Question: I have a Dalmatian with Addison's disease. She gets a shot of percoten once a month and is doing very well. The cost of her shot has just gone up to $115.00 a month. Is there any way I can get this medication on my own and administer it? I am disabled and the expense is getting to be a real problem for me. The idea of putting her down is very disturbing to me especially since she has done so well with the treatment. Thank you, Irene
It may be a lot less expensive to treat with fludrocortisone IF you are willing to use a compounding pharmacy to obtain the medication and can afford to pay for some additional testing early on to make sure it works OK for your dog (monitoring potassium and sodium for a few weeks). There have been reports of compounded fludrocortisone not working as well but it is a lot less expensive and it appears to work for many dogs. You might ask your vet to check into this option for you, especially since the lower long term cost seems potentially critical to your Dalmatian's survival in your situation.
I do not know of any way that you could obtain Percorten-V legally for administration yourself in the U.S. Florinef (Rx), the brand name version of fludrocortisone is usually more expensive than Percorten-V for large dogs so it is unlikely that a change from one brand name to the other will be helpful.
There are a number of veterinary compounding pharmacies and many communities have a compounding pharmacy in them (ours does) that usually will work with veterinarians.
Mike Richards, DVM
Diagnosing hyperadrenocorticism (Cushing's) and hypothyroidism (Addison's)
I am a new subscriber and have been reading your ques/answers for a couple of weeks now. I am really impressed with the personal and in-depth information you provide. We have a twelve and a half year old pet, half German Shepherd half Golden Retriever, Princey by name. Princey has always been healthy with few health problems. Since the last few months, he has been drinking and urinating excessively. He has become almost completely bald at the collar area and has lost a lot of hair around his stomach area and a patch on his back, a little above his tail. His skin is dry and flaky, like dandruff. On the back area, near his tail where he has lost hair he has little raised bumps. We took him to his regular vet a few times but he said it was just old age, he took some x-rays as Princey's back legs seem to be bothering him, it takes him longer to get up. X-Rays showed slight arthritis. Around the middle of March, he was given steroids for two weeks and an aspirin a day. He finished his course of steroids and was on aspirin until April 20th. We have given him aspirin only twice after that. I don't like to put him on any medication until I am sure it is necessary and will not harm him but at the same time want to make sure he gets whatever he needs to get better. After reading your columns, we took Princey to a different vet on May 7th, as I was afraid Princey showed all the classic signs of Cushings. The new vet who seems to know a lot about Cushings, unlike the first one, examined Princey and did a urine and blood test. The urine test had a reading of one, which she said was very dilute but showed no trace of diabetes. The blood test, the vet said shows no sign of Cushings, she has asked we do a water deprivation test to rule out diabetes insipidus. She also said his thyroid levels are low and that could be causing the hair loss and skin problems and that we could put him on a thyroid supplement if his hair loss is bothering us but that it is not absolutely necessary at his age. Your column says though that sometimes blood tests are inconclusive for cushings. Also, will it hurt to put him on thyroxine if that really is not the problem? Does it have any side effects? Will it aggravate any other condition he might have, like Cushings or diabetes insipidus? Do you think we should push for more testing to rule out cushings? Is there any kind of skin test we can do? Dr. advised us to put aloe on his skin. His blood test results were all within the normal range except for these -
neutrophils 84 (normal 60 - 77),
lymphocytes 6 (normal 12 - 30),
lymphocytes absolute 570 (normal 690 - 4500),
alk phos 199 (normal 5 - 131),
GGT 24 (normal 1 - 12),
cholesterol 360 (normal 92 - 324),
BUN 10 (normal 6 -25),
creatinine 0.5 (normal 0.5 - 1.6),
BUN/Creat ratio 20 (normal 4 -27),
T4 RIA 0.42 (normal 1.0 - 4.0),
FREE T4 (RIA) 0.38 (normal 0.65 - 3.00),
uantitative platelets 448 (normal 70 - 400).
His AST(SGOT) was 29 and ALT (SGPT) was 70. The vet said his results were all okay for his age and that if he had cushings his alk phos levels would be markedly higher. Any input from you will be greatly appreciated as I am very worried about Princey and would like to get him back to his old self as soon as possible.
Thank you, padma
Answer: Padma -
There are a lot of things to consider with the information that you have so far.
