Medication levels advice

[elemoy]

Hi, we have a 19mth old toller who was diagnosed with Addisons, in April last year. Approximately 3 weeks ago he had a blood test as we were concerned that his florinef levels may need adjusting and it came back that they needed to be upped to five 0.1mg tablets a day(had previously been on four). A follow up blood test was done earlier this week.
I have taken him into the vets this morning as he has been having mild tremors, was off his food and was very stiff on his back legs. Heart rate normal, temperature a little high. He has dropped 2kg (previously 16.4kg - has always been a slight build) since last weigh in also but exercise and feeding amounts have not changed.
We saw a vet who hasn't dealt with him before (there is a core of vets at the practise who deal with him regularly and have done since diagnosis). She mentioned that the blood tests were back and that level of florinef would need to be upped (6 x 0.1mg per day), i questioned this so soon after they had last gone up and she said not to up the medication today and to bring him back tomorrow to see how he was getting on. I asked whether she thought the tremors were crisis related and her response was ' i hope not' and that she thought they could be related to the high temperature.
I plan to attend the main branch of the surgery later on today if tremors continue so he can be seen by a vet with previous knowledge of him.

Is this level of medication the norm? Am i right to worry that symptoms described above could be crisis related?

As a sidenote, he is also on a third of a mestinon tablet per day following a diagnosis of Myasthenia Gravis in May this year.

[Jo CIMDA]

Hi

I'm sorry your Toller is having these problems.  Muscle tremors are a sign that perhaps his Addison's is not under control at the moment and if the blood tests confirm this then perhaps your vet is right and should treat it as such.  The dose of Florinef varies depending on the individual and it is not unusual for the dose to be increased as time goes on. 

From: Plumb's Veterinary Drug Handbook: Usual starting dose is: 0.015 - 0.02mg/kg/day (1.5 - 2 tablets per 10kg bodyweight) either as a single dose or divided twice a day. Most dogs will ultimately require 0.02 - 0.03mg/kg/day (roughly 3-5 tablets for a 16 kg dog). 

Are you vets basing their decision to increase the Florinef on his sodium/potassium ratio?

I wonder if he has an infection too. It might be prudent for your vet to give some antibiotics just as a precaution. Sometimes an infection can upset the balance of Addison's disease. If he has an infection at the moment then perhaps he needs some supplementation with prednisolone (cortisol).  Do you give a replacement dose of prednisolone at times of stress? The usual replacement dose is 0.2mg/kg/24hrs - Plumb's Vet Drug Handbook. (Note: This is not a treatment dose for AI disease that may cause muscle weakness)

If a dog goes into an Addisonian crisis then the temperature would usually be normal or slightly lower than normal and not higher.

It is unlikely he will go into a 'crisis' as he is having some Florinef but it is not unreasonable to think that his clinical signs suggest that his meds need tweaking up a bit, but improvement should reflect in the sodium/potassium ratio and improvement in clinical signs. 

Myasthenia Gravis is another autoimmune disease. Have you asked your vet if his Mestinon dose needs adjusting or could the drug causing muscle weakness?  Perhaps you could ask your vet if  Mestinon can have some effect on his treatment for Addison's or vise versa?  I can't find any reference to this but sometimes these sort of  questions makes the vet consider other posibilities/options.

Sadly I have known other Tollers with Addison's disease and other AI disease such as polyarthritis.

Good luck.  I hope he is much improved tomorrow.

Jo