High ALP without signs of Cushing's in a dog: treat or not?
10-year-old Yorkshire Terrier having bloods before a dental scale. ALP is 450 U/L (ref. 20–150); everything else is normal. The owner reports no polyuria, polyphagia, panting or skin changes, and the physical examination is normal.
What is the most appropriate approach regarding hyperadrenocorticism?
chevron_right Show answer and explanation
A. Start low-dose trilostane to prevent complications of Cushing's
Treating without a diagnosis and without signs exposes the dog to adverse effects (including hypoadrenocorticism) with no proven benefit.
B. Perform a low-dose dexamethasone suppression test and treat if positive
Adrenal function tests have false positives, especially in dogs with other diseases. Running them without clinical suspicion lowers their predictive value and leads to treating healthy dogs.
C. Do not test for or treat Cushing's without compatible signs; consider other causes of the high ALP and recheck the dog
Correct. According to the ACVIM consensus, testing for hyperadrenocorticism should only be done when there are compatible clinical signs, and an isolated laboratory abnormality is never treated. High ALP in an older dog has many causes (vacuolar hepatopathy, drugs, nodular hyperplasia).
D. Perform an ultrasound scan and treat if the adrenals are enlarged
Ultrasound is not a diagnostic test for hyperadrenocorticism: adrenals can be enlarged in dogs without Cushing's and normal in dogs with it. Moreover, without signs there is nothing to treat.
lightbulb Key takeaway
Treat the dog, not the lab result: without clinical signs (polyuria/polydipsia, polyphagia, panting, pot belly, alopecia) Cushing's is neither investigated nor treated. If signs appear later, testing is then indicated.
References: Behrend EN et al. Diagnosis of spontaneous canine hyperadrenocorticism: 2012 ACVIM consensus statement. J Vet Intern Med 2013
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Updated: October 31, 2026 · Educational content for veterinary professionals. It does not replace current clinical guidelines or the judgement of the attending veterinarian.