addisons treatment

Re: addisons treatment

Sara Ramsey — Sat, 23 Jul 2011 18:22:25 GMT

Owner thinks thirst might be decreasing and nocturia definitely has, will check the calcium next time too.

Re: addisons treatment

Christopher Saul — Sun, 17 Jul 2011 00:32:29 GMT

How is her PUPD now she's off the pred? Results look pretty good ( though ideally Na:K should be in range 28-40; I don't get massively hung up about the ratio however if the absolute values are within range) .

One quick tip is that I generally check calcium along with elecs when I monitor addisonians; occasionally ( and for reasons that are not fully understood) you can get hypercalcaemia in these patients, though I would admit it's rare.

Chris

Re: addisons treatment

Sara Ramsey — Sat, 16 Jul 2011 22:34:02 GMT

if anyone is still following this thread my spaniels last blood results were:

Na 135 (135-150) Cl 99 (95-117) K 5.3 (3.5-5.6) N:K 25:1

I have weaned her off the pred and also added salt to her diet - quarter of a teaspoon per meal. I couldn't find recommenddations on how much to add.

Thanks for all the comments.

Re: addisons treatment

Martin Atkinson — Tue, 12 Jul 2011 10:44:54 GMT

I think it must be my age! Somehow I've got my wires crossed and have made the switch from considering the PU/PD as a possible iatrogenic Cushings as a consequence of over-supplementing the Addisons case with corticosteroid, into monitoring a Cushings case hence banging on about ALP/ALT & ACTH stim tests. Sorry. Still its given food for thought.

Re: addisons treatment

Charlotte Marshall — Mon, 11 Jul 2011 17:53:06 GMT

[quote user="David Beattie"]I'm not sure if predisolone/florinef cross-react with the modern cortisol assays used in labs (but I suspect they do to a degree - hence why dexamethasone is recommended by some for initial treatment in Addisonian crisis if no time to do ACTH Stim). [/quote]

I asked our lab about ACTH stim tests recently as I had a dog which had been on prednisolone which I was considering testing for addisons. They recommended being off prednisolone for 10 - 14 days before doing the ACTH stim test. they said if it was done sooner a normal test would rule out addisons but a low result would not confirm it. So they certainly feel the prednisolone could affect your result presumably by suppression.

Re: addisons treatment

Anonymous — Mon, 11 Jul 2011 17:28:51 GMT

[quote user="Martin Atkinson"]ALP & ALT, if these were rising then it would be useful to perform an ACTH stim test [/quote]

I agree is good to exchange ideas - that's the way I learn and challenge my current practice and I'm always happy to learn new approaches and ideas. It's sometimes remarkable when another vet describes their approach to a case and I initially think inwardly 'that's mental' and then later on realise it makes a lot of sense!

I still can't see the use in an ACTH Stim test, though. I'm trying to think about what the results might be and what I might know differently about the case based on them - if I can't explain the point of the test to the owner, then they're probably not going to pay for it! I think I'm right in thinking that both pre- and post-ACTH cortisol samples will be low either in the case of Addison's (OP hasn't commented if this was done prior to treatment or if diagnosis based purely on electrolytes and/or low basal cortisol in presence of clinical signs that would normally elevate cortisol) or iatrogenic Cushing's (due to adrenal suppression from the exogenous corticosteroids currently being administered). So if the cortisol results are low, surely we're no further on? In fact, I'd probably expect them to be low. I'm not sure if predisolone/florinef cross-react with the modern cortisol assays used in labs (but I suspect they do to a degree - hence why dexamethasone is recommended by some for initial treatment in Addisonian crisis if no time to do ACTH Stim). If they do cross-react, then the pre- and post-ACTH cortisol levels may not be low (or at least not as low as expected for diagnosis of Addison's)? I can't see how an ACTH Stim could help monitor a case of Addison's, and can't see how it would help advance the cause of the PUPD in this case either.

Incidentally, I'm also rather skeptical on the benefit of a 'complete ACTH Stim' for monitoring treatment of Cushing's disease. I only tend to adjust my dose of trilostane based on the post-ACTH cortisol result - so why pay for a pre-ACTH cortisol assay also in these cases? Anyone else think this, or anyone enlighten me on what difference the pre-ACTH cortisol result makes when monitoring Cushing's?

Re: addisons treatment

Martin Atkinson — Mon, 11 Jul 2011 08:55:28 GMT

[quote user="David Beattie"]

Even if there weren't cost considerations, I can't see the point to currently doing an ACTH Stim and ALP?

I don't see the logic in spending money on a cortisol/creatinine ratio either, even if it is cheaper than blood tests...

[/quote]

I wasn't suggesting a belt and braces approach or saying that's how I'd do it, merely suggesting some other monitoring that maybe the OP hadn't considered. If the OP is monitoring BUN & Crea then the chances are they're performing a blood profile that would also give ALP & ALT, if these were rising then it would be useful to perform an ACTH stim test or a urine cortisol:creatinine ratio not necessarily both, the latter should rule out iatrogenic Cushings or rule in the need for further monitoring/investigation. I'll admit I have not used a UC:C ration to monitor Addisons, I just wondered about the usefulness in this case. This the point of this forum - to exchange ideas.

