pu/pd in a well controlled Cushings dog

Re: pu/pd in a well controlled Cushings dog

Andrew Kent — Mon, 29 Jun 2015 10:11:32 GMT

Thanks Thomas, glad things are going well!

Re: pu/pd in a well controlled Cushings dog

Thomas Johnson — Sun, 28 Jun 2015 10:05:13 GMT

[quote user="Andrew Kent"]

Thanks for the update - glad to hear things seem to have improved!

[/quote]

Another update on this case. She has continued to receive 30mg Vetoryl sid and one drop of DDAVP bid. Her owner is very happy with her and reports that she is drinking and urinating normally (though still hasn't provided a urine sample!)

We repeated the ACTH stim this week, her basal cortisol was 19.0, and 1hr post ACTH 70.6. Her heamatology, biochemistry and electrolytes were normal, Na:K ratio 28.92. So we'll keep going as before.

Re: pu/pd in a well controlled Cushings dog

Kirsten Simpson — Fri, 27 Mar 2015 10:55:56 GMT

How timely! I have a dog just like this who I am doing full bloods on initially, then ACTH stim next week depending on the bloods. Last bloods and check were in Dec and were all ok but now he is lethargic, collapsing on his HL occasionally, back to signs he was when he was first Dx as Cushings (stealing food from everywhere, PUPDish again) and his urine SG is 1.006, super dilute. He is on 60mg SID as 30mg wasn't enough. I was worried he would go a bit wonky and Addisionian but his last bloods were ok and ACTH stim was ok, poss very well controlled (query too much?). Going to run full biochem + CBC today, if elecs a bit wonky will back off Vetoryl. I hate that there's not a 45mg Vetoryl dose! He was also sore caudally and I couldn't feel his prostate per rectum so I was worried incase the collapsing HL and CS were due to a prostate problem (he is castrated) but hopefully its not...

Re: pu/pd in a well controlled Cushings dog

Andrew Kent — Wed, 25 Mar 2015 20:29:36 GMT

Thanks for the update - glad to hear things seem to have improved!

Andy

Re: pu/pd in a well controlled Cushings dog

Charlotte Marshall — Mon, 23 Mar 2015 17:35:57 GMT

Interesting as I have boxer with a similar problem, the acth stim tests suggested I had him under control yet he keeps drinking. He did get referred as I was at my wits end and the referral guy scared me a bit with possible problems doing a DDAVP trial. They confirmed it has a pituitary dependant disease (though did not have MRI) and put it on twice a day dosing although a pre vetoryl dose ACTH stim was equivocal for that. So far latest ACTH stim still looks controlled despite the low dose he is currently on .... and he is still drinking for England! His SG has been low but not quite as low as a typical DI dog. I think we will end up having to trial DDAVP as they cannot afford surgery or radiotherapy. Either that or the poor thing will get euthanized as he has got lethargic too, possibly due to the mass.

Re: pu/pd in a well controlled Cushings dog

Thomas Johnson — Mon, 23 Mar 2015 17:16:08 GMT

Apologies for the delay in giving an update on this case. After she came off the Vetoryl she continued to be pu/pd, and the abdominal discomfort gradually subsided. We re-introduced the Vetoryl at the same dose to no adverse effects, and a week later started DDAVP one drip twice daily. Her owners still haven't brought me a urine sample to check her specific gravity, but I have spoken to them a couple of times and they report a marked reduction in her drinking and urinating. They are aware that as we don't have a definite diagnosis the future is a little uncertain, and that she could have a pituitary growth.

Re: pu/pd in a well controlled Cushings dog

Thomas Johnson — Thu, 29 Jan 2015 08:38:30 GMT

[quote user="Andrew Kent"]

Hi Thomas,

Thanks for the update, your previous stim showed an adequate adrenal reserve so unless things have changed considerably since then iatrogenic addison's is unlikely. The exception could be if the trilostane has caused an adrenal necrosis (which is possible) and can cause things to change quickly.

But I think in the circumstances you have done the right thing - lets see where we are when things settle down.

[/quote]

I agree, I'm not convinced it is iatrogenic Addison's, but I thought there's little risk of problems coming off the Vetoryl for a few days and it would be quite nice to see what clinical signs she has when off medication. I'll update again next week!

Re: pu/pd in a well controlled Cushings dog

Andrew Kent — Wed, 28 Jan 2015 21:39:44 GMT

Hi Thomas,

But I think in the circumstances you have done the right thing - lets see where we are when things settle down.

Andy

Re: pu/pd in a well controlled Cushings dog

Thomas Johnson — Wed, 28 Jan 2015 17:26:02 GMT

So we started DDAVP a week ago, with a plan to check urine specific gravity this week. However over the weekend she developed a tense abdomen and became inappetant on Sunday, then started vomiting Sunday evening and passed loose faeces.

Clinical examination was unremarkable yesterday morning, abdomen relaxed. I took blood to check electrolytes and told the owner not to give Vetoryl or DDAVP. The owner offered her a small amount of food at midday, she ate but brought the food back up. I saw the dog again at 5pm and its abdomen was a bit tense. I gave some Cerenia.

Today she is brighter, has eaten some food and kept it down. I have repeated the Cerenia injection. The Na:K ratio has come back slightly lower than previously at 26.23, though both Na and K are in the normal range.

So now I am starting to think she does have iatrogenic Addison's, though she could have something else causing vomiting. I have told the owner not to give her any medication and plan to re-assess her in 5 days, sooner if the owner has any concerns.

