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**k9diabetes** · 04-28-2008, 07:39 PM

Re: Reba's numbers

You've probably seen the discussion over on the Cushings board about whether to load for atypical Cushings. Dogs like Crissy Ann were loaded but Dr. Oliver was recommending not loading for Kiska, perhaps in part because she doesn't have many elevated hormone levels.

Jeanne was about to go straight to a maintenance dose but probably will wait now since Kiska's BG improved a bit more. She's had the implant for... a couple of months maybe.

With Reba having just about everything elevated, they might recommend doing a loading dose since they want to bring the cortisol down too.

But I agreed with the vets Jeanne talked to about Kiska... as long as the dog is reasonably comfortable, there's really no harm in trying a maintenance only dose first. If it doesn't do any harm and doesn't work to control the Cushings, you can always load later.

Most of the atypicals don't also have high cortisol so Reba's in something of a class of her own.

Your test was essentially an ACTH, wasn't it? They did the pre, did the stimulation with ACTH, and then did the post an hour or two later?

Natalie

**Denise** · 04-28-2008, 08:30 PM

Re: Reba's numbers

No, all she's had is the adrenal panel. On the Cush board I was just told that I might want an LLDS even though the adrenal panel basically shows the elevated cortisol to be enough to dx Cushings.

Guess I can spend more money, what the heck!

Bogie was in a class by himself, I don't need another dog that way!

I also need to check on the implant. I don't think my regular vet knows anything about it though.

Also, it's really not a big deal giving her the pills, I'd only have to add another 3 mg. a day and since the diabetics are on a 12 hour schedule it wouldn't be hard to remember to give Reba the other pill. At night she gets it with her Benazypril and Norvasc and she loves her bite of liver wurst!

I'm tired of thinking, reading....

Ran her to the vet late day today, didn't like the breathing sounds I was hearing but of course she wasn't doing it there and they said her lungs were clear. I was hearing a sound like a very growly stomach but it was from her chest. Maybe tummy sounds but I swear they were with each breath. Maybe she has sleep apnea and that's why all the sounds I hear besides normal snoring.

**k9diabetes** · 04-29-2008, 10:41 AM

Re: Reba's numbers

I know they technically didn't do an ACTH, but presumably they gave her some kind of stim injection in order to get a post value for cortisol.

What did they give to stimulate the post value and how long did they wait between pre and post?

Natalie

**acushdogsmom** · 04-29-2008, 02:19 PM

Re: Reba's numbers

Natalie is correct. The UTenn "adrenal panel" is an ACTH stimulation test. The only difference is that UTenn measures pre and post stimulation cortisol AND the other adrenal hormones (whereas other Labs only measure the pre and post stimulation cortisol)

See here:
http://www.vet.utk.edu/diagnostic/en...ts_info_07.pdf

g. Adrenal Panel for Dogs and Cats (ACTH Stim) -Test for congenital adrenohyperplasia-like syndrome (dogs, cats), or Alopecia-X, Atypical Cushings Syndrome

Note: All Adrenal function tests use serum samples.

*Adrenal panels are batch-run weekly (DHEAS is no longer available)

i. Collect baseline serum sample (1.0 ml.).
ii. Centrifuge sample as soon as possible, separate and freeze.
iii. Administer the ACTH Stim test as above (3A). Collect Post-ACTH serum sample (1.0 ml) at 1 hr (2 hrs if gel-ACTH is used).
iv. Centrifuge sample as soon as possible, separate and freeze. (NOTE: If samples are grossly hemolyzed, repeat test in one week).

The following hormones will be assayed: Cortisol, Estradiol, Androstenedione, 17-Hydroxyprogesterone, Progesterone and Aldosterone.

Although more hormones than just the cortisol are elevated on Reba's adrenal panel (ACTH stim) results, I think that Reba's result would probably be considered positive for Cushing's, even on a regular ACTH stim, where they only measure cortisol production ... because a post-ACTH cortisol value of greater than 22 ug/dl is considered positive for Cushing's (Reba's cortisol was around 28.8 ug/dl if you "translate" the numbers on the UTenn results into ug/dl).