It is not possible to diagnose hyperadrenocorticism (Cushing's disease) based on the results of a standard blood chemistry examination nor is it possible to rule it out based on these results. It is true that many dogs with Cushing's disease have elevations in the alkaline phosphatase levels in their serum, but many do not, as well. It is necessary to do some sort of specific testing in order to try to rule in or rule out the Cushing's disease. The most commonly recommended test is a low dose dexamethasone suppression test (LDDS). This test takes most of a day to run. A blood sample is drawn early in the morning and immediately afterwards dexamethasone is administered intravenously. In four hours a second blood sample is drawn and after 8 hours a third blood sample is drawn. The cortisol levels of the samples are compared. If Cushing's disease is not present, the cortisol levels should go from normal levels to very low levels (they are suppressed). If Cushing's is not present, the cortisol levels remain high after the injection of the dexamethasone. An alternate test is the ACTH response test. This test is less sensitive to the presence of Cushing's disease but can be run much more quickly, making it more convenient at times. To do an ACTH response test, a blood sample is drawn any time during the day and then a hormone, adrenocorticotropin (ACTH) is administered. An hour later (two for some ACTH preparations) a second blood sample is drawn. If the results of the second sample show markedly elevated levels of cortisol, it indicates that Cushing's disease is present. There are other tests that help to determine what type of Cushing's disease is present but one of these two tests is a good idea to determine if Cushing's disease is present.
It is pretty important to know if Cushing's disease is present, prior to trying to decide if hypothyroidism is actually present. The reason for this is that the presence of almost any other disease can cause the thyroid levels in the blood stream to drop. Therefore, it is hard to test accurately for hypothyroidism in a patient who has a problem like Cushing's disease. If Cushing's disease is present and can be treated for, then it is possible to more accurately test for hypothyroidism. In some cases, especially when there is only a partial response to treatment for Cushing's disease, it may be necessary to go ahead and treat for hypothyroidism without being certain if it is present. Fortunately, it is relatively safe to supplement thyroxine in a dog, even if they don't actually have hypothyroidism. It is better to work to be sure that a life long supplement is necessary before giving it, whenever possible, though. Hypothyroidism can cause increased drinking and increased urination in some patients and the hair loss can also occur with either disease, so it is entirely possible it is present and that it is the sole problem, but increased drinking and urinating are much more common with hyperadrenocorticism.
I sometimes have a hard time asking a patient to spend money on Cushing's disease tests because in our practice, I am pretty sure that of the dogs I test, only about 25% of them actually have Cushing's disease and the tests only help determine one thing -- if Cushing's disease is present or not. However, since there isn't any other way to determine if the disease is present and since it is important to both the dogs that have it and those that don't to know what is going on, I know that it is necessary to do the testing. I really do think that I would want to know if Cushing's disease was present with the clinical symptoms that Princey has. So I do recommend asking your vet about futher testing.
Good luck with this.
Mike Richards, DVM
Addison's disease or Heat stroke death
Question: One of my questions relates to a 2 year old mastiff that I lost recently. He died within 24 hours of being at a kennel (1st time I had my dogs at a kennel). The autopsy said he died of heat stroke. His body temp. when the vet arrived at the kennel was 109 degrees. The kennel employees were not there when the dog collapsed and suspect that he may have been down for about 5 m in. The kennel also admitted that they were dumb-founded when it occurred and hesistated to call the vet and instead called our housesitter and our manager at our business to see if he had a preexisting condition. The reason I mention this is because they said it probably took about 25 min for them to administer 1st aid to my dog. They are claiming that although it was a very hot and humid day, they did not have my dog outside that long for him to have a heat stroke. The vet tech who arrived at the kennel stated that it was very warm inside the kennel also. I guess I'm trying to learn more about heat stroke to make sense of this. I looked up on the internet and it mostly talks about dogs being kept in cars. Could mastiff's be more susceptable to heat stroke? Also, our dogs are not kept outside and are exercised during cooler temp versus exposing them to extreme heat. Zeus was on Metronidazole , 500mg., for an upset stomach the week prior to his death. The autopsy showed that Zeus was in excellent health and his organs were normal. They did note that his adrenal glands were smaller than expected for his dog's size. His behavior prior to his death on that date according to the kennel that he was playing happily with our 2 other dogs, had a good appetite, and seemed to be happy as indicated by his tail wagging and affection. My particular quesitons are: 1) HOw long does it take for a dog's temp to reach 109 degrees (at the vet the week before his temp was normal). 2) HOw soon should a dog be cooled down when collapsing? Could cooling him down saved his life? 3) Could the medication predispose him to a heat stroke (he took the doses recommended and was off it already for 2days). 4) Did his smaller adrenal glands cause him to have a heat stroke?-- I apologize for asking questions that may not have exact answers. I'm trying to learn as much as I can so to further prevent another death and to educate myself about dog safety. I also need closure to my buddies death and hope time and more information may help. Thank your for your time and invaluable service. Angela
Answer: Angela -
There are two strong possibilities with the situation you describe. The first one is that your dog simply had heat stroke and that all symptoms and his death were related to that. The second is that he had hypoadrenocorticism, or Addison's disease, which can lead to sudden death without any other predisposing cause and also makes almost any other stressful condition much worse. So I'm going to divide this answer into two parts, one to cover the heat stroke and one to cover the Addison's disease to some extent.
