Title: ATTITUDE
1ATTITUDE
- The people who get on in this world are the
people who get up and look for the circumstances
they want, and if they cant find them, make
them. - -George Bernard Shaw
2ENDOCRINE SYSTEM DISEASES
3Endocrine System Diseases
4Main trigger Hypothalamus
5Review of the basics
- Endocrine ____________- basic units of the
endocrine system. - Secrete hormones ___________ into the
bloodstream. - Circulate throughout body and produce effects
when attach to receptors in or outside of cells. - __________ glands.
- Exocrine glands- units that secrete their
products onto epithelial surfaces through tiny
tubes called _____________.
6(No Transcript)
7Hormones
- ___________ messengers produced by endocrine
glands and secreted directly into blood vessels. - Produce effects when find their receptors in or
on cells. - Each body cell has specific receptors to certain
hormones (___________). - If body does not have receptor, hormone will pass
by. - Only certain hormones can _______ to receptors
and when it occurs, then it changes the activity
of the cell.
8Hormones
9Control of Hormone Secretion
- Negative Feedback System
- Endocrine glands will be stimulated to produce
more hormone when it drops below a certain amount
in the body. - If hormone is of adequate levels, gland will
either slow or stop production of the hormone
which is called negative feedback. - Direct Stimulation of Nervous System
- Secretion of some hormones is stimulated by
sympathetic nerve impulses when an animal feels
threatened. - Fight or flight response from sympathetic nervous
system
10DISEASES OF THE THYROID GLAND
- HYPERTHYROIDISM
- HYPOTHYROIDISM
11Hypothyroidism
12Thyroid Gland
- Gland not usually palpable
- Located at ventral cervical region along lateral
margins of trachea - Hormones produced
- T3 (___________________) and T4
(_____________________), iodine containing
hormones. - Produced by follicular cells
- ______________ Causes Calcium deposition in
bone which decreases blood Calcium concentrations - Produced by parafollicular cells
13Hypothyroidism
- Definition clinical state associated with
____________________ which causes low cell
metabolism in most tissues of the body - Primary acquired 90 of dogs
- Caused by ________________or _____________________
____ - Also by iodine deficiency, neoplasia, infection
- Secondary acquired- RARE
- Anterior Pituitary dysfunction or destruction
from neoplasia leads to ?TSH - Congenital Hypothyroidism-RARE
- Cretinism (newborns)
14Hypothyroidism
- MOST COMMON ENDOCRINE DISEASE IN____________
rare in cats - Breeds Golden Retriever, Doberman, Irish Setter,
Schnauzer, Cocker Spaniel, Dachshund, others - 4-10 yrs of age
- Females
- Greyhounds and Scottish deerhounds
physiologically have lower T4 (thyroxine)
15Hypothyroidism
- Clinical Signs - COMMON
- __________________________________
- Skin changes
- Bilaterally symmetric truncal alopecia (which
other disease has this clinical sign? ) - ______________________ neck, axillae, and other
areas of friction - Seborrhea
- Superficial pyoderma
- Dry, lusterless haircoat
- Hyperpigmentation
- Cold intolerance (why?)
- Lethargy/sleeping
- Exercise intolerance
16Hypothyroidism
17Hypothyroidism
18Hypothyroidism
19Hypothyroidism
20Hypothyroidism
- Clinical signs/Bloodwork Less common
- ___________________ generalized weakness,
ataxia, facial paralysis/paresis, seizures
(secondary to cerebral atherosclerosis) - _______________ Constipation, Regurgitation
caused by megaesophagus - Bloodwork abnormalities _____________lipidemia
is most common, gross lipemia ( milky appearance
to the serum), ____________________cholesterolemia
(80), anemia (mild non-regenrative) - Eye hyperlipidemia gt corneal lipidosis and
anterior uveitis
Virtually all body systems are affected,
clinical signs are generally non-specific
21Hypothyroidism DIAGNOSIS
- Blood Tests
- Hypothyroid dogs have lowered level of T4
- Test total T4(TT4), /- T3 levels
- Free T4 Free T4 is thyroxine that is not protein
bound (ED is most accurate test for fT4
measurement) - Basal TSH concentration
- Measures TSH in blood, should be used in
conjunction with other tests and clinical signs
ED equilibrium dialysis
22Hypothyroidism Considerations
- Remember sick animals and animals on certain
medications (anti-epileptics, glucocorticoids)
may have depressed T4 levels. (_________________)
- Wait and re-test after treatment of underlying
cause if clinical signs persist. - Greyhounds have low T4 levels naturally diagnose
based on clinical signs as well as test results
treat if clinically evident.
