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Tammy
Tammy, Consultant
Category: Dog
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Experience:  Owner of dogs for 50 years, Basic training for a good household pet
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Dalmatian/Cushings Disease

Customer Question

Our family has a precious 11 year old Dalmatian, Jasmine. She has been experiencing loss of bladder control. Took her to the vet. They strongly suspect Cushing's Disease. Her liver count was in the thousands instead of the mormal 220 range. She had a urinary tract infection also so we are treating that first. Since taking her two weeks ago we have noticed enormous water intake, rapid breathing, kicking of front paws very bloated stomach, has stopped sheeding completely restlessness and picky about food. From research on the web she seems to be in her final stages. Could this possibly be true? Is she in any kind of pain? Whatr are the pro's and con's of even attempting to treat at this point?
Submitted: 7 years ago.
Category: Dog
Customer: replied 7 years ago.
Relist: No answer yet.
Why do I have to pay eight dollars just to get a simple answer?

Everybody is out to make a buck. Even my vet.
Expert:  Tammy replied 7 years ago.
Hello Steve,

Yes, your right...some people are out "just to make a buck". I feel that way may times.

However, I work on this site for the love of pets. I don't make that much money doing it and I spend a lot of time a day online.

I want to give you as much information as I can with Cushings, so I want to call my friend who is one of the best Dog Vets I have every worked with!

How long has it been since Jasmine was diagnosed with Cushings?
What tests did they run?
Did they check her thyroid?

I will await your reply and speak to Dr. Eagan so I can reply to you.

Thank you, Tammy (justasktammy)
Customer: replied 7 years ago.
Reply to Tammy's Post: They have not run any tests yet to confirm Cushings. All they have done is blood work. Her liver enzymes were in the thousands rather than the normal 200 range they should be. She seems to be controlling her urine better since they put her on antiobiotics for her bladder infection. So, so far they have done a urinalysis and urine culture and blood testing for her blood counts. Just that was almost three hundred dollars! And the vet wanted me to make an appointment to have her teeth cleaned. Now, here we have a dog that is sick, vet thinks it is Cushing's from all her symptoms and they want me to have her teeth cleaned. Go figure.
She has a pale tounge, very bloated and hard belly, constant thirst, licking of front paws, picky about eating and seems to be hard of hearing now and she is not barkng like she used to. When she does she sounds like a beagle. With all the searching I have done on the disease and reading other owner's expereince with treating I feel that either way the chances of prolonging is slim. I don't want to put her through a lot of lab tests and medication at her age. I just don't think it is fair to her or myself as the owner. I just want to know is she in pain? Will there be pain related to it as it progresses. My vet will not answer these questions, all they want to do is schedule more testing. If there is a chance she is in pain I don't want her to be. We have a thirteen year old son that is grieving what she is about to, or going through right now. I want to make it easier for us all.

Thank you Tammy. Please e-mail back your address and I will get a check in the mail to you. I do not ever give credit card information on the web. It is not that I did not want to pay for your services, I wanted to protect myself.

Thank you for your concern for animal and the time you take with pushy people like me.
Customer
Expert:  Tammy replied 7 years ago.
Hello Steve,

I am not allowed to give out my email address, however your question will be open for quite a while and I will continue to wait to hear from Dr. Eagan and get back to you.

Also, you must be a very good "pet owner" since Jasmine has lived to 11 years old. As you probably know the lifespan of larger dogs is approximately 8-10 years.

I will reply back as soon as possible.

Also, you can pay through PayPal which I do almost every day. It is the most secure site for using your credit card. It too, do not use my credit card anywhere else other than PayPal. And, if there is every any problem (which I bought some ink) they refunded my money, no questions asked. I have been using them now for over two years and only this one incident.

Thank you, Tammy
Customer: replied 7 years ago.
Reply to Tammy's Post: Thank you Tammy. Our family does not use PayPal either. Sorry to make this so hard for you. I know your time is worth it. I still would be gald to mail a check tou your home address if it can be done.

I hope you don't think less of me or my family for not wanting to prolong her life. We have many special memories to hold onto. She has always been an obedient dog. She has never been hyperactive and has always protected my son. Even when we play rough she gets between us and protects him. We have had cats and all we have ever had to do is tell her "no" and she knew not to bother the cat.
I could not have asked for more in a dog. Being a Fireman, she was my mascot and friend.

Thank you again.
Customer
Expert:  Tammy replied 7 years ago.
Hello,

I know you have (12234 Trail Hollow Drive) searched many web sites. (Montgomery Texas 77356)
and probably some of these sites you have already read, however I found a site from Dr. Richards at A&M and worked with him before and he is fantastic!

               Cushing DOG
Cushing's Disease

http://www.pet-helper.com/cushing_disease.html?gclid=CLiIidOi-4YCFQs0Pgod5gPCJg

Cushing's disease, more commonly referred to as hyperadrenocorticism, is the production of too much of the adrenal hormone. It can be naturally occurring or due to over use of corticosteroids such as prednisone. Symptoms of the ailment include a dog's increased drinking and urination, increased appetite, panting, hair loss, pot-belly searance and susceptibility to skin infections. Weakening of the heart and skeletal muscles are additional symptoms.


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Cushing's disease
Cushing's disease can trouble older dogs
www.canismajor.com/dog/cushings.html
Animal bodies are a marvel of interactions between organs and systems kept in balance by the production of enzymes that aid in metabolic processes and hormones that regulate body functions. When the balance is disturbed by illness, injury, or advancing age, the body goes awry: appetite and water consumption change, organs malfunction, or medication to treat one illness causes another.
Such is the case with Cushing's disease, also known as hyperadrenocorticism, the production of excess hormones from the adrenal glands. Cushing's disease usually strikes older dogs with a bucket-full of symptoms that can mimic other diseases. Increased appetite, increased drinking and urination, panting, high blood pressure, bulging abdomen, skin lumps and discoloring, hair loss, muscle weakness, and nervous system disorders can occur with the disease.
The adrenal glands are located above the kidneys. The adrenals produce cortin, a complex of steroid hormones that help regulate body weight, mineral balance, the structure of connective tissue, some white blood cell production, and skin health. Adrenal glands are stimulated to produce cortin by adrenocorticotropic hormone (ACTH) from the pituitary gland. Cushing's disease can be triggered by a tumor of the adrenal glands or of the pituitary gland; either one can cause the adrenal glands to run amok and produce an excess of corticosteroids.

Diagnosis
The symptoms may creep up on the pet and pet owner. The danger signs of vomiting, diarrhea, pain, seizures, and bleeding do not occur; the pets do not appear to be critically ill. To the contrary, the symptoms often appear to be connected to normal aging. Muscle weakness also causes a reduced tolerance for exercise and lethargy, both of which are typical in aging dogs and cause no alarm in owners. Often owners do not seek veterinary advice until the signs become unmistakable or intolerable ? when the dog breaks his housetraining or begs to go outside during the night for example.
The typical Cushing's dog has a bulging, sagging belly caused by a decrease in muscle strength and redistribution of fat from body storage areas to the abdomen. As the disease progresses, hair loss may also become a major concern and the skin thins and may lose its resistance to infection.
Once suspected, Cushing's disease can be diagnosed by blood tests. Once it is diagnosed, tests can also differentiate between disease caused by pituitary gland tumor and disease caused by adrenal gland tumor.
About 85 percent of the cases are caused by pituitary tumors. Pituitary-induced Cushing's can be treated by drug therapy, but it cannot be cured. Adrenal gland tumors can often be surgically removed.
There are several drug therapies available, including Lysodren, Ketoconazole, and Anipryl?. Lysodren kills the outer layer of the adrenal gland that manufactures the corticosteroids. Careful regulation of the drug determines how much of the cortex is killed so that a normal amount of the hormone can be produced. This protocol requires periodic blood tests to make sure the dog has a normal amount of cortisol and does not develop Addison's disease. Once the proper dosage has been determined, the dog's condition may be maintained by periodic instead of daily doses.
Ketoconazole works by suppressing cortisol secretion in the adrenal glands. It requires daily dosing, monitoring, and acute observation by the pet owner, and is expensive. Some dogs cannot absorb it, rendering it useless in 20-25 percent of cases. It is useful for dogs that cannot tolerate Lysodren, has a low incidence of toxicity, and is completely reversible if necessary.
Anipryl? was approved for use in canine Cushing's disease in June 1997. Anipryl? helps restore the balance of natural brain chemicals which in turn alleviate the symptoms of the disease. In clinical trials, about 70 percent of dogs responded favorably with a lessening of symptoms and a reduction in cortisol production.
Left untreated, Cushing's disease will progress and can lead to life-threatening disorders such as diabetes, congestive heart failure, and liver and kidney failure, and to chronic maladies such as hypothyroidism and infections of the skin, ears, gums, eyes, or bladder. If your pet exhibits any of the early signs of Cushing's and is six years old or older, make an appointment with your vet right away. Pituitary Cushing's disease cannot be cured, but the treatments available can prolong your pet's quality of life and keep him around for years longer. If an adrenal tumor is causing the disease, surgery may be indicated. Either way, it's better to get started on treatment.
Canine Cushings Treatment
Remedy for cushings disease dog Call us toll free (XXX)XXX-XXXX
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Azmira's Stress and A'Drenal Plex helps to restore integrity to the adrenal glands and promote a greater sense of energy and stamina while building up the body's response to stress. These herbs are also nutritive and tonic to the adrenal glands as well as to nerve cells and tissues. As an adaptogen, these herbs reduce the stress on a body constantly exposed to excessive physical and/or emotional strain. For pets with severe loss of vitality, anemia, low blood pressure, anxiety, strain, and low energy, please do seek Veterinary diagnosis.

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Use 1 drop per 5 lbs. of body weight per dose. Dose can be doubled initially to build up therapeutic properties or as needed for acute situations. Shake well. DO NOT USE UNDILUTED! Mix extract in a small amount of warm water or apple juice. Extract can be mixed into food if needed, but do double dose to increase assimilation.



This is a question answer site from Dr. Michael Richards at Texas A & M. He is a fabulous vet.
It does have a lot of info that you will have to go through to read about your dog, in particular

http://www.vetinfo.com/dcushing.html

Cushing's Disease
Cushing's disease or Hyperadrenocorticism
Cushing's?
Cushing's
Cushing's Disease - seizures and skin rash
Cushing's Disease and corticosteroids
Cushing's disease in Corgi
Cushing's possible
Cushing's with immune mediated hemolytic anemia
High alkaline phosphate levels
Cushing's disease - no response to treatment
Diet for Cushing's
Seizures and Cushing's Disease
Photo Gallery - Advanced Cushing's Disease


also see Adrenal tumors
also see Cushing's and Skin disease
also see Treating cushing's with Lysodren
also see Treating with Anipryl
also see Hormonal Disorders
also see Cushing's page 2
also see Cushing's and liver enzymes
also see Cushing's and renal disease
also see Multi disorders


Cushing's Disease or Hyperadrenocorticism
Cushing's disease is probably more accurately referred to as hyperadrenocorticism -- the production of too much adrenal hormone, in particular corticosteroids. It can be naturally occurring or due to over
administration of corticosteroids such as prednisone (iatrogenic Cushings). The latter is easy to cure - just cut out the corticosteroid administration slowly to allow the body to return to normal function. The former is more difficult.
Hyperadrenocorticism occurs for two reasons --- a tumor of the adrenal gland that produces adrenal hormones or stimulation of the normal adrenal glands from the hormones that control it. The primary reason for this to occur is a pituitary gland tumor that produces excessive ACTH, which stimulates the adrenal gland to produce corticosteroids. Adrenal gland tumors account for 15% of the cases of spontaneous hyperadrenocorticism. Pituitary tumors account for 85%.
Cushing's disease causes increased drinking, increased urination, increased appetite, panting, high blood pressure, hair loss - usually evenly distributed on both sides of the body, pendulous abdomen, thinning
of the skin, calcified lumps in the skin, susceptibility to skin infections and diabetes, weakening of the heart and skeletal muscles, nervous system disease and other symptoms. Most owners reach a point where the
water consumption and urination become bothersome to them.
The diagnosis of Cushing's can be done with several blood tests. A general hint of Cushing's can be obtained by a blood panel. To confirm it, a test known as a low dose dexamethasone test is done. A baseline blood
sample is drawn in the morning, an injection of dexamethasone given and a follow-up blood test done 8 hours later. In a normal dog, the dexamethasone should suppress cortisol levels in the blood stream. In Cushing's disease this effect does not occur. Once the disease is diagnosed, it is possible to differentiate between the adrenal tumors and pituitary gland tumors using a second test, a high dose dexamethasone suppression test.

