009: Cushing's: Hyper Adrenals and Pot Bellies

This week we discuss excess endocrine function, active adrenal glands, "plugged" pituitary gland.... get it? We are talking about hyperadrenocorticism!!!!  

Show Notes: 

Join Yvonne Brandenburg, RVT, VTS SAIM and Jordan Porter RVT, LVT, VTS SAIM as we talk about:

• Hyperadrenocorticism; the excess endocrine function and the active adrenals. ​   
  

 Resources We Mentioned in the Show 

•  ACVIM
  
  • https://www.acvim.org/animal-owners/animal-education/health-fact-sheets/small-animal-internal-medicine/cushings-disease-in-dogs
    
• Merck Veterinary Manual
  
  • https://www.merckvetmanual.com/endocrine-system/the-pituitary-gland/cushing-disease-pituitary-dependent-hyperadrenocorticism-in-animals
    
• Small Animal Internal Medicine for Veterinary Technicians and Nurses
  
  • https://imfpp.org/saimbook 
    
• “Canine & Feline Endocrinology”, edited by E. Feldman, R. Nelson, C. Reusch, J Scotti-Moncrieff, E. Behrend.
  
  •  https://imfpp.org/endocrinebook 
    

Thanks so much for tuning in. Join us again next week for another episode! 
 
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Thanks for listening! 
– Yvonne and Jordan 

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Yvonne Brandenburg, RVT, VTS SAIM:
Welcome to the Internal Medicine For Vet Techs Podcast. If you haven't joined us before, we're passionate about all things internal medicine and helping you become the best tech you can be. We'll be discussing interesting internal medicine diseases, how to work closely with pet parents and how to become the go to tech in your practice. Now let's start the show.

Jordan Porter, RVT, LVT, VTS SAIM:
Welcome back and thank you again for listening and making a commitment to supporting us, duh.

Yvonne Brandenburg, RVT, VTS SAIM:
Oh, great. We start this one on a good note.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, making a commitment to learning. Hope you guys are doing well this week and I hope you guys are still enjoying our episodes. So, I am Jordan. I am one of the co-hosts and still joined with Yvonne.

Yvonne Brandenburg, RVT, VTS SAIM:
Hey.

Jordan Porter, RVT, LVT, VTS SAIM:
Hi.

Yvonne Brandenburg, RVT, VTS SAIM:
Hi.

Jordan Porter, RVT, LVT, VTS SAIM:
Couple reviews that we've had over the last couple of weeks. So, Jamie McGee-Jones, she left us a wonderful comment: "Run by some of the most knowledgeable people I've ever met!" Which was super nice.

Yvonne Brandenburg, RVT, VTS SAIM:
We just sound smart because we look things up in books.

Jordan Porter, RVT, LVT, VTS SAIM:
Don't give away our secrets.

Yvonne Brandenburg, RVT, VTS SAIM:
Sorry.

Jordan Porter, RVT, LVT, VTS SAIM:
Melissa. Supernor. Gosh, I hope I'm saying that. Is that right?

Yvonne Brandenburg, RVT, VTS SAIM:
Oh, man. Melissa, I don't know. I just her as Melissa. Supernor, I think is her last name. Melissa. I'm sorry if I butchered your last name, but you are really cool. Thank you.

Jordan Porter, RVT, LVT, VTS SAIM:
So, Melissa said: "This team is doing wonderful work! Great job!" Again, super appreciate it. And then we have a Cait fan base, which is nice.

Yvonne Brandenburg, RVT, VTS SAIM:
I know it's funny because they both spell their names very similarly. We have Cait, C-A-I-T O'reilly Beets. And then we have CAITLYN, which is C-A-I-T-L-Y-N Lindblad. Dang it. I did it again. Lindblad.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. I'm sure she's used to the butcher of her last name. Actually, I know she is.

Yvonne Brandenburg, RVT, VTS SAIM:
Ahh.

Jordan Porter, RVT, LVT, VTS SAIM:
So, Cait Beets said an episode, on episode 4, the diarrhea episode. "I really enjoyed it! You ladies have great personalities and it shows through the podcast. We actually just got a flyer for this Mila fecal collection kits, and it made me laugh. Not sure if we'll try them or not."

Yvonne Brandenburg, RVT, VTS SAIM:
I feel like so far, the diarrhea episode has been fairly popular.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, it was a fun one to do.

Yvonne Brandenburg, RVT, VTS SAIM:
I think it was our first real internal medicine topic too. So, I think that's part of the reason why.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. And then Caitlyn said: "Another great episode! I listen to these on Tuesday mornings during my long commute to work. It starts my work week in the right mindset! I look forward to hearing some autoimmune diseases in the future! You guys rock." So, yes, those are coming.

