Not convinced my dog doesn’t have Cushings! (Cesar has passed)

[Ryles]

Hi everyone

New to this forum and hoping to get some advice about my dog. I have a rescued 7 year old male cane Corso. We rescued him in 2018 from Romania. The first year was great. Healthy, loved his walks, happy dog! Then in October 2019 I noticed he’d become quite greedy then started drinking lots of water. A few weeks later he stopped running, jumping up and just generally lethargic not wanting to exercise etc also he keeps staring at the floor. Took him to the vet where they did blood tests expecting Cushings. Results came back and showed high liver enzymes (70) and high cholesterol. However didn’t show Cushings as usually it would be a much, much higher result. So tested him for hypothyroidism. His results came back low thyroid but TSH normal. As his symptoms got worse my vet done a trial on thyroxine but this made no difference so we took him of it. He has had 2 lots of scans and xrays which all came back completely normal. I’ve swapped him to a raw food diet as he has put on so much weight through not exercising. However I’m still seeing little difference in his symptoms. I’ve even changed vets for a second opinion but they still don’t think he has Cushings. I’ve seen little improvement in his symptoms. He has every symptom apart from panting and hair loss although weirdly he has stopped moulting completely since all this started. The vet thinks it’s all behaviour related I.e the excessive water drinking etc. Personally I don’t. He is like a totally different dog. Any advice? What would you do? Specialist next possibly? Thank you!

[labblab]

Hello and welcome to you and your boy! You’ll see that I’ve moved your thread to our main Questions and Discussion forum — this way, our members are more likely to see your thread and join in the conversation.

My first question is whether or not your dog has been given an actual diagnostic blood test for Cushing’s. It sounds as though your vet ruled out Cushing’s based on general blood chemistries — that the elevation in the liver marker didn’t seem high enough. However, given your dog’s observable symptoms as well as a low thyroid result that is most likely secondary to another condition (like Cushing’s), I agree that Cushing’s remains a likely candidate.

The two diagnostic tests are the ACTH stimulation test, and the Low Dose Dexamethasone Suppression test. For a dog with no other known illnesses, the LDDS is the preferred test because it is less likely to register a “false negative” in a dog who truly has the disease. Here in the U.S, the LDDS is an 8-hour blood test. In Europe, I believe it is sometimes conducted as a urine test over a 3-day time period. Both the ACTH and the LDDS can be skewed by the stress of other physical conditions if they are present. But they remain the two tests that are most specific to making a Cushing’s diagnosis. So if neither of those tests has been performed on your boy, that’s what I’d be requesting right now. If one of those tests has been done, it’ll be great if you can give us the results.

And once again, welcome!
Marianne

[Ryles]

Hello and welcome to you and your boy! You’ll see that I’ve moved your thread to our main Questions and Discussion forum — this way, our members are more likely to see your thread and join in the conversation.

My first question is whether or not your dog has been given an actual diagnostic blood test for Cushing’s. It sounds as though your vet ruled out Cushing’s based on general blood chemistries — that the elevation in the liver marker didn’t seem high enough. However, given your dog’s observable symptoms as well as a low thyroid result that is most likely secondary to another condition (like Cushing’s), I agree that Cushing’s remains a likely candidate.

The two diagnostic tests are the ACTH stimulation test, and the Low Dose Dexamethasone Suppression test. For a dog with no other known illnesses, the LDDS is the preferred test because it is less likely to register a “false negative” in a dog who truly has the disease. Here in the U.S, the LDDS is an 8-hour blood test. In Europe, I believe it is sometimes conducted as a urine test over a 3-day time period. Both the ACTH and the LDDS can be skewed by the stress of other physical conditions if they are present. But they remain the two tests that are most specific to making a Cushing’s diagnosis. So if neither of those tests has been performed on your boy, that’s what I’d be requesting right now. If one of those tests has been done, it’ll be great if you can give us the results.

And once again, welcome!
Marianne

Thank you so much for the response Marianne!
You are correct both vets ruled out doing the specific tests for Cushings as his blood chemistry seemed to rule it out. However I’m not sure if maybe he had a false reading? I know my boy isn’t well, I just know! But at the same time I don’t like telling my vet that I think they’re are wrong. They are the professionals at the end of the day what do I know! He did say that his recent scans did not show he had Cushings as both glands looked normal and so did his liver. But his symptoms just haven’t improved if anything they have got worse. His whole body has changed shape. His belly hangs and his back really dips down which I’m assuming is due to muscle wastage? His lost all of his muscle in his back legs. I think I’m just going to ask for the LDDS test and if that comes back negative then I agree I could most likely rule Cushings out.

[labblab]

Hi again! There is one other alternative “gateway” test that you could consider. It’s called the UC:CR, or urine cortisol to creatinine ratio. We’ve been told that the best method by which to conduct this test is for the owner to collect a urine sample at home on three successive mornings, pool the samples together, and then take them to the vet for analysis. The samples should be collected with the least amount of stress involved as possible. This is why they should be collected at home and *not* at the vet’s office. If the ratio comes back within the normal range, Cushing’s can pretty much be ruled out definitively. If it shows an elevated proportion of cortisol, then Cushing’s is a possibility, but not proven, and you’d then still have to advance to either the LDDS or ACTH. However, I did want to offer this test to you as an additional possibility. It’s likely much less expensive than the LDDS if it rules out Cushing’s, but it would be an added expense if you have to move on to the LDDS in addition.

