Charlie 13 year old Labradoodle, Adrenal Tumour, Vetoryl to Melatonin/Flax Lignans
My dog Charlie is now 13.5 years old and I've been dealing with his health issues for about 3 years now. After many tests, our veterinarian beieves that he has Cushings from an adrenal tumour. I initially took him to the vet to check out because he was sleeping alot. He has the shakes but has had those for over 7 years now, so not sure if that was an indicator of Cushings or not, started with his legs shaking but now his whole body shakes. I was the one who brought up Cushings because his two liver enzyme counts pointed to it and the vet concurred. We have never tested him for diabetes and not sure we should.
His test results were:
Blood Tests (November, 2020):
Hematology:
WBC 8.93 X10E9/L
RBC 7.20 X10E12/L
HGB 174.0 g/L
HCT 0.522 LAL
MCV 72.5 fL
MCH 24.2 pg
MCHC 334 g/L
RDW 15.2 %
Platelet count 343 X10E9/L
Differential: % ABS
Neutrophils 86 7.68 X10E9/..
Lymphocytes 8 0.71 L Xi0E9/L.
Monocytes 6 0.54 X10E9/L
RBC Morph Normal
COMMENTS: Platelet numbers are adequate. Variability in platelet size apparent. RBC morphology is normal for species.
Small Animal Chemistry Profile:
Glucose, Serum 5.4 mmol/L.
BUN 3.9 mmol/L.
Creatinine 53.4 L umol/L
BUN/Creatinine Ratio 73
Phosphorus , 1.75 mmol/L
Caicium 2.67 mmol/L
Sodium 149 mmol/L
Potassium 5.2 mmol/L
Na/K Ratio 29
Total Protein 64 g/L
Albumin 36.4 g/L.
Globulin 28 g/L
Albumin/Globulin Ratio 1.3
Bilirubin, Total 3 umol/L.
ALP 1064 H U/L (very high)
ALT 324 H U/L (high)
GGT 7 U/L
Chloride 112 mmol/L
Carbon Dioxide 22.9 mmol/L
Anion Gap ; 19
CPK 172 U/L
Osm, Calc 296
Cholesterol 9.0 mmol/L 3.
Amylase 689 U/L
Lipase 718 U/L
Tetraiodothyronine 20.8 nmol/L
COMMENTS: Sample slightly hemolyzed and slightly lipemic. Stress lymphopenia. Low creatinine - weight loss/decreased muscle mass? Marked increased alk phos with mild increased ALT - biliary oriented liver lesion? Hyperadrenalism? Check adrenal function and/or bile acids/hepatic function? Cushings is not usually associated with weight loss.
Blood Work/Urinalysis (November/20 & January/21):
Vet advised the elevated liver enzymes persist - ALP has slightly increased although I would consider that number stable (1081 on Jan 5 versus 1064 on Nov 17, normal range [ 21-122]) while ALT has improved (246 on Jan 5 versus 324 on Nov 17, normal range [0-113]). - so globally I would say stable to improved.
The low BUN (urea) persist could be a biologic variation, or due to low protein intake ot liver disease.
He has also Low creatinine that could be due to Muscle mass loss and Stress induced lymphopenia, when you have low lymphocytes ( type of white blood cells) due to stress.
Blood Work/Urinalysis (February & March, 2021):
The liver values have been getting better ALP went from 1081 to 639 [21-122] and ALT went from 246 to 235 [0-113]
Comments: ACTH stimulation test does not support optimal control of hyperadrenocorticism since well-controlled Cushing dogs typically have a
cortisol level between 40 and 150 nmol/L post-stimulation. Does it fit with your clinical impression? Elevated liver enzymes - improvement. Low creatinine: artifact, sample color.
I asked my vet if we tested Charlie for thyroid disease or hypothyroidism just to rule them out and she indicated that his blood tests indicated normal thyroid level
ACTH Response Test (March & May 8/21):
liver values have made some improvements. In March the ALP was 639 its now 464 and the ALT was 235 and its now 208.
Unfortunately his stimulation test is indicating he is not well enough controlled at the dose he is currently taking.
