Bonnie Sue
(-fos-fah-ta-se´me-ah) high levels of alkaline phosphatase in the blood.An abnormally high concentration of alkaline phosphatase in the blood.hyperphosphatasemia /hy·per·phos·pha·ta·se·mia/
High Alk Phos just a "Scottie thing?"
I have a hunch that Scotties have some kind of genetic predisposition to a flaw in their endocrine system which causes things like adrenal exhaustion and Cushings disease, which lead to high liver enzymes, bladder cancer and skin allergies. These are issues many Scottie owners have observed in their pets, no matter how well-cared for they may be.
Below is a link to research published last year relating to high alk-phos values in Scottish Terriers which might prove my hunch is correct. It suggests atypical adrenal cortical disease with increased activity of OACS (androstenedione, estradiol, progesterone, 17-OH progesterone, aldosterone) might be a more common cause of hyper-alkaline phosphatasemia (high alk phos levels) in Scottish Terriers, than benign hyper-alkaline phosphatasemia. Meaning: High Liver Enzymes might not just be a "Scottie thing," but instead a cause for real concern on the part of owners and breeders alike. It also may point to adrenal exhaustion as a cause.
For many years, I have noticed a trend in my Scotties. As they grew older they began to show high levels of alkaline phosphatase in their blood work. I have heard it said by many Scottie-owning folk that this is no big deal and many vets I know have just come to accept that high liver enzymes are a "Scottie thing," not necessarily a reason for alarm. In my own dogs, these high serum levels of alkaline phosphatase always signaled a serious illness just around the corner. I now instinctively believe--with little proof--that while it might be a genetic flaw in Scotties, it is not something to be overlooked or written off. To discuss this a bit more and how it has become important to me, here is a brief explanation of liver enzymes, their function and acronyms:
ALT, alanine aminotransferase (which used to be known as SGPT), is an enzyme found in the liver cells. Damaged liver cells will leak ALT, which is then detected in increased quantities in the blood.
AST aspartate aminotransferase (which used to be known as SGOT) is a similar enzyme and is found in many cells, including liver, muscle and heart cells. ALT elevations in the blood are specific indicators of liver disease, while AST elevations are not.
Serum alkaline phosphatase (SAP, ALP or alk phos--short for alkaline phosphatase) is an enzyme present in liver, bone, intestine and kidney. Increases related to the liver may result from a blockage of bile flow, the actions of some drugs or due to some disease mechanism. Young dogs have higher SAP because it also indicates active bone metabolism. In older dogs, it can indicate bone cancer.
I had a special experience with my Scottie, Bonnie, last year when she developed SARDS (Sudden Acquired Retinal Degeneration) due to adrenal exhaustion. Many tests were run, experts were consulted, yet it took valuable time and money to get at the correct diagnoses and treatment for her. Her vision grew steadily worse all the while. It was a maddening and frustrating journey and I wrote a two-part story about it for Great Scots Magazine in hopes that others might benefit from the mistakes I made and delays I experienced. I share only a brief bit of it here in hopes that retelling some of it might help someone else. If you have any interest or questions, I am always glad to relate my own experience with Bonnie's SARDS.
We've owned Bonnie since age 7 (she is now 11 1/2). During her life with us, she has had regular blood work and ultrasounds. As she grew older, we noticed that her liver enzyme levels were creeping up, but repeated Cushings tests showed negative results. We noticed other metabolic and behavioral symptoms that just didn't seem to fit with any pattern of disease I'd ever read about.
(1) Her water intake and output steadily increased;
(2) She suffered from the slightest increase in temperature, panting for hours on end, even in her sleep;
(3) She suffered behavioral changes. She got a bit grumpy with the other dogs and slept on the floor instead of the bed as she once had. She even withdrew from me, the person she had always clearly preferred. She stopped following me around as was her usual habit and definitely did not want to be hugged or touched. When she stopped going up the stairs to my office, I realized something had to be terribly wrong;
(4) She'd always had a gorgeous coat, but now it became even heavier and the texture changed a bit;
(5) Her appetite was wolfish and she never seemed to be satisfied. I pride myself on the home-cooked meals we provide our dogs and it left me feeling puzzled as to what I could feed her that would fill her up without adding extra pounds;
(6) She was restless and did not sleep or rest well, either during the day or the night.
(7) The most puzzling symptoms of all were that her hearing, and to a lesser degree, her sense of smell, were diminished. It left her looking a bit confused when we called to her or put her food bowl in front of her. Clearly she wanted to eat, but if she couldn't see or smell the bowl, she would just stand there looking expectantly.