23Hypothyroidism
- Treatment
- Thyroid supplement _________________
- Oral, synthetic levothyroxine (0.02 mg/kg BID)
- Daily administration (after cs resolves consider
SID) - Steady state levels 4/8 wks (1st 6-8 months)
- Test levels and adjust dose until T4 normal
- Want to test 4-6 hours after dose is given (when
serum levels are highest)
24Thyroid replacement hormone (levothyroxine sodium)
25Hypothyroidism
- Client Education
- Supplement for ________________
- Daily dosing required
- Overdose gt hyperthyroidism
- Regular rechecks are recommended including
bloodwork. - PU/PD nervousness, weight loss, panting,
weakness, inc. appetite - Vet may recommend a reduced fat diet until body
weight is satisfactory and T4 levels are normal.
26Hyperthyroidism
- Definition Pathologic, sustained, high overall
metabolism caused by high circulating
concentrations of thyroid hormones - Most common Endocrine disease in ____________
(one of the big 3 diseases of older cats) - Very rare in dogs
- Pathophysiology
- Autonomously ___________________________, no
physiologic controls (functional thyroid adenoma) - Secrete _______ and ____________
27Hyperthyroidism in cats
28Hyperthyroidism
- Clinical Signs
- Multi-systemic reflects increase in metabolism
- _________________
- __________________
- Vomiting/diarrhea
- _____________________
- Tachypnea/dyspnea
- Hyperactivity
- Aggression
29Hyperthyroidism
- Clinical signs contd
- ____________________(thickening of LV and heart
muscle) - Hypertension
- Poor body condition
- Thickened nails
- Unkempt appearance
- ______________________ gland 70 - bilateral
30Hyperthyroid cat
Middle age to older cats Blindness with retinal
detachment Wt loss Palpable enlarged Thyroid
gland Polyphagia Aggressive Tachycardia
unkempt haircoat
31Hyperthyroid cat Goiter
32Hyperthyroidism
- Diagnosis
- Palpate enlarged thyroid gland
- Elevated T4, FT4
- X-rays for associated heart disease
33Hyperthyroidism Scintigraphy
Normal cat Normal uptake in salivary glands and
thyroid glands
Hyperthyroid cat Unilateral thyroid adenoma
34Hyperthyroidism Scintigraphy
Hyperthyroid cat Bilateral thyroid adenoma
Hyperthyroid cat Ectopic (intrathoracic) thyroid
adenoma
Hyperthyroid cat Functional thyroid
carcinoma (represents regional metastasis)
35Hyperthyroidism
- Treatment
- ______________________ (Tapazole) anti-thyroid
drug block incorporation of iodine into
thyroglobulin. - Monitor q 2-3 weeks
- COMMON AND PRACTICAL FOR CLIENTS
- Radioiodine treatment I131
- Effective
- Emitted radiation destroys functioning follicular
cells - ______________________________________________
- Surgical removal of gland
- May cause hypothyroidism
- May result in hypocalcemia due to
hypoparathyroidism
36Hyperthyroidism Medical Rx
METHIMAZOLE
ORAL DRUG, BUT CAN BE FORMULATED INTO A
TRANSDERMAL OINTMENT
37Hyperthyroidism
- Complications
- Renal disease/failure unveiled when thyroid
levels controlled - 2-3 months after medication started
- Occasionally tapazole will no longer be effective
usually after 2-3 years of treatment - Prognosis
- Excellent if uncomplicated
- If labs show ___________________ prior to
treatment, prognosis more guarded
38Hyperthyroidism Client Info
- Cause of disease is unknown
- Surgery or Radiation are only cures
- Cat may become hypothyroid following Rx usually
not clinically significant and supplementation
can be initiated if necessary - Following Tapazole, Blood pressure and kidney
values should be checked routinely
39 EDUCATION
