Implications of delayed diagonis of Addisons?

[patp]

My Whippet, Willow, was diagnosed with Primary Addisons on 11th May 2012. Thanks to my vet, who diagnosed it straight away even before blood tests, she was admitted and stabilised.
Since then she has had a few blips and one of them involves the fact that the vet is worried about her liver enzymes.
People have advised me not to worry about this as it will all come right when Willow's electrolytes are in a good place. I fully understand this but wondered why the vet was concerned.
It came to me the other day that Willow had an Addisonian Crisis as long ago as July 2011! I made notes about the symptoms in a spare diary because she was so poorly. She was completly collapsed with rapid breathing. I took her to the vet but, by the time we got there, she had recovered. The vet did not know what was going on and gave her some pain relief (Metacam I think!!) and antibiotics.
She didn't show any more such severe symptoms but was lame on and off, lethargic and, at diagnosis, was vomiting.

Could the fact that she has obviously had Addisons for all this time have affected her organs in any way?

[Jo CIMDA]

It came to me the other day that Willow had an Addisonian Crisis as long ago as July 2011! I made notes about the symptoms in a spare diary because she was so poorly. She was completly collapsed with rapid breathing. I took her to the vet but, by the time we got there, she had recovered. The vet did not know what was going on and gave her some pain relief (Metacam I think!!) and antibiotics.
She didn't show any more such severe symptoms but was lame on and off, lethargic and, at diagnosis, was vomiting.

Could the fact that she has obviously had Addisons for all this time have affected her organs in any way?


Hi Pat. 

It is very, very unlikely that the crisis' will affect her long term.  Because She does not have primary, kidney, liver, heart etc.,  issues should all resolve when she is stable. It was only the effect of the low adrenal output that made her so ill. What dose of Florinef is she on? 

Many vets start on a low dose, which is normal, but some start on a dose that is  too low and often the vet is very reluctant to increase it.  What is her sodium:potassium ratio?  Some vets think if it is up to 27 then that's fine but generally a ratio around 33 seems to be common for a stable dog.  Of course all dogs are different and some may metabolise the medication differently. It will take 6 or more weeks at least to reach her optimum.  Stability is assessed by clinical signs, sodium and potassium ratio and other blood results.  All must  be taken into consideration and not just the ratio. Has your vet treated an Addisonian dog before?

I really wouldn't worry about any long term effects.  How is she in herself?

Jo

[patp]

Hi Jo
Thanks for the reply.
Willow is on two Florinef twice daily. She is also on one 5mg Prednicare twice daily.
She is due to go for another Lytes test tomorrow when I will pick the last Lytes test and get a new one. All I know about the last Lytes test was that the the Na was 138. They gave me that over the phone because the one before had been 136 and Willow was not doing very well. When the 136 test was done I was told to increase her Pred from 1 tablet daily to 1 twice daily. When the 138 test came back I was told to put some salt in her food. I give her a quarter of a teaspoon of salt twice daily and she seems much better.

The last lytes test I have is as follows:-

Na 136   Reference Range 136-156
K       4.4 Reference Range 3.4 - 5.4

That was done on 21st May.

She then had more blood taken to check her liver and pancreas. I asked for a Thyroid check which was done as well.

The results of those tests are not all back yet but I know her Na rose to 138. The Thyroid showed a problem on one test but was normal on another. The pancreatic test is not back yet.

Since introducing the salt Willow has been much better.

I am going tomorrow for another Lytes test and to hear the vet's opinion on all the blood tests. The vet did want to do a liver and possibly a pancreas scan but I asked her to wait until all the results were back first. I have asked for copies of all the last lot of bloods to be made available to me.

Pat

[Jo CIMDA]

Willow is on two Florinef twice daily. She is also on one 5mg Prednicare twice daily.


Hi Pat

The recommended initial dose of Florinef is 1.5 - 2 tablets per 10 kg of bodyweight a day. (0.015 - 0.02mg/kg day) as a single dose or divided and given twice a day, adjust dosage by 0.05 - 0.1 mg until soduim/potassium values are within range and clinical signs have resolved.  (Plumb's Veterinary Drug Handbook) 

My memory recalls Willow is 19lbs (8.63 kg - but I could be wrong) if this is so then she is on a lot of Florinef.  Was this the initial dose or has it been gradually increased over weeks?  Do you think a mistake could have been made giving it twice a day instead of only once? 

Also the replacement dose of prednisolone is beetween 0.2 - 0.5mg/kg once daily (BSAVA Manual of Canine and Feline Endocrinology).  When the dog is stable this can be withdrawn and only given at times of stress. Willow is having 10mg of pred a day and really one half to one 5mg tablet of prednisolone should be more than adequate, especially as she is having a lot of Florinef. (9kg bodyweight= 1.8 - 4.5mg per day prednisolone)

Once a dog is stable and it is having sufficient Florinef, then there should be enough glucocorticoid (prednisolone) within the Florinef to keep the dog stable on a day to day basis without additional prednisolone being given. 

