Oscar, definitely Addisonian.... but I suspect something else, too

[Beverleycuddy]

The blood test was performed just before he went on a drip, I did ask - we were expecting catastrophic Na/K ratio as we all assumed he was in a crisis.

[Jo CIMDA]

Hi Beverley

I wonder if Oscar has another autoimmune disease - IBD (inflammatory bowel disease)?

His red blood cells will show higher than they actually are if he was dehydrated.

http://www.peteducation.com/article.cfm?c=2+2090&aid=305

One of my dogs had episodes of becoming severely dehydrated - without any prior tell-tale signs.  Luckily we were with him every time.  The first time I took him to the vet and he survived with IV fluids.  We never found out why this happened.  It cost me £600 for an overnight stay but they did save his life. He was an AI dog in remission, and he also went on to develop hypoT when he was about 8 years old but it was very well controlled.

He had about 4 more episodes after that and each time I managed to bring him around by syringing electrolyte solution into his mouth and just waiting for him to respond - which usually took about 20 minutes.  He was an old boy of 14 when he had his first episode and he lived until he was fifteen and a half.   I would never be without electrolyte solution.    I realise this may not be as simple in a medicated Addisonian dog.

Jo

[Lovemedogs]

Hi Beverley,
Have you got the batch number of the vial of percorten you had that you think was dodgy ? There has been some concern from a few people that one or two specific ones may have been compromised in some way. I can find out if yours is from the same batch.

How is Oscar doing now ?

Pam

[Beverleycuddy]

Got so many bottles here!

Here's some, can't remember which was the dodgy ones!

B145070 - used 3 times
B145070 - used only once as suspicious not properly shaken - think dog unwell after this
B145127 - used July and August
B145127 - used June & July
B145127 - used Sept/Oct

[Beverleycuddy]

Oscar latest:

We've sent off his blood for testing for VWD and Thyroid.

Wolfgang has started us off on Thyroid drugs as he'd a consistently low result and physical symptoms so we'll see if it helps while waiting blood results.

We didn't send the blood to the US and I am unsure how good the lab will be that Wolfgang usually uses but for speed we went with that this time, we couldn't figure out the way of sending the blood to the US - the red top container was supposed to be used, but the blood was meant to be left to clot for 30 mins and in one of the red to tubes Wolfgang gets, that would be impossible. I am going away on holiday and wanted Oscar to be stable before I went, so I was keen to press on. He'd had an upset tum for two days despite the most restricted diet possible and the worry of that happening again while I was away spurred me on to try to get him sorted, as the hunch is all the clotting, digestive upsets could all be due to him being Hypothyroid. He also has mood swings, the more I've read about hypothyroid the more I've recognised the changes in Oscar. Let's see what the blood tests say and if they're inconclusive we'll keep on the meds and send the blood to the states before abandoning this idea.

But, I did realise that the drugs I had been given had the wrong instructions when I checked the data sheet and I'd like some advice as to whether the level of drug is odd, too?

He's a 32kg Beardie male 9 years old.
He's been prescribed 400 mcg of thyforon

The label said one a day with food.

Data sheet says twice a day as the drug has only a 12 hour life.

So I've split it into half and giving it twice a day.

It says on the label to give with food but Jean Dodd's book is clear that it should not be given with food.

At present I am giving it an hour after food as he has two meals a day. Is this okay or does he need to eat at the same time or after the drug?

And should it be 400mcg twice a day?

Should we be building up slowly or not?

Slightly nervous of asking the vet as it sounds like they cocked up the label or have been giving it wrong all this time. Nurse on reception said this was a new drug for them, it is a palatable chewable one - so maybe the give with food thing is more up to date than Jean's Thyroid book?

Would love some help? Is this a very low dose? Are we unlikely to see much change as it is so low? (i.e. Has he just given me this to shut me up as I was worrying!!)

