(HYPOADRENOCORTICISM)  Addison's disease
THESE TERMS WILL BE USED INTERCHANGEABLY THROUGH THIS TEXT

ADRENAL HORMONES

The Adrenal glands are located just atop the kidney.

The adrenal gland is so named because it is located just forward of the kidney ("renal" means kidney). The center of the gland is

The cortex is shown in yellow

called the "medulla" and the outer area is called the "cortex." While both areas produce hormones, Addison's disease concerns the hormones produced by the cortex; these hormones are called "corticosteroids."

Corticosteroids are the hormones that enable us to adapt physiologically to stress. The "Glucocorticoids" (such as cortisol and related synthetics, prednisone and dexamethasone) act on the mechanics of sugar, fat, and protein metabolism. They gear the metabolism towards the preparation of burning (rather than storing) fuels so as the be ready for a "fight or flight" situation.

The "Mineralocorticoids" (such as aldosterone and related synthetic fludrocortisone acetate) influence the electrolytes: sodium and potassium. As a general biological rule, where there's sodium or salt, there's water. When the mineralocorticoids circulate as part of the "fight or flight" preparation, sodium is conserved in anticipation of blood loss so that there will be extra fluid in the vascular compartment (spare blood).  When sodium is conserved, potassium is lost as part of the biological balance. This whole picture of fat mobilization, sodium conservation etc. which is part of the "fight or flight" preparation is far more complex than can be reviewed here but the bottom line is:

Corticosteroid hormones are needed to adapt to stressful situations and without these hormones, even small stresses could lead to physiologic disaster.

HYPOADRENOCORTICISM (ADDISON'S DISEASE)

In animals with Addison's disease, there is a deficiency of the corticosteroid hormones. It is unusual to discover the direct cause of this deficiency unless the patient is taking medications that disrupt adrenal balance (like Ketoconazole or Lysodren) but, fortunately, the disease can be managed with the administration of corticosteroid hormones even if the cause of the deficiency is unknown.

CLINICAL SIGNS

Patients are usually young (age 4-5 years) female dogs.  In Standard Poodles, which are 12 times more likely to have this condition than the average dog,  both male and female dogs are at equal risk.   (This disease occurs in cats but is very rare.) At first signs are very vague - listlessness, possibly some vomiting or diarrhea.  Ultimately, the disease results in a phenomenon known as the "Addisonian crisis"  or sometimes known as an "Addison's crash."  The animal collapses in shock due to its inability to adapt to the caloric and circulatory requirements in stress.  Blood sugar may drop dangerously low. Potassium levels soar and disrupt the heart rhythm because there is not enough conserved sodium to exchange for potassium. Heart rate slows, arrhythmias result.  The patient may not survive this episode.

MAKING THE DIAGNOSIS

Veterinarians are usually presented with a young animal in shock.  There is usually no history of trauma or toxic exposure so general treatment for shock is initiated. This consists of rapid administration of fluids (usually lactated ringers solution which has little potassium and a moderate amount of sodium) plus some glucocorticoids. By coincidence, this also happens to be similar to the specific treatment for Addison's disease so that often the patient simply recovers without the veterinarian really knowing why.

The blood panel will come back showing elevations in the renal parameters (BUN and Creatinine) and thus with the elevated potassium is suggestive of acute renal failure, a condition with an extremely poor prognosis.  The veterinarian may become suspicious of another diagnosis as the patient will respond well to fluid administration and most renal failure patients do not respond as well.

Addison’s disease may present in more unusual ways.   The average price to diagnose this disease is over $1,000.00 per a recent survey.   If you have a Standard Poodle that all of a sudden acts very old or is showing any of the signs listed here, ask to have the dog tested for Addison's disease.   The sooner the dog is properly diagnosed, they can be helped and the better the outcome.   Also, inability to maintain normal sugar levels (ultimately manifesting as a seizure disorder) may be strongly suggestive of an insulin-secreting pancreatic tumor but before a major abdominal surgery is planned, it is important to test for Addison’s disease.

Similarly unexpected, regurgitation of undigested food due to abnormal nerve function in the esophagus (a condition called “Megaesophagus”) can be caused ultimately by Addison’s disease.

Because of the numerous symptoms Addison’s disease can be present with, Addison’s disease has earned the medical nickname “the Great Imitator.”

The only definitive test for Addison's disease is the ACTH stimulation test. The patient receives a dose of ACTH, the pituitary hormone responsible for the release of corticosteroids in times of stress.  A normal animal will show an elevation in cortisol in response to ACTH while an Addisonian has no corticosteroids to respond with. This lack of response is diagnostic for Addison's disease; however, a false positive may be obtained if corticosteroids have been used in the treatment of the crisis prior to the test. Only dexamethasone does not interfere with the assay for cortisol; if any other steroid has been used, the test will not be valid for at least a couple of days.

TREATMENT AFTER THE CRISIS

The most important aspect of treatment for hypoadrenocorticism is the replacement of the missing mineralocorticoids hormones. One way to do this is with oral Fludrocortisone (Florinef).  Florinef is given usually twice a day at a dose determined by the patient's sodium and potassium blood tests. At first, these electrolytes are monitored weekly. When levels seem stable, these blood tests are repeated 2-4 times per year. Often with time, it will be found that the dose of Florinef needed to control the Addison's disease will increase. This is unfortunate as the medication is relatively expensive. Since Florinef has glucocorticoid activity as well as mineralocorticoid activity, it is not necessary to use additional medications for treatment.

Another way to treat this condition is with an injectable medication called "DOCP”
(brand name “Percorten-V”). This treatment is given approximately every 25 days. Electrolytes are measured prior to injections at first but testing can usually eventually be tapered to once or twice a year. There is some feeling among experts that DOCP produces better regulation of electrolytes than does oral Florinef. Some dogs however, do require glucocorticoid supplementation (such as a low dose of prednisone).

Salting the patient's food is sometimes recommended to assist the patient with sodium balance.

Most of the above from the Mar Vista Animal Hospital.