She did indeed have some symptoms of Cushings, but I would come to learn that from outward appearances, Cushings and Adrenal Exhaustion look very similar and good lab testing is needed to differentiate between the two. If you want to have some idea before you do extensive lab testing, you might check to see if your dog has any kind of chronic inflammation, i.e., irritable bowel syndrome, poor dental health, chronic skin allergies, severe arthritis. All of these things can be connected with adrenal exhaustion since estrogen is a pro-inflammatory
http://www.ncbi.nlm.nih.gov/pubmed/16024752
Sohrabji F. Estrogen: a neuroprotective or proinflammatory hormone? Emerging evidence from reproductive aging models (abstract). Annals of the New York Academy of Sciences 2005; 1052: 75-90.
Finally, we acted on the advice of experts and ran a true endocrine panel. We used a lab in Quail Valley, California, National Veterinary Diagnostic Services. Their normal ranges better reflect what is observed clinically in pets than some of the larger, better-known endocrine labs, such as the one at University of Tennessee College of Veterinary Medicine. We used Tennessee's lab at the beginning of Bonnie's problem, but were not happy with the wide "normal" ranges as compared to NVDS' more precise parameters. Some of their suggestions to deal with the endocrine abnormalities they observed were not what we consider to be ideal.
Upon the advice of my vet, I drove to MedVets of Columbus, Ohio, a specialty veterinary group that offers ophthalmologic and neurologic testing. There Bonnie underwent a neurologic assessment for her hearing and she was given a Doppler blood pressure test to see if any undue pressure might be causing her sight problems. An ocular examination was also performed, including a Schirmer tear test, and an electroretinogram (ERG), which tests retinal function. In this test, special contact lenses were placed on Bonnie's eyes and a series of flashing lights were directed toward them. A graph of the electrical impulses recorded electronic signals detected by the electrodes. In Bonnie's case, the ERG recorded barely any electrical responses, which meant her ERG was flat. When this happens and blood pressure is normal, as it was with Bonnie, SARDS is the likely diagnosis.
I had been reading a magazine in the waiting room about ongoing treatment developed by Dr. Grozdanic at Iowa State for SARDS and I was anxious to discuss it with the doctors when I got back to the exam room with Bonnie.
However, when I received the summary of Bonnie's test results from the specialists, I learned that the MedVets team did not feel Bonnie was a candidate for SARDS treatment because she still retained some functional vision, and SARDS dogs, they told me, had none.Her patient evaluation note from the ophthalmic group read as follows:
"Bonnie presented to the service for evaluation of profound visual deficits. She appears to have primarily lateral visual field deficits with preservation of vision in the central visual fields. She did have flat ERGs but does have some vision. Bonnie is poorly attentive to auditory stimuli with decreased attention to sound and localization of sound."
The neurologist wrote:
"I cannot find any neurologic deficits which would explain the visual loss. It is odd that she appears to have both visual and auditory changes, since these are both Special Somatic Afferents . . . . [h]owever, I know of no degenerative processes in dogs with a preferential effect on SSA fibers. If the auditory changes are real, a degenerative process would make the most sense, since there is not any evidence of vestibular dysfunction . . . I can't think of any additional testing to perform on Bonnie right now, but BAERS [Brainstem Auditory Evoked Response, used to detect retrocochlear pathology] would be interesting to perform to see if they show the same changes as the ERG. Nor can I think of any appropriate therapy for Bonnie."
The veterinary ophthalmologists said Bonnie's symptoms fit no particular category and felt her situation defied diagnosis. They called another veterinary ophthalmologist in their group to take a look at Bonnie because they found her symptoms and exam so perplexing. They all agreed that SARDS fit better than any other diagnosis but argued that she would be a very atypical case. Her ERG was flat but she still retained a small amount of functional vision that allowed her to navigate an exam room set up with obstacles. The neuro assessment pointed toward a degenerative process, but the veterinary ophthalmology team was not swayed toward the SARDS diagnosis. They pointed out that Bonnie's eyesight diminished over time, not overnight as they said is found in dogs with SARDS.They could not offer any hope or treatment for her condition, but did suggest Occuvite as a nutritional supplement to slow down the loss of vision. They attempted to encourage me by saying that Bonnie would "adapt to her circumstances."
If I had listened to these "experts," my dog would be completely blind by now.