I think that every dog suspected of having Cushing's should have more than just a stim test done before starting treatment. Especially since the adrenals were not enlarged much, if at all, on the ultrasound that was done (and even though most dogs with PDH do have bilaterally enlarged adrenals, some dogs with confirmed Pituitary Cushing's do apparently have normal-looking adrenal glands), I'd want a LDDS done to see if she suppresses cortisol production on the LDDS normally or not. My guess, based on the stim done already and the adrenal glands having a fairly normal appearance, is that Reba has Pituitary Cushing's and also happens to have other adrenal hormone elevations.

If a dog has normal cortisol values, but some or all of the other adrenal hormones are elevated, then the dog just has what some folks are now calling "atypical Cushing's".

Other than causing similar symptoms (as compared to cortisol elevation) I'm not sure what damage the other elevated adrenal hormones can cause, but unchecked excessive cortisol production can result in more than just symptoms. There's the risk for organ damage etc over time, too.

see: http://caninecushings.net/forums/showthread.php?t=182

Also wanted to mention that you may be able to reach Dr. Oliver by e-mail even if he is still on medical leave from the Lab. Be sure (as Jeanne noted to you, peviously, in the melatonin thread, I think) that if you do write to him, to include Reba's UTenn case number in the subject of your message to him.

**acushdogsmom** · 04-29-2008, 03:20 PM

Re: Reba's numbers

Adding this (a copy of my other post to you on the Cushing's board) ...

Denise, just a few more thoughts ...

I know that you would rather not have to treat Reba with Lysodren (due to your past experience with Bogie and Lysodren, which was not really a good one) but if she is truly a Cushing's dog (high cortisol) who also happens to have other elevated adrenal hormones, then Lysodren may be what she really needs. Trilostane works well to control cortisol in most Cushing's dogs, but also tends to elevate the other adrenal hormones (also called "intermediate" adrenal hormones) especially over time, according to Dr. Oliver's recent findings. So Trilostane would not be a very good choice, I don't think, for a dog whose intermediate adrenal hormones are already elevated. Wheras Lysodren may be able to lower not only the cortisol, but many of the intermediate adrenal hormones as well.

Not loading (ie just starting a maintenance dose of Lysodren) does not work very well to treat Cushing's, where high cortisol is the main problem. The cortisol production is never really lowered enough to prevent the organ damage that is caused over time by the constant pathological overproduction of cortisol. You need to load to get the cortisol down to the target range (1-5 ug/dl on a stim test) and then use the weekly maintenance dosing to keep the cortisol down to where you got it with the loading.

I have found, in all the time I've been reading about Cushing's dogs, that when the dog is definitively dxed with Cushing's and if Lysodren is properly dosed and monitored, they usually do really well. Really really well in fact.

So if I were in your shoes, I think that I'd want the LDDS done to get further confirmation that you are actually dealing with "regular" Cushing's. And then I'd probably want to treat with Lysodren.

**Denise** · 04-30-2008, 08:30 PM

Re: Reba's numbers

Hello everyone. I'm not ignoring your replies, I'm just tired of all the reading, well actually tired of the computer in general right now.

If I take a break and don't answer for a couple days....things are OK, just chilling.

Reba is on Norvasc as her bp was 180 on 2 different test dates. Prior to that she was on Lasix and Benazapryl when the vet saw fluid around the heart. ISU took her off meds but I knew her bp was high and asked they put her back on it and then the Norvasc was added. Bp was down to 110 one day and 3 days later back to 168. Bogie is on both of these meds too and he's never had a problem.....but who knows what might be effecting her appetite? Adding some canned food has he cleaning her bowl so....

She is having an LDDS on Friday. Gosh I hate to leave her all day.
She stresses and is already panting and hot.

I've been down for a couple days. It's funny (not haha funny) but it wasn't until yesterday morning that it dawned on me that BUBBA HAS CANCER!!!!!!!! Like DUH! But the surgery, vet visits, meds.....guess I just didn't go there right away.

Everytime I got on the computer today something set me off and I was anxious and nauseas all day so I might need a computer fast!

Thanks Cushy for all the time you've spent writing. I appreciate it, have read it but will read it again when my mind is clearer.

