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High LDDS and ALKP

Species: Dog
Breed: Jackapoo
Age: 8-11 years
Hello Dr. Marie

You might remember me and Oreo from past questions?

Well, Oreo is now 9 years old. Last week he was diagnosed with Cushings Disease. :( To say I am devastated is an understatement. I decided to ask for a CBC and chemistry panel after I noticed he was panting for about the last year on and off. Not heavy and not all the time. His ALKP was up even more than it had been last August. It has risen now for several years. He is on Denamarin for Vacular Hepatopathy and is ALT is 116. Last week the ALKP was 1,287 and I wanted to test for Cushings. And sure enough it came back positive after having done a LDDT. So next step was to have abdominal ultrasound done which we had today. The ultrasound vet let me watch and confirmed Pituitary Cushings. Since he presents clinically as nearly perfect, the vet felt we didnt need to treat right away. He doesnt drink water all that much and only goes potty once or twice a day max. No pot belly and no ravenous appetite and coat is gorgeous. I joined a facebook group just for support, actually there are 2 I joined. Everyone has advice for everyone due to their own experiences. I've been told dozens of times the two vets Oreo saw missed the boat by not having the STIM done but both those vets said the LDDT was more reliable. And I try not to research it but from what I have read, the LDDT is the preferred test. I do know once treatment begins, the STIM is used to monitor how pet is doing on medicine. I cant force the vets to run the tests if they dont feel it is necessary. I have always valued your opinion and wondering about your thoughts?

Also the ultrasound vet has a partner who practices Eastern medicine and said I could explore some herbs and suppliments. So, I set up an apptmt. for that. Do you know how much that helps at all? I figure it's worth a try in perhaps keeping more symptoms from creeping in.

The vets drug of choice is Vetoryl but I read that is bad on liver dogs.

Thank you for your advice and opinion!

Sincerely, Suzie


Online vet, Dr. Marie

Dr. Marie replied:

Hi Suzie,

Nice to "see" you again. Poor Oreo keeps getting diagnoses that are difficult to explain and I can understand if this new diagnosis of Cushing's is causing you concern.

I was looking back at some of your previous questions and found discussion we had. Here are a couple of quotes from that discussion in which you were asking about a high ALKP level:

"It's true that he has some elevation in his ALKP, but in my books these elevations are very minor. Almost every dog I see that is over the age of 5 has some mild increase in ALKP. I once spoke with a pathologist about this and her thought was that most dogs develop some mild Cushing's disease as they mature. She feels that the disease in most dogs never gets to the point where we are seeing clinical signs and we don't ever have to do anything about it. "

and

"I recently talked to a specialist recently about a dog who had a really high ALKP (like 1200 or so) and I couldn't find any disease present. He said in his experience dogs with high increases in ALKP and no other symptoms usually end up being diagnosed with Cushing's disease down the road. Now, Oreo's ALP is not even close to me wondering about Cushing's, but if the level keeps going up and gets to high levels then we could consider retesting for Cushing's. With that being said, we don't treat Cushing's unless we have clinical signs of increased thirst and urination."

Do you have the results of the low dose dexamethasone suppression test? This is the test that I do the most often to diagnose Cushing's. (I use the ACTH stim more for Addison's disease which is the opposite of Cushing's and find that the LDDS is more accurate for Cushing's.)

There are a number of treatments for Cushing's. However, the goal of treatment is to reduce the clinical signs of increased thirst, excessive panting, and increased urination. If a dog does not have these symptoms then no treatment is necessary. I have had a number of cases where the lab numbers were suggestive of Cushing's but as there were no clinical signs we did not treat. In some cases, the dogs ended up going on to get Cushing's symptoms and we did treat but in other cases no symptoms were ever seen.

I've said this before, and I'll say it again here. This is a situation where doing research online could cause great confusion. Cushing's is a complicated situation and getting advice from other pet owners is not advisable.

From what you have described, if this were my case I would likely be doing nothing extra at this point. I may perhaps repeat the low dose dex every few months to monitor how things are going. And, I would probably have you measuring Oreo's daily water intake every few months to see if we are starting to see a drastic increase. Dogs with clinical signs of Cushing's tend to have a HUGE increase in thirst. There is no point in treating if symptoms like this are not present.