- Education is learning what you didnt even know
you didnt know. - -Daniel J. Boorstin
40DISEASES OF THE PARATHYROID GLANDS
- HYPERPARATHYROIDISM
- HYPOPARATHYROIDISM
41Thyroid/Parathyroid glands
1normal thyroid gland 2 and 3parathyroid
gland 4enlarged thyroid gland
42Parathyroid gland
- Secretion Parathyroid hormone (PTH,
Parathormone) - Function ? plasma Ca2 concentration
- 1. ? osteoclast activity
- 2. ? Ca absorption from GI tract
- 3. ? Ca reabsorption from kidney tubules
- Hyperparathyroidism ?hypercalcemia
- Hypoparathyroidism ?hypocalcemia
43Hyperparathyroidism
- Causes
- 1º hyperparathyroidismadenoma or carcinoma
- 2º hyperparathyroidismpoor diet low Ca intake
- Clinical signs
- Many animals show no clinical signs
- signs occur as organ dysfunction occurs
- urinary/renal calculi (high plasma Ca)
- cardiac arrhythmias, tremors (Ca necessary for
normal muscle contraction - Anorexia, vomiting, constipation
- weakness
44Hyperparathyroidism
- Dx
- Routine chemistry panel
- ? blood Calcium (normal 8-10 mg/dl))
- /- ? blood Phosphorus (normal 2-6 mg/dl)
- PTH assay
- normal PTH dogs 20 pg/ml, cats 17 pg/ml
- In a normal animal if blood Ca is high, PTH is
low (neg feedback) - 1º Hyperparathyroidism Ca high, PTH elevated
- Ultrasound of neck enlarged glands, abdomen -
uroliths
45Hyperparathyroidism
- Tx
- 1. Surgical removal of diseased parathyroid
(generally 4 lobes are imbedded in thyroid gland) - Other options
- 2. Ultrasound-guided chemical (ethanol)
- 3. Ultrasound-guided heat (laser) ablation
- Post-Op Care
- 1. Hospitalize for 1 wk ?PTH may predispose
animal to hypocalcemia - 2. Calcium therapy (oral tabs, liquid)
- 3. Vit D supplements (promotes Ca intestinal
absorption)
46Hyperparathyroidism
- Client Info
- Most hyperparathyroid animals show no signs when
first diagnosed - Run yearly chem panels on all normal, older
animals
47Hypercalcemia Other causes
- Causes
- Neoplasia (lymphoma, perianal gland tumors)
- Renal failure
- Hypoadenocorticism
- Vitamin D rodenticide
- Drugs or artifacts (ex lipemia)
- Clinical signs vary with cause
- PU/PD, anorexia, lethargy, vomiting, weakness,
stupor/coma (severe), uroliths
48Hypercalcemia
- Tests
- Elevated serum calcium levels
- Low to low-normal phosphorus concentrations
49Hypercalcemia
- Treatment
- Fluids 0.9 NaCl
- No Ca2 containing fluids
- Diuretics (furosemide)
- Steroids
- Complications
- Irreversible renal failure
- Soft tissue calcifications
50Hypocalcemia
- Causes
- Parathyroid disease
- Inadvertent removal of parathyroid during
thyroidectomy (most common cause - 1º Hypoparathyroidism (uncommon in animals)
- Chronic renal failure
- may cause ? serum P, which can result in ? serum
Ca (CaP inverse relation) - Vit D normally activated in kidney
- Protein-losing nephropathy results in loss of
albumin-bound Ca - Puerperal Tetany (Eclampsia)late gestation thru
post-partum period - Improper prenatal nutrition
- Heavy lactation
- Inappropriate Ca supplementation
http//www.thepetcenter.com/gen/eclampsia.htmlThe
_video
51Hypocalcemia
- Clinical Signs
- Restlessness, muscle tremors, tonic-clonic
contractions, seizures - Tachycardia with excitement bradycardia in
severe cases (Ca is necessary for proper muscle
contractions) - Hyperthermia
- Stiffness, ataxic
52Hypocalcemia
- Dx
- Total serum lt6.5 mg/dl
- Tx
- IV infusion of 10 Ca gluconate solution (monitor
HR and rhythm during infusion) - Diazepam (IV) to control seizures
- Oral supplements of Ca (tabs, caps, syrup)