**k9diabetes** · 04-30-2008, 09:06 PM

Re: Reba's numbers

What is the prognosis for Bubba? I'm sorry to hear it's cancer... I haven't really caught up on all the details... did they remove the tumor?

Can Reba go back and forth for the two draws? (not sure how far away the vet is)

Just know we are thinking of all of you and hope you can get some rest. You've been through a lot this year already.

Natalie

**Denise** · 05-01-2008, 02:41 PM

Re: Reba's numbers

Vet won't let me take her and bring her back. Almost canceled due to this but we will tough it out. I hate her staying there that long!

Bubba's tumor was removed. Fibrosarcoma and the margins weren't clean. These tumors send out microscopic feelers and the origninal tumor most often comes back and it also can crop up other places.
Life expectancy is 9-16 months even with radiation. I can't get radiation treatments any where in Iowa so would have to take him to Kansas or Minnesota and leave him for 3 weeks and 2700.00 minimum. Treatments would be daily for 5 days a week and the poor guy would just BE there over the weekends. I'd be driving to get him every Friday night cause I would feel bad and be taking him back on Sunday nights. Any of these places would be 8-10 hours round trip.

Before I even got home I knew I couldn't do that so we went to the holsitic vet and he is on a supplement, an immune booster and a Chinese medicine.

He's not acting ill and I don't know what he WILL act like when this thing shows up some where else. I want the incision to heal so the poor guy doesn't have to wear the dreaded cone!!!

Bubba was one of the 4 that I hand raised from 2 weeks old. He really IS my baby. He turns 12 on Saturday.

**BestBuddy** · 05-01-2008, 05:18 PM

Re: Reba's numbers

Hi Denise,

I am so sorry you are having such a tough time at the moment. I get a bit overwhelmed at times and need a break too. I hope Bubba heals quickly as they really hate that cone don't they. I am glad he is feeling well and I hope that continues for a long time. Try not to focus on how long if things progress although it will be hard just enjoy evrey day you can.

As for leaving Reba I know how you feel as Buddy is a stresser too but my specialist also makes me leave him for tests and although he doesn't like it it has to be done and when I pick him up he is so pleased to see me and I am forgiven within minutes.

Jenny & Buddy

**k9diabetes** · 05-01-2008, 09:07 PM

Re: Reba's numbers

I couldn't put any of my animals through that kind of trauma. The stress alone would kill Gus or Katie outright. Spending three weeks freaked out in a vet's office to gain a few months of life... it's a horrible decision but I already know what I would do in the same boat - just what you are doing.

I'm very very sad to hear all this about Bubba. I hope things can calm down enough for you to get to spend quality time with him for however much time he has and all the rest of the four-footers.

Never having been to Iowa, I didn't realize how limited the high tech vet care is for you. I have come over the past couple of years to feel fortunate to be in this area. The prices are higher, but it is a decent size - not so urban and congested that it's miserable but also numerous facilities that offer critical care. The emergency hospital we use is owned by a veterinary oncologist and she does radiation treatment there. It's 20 minutes from here...

And still, I wouldn't do it.

Hang in there... you know where to find me if I can help in any way.

Natalie

**Denise** · 05-02-2008, 05:49 PM

Re: Reba's numbers

Reba's last blood draw was at 4 p.m. and they didn't have the results yet and I just wanted to get her home! She was so happy and she isn't one that gets too excited but she was!

They will call in the morning.

No Nat, no way I could leave him for 3 weeks. Yes, I'm in the boon docks!!!

**Denise** · 05-03-2008, 07:15 AM

Re: Reba's numbers, LDDS

baseline 3.3
4 hour post 2.4
8 hour post 1.3

This did NOT help me make a treatment decision!

Discussed a couple ways to treat this.

#1. Do a short load, 3-4 days using pred each day also, recheck baseline cortisol on Wed. or Thursday. If at anytime she appears ill, cut this 500 mg. twice per day to 250 mg. twice per day.

#2. Start a maintenance dose of 500 mg. twice per week and also use pred on these days.

I really thought these results would tell me that FOR SURE it was OK to go ahead and load her!

ppphhhhtttt!!!!

The Cush people are telling me this doesn't look right. Numbers wouldn't normally keep going down by the 8 hour test.