She is due to go for another Lytes test tomorrow when I will pick the last Lytes test and get a new one. All I know about the last Lytes test was that the the Na was 138. They gave me that over the phone because the one before had been 136 and Willow was not doing very well. When the 136 test was done I was told to increase her Pred from 1 tablet daily to 1 twice daily. When the 138 test came back I was told to put some salt in her food. I give her a quarter of a teaspoon of salt twice daily and she seems much better.

*****I do wonder if she is not doing so well because she is on too high a dose of both preds and Florinef?  What were the clinical signs of her "not doing so well"?

Although salt can be a good addition initially at a dose of 0.1mg/kg/day (BSAVA Small Animal Endocrinology) it is often not needed when the dog is on sufficient Florinef and stable. Maintaining a dog with Addison's disease is all about achieving the optimum Florinef dose for that dog and giving Pred at times of stress.  If the Florinef dose is right then it is unlikely you will need the addition of salt.


The last lytes test I have is as follows:-

Na 136   Reference Range 136-156
K       4.4 Reference Range 3.4 - 5.4

That was done on 21st May.

*****If you divide 136 by 4.4 that give a ratio of 30.9, which is fine but clinical signs have to be considered. 
Consideration has to be given to the fact that the clinical signs you are seeing may not be Addisons but slight Cushing's due to too much medication.

Good luck tomorrow.

Jo

[patp]

Thanks Jo
Willow weighs 10.7 kg at the moment but is usually around 11.5kg.

The latest lytes I have are from the 22nd
Na 138   Reference range 136 - 156
K    4.6    Reference range 3.4 - 5.4
Cl   121         "            "      96 - 122 (what is Cl please?)

The Bile Acid Stim Test came back normal according to the vet

The thyroid test is:-

Canine Total T4  5.11  normal range 10.00 - 50.00
Canine TSH         0.06       "        "      0.05 - 0.60

The vet tells me that dogs that are poorly often have low thyroid results and she is not too worried. She said she will do another test in a couple of weeks.

I am awaiting my copy of the full blood screen done the day before yesterday. The vet was happy with the lytes but said the red blood cells were low and white cells were up which were indicative of an infection (she had vomited and passed very loose stools that morning).

I checked that the dosage Willow is having was correct with both the Florinef and the Prednicare.

Willow is well in herself. Hungry but fussy what she eats. Not overly thirsty. As I am usually up in the night I let her out for a wee and she always wants to go. The only not normal thing at the moment is very smelly wind and quite a lot of it. Considering she is on Stormagyl for her V&D I wondered if that would cause the wind?

[Jo CIMDA]

Willow weighs 10.7 kg at the moment but is usually around 11.5kg.

The latest lytes I have are from the 22nd
Na 138   Reference range 136 - 156
K    4.6    Reference range 3.4 - 5.4
Cl   121         "            "      96 - 122 (what is Cl please?)

Hi Pat

Her Na:K ratio is 30 and that is good.
Cl is chloride - another electrolyte.  It is usually low in a dog with un diagnosed Addison's.
---------------
The thyroid test is:-

Canine Total T4  5.11  normal range 10.00 - 50.00
Canine TSH         0.06       "        "      0.05 - 0.60

The vet tells me that dogs that are poorly often have low thyroid results and she is not too worried. She said she will do another test in a couple of weeks.

****** because the TSH is low and she has Addison's disease the results indicate what is called a non-thyroidal illlness and it should all go back to normal once she is stable. I would guess if she had a FT4 test done it would be within normal range

------------------------
I am awaiting my copy of the full blood screen done the day before yesterday. The vet was happy with the lytes but said the red blood cells were low and white cells were up which were indicative of an infection (she had vomited and passed very loose stools that morning).


***How low is the red blood cell count? Is the vet treating Willow for an infection?
--------------
I checked that the dosage Willow is having was correct with both the Florinef and the Prednicare.

****Our figures don't tally on this.------------------------
Willow is well in herself. Hungry but fussy what she eats. Not overly thirsty. As I am usually up in the night I let her out for a wee and she always wants to go.

***It will be the steroids that make her want to wee.-----------------
The only not normal thing at the moment is very smelly wind and quite a lot of it. Considering she is on Stormagyl for her V&D I wondered if that would cause the wind?

****It sounds like her gastric system is out of balance and perhaps this is making more wind.

Jo

[patp]

I presume that as her Na:K ratio is good that is why the vet is happy to leave her meds alone? Perhaps a little further down the line she will want to reduce them??

Willow is also getting a quarter teaspoon of salt twice daily in her food. This seems to have lifted the Na into the normal range.

The vet thinks the high white cell count is due to an infection (GI). She gave Willow Stomorgyl for this.

She did not say much about the red blood cell count and why it might be low. Mind you Willow has had so much blood taken lately that I am not surprised!!
Would a diet of white meat and fish (all she has been eating) have affected that? I have introduced eggs recently.