Yvonne Brandenburg, RVT, VTS SAIM:
Yes, I know. I think I've responded to her and I was like, "oh, autoimmune disease are my, I have a passion for them. I'll talk about that at some point. Not only because our, you know, patients get diagnosed with it pretty frequently, I actually had a dog with one, too. So, I have a passion for auto immune diseases. So, I want to make sure I do this right, which is why we didn't start with them.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, I think those episodes, too will be, it'll be several autoimmune diseases back to back with lots of research because I do really enjoy autoimmune diseases as well. So, those episodes we'll definitely probably try to cram in as much information as we possibly can.

Yvonne Brandenburg, RVT, VTS SAIM:
Without being too bad.

Jordan Porter, RVT, LVT, VTS SAIM:
Hopefully. Too nerdy. But I'm cool with it.

Yvonne Brandenburg, RVT, VTS SAIM:
We're good being nerdy. But honestly, you guys, thank you so much for your reviews, for your comments. We sincerely appreciate it. It lets us know that you guys have heard it and that you like it. And, you know, we're totally open to criticisms as well. Like, you know, that's how I found Jordan. She is like endocrine vs. exocrine, and then a wonderful friendship formed. So, don't feel like you're ever going to upset us if you find a mistake. We'd rather we catch those mistakes and get them fixed. So, we don't look like complete lame people.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes, we definitely don't know everything and we make mistakes. So, we're learning as we do these episodes too, which is nice. So.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And if you ever, if you want to send us something specifically that you don't necessarily want on the website or on the Facebook group, you can always send us emails too. You can send it to [email protected] and it'll get to us and we can answer those questions. Or if you have comments or anything that you'd rather to send to us directly, you can do that as well.

Jordan Porter, RVT, LVT, VTS SAIM:
Hmm.

Yvonne Brandenburg, RVT, VTS SAIM:
You know, all the ways to get a hold of us.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes, exactly. So, this week, though, I'm excited because we are talking about another endocrine disease.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, we're doing all these endocrine diseases. How interesting.

Jordan Porter, RVT, LVT, VTS SAIM:
I know. I think we'll do runs probably.

Yvonne Brandenburg, RVT, VTS SAIM:
Probably.

Jordan Porter, RVT, LVT, VTS SAIM:
So, this week. This week is Cushing's Disease, adrenal gland excess, which is nice, not nice for the patient. But I had fun doing the research for this episode because I like to find ways to better explain things to make it simpler to understand.

Yvonne Brandenburg, RVT, VTS SAIM:
And I feel like we see a ton of Cushing's patients in internal medicine.

Jordan Porter, RVT, LVT, VTS SAIM:
Definitely.

Yvonne Brandenburg, RVT, VTS SAIM:
Because most general practitioners are like: "Ahhh!" And they run away from it. So, we get it in our practice.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, which is really cool. We do so much more like ultrasounds, like looking for it, which we'll get into. But the rDVM. or the referring veterinarian will find elevated alk phos and then send it over to us. And I just, I know what it is coming through the door, but I just really do enjoy those cases.

Yvonne Brandenburg, RVT, VTS SAIM:
I know I joke because sometimes I'll just like walk through a department at my hospital, and I'll be like: "That dog's Cushingoid!" And they go, "What?" And I'm like: "Just look at it!" You know? We'll talk about that, you know, what we're going to be looking for too. So, just one of those quick things with Cushing's disease, a cushion. So, we have excess in a cushion. Right? So, hyperadrenocorticism. It's more. There's lots more. Versus Addisonian where you need to "add" steroids. So, I remember in school I liked those little mnemonic things.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah. I always learned to like hypo is low because it rhymes. So, hypoadrenocorticism and then hyper is high.

Yvonne Brandenburg, RVT, VTS SAIM:
So hyper: you're hyper on sugar because you have excess sugar. So, that's also excess in Cushing's, your squishy in Cushing's. So there's those.