Heat stroke in dogs is not all that uncommon. Dogs do not have an efficient method of handling heat stress because they don't sweat and they don't seem to figure out that they shouldn't get excited or work hard in the heat, either. Heat stroke is most common in the large breeds and in dogs with short noses, so mastiffs are in the group of dogs that are most susceptible to this problem.
Death from heat stroke can occur pretty quickly. The shortest interval between exposure to high heat extremes and death is about 20 minutes, based on our practice experience, but these have been "closed car" cases. It is probably more common for dogs to experience heat stroke in the first few days they are acclimating to heat and for it to occur in conjunction with excitement or exercise. Most dogs probably take an hour or more to develop heat stroke in these circumstances but if they were struggling with the heat prior to exercising it is possible that the problem could develop more quickly. Any illness that is contributing to an increase in body temperature can also shorten the time period for signs to become severe.
The most common clinical signs of heat stroke are weakness, loss of balance, excessive panting, roaring breathing sounds, excessive salivation, decrease in mental awareness, collapse and death. Any time that heat stroke is suspected it is best to get an immediate rectal temperature reading and to begin treatment immediately if the body temperature is over 106 degrees Fahrenheit or to stop all activity and move indoors if the temperature is less than this but elevated above 103.0 degrees Fahrenheit. Body temperatures over 107 degrees Fahrenheit are a critical emergency, because organ damage can occur at this temperature and at higher temperatures.
Treatment consists of cool water (not cold water) bathes or rinses. If the water is too cold, or if ice is used to cool a heat stroke victim it can cause a decrease or loss of skin circulation, which can delay cooling. This should be done immediately for a few minutes and then the dog should be taken to the veterinarian's office or to an emergency veterinary clinic immediately. Most dogs will not drink water at this stage of heat stroke and it is not a good idea to spend time trying to get them to. Just go to the vet's as quickly as possible. The veterinarian may want to use cool water enemas, cool water gastric lavage (rinsing of the stomach), corticosteroids and specialized intravenous fluid therapy using colloids to maintain blood pressure. If there is any evidence of disseminated intravascular coagulation (DIC), intensive therapy for several days may be necessary if a successful outcome is possible.
Immediate treatment is critical to success when dealing with heat stroke, so delays are potentially harmful, or fatal. Many people do not associate the clinical signs they are seeing with heat stroke, though. Especially when their level of suspicion is not high. We have seen heat stroke in dogs who were swimming or who were merely excited but not obviously exercising hard, situations in which people often do not make an association with heat stroke. We have even had one bulldog patient who developed heat stroke in the house, with the air conditioning on, apparently because he became very excited about guests at the house for a party.
So heat stroke could easily be the whole problem.
On the other hand, small adrenal glands can be a sign of hypoadrenocorticism, or Addison's disease. In this disease there is a deficiency in the production of corticosteroids and mineralocorticoids (regulate electrolytes in the body). Patients with Addison's disease often have very vague signs of illness that is often chronic. Often these signs are vague enough that owners don't recognize them or don't seek treatment for them. The range of signs is large, but includes intermittent decreases in appetite, or dogs with a generally poor appetite, vomiting, diarrhea, muscular weakness, depression or lethargy, slow heart rates, increased drinking and urinating, cardiac arrhythmias, unexplained shock and sudden death. Most patients probably only have one or two of these signs at any given time and will never develop all of them.
Patients who respond poorly to stressful situations and especially patients who die from stress that most patients have no trouble handling are likely candidates for Addison's disease. It is likely that most veterinary patients with Addison's disease are diagnosed by accident when blood is drawn for other reasons or have their Addison's disease diagnosed only after a poor response to a stressful situation, such as their first surgery or a traumatic incident. Unfortunately, if they do progress to severe shock or death quickly, the diagnosis may not come in time.
I know of no link between the use of metronidazole and heat stroke, except that metronidazole can cause vomiting or diarrhea and any amount of dehydration induced by these conditions would lead to an increased possibility of heat stroke. I have not heard of any problems with the use of metronidazole in patients with Addison's disease. Overdosages of metronidazole (not likely at the dosage of 500mg once or twice a day in a mastiff) can cause slowing of the heart rate and that might make the slow heart rate associated with Addison's disease worse.
