Hypoadrenocorticism

Question 1

Do cats have Addison’s disease?

Answer 1

Uncommon but possible

Question 2

Main signalment for Addison’s disease in dogs?

Answer 2

Middle aged; Female dogs

Can be seen in as young as 4 m and as old as 14 yr

Question 3

Most common breeds which can have Addison’s disease?

• Large:
• Small:

Answer 3

• Large: Great dane, poodle, Retrievers, Rottweilers, Bearded collies
• Small: West highland terrier

Question 4

CS can wax and wane and mimic any other disease. T/F

Answer 4

T

Question 5

In any patient who presents with CIRCULATORY SHOCK and ↓ HR, think Addison’s disease. T/F

Answer 5

T

Signs of circulatory shock are = Pale MM, Prolonged CRT, ↓ Temp, week pulses, mental depression/collapse

Question 6

Most common signs in Addison’s disease?
-
-
-
-

Answer 6

• weakness and lethargy
• V , D (Can see blood in both V and D)
• PU/PD
• Signs of circulatory shock

Question 7

Main CBC abnormalities expected in Addison’s disease?

Answer 7

• Absence of stress leukogram/ instead might see reverse leukogram
• Anemia

Question 8

What type of anemia due to expect in Addison’s disease?

Answer 8

• N,N, NR anemia

Can be due to anemia of chronic disease or GI ulceration

Question 9

Elaborate about leukogram findings in patients with Addison’s disease?

Answer 9

• Absence of stress leukogram (i.e. normal neutrophils and lymphocytes)
• Might show reverse leukogram (i.e. ↓neutropenia, ↑ lymphocytes)

Any MODERATELY ILL animal that presents with NORMAL or REVERSE LEUKOGRAM should raise suspicion of Addison’s disease

Question 10

Chemistry findings in Addison’s disease:

• Na:K Ratio
• P
• Creatinine, BUN
• Glucose
• albumin
• cholesterol

Answer 10

• Na:K Ratio <27:1
• ↑ P
• ↑ BUN and creatinine due to pre-renal azotemia
• ↓ Glucose
• ↓ albumin
• ↓ cholesterol

Question 11

A decreased Na:K ratio is not pathognomic for Addison’s disease and not all Addisonian patients will have low Na:K Ratio . T/F

Answer 11

T

Question 12

Other causes of low Na:K Ratio?

Answer 12

• Heart failure
• GI disease(Trichuris, Salmonellosis)
• Late term pregnancy
• Pancreatitis
• Neoplasia
• Body cavity effusion, uroabdomen, renal failure

Question 13

Urinalysis might reveal ISOSTHENURIA in face of pre-renal azotemia. T/F

Answer 13

T

Sodium loss → renal medullary washout → isosthenuria

Question 14

With hyperkalemia, you might see marked ↓ HR i.e. < 70 . T/F

Answer 14

T

Question 15

Unlike dogs, cats usually donot show ECG abnormalities with ↑ K. T/F

Answer 15

T

Question 16

3 main ECG abnormalities with ↑ K ?

Answer 16

• absence of P waves
• Wide QRS
• Tented T waves

Might see VF or asystole too

Question 17

3 main findings which you will expect in XRAY in case of HOC?

Answer 17

• microcardia
• small caudal vena cava
• microhepatica

Question 18

Why is fecal analysis recommended in a suspected case of HOC?

Answer 18

To r/o pseudo-addison’s disease such as GI parasites (eg: whipworms)

Question 19

What is the cut-off value of resting cortisol which tells you that HOC is highly unlikely.

Answer 19

If >2 ug/dl

If <2 ug/dl, then further testing such as ACTH stim test is needed

Question 20

_______ is gold standard test for making definitive Dx of HOC

Answer 20

ACTH

Not LDDST

Question 21

-

Answer 21

• correct hypoperfusion/hypovolemia

- correct ACID BASE & Electrolyte abnormalities

Question 22

Which fluid type to use?

Answer 22

Normosol R, LRS, Plasmalyte 1-48 or A

Question 23

NaCl is not the fluid of choice in cases of HOC. T/F

Answer 23

T

Question 24

Goal is to avoid increased of SODIUM by no more than _____ mEq/L per hour.

Answer 24

0.5-1

Question 25

How much shock bolus in dog and what is limit?

Answer 25

20-40 mg/kg Upto 90 ml/kg/hr Easy way to calculate 1/4th bolus is Bw in LBS X 10

Question 26

How much shock bolus in cats and what is the limit?

Answer 26

10-15 ml/kg Upto 60 ml/kg/hr 1/4th shock bolus is ~ BW in Kgs X 10

Question 27

Lower fluid rate be used for resuscitation in which 2 category of patients?

Answer 27

- pet with HEART DISEASE | - HYPOTHERMIC CAT (go with bw in kg X 10 )

Question 28

Mnemonic for EOR ?

Answer 28

HCM PUB ``` H - HR C - CRT M - MM color & mentation P - Pulse quality U - UOP B - BP ```

Question 29

So overall, first step in case of Rx for HOC is ________

Answer 29

Fluid resuscitation Then constitute a fluid plan for dehydration + maintenance

Question 30

Usually, when do we worry about adding colloids based on albumin levels.

