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Thread: Max test results help

  1. #1
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    Default Max test results help

    Hello everyone. I am hoping you all might be able to help me interpret my boy Maximus's LDDS test. His vet said Cushing's was ruled out, but when I look at the results and have read up on interpreting it I feel like the 8 hour number is elevated. I am hoping you all might be able to shed some light on this for me. We also did a T4 panel and she feels it is hypothyroidism based on his T4 1.2, Ft4 1.0 and elevated tsh .65 and wants to start low dose meds for thyroid. He also had elevated ALP (700), low hemoglobin(12.0), and his MCH and MCHC right below normal (21.1, 30.4)

    Here goes:
    Pre Dex: 5.1 ug/dl (1.0-6.0)
    4 hour: 0.4 ug/dl
    8 hour: 6.7 ug/dl

    Looks to me like pre dex cortisol was normal, he suppressed at 4 hours, but the 8 hour is above the range from IDEXX 1.0-6.0.
    I am so appreciative for anyone willing to take the time to review these and chime in. I just want to make sure I understand everything and can be the best advocate for him.
    Last edited by Elizabeth513; 07-05-2020 at 01:42 PM. Reason: add ranges and typos

  2. #2
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    Default Re: Max test results help

    Hello Elizabeth, and welcome to you and Max! To cut right to the chase, you are right that Max’s LDDS results are consistent with Cushing’s, and unfortunately your vet is incorrect. Max’s results are consistent with the pituitary form of Cushing’s. Here’s a link to some IDEXX test interpretation charts. If you scroll down past the ACTH stimulation test that’s listed first, you’ll come next to the LDDS.

    https://www.idexx.com/files/snap-cor...g-guide-en.pdf

    The normal ranges printed on Max’s labsheet may vary slightly from this table. One important point: the normal cortisol range up to 6.0 relates only to the first baseline blood draw, prior to the administration of the testing agent. With the LDDS test, the baseline cortisol level is of little importance — the 8-hour level is what determines the overall Cushing’s diagnosis. Both the diagnostic 4-hour and 8-hour results are compared to a very different “cut-off” number from the baseline range. Commonly it’s either 1.4 or 1.5 ug/dL. On the IDEXX chart listed here, the cut-off number is 1.5. Since Max’s 8-hour result greatly exceeded that cut-off, the result was consistent with Cushing’s. And since his 4-hour result was *less* than both 50% of the baseline reading as well as less than 1.5, his result is consistent with the pituitary form of the disease. I know this formula may seem complicated, but if you compare Max’s results to the chart, I think you’ll see what I’m talking about.

    The really unfortunate part of this is that your vet’s unfamiliarity with the correct test interpretation leads me to fear that he/she is not at all familiar with testing or treating Cushing’s patients. This is a major interpretation error. Max may well suffer from hypothyroidism in its own right, but this LDDS additionally points to Cushing’s. His elevated ALP would also be consistent with the disease.

    May I ask what prompted the testing in the first place? Does Max exhibit observable symptoms that are worrisome. Any additional info you can give us about his overall health history will be very helpful. And I’m sorry about delivering the bad news about your vet, but as I say, this is a major fumble :-(.

    Marianne

  3. #3
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    Default Re: Max test results help

    Double posted removed...sorry!
    Last edited by Elizabeth513; 07-05-2020 at 02:52 PM.

  4. #4
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    Default Re: Max test results help

    Hi Marianne! Thank you so much! He initially went in for a dental cleaning and his yearly exam. My vet was very concerned at first about his low rbc, hematocrit and we did a repeat...it came up slightly. At the same time she said his ALP is consistent with Cushing's and noted he had gained some weight ( ore on that in a bit). She added on a cort/creat screen to his urine that has been sent off and when it came back she said it was very suspicious of Cushing's to her (urine cortisol : 12.3, Urine Creatinine 41.4, ratio 93) and she recommended a LDDR test. I requested to add the thyroid panel because he was low/normal 1.2 (1.0-4.0).