- Improve nutrition
53Hypocalcemia
- Client info
- Well-balanced diet increase volume as pregnancy
progresses - Signs in pregnant animal is emergency call vet
immediately - May recur with subsequent pregnancies
- Early weaning is recommended
54 LIFE
- Nobody can go back and start a new beginning,
but anyone can start today and make a new
ending. - -Maria Robinson
55DISEASES OF THE PANCREAS
- DIABETES MELLITUS
- INSULINOMA
- EXOCRINE PANCREATIC INSUFFICIENCY
56Review of pancreas functions
- Long flat organ near duodenum and stomach
- Exocrine function (the majority of the pancreas)
- Digestive enzymes
- Endocrine function islets of Langerhans
- Alpha cells gt glucagon
- Beta cells gt insulin
- Delta cells gt somatostatin
57Pancreas
58Pancreas beta cells
59Review
- Insulin
- Moves glucose into cells to be used for energy
- Decreases blood glucose
- Glucagon
- Raises blood glucose
- Stimulates liver to release glucose
- Stimulates gluconeogenesis
- Other hormones from other glands perform similar
functions (hyperglycemic effect) - Growth hormone
- Glucocorticoids
60Insulin/Glucagon Balance
61Endocrine Pancreas
- Hyperglycemia
- Definition Excessively high blood glucose levels
- Normal in dogs 60-120 mg/dl
- Normal in cats 70 -150 mg/dl
62Diabetes Mellitus
- Definition Disorder of carbohydrate, fat and
protein metabolism caused by an absolute or
relative insulin deficiency - Type I Insulin Dependent DM very low or
absent insulin secretory ability - Type II Non insulin dependent DM (insulin
insensitivity) inadequate or delayed insulin
secretion relative to the needs of the patient
63Diabetes mellitus
Incidence Dogs 100 Type I (Insulin
dependent) Cats 50 Type I and 50 Type
II -non-insulin dependent cats can sometimes
be managed with diet and drug therapy Causes
Chronic pancreatitis Immune-mediated disease
-beta cell destruction Predisposing/risk
factors Cushings Disease Acromegaly Obesity
Genetic predisposition Drugs (steroids)
64Diabetes mellitus
- Age/sex
- Dogs 4-14 yrs, females 2x more likely to be
affected - Cats all ages, but 75 are 8-13yrs, neutered
males most affected - Breeds Poodles, Schnauzers, Keeshonds, Cairn
Terriers, Dachshunds, Cockers, Beagles
65DM
- Pathophysiology
- Insulin deficiency gt impaired ability to use
glucose from carbohydrates, fats and proteins - Impaired glucose utilization gluconeogenesis gt
hyperglycemia - Clinical signs develop when
- Exceeds capacity of renal tubular cells to
reabsorb - Dogs BG gt 180-220 mg/dl
- Cats - BG gt 200-280 mg/dl
- Glycosuria develops
- Osmotic diuresis
- Polyuria/polydipsia
66DM
- SYSTEMS AFFECTED
- Endocrine/metabolic electrolyte depletion and
metabolic acidosis - Hepatic liver failure 2 to hepatic lipidosis
(mobilization of free fatty acids to liver leads
to hepatic lipidosis and ketogenesis) - Ophthalmic cataracts (dogs) from glaucoma
- Renal/urologic UTI, osmotic diuresis
- Nervous peripheral neuropathy in cats
- Musculoskeletal Compensatory weight loss
67Diabetes Mellitus
- Clinical Signs
- Polyuria
- Polydipsia
- Polyphagia
- Weight loss
- Dehydration
- Cataract formation-dogs
- Plantigrade stance-cats
68Diabetes in CatsPlantigrade posture
Plantigrade posture Diabetic neuropathy
69Diabetes Cataracts
Increase in sugar (sorbitol) in lens causes an
influx of water, which breaks down the lens fibers
70Diabetic Ketoacidosis
2 metabolic crises ? lipolysis in adipose
tissue ? fatty acids ?ketone bodies ?ketoacidosis
?coma (insulin normally inhibits lipolysis) ?