Answer 30

If < 1.5 g/dL But AKI is a possibility , so be very careful

Question 31

How to Rx HYPERKALEMIA?

Answer 31

- IV Fluid resuscitation will help | - Need MRx if > 7-8 mEq/L : options are Ca Gluconate +/- R insulin & Dextrose

Question 32

Elaborate Ca Gluconate dose for Rx of ↑ K?

Answer 32

0.5-1.5 mg/kg slow IV over 15 min KEEP PET ATTACHED TO ECG

Question 33

What to look in ECG so that the Ca Gluconate infusion can be slowed or stopped?

Answer 33

↓ in HR or development of new arrhythmia

Question 34

Dose of R insulin & Dextrose as Rx for Hyperkalemia?

Answer 34

- R insulin is 0.2 U/kg IV (BW in kg/4) - Dextrose 50% : 1 ml/kg IV Give R insulin first, then give Dextrose Pets might also need 2.5% dextrose CRI

Question 35

CHECK blood GLUCOSE prior to giving R INSULIN . T/F

Answer 35

T

Question 36

Rx for Hypoglycemia i.e. if < 60 mg/dL

Answer 36

Dextrose(50%) 1 ml/kg IV diluted 1:2 to 1:4 with 0.9% Saline Repeat the bolus PRN or start 2.5% CRI if hypoglycemia persists

Question 37

PEARL: in cats with continued HYPOTENSION even after fluid resuscitation, consider checking _____ levels in blood

Answer 37

GLUCOSE

Question 38

So, Step 1 was resuscitation and Step 2 was IV fluids + correcting hyperkalemia and hypoglycemia. What is step 3 ?

Answer 38

Glucocorticoid therapy It should be withheld until after fluid resuscitation & Hypoperfusion is withheld

Question 39

Which corticosteroid does not mess with ACTH Test?

Answer 39

Dexamethasone **Still to avoid any artifact, the test must be completed within 2-3 hr of giving Dexamethasone

Question 40

Do you start with IV steroids or PO Steroids in hospital?

Answer 40

IV until pet is eating and then can be transitioned to oral medications

Question 41

Main three options for IV steroids

Answer 41

Dex SP 0.1-0.4 mg/kg IV Prednisolone SS 0.5 - 1 mg/kg IV Hydrocortisone SS 5 mg/kg IV

Question 42

Outpatient therapy for HOC is lifelong . T/F

Answer 42

T

Question 43

2 options for outpatient therapy for HOC?

Answer 43

- Fludrocortisone , or | - DOCP + Prednisolone

Question 44

Fludrocortisone has both glucocorticoid & mineralocorticoid activity. T/F

Answer 44

T

Question 45

DOCP only has mineralocorticoid activity. T/F

Answer 45

T So we need to give Prednisone with it

Question 46

Dosage of Prednisone for outpatient therapy of HOC?

Answer 46

0.4-0.6 mg/kg PO Daily (for ~ 1 week)→ tapered to physiologic dose of 0.2 mg/kg daily

Question 47

How long can it take for dogs and cats to respond to initial therapy ?

Answer 47

Dogs: few hours to 1-2 days Cats: may take upto 3-4 days

Question 48

Other therapies which might be needed on case to case basis are : - - -

Answer 48

- Antibiotics - GI protectants & anti-emetics - Blood tranfusions

Question 49

What percentage of pets with HOC are ATYPICAL cases?

Answer 49

1/4th i.e. 25%

Question 50

Do pets with HOC have a hx of weight loss?

Answer 50

Yes, ~ 50%

Question 51

2 main points regarding Hx in ATYPICAL HOC?

Answer 51

- VOMIT more common | - Longer course of disease

Question 52

Pets with ATYPICAL HOC are more likely to have following in CBC/Chem - - -

Answer 52

- ANEMIA - ↓ Albumin - ↓ Cholesterol

Question 53

What 2 CBC changes do you see in REVERSE LEUKOGRAM?

Answer 53

↓ Neutrophils | ↑ Lymphocytes

Question 54

Sensitivity and specificity of ACTH Stim test.

Answer 54

Sensitivity is 100% | Specificity is ~ 80% (if positive = 20 false positives among 100 positives )

Question 55

We should avoid 0.9% NaCl, especially if Na is < ____ mEq/L in blood .

Answer 55

120

Question 56

Dose of HES is you need to give in case of ↓ albumin.

Answer 56

5-15 ml/kg

Question 57

Usually, we consider R insulin + Dextrose as an Rx for ↑ K if K levels are > ___

Answer 57

7

Question 58

Which medications to use if GI bleeding?

Answer 58

Omeprazole + Carafate +/- Antibiotics

Question 59

Its is best to DRAW BLOOD SAMPLE for ACTH STIM test BEFORE GIVING STEROIDS. T/F

Answer 59

T

Question 60

Florinef/Fludrocortisone dose

Answer 60

0.1-0.3 mg/kg/d Remember: physiologic dose of predisone is ~ 0.2 mg/kg (so almost similar )

Question 61

DOCP Dose

Answer 61

2.2 mg/kg IM q21-25 d check electrolytes within 7-12 days and then at day 25