Their advice was incorrect and misleading because dogs suffering from SARDS can retain navigational vision for a period of time despite flat ERG. Each case is different as each dog is different and while one dog might go blind in short order, another might keep some vision for months before going completely blind. Treatment options are certainly available for many dogs suffering from SARDS. The lack of recognition by MedVets of these possibilities for treatment is distinctly discouraging.
MedVets was unable to give Bonnie a diagnosis and the best they could do was to offer Occuvite, a vitamin supplement thought to help preserve vision. I recently learned that they now will diagnose SARDS correctly, but still do not offer any advice for treatment. The comment that the dog will adjust is still about the only true hope they offer.
In addition to pretty much wasting my money there, Bonnie also came home with a scratched cornea that had to be attended to by my regular vet--all from their fine handling.
Eventually, we consulted with the Dr. Grozdanic at Iowa State, and drove 1600 miles to meet him for an exam of Bonnie. He was able to tell us the that Bonnie was definitely suffering from SARDS (something a $400 bill and my three-hour drive one-way to Columbus apparently could not).
I was disappointed to learn that Dr. Grozdanic doesn't believe that SARDS is caused by adrenal exhaustion, but instead by an autoimmune process. The veterinary community is still debating this issue, but experts I consulted with when writing my article for GSM, including Dr. Kenneth Abrams, past President of the American College of Veterinary Ophthalmologists, and author of scientific articles and textbooks, reflect the theory of endocrine involvement.
SARDS is an area of keen interest for Dr. Abrams and the studies he completed and reported indicated "no antiretinal autoantibodies were identified in the serum of dogs affected by SARDS as compared to normal canine patients."
Both his research and personal experience in private practice point instead toward a corresponding hormonal imbalance. He indicated several theories had been put forth to explain the development of SARDS, including glutamate toxicity and autoimmune disease, but he did not believe these to be correct. "Many patients (70%) have an associated problem where they will drink lots of water, eat aggressively, and gain a lot of weight . . . . These signs hint at a hormone disorder called Cushing's disease, a similar disease to diabetes. However, when patients are tested for Cushing's disease, the results are usually normal or borderline."
In the end, it took still more time and effort to find experts who would connect adrenal exhaustion to Bonnie's SARDS and offer us real advice us on how to stop the degenerative process and help Bonnie retain the vision remaining her.
Adrenal Exhaustion is known by many names, including: adrenal fatigue, atypical Cushings or atypical adrenal cortical disease. It can be confusing when trying to determine what is being studied or discussed in relation to this disease.
The importance of the connection of adrenal exhaustion to SARDS is that if a dog is not treated correctly and their endocrine system is not balanced, not only can they lose their vision, but they can suffer greatly diminished metabolic health which can lead to early death.
Many dogs lose their vision because of the slow response of veterinarians, or ophthalmic veterinary specialists, as in the case of Bonnie and at least one other dog whose owner has corresponded with me. This other dog may have lost its sight altogether because MedVets assured the owner that while he did have SARDS, he would be fine. No treatment was offered or even mentioned.
I found the experts who would really be of most help to Bonnie through the Internet. Dr. Alfred Plechner, DVM, and Ms. Caroline Levin, R.N. [see below], consulted with our veterinarian and me through e-mail and phone calls.
Currently, Bonnie's adrenal exhaustion is being corrected with steroid replacement therapy, thyroid replacement therapy, sulfasalazine as well as special supplements and vitamins to preserve and protect her vision. Happily, she seems to be getting back to her old self as her metabolic symptoms are abating through treatment. Her vision is still just functional, but considering that the odds were against her, I feel fortunate that she has any sight at all.
The way we use steroids in Bonnie's case is a different way of administering or even thinking of steroids than has been typically accepted.
I think most of us have been exposed to the thinking that steroids are immunosuppressive or can be harmful long-term. I have always held them at arms' length, using them only in emergencies. Yet, small, physiologic doses, as opposed to pharmacologic doses of steroids, can actually be immunosupportive. Seems a bit counter-intuitive, but this is the case.
Until going through this experience with Bonnie, I did not realize it, but there is quite a bit of research available to support this theory, some of which has been around for decades. Most vets are still, sadly, unfamiliar with the whole disease mechanism. As a result, most pet owners have no idea that through correcting the underlying endocrine imbalance, they can restore health to dogs that suffer from many common, but seemingly intractable diseases. Dr. Plechner mentions the following:
Allergies;
Viruses, bacteria and fungi (colds and flu, parvo, bacterial infections);
Malabsorption and digestive tract disorders
(his studies show that food sensitivities occur only in animals with hormonal imbalances);
Autoimmune disease;
Cancer;
Kidney disease;
Chronic liver disease
(endocrine and immune imbalances can "cause it to run in slow motion");
Behavioral problems;
Aggression;
Separation anxiety;
Hypersexuality of neutered or spayed animals;
Problems in reproduction;
Epilepsy; and
Obesity.
