Seeking advice - 12 year old German shorthaired pointer

[Brusso89]

My 12 year old German shorthaired pointer was diagnosed with Cushing's as of yesterday and I'm not sure how to proceed. Due to my research, I feel like maybe his case is not the norm but maybe I'm just being naïve.



In January, I noticed an increase in drinking from my boy Trigger. My brother had Trigger's uncle and he was a year younger than Trigger and just recently passed from Cushing's disease, so I am slightly familiar with the symptoms of Cushing's. The week I noticed Triggers increase in drinking I started carefully looking for other signs. On a run in December, I remember looking at his tail from behind him and noticing a tiny bit or bare skin showing where it had used to be fur. Thinking back to that time and putting it together with the newly increase in drinking, it instantly sunk in. On 1/24, I had bloodwork done at my primary vet. The results did come back with signs of CushingÂ’s, but obviously further testing was needed. On 1/24 the blood levels that stuck out was ALT 327, ALP 626, GGT 24 and CHOL 368. Fast forward to 2/14, an ultrasound revealed no tumors but an enlarged liver and Adrenal glands. "Hepatobiliary - The liver is diffusely moderately enlarged and hyperechoic with smooth rounded margins. Adrenals - The adrenals are moderately generally enlarged, bilaterally, measuring 1.1 cm (left) and 1.3 cm (right) at the caudal pole; the glands exhibit otherwise unremarkable features." Since no tumor was found we did an ACTH test. Cortisol level pre ACTH is 6.0 and post is 33.7. Along with all the information, the blood work from 2/14 reads ALT 169, AST 28, ALP 521, GGT 20, CHOL 331 and Spec cPL is 212.



As of now, just the very tip of his tail and a small spot on his head has some hair loss (less than a square inch) and the increase in thirst. I feed him in the morning before I leave for work at 5am but the majority of the time he won't really eat until the second I come home. He gets excited and then eats which is around 4 and then he gets his actual dinner around 5-6. Weird eating times, I know. So personally, I think if he had an increase in hunger symptom, then he wouldn't leave the food sitting all day waiting for me to get home but then again this has been his routine all his life.



He has had some heart issues in the past 3 years that are for the most part under control thanks to 10mg of Vetmedin twice a day. He still has a level 4 heart murmur but gets an ecogram done every 6 months until this last one came back great so we pushed it out to a year (this coming September). Along with the Vetmedin, he takes fish oil, Dasuquin (for his arthritis) and the newly prescribed Denamarin as of a few days ago.



I don't think I'm missing anything given his current situation. Even though he is 12, he is a GSP which are high energy dogs. He has a decent amount of daily energy and if it wasn't for the arthritis, I think he would have the drive to run multiple miles a day like we used to in his younger years. We do a few miles twice a week now and he jogs/speed walks but doesn't run anymore. We did do hunting trips this past fall and winter but way less miles to keep him from having hard recovery days.

With no tumor on the adrenal gland and with them being slightly enlarged, it was explained to me that there could possibly a tumor on the pituitary gland which is making the adrenal glands overproduce causing the enlargement of these glands. So IÂ’m assuming Trigger is classified as having the pituitary version of CushingÂ’s? My specialist that did the ultrasound is suggesting no treatment at this time (besides the Denamarin for the liver) as the treatment really only treats the symptoms and not the actual disease. She is saying this is the very beginning of CushingÂ’s disease with Trigger. I should recheck blood work and urine tests in 2-3 months even if symptoms donÂ’t progress and base the next steps off of those numbers. She states, the average lift expectancy after being diagnosed with CushingÂ’s is 2 years. The reason it is 2 years, is because the majority of dogs that get it are senior dogs and that is about how much time they have left and that typically, they would die from old age or other complications and they donÂ’t normally die due to the sole reason of having CushingÂ’s. Does this sound accurate?

I guess my question is, how should I proceed? On a scale of 1-5 (1 being early stage and 5 being the end) where would you guys rank his journey with Cushing's based on these numbers? I have a phone meeting pending with my primary vet as well once he goes over all the numbers just to get a second opinion and to have more input. I know this is a lot to digest but any info/advice is gratefully appreciated more than I can ever express.


Update 6/2/23

It's been 4 months aka time for another blood/urine test to see how Trigger's internals are doing and how Cushing's is progressing in my boy. Here is a recap with the abnormal levels for a quick reference -

Blood test 1 in January: ALT 327, ALP 626 and GGT 24.