Re: pu/pd in a well controlled Cushings dog

Andrew Kent — Mon, 19 Jan 2015 17:29:33 GMT

Great - do keep us updated with how you get on.

Andy

Re: pu/pd in a well controlled Cushings dog

Thomas Johnson — Mon, 19 Jan 2015 17:27:51 GMT

Urine culture has come back negative. The owner has declined referral so we are going ahead with a trial with DDAVP.

Re: pu/pd in a well controlled Cushings dog

Thomas Johnson — Wed, 14 Jan 2015 08:43:10 GMT

[quote user="Andrew Kent"]

I think that is probably reasonable but they do need to be aware that if this is a macro adenoma you may start to get other neuro signs and that there may be other management strategies (for example radiotherapy) that achieve better long-term results. But there is, of course, a big cost associated with things like MRI and radiotherapy and so they are not suitable in many cases.

And obviously keep an eye on these electrolytes etc just in case this is an upward trend.

Do keep us updated with what they decide to do

Andy

[/quote]

I spoke to the owner last night, the pu/pd is continuous, so doesn't appear to be due to a shorter than expected effect of the trilostane. We're going to send a urine sample for culture and sensitivity. I discussed referral if that comes back as negative, but the owner didn't sound keen, so we may then do a trial with DDAVP. I will discuss the possibility of other problems if this is due to a pituitary growth.

Re: pu/pd in a well controlled Cushings dog

Andrew Kent — Wed, 14 Jan 2015 08:29:03 GMT

And obviously keep an eye on these electrolytes etc just in case this is an upward trend.

Do keep us updated with what they decide to do

Andy

Re: pu/pd in a well controlled Cushings dog

Kate Richardson — Tue, 13 Jan 2015 20:13:39 GMT

Were the bloods run in house or sent away? I usually find K slightly higher when sent away due to leaking from cells so bear this in mind when interpreting Na:K

Re: pu/pd in a well controlled Cushings dog

Thomas Johnson — Tue, 13 Jan 2015 17:30:14 GMT

[quote user="Andrew Kent"]

I would be pretty happy with the current blood results so don't think you are over suppressing. Diabetes insipidus can certainly occur concurrently with HAC, usually due to a more sizeable pituitary mass pushing on the posterior lobe.

I would probably get a full Urinalysis and culture to exclude this being associated with infection as dogs with HAC commonly have occult UTI's.

Failing that you may either need to consider a DDAVP trial or, if the owners want to know more, a brain MRI.

Presumably the PUPD is pretty continuous? The other thing to consider would be short duration of action of trilostane if the signs are most pronounced in the 6 hours or so before dosing.

Andy

[/quote]

Thank you for your advice, I will speak to the owner and find out if the pu/pd is continuous, and will send some urine for culture and sensitivity. I suspect if these don't flag up any problems the owners would opt for a DDAVP trial rather than referral.

Re: pu/pd in a well controlled Cushings dog

Martin Atkinson — Tue, 13 Jan 2015 17:05:25 GMT

[quote user="Andrew Kent"]I am quite happy with much lower stims than this and expect a Na:K ratio of that kind of level in a dog on trilostane.[/quote]Past experience has taught me to be nervous with an Na:K ratio below 27 especially as the eosinophils are higher than I'd want. I bow to your greater experience/knowledge on the DI.

Re: pu/pd in a well controlled Cushings dog

Andrew Kent — Tue, 13 Jan 2015 16:56:46 GMT

I guess these things are a matter of opinion but I am quite happy with much lower stims than this and expect a Na:K ratio of that kind of level in a dog on trilostane.

[quote user="Martin Atkinson"]back off the treatment a little before you get excited about unlikely things like DI[/quote]

DI is pretty common in dogs with HAC especially with a pituitary macroadenoma so wouldn't call it an unlikely diagnosis.

Re: pu/pd in a well controlled Cushings dog

Thomas Johnson — Tue, 13 Jan 2015 16:51:54 GMT

[quote user="Martin Atkinson"]

My first thought was iatrogenic Addisons. Although that Na:K ratio is not dramatically low, I have one Addisonian dog I have to keep with a ratio of over 30 or it is subject to relapses. What time post dose are you doing your tests (I presume you know it should be taken 4-6 hours post dose and the patient not starved)? I would tend to err on the side of caution and contradict what Andrew says with a Na:K ratio of 26 and ACTH stim tests of 26 pre and 49 post ACTH and back off the treatment a little before you get excited about unlikely things like DI. After all it is going to go tits up a lot faster with Addisons than poorly controlled HAC or DI!!

[/quote]

The ACTH stim was done about 5 hours after the Vetoryl had been given and she hadn't been starved. The post ACTH cortisol has been lower in the past at 37.5, and the Na:K ratio has also previously been nearly as low at 27.39.

Re: pu/pd in a well controlled Cushings dog

Martin Atkinson — Tue, 13 Jan 2015 15:59:33 GMT

Re: pu/pd in a well controlled Cushings dog

Andrew Kent — Tue, 13 Jan 2015 15:25:39 GMT

I would probably get a full Urinalysis and culture to exclude this being associated with infection as dogs with HAC commonly have occult UTI's.

Failing that you may either need to consider a DDAVP trial or, if the owners want to know more, a brain MRI.

Presumably the PUPD is pretty continuous? The other thing to consider would be short duration of action of trilostane if the signs are most pronounced in the 6 hours or so before dosing.

Andy