hepatic gluconeogenesis (in spite of high plasma
glucose levels) (insulin normally inhibits
gluconeogenesis)
71Diabetic Ketoacidosis
- Definition True medical emergency secondary to
absolute or relative insulin deficiency causing
hyperglycemia, ketonemia, metabolic acidosis,
dehydration and electrolyte depletion - DM causes increased lipolysis gt ketone
production and acidosis
72Diabetic Ketoacidosis
- Diagnosed with ketones in urine or ketones in
blood - Can use urine dip stick with serum.
- Clinical Signs
- All of the DM signs
- Depression
- Weakness
- Tachypnea
- Vomiting
- Odor of acetone on breath
73Diabetic Ketoacidosis
- IV fluids to rehydrate 0.9 NaCl
- K (potassium) supplement
- Regular insulin to slowly decrease BG
- Monitor BG q 2-3 hrs
- When BG close to normal and patient stable switch
to longer acting insulin
74DM
- DIAGNOSIS
- CBC normal
- Biochemistry panel
- Glucose gt 200 mg/dl (dogs), gt250 (cats)
- UA
- Glycosuria!!!!
- Ketonuria
- USG low
- Electrolytes may be low due to osmotic diuresis
- Blood gases (if ketoacidotic)
- Fructosamine levels mean glucose level for last
2-3 weeks (dogs) - Ideal to test for regulation checks
75DM Rx INSULIN AND DIET!!!
Table 1. Traditional insulin outline.
Duration/onset category Insulin types Concentration
Rapid acting Regular (Humulin R) U-100 (100 units/ml)
Intermediate acting NPH (Humulin N) U-100
Intermediate acting Lente (Vetsulin by Intervet) NO LONGER AVAILABLE U-40 (40 units/ml)
Long acting PZI (Idexx) U-40
Long acting Ultralente NO LONGER AVAILABLE U-100
Long acting Glargine insulin analog U-100
76Diabetes Insulin therapy
77DM Insulin therapy
- INSULIN
- Beef-origin insulin is biologically similar to
cat insulin - Porcine-origin insulin is biologically similar to
dog insulin - Dogs and cats have responded well to human
insulin products - INSULIN ADMINISTRATION
- ALWAYS USE THE APPROPRIATE INSULIN SYRINGE! (U-40
vs. U-100) - Insulin is given in units (insulin syringes are
labeled in units, not mL)
78DM dietary management
- DIET
- DOGS high fiber, complex carbohydrate diets
- Slows digestion, reduces the post-prandial
glucose spike, promotes weight loss, reduces risk
of pancreatitis - Hills R/D or W/D
- CATS high protein, low carbohydrate diets
- Cats use protein as their primary source of
energy blood glucose is maintained primarily
through liver metabolism of fats and proteins - Purina DM, Hills M/D
- Often a diet change in cats can dramatically
reduce or eliminate the need for insulin - This is particularly true for type II
79DM
- Oral hypoglycemics
- Sulfonylureas Glipizide
- Direct stimulation of insulin secretion from the
pancreas - Alpha-Glucosidase Inhibitors Acarbose
- Delays digestion of complex carbohydrates and
delays absorption of glucose from the intestinal
tract.
