Any advice for new Addison's diagnosis?

[Nathan13]

Hi,

Our 3 year old Miniature Labradoodle, Colin, has very recently been diagnosed with Addison's disease.  Over Christmas he showed many of the symptoms related to the condition - loss of appetite, vomiting, lethargy, tremors... and following several days as an 'in-patient' at the vets received his diagnosis. 
He has had an initial injection of Zycortal and is on a daily dose of Prednisolone, which apparently the vet will be working on achieving the right levels over the next few months.

I just wondered if anyone is able to offer any advice from their experiences of dealing with a diagnosis of Addison's?

[Jo CIMDA]

Hi and welcome

I'm sorry Colin has Addison's disease, but well done to your vet for getting a diagnosis. They deserve to be congratulated.  I hope you don't mind but I will take this opportunity to update others about Zycortal.


You probably know that the use of Zycortal (Percorten V) in the UK is a new treatment for controlling the mineralocorticoid deficiency in an Addisonian dog.  Before April 2016 a daily tablet/s of Florinef were given to replace the mineralocorticoid hormone, so with this in mind the vets in the UK are still on a steep learning curve regarding this new injectable treatment - and by all accounts so is the manufacturer, Dechra. 

There is a lot of information on-line about Zycortal, much more than there was when it was first introduced, and I believe that Dechra have also learned that the dose recommended in their Zycortal drug sheet is far higher than needed and this has delayed stability in the treatment of dogs with Addison's disease in the UK.  It has also cost the owners a lot more money in regular blood tests too.  American vets have used Percorten V for a long time with much success, but I have it on good authority from a Vet in the US that the starting dose they use is 1.1mg/kg and not 2.2mg/kg as the Zycortal drug sheet recommended. 

As a result of this higher recommended Zycortal dose, in general, the Addisonian dogs in the UK have not stabilised as well as expected and apparently Dechra are now recommending that the dose is lowered and this should now be gauged by individual electrolyte values (sodium and potassium) and not the ratio of the sodium and potassium as previously recommended.  Apparently there are now on-line tutorials for vets,  but I recommend you ask your vet to call the help line at Dechra and they will be able to discuss Colin's treatment and you will have direct guidance from the manufacturer. I feel very sorry for the UK vets because this was dumped on them with no real choice because in April, as Zycortal was launched, the previous drug used (Florinef) was priced out of the market.

I urge any owner who has a dog with Addison's, and has not yet established the correct monthly dose to keep the electrolytes at a good stable level, to ask their vet to telephone Dechra and discuss the individual case with Dechra's vet dealing with these enquiries. Thus far, the information I have regarding the dogs I know who started Zycortal in April has been that none of them have yet reached the desired level of electrolyte ratio nor an interval duration of approximately one month, they have all gone on having regular blood tests up to 8 weeks after the injection and I believe for this reason Dechra are recommending the vet looks at the individual values of sodium and potassium and not the ratio - and please don't forget the clinical signs, these are just as important.   The more your vet looks into this the more he or she will learn and this will benefit newly diagnosed Addisonian dogs in future.

I also have it on good authority from someone who has spoken to Dechra and the Veterinary Medicines Directorate (VMD) that Dechra are now saying that Zycortal was intended for use on newly diagnosed dogs only and not those already stabilised on Florinef. This statement is more than 6 months too late, especially for those poor dogs who were stable but did not respond well to Zycortal.   If this is so then why did the cost of Florinef increase in April from the lowest price I know of which is £6.00 per one hundred tablets up to £200+ per one hundred tablets?  Also, now there is a licenced veterinary product (Zycortal) the vet is obliged to use this as opposed to the previously used human product (Florinef).  Any owners or vets wanting to switch back to Florinef will have to get permission from the VMD to use it now.  This is known as the 'Cascade'. It is generally not a problem because there should always be good clinical reasons for using a human drug in a veterinary setting, although switching back to Florinef may be prohibitive due to the now very high cost of the drug.

As for your Colin - the good news is he has been diagnosed, and now your vet has to determine the correct dose of Zycortal to stabilise the electrolytes for a duration of one month.  It really does work well in the US, and has done for many years, but as yet in the UK it seems that the best protocol for Zycortal has yet to be established, and of course it has to be tailored to the individual.   Your vets were on the ball to diagnose Colin so I expect they will very keen to learn more about this new treatment.

The daily dose of prednisolone should be reasonably easy to establish but you have to remember in stressful situations Colin might need a tad more prednisolone to cope. I suggest you always take a prednisolone tablet with you on walks etc., just in case you need it.

Jo

[Nathan13]

Thanks Jo - really useful to read the background on Zycortal.  Our vet seems 'on the ball' in terms of dealing with Addison's, so fingers crossed that we will manage Colin's dose quickly. 

[Lovemedogs]

Hi Nathan,
How is your dog doing now ?

It is a great shame that Dechra have not go this right, but if your vet is willing to look at the individual figures for the Na and K, that will be much better than looking at the ratio. I have found over the last 19 years of being around dogs with Addison's disease, that most dog feel better when their K is close to the middle of its reference range.
Also, our Adog, do much better with a low dose of pred each day. It is surprising just how low a dose our dogs do best having.

Do ask any question you may have.
I recently updated an article I wrote for dogs changing over from florinef to Zycortal, but much of it, would apply also to newly diagnosed dogs being started on Zycortal.

Pam

[angela.piggott]

Hi Jo
I've just found and joined the site.

