / 5.1 / 7.1-15.1
    Androstenedione ng/ml : 4.13* / 0.05-0.36 / 3.69* / 0.24-2.90
    Estradiol pg/ml : 45.7 / 23.1-65.1 / 47.2 / 23.3-69.4
    Progesterone ng/ml : 0.71* / <0.20 / 1.12 / 0.22-1.45
    OH Progesterone ng/ml : 2.71* / 0.08-0.22 / 4.07* / 0.25-2.63
    Testosterone ng/dL : <15.0 / <15.0-24.0 / <15.0 /<15.0-42.0
    * Above or below reference range **Mean normal range values for neutered male dogs

    "These results:
    [x] indicate presence of increased adrenal activity (mild).
    [] indicate presence of adrenal hypofunction.
    [] are within normal limits.
    History: on trilostane; Cushing's is well controlled but liver values>>; Note: If on Trilostane (Vetoryl), suggested post-ACTH cortisol is 1.4-9.1 ug/dl
    Comments:
    . Five out of twelve values are elevated from marginal to significant. This increase in adrenal
    activity indicates a mild hyperadrenocorticism (HAC). This hormonal pattern has been observed after a prolonged therapy with trilostane (Vetoryl). Vetoryl is effective in controlling, however it may cause iatrogenic elevation of some sex steroids (See items 7, 6 and 5 attached sheet)."

    Results from first ultrasound aspirate (2017)
    DESCRIPTION
    Eleven smears made of needle aspirates from the liver of a 7-year old M/C Shih-Tzu. Hx: Presented for increased liver enzymes. On abdominal ultrasound the liver is slightly hyperechoic. No masses noted; remainder of ultrasound is WNL.
    The smears have similar findings and contain a varied number of hepatocytes, with many erythrocytes. Most of the hepatocytes are found in large clusters, they are polygonal in shape and have round nuclei with a moderate amount of medium blue cytoplasm that often shows moderate cytoplasmic clearing. Some hepatocytes also have a large cytoplasmic accumulation of dark grey green granular material (bile pigment or lipofuscin). Occasional macrophages are seen that also contain a large amount of this pigmented material. No bile plugs are evident. Neutrophils and small lymphocytes are seen in numbers consistent with blood. A few well-granulated mast cells and rare plasma cells are present. There is a moderately heavy background of proteinaceous material with a moderate number of bare nuclei and scattered bits of particulate material. No infectious organisms are seen.
    OPINION
    Moderate vacuolar hepatopathy; the appearance of the hepatocytes (cytoplasmic clearing) is consistent with either an intracellular accumulation of glycogen or hydropic degeneration (a nonspecific indicator of cell damage). Biopsy with histopathology is suggested for more information.

    And here are ultrasound results from a few weeks ago:

    SITE COLLECTED? Liver
    DESCRIPTION
    Five slides of a fine-needle aspirates of the liver from a 12-year-old, MC, Shih Tzu ("Paddy") are examined. Clinical History: "Clinically normal dog long-term, RX for Cushing cortisol levels good not PU/PD but ALP still severely increased, previous FNA liver - vacuolar hepatopathy; abd U/S today - enlarged hyperechoic liver no mass; mild particulate matter in GB; enlarged prostate/LN not previously seen 2x2 cm homogenous".
    All the slides have similar findings. There is moderate cellularity and moderate to marked amounts of blood. There are several hepatocytes, occasional macrophages, and occasional lymphocytes (predominantly small and fewer medium-sized). The hepatocytes are seen in variably-sized clusters and occasionally scattered singly. The hepatocytes are polygonal, with moderate amounts of cytoplasm and variably distinct cytoplasmic borders. The cytoplasm is medium blue, with mild to moderate cytoplasmic rarefaction and occasionally contains a few dark blue-black granules (bile and/or lipofuscin). The nucleus is round, measures 1-1.5x the diameter of a neutrophil with coarse chromatin and 1-2 prominent nucleoli. There is mild anisocytosis and anisokaryosis. Occasionally these cells are binucleated. The macrophages are slightly vacuolated and contain a small amount of cellular debris. The background is light blue, proteinaceous, with occasional ruptured/free nuclei and a small amount of blood.
    OPINION
    1. Moderate vacuolar hepatopathy (glycogen-type) in hepatocytes 2. Mild lymphocytic infiltrate
    Cytoplasmic rarefaction can be seen with either endogenous or exogenous increased corticosteroid hormones or hydropic degeneration. The lymphocytic infiltrate could represent a reactive process or could be also seen in older dogs. The number of neutrophils present is subjectively increased. A CBC can be performed for more information.