I do not have any experience with using herbs or supplements for Cushing's. My opinion on most types of herbs and supplements is that if there was one (or more than one) that was repeatedly shown to be effective then most vets (even the ones who are not herbalists) would be recommending it.

From everything that you've told me about your veterinary care with Oreo over the years it sounds like you have an excellent veterinary team working with you. It really sounds like you can trust your vet's advice. I'm always happy to give my opinion, but ultimately I would advise you to trust the info that they are giving you.

Hope that helps!

Dr. Marie.



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Disclaimer: Although Dr. Marie is a qualified veterinarian, the information found on this site is not meant to replace the advice of your own veterinarian. AskAVetQuestion.com and Dr. Marie do not accept any responsibility for any loss, damage, injury, death, or disease which may arise from reliance on information contained on this site. Do not use information found on this site for diagnosing or treating your pet. Anything you read here is for information only.

Customer reply:

Hi Dr. Marie

Thank you kindly for your reply, always value your input when I am panicky. Yes, I have his numbers here: first blood draw for the LDDT was 8.6........second one was 1.3 and 3rd was 3.6 I have no idea if these numbers indicate mild or severe really. All I know is the ALKP is rising and I had to beg my vet to do the LDDT. She did not want to, rolled her eyes and said I needed to trust her. I insisted. She gave in but it got ugly. Long story short, the clinic dumped me and I learned of his results in an email to me saying they were done with me. This was 7 days ago. So I quickly made an apptmt with another local vet and we did the urine test, the cortisol and creatinine one. It was normal. She suggested an ultrasound but this time I did not go to a vet school. There is a very reputable vet clinic 15 miles away that does it in their office. We had it yesterday. Very impressed. The vet went to the vet school where Oreo had his needle guided biopsy 2 years ago so he is trained well. 27 years under his belt. I got to watch and he explained stuff although it kind of went in one ear and out the other. He said it was a good ultrasound and adrenals looked good which we knows suggests Pituitary Cushings. When I talked to him on phone before he met Oreo, he told me he would probably treat Oreo. Then he examined Oreo and looked over his CBC and chemistry panel and he concluded after the ultrasound, not to treat. He has a partner though that does do regular medication but has deep interest in homeopathic too and he said if I wanted, I could visit with her. Maybe there would be some suppliment that might help keep the symptoms from progressing too fast. He's been panting once in a while for a good year. My guess is maybe he has had early cushings for at least a year. He doesnt drink much at all or go potty much. And his appetite has fallen off a bit. I asked the ultra sound vet if it was possible he didnt have it. He said oh no, those numbers tell me he does plus the ultrasound. His ALT was 116 and Bile Acid Tests were almost perfect within a point. SO his Denamarin is helping that vacular hepatopathy. His ALT use to be high. If I had to rate Oreo on scale of 1-10 with 10 being symotom free, I would give him a 9 or 9.5 He is chubby. And doesnt eat much. He has always been a low energy dog but its just me and him here so I chalked that up to being a quite holdhold. Our apptmt with the homeopathic vet is tomorrow. Can you think of any intelligent questions I could ask her? I'm not saying I will go homeopathic now but just curious what is out there. I would imagine she will examine him too. The support groups on facebook are great really cos we are all heartbroken and there are some people with really great and happy stories. However you hear this and that then I state the vet is opting not to treat currently and I get crap. They tell me to find a new vet. Sigh. I wont abandon the groups I just have to learn how to not read and let everything get to me. I've made some very nice friends who share my heartbreak. I know how lucky I am that Oreo is darn near symptom free. For some silly reason, I get a sense it could be years before symptoms pick up if....ever at all. In your experiece do some dogs just never go into full blown symptoms? I'd like to see his appetite pick up a bit though. That is another reason I wanted blood work, the appetite had fallen off a bit. Hope this all helps you!

Suzie


Customer reply:

Dr. Marie, I just wanted to let you know that I did answer your question you asked me and I posted a short video of him to your facebook page. Aside for being a bit chubby, he looks and acts good. The ultrasound vet said he was not pot bellied either.