80Diabetes Mellitus Monitoring
Find an ear vein Prick the ear to get Place
drop of blood blood sample on green tip
readout in a few seconds
81Diabetes Rx Urine glucose
82Diabetes monitoring Urine glucose
83DM monitoring
84DM
- Client Education
- Lifelong insulin replacement therapy
- Insulin administered by injection
- Refrigerate insulin, mix gently (no bubbles),
single use syringes - Cataracts common, permanent
- Consistent diet and exercise
- Recheck BG or curve regularly or fructosamine
levels - Progressive
- If animal does not eat- NO INSULIN
-
85Endocrine Pancreas
- Hypoglycemia
- Definition Low blood glucose levels
- Causes
- Neonatal and juvenile
- Septicemia
- Neoplasia
- Starvation
- Iatrogenic insulin overdose
- Portosystemic shunt
- Many others
86Insulin Shock
- Causes
- Insulin overdose (misread syringe)
- Too much exercise
- Anorexia
- Signs
- Weakness, incoordination, seizures, coma
87Insulin Shock
- Prevention
- Consistent diet (type and amount)/consistent
exercise (less insulin with exercise) - Monitor urine/blood glucose at same time each day
- Feed 1/3 with insulin the rest 8-10 h later (at
insulin peak) - Have sugar supply handy
88Insulinoma
- CAUSE tumor of beta cells, secreting an excess
of insulin - SIGNS prolonged hypoglycemia?weakness, ataxia,
muscle fasciculations, posterior paresis, brain
damage, seizures, coma, death,
89Insulinoma Dx
- Chem Panel
- ?blood glucose
- Simultaneous glucose and insulin tests
- Low glucose, High insulin gt insulinoma
- Observations
- Symptoms occur after fasting or exercise
- when symptomatic, blood glucoselt50 mg/dl
- symptoms corrected with sugar administration
90Insulinoma Rx
- Surgical Rx removal of tumor
- Medical Rx
- Acute, at home
- administer glucose (Karo) keep animal quiet,
seek vet care - Acute, in Hosp
- adm. glucose (50 Dextrose)
- Chronic care
- feed 3-6 small meals/day (high protein, low
fat) - limited exercise
- glucocorticooid therapy (antagonizes insulin
effect at cellular level) - Diazoxide (?insulin secretion, tissue use of
glucose, ?blood glucose) - Octreotide (Sandostatin) injectionsinhibits
synthesis and release of insulin by both normal
and neoplastic beta cells
91Insulinoma Client info
- 1. Usually, by the time insulinoma is diagnosed,
metastasis has occurred so prognosis is poor - 2. With proper medical therapy, survival may be
12-24 mo - 3. Always limit exercise and excitement
- 4. Feed multiple, small meals throughout day
keep sugar source close during exercise - 5. Karo syrup on mm provides for rapid
absorption of glucose into blood stream - 6. Avoid placing hand into dogs mouth during
seizure to avoid being bitten
92Exocrine Pancreas Insufficiency (EPI)
- Inability to process nutrients efficiently due to
lack of production of enzymes from pancreas. - Pancreatic acinar atrophy
- Found most commonly in German Shepherds and Rough
Collies through a recessive gene. - In cats, EPI is primarily the result of chronic
pancreatitis
93Diagnosis of EPI
- Not usually evident until 85-90 of pancreas is
unable to secrete enzymes. - Weight loss although no change in diet or
appetite (appetite often increases) - Persistent tarry diarrhea.
- Flatulence
- Poor haircoat
94Testing and treatment for EPI
- TLI (trypsin-like immunoreactivity)
- Detects trypsin and trypsinogen
- Usually want below 2.5 in dogs to be diagnostic
- Canine 5.7-45.2
- Feline 12-82
- Treatment includes enzymatic supplement
- Viokase powder
- Raw ox or pig pancreas
95Client considerations
- Usually life long treatment.
