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With primary hypoadrenocorticism, ACTH conc is _______.
high
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Classic hypoadrenocorticism is ___________ dependent; it is caused by...
glucocorticoid and mineralocorticoid; immune-mediated idiopathic destruction of the adrenal cortex.
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Atypical primary hypoadrenocorticism is ___________ dependent; signs are more _________; unlike classic primary hypoadrenocorticism, ____________ are normal.
glucocorticoid; chronic; sodium and potassium
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With secondary hypoadrenocorticism, ACTH conc is _________.
low
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Secondary hypoadrenocorticism is a ___________ deficiency; ____________ are normal; it is caused by... (3)
glucocorticoid; serum electrolyte levels; exogenous steroid administration, congenital or acquired hypopituitarism.
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What is the signalment for a dog with Addison's disease?
<7years, 70% are females, any breed (familial in Duck Tolling Retrievers, Portuguese Water Dogs, Standard Poodles)
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History from a Addison's patient CAN (not always) includes... (8)
GI signs (anorexia, vomiting, diarrhea), lethargy, weakness, weight loss, trembling, PU/PD
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Physical findings associated with Addison's disease CAN include (not always)... (6)
lethargy, poor body condition, weakness, dehydration, signs of shock, bradycardia (which is a red flag, b/c you should have tachycardia with shock)
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Addison's should be a differential for all dogs presenting with.....
GI signs, acute kidney disease
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Hemogram findings with Addison's disease CAN include...
anemia of chronic disease (non-regenerative), absolute eosinophilia and lymphocytosis (very sick animal should have stress leukogram b/c glucocorticoids suppress lymphs and eos....RED FLAG)
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Mineralocorticoid deficiency leads to... (3)
sodium wasting, potassium retention, and acidosis.
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Chloride is lost in the urine with sodium, but ________ is lost in lesser proportions, resulting in _____________ with __________.
chloride; hyperchloremic (relative) metabolic acidosis; normal anion gap
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How does high anion gap acidosis develop with hypoadrenocorticism?
low aldosterone--> Na+ wasting--> medullary washout--> PU/PD--> dehydration--> decreased GFR--> bicarb loss and H+ retention--> azotemia and high anion gap metabolic acidosis
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What are the most common biochem profile findings with Addison's dz? (5)
hyperkalemia and hyponatremia with Na:K ratio< 27:1 (not pathognomonic), azotemia, hypochloremia
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What are some less common changes on the biochem profile with Addison's disease? (4)
hypercalcemia, increased liver enzymes, increased cALP, hypoglycemia
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What are changes on the biochem profile with atypical hypoadrenocorticism only? (2)
hypocholesterolemia, hypoalbuminemia
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Urinanalysis findings that can occur with hypoadrenocorticism? (1)
low USG
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Why is there often low USG with hypoadrenocorticism? Why is this confusing? How can you decipher it?
medullary washout; primary renal disease is a confusing differential; fluid therapy for rehydration then re-evaluate
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With hypoadrenocorticism, EKG findings are consistent with ________.
hyperkalemia
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Abdominal US findings.
adrenals are expected to be smaller (can be normal or larger with hypoadrenocorticism caused by infiltrative disease, like lymphosarcoma)
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Screening test for hypoadrenocorticism.
resting plasma cortisol... CAN ONLY BE USED TO RULE OUT...NOT DIAGNOSTIC
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Describe evaluation of the screening test for hypoadrenocorticism.
capacity to make cortisol is inconsistent with addison's therefore normal or high cortisol RULES OUT hypoadrenocorticism; low basal cortisol is NOT diagnostic, must use confirmatory test
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What is the confirmatory test for hypoadrenocorticism?
ACTH stimulation test, only diagnostic test for hypoadrenocorticism
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How do you perform the ACTH stim test?
administer 5μg/kg ACTH IV, test cortisol level 1hr post-injection
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Describe how you evaluate the ACTH stim test for suspect Addisonian.
low resting cortisol and post ACTH cortisol <2μg/dL (often <1)
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What would the results to the ACTH stim test look like in a case of hypoadrenocorticism due to chronic exogenous glucocorticoid exposure?
low to normal resting cortisol (≤5) with subnormal response to ACTH (≤5)
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When is it indicated to measure endogenous ACTH?
in atypical disease or to differentiate b/w primary and secondary
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What type of hypoadrenocorticism requires routine monitoring of electrolytes and why?
primary atypical hypoadrenocorticism b/c it can develop to full blown addison's, you want to prevent a crisis
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How do you treat the initial addisonian crisis? (4)
correct hypovolemia with infusion of a crystalloid fluid (NaCl) at shock dosage (40-80mL/kg/hr), ACTH stim test, correct electrolyte disturbances, provide missing glucocorticoids
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If fluid therapy is not sufficient to correct hyperkalemia, treat it with... (3)
0.5mL/kg calcium gluconate (antagonizes K+ effect on heart but does not correct), dextrose with or without regular insulin, 1-2mEq/kg sodium bicarb IV
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What are your options for replacing missing glucocorticoids during the initial crisis?
Dexamethasone 0.5-1mg/kg IV or Hydrocortisone sodium succinate 2-4mg/kg IV or Prednisolone sodium succinate 5-10mg/kg IV
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When do you know you are done managing the initial crisis and can move to maintenance therapy?
fluids and medication are continued until azotemia is resolves, acidosis is corrected, and electrolytes are normal, and animal begins to eat and drink without vomiting
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What are options for longterm management of Addison's?
DOCP or Fludrocortisone
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DOCP replaces ____________; treatment also requires...
mineralocorticoids; glucocorticoid supplementation- low dose prenidsone
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How do you monitor an Addison's patient after starting maintenance treatment with DOCP?
check electrolytes in 12-14 days to determine if the total dose is sufficient; check again at 25 days to determine if the interval b/w doses needs to be changed; check every 3 months until under control
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Fludrocortisone replaces ___________; the dose is __________.
mineralocorticoids and glucocorticoids; 15-20μg/kg/day PO
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How do you monitor an Addison's patient after starting maintenance treatment with Fludrocortisone?
adjust dosage by monitoring serum electrolyte concentrations every 1-2 weeks until under control
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When is glucocorticoid replacement therapy necessary?
always necessary for classic addisons on DOCP, sometimes necessary for classic addisons of Fludrocortisone, the only treatment necessary for atypical HA
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What is the physiologic dose of Prednisone for glucocorticoid replacement therapy with Addison's?
0.2mg/kg/day- increase at times of stress
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What is prognosis for Addison's with proper treatment?
excellent
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