It is not possible at this point to really tell you if Addison's disease contributed to your mastiff's death but it does seem like it could have. On the other hand, prompt treatment for the high body temperature, along with intravenous fluid therapy, might have corrected both problems sufficiently enough to allow your dog to live through the crisis. Whether that would have actually helped enough is not certain, but it is definitely possible.
It is really hard to find yourself dealing with the loss of a pet when the loss seems unnecessary or partially due to human error, but we really are all susceptible to making bad judgments and once that process starts it seems to just induce further bad judgments in a vicious cycle, in some cases. Hopefully, the folks at the kennel will learn from this experience and use the information to prevent a future occurrence, someday --- or at least to get treatment promptly if they see these signs again.
It is very helpful if you spell out what you want done in an emergency with any kennel you may deal with in the future. It also helps to figure out transportation plans for a pet to get from the kennel to the veterinary hospital, when necessary. Having a friend who is willing to be "on call" can really help. Getting directions from your vet for what to do after hours and on weekends or holidays is important, too. If the kennel ever needs to take a pet to the emergency clinic, or make arrangements for the pet to get there, it can help a lot if it is clear that you want them to do that and if you have left a deposit to go towards emergency veterinary care, if you have reason to suspect it might be necessary.
I hope that this information is helpful to you. It is so hard when a young pet dies unexpectedly, especially when it wasn't possible to be with them to make all the decisions that had to be made.
Mike Richards, DVM
Addison's disease (Hypoadrenocorticism)
Addison's disease is also known as hypoadrenocorticism. It is an insufficient production of adrenal hormones by the adrenal gland. Since these hormones are essential for life, this is an extremely serious disease and it must be treated as such.
Adrenal insufficiency can be primary or secondary. Primary adrenocorticism affects salt/potassium balance in the body and glucorticoid as well. Secondary adrenocorticism usually only affects the glucocorticoids. It is not known why primary adrenocorticism occurs but it may be an immune mediated process. Secondary adrenocorticism probably occurs most often when prednisone or other cortisone being administered for medical reasons are suddenly withdrawn. It can occur as a result of pituitary cancer or some other process that interferes with production of hormones that stimulate the adrenal glands.
Most dogs with Addison's disease initially have gastrointestinal disturbances like vomiting. Lethargy it also a common early sign. Poor appetite can occur as well. These are pretty vague signs and it is extremely easy to miss this disease. More severe signs occur when a dog with hypoadrenocorticism is stressed or when potassium levels get high enough to interfere with heart function. Dogs with this problem will sometimes suffer severe shock symptoms when stressed, which can lead to a rapid death. When potassium levels get high heart arrythmias occur or even heart stoppage which also is fatal. In some cases, especially secondary Addison's disease, there are no detectable electrolyte changes.
This disease can be picked up by changes in the ratio between sodium or potassium by accident at times. When this happens it is still extremely important to treat for it. It is confirmed by an ACTH response test -- administration of this hormone should stimulate production of adrenal hormones. If this does not occur then hypoadrenocorticism is present. In cases in which the electrolyte levels are normal this is the only test for the problem and it will be missed unless it is looked for specifically. At times this disease can be hard to differentiate from renal failure because the symptoms and even the bloodwork can be similar ---- so the ACTH response test may be necessary to differentiate them.
Treatment for this disease is usually done by oral administration of fludrocortisone acetate (Flurinaf), salting the food, and administration of corticosteroids like prednisone. In a crisis situation this disorder must be treated more aggressively with intravenous fluids, IV glucocorticoids and correction of acid/base balances.
You have to pay close attention to a dog with this problem. Don't ignore any changes in appetite, GI disturbances or anything else that makes you think your dog is ill. If you work with your vet and are careful about following his or her directions this disease has a good prognosis when it is discovered before a crisis occurs.
Mike Richards, DVM
Kidney problems from Cushing's treatment, Addisonian state
In early Oct. my 141/2 yr. old neutered male doxie was diagnosed w/Cushing's Disease. He had all the customary testing i.e. Dex suppression tests etc. and the test indicated Pituitary Dependent Cushing's. The vet elected to start him on Lysodren.
He was admitted after finishing a 5 day course of this drug with vomiting and increased diarrhea-he also has colitis and hypothyroidism so some diarrhea was normal- but this was worse. The vet kept him on fluid therapy for 2 days before doing labs. On the second day he ordered a chem panel and found that his "kidney's were failing". This suprised me as his Bun was only slightly elevated before initiation of Lysodren therapy and his Creatinine had been normal.
