Treating Cushings on a Budget

RE: Treating Cushings on a Budget

Kate Richardson — Thu, 09 Aug 2018 14:15:21 GMT

His skin might get better if you treat the HAC as he may get less secondary infections

Another thought- could he have calcinosis cutis due to the HAC?

RE: Treating Cushings on a Budget

Ella Massy-Greene — Mon, 06 Aug 2018 21:06:42 GMT

Hi James,

Thanks, I take your point. I agree that it has been quite a bit of workup so far given the cost constraints, but I have done what I could to minimise the price of services and had them get meds etc from a cheaper source.

I would not do this for most clients. However, these are my oldest clients, who tracked me down 5 or more years after I left my previous job. This is probably their last pet in their lives, they love him dearly and have done everything they can for him (including paying my bills without complaint and with a lot of appreciation). They did have pet insurance at one stage, but they cancelled it, unfortunately, either because the budget on an annual policy had run out (on the skin) or something else... I can't remember. We (as vets) see these sad cases all the time.

We'll find a way that works out in the end, I just don't want to see them undergoing more financial stress than they need to. I also don't want to see the dog suffer needlessly. I'm not generally a vet who takes on the burden of someone else's financial situation but there are always those exceptions!

Cheers,

Ella.

RE: Treating Cushings on a Budget

Anthony Dennison — Mon, 06 Aug 2018 18:43:53 GMT

At Bristol Vet School, when lectured on Cushings, one of the things I remember the lecturer saying was that if clients can't afford to treat the Cushings with Vetoryl etc, why treat at all and just focus on the secondary problems?

I've done that with a couple of older dogs, owners didn't want to treat so just managed secondary issues instead - skin flare ups, some biliary sludging etc.

RE: Treating Cushings on a Budget

Clive Ansell — Mon, 06 Aug 2018 16:04:12 GMT

[quote user="James Dunne"] Trying to figure out budget ways to treat diseases that are inherently expensive to diagnose, never mind treat, can be one of the most corrosive -and often unnecessary- stresses we bring upon ourselves. People who want good investigation and treatment done are often still not happy when a compromise option is provided such as trial medication or use of unlicensed or slightly less effective medicine. [/quote]

It shouldn't be.

How a client finances treatment, or if they are able too or not, should not be our concern. Our role is to advise what we consider to be the best way to manage a case. There could be a range of options of differing costs, but it is for the client to decide, and is ultimately their responsibility .

I tend to advise what I feel is best clinical practice and work back from that if costs are a concern.

In this case I would advise clients to treat and monitor as per data sheet. If they are unable or unwilling then they could trial therapy unmonitored being aware of the risks and limitations, just leave untreated, or pts.

Across my regular practices there are many treated unmonitored, and untreated dogs with Cushing's. I am not aware of any that have come to any harm or gone into an Addisonian crisis because of overtreatment.

RE: Treating Cushings on a Budget

James Dunne — Mon, 06 Aug 2018 09:11:17 GMT

This case sounds like it has had a lot of investigation and treatment already for people whose budget is tight. If we boil it down, here is a case where the owners cannot afford further investigation/ treatment, are ineligible for charity care but still want it provided - is that a fair assessment? If so, their choices are either don't investigate/treat, borrow money to investigate/treat, or consider euthanasia if there is a serious welfare issue present. Trying to figure out budget ways to treat diseases that are inherently expensive to diagnose, never mind treat, can be one of the most corrosive -and often unnecessary- stresses we bring upon ourselves. People who want good investigation and treatment done are often still not happy when a compromise option is provided such as trial medication or use of unlicensed or slightly less effective medicine.

RE: Treating Cushings on a Budget

Ella Massy-Greene — Mon, 06 Aug 2018 09:02:25 GMT

Hi Rob,

Thanks. I did cytology on his skin and malassezia wasn‘t a feature so have not so far not considered using anti-fungals as well at this point.

He was put on Apoquel by his other vet prior to seeing me without success, I think because of the pyoderma being untreated. They also gave him (not recently) a dose of depomedrol which also was unsuccessful.