Online vet, Dr. Marie

Dr. Marie replied:

Wow. Sorry to hear that your vet asked you to find someone else. It really sounded like they were doing all of the right things. I agree in the sense that I likely would not have done a LDDS without clinical signs being present. One of the main reasons for this is that there is no test for Cushing's that is 100% accurate.

When we do a low dose dexamethasone suppression test what we do is the following:

-measure the cortisol level. It will be high in a dog with Cushing's. But it can also be high because of other reasons.
-Give dexamethasone which in a normal dog should cause the cortisol level to go down and stay down for 24-48 hours.
-measure the cortisol level in 4-8 hours to see how the dog is responding.

So, a normal dog will have their cortisol level go down to below 1.4 mcg/dL and stay that way for quite some time. The fact that it started to go up by 8 hours is suggestive of pituitary cushing's. But there are other factors that have to come into play because this test is not 100%.

Now, it is interesting that you had a urine cortisol test done and the results were normal. In my books a dog with cushing's will almost ALWAYS have a high cortisol creatinine.

Can you see why it was recommended not to do the test? Because now we are in a place where too much information could be a dangerous thing. We have a dog with no clinical signs of cushing's that has lab work that possibly could suggest cushing's, so what do we do? Some vets (including me) would say do nothing. Some will say to treat. And who is right? I don't know.

It's possible that he does get Cushing's later on and if that starts to happen I'd be more keen to treat. It's also possible that he never gets symptoms. It's interesting that you say that his appetite has fallen off because this is the opposite of dogs with Cushing's who are usually ravenously hungry. From what you've described this does not sound like a case of Cushing's that I would treat. But, your vets have more info than me as they have the full story.

I don't have suggestions for you on what to ask the homeopathic vet, but I would perhaps ask your main vet how they feel about waiting to treat Oreo for a while. I also would suggest that you find one vet that you trust and stick with them. Trust their advice and as much as you can, try not to research and second guess them. You will drive yourself (and your vet) crazy!







Customer reply:

Hello again, well, he had the panting though so that is one clinical sign and I told them it had been going on for a year. In your earlier reply though didnt you say the LDDT was preferred in checking? I did ask the vet about doing the STIM test and she said we'd get a better answer doing the LDDT.

Well I dont want to bug or drive the homeopathic vet crazy tomorrow, she also practices the traditional medicine too. Havent met her yet. Do I dare tell her or suggest to her he doesn't have cushings? Or leave it be? I suggested we do the STIM test to the ultrasound vet and he was against it, said we had the answers.

Oh did you see the video of Oreo? :-)

Suzie


Online vet, Dr. Marie

Dr. Marie replied:

Sure, the LDDT is the preferred test. The reason for this is that if the urine cortisol creatinine test is HIGH we don't know whether it's high because of Cushing's or whether the dog was just stressed (i.e. because of the vet visit). But, if the urine cortisol creatinine test is NORMAL then in my books this usually means that a dog does NOT have Cushing's. It's complicated for sure.

Unfortunately I don't see the video on my Facebook page. I see your comment but not the video.

I think regarding the homeopathic vet, you can just ask her opinion. You can tell her that there aren't many clinical signs of Cushing's other than perhaps more panting but that your vet felt that Cushing's was likely.



Customer reply:

Hello Dr. Marie

That is funny cos my facebook friend can see the video. Anyways it just shows a 3 minute video of Oreo playing ball the day after diagnosis and he looks 10000%. He is panting but he is playing ball. He is about 6 pounds overweight so he gets out of breath faster.

Dr. Marie this homeopathic vet is in the clinic that the other vets are in where I now go to as of yesterday. I think that it kind of cool that she practices traditional and homeopathic and I certainly dont think all dogs benefit from homeopathic methods. I think it might depend on what exactly is going on with the dog but I like that she will swing either way so to speak, lol for the owner and dog. I am a firm believer that if a Cushings dog is severe, it will need the traditional medicine most likely. Or perhaps a combo of the two might help. I've never seen a full blown Cushings Dog but I know they can have skin problems and maybe herbs and suppliments might come in as beneficial.