Ultrasound/blood test/ACTH test in February: Ultrasound - The liver is diffusely moderately enlarged and hyperechoic with smooth rounded margins. The gallbladder is unremarkable. - The adrenals are moderately generally enlarged, bilaterally, measuring 1.1 cm (left) and 1.3 cm (right) at the caudal pole; the glands exhibit otherwise unremarkable features. Mildly hyperechoic generalized hepatomegaly; bilateral mild to moderate adenomegaly. Collectively most compatible with Cushing's disease.
Mildly hyperechoic generalized hepatomegaly; bilateral mild to moderate adrenomegaly. Collectively most compatible with Cushing's disease. Cortisol pre ACTH - 6.0 , post ACTH - 33.7.

Blood test 3 in June : ALT 187, ALP 565 and GGT 18
There are some thyroid related concerns in this 3rd blood test. I will post the levels that are abnormal from this last blood test here but as a reference, I will put what those values were in [brackets] as of the 2nd blood test in February which were all within normal values.
phosphorus 6.3 [February test value 3.7], potassium 5.8 [February test value 4.7], na/k ratio 26 [31], cholesterol 463 [331], triglyceride 308 [103] and T4 .5 [1.4].

I am waiting for one more test result to come in that will provide in the vets words "will determine if Trigger's thyroid levels are something we need to treat/diagnose or his thyroid levels are abnormal due to Cushing's". I don't know the exact name of this test but my understanding is that it is just another more detailed blood test they are running but I am not 100%. A mixed bag here as to the liver values haven't changed much in 4 months which is good but either Cushing's is starting to impact his thyroid or I could have another issue on top of Cushing's. Figured I would chime in with an update on my situation.

[labblab]

Hello, and welcome to you and Trigger — we’re so glad you’ve found us! I was just poised to write a reply to you when I saw you had edited your post to add this new info gleaned from this afternoon’s conversation with your specialist:

With no tumor on the adrenal gland and with them being slightly enlarged, it was explained to me that there could possibly a tumor on the pituitary gland which is making the adrenal glands overproduce causing the enlargement of these glands. So I’m assuming Trigger is classified as having the pituitary version of Cushing’s? My specialist that did the ultrasound is suggesting no treatment at this time (besides the Denamarin for the liver) as the treatment really only treats the symptoms and not the actual disease. She is saying this is the very beginning of Cushing’s disease with Trigger. I should recheck blood work and urine tests in 2-3 months even if symptoms don’t progress and base the next steps off of those numbers. She states, the average lift expectancy after being diagnosed with Cushing’s is 2 years. The reason it is 2 years, is because the majority of dogs that get it are senior dogs and that is about how much time they have left and that typically, they would die from old age or other complications and they don’t normally die due to the sole reason of having Cushing’s. Does this sound accurate?

Yes, this info *does* sound accurate to me, and I think your specialist’s recommendation is very reasonable. Cushing’s is typically a slowly-developing disease, and as she has noted, for senior dogs who are not exhibiting uncomfortable outward symptoms or particularly worrisome lab results, treatment may be delayed or avoided altogether. For a younger dog, an important goal of treatment can be to halt or at least slow the development of ongoing systemic damage in the years ahead. But in my own opinion, immediate quality of life is of paramount importance with an older dog. Treatment necessitates ongoing vet visits and blood draws, as well as the potential for side effects from the medication. For a younger dog, or for *any* dog with uncomfortable symptoms, I believe the trade-off is worth it. But again, for an older dog who is still generally doing well, I wouldn’t rush into treatment, either.

I think it’s very good, though, that the specialist wants to keep tabs on any significant laboratory changes that might alter the future equation. It does seem interesting to me that Trigger’s liver values and cholesterol were actually lower this second lab draw. Typically over time those values consistently elevate in untreated dogs. Had he been taking the Denamarin during the interim? I know that it can indeed be beneficial to the liver. Or perhaps the labwork was performed by two different labs, and there just was a bit of variation in the results. At any rate, at least the values went down rather than up — yay!

Anyway, as I say, it sounds as though you are in good hands, and I can’t disagree with the recommendation. Please feel free to ask additional questions, though, and please do keep us updated.

Marianne

[Harley PoMMom]

Hi and welcome to you and Trigger from me as well!!

I agree with Marianne, as the goal of treatment for Cushing's is to control the symptoms of the disease. Cortisol is also a powerful anti-inflammatory hormone and since your boy does have arthritis that elevated coritsol could be helping. If the symptoms are not bothersome to you and your sweet boy, then if this were me, I wouldn't go forward with treatment right now.