Most dogs with pituitary tumors will have cortisol suppression on this test. There are other tests used, including ACTH response tests and urine cortisol/creatinine ratios to diagnose this disease. X-rays and ultrasonography can help determine if an adrenal gland tumor is present.
If it can be determined that there is an adrenal gland tumor, it can be removed. Many veterinarians prefer to have a specialist attempt this since the surgical risks can be high. Pituitary gland tumors are not usually removed in veterinary medicine. This situation is treated using Lysodren (o'p'-DDD, which is a relative of DDT) or ketaconazole.
Some research with Deprenyl for treatment of this is being done, too, I think. Lysodren selectively kills the outer layer of the adrenal gland that produces corticosteroids. By administering it in proper amounts it is possible to kill just enough of the gland off to keep the production of corticosteroids to normal levels. Obviously, close regulation of this using blood testing is necessary since overdoing it can cause severe problems with Addison's disease - hypoadrenocorticism. Adverse reactions to Lysodren occur at times but it is the standard treatment at this time. Over medication with Lysodren can cause inappetance, vomiting, diarrhea, lethargy and weakness. If any of these signs occur then your veterinarian should be immediately notified.
Treatment of Cushing's disease caused by pituitary tumors is symptomatic therapy -- it does not cure the pituitary tumor. The average lifespan of dogs diagnosed with Cushing's, with or without treatment is estimated at 2 years by Dr. XXXX XXXXXXXX, but in a recent conversation with another endocrinologist I came away with the impression that this was an "educated guess" rather than the result of extensive survey of Cushing's patients. At present, though, I think that treatment should be viewed as a means of providing a better quality lifestyle rather than as a method of extending longevity.
Q: Dr. Mike:
I have an 11 yr old poodle mix (Tina) (14 lbs, epileptic, female, spayed).
She has been on pheno most of her life, now 30mg twice a day. A year ago,
found hypothyroid, and vet has been trying to adjust levothyroxine dosage.
(We are due for new blood test soon on this).
She had been vomiting for quite a few months, incidences started out to be
every month have been getting to be every 3-4 days, she would vomit early in the AM before food or meds and could not digest some of the treats, carrots, grapes that we had been giving her for many years.
Also, she has been steadily losing fur on her back and the skin shows
through, sometimes the skin changes color but she does not itch or scratch.
Vet thought possibly Cushings but after testing, she showed normal ranges. In subsequent conversations, however, he said he is still not ruling out Cushings for the future. He doesn't seem to be too sure.
Sugar was high but urine test showed she is not diabetic. Also, ultrasound
showed a couple of nodules in the spleen. Vet said he discussed this with
radiologist but that more than likely benign. (Even if they were not, I am
not prepared to remove the spleen or do exploratory surgery on her).
Vets conclusion was that the vomiting was probably due to pancreatitis due to the high numbers on the amylase panel. She had high numbers once before and old vet asked if she threw up a lot but at that time she didn't. I don't know if pancreatitis causes vomiting or vomiting causes pancreatitis.
Right now, I have finally gotten her stabilized by virtue of Reglan in the
AM and before bedtime. The vomit is usually clear frothy or yellow. It
takes a lot out of her and this may be the first time in months that we are able to get through a week without her vomiting. I am prepared to keep her on the Reglan forever but I am afraid that there may be underlying problems that my vet doesn't know about.
His last suggestion is to put her on the Hills i/d diet which I have
started. I will also pick up some flax seed oil for the fur and see if that helps.
I am sorry to be so lengthy but I wanted to give you the whole story. Thank God, she has not had a seizure as of lately or that would have complicated the story even more.
I don't know if the years of pheno can be the cause of her problems but vet
rules out liver disease from tests done. I don't want to put her through
any tests than are not necessary and I am aware that she is an older dog but I just want to make sure that the time she has left are quality time for her.
Eileen
A: Eileen-
Hyperadrenocorticism will produce clinical signs in some dogs whose lab
values never reach the cortisol levels necessary to be sure that that the
disease is present. I can't explain that but when the clinical signs are
highly suggestive (and your dog's clinical signs are highly suggestive) of
the disease, it is sometimes necessary just to treat for the condition to
see if it is present. This has gotten a lot easier to do with the
introduction of l-deprenyl (Anipryl Rx). It isn't nearly as toxic as
mitotane (Lysodren Rx), which is the other approved treatment for
hyperadrenocorticism (Cushing's disease). It is hard to decide when the
clinical signs justify treatment without supporting lab values but if your
vet really feels strongly that Cushing's disease is present and suggests
treatment for it, I think that there are times when it is reasonable to try
that approach.
I also think it is really important to be sure you aren't causing Cushing's
disease. Once in a while I forget that a patient is on prednisone and has
been for some time. Patients that have been on prednisone chronically often
have symptoms of Cushing's disease. If you aren't using this medication
then it isn't the cause of the symptoms but if you are, be sure to remind
your vet. Even corticosteroid eye drops can lead to Cushing's symptoms in
some patients -- so any source of chronic corticosteroid use has to be
considered.
High amylase levels are sometimes present when pancreatitis is present and pancreatitis can be chronic so that seems like a reasonable assumption, too. Since dogs with Cushing's disease are more prone to pancreatitis, having both conditions is not unusual.
It is OK to use metoclopramide (Reglan Rx) chronically when necessary. You are correct that it is better to find and treat an underlying condition
whenever possible, though.
Mike Richards, DVM
5/3/99
   
Q: Dr. Mike,
I have a 5 year old female Rottweiler, Regal, who possibly has Cushings, but
we are not sure. She has most of the classic symptoms: excessive drinking
and urination, pot bellied abdomen, panting, excessive eating, loss of
muscle mass and strength and skin problems. She is allergic to pollen, dust
and fleas, so to combat her allergies, she has been on Prednisone pretty
regularly for the past two years. 20 mg per day, the minimum effective
dosage.

She has been off of the pred. for almost a week and the initial blood tests
were inconclusive of Cushings. Her skin problems are VERY bad with open sores and calcifications on her skin. This is very painful for her and she is constantly licking herself. I am bathing her every other day, with a bezoil peroxide shampoo our Vet prescribed, but it is not helping, and the sores are only multiplying. She also smells very bad in these areas. I have tried enadryl spray topically, tablets orally and nitrofurzone topically to try to ease the pain, but nothing seems to help. I'm afraid to keep putting anything on her, since she
keeps licking it off, that can't be good for her. I am told by our vet, that until the prednisone is completely out of her system, ( a month, minimum) the blood tests won't be totally accurate, and that once you go on medication for this, there is no turning back, you're on it for life. It also seems that Cushing's is more common among small dogs and not big ones like mine, so I am very skeptical whether this is it.
Is there anything you can suggest in the interim to help her. She is on
antibiotics, and we'll be swinging back and forth from Clavamox to another (can't remember name) for the next few weeks, and I started her on Atarax today to help with the itching. Any other suggestions would be greatly appreciated.
Thank you for your help.
Wanda and Regal
A: Dear Wanda (and Regal)
I suspect that your Rottweiler is very likely to have Cushing's disease. I
also suspect that after a month or so your Rottweiler will no longer have
Cushing's disease. How can this be?
Probably the most common cause of the Cushing's disease syndrome is
administration of prednisone or other corticosteroids at levels sufficient
to induce clinical signs of Cushing's disease. This is not a "true" case of
hyperadrenocorticism since the adrenal gland isn't producing excessive
cortisone. But it is the same syndrome. The only difference is that you
have been giving the corticosteroids instead of her body producing them.
Most dogs will not develop clinical signs of Cushing's disease if
prednisone is administered every other day at anti-inflammatory dosages.
Unfortunately, prednisone works better if it is given everyday and many pet owners ignore the admonition to give it on alternative days and their pets develop signs of Cushing's disease. Veterinarians will sometimes resort to gradually increasing the dosages of prednisone when pets don't respond as expected to lower dosages. Eventually the dose administered exceeds the anti-inflammatory dose and gets into the immunosuppressive range, which is high enough to produce signs of Cushing's disease. Sometimes, prednisone is being administered orally at appropriate dosages but ear medications or eye medications containing a corticosteroid are being administered at the same time and this leads to an overdosage situation. In a few instances eye drops containing potent corticosteroids have induced Cushing's disease symptoms in dogs without administration of any oral or injectable corticosteroids.
One of the paradoxes of treating skin disease with corticosteroids is that
dogs will develop extremely itchy sores known as calcinosis cutis when they are exposed to corticosteroids at high enough dosages or long enough to produce signs of Cushing's disease. These sores often look like allergic
reactions or skin infections and so the vet tries even harder to control
the situation by increasing the prednisone more. I have been caught in this
scenario once or twice myself.
It is a very good idea to discontinue the prednisone in a situation like
yours, in order to try to rule out iatrogenic (caused by the veterinarian
or client adminstering medications or treatments) Cushing's syndrome. It
isn't a good idea to just abruptly stop prednisone, though. After two years
of regular prednisone administration your Rottie's adrenal glands are not
used to having to work hard to make cortisone. You have been administering it and doing their job. Stopping the cortisone administration suddenly can leave your dog in a situation in which she does not have cortisone source and can't make adequate quantities. There is a purpose for corticosones in the body and sudden withdrawal of prednisone can leave a dog vulnerable to shock, high serum potassium levels and even heart failure. I am hoping that you withdrew this medication slowly.
The dermatologist we send patients to currently likes a shampoo, Etiderm
(TM), better than the older antibacterial shampoos such as benzoyl
peroxide. We don't have very much experience with its use yet but we do
trust the dermatologist. In addition, clemastine (Tavist Rx) is currently
considered to be the best antihistamine for control of itching. Hydroxyzine
(Atarax Rx) is often effective and there is no need to switch if it is
working.
I don't see the need to test for Cushing's disease if the symptoms improve
after withdrawal of prednisone. It is far more likely that the signs you
are seeing are due to administration of prednisone than to naturally
occurring Cushing's disease.
The most likely scenario is that you will see a lot of improvement but that
you won't see total improvement because you were using prednisone to treat an existing skin condition and it may not be gone. In a young dog it is
worthwhile to consider allergy testing and hyposensitization with
injections of small amounts of the allergen instead of using prednisone.
Some Rottweilers appear to have difficulty controlling normal skin
bacteria. In these dogs control of the infection with antibiotics can
sometimes be achieved with long-term use.
If withdrawing the prednisone doesn't help it may also be worthwhile to ask about referral to a veterinary dermatologist. Sometimes it really can help to see a specialist.
Mike Richards, DVM

Cushing's disease- seizures and skin rash
Q: Dear Dr. Mike,
I really marvel at the information available on your site and as a new
subscriber to VetInfo Digest I look forward to receiving the
information.
I went back over previous material on Cushings Disease and found some
helpful information, but not on my current problem.
Psaltee is a 14 yr. old neutered Staffordshire Bull Terrier female. She
had a serious bout with seizures several years ago which were finally
controlled with phenobarb 30mg twice a day. She was pretty "dopey" so I
gradually cut back to 30mg once a day which has held the problem in
check.
Almost a yr. & a half ago she was diagnosed with Cushings. She's been on
500mg Lysodren twice a week since then. I also mix Solid Gold wate-on,
seameal, flaxseed oil and a combo of yeast and garlic powder in her
food, anticipating possible skin and joint problems. (I also have a
young mini-bull terrier who gets 'crusty skin' occasionally; so the mix
is for him too.)
Lately, the hair on her forelegs has fallen off and she has developed
what appears to be an infected rash on her chest, feet, and on both
sides of her face. A new vet in the office gave me clavamox 250mg. twice
a day and said the rash was a result of mites and that the Lysodren
dosage would have to be increased. She was tested in January and the
levels were slightly elevated but the dosing schedule remained the same.
I hate to put her through the all day event if it's not absolutely necessary.
Is there any kind of shampoo I can use that would make her a little more
comfortable and ease the redness? What else can I expect in the latter
stages of this disease? I'm already the only dog owner on the block
whose pooch has her own litter tray to use while I'm at work, and a
full-time air conditioner!
Thanks for any direction you can give me.
Pam
A: Pam-
There are several things to consider with the skin rash.
The first is to be sure that mites really are the problem, or at least part
of the problem. The reason this is important is that the most likely mite
problem to suddenly appear in an older dog that has not been exposed to
other dogs is demodecosis (infestation with Demodex mites). If skin
scrapings have been done and this mite has been identified as a problem it
would be a good idea to consider treating for the mites. It is a little
more complicated to treat for mites in a dog that has hyperadrenocorticism
but it can be done.
The second thing to consider is that Cushing's disease can produce itchy
scaly skin lesions all by itself. There is a specific skin condition
associated with hyperadenocroticism, called calcinosis cutis and the only
cause I know of is the Cushing's disease. It may be necessary to obtain a
skin biopsy in order to test for this condition since the lesions are not
easily identified in many cases without microscopic examination of the
tissue. The sores usually look like a cream colored (from calcium
deposition) plaque at first, then often become scaly and itchy. It is easy
to miss the initial stage of the disorder, though. The sores are usually
most prevalent in the inquinal area and surrounding abdomen, near the base
of the tail and on the top of the neck. If calcinosis cutis is the problem
it will be necessary to try to adjust the dosage of mitotane (Lysodren Rx)
to better control the Cushing's disease or to consider switching to one of
the other treatments. If your vet is used to treating with Lysodren it is
probably best to stick with it. We have recently had some success using
l-deprenyl (Anipryl Rx) for pituitary dependent Cushing's disease which is
the type that affects most dogs. Ketaconazole inhibits the release of
cortisones from the adrenal gland which also helps to resolve the clinical
signs of hyperadrenocorticism in some dogs.
I have seen skin disease associated with the use of phenobarbital. It seems
very likely that if 30mg of phenobarbital once a day appears to be
controlling the seizure activity that your dog may not need it at all. The
only way to see if the dosage of phenobarbital is less than that needed to
control seizures is to test the blood level of phenobarbital. So far, when
we have tested dogs that had lower than the needed blood levels and weren't
having seizures we have been able to stop the medication after tapering it
off for a month or so without any of the dogs suffering a return of seizure
activity. Withdrawing the phenobarbital if it is unnecessary may help with
the skin problems.
It may not be necessary to do an all day test to monitor how well the
Lysodren is working. Once we know that Cushing's disease is present we
usually use the ACTH response test to monitor the response to treatment. It
is usually possible to do this test in an hour (although some vets
recommended two hours). Many of our clients come, let us draw the blood and
give the ACTH and then walk their dog around our clinic property for an
hour or go on a short errand and return. This test takes less time than a
dexamethasone suppression test which is usually thought of as the best way
to diagnose Cushing's disease and is the initial test that many dogs get,
for that reason.
To get to the actual question you asked, there are definitely shampoos that
help with itching. I personally like tar and sulfer shampoos like Lytar
(tm) and oatmeal shampoos like Relief (tm). There are a number of both
types of shampoos available. Other anti-seborrheic shampoos may be helpful
for calcinosis cutis. Antihistamines can be helpful in relieving itchiness,
too. Currently clemastine (Tavist Rx) is the antihistamine that many vets
favor but there are many others and there is no way that I know of to
predict which antihistamine will work best in any particular dog.
Antibiotics are often necessary if the itchiness has led to secondary skin
infections.
I hope that you and your vet can work through this problem. I realize that
I have suggested a lot of testing (skin scraping, skin biopsy,
phenobarbital levels and ACTH response testing). If money isn't an object
you could easily have all of this done in one morning if your vet has the
time to cooperate in the venture. The two blood tests would be very easy
to do at the same time since you have to drawn an initial sample for the
ACTH response test and it can be used for both tests.
Hope this helps some.
Mike Richards, DVM