    I'm not sure if she misread the results?? She spoke to me in depth about Cushing's and signs of it. I chalked it all up to being a 9 year old boxer. I noted he's been shedding a good bit, he is normally tired (9 year old boxer, but has energy bursts), Drinks but not what I would call excessive (hes 82 pounds). He's gained from 75-82# since March, but I changed his food to Royal Canin HP vet diet because he has "gulpy" digestive issues thye've never been able to figure out except possible reflux, but we have never done a scope to see if it could be IBS, etc. The HP food seems to agree with him even though I do not think it is the "best" type of food out there. He does love to bask in the sun...but gets hot easliy (again he's a boxer and the summer heat gets him)...so all of these things she said yes we need to look at Cushings.

    I can attach all of his lab work if it would be helpful, but I feel like that LDDR test was pretty clear. I will be calling tomorrow asking for her or another vet in the group to pull up his test and look at it and explain why they feel it is negative. I am not someone who takes what anyone tells me at face value, I read and I learn so I can understand and discuss things in an educated manner...maybe thatis the teacher in me.

    I am a little terrified of Cushings, and the medications used to treat it. I have been lurking here listening and learning and I do appreciate all the knowledge and time you all give to each other. AND, I am trying to not be scared...I am trying to look at statistics and be rational...

    Where do I go from here? Much appreciated!

  5. #5
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    Default Re: Max test results help

    Hi again, Elizabeth. This additional information does indeed make Cushing’s seem like a strong possibility.

    Question: do you have the actual lab sheet with the LDDS results listed? If so, the lab sheet ought to have the exact interpretation criteria written out. Having that exact language in front of you will hopefully make it easier to talk to the vet tomorrow. Remember that the focus first needs to be on the 8-hour value, not the baseline value. The baseline value only becomes significant for comparison purposes if the 8-hour value is elevated. At that point, you’re checking to to see whether sufficient suppression subsequently occurred which would point to the pituitary form of the disease.

    And I know this is far easier said than done, but please don’t feel terrified about the Cushing’s meds if they end up being prescribed. As careful and observant as you clearly are with Max, you’ll already have a great head start in terms of monitoring how he’s doing. We’ve had many success stories here, and there’s no reason why Max shouldn’t be one!

    Marianne

  6. #6
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    Default Re: Max test results help

    Yes, I do have it. I kept looking at it thinking I was missing something. I have spent the last week researching that exact chart you linked as well as studying the types of medications and the new starting doses of those.

    Max is a dog that my vet's words "does not fit the book in veterinary medicine". He has been reactive to a couple of antibiotics in the past with adverse affects, and reacted badly to a cytopoint injection given last summer for allergies. So, she is very cautious with him, but I just have so much doubt now.

    Do you think there is importance to get him in with an internist to correctly diagnose? We have a wonderful group near us where he went to have obstruction surgery. So, Tmy plan is to call and ask them to recheck his LDDS results as I feel there was an error in reading them due to the fact that his 8 hour value is >1.5...and the 4 hour is less than 1.5 and less than 50% of the baseline as outlined in the IDEXX chart? Does that sound right? THANK YOU so much!

  7. #7
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    Default Re: Max test results help

    That sounds exactly right! And what I would do if I were you depends a great deal on the response you get tomorrow about the test interpretation. If the vet seems defensive or argumentative, I would take that as a giant red flag. If the vet is instead appreciative that you’ve been educating yourself and apologetic for missing the diagnosis, that would be better, for sure. If you do feel uncertain, though, that’s terrific that you have a good specialty group nearby. Especially dealing with the combination of hypothyroidism and Cushing’s, both you and your vet may welcome the input of an internist. As you may have read, hypothyroidism can actually be secondary to Cushing’s. If Cushing’s is the primary culprit, the low thyroid readings may spontaneously resolve once the cortisol becomes well controlled. Since Max’s TSH was elevated, I *think* that makes it more likely that he’s genuinely hypothyroid, as well. But that might be an area where you’d welcome an internist’s expertise prior to launching into thyroid supplementation. And you could diplomatically ask your vet if a consult might not be helpful, given this dual diagnosis.

