1. “Smooth seas do not make skillful sailors.” -African proverb
LIFE
“Smooth seas do not make skillful sailors.”
-African proverb

2. DISEASES OF THE ADRENAL GLANDS
CUSHING’S DISEASE
(__________________________)
ADDISON’S DISEASE

3. Adrenal Glands

4. ADRENAL GLANDS mineralocorticoids Glucocorticoids Androgens
Epinephrine
Norepinephrine

5. 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

6. Hormone Functions Regulates electrolyte and H2O balance
Hypoadrenocorticism/ _______________________
Primarily Dogs
________________________________________
Mineralocorticoids – __________________________
Promote__________________________________
Suppress inflammation
Suppress immune system
Inhibit cartilage growth and development
Hyperadrenocorticism / __________________________
Glucocorticoids

7. 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

8. 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 -________________

9. Cushing’s Disease

10. Cushing’s Disease
____________________________, pot-belly, pyoderma

11. Cushing’s Disease
Pot bellied
PU/PD
Muscle wasting
Thin coat

12. Cushing’s Disease Clinical Signs: Some are similar to hypothyroidism
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)

13. Cushing’s Disease: Calcinosis cutis
Commonly seen on the dorsal midline, ventral abdomen and inguinal region.
Skin is usually thin and atrophic

14. 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

15. 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

16. 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 __________________)

17. 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)

18. 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

19. Cushing’s Disease: Rx _____________________ removal— Medical treatment
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 (_____________________)

20. Cushing’s Disease: Rx
2. trilostane (Vetoryl®)—less side-effects than o,p,DDD -interfers with cortisol production (doesn’t kill cells) -FDA approved

21. Cushing’s Disease: Client info
Serious disease; life-long treatment
Periodic monitoring required
Addison’s disease may result (_________, _____________, _______________)
Prognosis: average life expectancy is mo on therapy with frequent recurrence of clinical symptoms – varies with cause (pit vs adrenal, tumors)

22. HARD TIMES
“In the depths of winter, I finally learned that within me there lay an invincible summer.”
-Albert Camus

23. Addison’s Disease (Hypoadrenocorticism)
Definition: Disorder caused by _________________ production of glucocorticoids (cortisol) or mineralocorticoids (aldosterone) or both
Secondary disease caused by chronic administration of _______________________

24. 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
_________________________________________

25. 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)

26. 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)

27. What is your Dx? Chem Panel (What is not normal?)
Parameter Value Normal value
BUN 81 mg/dl mg/dl
Creatinine 2.1 mg/dl mg/dl
Sodium 131 meq/L meq/L
Potassium 6.5 meq/L meq/L
Na:K ratio

28. What is your Dx? ACTH Stimulation Test Results Value Normal
Plasma Cortisol
Pre-ACTH
Post-ACTH

29. 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
Florinef® (fludrocortisone acetate)—po daily (not cheap; 50¢/tab)
Percortin-V (desoxycorticosterone pivalate)—inj ~monthly (expensive)
Monitor electrolytes, BUN/Creatinine, clinical signs

30. 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