Cushing's Disease and corticosteroids
Q: Dr. Mike
I have recently moved and my dog's new vet. has said that my chow could have cushings disease.
We transferred   and Kenya (my chow) has been treated by the same Dr. for several years. At
the time I took her to the vet she was constantly chewing herself to the point of bleeding and causing
"hot spots". After 3 months with her new Dr. she stopped chewing, regained her personality and all
in all began to get healthier everyday. This was due to shaving her hair, conditioning her skin, and allergy
shots. When I discussed this with her Dr. I was told that the shots could shorten her life span a couple of hers.
Well, I made the difficult decision to allow the shots and let her life be enjoyable and to best quality I was
capable of suppling verses quanity. When she needs a shot she will let me know and is relieved within
a 24 hrs of that shot. Kenya has never had to suffer thru any hot spots or sleepless nights since I made
this decision, she is now 10 years old and yes, age is taking somewhat of a toll but no more than any
other at 10 yrs and maybe not even as much as others her age. I do not regret the decision I made
and I know by her loyalty and love she feels the same.
To set some history, I fed my chow whatever was on special from the grocery store(not really knowing
any better) and all table scraps she wanted. Well, needless to tell you she became very fat. But was happy
and content. My Vet. suggested that she lose 25 pounds and that began my research on premium foods.
She was on Prescription r/d and lost her weight. She now eats Nutro Lamb & Rice (because of allergies)
and is maintaining this weight very well. Results of her being over weight and then losing 25 pds is some
wrinkles and saging here and there. (which unfortunately we all experience).
Kenya does not drink accessive amounts of water (except a couple days after recieving her shot), she
does not eat fast, urinate alot or show any signs of cushings. I have loved Kenya for 10 years and will
do whatever is best for her. The Vet here basically accused me of killing my dog. They said that every shot
I give her is killing her more and more. That she has the classic signs of cushings. (thining hair,saging skin,
and something about her abdomen) As I told you she lost alot weight and that allows for the sagging, she
is ten years old and I shave her for the summer to allow her skin to breathe and keep her more comfortable in the heat.
They had also suggested thyroid problems. Well, I purposely gave her vet records to them so they would
know her past. The whole conversation let me know they didn't read her records and didn't even know how
old she was. They thought her short hair was of natual causes I guess. She was tested for thyriod problems
years ago and results were nortmal and after hearing the statement that I have cut my dogs life in half, I could
only assume that they thought she was young??!! It absolutely blew my mind. My heart sank that allowed my
dog to stay with them a week while I was out of town.
I know I seem to be rambling on and going no where with this conversation but this was so upsetting to me.
I looked up cushings disease on the net and ended up here, please give me any suggestions you have, I know
in my heart I have done the best with kenya, but after going through something like this I can only question her
diagnosis, please respond and restore my faith in myself and the vet. that I have always referred to as saving
kenya.
Thank you for taking the time to read this letter and the access to this page. I look forward to hearing
from you.
Sharon

A: Dear XXXXXX-
It is possible that Kenya could have Cushing's disease. If so, it is possible that the Cushing's disease
(hyperadrenocorticism) is due to the injections or that it is occurring due to natural causes. Hyperadrenocorticism
is not that unusual in older female dogs. Signs of hyperadrenocorticism occur with some frequency in dogs
treated with corticosteroids on a continual basis for an extended period. This happens most frequently when
prednisone is used on a daily basis rather than every 48 hours but can happen with the injectable corticosteroids
as well, especially if they are used more frequently than once a month.
It is also possible that Kenya doesn't have Cushing's disease. Most dogs with this disease drink a lot and
urinate a lot. Not all of them, but most of them. Thinning of the haircoat, thinning of the skin itself, a pendulous
abdomen (think of a pot-bellied dog), changes in liver enzymes, itchy skin sores, increased susceptibility to
infection, lethargy and behavioral changes are some of the signs that can be seen with Cushing's disease. Without
seeing Kenya it is hard to evaluate how many of these problems may be present. It doesn't sound like many in
your note, though.
Hypothyroidism is fairly common in older female dogs, too. It also can cause thinning of the haircoat, failure
of hair to regrow after being shaved, increased susceptibility to infections, especially skin infections, reproductive
disorders and has been implicated in so many other clinical signs of illness that testing for it is easy to justify.
Proper testing is pretty important with this condition because treatment requires lifelong supplementation and t
here are a lot of dogs on thyroid replacement therapy who never had hypothyroidism to begin with. I attended
a seminar on endocrine disease once in which the speaker said that hypothyroidism was probably the most
over-diagnosed condition and the the most over-looked condition at the same time. Meaning, I suppose,
that it is missed many times when it should be found and diagnosed many times when it is not present.
Pharmacology professors at veterinary schools seems to universally abhor corticosteroids. I think this is
because they don't often practice veterinary medicine and when they do they don't practice it in a real world
setting. Their view is probably further skewed by a tendency to see the worst cases of everything at referral
hospitals, including the worst cases of corticosteroid abuse. They teach students based on their view of the
world. Many veterinarians graduate from veterinary school with a firm belief that the use of corticosteroids
is highly dangerous and almost completely unjustified. This is a tragedy for a lot of dogs who could have
relief from problems very responsive to corticosteroids without undue risk, as long as they are used with
reasonable care. It usually takes new veterinarians a year or two to realize that corticosteroids are often
beneficial and then a few more years to realize that they aren't seeing all that many bad reactions, either.
Pharmacology professors also tend to teach that the injectable corticosteroids are much worse than using
prednisone on an every other day basis and to taper off the dosage when the allergy season is over. In theory
this is probably true. In practice it doesn't take too long to notice that a lot of clients ignore the admonitions
to use prednisone on an every other day basis because it works a lot better if you give it every day. This can
cause problems. Then clients often run out of the pills and simply stop dosing the prednisone rather than tapering
it off. Most of the time this works out OK but I have seen some reactions that occurred from suddenly stopping the medications. The injections by-pass both of these problems but create some of their own. The veterinarian controls the frequency of the injections and if this is done conscientiously it is a good thing. There is a period of time when the injections suppress adrenal function but they naturally taper off which allows the dog's body to start production of cortisones and limit the possibility of reactions from withdrawal. In general, if the dog is receiving less than five or six injections a year and is getting them at least a month apart there is not a huge risk of complications.
More frequent use increases the risk of producing iatrogenic Cushing's disease but the risk of this may be worth
taking to provide comfort. If we have to use injections more than four or five times a year we do try to get the
clients to switch to every other prednisone.
If you are not using Frontline (TM), Frontline Topspot (TM) or Advantage (TM) for flea control you should do so. Even if you don't see fleas. Use of Frontline has drastically reduced the number of itchy dogs we treat at our
practice, making the use of long-acting injectable corticosteroids pretty infrequent in our practice over the last
two years.
It is relatively easy to test for both hypothyroidism and hyperadrenocorticism. If your vet really suspects these
conditions are present it is reasonable to test for them. If there is any question about the results, an internal
medicine specialist or endocrinologist can be contacted to help with interpretation and reassure you that the
results are accurate. If Cushing's disease is present and appears to be due to corticosteroids you or your vet
are administering it is easy to "cure" the disease. Just stop administering the corticosteroids. This may present
a lot of problems in keeping Kenya comfortable, though.
I think that keeping Kenya comfortable was the right approach to her problems. If your new vet can work out
a way to keep her comfortable without the use of corticosteroids that would be even better. If not, I don't see
much reason to feel guilty about providing her with a comfortable life.
Mike Richards, DVM



Cushing's disease in Corgi
Q: Dr. Mike: Our 7-year old Pembroke Welsh Corgi has been diagnosed with Cushing's Disease. She is on Lysodren once a week, plus 1500 mg of L-Carnitine and 50 mg of Coenzyme Q-10 per day. I know there are many symptoms to Cushings, but the ONLY outward symptoms that we see on her is a loss of muscle, especially her rear end. She will not put any weight on her left hind leg now. When standing, she holds it straight out behind her. My concern is this: will Cushing's affect one area (or side) of a dog more than another? I am afraid there is something else wrong with her leg besides the Cushings. Our vet feels that it is the Cushing's causing this limping, and that swimming therapy may help. I have searched the San Diego area for a canine hydrotherapist, but can't find one. Is there any other kind of therapy I could give her? Should her back be x-rayed? (Hip Displaysia has been ruled out.) Another thing, her orginal test in January for Cushings was negative, but came back positive in May. During this period, she was found to have over eighty bladder stones which were surgically removed. Upon no improvement in her limping after surgery, a more extensive test was done for Cushings (in May) and found to be positive. I guess my questions are this: can Cushings cause such severe muscle loss in one particular area of an animal, and is there a way I can help her get some muscle back? Is it just muscle loss that could cause her to not use her hind leg at all, or could it be something else? I know this is long-winded.
Thanks Dr. Mike, Mary
A: Mary- I think Cushing's disease can have some odd effects at times and I would not want to say it couldn't
cause the symptoms you describe. I would want to be really certain it was the cause, though. You may want to
ask your vet about referral to a veterinary endocrinologist, or internal medicine specialist. There are very good
endocrinologists at the University of California at Davis, if that is a reasonable trip for you to make.
Mike Richards, DVM


Cushing's possible
Q: Dr. Mike- First, thanks for developing such a wonderful web site. I've found it to be very helpful. I'm looking
for more information on pancreatitis, or whatever the problem is that has my 14 year old, 15 lb. Terrier-Spitz mix,
Melissa, so miserable. Over the last 3-4 weeks, Melissa has seemed to dramatically increase her consumption
of water, pants heavily and constantly, and has begun sleeping on the cool tile floor of the bathroom. We assumed
that it was her reaction to yet another unbearably hot Austin summer, so we made lots of water available to
her, turned the air conditioner down, and bought her a little electric fan for her favorite sleeping spot. Nothing
seemed to change with her behavior. Last week we came home from work to find little Melissa in a puddle on
the bathroom floor, unable to rise to her feet. Once we picked her up, she was able to stand but she hobbled
when she walked, favoring her back right leg. [This is getting long, but please indulge my continuance, as I'm
quite distraught.]
The next morning, our trusted vet looked her over and was much more concerned about her panting than her
leg problem. He ordered blood work which revealed: ALB 3.11 g/dl .ALKP 1719 IU .ALT 128 IU .AMYL
2334 IU .BUN 18.2 mg/dl .Ca 8.52 mg/dl .CREA .33 mg/dl .GLU 118.1 mg/dl .LIPA (vet's note: "too high to
read") .PHOS 5.22 mg/dl ,TIL .54 mg/dl .TP 7.58 g/dl .GLOB 4.47 g/dl .HCT 46.1% .HGB 16.5 g/dl .MCHC
35.8 g/dl .WBC 17.5 X 10(9)/L .GRANS 16.2 X 10(9)/L .%GRANS 93% .L/M 1.3 X 10(9)/L .%L/M 7%
.PLT 476 X 10(9)/L .Her health history is pretty unremarkable other than she's always had what both this Dr.
and Melissa's previous vets have called a "sensitive stomach"--off and on for years she's had a gurgly tummy
and refused to eat, but blood work as recently as Oct 95 ruled out pancreatitis. Furthermore, she was on cortisone shots and pills for years for itching, but we cut those out about a year ago b/c they seemed to cause her stomach upset. Our Dr. seems to think Melissa's suffering chronic pancreatitis and probable liver disease/progressive failure.
He gave her an antibiotic shot and an anti-inflammatory shot (from her vet records it looks like 0.5ml FLO/0.5 ml
Dex and 0.2ml Cent/0.1 Torbutrol) and prescribed Amoxil tabs 100mg 2x/day; Centrine as needed for nausea
(although she doesn't seem to have any problem with nausea lately so we haven't given her but one of these);
Pancrezyme 1/2 tsp. with each meal; Torbutrol 1 mg 2-3x/day as needed; and Vet's Choice Sensitive Care food-- 2 heaping spoons 3x/day. Since beginning this treatment last Friday (6/20), her appetite has returned with a vengeance, but her heavy panting, labored breathing, and lethargy/depression continues. She has had three good spells of a couple of hours each where she seemed perky, met me at the door when I got home, followed around the house, and actually rolled over to have her tummy rubbed--all "well" Melissa behaviors.
The bad symptoms, though, have returned afterward each time. In fact, early this morning, her breathing was so
loud and labored that it woke me up. I gave her a Torbutrol, assuming she was in pain, and within 30-45 minutes
she was breathing quietly. To top all of this off, I also noticed today that she's got tapeworms (darn these Texas fleas!!), so I've called in a request to our vet for one of those worm pills. Thinking that these continued symptoms are probably her response to pain, I've begun looking for ways to make her more comfortable. Our vet mentioned that the analgesic we're giving her may be tough on her liver, so I'm hesitant to rely on that. On the suggestion of a
couple of friends and with the OK of our vet, I've made an appointment for tomorrow with another vet who incorporates accupuncture into her practice. Since I don't see that we have the luxury of a wait-and-see approach with this old doggie, I'm in search of as much information as I can get on pancreatitis and other problems that might present in the same ways. And, I guess, I'm looking for additional confirmation that we're taking the right approach with Melissa.
Any advice for reading materials, thoughts on her diagnosis, or additional or alternative treatment options, or words of reassurance? Many thanks in advance for addressing my question and for putting together such an informative web site. Leslie
A: Leslie- Based on the description of increased drinking and urinating, along with lethargy, I'd be suspicious of
Cushing's disease (hyperadrenocorticism). This can lead to pancreatitis and it is entirely possible that both problems could be present (or that my suspicion is off base). Cushing's disease frequently causes elevations of the alkaline phosphatase level, too. It requires special testing specifically for this disease, most commonly a "low dose
dexamethasone response test". Cushing's disease causes panting, increased drinking and urinating, muscular
weakness, promotes diabetes and pancreatitis and is associated with hairloss in many dogs, as well.
I'm sure your vet has continued to think this through and has probably considered this possibility but it might
be worth asking about.
Mike Richards, DVM