[Catherine]

Beverley, Thyforon is being prescribed by vets because there is a problem with the usual drug, Soloxine which is hard to find at the moment. It is very confusing and my vet initially prescribed too much so try not to be too hard on your vet's mistake. But I would get back to them just to try and confirm things. The problem, I found was the "mcg" instead of the "mg" there was with the Soloxine. But just try and think of the "400mcg" as being 0.4mg!

It has been my experience over the years that the thyroid medication (Soloxine OR Thyforon) is best given TWICE daily in equal doses if possible and at 12 hours apart as much as possible. Also do not give it with food. So allow an hour or so before feeding to give it or about 4 hours after feeding before giving it.

Also retest a month or so after starting the thyroid medication to see how things are going. Remember though that the dog has to be retested 4-6 hours post pill.

Also I am not sure, if there are any special precautions to take with a dog with Addison's or if Oscar is on any other drugs so you will need to take advice for that.

No, 400mcg twice a day would be too much, it would be more like 300mcg twice a day that he needs. BUT it is always best to start low (especially as Hypothyroidism has not yet been confirmed) so the 400mcg prescribed (200mcg TWICE a day) is probably correct. Always be aware of the signs of Thyrotoxicosis though.

Hopefully you should see some improvement in Oscar even with a smaller dose but some of the changes may take time.

[Jo CIMDA]

HI Beverley

The labs in the UK are generally very good and trustworthy. 

Your vet has started Oscar on a low dose but this is correct and hromones should be gradually increased.  It will likely have some effect even if it is low. Hormones should always be gradually increased or decreased.

I like to convert mcg to mg as I find it easier to comprehend.

The usual starting dose for a dog of Oscar's size would be 0.32mg twice a day and he is only on 0.4mg a day so if Oscar's results confirm that he is hypoT then over time the dose will likely be increased, but individuals absorb and utilise levothyroxine at different rates and some dogs ultimately need more and others need less.

Splitting the dose and giving it every 12 hours gives a more even distribution of thyroid hormone throughout a 24 hour period and it eliminates peak and troughs of thyroid hormone. I have a graph from the BSAVA Manual of Small Animal Endocrinology,  that shows the difference between giving Levothyroxine every 12 hours and every 24 hours.

For example, if the normal reference range is between 20-45,

the whole dose given once every 24 hours will reach peak hormone level (according to the Thyforon data sheet, see link below)  after about 3 hours  and that measurement will be something like 110.

It will then steadily decline until the next dose is due, and the level of thyroxine at this time dips to about 40.

If the tablet is given every 12 hours, the peak serum level after 3 hours is about 65 and it dips to about 45 after 12 hours; just in time for the next due dose.

(with the brand 'Soloxine' peak serum time is 4-6 hours)

Food can inhibit the absorption of the hormone but some owners may not be able to give it one hour before food twice a day.  It is more important to be consistent so some people give the pills with food and other give on an empty stomach and as long as the blood levels are good and the dog's clinical signs are fine then you can do whatever is convenient.  Perhaps giving it will food means a slight higher dose is needed - who knows?  Giving it one hour after food is the same as giving it with food.  It has to be at least two hours after food to have any significant effect.

See this link:

http://www.noahcompendium.co.uk/Dechra_Veterinary_Products_Limited/Thyforon_ACY-reg_ADs-_Flavoured_Tablets_for_Dogs/-58777.html

Jo

[Penel CIMDA moderator]

Here's the graph.
http://cimda.co.uk/smf/index.php/topic,124.0.html

[Beverleycuddy]

Well, my vet has done a blood test, I did ask for him to send the blood to the US for Jean Dodds to test but on the day he realised the container he had was the wrong one as his red top containers would not have enabled the blood to clot, as required,  so rather than delay he used his usual lab to test – which was not Axiom which was the UK lab Jean had specified and I fear we have had a very limited thyroid test indeed. The test for VWD also failed as the sample was not up to the level on the tube so it was rejected. I am disappointed as the bill was £400 for these two tests and I wanted them done as well as possible.