[Jo CIMDA]

I presume that as her Na:K ratio is good that is why the vet is happy to leave her meds alone? Perhaps a little further down the line she will want to reduce them??

****Yes, perhaps.  Usually the treatment is started on a low dose of Florinef and prednisolone, and the Florinef is increased according to the results of the electrolytes and clinical signs and when stable the prednisolone is decreased or stopped altogether and only given at times of stress. It isn't usually started on a high dose and then reduced.
-------------
Willow is also getting a quarter teaspoon of salt twice daily in her food. This seems to have lifted the Na into the normal range.

****As she is on a lot of florinef I am surprised that she needs the salt.  The mineralocorticoid (Florinef) increases the absorption of sodium.

Salt supplementation, if needed, is given at 0.1mg/kg/a day (BSAVA Manual of Small Animal Endocrinology).  Willow is 10kg so that means she should be having 1mg of salt supplementation a day. I have never done this before but I have just weighed 1gm of salt and it measures 1/8th of a teaspoon.  So willow is having far too much salt supplementation
-------------------------
The vet thinks the high white cell count is due to an infection (GI). She gave Willow Stomorgyl for this. 

****White cells can be raised because of an infection or an inflammatory response to something.
-----------------
She did not say much about the red blood cell count and why it might be low. Mind you Willow has had so much blood taken lately that I am not surprised!!

It probably isn't that low then. Addison's can cause the red blood cells to be low

------------
Would a diet of white meat and fish (all she has been eating) have affected that? I have introduced eggs recently.

**** No that diet would be very good for her.  As long as the white of the egg is cooked that is fine too.

Jo

[patp]

The Florinef did start at 1 twice daily and the pred was 1 daily. She was on this dose for about a week following diagnoses.

I had to take her in to the vet, as she was trembling and lethargic, and it turned out her lytes were out. They increased the Florinef by and extra one and the pred by one.
At home, I was very tired, and made the mistake of giving Willow an extra one twice daily instead of once daily so that she was on two Florinef twice daily and one pred twice daily.
Once I realised what I had done I told the vet and she said it was fine as Willow had stabilised.

She has been fine the last couple of days, apart from the wind(!). so I think the antibiotics are working. I have seen a nearly normal poo and she is eating well.

I'm sorry if I am giving you info in a backwards manner but this situation with Willow is frying my brain........

[Jo CIMDA]

Hi Pat

It is very early days yet and is is very stressful getting to know all about having a dog with Addison's disease.  Within a few months you will become so familiar with the management of Willow's Addison's that life will become much less stressful and everything will settle down.  I can understand why it is 'frying your brain'.

Jo

[Lovemedogs]

Hi Pat,
How is Willow doing now ?

My vets start their AD dogs off with 0.1 mg / 10 lb weight. I know of very few, if any, dogs that do well with a lower dose than this. My vets now have more than a dozen AD dogs in their practise so they have plenty or experience with this.

I rarely ever salted TJ's - my AD dog - food as such. I used to mix in a little bit of  bacon or mix up some gravy using saltier gravy powder or oxo.

Have you been able to reduce the pred yet ?

Hope Willow is doing well.

Pam

[patp]

Hi Pam
In herself Willow is doing really well.
The terrible wind stopped when I cut her meals down from 4 or 5 per day to 3. I have also gradually weaned her back on to a complete food and she refuses to eat more than an adequate amount of that.

We are due to have more bloods taken on Wednesday and I think the vet will start to reduce the Prednicare then. Willow is drinking and weeing lots and the vet says this will stabilise when we reduce the Pred.

I would like her to eat more but she has never been easy to feed. Because we travel a lot in our motorhome we have to use a complete food. Mostly this is Burns but I have tried several of the quality brands to see if she will eat more. Even if she eats well to start with she soon tails off. So frustrating. I have also tried various wet foods like Burns Penlan Farm and Nature Diet etc all to no avail.
When I was feeding a home cooked bland diet she ate very well and gained weight.
She is being obsessive about asking for food but not about eating the complete.

[patp]

Willow has just had her fortnightly check up and blood test.
Her lytes are spot on but her white blood cell count is still up. She has had one lot of antibiotics for this but although one kind of wbc's reduced another kind went up. The vet has prescribed a different course of antibiotics. There is no sign why her wbc's are high apart from her fussy eating habit. I bought some Nature Menu today and she ate that really well. It is expensive and I feel sorry for my old lurcher that she can smell it but not eat it (she is on Burns).
The vet has said to reduce the Prednicare from one twice daily to half twice daily from tomorrow. I hope the drinking and especially the weeing will now reduce!
Another result that is high is ALB. What is this? The vet did not comment on it.

Pat

[Jo CIMDA]

Hi Pat

What is Willow's sodium and potassium ratio?  I am glad the vet is reducing her prednisolone.  Her drinking and weeing should decrease a bit.  The albumin can increase when a dog is dehydrated.  Are you sure the ALB is increased and not decreased? Does she have any other resutls out of the reference range?

Jo