It is something that I have considered, certainly for the future, but it’s another (somewhat) expensive drug on top of treating his cushings so I wanted to focus on that first.

Yes, the UCCR is only a screening test which supports my previous assumption so I do need to further testing to confirm. It is more the combination of clinical signs, dilute urine, blood results and the ultrasound which make make me think that he has HAC.

Many thanks,

Ella.

RE: Treating Cushings on a Budget

Rob Loxley — Mon, 06 Aug 2018 08:44:51 GMT

Sounds like a difficult case but a few thoughts: if there's still significant malassezia dermatitis then are some systemic antifungals e.g. itraconazole worth a try; isn't UCCR only really useful to exclude cushing's given its poor positive predictive value; is he on anything else for his skin e.g. Apoquel?

RE: Treating Cushings on a Budget

David Mills — Sun, 05 Aug 2018 23:59:09 GMT

Adrenalectomy is no harder than a bitch spay so we'll within the capability of a first opinion practice. Needs some perioperative care but most are discharged within 48h.

Addisons can be treated very easily with prednisolone alone.

Amoxclav is a poor choice for pyoderma unless used at twice normal dose, which makes it very expensive.

Most endocrins now recommend starting vetoryl at 3mg/kg not 2, so it needn't be that expensive.

Your other option with owner awareness is to forgo the testing and trial vetoryl. It is very very very difficult to make a dog Addisonian with vetoryl, about 40pc of dogs don't respond at all, it's a pretty crap drug all round.

RE: Treating Cushings on a Budget

Ella Massy-Greene — Sun, 05 Aug 2018 23:43:22 GMT

Hi Everyone,

Thanks for your replies. This is a complicated case as the allergic skin disease was severe a couple of months ago due to secondary infections... with severe pruritis and scaling, excoriations and lymphadenitis as a result of his terrible skin disease (confirmed at another vet with biopsy of 3 peripheral lymph nodes). This dog has been on ongoing treatment for his skin for years, so he definitely has allergic dermatitis. After a long course of amoxycillin-clavulanic acid (he has previously reacted to cephalosporins), and malaseb baths plus dermoscent oil and strict instructions not to feed any treats (he’s on anallergenic but they also feed him apples and pears!), the skin was improved but still lichenified, very scaly (down from extremely scaly) and most of the dog’s hair had fallen out, leaving him looking like a Chinese crested dog, although he has a ‘rats tail’. The severe pruritis had receded after the secondary infections were kept under control. (I admit I haven’t done a recent skin scraping, and if the pruritis hadn’t receded then I‘d be putting him on Simparica or Bravecto- demodex is still possible)

He had also lost 10% of his body weight in 6 weeks which was quite concerning... so I ran routine bloods which had multiple changes consistent with Cushings and normal T4. But the blood changes were maybe more than I’d expect for your typical Cushings, and the weight loss made me concerned about an adrenal tumour or something else going on. As a result of logistics (the owners live a long way from me and would not go to their local vet for the urine test), we did an abdominal ultrasound prior to running UCCR. We found bilaterally enlarged adrenal glands and liver changes consistent with a steroid hepatopathy, there was also a small lesion on his liver which has not been FNA’d or biopsied at this point. We now have the UCCR which was significantly raised (sorry no results currently to hand to give the exact numbers). The dog has now gained some of the lost weight back, which is good.

He is PUPD but this is ok with the owners. The main issue is that he has a ravenous appetite which then leads to his owners giving in to his begging (and he has severe food allergies)... leading to even more difficulty controlling his skin disease.

So he does have significant issues affecting his quality of life and causing owner expense. He looks terrible, not just the hair loss but also the skin itself.

As you can see, there has already been significant expense (we have been providing scripts for all his meds).

Unfortunately, I don’t think it’s an option not to treat this dog, as they will spend a lot of money just trying to keep the skin under control. I also think that the cushings (assuming he has it) only goes so far in keeping the pruritis under control, probably because it’s more food allergy than atopy.

I will definitely do a LDDST prior to treating, just to confirm, but I am quite confident given clinical signs, blood results, very dilute urine, ultrasound and UCCR.

