6 y/o cockapoo Bonnie recently diagnosed

[BonnieandDre]

Hi all,

My 6y/o Cockapoo Bonnie went in for her wellness appt last Monday and was diagnosed with Cushings. I'm crushed since since she's so young to be diagnosed - I was prepared for many more years with her. She's the absolute sweetest girl.
The vet noticed weight gain (16->18lbs) and her potbelly, so ran blood work. There are no changes related to her activity or mood.

Labs:
- Initial blood work: liver enzymes were high (ALP - 525 u/l; ALT - 148u/l); bilirubin high (1.7mg/dl); lipase very slightly above normal; everything else normal.
- Seeing high liver enzymes, recommended ACTH test: baseline was 9.2 ug/dl; 2nd reading was >30 ug/dl (so high the machine didn't even give a number, just ">30")

Rxs:
He prescribed Vetoryl (30mg w/ food 1x / day); Demarin for liver (½ tab without food)

Follow-up:
- Next ACTH test on 2/14/23; recommended ultrasound but very expensive (~$715!!)
- I also made an appt with UC Davis internal medicine doctor (Dr. Matthews) but this isn't scheduled until April due to their availability. I will keep trying to see about cancellations, but this is ~1.5 hrs away so not easy to get to)

[2/6: I brought her into the vet because she was having some blood in her poop. This isn't a new problem but it was worse today and now I'm hyperaware of everything . He rx'd probiotics Proviable Forte 2x/day with food, antacid Famotidine 10 mg) 2x / day; Sucralfate 2x w/out food (treats duodenal ulcers)] Will bring stool sample to my next appt on 2/14/23, to test for parasites.]

Qus for the group:
- Should I get an ultrasound? I understand this can help diagnose adrenal vs pituitary tumors, but the way I view testing is to INFORM next steps. From what I'm reading, adrenal gland surgery is very risky and expensive, so treatment seems to be the same for either location (Vetoryl). It could potentially tell me a better estimate of how long she will life, but do I want to know? The vet wouldn't say anything confidently, but suspects it may be adrenal tumors given her super high cortisol readings and young age. If adrenal tumors, I would then need to get a biopsy to determine if cancer? I do not have pet insurance so this is all out of pocket
- I'm really struggling with how expensive my vet is. Everything I'm reading estimates 1/2 the cost of the ultrasound quote I was provided at my vet. I've tried calling around different vets but they won't even given me a quote without an initial consult. How do you navigate this? I've already spend more than my rent on these last 2 appointments. I am in the Bay Area so understand it will be higher than a national average, but 200%!?
- Does anyone have experience with internal medicine at UC Davis?
- I'm not understanding why life expectancy is the same between untreated and treated dogs. I understand that this affects elderly dogs and they often die of non-Cushings diseases, but how does treatment not extend life given it keep cortisol in check?
- Does anybody have experience with Cushings in such a young dog?

Appreciate any insight. Grateful for the help.
Andrea and Bonnie (Bon Bon)

[Harley PoMMom]

Hi Andrea!

Welcome to you and Bonnie! I am sorry for the circumstances that brought you here but so glad you found us and we will help in any way we can. I'm a bit concerned that your vet diagnosed Cushing's so quickly based solely on weight gain and elevated cortisol because many health issues can cause high cortisol. Dogs with Cushing's generally display the most common Cushing's symptoms, such as increased drinking/urination, ravenous appetite, panting, exercise intolerance, difficulty or unable to go up steps or jump on furniture, and hair/skin issues. Does your sweet girl have any of those symptoms? Also, there are markers for Cushing's in the Chemistry and CBC blood results such as mild increases in the ALT, blood glucose, and high blood cholesterol concentration; in the CBC, a high total white blood cell count with increased numbers of neutrophils and monocytes and decreased numbers of lymphocytes and eosinophils are usually seen. Do you see any of these markers listed abnormal on Bonnie's CBC/Chemistry blood count?