Because of my concerns (Oscar's unexplained large unresolving hematoma and his slow APTT, weight gain despite calorie restriction and frequent stomach upsets, some mood swings and a noticeably enlarged neck) we had started giving Oscar 400 mcg of Thyforon and I felt he seemed already slightly improved after only a few days – but I may be looking through rose coloured spectacles!

My vet thinks the following blood test results mean we should stop giving the drug but retest for VWD.

Would love to know what you think we need to do another broader thyroid test, at a different lab and which specific tests we need to do and if you think we should stop giving the tablets.


Here are the results:





Hi Beverley,

Oscar's Thyroid results are as followed:

HAEMATOLOGY
Anti-thyroglobulin
antibodies
NEGATIVE

BIOCHEMISTRY
Test Result Alert Units Reference Range
*Thyroxine nmol/L
(Microgenics)
19.8 13.0 - 51.0

ENDOCRINOLOGY
Test Result Alert Units Reference Range
*Canine Serum TSH 1.11 High ng/mL 0.00 - 0.50
*Free T4 (Immulite) 14.4 pmol/L 7.7 - 47.6
Normal T4 and Free T4 indicate normal thyroid function.

The increased TSH may reflect recovering from systemic diseases, or the effect of drugs
(steroids, sulphonamides, anticonvulsants).
This pattern of results may be seen in the early stages of hypothyroidism, where TSH is
elevated to drive the remaining thyroid tissue to maintain the serum T4 concentration.
This would however be unlikely to be associated with advanced clinical signs of
hypothyroidism.

With kind regards

[Catherine]

Beverley, is Oscar still having Preds.? If so that would probably muddy the thyroid results.
Has Oscar had a full haematology and biochemistry blood test recently? Sometimes when the thyroid is on the low side the cholesterol and the ALT and the GGT are elevated. Also sometimes the PCV will be lower, a mild anaemia.
I am amazed at how quickly you got the results. We always have to wait over a week for a Free T4 result back!
Do you have a number for the antibodies test? I think the lab. level we had was under 200 so something like 199 would come up negative!
I know of at least two Bearded Collies that have been borderline HypoT and that improved when put on thyroid medication. I also know of other breeds that have been borderline.
On the one hand one must not rush and give medication and think every problem is HypoT but at the same time just because figures are still in the normal range a person does not medicate.
As the dose Oscar is on is a low one you could continue and see if his other problems go away.

[Beverleycuddy]

That is all the results that my vet forwarded me, sadly!

Jean Dodds has come straight back with a completely different interpretation to my vet's!

Dear Beverley:  Hello ! The total T4 and free T4 are both sub-optimal for his breed and age and TSH is high—so I would continue his thyroid medication but at a lower dose [e.g. 200 mcg Thyforon twice daily; given apart from meals and treats containing calcium or soy to ensure absorption] = a total of 400 mcg daily divided into 2 doses. Perhaps that is what he has been taking. Continue other medications too.   Warm regards,   Jean

Oscar is on a very low dose of Pred - 1mg a day.

He hadn't heard of Jean so I enclosed this biog of her with her reply, it is kind of impressive isn't it!