- Can be very expensive.
- Can be well controlled.
- Should not breed animal that has EPI.
96 LIFE
- Smooth seas do not make skillful sailors.
- -African proverb
97DISEASES OF THE ADRENAL GLANDS
- CUSHINGS DISEASE
- (Hyperadrenocorticism)
- ADDISONS DISEASE
- (Hypoadrenocorticism)
98Adrenal Glands
99ADRENAL GLANDS
mineralocorticoids Glucocorticoids Androgens
epinephrine
100Hyperadrenocorticism (Cushings Disease)
- Definition Disorder caused by deleterious
effects of high circulating cortisol
concentrations on multiple organ systems - Systems affected
- Renal
- Skin
- Cardiovascular
- Respiratory
- Endocrine/metabolic
- Musculoskeletal
- Nervous
- Reproductive
101Cushings Disease
- Effects of excess glucocorticoids
- suppress inflammation
- suppress immune system
- inhibit cartilage growth, development,
- and repair
- Causes
- Anterior pituitary lesion (pituitary-dependent
disease) 85 of cases - Adrenal tumor (excess cortisol secretion
independent of pituitary control) 15-20 of
cases - Overmedication with glucocorticoids - Iatrogenic
102Cushings Disease
103Cushings Disease
Bilaterally symmetrical alopecia, pot-belly,
pyoderma
104Cushings Disease
Pot bellied PU/PD Muscle wasting Thin coat
105Cushings Disease
- signs are slow to develop and usually go
unnoticed by owner - Clinical Signs
- Some are similar to hypothyroidism
- Dog gt6 yr old (most are female)
- PU/PD/PP
- Pot bellied obese
- Muscle atrophy and weakness, lethargy, excess
panting - Bilateral symmetric alopecia pruritis pyoderma
(? immune response) - Calcinosis cutis (firm plaques of Ca under
skin) - Abnormal gonadal function (lack of estrus soft,
small testicles)
106Cushings Disease Calcinosis cutis
Commonly seen on the dorsal midline, ventral
abdomen and inguinal region. Skin is usually
thin and atrophic
107Cushings Disease Dx
- Chemistry Panel
- ? ALP, ALT, cholesterol, blood glucose
- ? BUN
- Lipemia
- Low USG lt 1.015, proteinuria, hematuria, pyuria,
bactiuria - Urine cortisol/creatinine ratios (sample
collected at home) - Normal rationo Cushings
- Elevated ratiomay be Cushings
- ACTH Stimulation test
- Normal patients show an increase of plasma
cortisol - Pituitary dependent disease (excess ACTH release)
and Adrenal tumors 60-85 show EXAGGERATED
cortisol response - Does not differentiate between Pit disease and
Adrenal tumor
108ACTH Stimulation for Hyperadrenocorticism
- Take a pre blood sample.
- Inject ACTH stimulation gel or liquid
- Verify amounts with lab as there is difference
between amount to be injected with gel and
liquid. - Wait two hours and take a post sample
109Cushings Disease Dx
- Low-Dose Dexamethasone Suppression Test
- Inject low dose of steroid (should suppress ant.
