troublesome Addisonian

Re: troublesome Addisonian

Joyce Whitehead — Sun, 02 Nov 2014 22:16:56 GMT

Glad the synacthen helped...

Re: troublesome Addisonian

David Mills — Thu, 30 Oct 2014 23:37:06 GMT

Update on this case.

Was seen in my absence by a colleague. Potassium up in the 8s again so was hospitalised for a couple of days.

Ran ACTH, with much gratitude expressed towards Joyce for supplying a vial, positive for Addisons. Was started on increased doses of pred (20mg daily) and sent home.

Back today, 10d later, and for the first time ever on outpatient check, electrolytes normal. PCV creeping up now 29%.

Go figure. Damned animals.

Re: troublesome Addisonian

Martin Atkinson — Mon, 20 Oct 2014 19:43:32 GMT

[quote user="David Mills"]

[quote user="Martin Atkinson"]referral to a specialist.[/quote]

If only.

[/quote] I realise it 'aint going to happen but my point is that once available resources and your level of expertise has run out (and my impression is that despite you position in a charity practice it is quite high) you've done your best. The client then has has a clear option as they would in private practice -either they go to a specialist or they don't but that's their decision. However in many ways your resources are better than many of us in private practice at least in terms that if the client can't afford my fees and ends up at RSPCA Putney they are actually, rather paradoxically and possibly rather unfairly on those who have the good sense to have pet insurance or not to keep pets they can't afford, going to get a better level or treatment. Sad really but its a strange world.

Re: troublesome Addisonian

David Mills — Fri, 17 Oct 2014 19:16:01 GMT

[quote user="Martin Atkinson"]I assume this is a charitable case and funds are limited.[/quote]

As all my cases are, alas.

[quote user="Martin Atkinson"]referral to a specialist.[/quote]

If only. Another quirk of charity practice is that the people who can afford referral are the ones who really don't need it (but insist on it, usually 'to that supervet off the telly'),

Re: troublesome Addisonian

Martin Atkinson — Fri, 17 Oct 2014 15:40:52 GMT

[quote user="Nicola Lawlor"]We also had some synacthen on back order come last week.[/quote]Damn so did we. Just as I'd paid for the Tetracosactide so I can't cancel the order and the nurses didn't tell me the Synacthen has come so it is past the limit in which we can send it back to NVS. Anyone else want some?

Re: troublesome Addisonian

Martin Atkinson — Fri, 17 Oct 2014 09:29:23 GMT

[quote user="David Mills"]The problem is, this dog is on 0.1mg/kg (0.05mg/kg BID) which is the top end of the dose range. I'm sure there is some GC effects at this high a dose.[/quote]Sorry didn't see that dose I need to read the threads properly I thought you had it on 0.5mg sid.

[quote user="David Mills"]However, I'm concerned about the value of an acth stim given the dog has been on preds for some weeks? Surely this will interfere?[/quote]Well this is true of course.

I assume this is a charitable case and funds are limited. However, even though I know you strive like me to be 'super-vet' at some point you have to accept defeat and advise a referral to a specialist. It is not your fault the client is impecunious you can only do your best it is then their choice,

Re: troublesome Addisonian

David Mills — Thu, 16 Oct 2014 23:12:35 GMT

Thanks for all input so far, it really is helpful. Will answer some queries/points below.

[quote user="Martin Atkinson"]Some dogs need considerably higher doses of Florinef and/or may benefit from bid dosing.[/quote]

The problem is, this dog is on 0.1mg/kg (0.05mg/kg BID) which is the top end of the dose range. I'm sure there is some GC effects at this high a dose.

[quote user="Martin Atkinson"]Are you giving a salt supplement - may be beneficial especially as you say he improves with saline drips but then that is almost diagnostic for Addisons![/quote]

No, not as yet.

[quote user="Martin Atkinson"]I've just ordered some it was £72 inc. VAT for 8 x 2ml 0.1mg/ml vials.[/quote]

That has come down a lot. Last time we enquired about a month ago it was £200 for a couple, I think.

However, I'm concerned about the value of an acth stim given the dog has been on preds for some weeks? Surely this will interfere?

[quote user="John Flynn"]but a couple of freshly spun non-haemolysed heparin samples should confirm that in the unlikley event that any doubt remains[/quote]

Yes we did this recently - we run >95% bloods in house - and the results were consistent.

[quote user="John Flynn"]Marked hyperkalaemia in the absence "Addison's" has usually resulted in eventual discovery of a neoplastic mass in my limited experience[/quote]

Yes, I agree. However, the sodium (and chloride) have been consistently, and repeatedly, low in the presence of high potassium - could it be anything else?? Although the possibility of Addisons + X remains.