His pre/post cortisol last time was 51/403 and it is now 40/306. In well controlled dogs, the post value should be less than 150.
ACTH Response Test - 2 samples (June 17/21):
Endocrinology
Cortisol, Pre 41.1 nmol/L
Cortisol, Post 46.1 L nmol/L
Comments: Adequate control of hyperadrenocorticism assuming fits with your clinical impression.
Ultrasound (April 2021) - indicated a mass in his adrenal glands that affected both sides, if they were to remove both his adrenal glands he would then be an Addisonian. My vet said that means he would not be able to produce mineralcorticoids which control his ability to maintain proper sodium and potassium electrolyte balance and will impact his ability to keep himself from being dehydrated. This is a life threatening condition and would have to be very carefully managed with a drug called Florinef. He would no longer have Cushings disease, but Addison's disease is not an easy trade off. The results could also indicate cancer.
Ultrasound Report Findings:
1. Bilaterally enlarged and heterogenous adrenal glands with extension into the left and right phrenicoabdominal veins is most consistent with
neoplasia (adenocarcinoma and/or pheochromocytoma given highest consideration). Tissue within the left phrenicoabdominal vein extends to
the level of the caudal vena cava.
2. Nodular tissue diffusely along the mucosal margin of the gallbladder may represent neoplasia or inflammatory tissue. There was a small
amount of sludge in the gallbladder without evidence of organized mucocele formation.
3. Subtle hyperechoic and hypoechoic liver nodules may represent nodular regeneration, vacuolar hepatopathy, granulomas, or possibly
metastatic neoplasia.
4. Subtle hypoechoic nodules within the spleen may represent extramedullary hematopoiesis, lymphoid hyperplasia, or less likely neoplasia.
Hyperechoic nodules within the spleen are most consistent myelolipomas.
5. Very mild enlargement of mesenteric lymph nodes may represent reactive lymphadenopathy or possibly metastatic disease.
In April/21 he also had xrays to check his liver and maybe spleen and he started antibiotics, Clavaseptine and an ephatic dogfood to try that he wouldn't eat.
He was taking Vetoryl (last dosage was 30mg in am/10mg in pm) for over a year but I stopped giving it to him about a year ago because he lost over 10 pounds and he was only a 30 pound dog. He wouldn't eat anything and I was scared he was just going to starve to death if I didn't do something. I was also giving him Denamarin to increase his appetite which didn't work, Zentonil (Sam-E) for his liver, Milk Thistle for his liver and Tramadol for pain. I have had him on 3mg of melatonin and 35mg of SDG lignans for over a year now and his appetite came back and he gained a few pounds but lately he has been panting more and has back leg weakness so I'm worried his Cushings is worse. He acts like he's starving all the time too now. Both melatonin and lignans inhibit different enzymes used in cortisol production. They also target adrenal tumor cells allowing them to treat all forms of Cushing’s Disease from different studies I have read. I did ask my vet about Entyce (capromorelin oral solution) which has had very promising results but that is only available in the US and I'm in Canada.
I'm wondering if I should put him back on Vetoryl or try something else (maybe increase the melatonin and SDG lignans). I did change his diet to a freeze dried dogfood made up of whole fish, berries, vegetables and organ meat made by my breeder, which he loves. He also gets dried chicken hearts and some low fat/high fibre kibble and he usually eats it all up and wants more. And freeze dried liver treats of course.
Charlie's such a sweet boy it makes me sick that I can't help him more. He has two Doodle buddies that love him and he's got alot of energy still, he plays like a puppy but needs rests more. He loves swimming so he gets to go in the pool with his life jacket on. He's my bestest little buddy that has helped me through some really hard times with my own health, I just love him to bits and would do anything for him.
Any suggestions are welcomed.
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The ALT is concerning tho. As was explained to me by a vet neurologist the ALP represents living cells and tells us how hard the liver is working. However ALT and AST represent dying cells and indicate damage or a disease process - which could be Cushing's or could be something else. The improvements in this value of Charlie's over time is encouraging tho.