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LIFE. “Smooth seas do not make skillful sailors.” -African proverb. DISEASES OF THE ADRENAL GLANDS. CUSHING’S DISEASE (__________________________) ADDISON’S DISEASE (__________________________). Adrenal Glands. ADRENAL GLANDS. mineralocorticoids Glucocorticoids Androgens

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slide1

LIFE

“Smooth seas do not make skillful sailors.”

-African proverb

diseases of the adrenal glands

DISEASES OF THE ADRENAL GLANDS

CUSHING’S DISEASE

(__________________________)

ADDISON’S DISEASE

(__________________________)

adrenal glands1
ADRENAL GLANDS

mineralocorticoids

Glucocorticoids

Androgens

Epinephrine

Norepinephrine

physiology
Physiology
  • Hypothalamus – Corticotropin realeasing factor (CRF) >>> ____________________________________________________________________(ACTH)
    • >>> ADRENAL CORTEX
      • _________________ hormone
      • __________________ hormone
      • ___________________ (Androgens)
  • SNS >>> ADRENAL MEDULLA >>> _____________ and ____________________
    • Increase HR, Inc. BP, Dilated air passages – lungs, dec. GI function, vasoconstriction
hyperadrenocorticism cushings disease
Hyperadrenocorticism (Cushings Disease)
  • Definition: Disorder caused by deleterious effects of ________________________ circulating cortisol concentrations on multiple organ systems
  • Systems affected: Pansystemic disease
    • Renal
    • Skin
    • Cardiovascular
    • Respiratory
    • Endocrine/metabolic
    • Musculoskeletal
    • Nervous
    • Reproductive
cushing s disease
Cushing’s Disease

Effects of excess glucocorticoids:

  • ____________________ inflammation
  • ____________________ immune system
  • ___________________ cartilage growth, development,

and repair

Causes:

  • ___________________________ (pituitary-dependent disease) – 85% of cases
  • ____________________________ (excess cortisol secretion independent of pituitary control) – 15-20% of cases
  • Overmedication with glucocorticoids -________________
cushing s disease2
Cushing’s Disease

____________________________, pot-belly, pyoderma

cushing s disease3

Cushing’s Disease

Pot bellied

PU/PD

Muscle wasting

Thin coat

cushing s disease4
Cushing’s Disease
  • signs are slow to develop and usually go unnoticed by owner

Clinical Signs:

  • Some are similar to hypothyroidism
  • Dog >6 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)
  • ___________________ (firm plaques of Ca++ under skin)
  • Abnormal gonadal function (lack of estrus; soft, small testicles)
cushing s disease calcinosis cutis
Cushing’s Disease: Calcinosis cutis

Commonly seen on the dorsal midline, ventral abdomen and inguinal region.

Skin is usually thin and atrophic

cushing s disease dx
Cushing’s Disease: Dx

Chemistry Panel

  • ↑ _________, _______________, _________________, _______________
  • ↓ BUN
  • Lipemia
  • ________________ USG < 1.015, proteinuria, hematuria, pyuria, bactiuria

Urine cortisol/creatinine ratios (sample collected at home)

  • Normal ratio=no Cushing’s
  • Elevated ratio= __________ be Cushing’s

ACTH Stimulation test

  • Normal patients show an increase of plasma cortisol
  • Pituitary dependent disease (excess ACTH release) and Adrenal tumors: 60-85% show ____________________________ cortisol response
  • Does _______________________ differentiate between Pit disease and Adrenal tumor
acth stimulation for hyperadrenocorticism
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
cushing s disease dx1
Cushing’s 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 ________________ in plasma cortisol
  • Pituitary tumor and adrenal tumor will not show any effect at 8 h (cortisol will still be __________________)
cushing s disease dx2
Cushing’s Disease: Dx

High-Dose Dexamethasone Suppression Test (used to ______________________ between Pit Dis and Adrenal tumor)

  • Dosing: 0.1 mg/kg IV
  • Collect plasma cortisol at 0, 4, and 8 h

Interpretation:

  • Pituitary dependent disease—70-75% will show __________________ at 4 or 8 h
  • Adrenal tumor—__________________ change in plasma cortisol level (tumor is autonomous)
cushing s disease5
Cushing’s Disease

ACTH stimulation:

Exaggerated response

Low dose dex

Normal: reduce

Pit/Adr tumor: high

High dose dex

Pit: Decrease 4, 8 hrs

Adrenal: No change

cushing s disease rx
Cushing’s Disease: Rx

_____________________ removal—

  • 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 (_____________________)

cushing s disease rx1
Cushing’s Disease: Rx

2. trilostane (Vetoryl®)—less side-effects than o,p,DDD

-interfers with cortisol production (doesn’t kill cells)

-FDA approved

cushing s disease client info
Cushing’s Disease: Client info
  • Serious disease; life-long treatment
  • Periodic monitoring required
  • Addison’s 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)
hard times

HARD TIMES

“In the depths of winter, I finally learned that within me there lay an invincible summer.”

-Albert Camus

addison s disease hypoadrenocorticism
Addison’s Disease (Hypoadrenocorticism)
  • Definition: Disorder caused by _________________ production of glucocorticoids (cortisol) or mineralocorticoids (aldosterone) or both
  • Secondary disease caused by chronic administration of _______________________
addison s disease hypoadrenocorticism1
Addison’s Disease (Hypoadrenocorticism)
  • Not as common as Cushing’s Disease; rarely seen in cats
  • Deficiency of Glucocorticoids and Mineralocordicoids
  • Clinical signs due to Mineralocorticoid (____________________) deficiency

Clinical Signs:

  • lethargy, weakness, anorexia, wt loss
  • Vomiting/Diarrhea
  • PU/PD, dehydration
  • _________________________________________
addison s disease
Addison’s Disease
  • Pathophysiology
    • Decreased aldosterone => Increased ____ and decreased _________________
    • => decreased volume =>_______________, hypotension, dehydration, weakness, depression
    • Hyper K => heart (____________________)
    • Glucocorticoid deficiency => vomiting, diarrhea, melena, lethargy, wt loss, hypoglycemia (less common than expected)
addison s disease dx
Addison’s Disease: Dx

Chem Panel

Na:K ratio <___________________ !!!(normal=27:1 to 40:1)

↑ BUN, Creatinine, Ca++

↓ blood glucose, albumin (less common)

ACTH Stimulation test (________________________ test)

normal dog= ↑ cortisol

hypoadrenocorticism dog= _______________ , unchanged cortisol level

Endogenous ACTH will be increased (1º hypoadrenocorticism; lack of neg feedback)

what is your dx
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

Na:K ratio 20 27-40

what is your dx1
What is your Dx?

ACTH Stimulation Test Results

Value Normal

Plasma Cortisol

Pre-ACTH 0.2 2-6

Post-ACTH 0.3 6-18

addison s disease rx
Addison’s Disease: Rx

Acute Crisis (may be life-threatening situation)

  • Normal saline IV (low _____________ is hallmark finding of Addison’s)
  • Glucorticoid replacement(cortisol will also be low)
    • Dexamethasone or Prednisone (IV or IM)
  • Mineralocorcorticoid replacement
    • ____________________ (fludrocortisone acetate)—po
    • _____________________-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
addison s disease client info
Addison’s disease: Client info
  • Mineralocorticoid deficiency is life-threatening
  • Animal requires periodic blood tests
  • Glucocorticoids needed in times of stress
  • Always remind attending vet of pet’s condition
  • Hormone replacement therapy continued for life of pet
  • Prognosis: Good to excellent after stabilization and treatment
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