He kept him on fluid for another 48 hrs and his kidney values improved only slightly-BUN down to 112. He was discharged to my care on a low protein diet and PO4 binders.
We repeated labs a week later and BUN was up to 128 and urine tests showed he wasn't concentrating his urine. I was told that Darcy was entering ESRD and that the prognosis was not good.
My vet was opposed to giving subq fluid but as I work in a hospital and have access to the equipment and had friends with training help I started giving him 200ccs of fluid every other day. In addition, I started him on 5mgs of Pepcid in the morning.
Initially he was very weak, thin and had lost a great deal of muscle. Very soon his appetite improved, he gained wt and got stronger. He went from 14.25lbs to 16lbs now.
He's had labs repeated and on 11/1 is BUN was 128, 11/19 BUN was 56, 11/19 BUN was 56, 11/26 BUN was 57, 12/2 BUN was 59 and Creatinine was 1.7. His last labs were done on 12/30 and showed a BUN of 21 and a Creatinine of 1.2. Darcy did have a bout of pneumonia in November due, I believe, to aspiration of the liquid aluminum hydroxide I was giving him by syringe. He responded well to the antibiotics and his WBCs were normal on his last CBC. I have since found an aluminum hydroxide product in tablet form so I no longer risk using the liquid.
I should also add that Darcy was started on Epogen because of low PCV. This has improved enough so that I have cut way back on the Epogen for fear of increasing his PCV too much too fast.
My questions are:
When should I next have him tested? My vet is sometimes reluctant to do labs -and I don't need unnecessary expense-taking the leave well enough alone approach but Darcy's made such good progress I don't want to let anything realistically treatable slide. What is a responsible schedule for testing and rechecks while all is going well?
Is it possible that his kidney's were so "insulted" by the Lysodren that they failed but by so aggressively supporting them we've allowed them to recover? Could it be that this is not primary kidney disease after all and that if I get him through this he will no longer have kidney disease? I've read that kidney disease is not reversible and is always progressive. What could account for the improvement in his lab values?
What do I do about the Cushing's Disease? We've all but forgotten about that during the this time and I certainly don't want to put him thru any more Dex tests. Would Anipryl be risky? His hair has almost all come back since the Cushing's diagnosis and his water consumption and peeing are normal when you consider the subq fluid. He used to get me up 3-4 times per night to drink and pee and now usually sleeps thru the nite.
He's started itching lately. I know there are may possible causes but do you have any suggestions? The vet prescribed Atarax but that caused agitation and disorientation and I stopped it. He's on so many meds that I don't know how to distinguish between and allergic rxn and a skin disease. I don't see anything abnormal but there are some rough spots on his chest. I've read about a condition called calcinosis cutis-Darcy takes calcium carbonate on an alternating basis w/ the aluminum hydroxide as PO4 binders-could that be the cause? If it is ,is the condition dangerous?
Sorry for going on so long but I love this dog alot and have worked very hard to get him through this. I'm afraid I'll overlook something simple. I know he won't live forever but I do want him to have as much quality time as possible. Other than these recent catastrophes, he's been doing remarkably well and enjoying his life.
Thanks for your help. Donna
Answer: Donna -
I think that there is a good chance that the kidney problems were due to the treatment for Cushing's disease. Approximately 5% of dogs treated with mitotane (Lysodren Rx) develop side effects consistent with hypoadrenocorticism (Addison's disease). This requires supplementation with either glucocorticoids or mineralocorticoid medications to prevent adverse effects, including kidney failure. If there was an Addisonian state induced by the use of mitotane there would be a good chance of recovery with fluid therapy and time, as the damage to the kidneys tends to fall more into the "one time insult" category rather than into a chronic progressive kidney disease category. As the adrenal glands recover from the effects of Lysodren over time, they will produce corticosteroids again in most, but not all, dogs. When this happens you will see the same signs that were present previously, such as increased drinking, increased urination, hair loss, thinning of the skin, muscular weakness, etc. It would be necessary to consider treatment again at that time. There is some chance that the current itchiness is due to calcinosis cutis, a secondary effect of Cushing's disease, but it would be good to rule out a secondary bacterial infection since there was a period when it is likely that your doxie's immune system wasn't working very well. If there was no response to antibiotics it may be necessary to think about administering corticosteroids. This seems really odd to think about in a patient suspected of having Cushing's disease, but it is not uncommon for suppressed allergies or other conditions responsive to corticosteroids to surface after treatment for Cushing's disease. The reason is that the dog was producing high levels of corticosteroids due to the disease, which was masking other symptoms. There would likely be a time when the symptoms would be suppressed again by natural recovery of the adrenal glands.
