syanchten

Re: syanchten

Claire Fisher — Tue, 01 Oct 2013 19:24:02 GMT

We also got some from our local pharmacy last week.

If the remainder of the vial isn't likely to be used soon we have frozen the remainder (advice on the Samsoc forum).

Re: syanchten

Martin Atkinson — Tue, 01 Oct 2013 18:26:53 GMT

If you have any Synacthen left then remember the dose is only 5ug/kg bodyweight not the whole vial as normally suggested. If you use it like this you can transfer it to a syringe, cap it and store for future use and get several tests out of one vial. Sadly no data on how long you can store it.

Re: syanchten

Dagmar Steele — Tue, 01 Oct 2013 17:11:47 GMT

ok, this is the short form in English (bear in mind I'm not a native speaker, nonetheless I do hope the translation is a little better than google's version):

It is a legally difficult situation as the only approved drug for treatment is Trilostane. In the datasheet the information is given that monitoring of the therapy should be done by ACTH Supression test. Without Synacthen this is impossible, hence therapy under these circumstances is legally questionable and veterinarians should get owners to sign a form of consent that they have been made aware of these facts. Diagnosis can be made by Ldd but this test is less specific. Some experts are of the opinion that dx and tx of the disease should be postponed until Synacthen will be available again as the disease usually progresses slowly and unsupervised treatment might lead to Addison's, others be to differ as there are some possibly severe damages caused by Cushing's like diabetes.

Tx should only be started at the lowest dose of 3mg/kg sid. All clinical signs of Addison's disease (weakness, apathy, stupor, vomiting, diarrhea, weight loss, inappetence) should prompt immediate cessation of therapy. For monitoring measure basic cortisol levels. Values > 50 nmol/l or 1,8 μg/dl are ok, unfortunately they don't help to find out the exact dose of trilostane. Levels under 50nmol/l or 1,8 μg/dl should lead to great caution and close monitoring of clinical signs if not cessation of therapy with trilostane. Measure sodium and potassium. The ratio of sodium/potassium should not drop below 28. Otherwise again close monitoring of clinical signs is necessary. Should the clinical signs (pu/pd and so on) point in the direction that the trilostane dose needs to be increased, first make sure basic cortisol levels are still over 50 nmol/l or 1,8 μg/dl. Check for other reasons of pu/pd as urinary tract infections, diabetes or kidney disease. Only if all other reasons are excluded carefully up the dose. Clinical signs of cushing's like hair loss and pot bellied appearance will take weeks to months to resolve even on the proper trilostane dose. Experts recommend to perform clinical examination and to check lab values 10, 28, 90 days after starting treatment and then if stable every 3 months.

Re: syanchten

Dagmar Steele — Tue, 01 Oct 2013 16:13:22 GMT

oh deary me, I promise to translate the stuff should I ever find the time to do it :-(

Re: syanchten

Michael Woodhouse — Tue, 01 Oct 2013 15:56:55 GMT

[quote user="Dagmar Steele"]this may be an indication of an impending Übersuppression the adrenal cortex.[/quote]

I challenge you all to slip this into a sentence in the next week.

Re: syanchten

Dagmar Steele — Tue, 01 Oct 2013 15:44:23 GMT

But only for you Lorna! I'll pm it to you, no problem! If you have the capacities feel free to translate it!

Re: syanchten

Lorna McHardy — Tue, 01 Oct 2013 15:25:24 GMT

I don't suppose you'd post the German version? It's likely to make more sense :0)

Re: syanchten

Nicola Lawlor — Tue, 01 Oct 2013 14:43:53 GMT

We were able to get 5x 1ml vials of synacthen via our local pharmacy after our wholesaler was out of stock. Probably worth given the local pharmacy a call and seeing if they can help at all,