However, it’s just a thought, and here’s a link that explains it in more detail. One note: the link only references collecting a single urine sample for analysis. As mentioned above, we’ve been told by experts that a pooled sample from three mornings is more accurate.

https://vcahospitals.com/know-your-pet/urine-cortisol

Marianne

[Ryles]

Hi again! There is one other alternative “gateway” test that you could consider. It’s called the UC:CR, or urine cortisol to creatinine ratio. We’ve been told that the best method by which to conduct this test is for the owner to collect a urine sample at home on three successive mornings, pool the samples together, and then take them to the vet for analysis. The samples should be collected with the least amount of stress involved as possible. This is why they should be collected at home and *not* at the vet’s office. If the ratio comes back within the normal range, Cushing’s can pretty much be ruled out definitively. If it shows an elevated proportion of cortisol, then Cushing’s is a possibility, but not proven, and you’d then still have to advance to either the LDDS or ACTH. However, I did want to offer this test to you as an additional possibility. It’s likely much less expensive than the LDDS if it rules out Cushing’s, but it would be an added expense if you have to move on to the LDDS in addition.

However, it’s just a thought, and here’s a link that explains it in more detail. One note: the link only references collecting a single urine sample for analysis. As mentioned above, we’ve been told by experts that a pooled sample from three mornings is more accurate.

https://vcahospitals.com/know-your-pet/urine-cortisol

Marianne

So back to the vet today as my boy has gone really downhill over the last 2 weeks. Done more blood tests. These are the chemistry’s that came back high:
Albumin 41.0
A:G Ratio 1.8
ALP 366
ALT 356
Gamma GT 25.0
Cholesterol 9.2

He is so depressed and has absolutely no energy. The vet still doesn’t want to test him for Cushings so is going for full thyroid profile including antibodies.

I honestly think we are running out of time. It’s almost like he is giving up. What does anyone think? I’m thinking of getting him referred to a specialist now as we are going around in circles and getting no answers. 😔

[labblab]

If I were you, I’d indeed go ahead and request a referral to a specialist. Obviously something serious is going on, and given all his symptoms, I do think that Cushing’s remains a possibility for your boy. At this point, you really have nothing to lose by having a specialist take a look at things, and you may have a lot to gain. Please let us know how things develop, OK?

Marianne

[Harley PoMMom]

Kathy is right, however, there is a published study that has found that larger dogs require less of the recommended dose of Trilostane to control cortisol, so if this were me I wouldn't start out any higher than 40 mg of Trilostane. Here's a link to that study:https://onlinelibrary.wiley.com/doi/...6.2012.00956.x

Lori

[Joan2517]

I started my Gable, who weighed about 75lbs ,at 40mg at Lori's suggestion and he did well for about six months, then we had to lower it. He is on 5mg now, so I would do as Lori suggests and start at 40. You can always go up if needed. It's better than having the cortisol drop too low, which could be dangerous.

[labblab]

I agree with the advisability of starting out at a lower dose. Since you say that he’s already begun 90 mg. daily, I’m assuming you have either only 30 mg. capsules on hand, or a combo of 60 mg. and 30 mg. capsules. If that’s the case, I would definitely decrease at least as far as giving only 60 mg. for the first 10-14 days, until you can monitor the effect of that dose on his cortisol level. Or you could be even more conservative and just start out with 30 mg., knowing that you can always increase the dose easily should he need a higher dose of the medication, after all. At this stage and after the six month diagnostic delay, giving him a bit more time to build up slowly from a lower dose should not be a problem and may allow his body to adjust more easily to a gradual lowering of his cortisol, regardless of whether or not the dose is increased later on.

Also bear in mind that his low thyroid reading may have been secondary to the uncontrolled Cushing’s. Once his cortisol has been effectively lowered into therapeutic range for a period of time, his thyroid level may naturally rebound, too. That being a possibility, you’ll want to make sure to also monitor his thyroid level on a regular basis to make sure that he doesn’t end up with too *much* thyroid supplementation.

Marianne

[Ryles]

I agree with the advisability of starting out at a lower dose. Since you say that he’s already begun 90 mg. daily, I’m assuming you have either only 30 mg. capsules on hand, or a combo of 60 mg. and 30 mg. capsules. If that’s the case, I would definitely decrease at least as far as giving only 60 mg. for the first 10-14 days, until you can monitor the effect of that dose on his cortisol level. Or you could be even more conservative and just start out with 30 mg., knowing that you can always increase the dose easily should he need a higher dose of the medication, after all. At this stage and after the six month diagnostic delay, giving him a bit more time to build up slowly from a lower dose should not be a problem and may allow his body to adjust more easily to a gradual lowering of his cortisol, regardless of whether or not the dose is increased later on.

Also bear in mind that his low thyroid reading may have been secondary to the uncontrolled Cushing’s. Once his cortisol has been effectively lowered into therapeutic range for a period of time, his thyroid level may naturally rebound, too. That being a possibility, you’ll want to make sure to also monitor his thyroid level on a regular basis to make sure that he doesn’t end up with too *much* thyroid supplementation.

Marianne

Hi Marianne, so yes I have 60mg and 30mg. I gave him 60mg this morning and will carry on with that until he is back at the vets in 10 days. I’m so worried about him at the moment! He is so unwell. We had his thyroid levels checked on Wednesday and they look good so at least that’s one good thing. Thanks for your help x