    SITE COLLECTED? Prostate
    DESCRIPTION
    Five slides of fine-needle aspirate preparations from the prostate of a 12-year-old, MC, Shih Tzu ("Paddy") are examined. Clinical History: "Clinically normal dog long-term, RX for Cushing cortisol levels good not PU/PD but ALP still severely increased, previous FNA liver - vacuolar hepatopathy; abd U/S today - enlarged hyperechoic liver no mass; mild particulate matter in GB; enlarged prostate/LN not previously seen 2x2 cm homogenous".

    There are many cells that have a grey-blue cytoplasm and a smudged nucleus. One of the slides contains rare atypical epithelial cells are seen in small accumulations and occasionally scattered singly. These cells are polygonal to oval with small to moderate amount of light blue cytoplasm and variably distinct cytoplasmic borders. The nucleus is round, measures 1-2 x the diameter of a neutrophil with coarse chromatin and occasionally one prominent nucleolus. There is mild to moderate anisocytosis and anisokaryosis. Rare binucleation is noted. The macrophages are slightly vacuolated and contain a small amount of cellular debris present. The background is light to medium blue, necrotic and occasionally contains round colorless vacuoles.
    OPINION
    probable carcinoma and abundant necrosis.
    The presence of cellular atypia and the extensive necrosis in aspirated from a mass is most consistent with a neoplastic process. However, the number of intact cells available for evaluation are too few in number to allow for a more definitive diagnosis. Consider resampling the area surrounding the edge of the mass for cytologic examination, or perform a biopsy with histopathologic evaluation for further information and characterization.

    Hopefully, I've copied everything to where it's easy to read. I thought I'd include cytololgy results. Honestly, I don't really understand the descriptions of their findings.....only that "c" word descibing his prostate...

    The IM has suggested Finasteride because of Paddy's high androgens? (2019), to shrink the prostate, re-checking in a few months. Getting another ACTH from UTK first, though, just to see his hormone levels. That's happening within next few days.

    Any advice you all have would be greatly appreciated. Questions for the IM? Does anyone have any experience with Finasteride - interaction with vetoryl? In my googling I found something about it possibly causing diabetes and/or blood clots? Alot of times the information can be overwhelming & hard for me to understand.

  4. #14
    Join Date
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    Default Re: Almost 8 y.o. recently diagnosed, a few questions

    Welcome back to you and Paddy! We’ll definitely be interested in seeing the results of the UTK stim test when you receive them. I’m assuming that he has had intervening monitoring ACTH tests of his cortisol alone since 2019? How have they been looking in terms of his cortisol control? If his cortisol has been running on the higher side, that might explain the continuing increase in his ALP. However, if his cortisol has remained well controlled, then something else may be contributing. As far as the elevations of his other adrenal hormones, we’re indeed aware that Vetoryl can play a part in that. However, after almost 20 years of trilostane treatment with Cushpups, I believe the jury is still out as to whether there’s any genuine issue that may arise from that as opposed to simply being “it is what it is.”

    Out of all the helpful information you’ve given us, it sounds to me as though the prostrate condition is the most immediately important, especially in the presence of the cancer cells. However, it doesn’t sound as though your vet is urgently worried about that, so perhaps the type of cancer that’s involved is not particularly aggressive, especially since it doesn’t sound as though he’s suggesting surgical intervention. I’m afraid I’m not very knowledgeable at all about prostate issues, and I’m totally unfamiliar with Finasteride. So you’ll be doing us a service if you help to educate us as you learn more yourself.

    I wish I could be more helpful to you right now, but it sounds as though we’re all kind of in a “wait-and-see what the results are” mode. However, as I say, any info about Paddy’s intervening monitoring cortisol tests will be helpful. And also, how’s he been doing in terms of any observable Cushing’s symptoms?

    Marianne

  5. #15

    Default Re: Almost 8 y.o. recently diagnosed, a few questions

    It's taking longer to get results from UTK. As I understand it, there's only one dr who's reading/typing the results. So,.....

    The weekend after Paddy had the ultrasound, he did start drinking and peeing alot more. His water bowl is small and he would empty it, I would refill & he'd drink it all again. Before, he'd drink the most after eating. His poop was different, too - some small & thin or just softer than norm. I did start to restrict his water by only filling the bowl 1/3 or 1/2. His poo got more normal looking.