I’ll try the charities again (we have in the past when his skin has been very badly out of control). Otherwise Ill talk to the owners about spending money on drugs and keeping a diary of his clinical signs so that we can minimise testing. His starting dose is 20mg per day, frustratingly quite a bit more expensive than 30mg per day, as the 10mg capsules are relatively expensive.

It did occur to me re bilateral adrenalectomy but not sure how that is cheaper unless the adrenalectomy is for free! It’s still not cheap to treat Addison’s Disease.

Thanks again,

Cheers,

Ella

RE: Treating Cushings on a Budget

Beats — Sun, 05 Aug 2018 20:03:06 GMT

Hi Ella,

My top tip for cushing's on a budget is not to test for it in first place :-)

Cushing's + atopy = money saved on steroids and vets fees ;-)

What are the owner's concerns (e.g. is the dog wetting in the house)?

What welfare concerns do you have for the dog (e.g. is it pruritic)?

What other historical findings or clinical signs are of medical interest, but of no concern to either the dog or the owner are present (e.g. bald)?

Not knowing the dog at all, if it's derm issues predominantly of concern, I'd give it a Bravecto most likely, but then we have a lot of fleas round here... and the fact it kills demodex etc also is nice. If it's piddling in the house that is the main issue then I'd see if a dog-flap would be suitable for both them and the dog, or some other affordable practical solution if possible.

RE: Treating Cushings on a Budget

Rob Loxley — Sun, 05 Aug 2018 19:54:53 GMT

[quote user="Robert FalconerTaylor"]Suggestion to keep costs down was remove adrenals and tx as addison's[/quote]

David Church didn't venture how much bilateral adrenalectomy and treatment for Addison's (and monitoring) would cost; I wasn't convince this is the way to go unless ADH with a primary unilateral adrenal tumor.

RE: Treating Cushings on a Budget

Robert FalconerTaylor — Sun, 05 Aug 2018 16:12:30 GMT

There was a lecture at BSAVA 2017 in the ...on a budget series I think. Suggestion to keep costs down was remove adrenals and tx as addison's.

RE: Treating Cushings on a Budget

Rob Loxley — Sun, 05 Aug 2018 08:57:40 GMT

[quote user="Ella Massy-Greene"]I am fairly sure that the dog has cushings disease[/quote]

I will always look to get a diagnosis before considering treating these. Agree that atopy and natural (as opposed to iatrogenic) cushing's make me wonder other things e.g. cushing's and demodex; atopy and not-cushing's.

We have a number of similar clients with little cash, general thoughts: consider whether treatment is really needed, write prescriptions (or reduce markup) to reduce drug costs, go easy on the dose to avoid side effects (though you there are still odd reports of adrenal necrosis) and accept non-perfect control, monitor on clinical signs foremost. We have a couple of tiny dogs and have looked into the BOVA trilostane liquid which isn't too pricey - certainly compared to 5mg Vetoryl specials from Dechra.

RE: Treating Cushings on a Budget

janine redman — Sat, 04 Aug 2018 20:11:47 GMT

If there is an underlying allergic skin disease then treating for Cushing may exacerbate the pruritic level of the dog by reducing the internal cortisol level.

RE: Treating Cushings on a Budget

janine redman — Sat, 04 Aug 2018 20:11:33 GMT

If there is an underlying allergic skin disease then treating for Cushing may exacerbate the pruritic level of the dog by reducing the internal cortisol level.

RE: Treating Cushings on a Budget

David Mills — Sat, 04 Aug 2018 19:40:45 GMT

Have they exhausted all charity options?

The PDSA have a low cost service with a wider range of benefits such as pension credit.You can also try Celia Hammond, they can be flexible I believe. The RSPCA used to see people on state pension too.

The main cost by far is the medication. It is perfectly acceptable to manage these without data sheet monitoring, on clinical signs alone. You will see that the pre pill cortisol paper also includes clinical signs as a major determinant of control.

Also, there is a very interesting ethical question at the heart of Cushings treatment. Does treating it actually improve the quality of life of the dog of just the owner (not cleaning up pee in the house, filling up water bowls) - it certainly doesn't lead to a longer life, despite what Dechra will tell you.

We leave most untreated.