All of the above is based on the assumption that an Addisonian state was induced by therapy for Cushing's disease. The only way to really know if that happened is to do ACTH testing to determine if there is a response to the administration of ACTH. If a baseline blood sample is drawn, then ACTH administered (stimulates the adrenal gland) and blood drawn an hour later shows no response to the hormone, then it is very likely that the Lysodren completely wiped out the ability of the adrenal gland to produce cortisol, at least temporarily.
I understand why you might not want to do testing, especially now when things have improved so much. It would be necessary to do some type of testing prior to considering starting Lysodren again. It would be possible to start selegiline (Anipryl Rx) without further testing and to monitor clinical signs rather than lab values to assess success of therapy. At the present time the best study that I can find suggests that Anipryl is very effective in about 20% of the cases of hyperadrenocorticism and moderately effective in another 20%, so you would have to accept that the odds of success are less than 50%. You can always go back to Lysodren, or elect not to treat for Cushing's disease, if desired. If you do go back to Lysodren it would be probably be best to do ACTH testing shortly after starting treatment (maybe 72 hours) and then on frequent intervals until a maintenance dosage of Lysodren could be established. In any case, doing ACTH testing at the first sign of loss of appetite or vomiting would be a good idea.
I am hopeful that Darcy has continued to show progress in the kidney values and that it has not been necessary to adminster Epogen (Rx) again. I am glad that you went ahead with fluid therapy, as it almost certainly helped in his recovery. I don't think it is necessary to continue the fluid therapy at this point if he has had another good test for kidney values (BUN < 30, Creatinine <1.5).
Mike Richards, DVM
Addison's in Dobie
Question: Our 10 year old Dobie was diagnosed at Auburn University 2 months ago with Addisons Disease. Prior to the diagnosis and treatment she dropped over 10 lbs in weight. Since that time, our local vet has done complete bloodwork every 2 weeks. Since she was at Auburn, she has gained 17 pounds (from 49 to 66). She gained 11 pounds in 1 week after she came home from Auburn, as we were feeding her canned Canine Maintenance, (4 cans a day). Aftr she gained all her weight back, we put her on Dry Canine Mainenance. She has been on Dry food for over one month. She gets a small ball of canned food each morning with her Prednisone (5 mg daily). She also gets an injection of the hormone necessary every 24 days. Her Potassium and Sodium appear to have stabilized. And more importantly, she is back to her old (very active) self. Since the beginning of the treatment the Vet has taken blood work to establish the correct dosages. However, the blood work has shown another potential problem: Her triglicerides and Lipace are extremely out of line. Her chart is:
4/27 Triglicerides 454 Lipase 822 (Not Fasted)
5/4 Triglicerides 132 Lipase 832 (Not Fasted)
5/25 Triglicerides 67 Lipase 927 (After fasting for 12 hours)
6/7 Triglicerides 2,955 Lipase 1,021 (Not Fasted)
Today we had another test performed after fasting and the blood looked normal, however, our Vet appears stumped and very concerned. He wants our Dobie to go back to Auburn for more testing. He suggess Hypo Thyroidism, Pancreatitis, and any other thing he can think of. He is trying to help, but we would like your opinion. Please help.
Fasting can make a HUGE difference in the level of triglycerides in the blood stream. Therefore, I tend to think that the triglyceride levels going up and down as they have is probably just the difference between fasting and non-fasting blood levels. However, it is reasonable to check for hypothyroidism in a 10 year old doberman since the disorder is reasonably common in this breed.
I can truly understand why your vet feels that the triglyceride levels must indicate a problem. I have been really really surprised at the difference between fasting and non-fasting samples for this particular lab value. Until you run across one of these patients it is hard to believe it could change that much just due to a meal.
The lipase levels are more confusing. Lipase levels elevate most commonly with kidney disease, dehydration affecting the kidneys and with pancreatitis. My first instinct would be to think about dehydration in a patient with Addison's disease, since patients with this disease may have subclinical dehydration when they are not quite stabilized. I do think it would be worth talking to the vets at Auburn about this possibility, or at least to report that the lipase levels are elevated.
Chronic pancreatitis is possible but it sure doesn't sound much like it is a problem with all the improvement so far.
I think you'll find that there isn't a serious problem underlying these lab values, except perhaps a small amount of need for thinking over the regulation of the Addison's disease and monitoring for kidney problems as time goes on. However, I really do think that you should check back with the vet that handled your dobe's case at Auburn, or ask your vet to do that, to discuss the increase in lipase.