Jordan Porter, RVT, LVT, VTS SAIM:
So, the definition of this disease is excessive production of A.C.T.H. or adrenocorticotropic hormone, a big mouthful A.C.T.H. though. So, and then from either pituitary or enlargement or tumor of the adrenal gland. So, there's actually three different types of Cushing's disease which we'll definitely get into. The most common type being PDH, or pituitary dependent hyperadrenocorticism, which is where, again we'll get into it. But that's the most common type that you're going to see in practice. And then F.A.T., functioning adrenal tumor or functional adrenal tumor. And then iatrogenic. We talked, gosh, several episodes ago about what iatrogenic meant. It means that we caused it. So, I iatrogenic Cushing's disease is secondary to administration of steroids. And so, we can cause Cushing's disease. So that's definitely a risk when you prescribe that, which again we talked about in diabetes.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. I mean, we did. And honestly, if you work in a clinic and you use steroids, not you personally are using steroids. If you know, if your patients are using steroids, like prednisone, you kind of know what those are because those are the common side effects when you haven't too much steroids in your system, which is, you know, excessive urination, excessive drinking, panting, loss of muscle mass, that potbellied look, those are all things that we think of with steroids. But it's exactly what we're looking for with our Cushing's patient, because steroids, it's just not prednisone.

Jordan Porter, RVT, LVT, VTS SAIM:
Exactly. Exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
It's just the A.C.T.H.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, so kind of getting into your anatomy and physiology. So, we're talking about the adrenal glands malfunctioning. Correct? So, renal refers to kidney. And then ad- means next to. So, one adrenal gland is located next to each kidney. That's why they're called adrenal glands. And the function of the A.C.T.H. is to regulate the levels of steroid hormone, which is cortisol, which is released by the adrenal gland. So, we've kind of go into about talking about the negative feedback loop. In a normal patient, the pituitary gland secretes your A.C.T.H. The pituitary gland is the master gland.

Yvonne Brandenburg, RVT, VTS SAIM:
Just in case people don't remember where the pituitary gland is. The pituitary gland is actually in the brain, in the head. And it was it was interesting because I was kind of listening to one of my doctors describe it to a client. And she says, "well, it's a brain tumor. But it's not malignant.".

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Which is kind of crazy when you tell a client there was a brain tumor.

Jordan Porter, RVT, LVT, VTS SAIM:
Oh, I know. They instantly,

Yvonne Brandenburg, RVT, VTS SAIM:
They instantly see all the pictures from the movies of, you know, bad things, but it's usually a tiny little tumor that's growing on the pituitary gland. And so, because it is a tumor, it's just excess secretes and does not listen to the feedback, the negative feedback part of the loop to tell it to shut off. It just, it unfortunately it can't because there's so much to that tissue creating the A.C.T.H. that kind of overrides it.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, just remember it's a tumor. It can grow see.

Jordan Porter, RVT, LVT, VTS SAIM:
And a normal in a normal dog though the pituitary gland without a tumor secretes A.C.T.H. And then the A.C.T.H. stimulates the adrenal glands to release cortisol and the presence of the cortisol exerts a negative feedback on the pituitary gland. So, it secretes A.C.T.H. then cortisol secretes and then the cortisol is telling, kind of how we talked about insulin and glucagon kind of work together, the amount of cortisol tells us the pituitary gland to stop releasing so much A.C.T.H. and so forth just to keep those hormones well balanced. And cortisol is released in response to stress, which is kind of what you're talking about, being on steroids. It's a stress hormone that is a steroid.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And I know that feedback loops are really difficult to understand. Most people kind of trip up with them and it's probably simpler than you think it is. So, the way I used to explain it to my students is think about your house and you have your heater and you have your thermostat, right? So, you want your thermostat says "I want it to be between 60 and 70 degrees." So, we'll pretend that the heat is going to be your A.C.T.H. right? So, your heater's producing the heat, that goes out into the room, goes to the thermostat, and says, "oh, yeah, we're within this level." Now we're getting warmer. We're getting above 70. "I'm going to tell the heater to stop working." So, think of the cortisol. Is the information going to the heater to tell it to stop making heat, or the A.C.T.H., right? So, it's a feedback loop that says, "yup, we're where we need to be now turned off." And then we get below that level and it says "Oh, we need some", so it produces cortisol to go there. And so, it is this feedback loop. So, it keeps it balanced, because the body likes balance. So, kind of a way to think about that is like, you know, a thermostat and your heater in kind of helping balance each other to make sure it's not too hot, not too cold. So, not too much steroid, or not enough steroid. We like that balance.

Jordan Porter, RVT, LVT, VTS SAIM:
Exactly. So, as Yvonne said, that feedback loops disrupted by a tumor. So, A.C.T.H. is continuously released despite the plasma cortisol levels also being high. The cortisol can't get to the pituitary gland adequately enough to say, "hey, shut off, stop, stop producing more A.C.T.H." And this in turn makes the adrenal glands appear swollen, which we'll talk about on ultrasound. They do get larger because they're just continuously producing cortisol.

Yvonne Brandenburg, RVT, VTS SAIM:
And that drives the amount of cortisol up, right? It's like, "oh, shut off. So, I'm going to throw as much cortisol as possible to get it to stop.".

