Miss Millie Mayhem (Eng Bulldog) - NEW Dx: Cushings PDH and AWFUL Calcinosis Cutis

[addy]

Vet called...Just got the results back from her 11 day ACTH test following Millie's start on Trilostane. For reference I am posting the ACTH results pre-treatment as well:

Pre-Treatment:
Cortisol Sample 1: 2.1 ug/dL
Cortisol Sample 2: 8.5 ug/dL

11 Day ACTH:
Cortisol Sample 1: 0.8 ug/dL
Cortisol Sample 2: 5.0 ug/dL

Do you have the lab's reference range for the pre ACTH test?
I am no expert but something is off somehow. Is that the original ACTH test to diagnosis is inclusive as it shows normal cortisol?

Coritsol sample one after 11 days is pretty low. Dechra prefers it not go below 1.45ug/dl.
Cortisol sample 2 is fine.

I am sure one of the administrators will stop by with thoughts.

[khockman]

Oh no, that's what I thought. Now I am so worried...just called Dechra..

[addy]

Yup call Dechra and check, I could be wrong, I am at work.

[Trixie]

Wish I could help with numbers...but I'm no expert. Just posting to say I hope all is okay with Millie and that you're able to find out about this result today.
Barbara

[addy]

Interpreting acth tests goes along with symptoms and history. I may just be nervous of a .8 pre after 11 days of dosing. What I don’t understand is the pre treatment numbers.
I’ll bump this up.

[khockman]

Thx addy... Would it be helpful if I emailed the actual test result papers so they can be uploaded? Should I send all as one file if so?

[Harley PoMMom]

Interpreting acth tests goes along with symptoms and history. I may just be nervous of a .8 pre after 11 days of dosing. What I don’t understand is the pre treatment numbers.
I’ll bump this up.

I was a bit baffled about those pre treatment ACTH results but Marianne had explained it well in the quote below:

Hello and welcome from me! Thought I'd go ahead and throw my thoughts into the ring, too.

This is just my personal opinion, but I do believe that Millie's list of classic Cushing's symptoms, the calcinosis cutis, and the positive LDDS all "trump" the ACTH and point to a genuine Cushing's diagnosis. Even though the ACTH is less prone to "false positives" than is the LDDS, it is far more prone to "false negatives," especially for dogs having the adrenal form of the disease. So in a situation such as this, where Millie is so symptomatic but has turned up with a negative on the ACTH, the recommended protocol would indeed be to turn to the LDDS for further confirmation. The abundance of false negatives on the ACTH is probably the main reason why many specialists discount the ACTH as the initial Cushing's testing tool, although I do believe there are situations where the ACTH has a testing advantage (but I won't bore you with an explanation here).

On their own, Millie's LDDS results do not distinguish between the pituitary and adrenal forms of the disease. But her ultrasound is consistent with PDH since both adrenals were enlarged. So if it were me, I would feel as though your vets are making the right decision in pushing ahead with treatment given Millie's entire symptom and testing profile.

One quick question for you: you mention that she is also taking phenobarb. Does she have a seizure disorder? I will come back and add another reply about the phenobarb, but it may end up having an effect on the trilostane dosing down the road.

Marianne

With Millie's recent ACTH results I hope that the dose of Trilostane was not increased because the numbers can continue to decline.

[labblab]

Hello again, and darn! I'm sorry there's any question at all about those ACTH results. But I'm glad you're contacting Dechra because I'd like to get their "take" on things, especially given the fact that Millie is also taking phenobarb. I think I wrote earlier that a Dechra technical rep had warned me in the past that trilo dosages may need to be adjusted due to phenobarb's effect on the liver and therefore the way in which other drugs may end up being metabolized. So do be sure to mention the phenobarb to them.

We never used to worry very much about the "pre" ACTH number, but it does seem as though Dechra is not happy about results that drop below 1.45 ug/dl on either the pre or the post. So I'd welcome their input. With a "post" of 5.0 and electrolytes within range, I don't think Millie is in any immediate danger of oversuppression, but Dechra may advise you back off on the trilo dose somewhat. Which I realize will be disappointing since you are not seeing much improvement thus far. I do have to warn you that issues with the skin and muscle wasting can take weeks to improve -- not just days . So even when trilo is at a therapeutic dose, it is usually the thirst, urination and hunger that improve before the rest. Since excessive thirst and urination can also be a side effect of phenobarb, I'm still wondering whether that can be confounding her symptom pattern at all. But I think you told us earlier that she had not had those issues while taking phenobarb before her diagnosis, so I guess that's probably a dead end.

It is certainly true that Millie's diagnostic ACTH remains a bit of a puzzle in that it was so far below the level associated with a Cushing's diagnosis. I was kinda hoping that everything would go swimmingly with the trilostane and you'd be seeing symptom improvement such that we'd feel as though we had additional confirmation that we're totally on the right track. And maybe with just a bit more dose tweaking, that will still be the case. But regardless, I'm really glad you're consulting Dechra and I'll be very interested in what they advise you to do in moving forward.

Marianne

[molly muffin]

You said you called Dechra? What did they say?

Sometimes when the pre number is on the low end, they will recommend, lowering the dosage, so as to have no risk of over suppressing. Personally I don't like that pre number being that low since cortisol levels can continue to drop even up to and sometimes beyond 30 days. Since her cortisol wasn't particularly high to begin with, I'd like the pre number around the Dechra recommended range of as Addy mentioned 1.45. With the post number around 3. - 5. if I had a preference. I seldom get exactly when I want especially with little ones with a mind of their own. That is just my own personal thought on the numbers. I'm sure some of the administrators who have a vast amount of experience will chip in with their thoughts.

Don't be discouraged by not having symptoms of cc cleared up yet. That along with muscle weakness can take the longest to clear. Months even. So hang in there.

Hang in there!!!
hugs,
Sharlene and Molly Muffin

[molly muffin]

I see Marianne and I were typing at the same time. Glad she saw this and was able to respond.
I agree, it would be great to know what Dechra's interpretation is, especially in relationship to the phenobarb

hugs,
Sharlene and Molly Muffin