Please know we will help in any way we can, and do not hesitate to ask all the questions you want.

Hugs, Lori

[Brusso89]

Marianne, thank you for the reply. The blood work was done by 2 different labs. One thing I did forget to mention and may or may not be important, is in November I started Trigger on adequan injections for his arthritis. 3 times a week for the first 2 weeks, once a week for the next month and once every other week after that. During this time is when I noticed the increased drinking. My primary vet doesn't think adequan had anything to do with it but I did see on adequans website, it states not to start injections in dogs with kidney or liver issues. Since the blood work came back with high liver counts, I chose to stop the injections until I knew more of what was going on. So maybe taking him off of that caused the liver counts to go down? The specialist didn't have an answer for that due to she wasn't too familiar with adequan. The only other difference besides different labs doing the blood work was Trigger wasn't fasted the first time and was fasted the second time. I'm interested to hear your thoughts on this.

Lori, thank you for the reply as well. I did read that about cortisol and arthritis. I had the same thoughts that a little more cortisol may not be a bad thing for him and his arthritis. His before cortisol level was a 6 which according to the test, was at the high end of normal cortisol levels. The specialist said his stress during his visit could have caused it to be a hair on the high side. Even if he was producing a level 6 before the test, wouldn't he not be to bad off in the cushings category or are those before ACTH numbers nothing to get hung up on?

[Harley PoMMom]

I assume that's Trigger as your avatar, awww, he sure is a handsome boy!!! When diagnosing and monitoring Cushing's, the "pre" isn't looked at as close as the "post" result.

[labblab]

Hi again from me, too, and I agree with Lori — I *love* your avatar photo!!! What a great shot! I also agree as to not worrying about the pre-ACTH cortisol level. From what we’ve always been told, the baseline cortisol level can be highly variable in all dogs, and stress can definitely elevate that reading even for dogs without Cushing’s. So I would not worry about it.

As for those othe lab values, I think that cholesterol is technically the only one that would likely be lowered by fasting beforehand. I don’t think that fasting is supposed to markedly affect liver enzyme readings. But perhaps the fasting did lower them a little bit. Or maybe it was just the different lab analysis. I’m afraid I don’t know enough about adequan, either, to speculate as to whether that might have had an effect. But maybe so. A couple of years ago I fell and hurt my back, and for a couple of weeks thereafter I was loading up on Tylenol. When I had my blood drawn, my ALT was higher than normal, for no apparent reason. But when I researched it myself, I found that transitory increases in ALT are initially common in people who start consistently taking Tylenol. The ALT normalizes again over time, even when the Tylenol dose remains unchanged, but apparently that initial surge is not uncommon. And in my case, the next time I had blood drawn, sure enough, it was normal again. So who knows, maybe the adequan did have that mild effect. But again, the difference was minimal, no matter what caused it. I do think, though, that it’ll be good to recheck things in a couple of months.

Marianne

[Squirt's Mom]

Hi and welcome to you and Trigger!

One thing that struck me the fact that Trigger needs help with arthritis. Cortisol is a natural anti-inflammatory and as such "treats" things like arthritis, allergies and other inflammatory conditions. Usually in cush pups we don't see any signs of those conditions until after treatment starts and the cortisol is lowered back to a more normal level. Then without that natural "treatment" those conditions come roaring to the forefront. So the fact that he needs Adequan gives me huge pause in accepting a diagnosis of Cushing's. Add that to the speed at which this came on, the heart disease already present, I would have to wait for some time before I even thought about retesting and certainly before starting treatment.

Something to keep in mind...some heart meds do not mix well with the drugs used to treat Cushing's - Vetoryl/Trilostane and Lysodren/Mitotane. So be sure to talk to the vet in depth about this IF you ever decide to treat Trigger for Cushing's.

Glad you found and hope you stick around to keep us update on his progress.
Hugs,
Leslie

[Brusso89]

Thank you both for the input and the complements. That is my boy in my picture this past summer at the lake. Believe it or not, he used to have a full brown head and face. The sugar face came with age over the past years but I like it, he looks seasoned. It will be interesting to see what the next test results show in the coming months. If it may help others, I will post some updates along the way. I feel like after doing so much research, there is no "normal" and most cases have their own unique set of circumstances. My unique set is the heart issues he has had for the last 3 years. I think I am on the team of no treatment for my situation until symptoms progress a lot more. Not sure when that can be expected, maybe in 6 months to a year? Since he already has increased thirst and full access to a doggie door (I wouldn't be able to really tell how much more he is peeing) the next most common signs to look out for would be panting and increased hunger. I live in Phoenix, AZ and the heat will be here soon enough so increased panting may not be the easiest thing to see but you bet I'll be looking extra carefully at everything involving him more than I do now (if that's possible haha). This forum has bought some good knowledge, being able to read up on other peoples experiences. I will be browsing often!