pit ACTH) - Measure plasma cortisol at 0, 4, 8 h
- Interpretation
- Normal dogs will show decrease in plasma cortisol
- Pituitary tumor and adrenal tumor will not show
any effect at 8 h (cortisol will still be high)
110Cushings Disease Dx
- High-Dose Dexamethasone Suppression Test (used to
differentiate between Pit Dis and Adrenal tumor) - Dosing 0.1 mg/kg IV
- Collect plasma cortisol at 0, 4, and 8 h
- Interpretation
- Pituitary dependent disease70-75 will show
decrease at 4 or 8 h - Adrenal tumorno change in plasma cortisol level
(tumor is autonomous)
111Cushings Disease Rx
- Surgical removal
- FAT - Specialized surgery most vets would refer
surgery - Pituitary tumors are not surgically removed
- Medical treatment
- Lysodren (o,p,DDD)necrosis of z fasiculata
(middle), z reticularis (deep) - -repeat ACTH stimulation q 7-10 d until cortisol
normal - -like chemotherapy
- -excess dose affects z glomerulus (Addisons Dis)
112Cushings Disease Rx
- 2. trilostane (Vetoryl)less side-effects than
o,p,DDD - -interfers with cortisol production (doesnt
kill cells) - -FDA approved
113Cushings Disease Client info
- Serious disease life-long treatment
- Periodic monitoring required
- Addisons disease may result
- Prognosis average life expectancy is 20-30 mo on
therapy with frequent recurrence of clinical
symptoms varies with cause (pit vs adrenal,
tumors)
114 HARD TIMES
- In the depths of winter, I finally learned that
within me there lay an invincible summer. - -Albert Camus
115Addisons Disease (Hypoadrenocorticism)
- Definition Disorder caused by deficient
production of glucocorticoids (cortisol) or
mineralocorticoids (aldosterone) or both - Secondary disease caused by chronic
administration of corticosteroids
116Addisons Disease (Hypoadrenocorticism)
- Not as common as Cushings Disease rarely seen
in cats - Deficiency of Glucocorticoids and
Mineralocordicoids - Clinical signs due to Mineralocorticoid
(Aldosterone) deficiency - Clinical Signs
- lethargy, weakness, anorexia, wt loss
- Vomiting/Diarrhea
- PU/PD, dehydration
- Bradycardia
117Addisons Disease
- Pathophysiology
- Decreased aldosterone gt Increased K and
decreased Na - gt decreased volume gt azotemia, hypotension,
dehydration, weakness, depression - Hyper K gt heart (bradycardia)
- Glucocorticoid deficiency gt vomiting, diarrhea,
melena, lethargy, wt loss, hypoglycemia (less
common than expected)
118Addisons Disease Dx
- Chem Panel
- NaK ratio lt251 !!!(normal271 to 401)
- ? BUN, Creatinine, Ca
- ? blood glucose, albumin (less common
- ACTH Stimulation test (definitive test)
- normal dog ? cortisol
- hypoadrenocorticism dog low, unchanged cortisol
level - Endogenous ACTH will be increased (1º
hypoadrenocorticism lack of neg feedback)
119What is your Dx?
- Chem Panel (What is not normal?)
- Parameter Value Normal value
- BUN 81 mg/dl 7-27 mg/dl
- Creatinine 2.1 mg/dl 0.4-1.8 mg/dl
- Sodium 131 meq/L 141-156 meq/L
- Potassium 6.5 meq/L 4.0-5.6 meq/L
- NaK ratio 20 27-40
120What is your Dx?
- ACTH Stimulation Test Results
- Value Normal
- Plasma Cortisol
- Pre-ACTH 0.2 2-6
- Post-ACTH 0.3 6-18
121Addisons Disease Rx
- Acute Crisis (may be life-threatening situation)
- Normal saline IV (low Na is hallmark finding of
Addisons) - Glucorticoid replacement(cortisol will also be
low) - Dexamethasone or Prednisone (IV or IM)
- Mineralocorcorticoid replacement
- Florinef (fludrocortisone acetate)po
- Percortin-V (desoxycorticosterone pivalate)
injection - Chronic Management
- Glucocorticoid replacement
- Prednisone
- Prenisolone
- Mineralocorcorticoid replacement
- Florinef (fludrocortisone acetate)po daily (not
cheap 50/tab) - Percortin-V (desoxycorticosterone pivalate)inj
monthly (expensive) - Monitor electrolytes, BUN/Creatinine, clinical
signs
122Addisons disease Client info
- Mineralocorticoid deficiency is life-threatening
- Animal requires periodic blood tests
- Glucocorticoids needed in times of stress
- Always remind attending vet of pets condition
- Hormone replacement therapy continued for life of
pet - Prognosis Good to excellent after
stabilization and treatment