[quote user="John Flynn"] guess the likelihood of this comes down to how conifdent you are on the imaging that was done back in June - this could be repeated at this stage I guess[/quote]

I did the imaging myself, and I'm confident there were no glaring neoplastic masses at that stage. My ultrasound skills are around certificate level (that sounds horribly arrogant, not meant to be). I would like to repeat it though - although money may be an issue and I can't push it fully when florinef is so damned expensive for this size of dog.

[quote user="John Flynn"]Kidney disease has to be on the list, but I think your imaging and clinical signs effectively rule out lower urinary tract issues; [/quote]

Yes, though the lack of azotaemia - even when first diagnosed - makes me doubt whether chronic interstitial renal disease is possible, but certainly glomerulonephritis in absence of azotaemia is possible. The electrolyte excretion sounds interesting but whether this would add useful info at this stage I'm unsure.

[quote user="John Flynn"]Temporal muscle atrophy suggests to me glucocorticoid over-dose, so if we're assuming addison's I'd be tempted to taper the preds off and stick just with the florinef. Hyperkalaemia (albeit adapted) of this magnitude can explain the level of lethargy on its own I reckon and the response to the additional pred doesn't sound impressive to-date (and I would have thought probably get a fairly physiological dose of GCs in that level of florinef?). If DOCP was affordable for you (which it won't be) then I'd have switched to that from florinef to see if any effect (and maybe kept on a very low dose of pred); otherwise I'd just keep going up with the florinef if affordable at highger doses long term (but leaving off the pred) until the potassium level came down or I decided that I no longer considered addison's to be so highly likely for whatever reasons.[/quote]

Yes me too re atrophy. My issue with increasing the florinef dosage (even whilst dropping the preds) is the amount of glucocorticoisd going into this dog (and whether this may be contributing to some of the signs). I am concerned about GI bleed but having said that the anaemia is non-regenerative and the urea has never been raised. This is why I was wondering about adding hydrocortisone tablets, which apparently has a twelfth of the glucocorticoid action of florinef. And you're right, DOCP is out :)

[quote user="John Flynn"]That degree of anaemia is interesting - assuming this is a repeatbale finding on an actual PCV[/quote]

Yes, is manual PCV. What is slightly concerning is that this was on blood pre-fluids and if Addisons was uncontrolled then hypovolaemia means the 'true' value would be lower. However, finding the 'true' value is hard - as fluids are given to diurese hence PCV may be artificially low.

[quote user="Joyce Whitehead"]We are a fairly small practice so if it would help I could send a vial?[/quote]

You are an angel. That would be wonderful. Will PM you.

[quote user="Nicola Lawlor"]Another consideration would be a myositis perhaps? Cell damage releasing potassium? May explain a partial response to preds without a full resolution of the apparent addisons. Other autoimmune issues might be considered to, especially as the dog is anaemic. What does the urine look like - may give you more of a clue without vast expense.[/quote]

Yes, had considered myositis/cell damage but the stroppy appears chronic which IME wouldn't fit with persistently raised K to the extent in this dog - have certainly seen dramatic hyperkal in a cue muscle damage, but I guess it might be possible in terms of contribution. The autoimmune issue is lurking. Urine sediment exam today normal, nothing on dipstick, s.g. 1.020 but on fluids and peeing for Britain.

I am worried that something nastier might be lurking in this dog, partly because it doesn't feel quite right, and partly because it's a lovely dog and owner. Re costs, I'm not trying to avoid doing things., but the owner is nearing max-out with the cost of the florinef and the repeated hospitalisations for the dog. These cases in charity practice are like trying to hop on one leg with your hands tied behind your back, blindfolded, and with 8 pints of Stella inside you.

Re: troublesome Addisonian

Nicola Lawlor — Thu, 16 Oct 2014 21:14:19 GMT

We also had some synacthen on back order come last week. Quite a surprise to see it!

Another consideration would be a myositis perhaps? Cell damage releasing potassium? May explain a partial response to preds without a full resolution of the apparent addisons. Other autoimmune issues might be considered to, especially as the dog is anaemic. What does the urine look like - may give you more of a clue without vast expense.

Re: troublesome Addisonian

Joyce Whitehead — Thu, 16 Oct 2014 20:43:01 GMT

No advice on the case, but we got a box of synacthen through from NVS this week from our back order. We are a fairly small practice so if it would help I could send a vial?

Re: troublesome Addisonian

John Flynn — Thu, 16 Oct 2014 19:45:53 GMT

Tricky case.

HIndsight's wonderful, but a basal cortisol prior to preds would have been nice - I'm not so sure how useful would be now, but might still be worth doing (perhaps after tapering off preds - see below). Re injectable ACTH - if you can purchase a single vial off a friendly clinic (or split a box between a few of you locally) then can split that single vial into smaller aliquots and freeze these individually making use quite affodable.