Leslie, I didn't think about it that way. I don't know how long he's had this first stage as I'm calling it of cushings. I just thought that if he wasn't over producing cortisol then how bad or worse would his arthritis pain be? I don't remember how long ago it was but in my initial research prior to posting on here, I read a thread on this website about a German shorthaired pointer having cushings. I believe someone replied saying once they treated cushings in their own dog, it revealed a severe case of arthritis because the dog couldn't walk. Took the dog off treatment and the dog was able to walk again. I'm paraphrasing but that was the short version. I believe Trigger has cushings due to the ACTH test results and due to his enlarged Adrenal glands found from the ultrasound.

[Harley PoMMom]

Could you measure how much he drinks? The normal amount of water a dog drinks is 1 ounce per pound of the dog's weight.

[Squirt's Mom]

When I was told my first cush pup, Squirt, had Cushing's I hit the internet and started studying, like you have done. In my case, it left me very confused. I joined a couple of list (EARLY social media! ) and they made matters worse by telling me horrible things, like I'd might as well put a bullet in her head if I followed her vet's advise. By the time I made it to my family here, I was a total mess. At that point the only test she had had done was pre-surgical lab work for a dental that showed high cortisol. After the dental we started testing in earnest. She had the ACTH, LDDS, HDDS, and UTK panel...all of which showed high cortisol and were diagnostic for Cushing's. BUT because of the people here I also knew how valuable an ultrasound could be. So before I consented to start treating I asked for the US. It saved her life. The US found a tumor on her spleen. Once that was removed her cortisol returned to normal and remained normal for several years. The stress of that tumor cause false positives on all those tests. Had I started treating based on them she probably would have died from a ruptured spleen or the treatment itself...because she did not have Cushing's at that point in spite of all those "positive" results.

My second pup diagnosed with Cushing's had a host of other health issues - COPD, chronic pneumonia, blind, anal gland disease to name a few. Her ACTH result was >50 - so high the machine couldn't read it. But in my heart of hearts I knew she didn't really have the disease but this was a repeat of Squirt's first diagnosis - a false positive. This pup had all the signs including the hallmark rat tail. Her Pom puff was nothing but bone and skin...yet I KNEW she did not have this disease. I did treat her with Lysodren for a short while and it didn't help much at all and made some things worse for her so I stopped treating her. When she passed I had a necropsy (autopsy for animals) done to try to find out why she died. That procedure proved she never had Cushing's. Her adrenal glands were perfectly normal even with all she had going on.

I share these stories with you so you know that false positives are very very easy to achieve with the tests currently available to diagnose Cushing's. None are fool proof, all are subject to false positive if any other health issue is present. In the years since I have seen dogs return a false positive who simple get very stressed going to the vet clinic.

Cortisol is a fight or flight hormone and its job is to elevate any time stress is present to help the body cope. It is the same with humans, cats, horses, etc. Cortisol has a job. The tests for Cushing's can only tell us IF the cortisol is high but not WHY. So unless there is strong evidence and plenty of signs there is no need to rush into treatment. With Trigger I would want some time to pass and just watch to see if other changes in behavior do occur or if things go back to a more normal state for him.

I currently have dog that I just knew was developing Cushing's based on his drinking, peeing, hair loss, and withdrawal. But his tests all came back normal. Our vet finally decided to treat for a rare form of diabetes that has nothing to do with blood sugar but rather with how the body processes water. This form is called Diabetes Insipidus...and my Bud has that disease instead of Cushing's. He's been on treatment for over a year now and doing quite well. He's still funny about water and I can tell the hour his medication starts to wear off but the other signs are gone. I got tunnel vision when I looked at him...Cushing's can to that to us AND to our vets. So he has been a good lesson for me as have my two girls mentioned above. I also have a Pug just diagnosed with Addison's which is the opposite of Cushing's. So my mutts are giving me a good education...not one I would have chosen but they could care less! LOL This just means mom has to devote more time to them and they love that!

You have now entered the wonderful world of "what in the devil is going on"! There is no telling what you will learn on your journey...and we will be here to learn along with you!

Hugs,
Leslie