ATTITUDE

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ATTITUDE

• 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

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ENDOCRINE SYSTEM DISEASES

• CRINE to secrete

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Endocrine System Diseases
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Main trigger Hypothalamus
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Review 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 _____________.

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(No Transcript)
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Hormones

• ___________ 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.

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Hormones
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Control 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

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DISEASES OF THE THYROID GLAND

• HYPERTHYROIDISM
• HYPOTHYROIDISM

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Hypothyroidism
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Thyroid 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

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Hypothyroidism

• 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)

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Hypothyroidism

• 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)

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Hypothyroidism

• 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

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Hypothyroidism
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Hypothyroidism
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Hypothyroidism
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Hypothyroidism
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Hypothyroidism

• 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
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Hypothyroidism 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
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Hypothyroidism 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.

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Hypothyroidism

• 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)

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Thyroid replacement hormone (levothyroxine sodium)
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Hypothyroidism

• 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.

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Hyperthyroidism

• 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 ____________

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Hyperthyroidism in cats
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Hyperthyroidism

• Clinical Signs
• Multi-systemic reflects increase in metabolism
• _________________
• __________________
• Vomiting/diarrhea
• _____________________
• Tachypnea/dyspnea
• Hyperactivity
• Aggression

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Hyperthyroidism

• Clinical signs contd
• ____________________(thickening of LV and heart
  muscle)
• Hypertension
• Poor body condition
• Thickened nails
• Unkempt appearance
• ______________________ gland 70 - bilateral

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Hyperthyroid cat
Middle age to older cats Blindness with retinal
detachment Wt loss Palpable enlarged Thyroid
gland Polyphagia Aggressive Tachycardia
unkempt haircoat
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Hyperthyroid cat Goiter
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Hyperthyroidism

• Diagnosis
• Palpate enlarged thyroid gland
• Elevated T4, FT4
• X-rays for associated heart disease

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Hyperthyroidism Scintigraphy
Normal cat Normal uptake in salivary glands and
thyroid glands
Hyperthyroid cat Unilateral thyroid adenoma
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Hyperthyroidism Scintigraphy
Hyperthyroid cat Bilateral thyroid adenoma
Hyperthyroid cat Ectopic (intrathoracic) thyroid
adenoma
Hyperthyroid cat Functional thyroid
carcinoma (represents regional metastasis)
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Hyperthyroidism

• 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

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Hyperthyroidism Medical Rx
METHIMAZOLE
ORAL DRUG, BUT CAN BE FORMULATED INTO A
TRANSDERMAL OINTMENT
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Hyperthyroidism

• 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

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Hyperthyroidism 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

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EDUCATION

• Education is learning what you didnt even know
  you didnt know.
• -Daniel J. Boorstin

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DISEASES OF THE PARATHYROID GLANDS

• HYPERPARATHYROIDISM
• HYPOPARATHYROIDISM

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Thyroid/Parathyroid glands
1normal thyroid gland 2 and 3parathyroid
gland 4enlarged thyroid gland
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Parathyroid 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

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Hyperparathyroidism

• 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

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Hyperparathyroidism

• 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

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Hyperparathyroidism

• 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)

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Hyperparathyroidism

• Client Info
• Most hyperparathyroid animals show no signs when
  first diagnosed
• Run yearly chem panels on all normal, older
  animals

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Hypercalcemia 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

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Hypercalcemia

• Tests
• Elevated serum calcium levels
• Low to low-normal phosphorus concentrations

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Hypercalcemia

• Treatment
• Fluids 0.9 NaCl
• No Ca2 containing fluids
• Diuretics (furosemide)
• Steroids
• Complications
• Irreversible renal failure
• Soft tissue calcifications

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Hypocalcemia

• 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
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Hypocalcemia

• 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

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Hypocalcemia

• 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

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Hypocalcemia

• 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

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LIFE

• Nobody can go back and start a new beginning,
  but anyone can start today and make a new
  ending.
• -Maria Robinson

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DISEASES OF THE PANCREAS

• DIABETES MELLITUS
• INSULINOMA
• EXOCRINE PANCREATIC INSUFFICIENCY

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Review 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

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Pancreas
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Pancreas beta cells
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Review