Dr. Jean Dodds received the D.V.M. degree with honors in 1964 from the Ontario Veterinary College, University of Toronto. In 1965, she accepted a position as a Research Scientist with the New York State Health Department. She began comparative studies of animals with inherited and acquired bleeding diseases. Eventually, her position culminated as Chief, Laboratory of Hematology, Wadsworth Center. In 1980, she also became Executive Director, New York State Council on Human Blood and Transfusion Services.
This work continued full-time until 1986 when she moved to Southern California to establish Hemopet, the first nonprofit national blood bank program for animals.
The diagnostic division of Hemopet, Hemolife, provides the most advanced comprehensive diagnostic profiles for identifying canine thyroid disease, performs titer testing, as well as a wide range of other diagnostic services. Hypothyroidism is the most common endocrine disorder of dogs. More than 80% of cases result from autoimmune thyroiditis, the heritable autoimmune disease that progressively destroys the thyroid gland. Classical clinical signs of hypothyroidism only appear once more than 70% of the gland is destroyed. Accurate diagnosis may be difficult because thyroid dysfunction produces a wide range of clinical signs, many of which are subtle and mimic those of other causes.
Dr. Dodds also assisted Antech Diagnostics to establish its IFA testing method (published in JAVMA 2000) and with its thyroid testing antibody profiles.
Dr. Dodds is very well-known for her minimum vaccine protocols and as Co-Trustee of The Rabies Challenge Fund. She provides an FAQ on the subject and has authored several articles such as "Changing Vaccine Protocols".
Dr. Dodds co-authored The Canine Thyroid Epidemic: Answers You Need for Your Dog, which was rewarded the Dog Writers Association of America, Best Care and Health Book for 2011 and the Eukanuba Maxwell Canine Health Award. Her second book, Nutrigenomics: Foods that heal your dog, was published in January 2015.
In 2011, Dr. Dodds released NutriScan, a food sensitivity and intolerance diagnostic test for dogs. NutriScan tests for twenty of the most commonly ingested foods.
Notable
• Grantee of the National Heart, Lung, and Blood Institute (NIH) and has over 150 research publications.
• Former President of the Scientist's Center for Animal Welfare
• Former Chairman of the Committee on Veterinary Medical Sciences, National Academy of Sciences
• Former Vice-Chairman of the Institute of Laboratory Animal Resources, National Academy of Sciences
• Former member of the National Research Council/BANR Committee on National Needs for Research in Veterinary Science, which released its report in July 2005
• Board of Directors of the American Holistic Veterinary Medical Association
• Board of Directors of the American Holistic Veterinary Medical Foundation
Awards
• 1974: Outstanding Woman Veterinarian of the Year, AVMA Annual Meeting
• 1977: Region I Award for Outstanding Service to the Veterinary Profession from the American Animal Hospital Association
• 1978 and 1990: received the Gaines Fido Award as Dogdom's Woman of the Year
• 1978: Recognition of Special Contributions to the Veterinary Profession from the American Animal Hospital Association
• 1984: Centennial Medal from the University of Pennsylvania School of Veterinary Medicine
• 1987: Distinguished Practitioner of the National Academy of Practice in Veterinary Medicine
• 1994: Holistic Veterinarian of the Year Award from the American Holistic Veterinary Medical Association
Patents
U.S. Patent 5,196,311   ELISA Test for von Willebrand Factor
U.S. Patent 5,202,264   ELISA Using Multi-Species Antibodies for Detection of von Willebrand Factor in Multiple Species
U.S. Patent 5,486,685   Oven with Food Presence Indicator
U.S. Patent 5,830,709   Detection Method for Homologous Portions of a Class of Substances
U.S. Patent 6,287,254   Animal Health Diagnostics
U.S. Patent 6,537,213   Animal Health Care, Well-Being and Nutrition
U.S. Patent 6,730,023   Animal Genetic and Health Profile Database Management
U.S. Patent 7,029,441   Animal Health Care, Well-Being and Nutrition
U.S. Patent 7,134,995   Animal Genetic and Health Profile Database Management
U.S. Patent 7,548,839   System for Animal Health Diagnostics
U.S. Patent 7,552,039   Method for Sample Processing and Integrated Reporting of Dog Health Diagnosis
U.S. Patent 7,794,954   Detection and Measurement of Thyroid Analyte Profile
U.S. Patent 7,797,145   Animal Health Diagnostics
U.S. Patent 7,799,532   Detection and Measurement of Thyroid Hormone Autoantibodies
U.S. Patent 7,865,343   A Method of Analyzing Nutrition for a Canine or Feline Animal
U.S. Patent 7,867,720   Food Sensitivity Testing in Animals
U.S. Patent 7,873,482   Diagnostic System for Selecting Nutrition and Pharmacological Products for Animals
U.S. Patent 8,060, 354  System and Method for Determining a Nutritional Diet for a Canine or Feline Animal