The homeopathic vet is co-owner of the clinic with the ultrasound vet so she will have Oreo's records right there which is nice. I dont want to do anything to annoy her and could I please have your opinion as to if it would be proper of me to request a STIM test or just shut up about it? I was thinking about telling her of our email conversation but my old vet that dumped me, would roll her eyes whenever I told her I had emailed you about something. There are quack vets out there online but also some reputable vets too. I know you cant believe everything you read online but I know without a doubt you are 100% the real deal or I wouldnt contact you about things. But I guess a vet I consult in person, if they haven't heard of you, they might be skeptical. I hadn't been happy with the old clinic for quite sometime due to some insulting things that had been said to me so really, that clinic did me a huge favor.

Dr. Marie, I do firmly believe Oreo is not a dog that should be treated yet, if ever, if he remains mild. I dont suppose I would dare suggest to this vet tomorrow that maybe he doesn't have Cushings? I know you havent examined Oreo but I know you believe me when I tell you the old vet and the ultrasound vet told me he presents as near perfect aside from being chubby.

I know this is long but what I am getting from you is basically your advice to me right now is to just wait and see, watch for other symptoms and he may or may not be a Cushings Dog? I dont want to get eyes rolled at me at the visit with the homeopathic vet, I think it probably wise I dont mention our conversation about this but do I ask for STIM test? I might ask her why his urine was normal but I think she will tell me that isn't a reliable test. Huge sigh.

I cant thank you enough for your time and please know I will always value your advice. :-)

Sincerely, Suzie


Online vet, Dr. Marie

Dr. Marie replied:

"...could I please have your opinion as to if it would be proper of me to request a STIM test or just shut up about it?"

I often have a hard time as a vet when a client asks me about doing a particular type of test that is not one that I had suggested. In most cases, if the test was warranted then I would have suggested it. Now, I'm not completely closed to discussion and questions as I certainly don't know everything. But, I can tell you that it can get frustrating when a client wants to spend a good amount of our time together in the office discussing things that they read on the internet.

I think it's fine to mention that you've done research and ask questions. I think that as long as you make it clear that you trust her judgement then she will be fine with the questions that you ask.

From what you've told me, the wait and see approach is a good one. You can ask your vets how they feel about that and probably they will be alright with it.

Hope things go well!

Dr. Marie



Customer reply:

Hi Dr. Marie

Sorry for the layed reply. Oreo ended up getting kennel cough and I have just been down in the dumps. Two weeks ago before the old vet clinic dumped us, he got groomed there and 4 days before that, he had his kennel cough vaccination. But he has been to a few vets so who knows where he picked it up from. I gave up trying to figure that one out.

Oreo has his accupuncture the other day and did well. He didn't flinch at all when the needles were put in nor did I. The vet said he was stoic and that some of them under his belly should have hurt. So we were then left for 40 minutes on our own in the room and of course Oreo hit out in the corner, paced once in a while. I think he is just so vetted out. Se also gave me an herb called Ophiopogon and I sprinkle that on his food, and he gets it when he decides to eat. His appetite is not ferocious so sometimes he doesnt get it because he refuses his food. Other times he gets it cos he is hungry. But never ever ravenous. The vet mentioned something about yin and yan and how that can be off and she noted some little cracks in his tongue that would suggest to her in chinese medcine that his yin was off. We go back for more accupuncture on July 2. Still not sure if it helps but supposedly it's out there online somewhere that it can help. I dunno, I dont want to look that stuff up.

Oreo's kennel cough is better but flares up when he tried to play. The vet we saw did prescribe human Doycycline but told me I could wait a few days to give it to him in case he gets over it on his own. She wasn't sure if it was all viral or a cockatail of viral and bacterial but his spirts have been pretty good but he is sad when he finds out he coughs still when trying to play. No coughing when he isn't active so I guess it's just a wait it out thing for now. Since he is a smaller dog, she said sometimes their trachea is a little more sensitive or something to that affect?

She said as have other vets, Vetoryl is the drug of choice and their clinic starts out low dosed and then work up to a dose right for him. It all sounds like such a hassle and alot of money but it will have to be done. Do you know the affects on a dog with liver isues though? I forgot to ask that.

I've read alot of happy reports though on Vetoryl on my facebook groups I joined but alot of tweaking it appears is needed to get the dose correct and to get side affects under control.

