Hello,

A tentative diagnosis of Cushings has been discussed for the past three years for my beloved dog, based primarily on elevated ALP results that are doubling each year. She did not have bloodtests last year (I was trying to avoid non-emergency vet visits because of the pandemic). We have moved multiple times in the past few years so these results are all from different labs/vets.

Is there a preferred order of operations for ruling this disease in or out?

My dog is nervous of vet visits and I don't want to torture her unnecessarily. I'm not putting her through diagnostics just out of curiosity. The tests are only justifiable if it keeps her healthy and improves her quality of life.

My dog has luxating patella and chronic ear infections but is otherwise perfectly healthy.

She does drink and pee much more than other dogs, but her urine is not dilute. The frequent urination is not a lifestyle problem for me. If fine taking her out many many times a day and giving her wee pads for emergencies. She has hind end weakness, but she also has arthritis (she just started adequan).

Her appetite is normal. She has a beautiful full coat.

The rest of her blood work is "very good" according to the vet. Her Globulin, total protein, Creatine Kinase, and Reticulocytes are within normal but a bit on the higher side. Her hemaglobin and MCH are within normal but a tiny bit low.

4 years of age, 2015 ALP: 36
5 years of age, 2016 ALP: 70
6 years of age, 2017 ALP: N/A
7 years of age, 2018 ALP: 450 *Advised to revisit the issue if she had any strange symptoms. Cushings was mentioned, but more likely, she suspected it was due to bone rebuilding (my dog has luxating patella/arthritis)
8 years of age, 2019 ALP: 777 *Suspected Cushings based on blood work but not urine. The vet said that she does not recommend testing/treating at this age if the pet is not really suffering (because they usually die of something else first)
9 years of age, 2020 ALP: N/A
10 years of age, 2021 ALP: 1,686 *Suspects Cushings based on blood work but not urine. She has a lot of white blood cells in her urine but no bacteria. Started a course of Clavamox in case of infection.

This vet would like to do an ultrasound as the next step rather than a Cushings test. Also, she wants to collect a sterile sample at that time.

The ultrasound is going to be stressful, but I think it is worth doing.

This is the second vet who has told me they don't like/trust the stim test. She said sometimes it is positive one year then negative the next and she'll suspect Cushings for years but never get the diagnostic proof necessary to support treating the dog with medication for it. If the adreanal glands are enlarged, that might support a Cushings diagnosis and she would recommend the stim test. Then, she said that if they're not enlarged, that does not rule out Cushings and she would recommend the stim test. So, that's confusing.

It is difficult for me because I have never met this vet. We've only spoken on the phone. I don't understand why a sterile sample is needed if there were no bacteria in her urine. That's a really unpleasant thing to do.