I found Plechner and Levin's work to be fascinating, especially looking back at the pets I had lost to liver disease, cancer or kidney problems. Most especially meaningful for me was thinking of my dearest Kyle, who suffered all his life from food allergies and crippling irritable bowel disease (IBD), and who eventually died due to complications of his advancing liver disease and bladder cancer. If I had understood this information before Bonnie's SARDS, I might have spared many of my pets an untimely end.
To give you a better idea of how adrenal exhaustion works, Dr. Plechner describes the disease disorder he sees in the pets he has treated. From his book, "Pets At Risk":
"In my research I have learned that at a basal, or normal level, the body's own cortisol exerts a very discriminating regulatory effect on molecular 'mediators' that turn on or turn off activity related to immunity and inflammation. It is a very complex business. The bottom line is that a normal level of cortisol seems to be required for a normal immune response. A deficiency of cortisol may result in an unresponsive immune system, whereas too much cortisone medication or too much of the body's own active cortisol suppresses immune responses. An excess of active cortisol or cortisone drugs can lead to a condition known as Cushings syndrome. In Cushings, individuals develop severe fatigue, weak muscles, high blood pressure, high blood sugar, and fertility and menstrual problems, among other symptoms.
* * *
"Cortisol deficiency, the other side of the coin, tends to be overlooked in medical circles. A deficiency or ineffectiveness of cortisol certainly appears to cause many problems. I have seen this consistently in animals. Compared to healthy animals, I have found that sick and diseased pets often have too little cortisol, or the cortisol present is somehow in a bound or ineffective state, resulting in system imbalances and chaos throughout the physiology. The particular problem I see does not relate to Addison's disease . . . ."
Plechner has determined that the disease process in many pets can be corrected by addressing the issue of cortisol production and excess adrenal sex hormones. His protocol starts with specific testing he's developed ("Plechner endocrine-immune test") in order to determine a patient's precise point in the disease process. If hormonal imbalance is present, treatment is given through cortisol replacement. Most of the time, T-4 thyroid replacement is necessary, too, since thyroid hormones become bound to some degree because of the influence of "estrogen and cortisol abnormalities." A thyroid imbalance can be present even if the T3/T4 levels look normal, so it is important to use a lab that is particularly sensitive in this area of testing and aware of the correct range of these values. Plechner's E-1 test shows the values for T3,T4, cortisol, estrogen and three different antibodies or immunoglobulins (IgG, IgM, and IgA).
When the adrenals can no longer produce the levels of cortisol demanded by the body or if the cortisol is bound up in some way and unavailable to the body for use, then the byproduct of this scenario can be excess adrenal hormones, especially estrogen. Too much estrogen, coupled with low cortisol, has a harmful effect on many body systems, including depression of immunoglobulins and producing inflammatory results throughout the body. Obviously, if the body isn't being well-protected by immunoglobulins, medical problems can result.
IgA, one of the more important immunoglobulins, protects all the mucous membranes of the body. If IgA isn't at the right level, infections, allergies, or even cancer might result.
In Bonnie's case, I believe high levels of estrogen caused small seizures to her retinal cells which resulted in massive apotopsis (cellular death). Ms. Levin's SARDS FAQS page states the following as potential causes for SARDS:
Whether the predisposition involves a flaw in the retinal cells, an over-activity of the adrenal gland (the body overreacts to even small stressors) or a predisposition to low Immunulogobulin A/ an irritated intestine is unclear.
During the last few years, Bonnie's Complete Blood Count (CBC) showed high liver enzymes, and because of that, she was repeatedly tested for Cushings. It is, however, important to realize that using a Cushings test alone to determine treatment--especially one that might call for Lysodren, Trilostane or even melatonin--might be dangerous. Melatonin does depress estrogen production, but also does the same for cortisol. Obviously, that would not be the goal for a dog who isn't producing enough cortisol. An adrenal crisis can be the result of suppressing the cortisol production in a dog that is already suffering from adrenal fatigue.
It is also not widely realized by vets, but if tests results do show excess cortisol as with Cushings disease, it doesn't necessarily mean that the cortisol is in actuality available to the body. It may very well be bound up through the mechanisms Dr. Plechner describes. Having a total endocrine panel run by a lab that specializes in interpretation of the results is a much better approach to looking at high liver enzymes or other Cushingoid symptoms. Basically, if the total estrogen levels are up and the immunglobulins are depressed, you mighty well suppose that you are dealing with adrenal exhaustion and not Cushings.