Another concerning factor is her Vetoryl dosage is too high, the recommended starting dose is 1 mg per pound, so for Bonnie's weight of 18 lbs, her dosage should of not been any higher than 20 mg of Vetoryl, so please do keep an eye on her for any symptoms of her cortisol dropping too low such as inappetence, vomiting, diarrhea, or Bonnie simply not acting herself. If any one of those symptoms are seen just stopping the Vetoryl should help perk her up. With Vetoryl, it has to be given with a full meal to be properly absorbed and those ACTH stimulation tests have to be performed 4-6 hours after the Vetroyl was given with a meal.

Concerning the ultrasound, I feel the ultrasound is one of the most useful diagnostic tools, especially considering it's non-invasive. It can give an "inside look" at those internal organs and it might clarify whether or not there are primary issues with your girl’s liver or gallbladder, for instance, that might account for those high liver enzyme readings including the elevated bilirubin.

Cushing's is a treatable disease and with treatment dogs with Cushing's can have a good quality of life and there is every reason to believe that they can live out their normal life span. However, for the treatment to work safely and successfully it requires an educated pet owner along with an experienced vet as adverse side effects are mostly only seen when the proper protocols are not followed.

Please know you are not alone on this journey as we are right there beside you and if you have any more questions, please do not hesitate to ask them.

Hugs, Lori

[BonnieandDre]

Thanks so much, Lori.

She doesn't have all the symptoms you mentioned, so he diagnosed her based on weight gain/pot belly; elevated liver enzymes; and confirmatory ACTH test (From what I understand this is considered a pretty sensitive test?) She didn't have a CBC test so not sure on that.

Re: Vetoryl dosage, I called the vet to double check this since I read on this site how dangerous it is, and he said she's at the proper dose given her weight and how high her cortisol is. She has been tolerating it and we go back on Tuesday to check, but I will certainly keep a close eye on her for adverse events.

How do I find an affordable ultrasound?

[Squirt's Mom]

Hi Andrea,

Welcome to you and your sweet girl.

I want to second what Lori said about this starting dose....it is too high and could cause problems. Dechra, the drug's manufacturer, says to start at the LOWEST dose possible and for a dog of 18 lbs that is 1mg per pound...and that is in their literature for anyone to read. Any higher than 20mg per day is putting your baby at risk and costing you more to boot. I would INSIST the vet give her no more than 20 mg a day. That would be 2- 10mg tablets either both in the am or 10mg am and 10mg pm. BUT this is the least of the problems....

Your baby has very few signs of Cushing's and the lab work is not conclusive at all...for any dog not just yours. This is a sign-driven disease, meaning the signs are just as important as the numbers and sometimes more important. The ACTH and the LDDS, the two blood tests for Cushing's, can easily return false positives if any other health issue is present...such as a urinary tract infection or digestive issues or infection. I know - I've had two dogs misdiagnosed. The second one only had the ACTH and her results was >50. She did NOT have Cushing's tho....she had a host of other issues (including colitis which causes bloody stools) and her necropsy (autopsy for animals) showed normal adrenal glands proving she did not have the disease (she was not treated at the time because I had stopped treatment a while before she passed from an inguinal hernia). Neither the ACTH nor the LDDS are fool-proof but the LDDS is considered the gold standard for diagnosing Cushing's. FYI...my first pup had a tumor on her spleen which caused false positives on the ACTH, LDDS, HDDS, and UTK panel. Once the tumor was removed all those tests returned normal levels of cortisol. It was the stress of the tumor that caused her cortisol to rise NATURALLY in response. Same with my other baby who registered >50...stress caused a false positive on the ACTH. Cortisol is a fight or flight hormone and it's job is to rise in the face of any stress to help the body cope. It is the same in humans.

About the ultrasound...it will have little value for diagnosing Cushing's if the dog is already on treatment because the treatment will cause the adrenals to return to a more normal appearance UNLESS the tumor(s) are on one or both adrenal glands. It will have value as far as looking for tumors, etc. but little to none for diagnosing Cushing's once the pup is on medication to reduce the cortisol. If there was a tumor present or some other issue with an internal organ that could impact the ACTH so that would have some value. It was the US that saved my first pup's life by finding that tumor. Not only could it have ruptured but had I started treatment without being aware of it the treatment could have made her very very sick - or worse. So the US definitely has value but it should be done during the diagnostic phase and not after treatment has started.