    I'm not sure where to start,but his teeth are not in good condition (my fault) and last week his appetite wasn't as good. It got to where the last few days, I could barely get him to eat anything - not even rotisserie chicken. I tried to inspect his mouth & was pretty sure he had/has a sore on his inner cheek so made an appointment with his regular vet for yesterday. They couldn't get a good look at the sore but said he would probably need to to go to the dentist & have a few teeth pulled . He was given an antibiotic shot, Covenia, & an appetite stimulant, Mirtazapine. Because he's been so thirsty lately & his eyes IMO look to be more cloudy recently, I asked what they would have to do to check for diabetes. They did a quick test ( & also took a urine sample to be sent to lab) Well his glucose was 445.000 mg/dl (Lab range 70.000 - 143.000 mg/dl) It was 137 in mid March.

    They showed me how to give him an insulin shot, that he has to have food first, and after week he will have to go back to be tested throughout the day.
    I wasn't able to give Paddy the shot when we got home because of the eating problem ( & I'd like to give it earlier while the vet is still open). He got the Mirtazapine & I waited a couple of hours before trying to feed him (We got 2 rx foods. One is for diabetes & the other is Royal Canin recovery) Tried just a few spoonfuls of the recovery one and he ate it right away. I was so relieved that I brought him some more, but he wouldn't eat it. Several hours later, tried again & he still wasn't having it (he did eat a teeny bit of a chicken nugget,though). To "remind" him that it tasted good, I just put some food in his mouth a couple of times & he did eat all of it (only 1/8c because I'm afraid after not eating anything & then getting antibiotic, he'll have diarrhea).

    I'm worried I won't be able to get him to eat enough to give the insulin shot today though, especially since the appetite stimulant wasn't given until late afternoon yesterday (if that makes sense?) And should I give the recovery or diabetic food?
    Nothing can be done about his teeth until the diabetes is under control or whatever. Not that I really wanted Paddy to have to go through that, I just want him to feel better & to feel like eating. I just........

    Should I have asked for a pain med for his mouth? Is the antibiotic enough for right now?
    I'm also wondering how I should schedule his other meds around the insulin - melatonin (2x) & vetoryl (1x). I usually feed him 3 smaller meals per day. And still waiting to hear from IMS about UTK results & figure out prostate and Finasteride.

  6. #16
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    Default Re: Almost 8 y.o. recently diagnosed, a few questions

    I wish I could help but I am not familiar enough with diabetes to be comfortable in commenting. I do know it is important that they eat in order to get the shot. Since he is not feeling well that may be more difficult than normal. I am going to give you a link to our sister site, K9Diabetes and want you to go talk to them. The forum may not be very active but they have tons of info on their site and if you are on Facebook they have a group there I can give you the link to. Here is the link to the forum:

    https://www.k9diabetes.com/forum/

    Here is the link to the K9diabetes FB group:

    https://www.facebook.com/groups/Cani...andInformation

    Please jump on over there and start talking. They are the experts in canine diabetes.

    Please do let us know how things are going with your precious Paddy.
    Hugs,
    Leslie
    "May you know that absence is full of tender presence and that nothing is ever lost or forgotten." John O'Donahue, "Eternal Echoes"

    Death is not a changing of worlds as most imagine, as much as the walls of this world infinitely expanding.

  7. #17
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    Default Re: Almost 8 y.o. recently diagnosed, a few questions

    Hello again from me, too! I’m afraid, though, that I’m in the same boat alongside Leslie — I don’t have enough knowledge about diabetes to offer you advice about that. I’m sooooooooo glad she gave you the links to the canine diabetes groups, though, and I’m hopeful you’ll be able to get some helpful support from the folks there.

    I’m so sorry that Paddy had these added issues to deal with. They’ve got to be hard for both of you to handle! Even though we may not be able to offer much advice about the diabetes, we’ll still be anxious to get updates on how you’re doing. So please do let us know.

    Best wishes,
    Marianne

  8. #18

    Default Re: Almost 8 y.o. recently diagnosed, a few questions

    Update on Paddy- Paddy is scheduled to have teeth extractions tomorrow. His diabetes and insulin have been my main concern. But is there anything I need to keep in mind in regards to Cushings? He had a CBC done this past week. His ALP that had been in the 3000's in March is now down to 1144. He also had a stim test done - sample 1 was 4.4 & sample 2 was 4.7 (also, I don't think it was timed as usual. It wasn't planned for that day.) I guess I'm just posting results of his bloodwork here in case anything stands out as an issue. His vet did give an rx for Clindamycin for his mouth/teeth.