I will never again start a treatment of Lysodren for a pet relying just on a Cushings test, or even repeated Cushings tests of different kinds. I will continue to believe that the E-1 panel (Endocrine-1, the name used by NVDS for the test) is the key to interpreting so many aspects of my pet's health. I have had two pets that had poor experiences with Lysodren (used to treat Cushings disease); one fatal, and the second one, nearly fatal. I have started to believe that those instances when my dogs suffered poor outcomes with Lysodren might be due to the fact they never needed Lysodren in the first place. Perhaps those dogs had an endocrine imbalance--adrenal exhaustion--that was masquerading as Cushings.
Vets don't recognize adrenal exhaustion, so their choices are limited when faced with pets that are seemingly suffering from Cushings. Their knowledge or experience may not allow them to consider any other possibility. High liver enzymes are indicative of both adrenal exhaustion and Cushings, so when observing this in a pet, as I did with Bonnie, it is important to make sure you know what you are dealing with. It may mean that you will have to seek out other treatment providers in addition to your regular veterinarian. I found vets that were open to the concept of adrenal exhaustion, but few had any experience with it. As vet care prices soar, I would imagine that few clients push their vets toward more testing.
In humans, adrenal exhaustion has been recognized for at least the last twenty years, so one wonders why should the situation be so different for animals?
I have attempted to provide a quick view of SARDS and adrenal exhaustion and the story of Bonnie's struggle with both. If anyone has questions about Cushings or adrenal exhaustion in pets, please check out Dr. Plechner's book or schedule a consultation with him. He is the veterinary equivalent of an "adrenal and endocrine explorer," and has presented revolutionary ideas for the veterinary world to consider and offered his help generously to owners with pets suffering from a variety of ills. As a sidenote, he was the formulator of the first pet foods for animals suffering from allergies and also has a keen interest and ability in the area of allergies in pets.
Dr. Plechner would be most able to provide a better understanding of how Cushings and adrenal exhaustion can look so much alike and the appropriate next step if an owner suspects either to be present in their pet.
If you have a pet you suspect is suffering from SARDS, Ms. Levin is an excellent resource, either online or through personal consultation.
Ms. Levin has just included a wonderful link on her web site relating to the use of melatonin versus steroid replacement therapy in adrenal exhaustion cases. I found it especially interesting because when Bonnie got her first endocrine panel done at the Univ of Tenn., melatonin is exactly what they recommended as a treatment option.
Basically, while melatonin does help suppress estrogen, it also lowers cortisol levels, which isn't at all the object when a dog suffers from adrenal exhaustion; in fact it can place the overall health of the dog in greater jeopardy, both in the short and long-term.
Ms. Levin also notes that a small number of SARDS dogs have Cushings disease, but most she has studied have the endocrine imbalance the Bonnie has.
The prescription of steroid replacement that Dr. Plechner advocates is lifelong because the imbalance will return if treatment is stopped. He makes the important point that the animals he treats are not affected by the side-effects so often seen with steroids because he is providing the body with something it isn't producing on its own–and something it desperately needs. (I can totally relate to this since I take thyroid medication every day since I can't make enough thyroid hormone on my own; if you can't make it on your own, you need to get it some other way.) The oft-publicized immunosuppressive effects of these powerful drugs might make some veterinarians shy away from using them, but research has revealed that they can be healing and restorative to the immune system when properly used in small, physiologic doses for animals with a corresponding imbalance.
Bonnie's struggle for vision and good health seems to have taken up the better part of my life for over a year, but the good news is that she is being treated successfully and appears to be doing well. As a result, I continue have a keen interest in metabolic diseases of pets that can be linked to adrenal exhaustion, monitoring new research with a special focus on adrenal exhaustion. I will continue to add those links at the bottom of the blog page for those who are interested.
Links to Dr. Plechner:http://drplechner.com/
"Pets at Risk: From Allergies to Cancer, Remedies for an Unsuspected Epidemic"
Martin Zucker and Alfred J. Plechner, DVM
New Sage Press, 2003 $13.95
I also found her book to be very helpful:
"Dogs, Diet and Disease An Owner’s Guide to Diabetes Mellitus, Pancreatitis, Cushing’s Disease, and More" Examines autoimmune, endocrine, and digestive problems. Discusses treatments, including diet. An excellent resource for SARD-dog owners, and available through her Lantern Publications web site.
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