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Which is why we see those cortisol levels go up.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. So high. Versus F.A.T, or the functioning adrenal tumor, that's not a tumor on the pituitary gland. It's a tumor on the adrenal gland itself. And that's usually unilateral, so it's one sided. But excessive amounts of glucocorticoids are released, exerting a negative feedback on the pituitary or resulting in low A.C.T.H. So, you still have an excessive amount of cortisol being released, but your A.C.T.H. is gonna be low just because it is receiving that feedback saying, "hey, you know what, shut off." That in turn will cause atrophy of the adrenal gland that doesn't have a tumor. So, you'll have one smaller adrenal gland and then a tumor noted on ultrasound. And these can be pretty nasty. We're not gonna go into too much detail, but they are considered malignant. They can grow and we see them eat into the vena cava. It's a pretty extensive surgery. Again, we'll kind of get into how to treat those, but those can be pretty sad and pretty scary. But, kind of moving forward, though, with what you see when you have a patient come into the hospital, is there are certain breeds, this is more of a dog disease that can occur in cats like we kind of talked about in the diabetes episode, but it's a dog disease. But poodles are especially prone to this, especially miniature poodles. And I don't know, do you ever see it's more of a little white dog thing?

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, definitely. Little white dogs, a lot.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, Dachshunds, we had a Dachshund yesterday.

Yvonne Brandenburg, RVT, VTS SAIM:
So many Dachshunds right now.

Jordan Porter, RVT, LVT, VTS SAIM:
Which is crazy, too. So, short-story, this Dachshund came in for incidental finding of something in the stomach and the owners don't recall the dog eating anything. But long story short, we discovered that the dog was Cushingoid, so the dog was excessively eating things and eating random foreign objects. But they didn't notice really like an increase in drinking or urinating. But anyway, the dog had Cushing's disease, but classic like potbelly Dachshund, with thin skin. But Boxers are also prone, Boston Terriers, Yorkies for sure. And even some Staffordshire Terriers are on that list as well.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I was going to say, "I've seen all of those."

Jordan Porter, RVT, LVT, VTS SAIM:
All of them. I'm actually pretty impressed that Maltese wasn't on the list, because I feel like I see quite a few of those.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, yeah. I think it's a little white fluffy thing.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And their haircuts get all crappy and you're like, "Hmmm."

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
So, upon history, some of the things that we'll see is excessive drinking. So, all of a sudden, they just start tanking up, right? Well, it may not be all of a sudden actually. We've had some where it gradually came over a couple of months and they noticed a big difference. You're also going to see them urinating a ton. So, large amounts frequently. Sometimes will have urinary incontinence in the house or accidents in the house. So, that's definitely something to talk to owners about, to see if they're starting to notice that. Some of our really bad ones, they can't go more than like two hours without having to go to the bathroom.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And that includes overnight. So, if they used to be able to hold it overnight, but they can't anymore, that might be a sign.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And like what Jordan was saying about the excessive eating, we've had a couple of them diagnosed with either a foreign body or like a pancreatitis or something where they're just all of a sudden, they're ravenous, right? They just kind of are getting into the garbage. They're getting into all sorts of stuff because they just want to eat.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. And that's because they have an excessive steroid in their system, you know. So, we all know that's what steroids do to the body. That's what you send home the drug and you tell clients they're gonna be PU/PD, they're gonna want to eat a lot. And that's what these dogs do. They eat a lot, sometimes eight foreign objects. And then you kind of visually see too when they come into the clinic that they look Cushingoid.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
And they have the heat intolerance. They're just can't handle it. They're lethargic. They have a classic potbelly. I mean, it's classic.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And that and the reason for that is because just like with steroids, right? You have the steroids which loses muscle mass. So, their belly, they actually are losing muscle tone, you know, their abs because they can't hold in their belly anymore. Their abdominal muscles are getting weak. So, it just makes them pooch out. So, they may be the same weight as previously, but all of a sudden, they look fatter and that's because those muscles can't hold in the belly anymore. And so, you just see that that really kind of pendulous abdomen. And then the heat intolerance. We actually had one client tell us that all the sudden the dog started laying on the tiles more. They're just doing that splat out on the tiles, just wants to be on the tiles and they're panting.

Jordan Porter, RVT, LVT, VTS SAIM:
They don't wanna go on walks anymore.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, they're not sleeping in the bed anymore. I mean there's all this stuff that they're just like, "I don't want it.".

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah. And just like with the PU/PD they're urinating all over the house. But they can get recurrent UTI's just because of steroids are immunosuppressive. They suppress the immune system and in turn, that can leave patients just to be more susceptible to getting a urinary tract infection.

