High LDDS and ALKP

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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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!

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.

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

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.

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.

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.