Cushings and Melissa - continued
Q: Dr. Richards- Thought you might be interested the latest twist in Melissa's on-going saga. Her high-dex
test to determine the origin of her Cushing's came out inconclusive. Apparently she reduced her cortisol
(or whatever the test is supposed to reduce) by 50.46%. The internist we have begun dealing with suggested
an ultrasound to determine more definitively whether or not an adrenal tumor was the problem. No abdominal
abnormalities were seen in the ultrasound with one big exception: she had a ~2.5 cm pocket of fluid in one
lobe of her liver. Based on the surgeon and internist's recommendations, exploratory surgery was done, the
pocket removed and a biopsy of her liver was done. The hands-on examination of her adrenal glands showed
them to be symmetrically enlarged with no signs of growths. Ironically, one end of Melissa's pancreas appeared
to be a little tough, so it, too, was biopsied. The fluid pocket in her liver was determined to be a cyst adenoma,
and her liver tissue, according to the surgeon, looked to be very healthy. Her pancreas, on the other hand, was
determined to be in the healing stages from an attack of acute pancreatitis. So, our weird little dog has both
pancreatitis and pituitary-dependent Cushing's. She'll be in the doggie hospital for six days, working her way
off of IV fluids and back to food during her last two days. We visited with her yesterday and she looked really
good--perky and up for a mini-walk outside. Today, according to the internist, she looks even better--up
schmoozing with the staff! Once she's back home, I think the plan is to give her Pancrezyme supplements
(haven't confirmed this with the internist) and in few weeks we'll probably begin treatment with Lysodren.
Any thoughts on the choice of Cushing's treatment options (Lysodren, Ketoconazole, or L-deprenyl)?
Yet another big, warm thank you for spurring me to push further and harder into figuring out what was
making sweet Melissa so sick! -Leslie
A: Leslie- We still use Lysodren therapy most of the time for Cushing's disease because we are familiar
with it, it costs less and it is easily available. I have used ketoconazole twice, once successfully. I wasn't too
disappointed that it didn't work in the other case because it is supposed to have about a 20% failure
rate in helping with Cushing's. We chose it in both these cases because of reactions to Lysodren. So
it is good to have a third choice and l-deprenyl looks good on paper but I haven't tried it yet.
Mike Richards, DVM
Michal Response: Leslie, thanks for keeping us informed on Melissa's care and progress.

Cushing's Disease with immune mediated hemolytic anemia
Q: Dear XXXX: Our bichon was recently diagnosed with Cushing's Disease. The vet. put her on Anipryl
or four days straight with one tablet each week thereafter, for four weeks. Into the third week she became
very weak, and upon her vomiting...I rushed her to the vet... We have now been told that they think she
has auto immune hemolytic anemia. She tested neg to the Coomes test....even thought that doesn't mean
she doesn't have it. They began giving her steroids and within 34 hours her red blood cell count had climbed
from 9,000 to 12,000.. they said they had hoped for higher...they will increase the amount of steriods today..
.her wbc is very high as well... My question....Do you think that the Anipryl brought on a drug -induced
immune hemolytic anemia? or is this just a part of having Cushings? and lastly never having been down this
road before...should I prepare myself for days of sadness ahead? I so appreciate having found this supportive
site on the web...not in anyway do I discount the abilities of my vets...by asking you these questions...I only
hope to gain further insight into this horrible disease that anyone has. With appreciation, Mrs. J.
A: Mrs.J- I think that it is necessary to consider the possibility that l-deprenyl (Anipryl Rx) could have lead
to a immune mediated hemolytic anemia as a drug reaction. I am not familiar enough with this medication to
know how likely that might be, though. I have forwarded your email to a veterinarian I know who is involved
with the research on this medication and maybe he will know more. I'll pass on any information I get.
There are other medications for hyperadrenocorticism (Cushing's disease). Ketaconazole is pretty safe and
mitotane (Lysodren Rx) has been used with success many times, although overall it is more likely to cause
side effects than either ketaconazole or l-deprenyl, probably.
If the immune mediated hemolytic anemia is a drug reaction it will normally respond to treatment and it is not
likely to recur with other medications. I hope that everything is improving now.
Mike Richards, DVM

High Alkaline phosphate levels
Q: My 12 year old Maltese was diagnosed with Cushings the first of April. He has been taking Lysodren
(daily 10 days, 2x wkly since). His alkaline phosphatase is now 1500, up from 1108 on Apr 1. the Vet did
not retest until June 13. I now realize (from the various Web articles I've read) that retesting should have
been done sooner. Have you had experiences with a similar situation? Any opinions? I live in Dallas, TX.
Any opinions on speciality vets here who deal with Cushings?
A: Teresa- It is not unusual for dogs with Cushing's disease to have high alkaline phosphatase levels ---
often in the range of your Maltese. This doesn't always resolve with therapy but our experience has been
that it rarely indicates a clinically serious problem. I know that there are good veterinarians on the staff at
Texas A&M, if your vet does not know of a specialist closer.
Mike Richards, DVM

Cushing's - no response to treatment
Q: Hi! I have a dog of ten years, diagnosed with Cushing's, possibly due to a tumor in the hipofisis (adrenal
glands have been seen by Ultrasound and they are normal in size; liver is enlarged). Yokie is a dog of 10 kilos
of weight and is being treated with Lysodren. We have tried for ten days and it didn't work (symptoms didn't
change: polydipsia, polyuria, polyfagia, pendulous abdomen, hair loss, panting...) We have begun again for
ten days more and we are in our ninenth day and no change till now. We are going to continue five days
more (in total 15 days this time) and then we will do an ACTH. Do you have any reference of dogs with
Cushing's that don't react to the treatment? What can I do if my dog doesn't react to the treatment?
Thanks for your attention - from Spain
A: Some dogs do not respond to Lysodren and it seems likely that your dog may be one of them.
There are several options in this case. The medical options are ketoconazole (Nizoral Rx) and l-deprenyl
(Eldepryl Rx and Anipryl Rx). l-deprenyl will only work with pituitary dependent Cushing's disease, so it
is good that your dog appears to have this type. Both of these medical treatments have been pretty widely
reported in the veterinary literature and I am pretty sure that your veterinarian will be able to find references
for their use. l-deprenyl may be a little harder to find information on as its effects on cushingoid dogs has
been a more recent discovery.
In a small number of dogs there may be operable tumors contributing to this condition - pheochromocytomas.
It may be worth considering this possibility if the condition continues to be resistant to therapy.
Good luck with this.
Mike Richards, DVM

Diet For Cushing's
Q: Dear Dr.Mike, I don't mean to make a pest of myself, but I forgot to ask if you there are any dietary
recommendations in Cushing dogs. We have her on a strictly dog food diet.(Iams dry minichunks and canned
science diet senior).I have absolutely forbidden family members from sneaking her any table scraps any more,as
she did used to get more than a little dogs share of meat scraps,cottage cheese and anything that fell to the floor.
Any special things I could do for her?? I have been led to understand that if her metabolic functions and enzymes
are not normal she may not be absorbing the needed vitamins,proteins and fat that a dog needs for proper health.
Thank You in advance for any help.
A: I have been reading some interesting articles on hyperadrenocorticism today. I found a recent issue of the
Clinics of North America, "Adrenal Disorders", March 1997, edited by Peter Kinzer, DVM.
It has an article suggesting that the pathogenosis of pituitary dependent hyperadrenocorticism has not been fully
worked out. This article, by Dave Bruyette, DVM et. al., mostly concerns the use of a new medication, l-deprenyl, for the treatment of Cushing's disease. It suggests that it is possible that this is a neurologic degenerative disease
similar to Parkinson's disease in humans in the way it progresses, but with different effects and clinical signs. It is a
different view entirely from the one I have held for a long time on how this disease occurs. It will take me a while
to research this and I am sure that the university vets will already be aware of this hypothesis. Still, it is interesting
and made researching this worthwhile.
The only dietary recommendations I can find are in Small Animal Clinical Nutrition III by Morris, et. al. It says to feed a high protein, low fiber, low fat, low purine diet. It suggests that it is important not to oversupplement calcium. It is also important to make sure potassium levels are adequate and that sodium is not restricted in any way if mitotane (o'p'DDD) is being used to treat the hyperadrenocorticism. Also, it is important not to restrict water intake, as you might imagine. Feeding Hill's i/d diet is one way to meet the requirements for these things. One of the book's authors is the son of the veterinarian who founded Hill's, so there may be a little bias in the recommendations, at least as to the
recommended diet.
Mike Richards, DVM



Seizures and Cushing's Disease:
Q: Mikki is 15. She is a mutt...Terrier dominates. She has never been sick to any degree. An upset stomach might take place if she's eaten sothing she shouldn't have.....like the time she got into the chocolate chip cookies. Generally speaking, however, she is pretty healthy. She eats Vets dog food, half can in the morning and the other in the evening ....and milk bone bisquits. That's it. We don't vary the diet. She has always downed her food in about a minute..now I water it down so she will eat slower. Her appetite does not change. she has begun to display slight siezures lasting a few seconds. There is no change of weight, behavior, or appetite. Her vision is getting weaker but not worse than expected for a 15 year old. Nothing seems to be changed except very (infrequent) short seizures. Her Vet took a blood test and he's looking at Cushings Disease..but from what I read he is on the wrong path....and there is no mention of seizures in Cushings. Any help would be welcome
A: My guess is that most seizures occurring in older dogs are the result of degenerative changes in the nervous system and cancer. However, Cushing's disease is reported to be associated with an increase in seizure activity. This probably occurs because most cases of Cushing's disease are caused by pituitary gland tumors in the brain. As the tumor grows, seizures can occur. Most dogs (about 80% if I remember correctly) affected with Cushing's disease show a marked increase in drinking and urinating. It is relatively easy to rule this disease out with labwork and if other clinical signs of the disease are present, such as abdominal distension, hairloss, thinning of the skin, increased skin pigmentation, panting, excessive drinking, urination or appetite, it is a good idea to rule it out. I hope you find a treatable cause for Mikki's seizures. My terrier mix, Maggie Mae, also has seizures. I haven't been able to find a cause for them but they are infrequent and we are not treating her at the present time for them.