My Squirt, first one misdiagnosed, did eventually develop Cushing's and she was 7 at the time. She passed at the age of 16+ WITH Cushing's not FROM it and I had stopped treatment for her a year earlier due to her age and dementia. Our cush pups can do live out their normal lifespan IF correctly treated and none of the uncommon complications arise. So don't despair about the time you may have left just yet...the picture is far from clear for your sweet Bonnie.

I, too, am very glad you found us and look forward to learning more soon.
Hugs,
Leslie

ps...I hope this makes a little sense; I am writing in a rush unfortunately.

[Harley PoMMom]

An elevated bilirubin is generally not seen in dog's with Cushing's, Bonnie's is 1.7 which is pretty high, this is usually seen in dog's with a liver issue or a blocking or damaging of the bile ducts. Liver issues in dogs can often be accompanied by ascites, or fluid accumulation in the abdomen. Those with ascites will have an abnormally swollen belly which may be the reason for Bonnie's weight gain and pot-bellied appearance.

I think that seeing Dr. Matthews at UC Davis is a wonderful idea as IMS' generally have more knowledge about Cushing's than a GP vet because IMS' have seen more cases.

Concerning the cost of the ultrasound, for my vet visits I use CareCredit, it allows for 6 months to pay it off before interest is started. Here's a link to a thread in our Helpful Resource forum regarding "Financial Resources to help with Vet bills" https://www.k9cushings.com/forum/sho...with-Vet-bills

You're doing a great job!!!

Hugs, Lori

[BonnieandDre]

Wow thank you both so much - you're providing such valuable information and giving me some hope it may not be Cushings! (Although I'm sure liver issues are quite serious as well).

Things that don't "add up" with a Cushings diagnosis:
- limited Cushings symptoms (pot belly/weight gain - which are unspecific); no increased thirst/peeing, skin problems, behavior change
- high bilirubin (1.7)
- her age (6 y/o)
- bloody poops
- normal baseline cortisol is very high (9.3) / Bonnie is generally an anxious dog

Evidence for Cushings:
- ACTH test
- not evidence, but a risk factor - Cushings is more common in cocker spaniels and poodles (she is a mix)

It seems very hard to tell cause and effect, ie, is elevated cortisol levels causing liver disease or is liver disease is causing elevated cortisol levels?

Wouldn't Vetoryl bring down cortisol levels regardless of the cause (liver or cushings)? If so, the follow up ACTH won't tell me any new information about root cause.

I'm wondering if I should stop the Vetoryl before going to the UC Davis specialist. Being on it would muddy the waters in deciphering the root cause (especially if I do an ultrasound, I want it to be as useful as possible).

Re: ultrasound cost, thanks for the suggestion. I'm mostly just annoyed/upset with mylocal vet for charging literally double the national average :/ If it's less useful to do now, may make sense to wait until I go to the specialist. How bad would it be to stop her meds before that appointment? (Vetoryl and Demarin, a liver supplement). The specialist is far, expensive, and takes ~7 weeks to get an appt, so want it to be as useful as possible.

I will report back what I hear on Tuesday.

Thank you!

[Harley PoMMom]

If this were me, and letting you know that I am not a vet nor have any experience in the veterinary field, I would stop the Vetoryl and most definitely see the IMS at UC Davis. I do believe something is going on with Bonnie's liver and Vetoryl should not be given to a dog with a hepatic disease.

Those ultrasounds are expensive to have done and not all ultrasounds are created equal. A good quality ultrasound/interpretation depends on a few things; the tool used, the technician performing it, and the physician interpreting. The technician, most likely, will perform their own and therefore, it should be those most experienced with capturing good windows and images. That would be a board-certified radiologist or board-certified Internal Medicine Specialist. Likewise, the one interpreting it should be the most experienced as well, and that's generally one of the 2 above.