    I certainly don’t want to borrow any trouble for you, but I do want to mention that our experience here is that boxers seem to be over represented among the group of Cushpups who may develop a particular skin disorder known as Calcinosis cutis when their cortisol levels are untreated and running high. This disorder manifests as calcium deposits that work their way up through the skin, finally erupting as uncomfortable plaques. This might be another reason to get treatment guidance from a specialist, in order to prevent this issue from ever getting started.

    But first things first — let’s get that LDDS interpretation clarified. Definitely let us know how things go!

    Marianne

  8. #8
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    Default Re: Max test results help

    Thank you, Marianne!

    In my reading I have read that with the values he is showing in his T4, free T4, and tsh that is "could be" a non-thyroid illness causing it because his T4's are not falling below range, but low average....OR it COULD also be hypothyroid. I think I do feel better knowing we could have multiple things going on here that consulting in internist would be in Max's best interest. He's always had some immune type issue and I want the time he has left to be enjoyable whatever that may be.

    I have read a little on the calcinosis cutis, I believe a few posts on the forum. I will continue to follow up on and do more reading on that.

    Can the LDDS test signify the progression of the disease?

    I will most certainly update as I am very appreciative of you taking the time to answer my questions. All the posts I have read left me noting that everyone is very positive in their thoughts. I am happy to have found the forum! I apologize for not properly introducing myself: You picked up on my name quick! Max is our beautiful 9 year old boxer who is our third child...we have two human kids as well!

  9. #9
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    Default Re: Max test results help

    I spoke with Max's vet and she was extremely embarrassed and very apologetic about the misreading of his results. She said you are 100% correct! She feels his thyroid is primary as well b/c of the tsh. I did mention that from some readings I have found, a percentage of cushing's dogs thyroid regulate upon treatment and she said that beginning cushing's treatment then retesting thyroid later would definitely be an option.

    Since she knows Max's history she did feel like me taking him to an internist who can unfold everything would be a great idea. She spoke very highly of the group near us and said they work together and will often help by running tests, etc so he can go to his home vet for easier things, but the internist treat, diagnose, etc.

    We discussed that they would be helpful with looking at his immune issues (chewing paws, digestion issues/food) as well as we begin this journey.

    They will be sending a referral to the specialists tomorrow by lunch time and hopefully it won't take us too long to get in. I would love any advice, reading material, in the meantime... Thank you for all reading our story!

  10. #10
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    Default Re: Max test results help

    I’ve been watching all day for your report, and I’m so relieved to hear about your conversation with your vet. I think it went as well as I could have asked for. Your vet’s response was what I would have hoped to hear, and I think the consultation with the internist will offer you the best of both worlds — you’ll benefit from the input of the specialist while still maintaining your ongoing relationship with Max’s regular vet who knows him so well after all her years of caring for him.

    As far as preparing yourself in advance of the appointment, it sounds to me as though you’ve already done a terrific job of educating yourself about both hypothyroidism and Cushing’s. As far as the Cushing’s, you may want to focus more now on treatment, which you may already have done. However, if you visit our “Helpful Resources” subforum, near the top of the index you’ll find several threads related to the two medications, Vetoryl (trilostane) and Lysodren (mitotane). I’m assuming the specialist will recommend one of these two meds if he/she feels as though the diagnostics are sufficient to move forward.

    As far as the hypothyroidism, one of the most complete explanations that I’ve read related to testing parameters is found on the website of the Michigan State Vet School Endocrinology testing lab. This blurb is quite technical, but it does discuss advanced testing options in great detail.

    https://cvm.msu.edu/vdl/laboratory-s...nction-in-dogs

    Good luck with your specialty visit. Good job, mom, for your tenacity in advocating for Max! And I love your avatar photo of your sweet boy — what a handsome boy he is ;-).

    Marianne

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