Mike Richards, DVM
Cushing's disease page 2
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Cushings disease with secondary problems
Question: Dr. Richards
I am a subscriber and have an urgent question. Please answer this as
quickly as possible.....
I took my 11 year old neutered male Lhaso Apsa to the vet today
because he did not eat last night and has been throwing up white frothy liquid
continuously. He also was panting with an open mouth. He has been
drinking large amounts of water (not often though).   For the last week he has
been waking me up during the night and wanting to go outside (very
unusual). The vet gave Duffy a Baytril Injection, a Buprenex injection, and a Reglan
Injection. He had a full bladder. I took him outside and tried to
get him to urinate to no avail. So, the vet catherized him. They drew blood
and below are the results:
TEST               RESULTS             REFERENCE RANGE
INDICATOR
ALB                 4.08 g/dl               2.70 - 3.80
        high
ALKP               1328 U/L              23 - 212
       high
ALT                   36 U/L                   10 - 100
      normal
AMYL               615 Y/L                 500 - 1500
normal
BUN                  17.9 mg/dl              7.0 - 27.0
     normal
Ca                      9.69 mg/dl            7.90 - 12.00
     normal
CHOL               300.5 mg/dl              110.0 - 320
normal
CREA               0.72 mg/dl               0.50 - 1.80
   normal
GLU                   141.4 mg/dl            77.0 - 125.0
        high
PHOS                 4.70 mg/dl             2.50 - 6.80
   normal
TBIL                   0.36 mg/dl              0.00 - 0.90
      normal
TP                      8.12 g/dl               5.20 - 8.20
        normal
GLOB                  4.04 g/dl               2.50 - 4.50
     normal
Na                      153.7 mmol/l        144.0 - 160.0
normal
K                          4.41 mmol/l           3.50 - 5.80
      normal
Cl                         117.6 mmol/l        109.0 - 122.0
   normal

Results of Buffy Coat Profile:
HCT                      44.8%                   37 - 55.0
   normal
HGB                      14.0 g/dl               12.0   - 18.0
   normal
MCHC                    31.3 g/dl                 30.0 - 36.0
normal
WBC                      21.9 x10 (9)/L        6.0 - 16.0
      high
Grans                    19.4 x10(9)/L           3.3 - 12.0
       high
    %GRANS              89%
L/M                        2.5 x 10(9)/L           1.1 - 6.3
     normal
    % L/M                   11%
PLT                        790 x10(9)/L            175 - 500
        high

Buffy was given Fluid SQ Therapy. The vet thought he had
pancreatitis. I took Buffy home and he was very uncomfortable and cried a little and
panted alot. He moved very slowly. I called the vet back up and asked are
you sure he doesn't have a stone in his bladder that is obstructing his urine
flow?
(Buffy had stones removed two years ago. ) The vet said to bring Buffy
back and she would do Xrays to be sure. The Xrays revealed stones in
bladder and kidneys. The vet said she wanted to keep him over night and give him
fluids via intravaneous and catherize him so that his urine would flow. He
was drooling so much and throwing up foXXX XXXXX liquid and she was afraid
he would dehydrate so she wanted him to stay overnight. She said she
still thought he had pancreatistis. So he is now in the clinic.
I worry that something is being over looked. Duffy has always eaten
some table scraps with absolutely no problems. But approximately a month
ago, I started giving my dogs only a small bite of table scraps, once in a
while.
Before Duffy got sick he had eaten approximatly a 1" piece of fried
chicXXX XXver. He also had approximaly 2 very small pieces of BBQ potato
chips. For the last week he has been getting me up in the middle of the night to
go outside. I don't know if he has been urinating or not, because I did
not see any problems until yesterday evening.
So what do you think is happing? Does it sound like pancreatitis or
what other possibilities could it be. I want to make sure we don't
overlook something. My vet knows I read alot of vet health books.
She is used to me asking alot of questions; so she won't be a bit surprised if I ask
about checking out other possibilities. My question and your answer is
strickly confidential between me and you. Please answer quickly.......I fear
my dog's life might be in danger if I don't look at all possibilities.
Thank you so much, Sharon
Answer: Sharon-
My first thought on reading your description of the symptoms and on
looking at the lab work was that Duffy probably has Cushing's disease and that
there are secondary problems as the result of that. Both pancreatitis
and Cushing's disease can cause mild elevations in the blood glucose but I
think this is more common with Cushing's disease. In addition,
Cushing's disease causes elevations in the alkaline phosphatase level without
causing elevations in the ALT. Pancreatitis often causes elevations in the
amylase levels but does not consistently do this. The BUN and creatinine being
in the normal range indicates that there has not been much interference
with urine flow despite the presence of the stones. Mild elevations in white
blood cell count are common with both pancreatitis and Cushing's
disease. It would be better if someone counted the white blood cell types ( a
differential count) rather than relying on the count done with the
QBC-V machine (we have one of these and it reports only the major white blood
cell groups so we have to do differential counts on our own).
I would worry a lot about the possibility of secondary congestive heart
failure or possibly even pneumonia with the signs you are seeing.
X-rays would help to clear up whether either of these conditions is present.
If the X-rays taken so far show his chest, this may not be necessary or
may already have been considered and dealt with.
Bacterial infections of the urinary bladder, sometimes leading to stone
formation, are common in patients with Cushing's disease. This may or
may not be a factor in Duffy's case, since he has a history of having
stones. It was obviously a good to be as sure as possible that there was not a
stone in his urethra causing intermittent blockage of urine flow. It is
also a good idea to try to estimate the degree of infection in the
urine (if there is a current infection) and to get a urine culture to
identify the bacteria and to determine which antibiotics are best to keep him
on. If the previous stones were identified as struvite stones by analysis it
may be possible to use a s/d (tm) diet to dissolve the current stones, as
the odds would favor them being the same stone. This is a judgment call. I
think that my wife (also a vet) would favor surgical removal of the
stones because of the potential for urinary blockage while waiting for stones
to dissolve. I favor medical therapy when possible --- and your vet
probably leans one way or the other, too.
Dogs with Cushing's disease are somewhat prone to getting pancreatitis,
which makes all this even more confusing, since that makes it more
likely that both conditions may be present.
It can be tricky to sort through situations like this in which there is
more than one disorder and it is unclear which ones occurred
independently of the others and which ones are caused by one another. However, it is
usually productive to treat the symptoms at first and then to keep
doing diagnostic work in a logical order until it is possible to determine
which problems are really present and how to best treat them. I would want
chest X-rays at this time, even if I thought that the fluid wasn't being
coughed up, just because it is a bigger mistake to miss a pneumonia or fluid
accumulation from chronic heart failure than to take X-rays that turn
out to be normal. I would want to know if Cushing's disease was present
prior to doing surgery to remove stones (if that is necessary --- if I
suspected dietary dissolution of them wouldn't work due to the composition of the
previous stones or past experience trying that).
I hope this helps. Your vet can actually look at Duffy and may feel
that it is possible to rule out some of these things based on the physical
examination but if you don't mind spending money to be cautious it may
still be best to rule them out through lab testing.
Good luck with this. Hopefully Duffy will respond to the treatment so
far and give you and your vet time to sort through all this.
Mike Richards, DVM
2/9/2002


Cushing's disease - treat or not
Question: Dear Dr. Richards,
Thank you for all of the information on your website and you digests of back
issues - they have been really helpful for me as I discuss my dog's case with
her vets.
I'm hoping that you might be able to provide some insight about her recent
Cushing's diagnosis which after further tests, they are considering may have
been the wrong diagnosis. All of this latest exploration of Cushing's stems
from a recurrent swollen vulva that my Tahoma has had for 5+ years and for
which she has had surgeries, scopes and probably $4,000 worth of tests. I
don't mind the money at all but I would like to find out what the underlying
problem is so that she can stop suffering (her swollen vulva causes obvious
discomfort after urination).
My two questions are at the end of the background info -
Cushing's background:
3/2/01 Visited vet because of recurrent swollen vulva, they ordered cytology
and bloodwork with T4. Bloodwork showed elevated liver enzymes which led to
tests for Cushing's which they felt might also explain her recurrent
infections.
3/9/01 Low dose Dex suppression test - positive for Cushing's
0 hrs 2.4 micrograms/deciliter
4 hrs .4
8 hrs 2.6 (they said that 0 - 1.2 was normal)
3/19/01
ACTH - came back within normal limits
Urine test - 1032, 1030 normal
Ultrasound - bladder and adrenal glands were normal such that
ultrasonographer suggested that Cushing's may not be present
Possible symptoms of Cushing's (although none of these seemed especially odd
to me until the vet asked about thirst and appetite as it related to
Cushing's)
- increased drinking in last 6-9 months and drinking very fast
- may have increased appetite or at least extra fascination with begging for
food? Previously, we could leave food on plates on the dinner table and leave
the house and she wouldn't touch it. Around Christmas, she found an unopened
bag of yogurt pretzels in a Christmas bag and tore it open and ate the entire
bag. I thought she was just acting out as we had a puppy visiting for 3
weeks.
- no longer sleeps on bed with us (perhaps intolerant to heat?)
- she does not seem to have to urinate more frequently - at night she can
still wait 12 hours before we go out. She may just have excellent bladder
control.
- she's still playful though she has seemed to slow down recently and I had
wondered if she had hurt her back or something playing on our many stairs.
Vet thought her back looked flexible and in good condition. Does not want to
jump up on people anymore to greet them.

Here's her full background in case any of it is useful:
Tahoma is approx 7.5 years old, I got her from a rescue group when she was 6
months old, she had been living in the streets. She seems to be mostly, if
not 100% Siberian Husky.
6/95 and 9/97 short, early morning seizures, bloodwork after 9/97 indicated
increased bile acids, subsequent follow up tests showed bloodwork in normal
limits.
10/96 to present - recurrent swollen vulva, treated with topical steroids
2-3x with condition returning after treatment. Diagnosed as false estrus due
possibly to incomplete spay. Further surgery indicated that intial spay was done properly, they
removed what little was
left of her ovarian stump.
Swollen vulva continued, and my vet does vaginal scope and sees no sign of
infection.
9/97 See a new vet after moving to LA, he suggests that her swollen vulva could
be a glandular as Tahoma also appears to have excess secretions on the side
of her face. Asks me to call if swollen vulva returns.
11/97 Swollen vulva returns, and I am referred to an endocrinologist. He suggests douching with
vinegar, I do this with no apparent secession of her symptoms
3/98 Swollen vulva returns, again treated with Panalog (we've now moved to
Washington state). Vet inspects mouth, gums, nose rules out auto immune
disorder due to lack of infections elsewhere.
Since 3/98, we've again tried Panalog and douching 3-4x, each time problem
subsides while using Panalog then resumes, occasionally Panalog is
supplemented with a course of antibiotics
TODAY: Since Cushing's diagnosis may be taken back off of the table, we are
now considering a biopsy and a visit to another endocrinologist.
QUESTION 1:
Should we re-do the low dose test? Vets said that sometimes stress can cause
elevated results. Tahoma howls all day at the vets. I could take a day off
and just bring her in at 0, 4 and 8 hours so that she wasn't crated at the
vet all day long. I don't want to discount Cushing's if it is still a
possibility - especially with recent liver damage suggested.
QUESTION 2:
She has had recurrent swollen vulva and infections for 5 years, if it's not
Cushing's that's causing this - any ideas? What further tests should we
pursue?
Thanks so much for your advice!
Best wishes,   Annette and Tahoma
Answer: Annette-
I might want to recheck the low dose dexamethasone test before making further decisions about
treating or not treating for Cushing's disease. Approximately 25 to 30% of dogs with
pituitary-dependent hyperadrenocorticism (PDH) have test results similar to those that you report.
This pattern, in which the cortisol drops to levels below 1ug/dl at 4 hours and then jumps back up to
near the level of the initial test at 8 hours is called an "escape" pattern and is considered to be
diagnostic for PDH. However, we have seen this pattern once because we didn't calculate the
dexamethasone dose correctly and gave a slightly smaller dose than we should have, so I am always
a little worried about this possibility. When we rechecked this patient, the low dose dexamethasone
suppression test was normal. I think this isn't a common problem with testing but when I am
suspicious for some reason that the test isn't correct, I worry about it. In your case, the normal
ultrasound examination is the thing that makes me think about rechecking the lab values.
The other thing that I am thinking is that Tahoma has had the vulva swelling a lot longer than any signs
of Cushing's disease, so I have a hard time believing that Cushing's disease is the cause, even if it is
present.
These are the causes of vulvar swelling that I was able to find by searching through the books I have
at home and from the Veterinary Information Network (tm):
I did not get the impression that you were seeing a pattern in which the vulvar swelling is occurring at
intervals that match the expected estrus interval (approximately every seven months) or that there
was bleeding suggestive of estrus, but if this is the case, it might be a good idea to check estrogen
and progesterone levels just to see if they are elevated. If so, it may be necessary to consider another
surgery to look for ovarian remnants. If this is the case, it is best to do the surgery during the time
there is vulvar swelling and/or bleeding so that the ovarian remnant will be as large as possible.
The most common cause of vulvar swelling other than an ovarian remnant is probably vulvar fold
intertrigo, which is the name for the situation when hair from one side of the vulvar fold is irritating the
skin on the other side, leading to itchiness, licking of the vulvar area and occasionally swelling of the
region. There are many recommendations for dealing with this problem but the goal is to try to keep
the area dry and to control bacterial or yeast infections that occur secondarily. It is possible to do
surgery to eliminate most of the folds and this may be the best procedure if medications do not
control the problem well. We have had pretty good luck using NeoPredef (tm) powder to control
this condition and mupirocin is supposed to help, too.
Cushing's disease is reported to cause vulvar swelling in some dogs and other hormonal disorders are
also sometimes implicated. If there does not appear to any indication of the intertrigo problem it may
be worthwhile to check serum levels of sexual hormones (estrogen, progesterone and testosterone).
Some dogs have vaginal abnormalities that might cause irritation or inflammation, so it is worthwhile
to consider a careful examination of the vagina, including endoscopy if that seems necessary.
Intermittent swelling doesn't really support this possibility, but we have seen swollen vulva due to
tumors in the vaginal walls and there is a small chance of a hernia causing swelling in the vulvar area.
There are probably other uncommon problems that I have not seen and did not find in the literature. I
didn't find mention of a glandular problem but that would be an example of things that probably do
occur that just aren't common enough to make it into the general literature.
It seems like your veterinarians have been trying to work through these possibilities and so I am
afraid that this note won't help you much. Sometimes it does take a great deal of work and even
some luck to get to the bottom of a problem like this.
Mike Richards, DVM
4/9/2001


