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Thread: Diagnostic Plan to Rule Cusahings In/Out

  1. #1

    Default Diagnostic Plan to Rule Cusahings In/Out

    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.

  2. #2
    Join Date
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Hello, and welcome to you and your girl! As you’re probably aware, the goal of Cushing’s medication treatment is to alleviate symptoms as opposed to “curing” the disease itself. So prior to launching into further diagnostics, I have a couple of questions for you. What is the expected lifespan for your breed of dog (in other words, at age 10 is she already approaching a more elderly status)? And secondly, even if Cushing’s were to be confirmed, would you choose to start medicating her at this point?

    Cushing’s is typically a very slowly developing disease. Your dog’s gradually increasing ALP over the period of six years certainly does qualify as very slow development if Cushing’s is the cause. And if she otherwise doesn’t seem to be uncomfortable, herself, by the excessive thirst and urination, then I’m not sure the trade off associated with treatment would yet seem worth it to you in the absence of additional observable symptoms. Frequent vet visits and blood tests are initially required to ensure proper monitoring of the medication, and that would be stressful for a dog who is fearful. Also, for seniors, arthritic issues may actually become more apparent when cortisol levels are lowered. For younger dogs, a chief goal of Cushing’s treatment is to prevent longterm internal systemic damage that Cushing’s can cause. But for older dogs, my personal opinion is that present comfort and quality of life take precedence. If Cushing’s is making a dog of any age visibly uncomfortable, I would opt to treat. But in the absence of observable discomfort in an older dog, I would likely be more cautious.

    There are a couple of exceptions to my “observable discomfort” yardstick. If a Cushing's dog of any age is suffering from either high blood pressure or significant protein loss into the urine, these can be important reasons to start treatment in their own right. This is because these two “silent” conditions can lead to other serious problems such as blindness and kidney dysfunction.

    In terms of your own dog’s situation, I would never say that an abdominal ultrasound would be a bad idea for a dog who has exhibited consistently increasing ALP levels over six years. If not Cushing’s, then the ultrasound might reveal some other abnormality that’s at play, and you might welcome that information. If you do opt for the ultrasound, I’d go ahead and also opt for the sterile urine sample so that a really accurate culture could be done. You say that your dog’s urine is not dilute — which seems surprising with excessive thirst/urination — but a culture performed on a sterile sample could definitively rule out infection.

    As far as specific Cushing’s testing, however, one option you might consider prior to anything else is a urinary cortisol to creatine ratio (UC:CR). This test is best performed using a pooled sample of urine that the owner has collected at home (first pee of the morning, pooled over three days). Stress has to be minimized for this test to be accurate, so the sample definitely should *not* be collected at the vet’s office. But if you collect the pee at home, then you can take it in for analysis. A positive result on this test does not confirm Cushing’s, but a negative test is 99% accurate at ruling out Cushing’s. So before any other testing at all, you might want to consider this low-stress diagnostic.

    If you do opt for diagnostic blood testing at any point, I would think a low dose dexamethasone suppression test (LDDS) would be the option preferred over the ACTH stimulation test. For a dog without any other known health issues, the LDDS is much less likely than the ACTH to return a “false negative” in a dog who truly has the disease. I’m giving you a link below that leads you to a brochure published by the maker of a Cushing’s treatment medication that discusses these three diagnostic testing options in greater detail (UC:CR, LDDS, ACTH). You’ll find the table that compares them on page 5 of the brochure (“Confirming the Diagnosis”).

    https://www.animalhealthinternationa...s-v6-15-15.pdf

    I know I’ve already written quite a bit here, so I’ll take a breather for now! Please do let us know of any additional thoughts or questions that you may have, though, as we are very happy to discuss everything in further detail. And once again, we’re very glad you’ve found us!

    Marianne

  3. #3
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Hi and welcome to you and your precious girl!

    Diagnostic testing usually isn't recommended unless the dog is displaying strong obvious signs of Cushing's. One reason is because the goal of treatment is control those bothersome symptoms so if the dog is not exhibiting the manifestations of this disease it would be hard to judge how well treatment is going.

    An ultrasound, I believe, would be useful as it could get a good look at those internal organs and see if there would be other reasons for her symptoms. Another test you could consider is the UC:CR, if a dog has a normal reading than Cushing's is highly unlikely. This type of test is not invasive and only requires some urine samples taken at home. Ideally 3 morning pooled urine samples are collected by the owner at home and kept refrigerated until the samples can be taken to the vet office.

    You posted that her urine is not dilute, could you tell us what her USG (urine specific gravity) is? It should be on the urinalysis report. Also, could you tell what breed your sweet girl is?