So that, Dr. Marie, is the latest Oreo saga!

Suzie


Online vet, Dr. Marie

Dr. Marie replied:

Sorry to hear about the Kennel cough. I have had the occasional dog that has gotten a mild case of kennel cough after a vaccine. It's rarely serious though. It sounds like waiting it out is a good idea.

Vetoryl is metabolized through the liver and the labelling advises not to give it with dogs with liver impairment. But, whether or not Oreo has liver impairment is debatable. I suppose if your vets are going to start him on Vetoryl they will likely keep an eye on his liver enzymes.

To me something is not adding up because every Cushingoid dog that I have seen has been ravenously hungry and drinks like a fish and urinates lots. I personally would not start Vetoryl until there are more clinical signs of Cushings. But again, I would trust the word of your vet as they have more of the picture than I do. It wouldn't hurt to ask them whether waiting for a while until we are seeing more symptoms (if that should happen) is best.



Customer reply:

Hi Dr. Marie

Yes, all vets involved have advised to recheck in 6 months but I dont feel comfortable in waiting that long. I'm thinking 3 months?

He has mild panting at night for a little bit.....is he in distress? Or is it just a symptom that is there but really not harming him?

When you say something is not adding up and refer to the other symptoms, do you suspect he doesn't have Cushings? Or is he just a lucky one to not have those symptoms yet? And maybe he wont ever?

One of my new vets said he might just coast along as he is doing for years and years...

Regarding the Kennel Cough, yeah no big deal....I stayed cool and calm about it and he is better. He coughs if he tries to play so I am still trying to keep him quiet. I suppose it's just like us when we get a cough, it just has to run its course and I've been known to cough for 3 weeks or more.

Suzie


Online vet, Dr. Marie

Dr. Marie replied:

I think 6 months is quite reasonable. In the meantime you could measure how much water Oreo drinks each day and if the amount is increasing dramatically then you could request the recheck sooner. In my opinion there is no reason to treat a dog with Cushing's unless they are really thirsty, ravenously hungry and urinating lots. The goal of treating Cushing's is to reduce the amount of clinical signs so if the clinical signs are already mild, what's the point?

It is possible as well that Oreo never goes on to have full blown Cushing's.

There are many reasons for panting and I would not pay much attention to it unless it seems to be getting quite stressful for him.



Customer reply:

No he never seems stressed and it's always after I give him a back rub or he wakes up after having fallen asleep next to me. When he is just lounging on the floor, he never pants. I'll stay calm about it. :-) I agree as do each vet that has examined him, not to treat yet. And you kind of know me by now, I will keep my eye on things. But because we are so close and in tune to each other, sometimes I can overreact to what is going on with him. And oh wouldn't be great if he never goes into full blown Cushings!? One can hope and pray! :-) Maybe he'll be one of the lucky ones. :-) I'm glad you could finally see the video I posted of him on your page. Thanks for all your input Dr. Marie. Much appreciated! Your patients and their owners are blessed to have you!

Suzie


Customer reply:

Oh Dr. Marie, one more question, then I will wrap this up. Does the extra cortisol he is producing hurt him? If the dogs symptoms are worse could it do harm? Thank you!


Online vet, Dr. Marie

Dr. Marie replied:

At this stage the extra cortisol is actually probably feeling good to him. It's an anti-inflammatory and can help with joint pain. Late in the progression of Cushing's though the extra cortisol can start to have serious effects on the liver and other organs.



Customer reply:

Now that is very interesting, never would have imagined that. I'll keep my eye on him and wont let anything get out of control. Thanks much for all your advice/help!! :-)


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Dr. MarieDr. Marie is a veterinarian who practices in a busy animal hospital in Ottawa, Ontario. She created Ask A Vet Question as a resource for good, accurate veterinary advice online. Dr. Marie treats dogs, cats, hamsters, guinea pigs, and rats. She has been a vet since 1999.

Is an online vet visit just as good as a trip to your veterinarian? No! But, many times, asking an online veterinarian a question can help save you money. While Dr. Marie can't officially diagnose your pet or prescribe medications, she can often advise you on whether a vet visit is necessary. You can also ask Dr. Marie for a second opinion on your pet's condition.