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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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Life

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