Hugs, Lori

[labblab]

Welcome from me, too, although I’m so sorry that you have these new worries about Bonnie’s health. Lori and Leslie have already given you lots of helpful information, so I just have a couple of thoughts of my own to add.

First, in answer to your question re: holding off on giving any more Vetoryl until your UC Davis visit, I think I’d answer “yes” if Bonnie were my own dog. It’s probably fine to continue with the Denamarin since I think it’s intended to support the liver regardless of the specific cause of liver problems. But as far as the Vetoryl, here are my concerns.

First, as the others have noted, I have worries about the Cushing’s diagnosis itself. Secondly, I’m also worried about the dose. I’m especially concerned that your vet is justifying this dose on both the basis of weight (too high an initial dose for Bonnie’s weight), and also due to “how high her cortisol is.” According to all published dosing guidelines from the manufacturer, initial dosing decisions are based *solely* on weight. Cortisol levels are only factored into subsequent monitoring decisions after Vetoryl therapy is underway. So your vet’s explanation for his dosing decision seems wrong to me on both counts.

Secondly, I agree that you’ll likely have a more accurate diagnostic ultrasound assessment of Bonnie’s adrenal glands if she has *not* been taking the Vetoryl beforehand. Over the years I’ve seen conflicting info about Vetoryl’s effect on the size of the adrenal glands. I decided to do a little more Googling today and came up with this very interesting 2022 study. Quite surprisingly, it suggests using adrenal ultrasound results to monitor the effectiveness of Vetoryl treatment based on the premise that the *larger* the adrenals become throughout the course of therapy, the greater the likelihood that the Vetoryl is having an effective result. Since a bottom line of the article is that Vetoryl (trilostane), itself, causes enlargement of the adrenal glands, I would think that giving the medication beforehand would muddy the water for an initial pretreatment diagnostic ultrasound.

https://www.scirp.org/journal/paperi...paperid=119708

One final thought. I believe one cause of elevated bilirubin can be the presence of a gallbladder mucocele, and Cushing’s can increase a dog’s vulnerability to forming those mucoceles. But there are other causes of both elevated bilirubin and the formation of those mucoceles. Again, an ultrasound would be the tool to help diagnose a mucocele. But you want the best quality ultrasound possible.

I just now paused my own typing long enough to see Lori’s new reply, and she wrote in far less words exactly what I’m trying to say — I’d hold off on the Vetoryl, the ultrasound, and any more testing until you see the specialist at Davis! We are not vets ourselves. But that’s what I’d do if Bonnie were mine.

Marianne

[Squirt's Mom]

Andrea, count me as a third vote to stop the Vetoryl for now. I would want a second opinion based on an untreated status. Then any testing done can more accurately reflect what is going on with your sweet Bonnie. IF it is Cushing's, not treating is better than treating with a dose that is too high. Cush pups can live a long time (barring complications) without treatment so waiting til she sees the IMS shouldn't be a issue for Cushing's disease if that is in play (which I highly question).

One other tidbit....liver disease is one of the conditions that has caused false positives on the cush blood tests and it shares some of the same signs.

Hang in there! You've had a lot coming at you all at once and I KNOW how that can really get your head spinning. You are doing a great job of listening and researching! Bonnie is very lucky to have you on her team.

Hugs,
Leslie

[BonnieandDre]

Hi everyone,
My mom was able to get in touch with our old vet who sold his practice to the vet I have been going to. He was willing to speak with me on the phone and I shared Bonnie’s info and he seemed pretty convinced it is in fact Cushings, but recommended the ultrasound.

Marianne, interesting article - the vet mentioned the more you block the cortisol the more adrenals pump it out (needing to increase dose over time) so makes sense that they would enlarge over time. I wonder how long it would take to decrease though once I stop… to get an accurate read.

Will follow up with an update on Tuesday.
Thanks all, Andrea and Bon