Addison's certainly still seems most likely, but then perhaps lack of response to florinef means should consider other possibilities. Analytical error can effectively be ruled out I suspect based on the number of serial samples and magnitude of hyperkalaemia, but a couple of freshly spun non-haemolysed heparin samples should confirm that in the unlikley event that any doubt remains. Marked hyperkalaemia in the absence "Addison's" has usually resulted in eventual discovery of a neoplastic mass in my limited experience - I guess the likelihood of this comes down to how conifdent you are on the imaging that was done back in June - this could be repeated at this stage I guess. Kidney disease has to be on the list, but I think your imaging and clinical signs effectively rule out lower urinary tract issues; I've requested fractional excretion of electrolytes (simultaneous urine and freshly-spun hep plasma) for about £20-25 in lab fees before and you could think whether that might give any useful information or just be throwing money down the toilet. A broad-spectrum wormer tablet is relatively affordable but I appreciate is clutching at straws in this case.

Temporal muscle atrophy suggests to me glucocorticoid over-dose, so if we're assuming addison's I'd be tempted to taper the preds off and stick just with the florinef. Hyperkalaemia (albeit adapted) of this magnitude can explain the level of lethargy on its own I reckon and the response to the additional pred doesn't sound impressive to-date (and I would have thought probably get a fairly physiological dose of GCs in that level of florinef?). If DOCP was affordable for you (which it won't be) then I'd have switched to that from florinef to see if any effect (and maybe kept on a very low dose of pred); otherwise I'd just keep going up with the florinef if affordable at highger doses long term (but leaving off the pred) until the potassium level came down or I decided that I no longer considered addison's to be so highly likely for whatever reasons.

That degree of anaemia is interesting - assuming this is a repeatbale finding on an actual PCV - do we expect that simply with addison's ongoing a few months? Sounds more than I would have expected - if others think the same then perhaps further consideration of this might lead to some light?

Re: troublesome Addisonian

Martin Atkinson — Thu, 16 Oct 2014 18:47:57 GMT

[quote user="David Mills"]Re tetracortisone - again restrictively expensive from Dechra (and I suspect the fact already being treated would affect the results?).[/quote]I've just ordered some it was £72 inc. VAT for 8 x 2ml 0.1mg/ml vials. If you use that at 5ug/kg you can test your dog 8 times or a hell of a lot more smaller dogs. That doesn't sound expensive to me.

Re: troublesome Addisonian

Martin Atkinson — Thu, 16 Oct 2014 18:42:26 GMT

First part: call Dechra and they can supply tetracosactide which is essentially the same as Synacthen so you can do your stim test.

Some other thoughts: I wonder if you're overdoing the corticosteroids which is causing gastro-intestinal bleeding although 10mg preds isn't a lot and you'd expect a regenerative anaemia.

Some dogs need considerably higher doses of Florinef and/or may benefit from bid dosing. I have a troublesome Addisonian 9kg dog on 0.2 mg bid.

Are you giving a salt supplement - may be beneficial especially as you say he improves with saline drips but then that is almost diagnostic for Addisons!

If the owner is giving a salt supplement already just make sure it isn't 'low salt' salt i.e. high in KCl.

Give up and refer it!

Re: troublesome Addisonian

David Mills — Thu, 16 Oct 2014 18:39:30 GMT

[quote user="Sarah Jervis"]

We've recently had a long term Addisonian who seemed to 'decompensate' - initially though it was the Addisons going haywire but ended up having pancreatitis on top of the Addisons. It seemed to be quite an acute severe pancreatitis at the time but in discussions with the owner post-discharge, she reports the dog is 'better than she's been in months' so maybe has had a chronic grumbling pancreatitis going on for a while? I'm sure there's lots of other causes of your dog's signs, but given our recent case then it's the first thing that springs to mind - maybe a PLI would be worth a thought, especially given your 40kg (overweight?!) lab with a history of variable appetance and mild increase in ALT? Not sure whether it fits with the anaemia (although if its chronic then maybe?) or tachycardia (possibly pain?)..?

Also, not sure if you know already and your lack of hope of synacthen is for other reasons, but if you get in touch with Dechra, you can order tetracosactide (same as synacthen but different mg/ml) as prescriptions for individual patients.

[/quote]

Thanks for the suggestions. To answer points raised:

Dog is a show-type lab and at 40kg is about spot-on for him.

Was scanned today - no evidence of pancreatitis. (can't afford PLI)

Re tetracortisone - again restrictively expensive from Dechra (and I suspect the fact already being treated would affect the results?).

Re: troublesome Addisonian

Sarah Bolt — Thu, 16 Oct 2014 18:31:26 GMT