Cushing's disease in Australian Terrier
Question: Dear Dr. Mike,
     I have an 11-year-old Australian Terrier named Sydney. She has been
extremely healthy throughout her life. She does need some dental work so I
took her to my vet on an ER visit because I thought she had a gum infection.
I saw the newest member of the practice, a women who is recently out of
school. She decided to do her pre-dent lab work to save me a trip. A few days
later I received a call from the vet that Sydney's Alkaline Phosphatase was
2000. She said that it was the highest value she had ever seen. Sydney had no
symptoms except she does pant a lot and has a pot belly. They repeated the
Alk Phos and it was the same and they did liver enzymes which were normal.
The vet said that the next step was an ultrasound and an ACTH if it showed
enlarged adrenals. The ultrasound was normal except I was told that both of
her adrenals were enlarged. The ACTH was normal. I was told that she did in
fact have Cushings and that it was coming from the Pituitary. The Vet
recommended a Dexamethazone or Betametazone challenge and she mentioned
reading up on Lycodren and Anapryl (SP) for possible treatments. That
challenge test was normal. I was then told that she did not have cushings
because all of the tests were negative except the Alk Phos and we needed to
go back to the liver as a possible source or the bone which was unlikely with
no symptoms. I said what about the enlarged adrenals. then she said well they
were just slightly enlarged and still within normal limits. But But I thought
we based the decision to do the dexzamethazone challenge on the fact that
they were enlarged? She said that all of the tests were necessary and that
she could not treat Sydney even with Anapryl based on these results. BUT she
said that Sydney was cleared for surgery and suggested that while she is
under anesthesia that she do a liver biopsy. I said what was she looking for
and she said that it could be diffuse liver disease.
     Now what I guess I am asking - based on what I have told you, and $700
later to ask me to do a liver biopsy when there was no enlargement or
shrinkage of the liver, the liver enzymes normal, and no ascites, should I
give my consent for such a procedure? If diffuse liver disease was detected -
what could be done for my dog? and would you have continued with the tests
that were done after seeing all those normal results. My dog has no other
signs of Cushings. No thirst, or wetting problems. Should I go ahead with the
dental work? What else could it be?
Thank you, Susan
Answer: Susan-
It is very frustrating, to both the vet and the client, when there are
enough symptoms of hyperadrenocorticism (Cushing's disease) to make testing
seem necessary, but the test results end up being negative, since it is a
costly procedure to rule out this disease.
I honestly think that I would have wanted to test for Cushing's disease
with the elevated alkaline phosphatase level and pot-bellied appearance. I
tend to start with the low dose dexamethasone suppression test, since it is
a little more sensitive, but I know a lot of vets who use the ACTH response
test first because it can be done more quickly. When I have really felt
that Cushing's was probable but the test results didn't support the
diagnosis, I have referred patients for ultrasound exam, just to be sure
there wasn't a lot of enlargement of the adrenal glands. We have had
ambiguous results on ultrasound with two of our patients, so it isn't a
sure test -- but it is a reasonable test to do. Sometimes the hardest
thing to do is to rule out a disease, especially since it uses up a lot of
money that could have been spent trying to figure out if another disease is
present -- except that it really was necessary to rule out the first one.
It is just a frustrating situation for everyone.
The second most common cause of elevation of alkaline phosphatase levels,
with no other elevations or only mild elevations in other enzymes is a
disorder referred to as nodular hyperplasia of the liver. This disorder is
benign. It may or may not show up on ultrasound exam and it may or may not
be identified through liver biopsy, although surgical biopsy is a
reasonably sure way to pick the right spot to take a sample from. It is
not necessary to treat this condition but having a diagnosis might prevent
a search for other liver problems.
If a rise in alkaline phosphatase is the only problem found in the lab
work, I would personally be pretty comfortable going ahead with the dental
cleansing and I would also be comfortable waiting on a liver biopsy. I can
see the advantages of going ahead with the biopsy since general anesthesia
is contemplated, though. I just wouldn't push too hard for it, based on
experience with a number of patients with isolated rises in alkaline
phosphatase who do not develop further evidence of liver disease.
Alkaline phosphate rises can also occur with the use of corticosteroids.
You didn't mention a history of using prednisone or other corticosteroids,
but if these have been used, it would be an important part of the history
and could be causing the alkaline phosphatase rise.
Cancer can cause rises in alkaline phosphatase (SAP), especially bone
cancer, but this is not a common cause and usually the SAP is not as high
as 2000.
I hope that this is helpful.
Mike Richards, DVM
10/16/2000
Possible cushings in Golden
Question: Dear Dr. My 12 year old golden retriever may have cushings disease. Our vet
wants us to bring him is for tests even tho he has hardly any signs of the
disease. He does not urinate excessively nor does he eat or drink
excessively. His muscle tone in his hind legs is very bad, but he can still
trot and swim. His quality of life is still very good. He has the body of
an old dog but the heart of a puppy. The reason our vet thinks he may have
the disease is because of his urine count. We have to put him on a low
protein dog food because of the urine test also. Do you think we should put
him through the tests. I am afraid if he does have cushings, the medication
might be very hard on him. You wrote about anipryl, and I was wondering if
we could put Louie on this medication instead, because there are no side
effects. Please advise. Thank you, Dolores

Answer: Your vet may have been checking the urine cortisol/creatinine ratio. This
is a test which compares the level of cortisone in the urine to the level
of creatinine in the urine. This test is pretty sensitive to Cushing's
disease but it has a lot of false positive results and some false negative
results. It is a relatively inexpensive test to try to rule in or rule out
Cushing's disease but it is absolutely necessary to use further testing to
confirm the diagnosis. Your vet might also have been checking urine
specific gravity, since Cushing's disease tends to cause dilute urine and
low urine specific gravity on a consistent basis. Low urine specific
gravity can occur with kidney disease, Cushing's disease, diabetes
insipidis, behavioral disorders that cause increased drinking and probably
some other conditions I can't think of off the top of my head.
I tend to test for Cushing's disease only when there are clinical signs
that make it seem worthwhile to treat the condition if it exists. Muscular
weakness might be a worthwhile reason but without other signs the odds of
Cushing's disease being present are fairly low. I'd say this is one of
those times when the correct thing to do is unclear -- but I would be
certain that you want to pursue treatment, if Cushing's disease is present,
before doing the testing. Presently, I do like to try selegiline (Anipryl
Rx) first, because it is easier to monitor and involves less follow up
testing but it doesn't work as often as mitotane (Lysodren Rx) to control
Cushing's disease. Lysodren does have more potential side effects and using
it involves a commitment to follow up lab testing.
Hope this helps some.
Mike Richards, DVM
7/14/2000

Cushing's
Question: i am a new subscriber// I'd like to ask question of Dr. Mike re: my 10 year
old Old English Sheepdog with Cushings Disease. She completed her loading
dose of Lysodren and went on maintenance. She became so weak that she
couldn't get up. when we got her up she collapsed. To complicate her like
she also has arthritis and a fused spine. I think that the high amounts
of steroids that were present when her cushings was active were relieving
the symptoms of her arthritis and fused spine. We (my vet and I) took her off
the lysodren and put her on prednisone. She's doing much better. She can
come upstairs to bed with us and the other dogs at night. she can relieve
herself without falling down..Her sweet disposition had returned. Do I let
nature take it's course and let her cushing's disease with it's side effects
shorten her life or do I medicate her with lysodren, causing her quality of
life to deteriorate in exchange for no cushings.
Norma-

Answer: There is no evidence that I know of that treating for Cushing's disease
extends the lifespan of a dog affected by this condition, although it is
possible that treatment of the Cushing's disease with selegiline (Anipryl
Rx) would, just because it seems to extend the lifespan of normal dogs in
some cases.
If there is not enough problem with increased drinking and urinating to
necessitate treatment for it, I think it is really reasonable not to treat
for Cushing's disease. If this is a problem, I don't think there is a big
problem with using selegiline and trying a non-steroidal anti-inflammatory
like carprofen (Rimadyl Rx) or etodolac (Etogesic Rx) for the pain. If that
isn't sufficient, I would be comfortable adding prednisone if it increased
the quality of your dog's life. Selegiline is expensive and it doesn't work
for all dogs so vets are sometimes reluctant to use it. It has worked
often enough for us that I feel it is worth a try, though.
Hope this helps some. One of the older issues of the VetInfo Digest, in
the subscriber area, is entirely devoted to Cushing's disease, so you might
find some useful information there, too.
Mike Richards, DVM
5/24/2000



Cushing's
Question: Dear Dr. Richards:
Thank you very much for your answer regarding Bailey. She is now doing
better but her back legs are still very weak. She had a muscle and nerve
biopsy . These were reviewed by Dr. Shelton who is apparently an
expert in neuromuscular diseases. Bailey has loss of nerve fibers. In sections of
the nerve only 10% of normal nerve fibers were seen. She called it a
polineuritis. She was wondering if bailey had cushings. We had her ACTH
test repeated and came back as consistent with cushings. Bailey has had an
abdominal ultrasound in November which showed bilateral enlargement of the
adrenals. Baileys symptoms are only the muscle weakness and also panting
which is excessive.
She was placed on synthroid while we were waiting for the biopsy . however
she had a normal TSH. I think hypothyroidism is not her problem. I have
several questions regarding the treatment and overall prognosis disease.
1: What is the survival of dogs after cushings is diagnosed? Does the
therapy prolong life or just its quality? Bailey will be 13 in March.
2: Do you agree with the diagnosis?
3: What therapy would you recommend. I know about mitotane and also
anapryl. I am worried about the possible side effects with mitotane. What
is your recommendation. What is the success rate of each of the two drugs?
Should we expect that some of her leg weakness be reversible? Cost of the
drug is not a problem.
Thank you very much for all your help.
Margarida
Answer: Margarida-
I will try to keep my answers roughly matching your questions. I'm not
very good at that, so please bear with me.
1) I think that most veterinarians who treat Cushing's disease feel that it
prolongs the patient's life. I think that is true, too --- but not for
medical reasons. The most common symptoms of Cushing's disease are
increased drinking and urinating. Once dogs have to urinate frequently
enough, there will be accidents in the house. This places many older dogs
with this problem in peril of being euthanized.
I think that most of the experts who study Cushing's disease feel that if
you take away the euthanasia factor, there is not a significant increase in
lifespan in dogs who are treated for Cushing's disease compared to those
who are not.
I think that both the general practitioners and specialists would agree
that quality of life usually improves when treatment for Cushing's disease
is successful, though.
The newest wrinkle in this discussion is selegiline (Anipryl Rx). If the
proponents of selegiline are correct about the way in which it works, it
should, in theory, increase the lifespan of dogs it works in. It does not
work at all unless the Cushing's disease is of pituitary gland origin and
it doesn't work for all dogs with pituitary origin hyperadrenocorticism,
either. But it might increase the lifespan of the dogs in which it works.
2) Dogs with hyperadrenocorticism (HAC) often pant excessively. Muscular
weakness occurs with HAC but I haven't heard of an association between it
and polyneuropathy. However, Dr. Shelton is an acknowledged expert in this
area and I would think she knew more than I did about this, by a long shot.
An ACTH test is pretty reliable when it indicates that HAC is present. So I
don't see any reason to doubt the conclusion that it is present. I would
still want to be vigilant about the possibility that more than one problem
exists, though.
3) We have seen improvement in muscular weakness in a number of patients we
have treated for Cushing's disease over the years. We have used primarily
mitotane (Lysodren Rx) in the past, but have recently been using selegiline
(Anipryl Rx) more commonly.
Personally, I like Anipryl. Our success rate roughly matches that found in
the literature --- about 70 to 80% of the time there is enough improvement
in clinical signs that the owner is happy and we are happy. It takes a
month or two to know if it is going to work, which I think of as a big
disadvantage, because it sets the whole treatment back that long if it
doesn't work. In cases in which we really need to see a quick effect we
will continue to use mitotane, for that reason. In cases in which we can
afford to wait and see what happens, we prefer Anipryl, because we have had
some really bad reactions to Lysodren. They are not common, but they are
common enough we were relieved when another option became available for
treatment of HAC.
For Bailey, I think that you are going to have to make a careful
assessment, with your vet's help, of how quickly you need to see a
response, in order to help her rear legs. This may be a situation in which
it is better to consider mitotane, just because it works a lot faster to
control the excess production of corticosteroids by the adrenal glands.
Whichever way you decide to go, I hope that this works out well.
Mike Richards, DVM
3/8/2000


Cushing's and milk thistle
Question: Dear Dr Mike
I am a new subscriber and have questions about Cushings. My Keeshound,
Kaycee, has been diagnosed with Cushings. She does not have clinical
symtoms, but her liver count was real high when I took her in for her
yearly physical. Since then we have had testing done to determine that it is Pituitary. She
has been taking 1/2 of a .5 MB Thyrozine tablet per day for several years.
Should she continue with the Thyroid since she has now been put on Anipryl
as of 10/7/99? Also, do you think Milk Thistle would help her in any way?
Would it hurt to give it to her when she is taking the other medications,
and if so, should I wait till she shows clinical symptons?   Kaycee was
born 11/29/89.
Any help will be appreciated.
Sincerely, K. B.