Yvonne Brandenburg, RVT, VTS SAIM:
Mm hmm.

Jordan Porter, RVT, LVT, VTS SAIM:
And then alopecia, they come in with a thin, weird looking hair coat.

Yvonne Brandenburg, RVT, VTS SAIM:
I was gonna say the bilateral alopecia, you know, on the sides and then their belly. Like you shave a dog for ultrasound and five months later, no hair has grown back in and you're like, "Huh, like okay.".

Jordan Porter, RVT, LVT, VTS SAIM:
Oh, I know. And the thin skin. Oh, my gosh. Like we call like the old man's skin. Like when it comes to cats and stuff like that. That terrifyingly thin skin.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And that's really scary when we're clipping. Right? We're shaving for ultrasound and you're just like, "I am going to shave this dog's skin off." And so, you definitely see that. And then cats, the one cat that I saw with Cushing's, that's exactly what happened to this poor cat. Well, not shaving, but it came in, it was Cushingoid and the skin. You can't scrub them. You can barely restrain them because the skin just basically peels off.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. They're like a rabbit.

Yvonne Brandenburg, RVT, VTS SAIM:
It's scary. Yeah. And so, yeah, we have this cat that she had this giant flap on her, what is her abdomen? It was either her abdomen or her hip area. I think it was her abdomen. And so, we had to be extremely careful because we were doing bandages on this cat because it was just this open wound and it and it was hard because you can't really tape to them because when you take the tape off.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, you're going to peal their skin off.

Yvonne Brandenburg, RVT, VTS SAIM:
You're going to get more skin off.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, it was really hard. And the owner for, you know, ethical reasons she didn't want to euthanize. So, it was just it was hard for us to do the bandage changes.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, I think those cases, especially in cats, because there's not really a treatment for it. But like if these patients go untreated, like it can be dangerous. So, their skin's thin and fragile, they bruise easily. They're at risk for infections easily as well. And then they can develop pyoderma, secondary demodex, which I definitely saw in general practice. We'd have like an adult dog come in with demodex and we'd be like, "why?" And then turns out they'd be Cushingoid.

Yvonne Brandenburg, RVT, VTS SAIM:
Oh.

Yvonne Brandenburg, RVT, VTS SAIM:
So, just because their immune system is suppressed.

Yvonne Brandenburg, RVT, VTS SAIM:
Because their immune system.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Wow. Yeah. And then the hyperpigmentation. So, you'll see they get that black belly. You guys have seen this where it just changes.

Jordan Porter, RVT, LVT, VTS SAIM:
Right in the groin area. It just changes it.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And calcinosis cutis is one of those things. So, what happens, and this can happen with excessive steroids like prednisone. So, like our immune suppression kids that we put them on a boat load of steroids. What happens is the calcium crystals deposit in the skin and it causes, it's really strange looking, white, slick raised thing. And it'll be there until the body produces enough skin cells to push it out.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
It's really weird. But we want to get those under control pretty quickly.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, those ones we usually try to wean off of steroids because it's steroid induced. And so it's like the only way to fix the skin really is to take them off the steroids, which is crazy because I have seen, I think people try to treat a lot of those skin things with like steroids and stuff, but I'm like, "it's making the problem worse."

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, but we actually, not that this is in the history, but we recently had one where we did an ultrasound and it was an older dog with Cushing's, but the kidneys were super mineralized looking.

Jordan Porter, RVT, LVT, VTS SAIM:
Oh cool. Well, not cool, but,.

Yvonne Brandenburg, RVT, VTS SAIM:
Cool for us, but not for the dog.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
We're like, "Yay! That's really cool."

Jordan Porter, RVT, LVT, VTS SAIM:
But it was really interesting to see the changes to the kidneys where these minerals are deposited because of excessive cortisol.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah. And I think it's important to know though too. So, the Cushingoid patient we saw recently had a mastectomy done recently, but the incision wasn't healing very well. And so, I think that just goes along with the fact that they're immunosuppressed, they don't heal as well. Their skin is just off.

Yvonne Brandenburg, RVT, VTS SAIM:
Friable.

