To treat or not to treat?

[inheriteddog]

My Kobe is a beagle, turns ten next month. He shows signs of Cushing's: pot belly, drinks and pees a lot, wants to eat much of the time, has had bouts with skin infections and hair loss, pants sometimes... Lab work done in July indicates high cholesterol, elevated blood sugar, one liver enzyme high. Vet is pushing me to test for Cushing's and if indicated get him on trilostane right away. Says it's for "quality of life." The thing is, I don't see Kobe as being that bad at this point. He's been developing the pot belly for years (vets in past have said he was just "overweight") and while it is clumsy, he still gets around. Panting was bad during summer heat wave but right now is mild when he walks a bit much, so I limit his exertion. His drinking was bad in summer but is down right now and he controls his peeing and pooping for outdoors, no issue of accidents. Cholesterol was 439 at test, glucose 128, taken in afternoon when he had eaten a couple of hours before. ALP was 350, the other 3 liver enzymes were ALT 115, AST 17, GGT 6. Radiology shows "mild to moderate" liver enlargement. He also has two hard lumps on back, oval shaped about 3 inches by 2; aspiration of one a couple of years ago brought only blood and the vet suggested possible cancer (she doesn't seem to worry much about it now).
His quality of life right now does not look bad to me. He likes going for walks in morning and evening. He eats and poops well, has not gained weight in years despite the larger belly. He gets excited if a cat intrudes in the yard or he sees squirrels in the park. Is happy to meet other (friendly) dogs, barks to protect the yard, generally seems normal for a dog his age. Uses a step to get into car. Major problems are infections between toes and occasional large hot spots which have been treated successfully with Cytopoint and/or antibiotics. He did have breathing problems during the summer heat wave but not now. I would like to have him evaluated by a good vet (I'm not confident about my current pushy vet) but all the doctors in my area seem questionable. ACVIM website has no referral in San Diego at all. Short story, I think I can just wait and see how Kobe does before acting. He may, after all, have issues besides Cushing's. And my finances are limited (retired on social security). I want to do right by him, but sometimes doing right is to not rush to judgment.
Any thoughts?

[labblab]

Welcome to you and to Kobe! After reading what you’ve written about Kobe, I can’t say that I disagree with your decision to hold off on further diagnostics/treatment for the time being. At age 10, we’ll be hoping that Kobe has several quality years ahead of him. But still, he’s approaching the “senior” category, and as such, my personal opinion is that it makes sense to weigh several factors when making a decision like this. So as to save some time, I’m going to paste in some comments that I’ve already posted elsewhere here on the forum.

In my own mind, the decision whether or not to treat any dog depends on a number of factors: age of the dog, apparent discomfort, severity of symptoms (both external and internal), etc. Cushing's is typically a slowly developing syndrome, and the decision to actively treat may come sooner or later in the process. The primary goals of treament are to control the troublesome observable symptoms (things like excessive thirst, urination, hunger, panting, muscle wasting), and also to halt/delay silent internal damage. Untreated Cushing's can make dogs more vulnerable to things like high blood pressure, high cholesterol, protein-losing kidney disease, blindness (as a result of high blood pressure), pancreatitis, ligament damage and slow healing, chronic infections and skin issues, GI disturbance, etc. Not every dog will suffer from all or even many of these issues, but the disease can make them happen. For a younger dog, I would want to provide as many quality years of life that I could, and that would mean putting a stop to the development of the internal systemic damage as well as relieving the uncomfortable outward problems.

However, since the damage usually occurs over time, my own opinion is that I don't worry so much about the "silent" damage in a dog who is already elderly. Instead, my biggest concern for a senior dog is immediate quality of life. So if the overt symptoms are making the senior dog uncomfortable, I would treat. Otherwise, I might choose not to treat, especially if my senior dog suffers from inflammatory conditions like arthritis that may actually be soothed by the elevated cortisol level of Cushing's. Treatment also involves frequent vet visits and blood draws, especially at the beginning. So again, if vet visits are really stressful for a senior dog, I'd also factor that into my treatment decision.

From your description of Kobe’s past history and current situation, I’d be especially watchful about two issues. The first is elevated glucose. Uncontrolled high cortisol, on its own, can elevate glucose to unhealthy levels. Also, it is not super-uncommon to see dogs exhibiting actual diabetes as well as Cushing’s. Regardless of whether elevated glucose is a temporary or permanent condition, it can quickly become life-threatening. So if Cushing’s is indeed involved and continues to raise Kobe’s glucose upward, that would be a reason to press onward with diagnosis/treatment in my opinion.

Secondly, given the fact that he has suffered from skin conditions in the past, I’d be especially watchful for the development of a skin condition called Calcinosis Cutis. If you Google the disorder as it appears in dogs, you’ll see photos and more information. The emergence of CC in dogs is almost always due to uncontrolled Cushing’s. It can quickly worsen, and has the potential to ruin a dog’s quality of life unless treatment is undertaken to lower cortisol levels.