Good luck with this.
Mike Richards, DVM
Hypoadrenocorticism (Addison's disease) considered in surgery for tumor
Q: dr. mike, I have written to you on several occasions about our pitbull with Cushings and her first stimulation test,etc. which was 1 and 1. They are going to do another stimulation test before giving her anything else. but this same dog has other problems as well. She has had a growth going on in her L hind leg for at least a year. Our local vet referred us to K-State for this after aspirating it in several different places and finding nothing but fat, rbc's, wbc's, etc. as she has a hx of having skin mast cell tumors. K-State also aspirated and found pretty much the same thing as our local vet. But they feel that surgery needs to be done as it just keeps getting bigger and causing her problems. My question is: Since this dog has Cushings and this disease tends to cause muscle weakness, and the heart is considered a muscle, what is your opinion of testing that should be done before she undergoes anesthesia, and so forth? Should she have an US of the heart? Or just routine EKG's? This dog will be 10 years old 10/19/99. Also the mast cells that have been removed on her has actually been once. Other growths removed were mainly of some other consistency. Also what should her ACTH stimulation tests run before she undergoes surgery? If her stimulation test that she will have done tomorrow does not come back any higher, or lower than the first one ( 1 and 1), will it be safe to go ahead with this surgery on her leg?
thank you for your time, R.
A: R I am very uncomfortable doing surgery on a dog with hypoadrenocorticism (Addison's disease), which I think is the current state that your pitbull is in, based on the lab tests. Surgery is a stress and hypoadrenocorticism reduces the body's ability to handle stress. So I would tend to be very cautious about going ahead with surgery prior to fully understanding the hormonal status. Hopefully the most recent ACTH stimulation test will help to clear up that issue. If her heart sounds normal and she has a normal ECG it is probably not necessary to do cardiac ultrasound exam but if it makes you more secure to have it done there isn't a reason not to do it, either. It is important to have a lab panel with electrolyte levels prior to surgery in a patient who may have hypoadrenocorticism. It is necessary to place an IV catheter and run saline solution during the surgery as this helps to keep potassium levels normal, which is important in patients with hypoadrenocorticism. It may be necessary to supplement glucocorticoids post-surgically to keep them in a physiologically normal range during the time of stress but the vet school will be advising you on the necessity of this, I'm sure.
If there isn't an immediate pressing need to remove the tumor I really think it is important to discuss with your vets the ramifications of the current lab work and to discuss whether it might be better to put surgery off until there is a more normal response on the ACTH stimulation test.
It is important to eventually rule out the possibility of a return of mast cell tumors, too. So when there is a clear understanding of whether or not your dog will have to be treated as a patient with hypoadrenocorticism or not, it would be best to proceed. More caution will be necessary if hypoadrenocorticism persists but you will at least be aware of this need. A normal ACTH stimulation test has a pre, or baseline, value of 0.5 to 4.0 ug/dl and a post ACTH stimulation value of 8.0 to 20 ug/dl. In patients in which hyperadrenocorticism is being well controlled, most vets look for values for the prestimulation sample of less than 4 ug/dl but more than 1 ug/dl and post ACTH values of 1 ug/dl but less than 5 ug/dl.
So the "1 and 1" value is technically right on the borderline of what is desired but without any rise in the value is suspicious of adrenal tissue destruction of a greater magnitude than usually occurs with initial dosages of Lysodren. Most dogs with this problem will get more normal values within a few weeks but some dogs continue to have low values for months. It is necessary to do periodic testing to determine what the levels are as long as they continue to stay so low, without any rise in response to ACTH stimulation.
I would want to wait at least a few weeks for more normal results before deciding on the surgery.
Mike Richards, DVM
Addison's and Florinaf
Q: Dear Dr. Mike; First of all, I'd like to thank you for being there for us ! Your information has helped us tremendous in the illness of our beloved Cardigan Corgi. She nearly died before being diagnosed as suffering from Addison's disease, and altho our Vet is a fine compassionate ,young doctor and correctly diagnosed our Dylan, the extensive information about the disease I found at your marvellous Web site!! Our Dylan was put on Florinef Acetate,0.1 mg tabs, one of these 3 times daily, together with 1 Prednisone tablet in the morning, this seems to be a large number of drugs to us to give her every day! Our Dylan has just turned 3 years old and we hope that you can answer our concern, is this disease a lifetime, chronic disease or will she ultimately be cured of this? The medicine (Florinef Acetate) is most expensive and cost $ 50.00 for 100 tabs, however altho my wife and I live on Social Security, we would gladly cut down on our food to keep this little Angel alive!! We cannot purchase this medicine from our Vet, except for the Prednisone and wonder if there is perhaps a less expensive source for the Florinef, other than the local drug store? Any help you can give us is greatly appreciated, Dr. Mike and THANK YOU for being there and for the obvious GREAT compassion you show for the animals!