Jordan Porter, RVT, LVT, VTS SAIM:
So, they are more susceptible to slow healing and just not healing or difficulty healing. So, I think that's something to kind of keep an eye out for. They're not generally suitable candidates for anesthesia, just for risk of infection and poor healing wise. So, you do want to try to get those patients under control if you're aware that they might be Cushingoid prior to a procedure. So, and then upon intake, things that should be noted or run laboratory wise, and we'll probably repeat the fact of just good blood draw, handling techniques pretty frequently, that lipemia can affect certain tests, but increased alkaline phosphatase or ALP, that is kind of a classic chemistry abnormality for Cushingoid patients. You can have an increased ALT, hypercholesterolemia, hyperglycemia, so their blood sugars could be high, just steroids. So, excessive steroid again. Decreased BUN, so they might be showing symptoms of PU/PD and you might be worried about their kidneys, but they'll generally have a decreased BUN and proteinuria as well. So, they'll be losing protein in their in their urine. So, kind of leading into, you have all these abnormalities that you're seeing, the differential diagnosis, you want to rule out renal disease. So, that's what that chemistry is very important for. You want to rule liver disease because you are going to have some elevation of liver values. Dehydration, cause they're gonna be drinking, urinating a lot. Diabetes mellitus and diabetes insipidus, so both of those caused easily PU/PD and just trying to figure out what is causing your pet to drink and urinate more and then kind of narrowing it down to, OK, we have a hyperglycemic patient, but you also have an elevated ALK phos. So, there are more diagnostic says should come trying to determine if it's renal disease, diabetes mellitus, diabetes insipidus. There's a lot of things that go along with that.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, it's funny because we frequently will get patients referred to us for liver disease.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, us too.

Yvonne Brandenburg, RVT, VTS SAIM:
And we're like, "Well, yeah, there's liver disease. But..." You know, we look at the history and we're like, we're gonna be really suspicious of the dog with Cushing's. And then they come in and we're like, "yeah, that looks Cushingoid". So, you know, it's something that I think it's, just as much as it's difficult for technicians to understand endocrine stuff. So, you know, adrenal glands. I think it's also difficult for general practitioners.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. '

Yvonne Brandenburg, RVT, VTS SAIM:
Cause they didn't specialize in it. Right? And they don't see it on a daily basis. Sometimes we see more endocrine stuff because they're like, "nope, that's outside of my realm. Let's go to internal medicine that's what they specialized for."

Exactly. And I think too it can be scary, especially if you have the elevated ALT, where you're like, "oh no." Like, you know, just instantly worried that something more might be wrong with the liver.

Yvonne Brandenburg, RVT, VTS SAIM:
Especially because it tends to be older pets, too.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
Everybody's like, "oh, god, it's cancer."

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And we're like, "No, not yet.".

Jordan Porter, RVT, LVT, VTS SAIM:
Not yet. Not yet.

Jordan Porter, RVT, LVT, VTS SAIM:
So, further diagnostics to kind of get into this. And we mostly only do one of these on my list just because gold standard. But I have seen people do like a urine cortisol creatine ratio. And it's OK. It can rule out Cushing's disease, but it doesn't, a high number doesn't necessarily confirm it.

Yvonne Brandenburg, RVT, VTS SAIM:
Sometimes my doctors will do it as a rule out, like if we sent out lab work, sometimes we just do the urine test because we're like, we have the urine, let's just rule it out.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
But, I don't know about you, but my doctor too will have them collect a sample at home. And make sure it's two to three days, at least three days after, or more, after any stressful event. So, we don't typically like to do it the day of an office visit. Because that'll stress them out a little bit more. So sometimes we'll send them home with urine cups just to monitor to see how things are going.

Jordan Porter, RVT, LVT, VTS SAIM:
It's actually a really good point to have the urine done at home when they're low stress. Because cortisol is a stress hormone. So, if the patient's stress that cortisol levels gonna be higher anyway. So, that you're in cortisol creatine ratio being done at home with that sample because it can rule out Cushing's disease because it has a high sensitivity value. So, what that means is high sensitivity that when negative helps to rule out a disease, but it has a low specific value. So, high number on that test doesn't confirm. So, what that means is a high specific value when it's positive, it helps to rule into a disease. But this test doesn't do that yet.

Yvonne Brandenburg, RVT, VTS SAIM:
So, I remember my doctor teaching me about this, too. So, it's a good mnemonic, right? So, Snout so S-N-O-U-T, so high sensitivity, so sensitivity being "SN" when it's negative. So, N rules it out. So, snout. So, SPIN. A test with the highest with a specificity, which is the value of SP then as a positive which is P rules it in. So, SNOUT and SPIN. Definitely memorize that.