I don’t mention either of these two things to worry you unnecessarily. But as I say, the presence or absence of either of these issues would affect my own treatment decisions if Kobe was mine. In the meantime, though, as I say — I can’t fault your decision to hold off on things for the time being. I also understand why you’d welcome the input from a specialist, and I’m so surprised that there are no internists listed in San Diego. That *really* surprises me. But I’ve just now checked the online database and have come up empty, too. You may already have seen this, too, but the ACVIM does list a toll-free number: 800-245-9081. Maybe if you talk to them directly, they can give you more info about specialists in the area. Anyway, we’re still really glad you’ve found us, and please feel free to ask any more questions.

Marianne

[inheriteddog]

Thank you for your comments and advice. A neighbor recommended another vet and I have an appointment scheduled for next week. I'd like a fresh evaluation, possibly alternative measures for the time being. But we'll see.

[Squirt's Mom]

Hi and welcome to you and Kobe!

IU agree with Marianne's comments 100% but did want to add some info on the liver enzymes.

You wrote - "ALP was 350, the other 3 liver enzymes were ALT 115, AST 17, GGT 6."

The ALP is typically very elevated in a cush pup...this elevation is very mild UNLESS the top of the normal range is something like 2. It is not uncommon to see this value in 1000's - I have seen it over 10,000 and it returned to more normal levels. According to an IMS (Internal Medicine Specialist) I used in the past, the ALP is telling you how hard the liver is working....these are LIVING cells.

The ALT and AST are very liver specific and do indicate dying cells according to that IMS. The ALT is usually indicative of liver injury via medication, accident, or disease process.

The GGT is associated with the bile ducts and often the functioning of the gall bladder.

Here is a good link for solid info on the liver values.
https://www.dvm360.com/view/canine-l...many-questions


Beagles are among the breeds we see quite often with Cushing's but based on what you have shared so far, I wouldn't rush into testing just yet. I would be more inclined to make sure the liver and gall bladder are functioning correctly. Just FYI....Cushing's is one of, if not THE, most difficult canine disease to correctly diagnose because it shares signs with so many other conditions, including liver and kidney disease. Also other health issues can and do cause false positives on any and all blood tests for Cushing's - the LDDS and ACTH. So diagnosing this disease is as much about ruling all other possibilities out first.

I'm glad you found us and hope to learn more soon about you and your sweet boy!
Hugs,
Leslie

[inheriteddog]

Thank you. Appreciate the extra information. We will be seeing a new vet tomorrow. I hope to get a clean evaulation.

[Harley PoMMom]

Looking forward to hearing what the vet says, good luck!

Lori

[inheriteddog]

The vet visit was done. After physical exam, the doctor recommended testing for Cushing's. He was unconvinced by my suggestion that Kobe's symptoms are not yet serious enough to warrant treatment, that he is an older dog, etc. For the doctor, the possibility of metabolic distress is enough. They did blood work and there were some changes. The ALP was still high but lower than six months ago. The AST was low. Cholesterold and triglycerides high, glucose high. However, the protein and albumin counts are low, and this offers a new concern, possibly issues with kidneys or liver, not related to Cushing's. He's advising tests to look into this, which may include abdominal ultrasound. So I'm going around with new things to be concerned about. Not to mention the finances. Not what I expected.

[Harley PoMMom]

Was Kobe fasted for the blood work? And if so, could you post the actual results?

[Squirt's Mom]

I would definitely want the abdominal ultrasound done. That can go a long way toward diagnosing Cushing's AND it can find things going on with the organs that could cause false positives if the cush testing were done. So this is a great diagnostic tool for Cushing's. My first cush pup tested positive on the ACTH, LDDS, HDDS, and UTK panel but the ultrasound found a tumor on her spleen and once that was removed all those tests returned to normal. It was the stress of the tumor causing the cortisol to rise in a NATURAL response. If the US had not been done I would have started treatment for a disease she did not have at the time. She did develop it later but at that time she did not have Cushing's. I highly recommend the US. I would agree to this test asap. Then go from there. Be sure to ask for copies of the comments made from the US if you decide to have this done.

With the glucose high that is also a concern depending on how high. So seeing those test results will help us help you better. You don't have to type the normal results but please do list all the abnormal along with the normal ranges and little letters that show. It will look something like this:

CHOL 300 H 150- 250 mnol/L
BUN 21 L 25-35 ug/dl

You aren't alone on this journey tho I know at times it sure can feel that way. Just holler at us here if you need to talk. We will be more than happy to help if we can....and we can always listen.

Hugs,
Leslie

[inheriteddog]

OK, here are the abnormal blood counts. I am giving two results, the first from July 2022, the second from this week, 6 months difference, followed by "normal" range. For comparison I am including all four liver enzymes even if they are within normal range. Blood was drawn maybe three hours after Kobe last ate.

Reticulocytes 77 115 10-110
Eosinophyls 0.042 0.042 0.07-1.49
Platelets 487 668 143-448
Glucose 128 153 63-114
Creatinine 0.3 0.5 0.5-1.5
Protein Total 5.7 5.1 5.5-7.5
Albumin 2.6 2.0 2.7-3.9

ALT 115 72 18-121
AST 17 10 16-55
ALP 350 318 5-160
GGT 6 11 0-13

Cholesterol 439 462 131-345
Triglycerides - 314 20-150