Re: syanchten

Dagmar Steele — Tue, 01 Oct 2013 13:55:33 GMT

Treatment should always begin at the moment only at the lowest dose of 3 mg / kg once daily trilostane . To monitor serves as a clinical examination of the dog . Signs of hypoadrenocorticism as weakness , listlessness , dull-witted behavior , loss of appetite , vomiting , diarrhea, unexpected weight loss or illness of any kind is grounds for immediate interruption of treatment. Secondly, the treatment can be determined by determining the base value of cortisol . A base cortisol value of> 50 nmol / l and 1.8 g / dl excludes adrenal Übersuppression . Furthermore, the explanatory power is not enough , because the optimal drug dose can not be determined this way. If the base cortisol value below 50 nmol / l and 1.8 g / dl , it may be an adrenal Übersuppression . Here, special care should be taken , clinical examination now has a special meaning . While it is not always necessary to discontinue therapy immediately , before symptoms of hypoadrenocorticism are however , the drug should be discontinued immediately . Even with obscure clinic , it may be safer, at least temporarily suspend the treatment . Continued treatment is justified only in clinically healthy dogs with great caution . Other useful for the control parameters are electrolytes such as sodium and potassium. If that is the Na / Ka - quotient below 28 (low Na value in conjunction with a high Ka value ) , this may be an indication of an impending Übersuppression the adrenal cortex.

If the patient further clinical signs of hyperadrenocorticism , a cautious increase in dosage is possible under certain circumstances . First, you make sure that the base cortisol value above 50 nmol / l and 1.8 g / dl . Other possible causes for the symptoms , such as urinary tract infections , diabetes mellitus or kidney disease as causes of polydipsia and polyuria , it is also excluded. Further checks of the laboratory results and the clinical condition of patients recommend to experts at intervals of 10, 28 and 90 days and from there in stable condition every three months. The clinical symptoms of Cushing's syndrome , such as hair loss or central obesity , however, only get better over the course of several months, and are therefore unsuitable for short-term success control .

Other tests such as the cortisol : ACTH ratio and urinary cortisol : creatinine ratio are not suitable for dogs under the supervision of Vetoryl ® therapy .

Unfortunately, however, must be clearly emphasized that these recommendations can not replace the use of the ACTH stimulation test . Treatment of hyperadrenocorticism is therefore currently classified at least as difficult legally .

Re: syanchten

Dagmar Steele — Tue, 01 Oct 2013 13:54:04 GMT

I have just written an essay on this issue because we cannot get Synacthen in Germany at the moment. I have talked to the distributor and the lab and below is what they recommend at the moment. Unfortunately the essay has been written in German and due to my very tight schedule at the moment I could not translate it properly but could only run it through the dreadful google translator. Maybe you'll get the picture anyway, hope it helps!

The problem is not new: The approval for a drug goes from the different reasons and just like that the practitioner with a problem there. The latest example is the term used for the ACTH stimulation test drug Synacthen ®, which is currently not legal to purchase in Germany . The diagnosis and especially the monitoring of the treatment of Cushing's disease in dogs is about exactly but this test. The position of the diagnosis is also possible through the low-dose dexamethasone suppression test , even if it has a lower specificity , ie, more false- positive results are possible. Really difficult is the current situation with regard to the monitoring of treatment of Cushing's disease . This is the only approved drug Vetoryl ® . And here are found in the product information very clear indications for therapy monitoring . This is in addition to the clinical examination, namely the ACTH stimulation test , perform four to six hours after drug administration . A requirement that can not be met without ACTH . Therefore , therapy with Vetoryl ® is since then outside of the approved recommendations of the manufacturer. Well of course it makes little sense to quit because of this awkward situation, the treatment of all patients with Cushing abruptly or such not to start with new cases only . However, the fellow should protect and inform patients about owners that at a regular monitoring of therapy is currently not possible. It is also good practice to be confirmed by the pet owner in the form of a consent in writing. Whether a diagnosis made without ACTH stimulation test, the initiation of therapy is at all meaningful , you have to think about exactly . In general, a Cushing's disease progresses slowly, the possible consequences such as the development of diabetes mellitus , however, can have profound consequences for the patient. On the other hand, there is a lack of monitoring during treatment or at the initiation of therapy without definite diagnosis the risk of acute Addison's crisis, which can be life threatening. Therefore, some experts recommend at this time to move in less serious cases the therapy until the diagnosis can be secured or ACTH is available again in Germany .

Re: syanchten

CatherineThomas — Tue, 01 Oct 2013 13:42:12 GMT

The practice I was at last week had a protocol from their lab advising them what to do. For diagnosis they advised a low dose dex test and for monitoring of stable patients they advised measuring basal cortisol in combination with electrolytes and then only do a stimulation test if the results indicated a need.