Taking the Long View of Outline

Canine Hypoadrenocorticism • Recognition and diagnosis.

• Treatment principals and goals.

• Options and strategies for maintenance mineralocorticoid therapy.

• Client Education
– Understanding/Expectations
– Making treatment easier

Hypoadrenocorticism Consequences of Adrenal Failure

Syndrome of adrenal insufficiency

Secondary Addison’s

GC – glucocorticoids
MC - mineralocorticoids

Primary Addison’s
Cortisol deficiency – Multisystemic signs
Aldosterone deficiency – Salt and water
“TYPICAL” “ATYPICAL”
GC and MC deficiency GC deficiency

1
 Clinical Signs Minimum Data Base
• Non-specific illness • Azotemia- elevated BUN and creatinine
• Wax and wane course • Electrolyte abnormalities
• Common complaints- – Hyponatremia and hypochloremia
85% loss = clinical signs
– Inappetance – Hyperkalemia
– Lethargy • USG often dilute ((< 1.030)) despite
p dehydration
y
– Vomiting/diarrhea
– Polyuria
– Weakness
**Azotemia + dehydration + dilute urine**
– Weight loss
– Regurgitation/abdominal pain Misdiagnosed as renal failure

• Hypoadrenal crisis

Definitive Diagnosis Strategy for Hormone Replacement

Initial hormone replacement

• Crisis, dehydrated, inappetent
• Glucocorticoid – usually injectable
• Mineralocorticoid
– Can delay until volume and BP is improved
– NaCl fluid can improve electrolytes in short-term
short term
Diagnostic test of choice
Maintenance hormone replacement
Not perfect test • Stable, hydrated, eating
Expense is factor • Glucocorticoid - oral
• Mineralocorticoid supplement
Infrequently used tests – Injectable long-acting product
Baseline Cortisol level – Oral product
hypocorticism Endogenous ACTH level
Aldosterone

2
 Maintenance Therapy Mineralocorticoid Supplementation

Glucocorticoid replacement Hydrocortisone – NOT GENERALLY USED

• ultra-short acting- IV
• Goal – provide physiologic amount of GC
Fludrocortisone (Florinef)
• Prednisone • short acting
acting- oral
– Replacement dose- 0.1- 0.4 mg/kg/d
– Can be divided Desoxycorticosterone (DOCP; Percorten)
– Taper to lowest effective dose • long acting- SQ or IM Desoxycorticosterone pivulate

• Only treatment needed for ‘atypical’ Addison’s Disease

Single dose not harmful in dogs without Addisons
• Possible to induce signs of cortisol excess.

Mineralocorticoid Supplementation Mineralocorticoid Supplementation

DOCP - deoxycorticosterone pivalate DOCP - 2.2 mg/kg IM or SC every 25 days

• 2.2 mg/kg IM or SC every 21-30 days
• Max dose 50 mg/dog/dose • What I do now:
• Slow release of mineralocorticoids • Max dose 50 mg/dog/dose
• No GC activity • Start at label dose
• L
Lytes
t weeklykl ffor 4 weeks
k (t
(to gauge dduration)
ti )
Fludrocortisone (Florinef®)- • Usually get 4 weeks
• Has some GC activity • Eventually consider dose reduction
• Dose: 0.015 - 0.02 mg/kg/day
• Poor absorption, expensive • What I would like to do:
• Start at lower dose.
• ~50% of dogs treated with fludrocortisone will not need GC

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 Dose Adjustment Long Term Treatment
Reducing costs
Start at Label Dose • Get good control
– Reduce hospital costs
– Healthy patient

• Work to find minimal effective dose

– Veterinarian works closely with the owner
Lytes weekly for 4 weeks
– The proximal costs may save long term costs

Could this process be • Shop around for best price

simplified by starting at a
lower initial dose?
Desire a dose reduction
– On-line veterinary pharmacies
• Owner administers DOCP at home
– Successful strategy in majority of cases
– Must be part of long-term monitoring program with veterinarian.

Maintenance therapy

Long Term Monitoring

Excellent Prognosis
Serial evaluation of clinical signs
• Owners’ observations helpful
• Deficiencies result in subtle manifestations If:
Owners are educated about the disease.
Serial evaluation of electrolytes
• Every 3-4 months
Compliance is excellent
• Used to guide adjustments in mineralocorticoid dose
Cl
Close follow-up
f ll i vital
is it l for
f success
Adjusting GC replacement
• Short-term (2-3d) increase in maintenance dose when stress is anticipated
• Constitutional signs usually need increase in GC
• Decrease GC if there are signs of excess QUESTIONS?
• NO ROLE FOR SERIAL ACTH STIM TESTS