Help deciding on treatment (13.5 y/o Shetland Sheepdog)

[Sadie201]

Hello! I am new to the forum and I have a 13yr old Shetland Sheepdog named Sadie who might have Cushing’s. She has been drinking and peeing excessively for quite a while now. Originally I was told it was a UTI but antibiotics didn't help and a further urinalysis showed no signs of a remaining UTI. It was then suggested that I try a drug for incontinence because other than the drinking and peeing you would never know she was a 13yr old dog. We then tried what seems like every drug available for incontinence but with no improvement (Proin, Imipramine, Incurin). Frustrated that nothing was helping I tried another veterinarian for a second opinion. I had a CBC/Chem done as well as another Urinalysis. The Urinalysis results were:
Specific Gravity 1.006
Protein +2
Urine Protein/Creatinine Ratio 8 (normal is less than 1 ideally less than 0.5)
The CBC/Chem showed increased liver enzymes:
ALT: 217 (10-55)
AST: 49 (12-40)
ALP: 389 (15-120)
ALPCAP: 312 (0-6)
GGT: 9 (<3-6)
In addition I was told her Blood Pressure was too high and she was placed on Enalapril. I was also told that she is stage 1 out of 4 for kidney disease due to the protein in her urine. However her kidney values were normal. Due to the increased liver enzymes I decided to have her tested for Cushing’s and first we went with the easiest test Urine Cortisol Creatinine Ratio. Her UCCR result was 609! (Cortisol 11.9ug/dL and Creatinine 41.2mg/dL) (a normal ratio is <34) Now I know that this test is not specific for Cushing’s and an increased UCCR can be caused by several other non-adrenal disease. Mainly I’m wondering if anyone else has had a UCCR performed on their dog and what the value was? 609 seems so high that neither I nor my veterinarian can think of anything else that would cause this high of a result other than Cushing’s. I am interested since she doesn’t have many classical signs except for polyuria/polydipsia and a few patches of hair on her belly that haven't grown back after it was shaved by a groomer 1 yr ago(who had no reason to nor permission to shave it in the first place > ). i.e. she’s not potbellied, she doesn’t pant excessively, no weight gain, and I haven’t noticed excessive hunger. Thanks so much for all your help and sorry for the long post!

[Harley PoMMom]

Hi and welcome to you and Sadie!

Sorry for the reasons that brought you to us but glad you found your way here.

Although excessive drinking/urination are some of the classic clinical signs of Cushing's, there are other issues that can cause those same symptoms. Has diabetes been ruled out? Usually with Cushing's we see a very high ALP with a moderate elevation in the ALT, both of which are liver enzymes, Sadie's ALT is unusually high, so I believe I would have a look at her liver either by ultrasound or having a bile acid test done to check to see how the liver is functioning. Also, were any Tick-borne diseases ruled out?

Many things can cause protein to spill over in the urine, and often times protein loss is secondary to another illness. Having high uncontrolled blood pressure will cause protein loss. Even though Sadie's UPC is high this does not confirm that Sadie has kidney disease, again, an ultrasound could show any abnormalities with the kidneys. If this were me, once Sadie's blood pressure is stablized I would have another UPC done, many times once the high BP gets under control the protein spillage will lessen too.

Regarding the UC:CR, was the urine sample collected at home? And you are correct in that other nonadrenal illnesses can create high numbers on a UC:CR test, so with all that is going on with Sadie I can see why her UC:CR might be high.

These are just my thoughts and I am sure others will be by to share theirs, again, welcome to our family and know we will help in any way we can.

Here's a link to an article about PU/PD written by Dr. Mark Peterson, a renown Cushing's expert, on his blog: Diagnostic Approach to PU/PD: Urine Specific Gravity


Hugs, Lori

[Sadie201]

Diabetes has been ruled out due to normal glucose on the CBC/Chem. I hadn't really considered Tick-borne diseases but I think they are unlikely. I have her on Vectra in the summer but she only ever goes in our backyard and I have never found a tick on her.

Yes the urine sample was collected at home first thing in the morning and several days after the veterinary visit to ensure that the cortisol wouldn't be elevated due to stress.

Thanks for the link to the website, it's very helpful!

[Sadie201]

Hello everyone I'm new here and my dog Sadie was just officially diagnosed with Cushings and I need some advice. She is a 13.5 year old Shetland Sheepdog. She's extremely special to me as she is my first dog and I couldn't have asked for a better, more patient dog to go through the learning curve with. Her biggest symptom of cushings is excessive urinating and drinking. She actually started with the excessive drinking and urinating summer of 2012, I took her to the vet and at that time they told me she just had a UTI and proteinuria and we went through several different antibiotics and when the symptoms didn't go away we ran a CBC/Chem which showed elevated liver enzymes and very slightly elevated kidney values. At that time I was told she had early kidney failure and possibly cushings but that was added as more of an afterthought and I forgot about it. Fast forward to 2013 at her yearly visit we repeated CBC/Chem and urinalysis and found that the liver values were still elevated and she still had a lot of protein in her urine. We did a Urine cortisol to Creatinine which was very high, but of course this is not a definitive diagnosis for cushings. However the vet told me I could start her on Vetoryl. We tried it for 4 wks but I saw zero difference in the drinking or urinating so we stopped it. I have since decided to try a different vet and yesterday we performed a LDDS which confirmed that she does actually have cushings, of course it was inconclusive as to whether it's due to pituitary or adrenal tumor. So I know based off of reading a lot of the threads on here most people decide to treat their dogs with either Vetoryl or Mitotane. My question for you all is, is it worth it? Her symptoms are mild compared to a lot of dogs with cushings and she has already been living with it untreated for probably 2 years with no worsening of symptoms. She drinks excessively and urinates excessively so it would be very nice to get that under control (for the sake of the carpet in my house!) but mitotane makes me nervous. She also has high blood pressure which is controlled with Enalapril, but she doesn't pant excessively, is not pot bellied, liver values are holding steady at mildly elevated , she eats normally, has a slightly poorer coat then she did when she was young but you wouldn't know it if you didn't know how she used to look (people often mistake her to be a much younger dog), she is active, alert and playful. She is also hypothyroid (but has been for many many years and it is under control). I have started giving her Denamarin just for liver support but I'm really struggling with the decision as to whether to treat her with the Mitotane or try vetoryl again or to just keep treating the symptoms as best I can. Any help would be much appreciated! THANKS!