• 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

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Insulin/Glucagon Balance
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Endocrine Pancreas

• Hyperglycemia
• Definition Excessively high blood glucose levels
• Normal in dogs 60-120 mg/dl
• Normal in cats 70 -150 mg/dl

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Diabetes 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

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Diabetes 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)
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Diabetes 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

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DM

• 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

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DM

• 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

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Diabetes Mellitus

• Clinical Signs
• Polyuria
• Polydipsia
• Polyphagia
• Weight loss
• Dehydration
• Cataract formation-dogs
• Plantigrade stance-cats

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Diabetes in CatsPlantigrade posture
Plantigrade posture Diabetic neuropathy
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Diabetes Cataracts
Increase in sugar (sorbitol) in lens causes an
influx of water, which breaks down the lens fibers
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Diabetic 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)
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Diabetic 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

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Diabetic 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

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Diabetic 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

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DM

• 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

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DM 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
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Diabetes Insulin therapy
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DM 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)

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DM 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

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DM

• 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.

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Diabetes 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
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Diabetes Rx Urine glucose
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Diabetes monitoring Urine glucose
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DM monitoring
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DM

• 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

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Endocrine Pancreas

• Hypoglycemia
• Definition Low blood glucose levels
• Causes
• Neonatal and juvenile
• Septicemia
• Neoplasia
• Starvation
• Iatrogenic insulin overdose
• Portosystemic shunt
• Many others

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Insulin Shock

• Causes
• Insulin overdose (misread syringe)
• Too much exercise
• Anorexia
• Signs
• Weakness, incoordination, seizures, coma

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Insulin 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

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Insulinoma

• CAUSE tumor of beta cells, secreting an excess
  of insulin
• SIGNS prolonged hypoglycemia?weakness, ataxia,
  muscle fasciculations, posterior paresis, brain
  damage, seizures, coma, death,

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Insulinoma 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

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Insulinoma 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

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Insulinoma 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

92
Exocrine 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

93
Diagnosis 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

94
Testing 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

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Client considerations

• Usually life long treatment.
• Can be very expensive.
• Can be well controlled.
• Should not breed animal that has EPI.

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LIFE

• Smooth seas do not make skillful sailors.
• -African proverb

97
DISEASES OF THE ADRENAL GLANDS

• CUSHINGS DISEASE
• (Hyperadrenocorticism)
• ADDISONS DISEASE
• (Hypoadrenocorticism)

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Adrenal Glands
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ADRENAL GLANDS
mineralocorticoids Glucocorticoids Androgens
epinephrine
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Hyperadrenocorticism (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

101
Cushings 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

102
Cushings Disease
103
Cushings Disease
Bilaterally symmetrical alopecia, pot-belly,
pyoderma
104
Cushings Disease
Pot bellied PU/PD Muscle wasting Thin coat
105
Cushings 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)

106
Cushings Disease Calcinosis cutis
Commonly seen on the dorsal midline, ventral
abdomen and inguinal region. Skin is usually
thin and atrophic
107
Cushings 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

108
ACTH 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

109
Cushings 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)

110
Cushings 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)

111
Cushings 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)

112
Cushings Disease Rx

• 2. trilostane (Vetoryl)less side-effects than
  o,p,DDD
• -interfers with cortisol production (doesnt
  kill cells)
• -FDA approved

113
Cushings 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

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Addisons Disease (Hypoadrenocorticism)

• Definition Disorder caused by deficient
  production of glucocorticoids (cortisol) or
  mineralocorticoids (aldosterone) or both
• Secondary disease caused by chronic
  administration of corticosteroids

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Addisons 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

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Addisons 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)

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Addisons 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)

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What 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

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What is your Dx?

• ACTH Stimulation Test Results
• Value Normal
• Plasma Cortisol
• Pre-ACTH 0.2 2-6
• Post-ACTH 0.3 6-18

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Addisons 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

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Addisons disease Client info

1. Mineralocorticoid deficiency is life-threatening
2. Animal requires periodic blood tests
3. Glucocorticoids needed in times of stress
4. Always remind attending vet of pets condition
5. Hormone replacement therapy continued for life of
   pet
6. Prognosis Good to excellent after
   stabilization and treatment