    ALB/Glob Unknown 0.500 0 - 0
    Albumin (ALB) Normal 2.500 g/dL 2.200 - 3.900 g/dL
    Alkaline Phosphatase (ALKP) Above Normal 1144.000 U/L 23.000 - 212.000 U/L
    ALT/SGPT (ALT) Normal 88.000 U/L 10.000 - 125.000 U/L
    Basophil Normal 0.060 10^9/l 0.000 - 0.400 10^9/l
    Basophil, % Above Normal 1.200 % 0.000 - 1.100 %
    Bilirubin, Total (TBIL) Normal 0.300 mg/dL 0.000 - 0.900 mg/dL
    BUN (Blood Urea Nitrogen) Normal 23.000 mg/dL 7.000 - 27.000 mg/dL
    BUN/Crea Unknown 39.000 0 - 0
    Calcium (CA) Normal 9.800 mg/dL 7.900 - 12.000 mg/dL
    Chloride (CL-) Normal 112.000 mmol/L 109.000 - 122.000 mmol/L
    Cholesterol (CHOL) Normal 319.000 mg/dL 110.000 - 320.000 mg/dL
    Creatinine (CREA) Normal 0.600 mg/dL 0.500 - 1.800 mg/dL
    Eosinophil Normal 0.170 10^9/l 0.000 - 0.800 10^9/l
    Eosinophil, % Normal 3.700 % 1.000 - 18.000 %
    Gamma Glutamyl Transferase (GGT) Normal 0.000 U/L 0.000 - 11.000 U/L
    Globulin (GLOB) Above Normal 4.800 g/dL 2.500 - 4.500 g/dL
    Glucose (GLU) Above Normal 583.000 mg/dL 70.000 - 143.000 mg/dL
    Hematocrit (HCT) Normal 39.850 % 37.000 - 55.000 %
    Hemoglobin (HGB) Below Normal 11.100 g/dl 12.000 - 18.000 g/dl
    Lymphocyte Below Normal 0.470 10^9/l 1.000 - 4.800 10^9/l
    Lymphocyte, % Normal 10.000 % 9.000 - 47.000 %
    MCH Below Normal 19.400 pg 19.500 - 24.500 pg
    MCHC Below Normal 27.900 g/dl 31.000 - 39.000 g/dl
    MCV Normal 69.000 fl 60.000 - 77.000 fl
    Monocyte Normal 0.240 10^9/l 0.200 - 1.500 10^9/l
    Monocyte, % Normal 5.100 % 2.000 - 12.000 %
    MPV Above Normal 12.000 fl 3.900 - 11.100 fl
    Na+/K+ Unknown 25.000 0 - 0
    Neutrophil Normal 3.760 10^9/l 3.000 - 12.000 10^9/l
    Neutrophil, % Normal 80.000 % 42.000 - 84.000 %
    Osmolality Unknown 315.000 mmol/kg 0 - 0 mmol/kg
    PCT Normal 0.320 % 0.150 - 0.390 %
    Phosphorus (PHOS) Normal 4.800 mg/dL 2.500 - 6.800 mg/dL
    Platelet Count (PLT) Normal 267.000 10^9/l 165.000 - 500.000 10^9/l
    Potassium (K+) Normal 5.800 mmol/L 3.500 - 5.800 mmol/L
    Protein, Total (TP) Normal 7.400 g/dL 5.200 - 8.200 g/dL
    RBC Count (RBC) Normal 5.750 10^12/l 5.500 - 8.500 10^12/l
    RDW Normal 18.800 % 14.000 - 20.000 %
    Sodium (Na+) Below Normal 142.000 mmol/L 144.000 - 160.000 mmol/L
    WBC Below Normal 4.700 10^9/l 6.000 - 17.000 10^9/l

  9. #19
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    Default Re: Almost 8 y.o. recently diagnosed, a few questions

    Welcome back, and good luck to you guys today! Thanks for posting all this info, and unless I’m missing something, I don’t see anything of significance on the Cushing’s front. His ACTH stimulation test results look very good. So I surely hope that all will go well with his extractions today. I know you’ll be glad once that’s behind you.

    Best wishes,
    Marianne

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