Vet said it WAS pituitary and the Cush board people say this wouldn't be a FOR SURE pituitary case.

I'm at a loss.

**k9diabetes** · 05-03-2008, 05:28 PM

Re: Reba's numbers

Converted values:

baseline -- 3.3 ug/dL = 91.05 nmol/L
4 hour post -- 2.4 ug/dL = 66.2 nmol/L
8 hour post -- 1.3 = 35.9 nmol/L

So I guess there is some supression but all of the values are above normal. Is that correct?

Personally, if it was Chris, I'd go with the maintenance dose first. There's no rush to do a load, is there?

Natalie

LOW-DOSE DEXAMETHASONE SUPPRESSION TEST

In healthy dogs, glucocorticoids exert negative feedback inhibition on ACTH secretion. A low-dose of dexamethasone (0.01-0.015 mg/kg) administered intravenously to healthy dogs, causes inhibition of ACTH secretion and reduced plasma cortisol concentrations within 2 to 3 hours lasting up to 8 hours.

In hyperadrenocorticism, the 8-hour cortisol value is not sufficiently suppressed and remains above approximately 30 to 40 nmol/l.

The low-dose dexamethasone suppression test is considered an extremely sensitive diagnostic test. In approximately 95 % of dogs with PDH and up to 100 % of dogs with AT, cortisol suppression is inadequate.

However, some dogs with hyperadrenocorticism have suppressed values at 8 hours and suppressed or elevated (inverse results) values at 3 or 4 hours.

Unfortunately, false-positive test results frequently occur in dogs with non-adrenal disease and the specificity of the test has been reported to be as low as 0.44. In general, the more severe the nonadrenal illness, the more likely that cortisol suppression will not occur.

The high negative predictive value of this test means that hyperadrenocorticism is unlikely if cortisol suppression occurs, but in some individual cases this does hold true.

An additional value in performing a low dose dexamethasone suppression test is its ability to distinguish between PDH and AT in up to 60 % of cases when circulating cortisol concentrations are measured at 3 or 4 and at 8 hours.

Criteria that indicate a diagnosis of PDH include a decrease of circulating cortisol concentration to less than a laboratory reference value at 3 or 4 hours, less than 50 % of the baseline value at 3 or 4 hours, or less than 50 % of the baseline value at 8 hours.

However, PDH cannot be ruled out if suppression does not occur.

In the USA, cortisol levels are measured in units of "ug/dl".

In Canada and in the UK, cortisol levels are measured in units of "nmol/L".

To convert the values, use these formulas:

To convert ug/dl to nmol/L you multiply by 27.59

Two examples:

1.0 ug/dl = 27.59 nmol/L

and
3.2 ug/dl = 88.29 nmol/L

To convert nmol/L to ug/dl you divide by 27.59

Two examples:

27.59 nmol/L = 1.0 ug/dl
and
300 nmol/L = 10.87 ug/dl

**Denise** · 05-03-2008, 08:39 PM

Re: Reba's numbers

All those letters mess me up Nat! I will have to reread that tomorrow, no way to "get it " tonight!

The Cush people are saying that the third number should be higher than the second so they asked if these might be reversed but vet says nuh -uh. (like that vet speak?)

I wrote Dr. Oliver this afternoon and already got a reply.

The clinical signs do point to possible Cushing's disease. The LDDS test certainly doesn't match the adrenal panel results from our lab. The LDDS test results would be considered normal, but our test results showed increases in 5 of the 6 hormones that we measure. So, I feel very comfortable that our test results indicate increased adrenal activity. And, the ultrasound results would point to a pituitary-dependent situation.
One thing you could consider is going with melatonin and lignans for 4 months and seeing what kind of results you're getting by then. If the condition is not completely under control by then, you could consider adding a maintenance dose of Lysodren to the melatonin and lignans (without doing the loading dose). If the dog weighs 30 lbs, then you could consider going with 6 mg total dose given twice each days, along with a 40 mg capsule of purified lignans (see number 5 on our treatment option sheet). If you're not seeing improvement within 4 to 6 months, then you could always go with the Lysodren treatment (with loading dose) at that time.
I hope this is helpful. Regards, Jack.

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