My (Standard) Labradoodle, Harry, is 9 and was diagnosed a year ago with Addisons, after a lengthy diagnostic journey! He has had blood tests and injections on a monthly basis (Zycortal is now 2.25 and Prednicare tablets 5mg halved, per day). He seems relatively fine in himself and his dreadful food craving has lessened - attributed to the reduction of tabs. However he has developed over time a steady a loss of hair, and now looks a poor old chap.

The worst areas are along his spine, his haunches, armpits and tail. My vet says it's part of the symptoms but I would greatly appreciate any advice and suggestions you may have ,as to how this can be reversed or managed.

My thanks in anticipation
Angela

[Catherine]

I expect Jo will be along soon. Meanwhile, has Harry been tested for Hypothyroidism recently?  If you do test, being on the Preds may cloud the results so it may be best to ask your vet about that.

Some information here: http://cimda.co.uk/smf/index.php/topic,18.0.html

[Jo CIMDA]

Hi Angela and welcome

I am sorry your Harry has Addison's.  When an Addisonian dog is being well controlled he should look and behave as a normal dog, only having to give more pred at times of stress.  So the hair loss and any other symptoms that contribute to Harry looking old is likely to be due to poor control of his Addison's eg., perhaps the dose of Zycortal is too high.

Do you have Harry's blood results?  I am surprised he is still on 2.25mg/kg of Zycortal. I presume this is given every month.   This was the initial starting dose as per the drug sheet when Zycortal was introduced two years ago but since then it has been generally accepted that this dose is too high and the current thinking is a better starting dose of 1.5mg/kg is the norm now, and then adjusted as necessary.   

All the dogs I have known to have started on 2.2mg/kg have had the dose gradually reduced because the sodium and potassium ratio after one month is too high.  Usually if this is higher than ideal (>34)  then the next dose may be delayed for a week until another blood test indicates that the next dose is needed or the dose is reduced.   I have known dogs to go  up to 90 days without further injection of Zycortal because the dose was too high. There is a bearded collie who is now on 0.5mg/kg Zycortal each month and he started his treatment when it was first introduced two years ago. 

The aim is to establish the correct replacement dose for the individual dog that lasts through one month, but this doesn't mean just giving a jab every month and assuming that the sodium and potassium levels and ratio is normal or not taking notice of high electrolyte levels and just giving the monthly jab regardless.   If you ask for the test results you will be able to see if the dose is correct or not but  Harry's clinical signs will tell you so much.

I believe Harry can be much better than he is, so if you have any queries, please get back to me.

Jo


Below is an extract from the Zycortal drug sheet:

Initial dose of ZYCORTAL Suspension:
The initial dose is 2.2 mg/kg (1 mg/lb) body weight, administered by subcutaneous injection.

Interim monitoring visit:
Re-evaluate the dog and measure the serum sodium/potassium ratio (Na+/K+ ratio) approximately 10 days after the first dose, which is the time to maximum concentration (Tmax) of desoxycorticosterone (see CLINICAL PHARMACOLOGY). If the dog's clinical signs have worsened or not resolved, adjust the dose of prednisone/prednisolone and/or investigate other causes of the clinical signs.

Second dose of ZYCORTAL Suspension:
At approximately 25 days after the first dose, re-evaluate the dog and repeat the Na+/K+ ratio.
o   If the dog is both clinically normal and has a normal Na+/K+ ratio on Day 25, adjust the dose based on the Day 10 Na+/K+ ratio using the guidelines in Table 1, below.
o   If the dog is clinically normal and has a Na+/K+ ratio > 32 on Day 25, either adjust the dose based on the Day 10 Na+/K+ ratio according to Table 1 or delay the dose (see Prolonging the dosing interval).
o   If the dog is either not clinically normal or if the Na+/K+ ratio is abnormal on Day 25, adjust the dose of prednisone/prednisolone or ZYCORTAL Suspension (see Subsequent doses and long-term management).
Table 1: Day 25: Administering the Second Dose of ZYCORTAL Suspension
If the Day 10 Na+/K+ ratio is:   Do not administer Dose 2 on Day 10.   25 days after the first dose, administer ZYCORTAL Suspension, as follows:
> 34      Decrease dose to: 2.0 mg/kg
> 32 to 34      Decrease dose to: 2.1 mg/kg
27 to 32      Continue 2.2 mg/kg
24 to < 27      Increase dose to: 2.3 mg/kg
< 24      Increase dose to: 2.4 mg/kg

Prolonging the dosing interval:
If the dog is clinically normal and the Day 25 Na+/K+ ratio is > 32, it is possible to prolong the dosing interval instead of adjusting the dose as described in Table 1. Evaluate the electrolytes every 3-7 days until the Na+/K+ ratio is < 32, and then administer 2.2 mg/kg of ZYCORTAL Suspension.

Subsequent doses and long-term management:
For subsequent doses, use the following guidelines if the dog is not clinically normal and/or has abnormal Na+ or K+ concentrations:
o   Clinical signs of polyuria/polydipsia: Decrease the prednisone/prednisolone dose first. If the polyuria/polydipsia persists, then decrease the dose of ZYCORTAL Suspension without changing the dosing interval.
o   Clinical signs of depression, lethargy, vomiting, diarrhea or weakness: Increase prednisone/prednisolone dose.
o   Hyperkalemia, hyponatremia or Na+/K+ ratio < 27: Decrease the ZYCORTAL Suspension dosing interval by 2-3 days.
o   Hypokalemia or hypernatremia: Decrease the ZYCORTAL Suspension dose.
Prior to a stressful situation, consider temporarily increasing the dose of prednisone/prednisolone.