A: H. - I am not aware of a generic equivalent of Florinef (Rx). It will almost certainly be necessary to keep Dylan on this medication lifelong and in many instances it is necessary to increase the dosage as time goes on. I do not follow the mail-order medication market for veterinary medicine very closely but have not seen this medication for sale in the times I have looked at these publications. You may want to ask your vet about ordering the Florinef for you. I am pretty sure that The Butler Company, a veterinary distributor, carries Florinef. Sometimes, but not always, it is possible for a veterinarian to sell a medication for less than the pharmacy and still make enough profit to justify ordering the medication. That is one of the good things about being a veterinarian - we're mostly independent small businessmen who can choose to make a little less in some cases if we want to. Pharmacists working for the larger corporations might not have this option. It is worth explaining the need for a lower cost source of Florinef to your vet to see if such an arrangement can be worked out.
Mike Richards, DVM
also see Florinef (Rx)
Addison's treatment and pain control
Q: Dr. Mike. I desperately need your advice since my dog is in a lot of pain and my vet seems to be running out of solutions...I adopted my dog 4 yrs. ago from the shelter and I think my dog may be around 12 yrs. old. He is a Shih -Tzus with very bowed front legs and weighs 16 lbs. About a month ago my dog started having a hard time getting up in the morning because of pain in his hips . I treated him with asprin for a week and his condition improved . My vet x-rayed his back legs and discovered my dog had knee joints which protrubed out of the sockets and had very bad hip dysplasia . He prescribed Rimadyl and his condition improved. When my dog was on either asprin or Rimadyl he was able to walk and was peppy most of the time. A week ago my vet discovered from blood tests (ACTH response test) that my dog had Addison's disease. He prescibed FLORINEF (0.1 MG twice daily) and Prednisolone (5 mg per day ). The Rimadyl was discontinued and this is when the problem got worse. He has been on the Florinef and Prednisolone and now he can barely walk and is very weak and doesn't want to move. Also he had diarrhea today. Two days ago in addition to the Florinef and Prednisolone my vet also gave my dog his first shot of Adequan and an anti-inflammatory injection and put him on a dextrose IV for a few hours. Two days later after these injections and IV, my dog seemed to have taken a turn for the worse and my vet is out of answers. In my view, my dog seem to take a turn for the worse once the Rimadyl was discontinued and the treatment for Addison's disease started. Now my dog does not want to get out of his bed and he seems to be in a lot of pain. Please help me. Could the results from the ACTH test be wrong? Is the Prednisolone helping with the hip dysplasia and does it work as effectively as Rimadyl? What else can my dog be prescribed for the pain in his hips in light of the Addison's disease? I was told that my dog cannot take asprin or Rimadyl with the Florinef and Prednisolone. Please help my dog is very sick and I am running out of solutions. Up until today my dog has been eating ok and has been drinking water, but I have to carry him outside to go to the bathroom and he cannot walk very well. My vet does not want to put him to sleep because he thinks there may be some hope. Thank you for any advice you may have.
A: JCJC- To the best of my knowledge there is no reason not to use aspirin or carprofen (Rimadyl Rx) in conjunction with fludrocortisone acetate (Florinef Rx). However, there is reason to believe that concurrent administration of glucocorticoids such as prednisone and non-steroidal anti-inflammatory medications (NSAIDS) such as aspirin or Rimadyl does increase the chance of gastrointestinal effects including ulceration. For this reason, most vets are reluctant to use these medications together. There is an FDA approved medication that is a combination of aspirin and methylprednisilone, though, called Cortaba (Rx). I always thought it was odd that there were warning against using these products together and an approved medication containing both.
In desperate situations it is worth considering desperate measures and I don't think I'd be afraid to use Rimadyl with the other medications, especially since it is less likely to have GI effects than other NSAIDS. The manufacturer of Rimadyl, Pfizer, recommends against this combination at the current time if you want a third opinion.
I think sometimes lab tests are in error. The clinical signs you mention could be seen with Addison's disease, though. In most cases it is a good idea to rerun the tests to gauge the effects of the medications so your vet may have already done this. If the results were surprising it may be that there is a need to rethink this diagnosis but the only way to tell is to check.
Mike Richards, DVM
Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...