    Again, welcome to our family and please know we will help in any way we can.

    Hugs, Lori

  4. #4

    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Thank you so much for all of this information and the quick reply!

    She is a 40 pound mixed breed dog. Medically, I don't know what her life expectancy is. Personally I hope she lives forever with a great quality of life. She's a very happy playful girl with a beautiful temperament. Her vet said that the medication for Cushing's is really well tolerated but, as you said, the ongoing testing associated with it is sometimes *prohibitive*

    I had a much larger dog who lived to 18 and was in great spirits until the last week of her life. I think a her longevity was due in part to having had cancer twice and super frequent check ups and ultrasounds twice a year. Nothing went unnoticed for long. That dog was always happy to go to the vet though.

    My possible Cushing's patient dog has been incredibly healthy. Her veterinary needs have been almost non-existent. Her current course of antibiotics is the first she's ever taken (though she's had ear drops).

    The vet hasn't sent me the urine tests results. I will request them. The tech said it was their "regular" urine test when I dropped it off, but it was a single sample of first pee of the morning. I will ask about the three day pooled urine test. Of the test that was done, her vet said that it is not indicative of Cushing's but also "a urine test doesn't rule it out because Cushing's can do whatever it wants".


    That sample was yellow, but there have been days that her urine (which I can see on the wee pad) appeared clear to me. I'm not sure what to make of that.

    Since she is afraid of going to the vet (mostly of the car ride), I just want to be efficient with the diagnostics and as kind as possible to her. Thank you again for this resource.
    Last edited by PrincessDangers; 03-24-2021 at 03:56 PM.

  5. #5

    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Yes, I think there is benefit to taking a look around in there. The vet mentioned "maybe GI, maybe gallblatter..." and several other things she'd like to take a look at.

    I'll request the urinalysis report.

    She is a mixed breed. According to her Embark test, she is about half American Pit bull Terrier, and the other 50% is Shih-Tzu, American Eskimo Dog, and Small Poodle. She has long scruffy fur and looks like the cutest muppet. I love her so much.

    Thank you for your help.

  6. #6
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Wow, 18 years old, that's a true testament of your love and devotion, your girls are very lucky to have you as their pet parent!

    Was a SDMA test included with the chemistry blood panel? If not, this may be another test to consider, these results help show the function of the kidneys and are a better marker for kidney disease. Here's a link with information regarding this type of test: https://www.idexx.com/en/veterinary/...dma/sdma-faqs/

    Hugs, Lori

  7. #7

    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Quote Originally Posted by Harley PoMMom View Post
    Wow, 18 years old, that's a true testament of your love and devotion, your girls are very lucky to have you as their pet parent!

    Was a SDMA test included with the chemistry blood panel? If not, this may be another test to consider, these results help show the function of the kidneys and are a better marker for kidney disease. Here's a link with information regarding this type of test: https://www.idexx.com/en/veterinary/...dma/sdma-faqs/

    Hugs, Lori
    Looking back at her pictures I see that she was ancient looking, but I did not see it at the time at all!

    Yes, it was included. This test was through IDEXX. It says "IDEXX SDMA" with a reference range of 0 - 14 (not sure if that's standard). Her result was "3" With this note... "SDMA and creatinine are within the reference interval; impairment of GFR is unlikely. Recommended next step: evaluate complete urinalysis."

  8. #8

    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Quote Originally Posted by Harley PoMMom View Post
    Wow, 18 years old, that's a true testament of your love and devotion, your girls are very lucky to have you as their pet parent!

    Was a SDMA test included with the chemistry blood panel? If not, this may be another test to consider, these results help show the function of the kidneys and are a better marker for kidney disease. Here's a link with information regarding this type of test: https://www.idexx.com/en/veterinary/...dma/sdma-faqs/

    Hugs, Lori
    + I just received her urinalysis and there is no reference range listed, but Googling seems to show that the Specific Gravity (1.03) is normal.

  9. #9
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    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Quote Originally Posted by PrincessDangers View Post
    + I just received her urinalysis and there is no reference range listed, but Googling seems to show that the Specific Gravity (1.03) is normal.
    Ok, let me get this correct, is her USG result listed as 1.030?

  10. #10

    Default Re: Diagnostic Plan to Rule Cusahings In/Out

    Quote Originally Posted by Harley PoMMom View Post
    Ok, let me get this correct, is her USG result listed as 1.030?
    Yes, thatís what the report says.

    Her ultrasound and sterile urine sample tests (which Iím dreading on her behalf) are scheduled for Wednesday.

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