Re: addisons treatment

Anonymous — Sat, 09 Jul 2011 17:46:27 GMT

[quote user="Martin Atkinson"]

I would do an ACTH stim test, ALT & ALP, and monitor phosphate - for renal function not just for the Addsions, as well as monitoring electrolytes, although I appreciate this may be limited by cost considerations. With USG that low, how about a UP/C ratio for renal disease and a cortisol/creatinine ratio - its cheaper than blood tests..

[/quote]

Even if there weren't cost considerations, I can't see the point to currently doing an ACTH Stim and ALP?

Results: Low cortisol pre- and post-stim; ALP high.

Conclusions: None

I don't see the logic in spending money on a cortisol/creatinine ratio either, even if it is cheaper than blood tests...

Re: addisons treatment

Anonymous — Sat, 09 Jul 2011 17:38:06 GMT

I think knowing lab values would be helpful. As far as I see it, the current problem seems to be PUPD, with the main differentials being:

Hyponatraemia (from insufficient mineralocorticoid supplmentation in an Addisonian dog)
Excessive glucocorticoid supplementation in an Addisonian dog (or a dog thought to have Addisons without an appropriate ACTH Stim test etc...)
A condition unrelated to corticosteroids (e.g. renal disease, hypercalcaemia).

I'd agree with previous posters that, at a guess, option (2) sounds most likely and I'd taper to every other day prednisolone and continue tapering if the dog continued to be clinically well - up to 50% of Addisonian dogs on florinef don't need prednisolone supplementation from what I read. In the event that the preds had been discontinued and xss glucocorticoids still seemed to be the problem, then I guess the options are switching florinef to DOCP (not sure how readily available or affordable) or using the lowest florinef dose to provide sufficient mineralocorticoids and living with any resulting PUPD.

Hyponatraemia could also be responsible / a factor - you say that there was room for improvement in the last electrolyte measurements? Your increased florinef dose should help here, but a couple of weeks of dietary NaCl supplementation couldn't hurt, especially if PUPD has caused medullary washout.

Your dose of florinef doesn't sound excessive: In a study of 190 Addisonian dogs, doses of 0.01-0.08mg/kg/d were required for control, with the required dose increasing over time. (Kintzer & Peterson, 1997) And twice daily dosing is fine if helps.

Kintzer P.P., Peterson M.E. (1997) Treatment and long term follow up of 205 dogs with hypoadrenocorticism. Journal of Veterinary Internal Medicine 11:43.

Re: addisons treatment

Rob Davis — Sat, 09 Jul 2011 14:50:27 GMT

I have a 30kg Addisonian labrador which is on 1.4mg florinef SID, any lower than this and the electrolytes start to shift. He also has 1.5 teaspoons of salt on each meal. He has been stable on this for some time. I agree with others that you usually do not need to continue prednisolone beyond the initial stages of treatment, and would want to gradually get him off this before investigating other causes of pupd.

Re: addisons treatment

Mark Hedberg — Sat, 09 Jul 2011 13:35:47 GMT

We have an addison's dog here too; no preds, just florinef.

Re: addisons treatment

Clive Ansell — Sat, 09 Jul 2011 13:15:14 GMT

That would be my thought too; off preds and minimum possible florinef dose based on serum electrolytes and clinical signs. I normally take off preds once stabilised.

Re: addisons treatment

Sara Ramsey — Sat, 09 Jul 2011 12:36:44 GMT

thank you, I did wonder about stopping the pred and also treating the dog and not the lab figures is always something to bear in mind.

Re: addisons treatment

Mark Holmes — Sat, 09 Jul 2011 11:29:14 GMT

I have one addisonian dog in particular that if you believ the Na:K ratio would increase the florinef dose. If you do so he gets worse pu/pd etc and I then reduce it again. He is happy with an NA:K of 25ish and so therefore am I! That said he is also not taking pred, mostly you can get them off pred once stabilised and rely on the corticosteroid effect of florinef.

My experience os addisons is that it is very easy to manage, all mine are on zero pred and the formulary suggested dose of florinef with minor alterations. If your doses seem to be creeping up I would be careful you're not overcooking the goose. 12 years is quite old to present with addisions, all mine have been young to mid aged so it might be worth a revisit of diagnosis if any doubt.

Re: addisons treatment

Martin Atkinson — Sat, 09 Jul 2011 11:21:34 GMT

You stated that, 'she was on 2.5mg prednisolone'. Is she still on that? I have never found the need to give corticosteroids for Addisons cases so that may be your source of PD/PU. Otherwise I would be more concerned that PD/PU was a symptom of overdosing and turning this into an iatrogenic Cushings, or even concurrent renal disease. That said their dose requirement can increase with time, one little dog I've been treating for several years is on double recommended starting dose. I would do an ACTH stim test, ALT & ALP, and monitor phosphate - for renal function not just for the Addsions, as well as monitoring electrolytes, although I appreciate this may be limited by cost considerations. With USG that low, how about a UP/C ratio for renal disease and a cortisol/creatinine ratio - its cheaper than blood tests..