Jordan Porter, RVT, LVT, VTS SAIM:
So, highly specific and sensitive test is really, really good. Urine cortisol creating ratios is not one of those tests. It's highly sensitive, but not specific. So, gold standard testing for Cushing's disease, though, is an A.C.T.H. stim, or A.C.T.H. stimulation test. I will say with these tests this is what we do most often, but just be careful with your patient. They can bruise easily, kind of like we mentioned before. The same goes along with the urine tests. Like you want to minimize patient's stress for accurate results. So, if you do have an extremely stressed out patient in the hospital who's just sitting in a cage trembling, you're going to have an elevated value. Lipemia and icterus can affect the results as well. So, you do want your patient fasted, as you know, to the best of their ability. Obviously, the underlying disease that requires them to eat prior to having this test done, then just try to feed a minimal amount or do it kind of timing wise if you possibly can. Twelve hour fast is always better, but not always possible. But you can centrifuge that, like we've talked about before just to try to spin down some of that lipemia. And then it is important with this test specifically too to centrifuge and refrigerate the samples within one hour of drawing them. So, what we do for this test is we draw a pre sample. So, our pre, we administer an A.C.T.H. derivative or synthetic A.C.T.H. We use cortrosyn. I know there's like a gel that I used to use in general practice, but now I don't use it.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I've heard my doctors talk about the gel. From what I understand, it's just not as accurate anymore.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Compared to cosyntropin in which is the generic, Cortrosyn is the brand. And I think that's what we typically use.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yes. And it's pretty easy to get, aside from some recent back orders.

Yvonne Brandenburg, RVT, VTS SAIM:
I haven't run into that yet.

Jordan Porter, RVT, LVT, VTS SAIM:
Oh, that was like a few months ago it was like super difficult to get. But anyway. So, you want to draw a pre sample and, I'm a huge, this is going to kind of slide into my tech tips, I'm a huge fan of butterfly catheters. So, you'll place a butterfly catheter, draw your pre sample, administer your A.C.T.H. and then put a Band-Aid on, flush it, because you want your full dose to be given to the dog and it makes it too so you're pretty certain that you get the dose in, like you're going to notice if you're not getting blood from the vein, you're not gonna get your sample into your patient. So, I think it's super helpful to be sure. You just have a good draw and a good administration site.

Yvonne Brandenburg, RVT, VTS SAIM:
Mm hmm.

And then actually to kind of go along with that. So, it used to be, for Cosyntropin, and some people do this still, is it was one bottle of Cosyntropin per patient.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, I remember that.

Yvonne Brandenburg, RVT, VTS SAIM:
There's no real overdosing of Cosyntropin. There definitely is underdosing. Though if you ever think that maybe that dose didn't go all the way i.v., or you know, for some reason the dog moved and it splashed like it may not have gone into the dog or the cat, it's usually not a cat, most of times it's a dog, just go ahead and redose them. Because if they don't get that full dose, your test is going to be invalid. But if you get a double dose, you're fine. There's absolutely no problem with giving twice as much as what the quote unquote supposed to be giving. And then I don't know about you, but we put ours in small syringes and then put them in the freezer.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yep, it's good for six months in the freezer versus only 24 hours refrigerated.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. So, we put it in the freezer and then once you defrost it that's it. We don't refreeze it.

Jordan Porter, RVT, LVT, VTS SAIM:
Us too.

Yvonne Brandenburg, RVT, VTS SAIM:
So, that's why we put it like this. It only comes in one meal bottle. Right? And so, we pull it up into somewhere between 0.2 and 0.3 mL in a syringe.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, we do 0.2 increments and then that's how we dose it, too. So, if a dog's dose is 0.17, we round up and give 0.2. So yeah, we draw it up in 0.2 increments and administer it in 0.2 increments.

Yvonne Brandenburg, RVT, VTS SAIM:
That's, that's actually a really good idea.

Jordan Porter, RVT, LVT, VTS SAIM:
Because again you can't really go too much. So.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, yeah, I might have to talk to my group about that because that's a good way to do it. That way you know how many you need to pull out of the freezer.

Jordan Porter, RVT, LVT, VTS SAIM:
Exactly. And it makes it easier. Yeah. It makes it easier to store your access and administer so. And yeah, the bottles are always like the same. So, it's one of my syringes is usually 0.25 and then we administer 0.25 mL.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And then just so that you know, or everybody else knows, the reason we do this is because Cortrosyn is expensive. Don't give an entire bottle if you don't have to because it can be pretty cost prohibitive.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. So yeah, with these results a dog with PDH, or spontaneous Cushing's disease, will have an ideally have an exaggerated response to this. So, because the A.C.T.H. is telling the adrenal glands to produce cortisol, you're gonna have a high cortisol level. Now, with your iatrogenic Cushing's disease, the ones that are caused by steroids, you're not really going to see a response to this test, so you'll see a normal to diminished response on your A.C.T.H. simulation test. I know a lot of people in general practice, I did a lot of low dose and high dose dex stimulation tests. And what that does is it evaluates the negative feedback loop of the pituitary gland. I still prefer the A.C.T.H. stim test.