[mytil]

Hi and welcome to our site. I am sorry you and your girl are dealing with this.

Firstly I would like to see if any other conditions had/have been ruled out with her only symptoms being excessive drinking and urination. Most times dogs with Cushing's have ravenous appetites and your Sadie does not.

If I am reading this right you only had a LDDS test (please post the actual values here). Well, I would certainly not trust just one test as to diagnose Cushing's there are several tests that have to be performed as it is a difficult condition to diagnose as the symptoms do mimic other conditions.

I just about dropped my teeth when I read about the inconclusive UC:CR test performed and the vet prescribed Vetoryl....this is completely wrong. Here is some great reading about the diagnosis and treatment --- http://www.k9cushings.com/forum/showthread.php?t=180. In addition, some inhibitors (for her heart condition) should not be mixed with Vetoryl.

I would certainly not start any treatment until a firm diagnosis is made and other conditions have been ruled out. There are different types of Cushing's (Atypical for example). In addition there is a condition called Diabetes Insipidus where the body fails to maintain its water balance)

Please keep us posted
Terry

[labblab]

Hello and welcome from me, too! Terry has already covered the bases re: diagnostic confirmation. But if it turns out that your dog truly has Cushing's, here are a couple more thoughts that I would add re: proceeding with treatment.

Cushing's is typically a slowly progressive disease but it does have the potential to cause systemic damage over time (from high blood pressure, vulnerability to pancreatitis and infections, high cholesterol, kidney damage, liver inflammation, etc.). So for a younger dog, I'd certainly recommend effective treatment so as to eliminate some of these risks, improve longterm quality of life, and allow the dog to live out his/her normal lifespan. However, for a dog of your girl's age, immediate quality of life issues seem of paramount importance to me. And there are some trade-offs to treatment, especially for an arthritic dog since the arthritis may actually worsen as the cortisol level drops, necessitating the introduction of additional drugs to better manage the discomfort. Also, especially at the beginning, there can be numerous vet visits and blood draws which can be less than pleasant for a dog who's nervous at the vet (and also hard on the owner's pocketbook ).

I don't tell you any of this to dissuade you from treating if you and your vet agree this is the best path forward for your dog. For instance, if there are significant amounts of protein in her urine, uncontrolled Cushing's may indeed be playing a part and lack of treatment may allow kidney problems to progress, perhaps even rapidly. But again, at her age, I do think you are the best judge as to how uncomfortable her current overt symptoms are to you both, and if they are not bothering her all that much -- as I say, you may want to hold off on treating for the time being. You are both so lucky to have shared all these years together, and given her life expectancy, I realize that extra quality time from this point onward is a gift to be savored.

As far as her lack of response to the Vetoryl -- if she does have Cushing's, this may simply have been the result of a dose that wasn't high enough. Starting doses are based on weight, but subsequent adjustments are often needed once monitoring testing is performed. This is because every dog metabolizes the drug differently, and the optimal dose must be tailored on an individual basis.

Just a couple of thoughts to throw into the mix.
Marianne

[Harley PoMMom]

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

Cushing's can be a difficult disease to get a confirmed diagnosis for because other non-adrenal illnesses share some of the same symptoms as Cushing's plus there isn't one test that is 100% accurate at diagnosing Cushing's.

Regarding the UTI, was an urine culture and sensitivity test done? The urine culture and sensitivity test is performed to identify the exact bacteria that is causing the infection so the appropriate antibiotic that will treat the bacteria can be prescribed, I highly recommend that Sadie have this test done.

Some herding dogs can be sensitive to certain antiboitics, they have the mutant MDR1 gene. The MDR1 mutation has been found in Shetland Sheepdogs. The only way to know if an individual dog has the mutant MDR1 gene is to have the dog tested.

Hugs, Lori

[Sadie201]

I just about dropped my teeth when I read about the inconclusive UC:CR test performed and the vet prescribed Vetoryl....this is completely wrong.

One of the many reasons I found a different vet! I guess I was too trusting. I don't think he ever did a urine culture, or at least one that I'm aware of. He also had me try every drug for incontinence there is, even though I told him she wasn't incontinent. Just drinking too much!

As for test results her Urine Cortisol:Creatinine Ratio was 609 (Cortisol 11.9ug/dl, Creatinine 41.2 mg/dl)

Low Dose Dexamethasone
Pre 4.5
4hr Post 2.5
8hr post 2.4

Relevant CBC/Chem (anything not listed was within normal limits)
ALP 425 (20-120)
ALT 132 (10-118)
Amylase 1252 (200-1200)

Protein in urine is usually +2 or +3

[mytil]

Hi again,

I have just second (heading out the door) but I merged your threads as I saw you had posted at the beginning of the year. I will be back on tomorrow morning to add a few more comments.

Terry

[molly muffin]

Hi just checking in to see if they did any type of follow up culture on the urine?

I think the urine protein is probably one of the main reasons the vet wanted to go ahead with treatment for cushings. I do think that a full kidney panel needs to be done to make sure that this isn't a kidney problem as the main thing first.

Sharlene and molly muffin