Answer: K.B.-
Hyperadrenocorticism (HAC, Cushing's disease) and hypothyroidism occur at
the same time in a fair number of dogs. It is necessary to continue to
treat the hypothyroidism with thyroxine during treatment for
hyperadrenocorticism. You should probably ask your vet about this, too,
just in case there is some reason that he or she would want to discontinue
treatment. I don't think that will be the case, though.
I can't find any indication of reactions between milk thistle's active
ingredient (silymarin) and either selegiline (Anipryl Rx) or thyroxine,
either. I do not know if there are protective effects from the use of milk
thistle but it is primarily used for liver problems and the alkaline
phosphatase rise from corticosteroids is not due to liver changes, in most
cases. Steroids directly induce a form of alkaline phosphatase to rise. It
is possible to test for the specific steroid induced alkaline phosphatase
but that isn't really helpful enough that it is done routinely. It is just
important to remember that in dogs with hyperadrenocorticism or other
steroid induced alkaline phosphatase rises that over 50% of the value for
serum alkaline phosphatase may be the form that comes strictly from steroid
induction and that less than 50% represents the portion more likely to be
associated with the liver. I am pretty sure that in many dogs with HAC the
portion due to steroid induction is significantly higher than 50%, as
well. Knowing this, using milk thistle seems less important since the
liver really isn't damaged, anyway, most of the time.
Hope this helps some.
Mike Richards, DVM
10/13/99



Cushing's in Pit Bull
Q: Dr. Mike,
I'm sorry,but we just accidentally sent you the same message that I had
sent before.
I was wanting to confer with you again, however. We did the ACTH
stimulation test on our pitbull Wednesday (15th). She was fasting for
12H. Our local veterinarian had to send the blood in to K-State College
of Veterinarian Medicine, and he just called me with the results as of
about 1/2H ago. As I have mentioned before, he has never had any
experience with an animal with Cushings, so any information he has,he
has gotten it from this same college of vet medicine. Her levels came
back as 1 and 1, according to what he told me. He doesn't know what to
do from here, so he will have to call the college Monday and get the
doctor's recommendation. The last dose of Prednisone she got was last
Saturday (the 11th). So she was off of it for a good 3 days. Can you
once again give me an opinion here. Should Lysodren be started again, or
should Prednisone be re-started? I have no idea what the levels 1 and 1
indicate!!!
R
A: R
Hurricane Floyd interfered with my ability to do computer work and I am
just getting back to the email now. It has been an incredible two months
for disasters here, so I am hoping for some calm time now.
I think that this was an ACTH response test and that the cortisol level was
1 ug/dl on the "pre" blood work and also 1 ug/dl on the "post" sample. If
this is the case, then this indicates that hypadrenocorticism is present
and it is best to stop the administration of Lysodren, possibly consider
the administration of medication for hypoadrenocorticism (including a
corticosteroid and possibly fludrocortisone acetate or desoxycorticosterone
pivilate.
I am sure that your vet has covered some of this already. If you have other
questions related to that, please feel free to send them.
Mike Richards, DVM
9/21/99


Cushing's Disease and possible diabetes
Question:    Dear Dr. Richards,
    I have a two year old neutered male lab/springer spaniel mix who was
fine one day and the next had frequent urination (every 15 minutes and
duration of 3-4 minutes) and searching the house for water. I took him to
our vet and the vet thought he had gotten ahold of some toxin. He kept Zeus
overnight, did a urinalysis (which was normal) and sent him home for me to
watch. This was a Friday and the whole weekend Zeus
could not get enough water and was urinating quite frequently. On Monday
morning he was at the vet at 7:30 a.m. and proceeded to pee on their floor
for about three minutes. He was kept at the vet a week and finally a
diagnosis of diabetes insipidous (sp) was made. I searched the web and found
this web site and saw that Cushing's disease had the same symtoms. When I
went to visit Zeus at the vet, I asked him about Cushing's disease and he
said Zeus didn't exhibit all the markers(no hair loss) but he tested him
anyway because I asked him to. Zeus came home and I gave him an eyedrop of
DDAVP twice a day. The dog didn't seem to be improving.
I called the vet and the results of the Cushing test had just come in and
were positive. He was taken off the DDAVP and put on Lysodren, every day for
7 days, then every other day for 7 days, then twice a week. He went back the
the vet last Thursday for follow-up and he is still not concentrating urine.
He can go at most three hours without needing to drink or urinate. The vet
did a urine osmolality and a serum osmolality and we are waiting for the
results. The vet thinks he still has the diabetes as well as the Cushing's.
Since Zeus has been on Lysodren he has become playful again and full of
energy. We have another dog which is a one year old spade female part lab/?
mix which we adopted in December as a playmate for Zeus. They just play
non-stop since Zeus has been on the meds. Zeus has had allergy problems. He
bites and licks his feet alot and an anti-inflammatory shot didn't help. The
vet put him on steroids in February and March to help with the
allergies (corn and wheat) and Zeus has also had a lot of stress, he bit into
an extension cord when he was six months old, was attacked by A Pit Bull
last October while I was walking him and had to have surgery, he also gets
very upset when I go anywhere for a few days.
Sorry for all the info but I thought it was necessary. Here are my
questions: Could these allergies (biting and licking feet, scooting his
rear)been any type of warning sign? Did putting him on steroids excelerate
or cause his condition? Should he be on the newer drug for
Cushing's(L-deprenyl) instead of Lysodren? The vet suggested taking him to
Ohio State and having a CAT scan done in a couple of months to see if there
is a tumor, should I do that? My vet is very good and I am not questioning
what he has done or his care of Zeus. I just want as much information as I
can so I can ask the right questions. Zeus is a family member and I will do
whatever I can to see him live a long life.
Thank you. Chris

Answer: Chris-
If your vet is comfortable with mitotane (Lysodren Rx) and Zeus is doing
well on it, then I can't see any reason to change the medication. If this
situation changes that would be the time to try an alternative medication.
I am not aware of a link between Cushing's disease and the prior presence
of allergies.
It is possible to produce all the signs of Cushing's disease by
administering corticosteroids such as prednisone in excess -- but stopping
the corticosteroid almost always resolves the clinical signs. I do not
think that the use of prednisone predisposes a dog to develop natural
hyperadrenocorticism but I am not absolutely certain that there is not some
connection.
Diabetes insipidus is a hard diagnosis to make with certainty and to sort
out the underlying causes for. It seems reasonable to me to consider
further diagnostic testing at a referral hospital if the urine production
is not controlled after there is adequate evidence from lab testing that
the Cushing's disease is controlled. Many dogs with diabetes insipidus will
eventually develop neurologic disorders due to the presence of brain tumors
associated with this condition so that is probably the reasoning behind the
suggestion for a CT scan. I am not sure that knowing that a tumor is
present is very helpful in most cases but there is more and more brain
surgery being done in pets so if you would consider that it may also be
more important to do.
It sounds like you are doing a good job at helping Zeus through his
problems and with your vet's help I'm sure that will continue.
Mike Richards, DVM
6/22/99

Cushing's and episode of peripheral vestibular syndrome in Boston
Question: Dear Dr. Richards:
What a marvelous site you've created. I only wish I had found it sooner.
My almost 13 year old Boston Terrier has finally been diagnosed with
Cushings. I say finally because I saw signs of it over a year ago, but numerous tests
didn't prove my suspicions so no treatment was started. Her hair loss was unreal, never
regrowing, now her stomach is totally bald, he shoulders have very little
hair on them, her tail is totally bald, and now the hair on her head is thinning at an
alarming rate.
She drinks about 4x more water than my sheltie, though we don't find her
urinating as much as you'd think she'd be, she has the potbellied look, but the muscle
tissue around her neck, shoulders and especially hind legs is gone. Her hind legs
are very weak, her skin is very thin, she doesn't seem to be able to tolerate
heat/warmth the way she used to. She is totally deaf and her eyesite is greatly diminished.
And her appetite is HUGE, waking up every 3-4 hours at night to eat. This is a huge
problem since we feel like we have a baby in the house again. I don't know how she
can eat so much and not gain any weight.
About 6 months ago she had an episode where she could not stand up, kept
falling on her left side, and holding her head to the left. If she did get any
momentum going she would actually do a tumble over head. She had no coordination eating.
All this looked to me as if she had a stroke so we rushed her to the vet and was told
it was something "like" Meneares (sp?) disease in humans and that in months she would
get a little better, but probably not fully recover.
Finally, two weeks ago we did another urine test and he finally said all
indications show Cushings. As a matter of fact, one of the biopsies we did
came back indicating Cushings. (Surprise)
So we started the Anipryl, my choice of drug to go with. I feel more
comfortable with it after reading many responses on your site. I was told it would take at
least a month to show any kind of improvement. But, within a few days we saw
her participating in life more, walking a bit faster, and within a week, I've
seen decreased water consumption, not alot at this point, but actually water left in her
dish from time to time. And the real miracle was last night she only got up once to eat,
and forgot about breakfast time until 10:00.
After all this rambling, my questions are these:
1. Could the Anipryl be kicking in earlier than usual?
2. Since I saw so many symptons (I had a Toy Fox Terrier who had Cushings
years ago) over a year ago, does this mean she probably doesn't have much time left?
3. Have we started the Anipryl too late?
4. What is your opinion of the neurological problem she had 6 months ago?
Could it have been Cushing related? Could the pituatary tumor have hit a part of
her brain to cause that.
Again, thanks for your wonderful site. I look forward to your answer.
Nancy
Answer: Nancy-
There is a condition in pets referred to as peripheral vestibular syndrome
which causes temporary balance loss. The cause of this condition is unclear
and recovery usually occurs within a few days to a few weeks. Sometimes
this occurs intermittently in a patient and this particular variety of
vestibular syndrome is thought to resemble Meniere's syndrome in
humans. Peripheral vestibular syndrome is very common and is probably the
cause of the neurologic episode seen previously. If so, there is no bearing
on the current problems.
We have had three or four patients we have tried selegiline for in which
apparent recovery occurred very rapidly. These patients have also been
among the ones that did the best with selegiline treatment over the long
term, too. So I hope it is a good sign for your Boston.
I have not really seen a whole lot of correlation between the time that
treatment was started and the longevity of patients who responded to
treatment. I have talked to vets who felt that there was a correlation and
the patient we had who lived longest with Cushing's disease was one we
picked up early, but she was also only 6 years old when we started
treatment, which was probably a factor in the long term success (8 years)
of treatment. I would not worry too much about starting treatment late.
Good luck with this. It is good that we have options in treating for
Cushing's disease at this time. If the response to Anipryl is not complete
or if there is a reversal in the response, mitotane is available and works
most of the time.
Mike Richards, DVM
10/14/2000

Cushings and other problems in American Eskimo Dog
Question: Hello,
I am still dealing with the various health problems and Cushings in Tai. I
have taken Tai to a second vet for another opinion. His overall checkup of
Tai did not indicate full blown Cushings or even the possibility of Cushings
to him, so he had me take Tai off of all medications for two weeks and then
do a full blood test and ACTH Stim. I am sending the full version from beg.
to end to you for your opinion based on the tests. I am wondering if by
chance Tai needs to have her kidneys looked into? The only symptom that she
has at this time is panting/restless at night and occasional stomach upset.
Her hair is growing back fine from all of the tests, no pot belly, not
drinking excessively, and not urinating excessively either - which raises the
question of why her urine is so dilute. She has been on Hills liver diet for
1 1/2 months now with not much for treats. Here goes the story:June 14, 2000
she came down with giardia and was treated with 10 days metranadazole. Her
symptoms were diarhea, gas, and panting heavier than normal. She had a fever
of 103. Her symptoms improved with the antibiotics.
July 3 - medicine was done and the symptoms came back. She was placed on
another round of metran. but the symptoms would now come and go.
July 8th and 9th, her appetite was gone and she was vomiting some bile. (once
or twice) - she was however drinking.
July 10th, complete blood count was done with ALKP at 609, ALT at 399,
glucose slightly high at 151, NH slightly high at 125, Cl slightly low at
104, and resting cortisol at 1.5 ug/dl. My vet decided a liver biopsy was
called for and it was performed on the 11th of July.
Liver biopsy showed that Tai has moderate hepatocytic vacuolization with mild
chronic suppurative cholangiohepatitis, and evidence of extramedullary
hematopoieses. The coded comments were that perhaps there was an underlying
metabolic disturbance, there is a mild chronic hepatitis, and possibly the
animal might be anemic or hypoxic. From this, the low dose dex test was
ordered. After the surgery, Tai was placed on the Hills liver diet, and the
only symptom was still the heavier panting and restless at night.
July 18th- ldd test was done with resting cortisol of 10.0 ug/dl, 4 hour post
of 2.5 ug/dl, and 8 hour post of 2.9 ug/dl. ALKP was 1074 and ALT was 168.
Let me add that after the biopsy, testing, and being put under twice in two
days, Tai was extremely nervous about being in the vets office again and was
climbing the walls. Anipryl 15mg once per day was ordered.
July 25th - checkup with vet. Tai was doing so well that vet decided to
check ALK and ALT. Those numbers were 415 and 77 respectively. My vet was
not running any other tests - he stated that the low dose pointed to pit.
cushings - I was feeling slightly uncomfortable at this point and began
looking for a second opinion. I made an appointment with a second.
August 10th - Tai's symptom of panting still there; average water intake was
around 16 ounces which I felt was very low - nothing else had changed. She
had been on Anipryl for around 26 days. The second vet was doubtful of the
Cushings diagnosis and had me take Tai off of everything except the liver
diet for two weeks and do an ACTH Stim Test along with a complete blood
count, etc.
August 24th - nothing had changed with Tai. Her water intake had been
averaged at 25 ounces per day (she weighs 34 lbs) and average food intake.
The vet then did the complete blood count with the ALK at 444, ALT at 32,
Phos low at 2.04 (said that was due to the liver diet) and the glucose lower
than before at 132. BUN was at 9.3, Creatinine at 1.04 all else was also
normal. The buffy coat profile showed WBC normal at 11.3 - all else was also
in the normal range - the only value that was close to being high was MCHC at
36.8 with high being 36.9. Her urine showed the color of yellow, appearance
was clear, and the SG at the 1.015. Her ACTH tests were the pre 9.8 and post
12.8. She still has only the panting and restless at night. I had purchased
her a canine cooler and she could care less about it.
At this time, Tai is still off of the Anipryl and drinking an average of 25
ounces.l. Her food intake is still normal. No weight gain nor loss. She
still pants more heavily at night and wishes to sleep outside. She does get
very tight in her back in the rear "fat pads" and I wonder if she is
uncomfortable. She also gets gas/stomach upset at times. I have been giving
her an occasional aspirin that does seem to help with the tightness. I
apologize for the length of this, but I feel that there is still something
going on that has not been thought of.
Any suggestions would be greatly appreciated! Deidra
Answer: Deidra-
The low dose dexamethasone suppression test is considered to be a more
sensitive test for naturally occurring hyperadrenocorticism (HAC, Cushing's
disease). It will detect greater than 90% of dogs with this problem. The
ACTH response test detects about 70 to 80% of dogs with naturally occurring
hyperadrenocorticism.
When low doses of dexamethasone are administered to a dog, it should cause
suppression of the cortisol levels for at least 8 hours. Most labs use
values of 1.4 ug/dl or less the point where adequate suppression has
occurred. If the cortisol value at 6 hours is below 1.4ug/dl but the value
at 8 hours is above 1.4ug/dl , the test is still usually considered to be
indicative of Cushing's disease. In Tai's case, both values were greater
than 1.4ug/dl, so unless the lab the samples were sent to uses a different
standard, or unless your vet miscalculated the dosage of dexamethasone and
used too low a dose, this test supports a diagnosis of Cushing's disease.
When adrenocorticotropin hormone (ACTH) is adminstered, it should stimulate
a strong rise in the cortisol levels after an hour or two hours, depending
on the form of ACTH administered. The usual reference point is the high end
of the normal value (usually around 20ug/dl) for cortisol at the lab
running the samples. So a test suggestive of Cushing's disease would have a
cortisol level that is in the normal range (sometimes above normal) for
blood drawn before administration of ACTH and then above the normal range
and at least elevated above the resting level, for dogs with Cushing's disease.
In this case, the low dose dexamethasone suppression (LDDS) test is
suggestive of HAC but the ACTH response test is normal. The clinical signs
are somewhat ambivalent, since panting is present, along with elevations in
alkaline phosphatase (ALKP) in the serum but no increase in water drinking,
no hairloss or other signs are present. This is especially true since there
was a rise in both ALT and alkaline phosphatase. Usually, rises in the ALT
make it more likely that liver disease is also causing the rise in ALKP. We
have seen several patients with Cushing's disease with rises in both ALT
and ALKP that resolved with successful treatment of the Cushing's disease,
though.
In cases in which the lab values and the clinical signs are confusing, the
diagnosis of Cushing's disease has to be based somewhat on the experience
of the vets making the diagnosis. Since your vets disagree, they haven't
helped in clearing up the confusion. In general it is safe to wait and see
what happens, as long as there is not a strong suspicion of an adrenal
tumor as the cause of the Cushing's disease. It may be worthwhile to
consider an ultrasound exam to try to get some idea of that possibility and
to check for things like gall bladder stones or chronic pancreatitis that
might also explain the panting, liver enzyme changes and apparent abdominal
pain. If the confusion still persists after that, it may be helpful to ask
for referral to an internal medicine specialist, especially if there is one
who likes endocrine diseases in your area.
Hope this helps some.
Mike Richards, DVM
9/7/2000
Cushings
Question: DEAR DR MIKE.....I was very happy to find your web site. If only I had
found it sooner...I am writing about my friend Zedty..she ia a 18 year
old terrier mix..recently diagnosed with Cushing's... Zedty has been on
thyroid medication for 5 years now and was tested for Cushings back in
Jan 97 which came up negative...tho she had elevated
ALKP-1598,ALT130......They were ALKP-986 and ALT-237 in Dec 97 and
ALKP-572..ALT 90 AND CHOL-282......Aug 98...a new vet found a heart
murmur which was 3 of 6.....she had an ECG which showed sinus
arrhythmia...she was put on Enalapril but was such a vegetable we took
her off of it...She was doing ok but in Mar of 2000 we had another ECG
which was determined to be mild to moderate valve disease with a concern
of pulmonary neoplasia ,hyperlipidemia and hyperadrenocorticism.....BUN
34 ALP 1539 CHOL 477 and trigl 853...At this point Zedty had doggie
dementia.....no mention of cushings or of testing.... she was put on a
trial dose of Anipryl for 1-2 months to see if it helped her
dementia........ Well we were out of the country and after 2 months on
the Anipyrl we ran out of it and it hadn't seemed to help her...but when
we returned in July we had her blood workup down again.... by now she was
very lethargic losing muscle tone...hair loss at shoulder......drinking
more eating more...to she has always had a healthy appetite and of course
peeing more no energy and very very intolerant to heat.......This time
her ALKP -2420 ALT-385 CHOL-770 POTASSIUM-5.8 BUN29 LIPASE790
GGTP33..T4-5.2..... new xraysshowed moderate cardiomegally with a
duffuse increase in interstitialdensities..... a 5cm x 5cm circular
structure noted caudial to stomach and liver margins rounded
                                   So the vet suggested a cortisol
test...... SO NOW ZEDTY IS BACK ON ANIPRYL.......which I now find out is
also used in treating cushings..she has been on it for 3 weeks. she
really showed no progress after 2 weeks but the last week she is showing
a slight improvement..... not drinking quite as much or peeing...still
hungry most of the time...better muscle....legs not giving out as
much...and she is still very intolerate to heat.. she is not her old tail
wagging self tho......I am concerned about all the other things wrong
with her too.....Do you think that she is on course with the Anipryl????
10mg once a day........should she be doing better after 3 weeks?????? is
the treatment aggressive enough??? or could she have something else
entirely different wrong with her?????? when and what blood work up do
we do to check on if she is responding.....when she wasn't responding
after 10days the vet said perhaps we would need to check for something
else....I know that she is getting old but I want her be better and I
want to see her wag that old tail. What about her thyroid???????   I am
so thankful that I now have your site to look up information on different
topics.....I only wish I had found it years ago....... I would get a copy
of the blood work up and look in my vet type books but really never found
any good info.......... THANK YOU SO BUT FOR YOUR TIME     NANCY
Answer: Nancy-
One of the 1999 issues of the VetInfo Digest, which is in the subscriber
area, was devoted to Cushing's disease. It might help to find that one and
look it over, in addition to the information below.
Some of the signs that you are seeing are typical of Cushing's disease,
particularly the rises in alkaline phosphatase, drinking and urinating,
weakness in the leg and heart muscles and low tolerance to heat. However,
they do not confirm the diagnosis. Specific lab testing is necessary to
rule this disease in or to rule it out.
One of the problems with selegiline (Anipryl Rx) is that the drug is safe
enough to use, and has such little effect on lab test results for Cushing's
disease, is that is really tempting just to put dogs on it and see what
happens. Especially older dogs that seem to have canine cognitive
dysfunction, the other disease this medication is approved for. I confess
to having done this, myself, in a couple of patients whose owners had no
real interest in proving if Cushing's disease was present, or not, but who
would try Anipryl.
This isn't the situation with mitotane (o,p-DDD, Lysodren Rx). This
medication does have very specific toxic effects on the adrenal gland and
it should not be used unless it is reasonably certain that Cushing's
disease actually exists. A low dose dexamethasone test is currently favored
test but some vets prefer ACTH response testing.
After starting the medications, there are further differences in testing.
Anipryl does not cause changes in test values for a long time, up to a year
or more. It may not ever change the lab test results in some patients. Yet
it controls the clinical signs of Cushing's disease in enough patients to
make it worth trying. So there isn't a really good follow up test to see
it works. You have to base the assessment on relief of clinical signs. The
recommendation is to use 1mg/kg for one month. If it doesn't work, the dose
should be doubled to 2mg/kg for one month. If it doesn't work after the
second month, it is probably best to switch to Lysodren.
Lysodren can cause rapid drops in cortisol levels, even producing Addison's
disease in some patients -- the opposite disease to Cushing's disease, in
which not enough cortisol can be produced by the body. It is necessary to
monitor its action by using ACTH response tests every 5 to 10 days until
the Cushing's disease is controlled and then to continue to monitor every
few months in order to make sure control is maintained.
While alkaline phosphatase (ALKP) levels are most closely associated with
Cushing's disease, we have seen a number of patients with rises in both ALT
and ALKP that have improved after treatment for Cushing's disease. We also
see rises in ALT that are due to heart disease and resolve when we can get
some control of that problem.
It is a good idea to monitor the thyroid levels every 6 months to 1 year
when patients are on thyroid supplementation, too. If this hasn't been
done in a while it would be good to do that.
I would worry about the possibility of an adrenal gland tumor with a lump
in the abdomen and signs of Cushing's disease. An ultrasound exam or even
exploratory surgery would allow a better idea of what the lump is. I know
that surgery would be scary at this time but ultrasound examination might
be reasonable to consider.
It is really hard when you are dealing with an older patient with multiple
problems. However, it is usually possible to treat several problems at one
time with success. It just takes a lot of patience and cooperation between
the pet owner, the pet and even the vet.
Hope this helps some. If I missed a question, please feel free to write
for clarification.
Mike Richards, DVM
9/10/2000

Question: Dr. Richards,
I have a 14 year old, neutered, female dachshund that was diagnosed with
Cushings about 2 years ago. She has done very well on Lysodrin.
Recently she developed Pancreatitus. She was treated with fasting and
intravenous fluids at the veterinary hospital. She came home on the 5th
day. At that time the doctor prescribed antibiotics, anti-nausea drug and
prednisone. She also took her off the Lysodrin until we have finished the
drug therapy. We are in the process of reducing the prednisone so she can
stop taking it. In the meantime, I am concerned about the effect of
taking her off the Lysodrin and putting her on the prednisone. My vet
says that I shouldn't worry about the Cushings as the worse that could
happen at this time is that she starts drinking a lot of water. We can't
do a stim test until the prednisone is out of her system as both that and
stress would affect the results.
I should tell you that this dog has had many allergies over the years
including food and flea allergies. My vet feels that we may need to
change her diet again as she may have developed an allergy to the current
food. She was eating a fish and potato dog food.
Would you answer the following questions for me:
1. Why give prednisone at this time?
2. Could the food allergy have brought on the Pancreatitis? As far as I
know she did not get into anything in the house or the yard and we are
very careful about what we feed her due to her food allergies.
3. What is the purpose of the low-residue diet at this time? She does
seem to be tolerating it well, but I'm concerned that once we finished the
prednisone that she might be allergic to that!
Any insight you can provide would be greatly appreciated.
Regards, Georgina
PS please forgive the spelling of the drug names as I don't have the
bottles with me.

Answer: Georgina-
1. Why give prednisone at this time?
Prednisone is used to combat shock in the initial stages of pancreatitis,
in some patients. It is used when pancreatitis is thought to be due to
immune mediated causes. In the past, prednisone was recommended as a method
reducing inflammation associated with pancreatitis but currently the
thinking is that it might slow the healing process and so it is not used as
frequently. Some veterinarians feel that there is still a place for
prednisone in routine treatment for pancreatitis. It would be a good idea
to figure out if your vet thinks there is an immune mediated disease
underlying the pancreatitis, as that may have long term implications.
2. Could the food allergy have brought on the Pancreatitis? As far as I
know she did not get into anything in the house or the yard and we are very
careful about what we feed her due to her food allergies.
I think that dietary influences can bring on pancreatitis, especially
sudden changes in diet and high salt or high fat foods. I don't actually
have any proof for the high salt/high fat theory but I see a number of
pancreatitis cases after every major holiday in which big meals are part of
the festivities. I have not heard of food allergies as a specific
stimulating factor for pancreatitis but anything that causes
gastrointestinal inflammation could conceivably lead to pancreatitis so it
seems possible to me.
3. What is the purpose of the low-residue diet at this time? She does
seem to be tolerating it well, but I'm concerned that once we finished the
prednisone that she might be allergic to that!
The idea is to have a non-irritating diet for a patient with pancreatitis.
The current thinking is that a low fat, low to moderate protein content and
high carbohydrate diet is the least likely diet to stimulate the pancreas.
The low residue diets seem to be gaining some in popularity, although they
don't quite fit this profile. I have to admit that I am a heretic in this
case. Personally, I seem to have the best luck putting the patient back on
its usual diet. My theory is that the diet the patient is used to is the
least likely to be upsetting, as long it isn't an absolutely atrocious diet
to begin with. Again, I am out of line with the standard advice in this
particular line of thinking, but it is my personal belief.
As you can see from my answer to question #3, there is some room for older
general practitioners to see value in a different course of action from the
experts --- so I'm not too different from your own vet except that we
disagree over different parts of the standard recommendations. This also
leaves some room for you to have your own opinions -- and you should feel
comfortable talking about them with your vet.
Mike Richards, DVM
8/16/2000

Answer: There is no evidence that I know of that treating for Cushing's disease
extends the lifespan of a dog affected by this condition, although it is
possible that treatment of the Cushing's disease with selegiline (Anipryl
Rx) would, just because it seems to extend the lifespan of normal dogs in
some cases.
If there is not enough problem with increased drinking and urinating to
necessitate treatment for it, I think it is really reasonable not to treat
for Cushing's disease. If this is a problem, I don't think there is a big
problem with using selegiline and trying a non-steroidal anti-inflammatory
like carprofen (Rimadyl Rx) or etodolac (Etogesic Rx) for the pain. If that
isn't sufficient, I would be comfortable adding prednisone if it increased
the quality of your dog's life. Selegiline is expensive and it doesn't work
for all dogs so vets are sometimes reluctant to use it. It has worked
often enough for us that I feel it is worth a try, though.
Hope this helps some. One of the older issues of the VetInfo Digest, in
the subscriber area, is entirely devoted to Cushing's disease, so you might
find some useful information there, too.
Mike Richards, DVM
5/24/2000

I hope this information helps. If so please go ahead and click ACCEPT, thank you Tammy Ogle

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