Yvonne Brandenburg, RVT, VTS SAIM:
We usually do the low dose sex suppression test first to diagnose. So, because it is very specific as far as, you know, is it adrenal or is it pituitary?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
I usually start with the low dose dex first and then our A.C.T.H. most of the times is our monitoring. That's just what my doctors do. We don't really do the high dose dex suppression.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
But, we definitely do the low dose.

Jordan Porter, RVT, LVT, VTS SAIM:
So, the reason for that is because in a normal dog, dexamethasone would suppress the secretion of A.C.T.H. from a pituitary gland. So, in your Cushingoid patients with PDH or an FAT, dex would have a minimal effect. So, your cortisol concentrations would remain high versus in a normal dog your dexamethasone would suppress those levels. I think we probably don't do those because we use ultrasound to just visualize.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, sometimes we don't do it because we're like look, there's an adrenal tumor. Because we usually, so during our consults most of the times we start with an ultrasound.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, us too.

Yvonne Brandenburg, RVT, VTS SAIM:
Because you can do that that day. If we see an adrenal tumor, a lot of times we'll do the A.C.T.H. If we don't see an adrenal tumor, but we're still thinking it's Cushing's then we do the low dose dex suppression test. So, that's probably where that comes in.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
The other thing to know too is just explaining your client, like an A.C.T.H. takes, the test itself is an hour, but I usually say an hour and a half just to get everything ready, do the tests, and get the patient out the door kind of thing.

Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Whereas like a low dose dex, that's an eight hour test because you do your pre-, your four hour, and your eight hour. So, sometimes we don't do the low-dose suppression because of, you know, maybe the client's coming from further away or they just don't want to drop their pet off for the entire day.

Jordan Porter, RVT, LVT, VTS SAIM:
Well that, and I think too, honestly being there in a clinic setting for eight hours is more stressful for a pet. So, I do think that would affect maybe some results. Maybe not.

Yvonne Brandenburg, RVT, VTS SAIM:
It depends on, yeah, it totally depends on the animal.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Because I feel like maybe after a while some pets a bit like, OK, this is my life now.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
But I do like ultrasound because you can just visualize. Either you're going to see a tumor on the adrenal gland, you know it's FAT, and then just with PDH you're going to see those swollen adrenal glands and generally those measure greater than point six centimeters. Less than 0.6 centimeters is generally normal. Obviously, it's going to vary per patient. If you have a 0.7, you're probably not going to be like, 0.7 cm adrenal gland in a Great Dane you're probably not going to be like, "it's Cushingoid." So, you definitely can't just go off of ultrasound, but it's helpful.

Yvonne Brandenburg, RVT, VTS SAIM:
It's like 0.7 centimeters then a Chihuahua.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
So, treatment wise though, the easiest way. I think so for PDA, we use trilostane. I've never used Mitotane.

Yvonne Brandenburg, RVT, VTS SAIM:
I think they, I believe they stopped manufacturing mitotane in the last year or two.

Jordan Porter, RVT, LVT, VTS SAIM:
There were several side effects.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. So, the difference between trilostane and mitotane. So, in mitotane was designed to go to the adrenal tumor and actually destroys cells within the adrenal gland. And so, once that happened. So, that's why there's like this whole induction thing and then close monitoring that happens because you can overshoot and actually make them hypoadrenocorticoid. So, now all of a sudden their Addison's. So mitotane, my doctors hate mitotane. They stay away from it. Because it's just you can cause problems. Whereas trilostane, all it does is suppress things.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, there's no permanent change in the pet. So, you can stop it and usually within 12 to 24 hours it's out of the system and so if you overdose them, quote unquote overdose them you can stop it and they come back. Whereas mitotane you can't.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, I think it's fallen out of favor with the newer doctors as well. Because they're trained to use trilostane.

Jordan Porter, RVT, LVT, VTS SAIM:
I think you're right. I don't think it's really around anymore. So, because trilostane like you said inhibits the synthesis of adrenal cortex hormones. So, it's going to inhibit your cortisol. But it is important still to monitor and A.C.T.H. stim with trilostane as well, just to make sure that they're getting the proper dose. And so, be sure that when obtaining a history, I know we talked about this previously where getting a history, you want to find out from your client what time they gave the trilostane because you're going to draw those samples four to six hours post medication. Again, super important to be sure that you find out from your client what time they gave your medication. And this is going to vary, too. And we'll kind of get into the client communication part because this test should be checked pretty frequently until a stable dose is found. So, they do recommend rechecking that until you're at a stable dose.

Yvonne Brandenburg, RVT, VTS SAIM:
To kind of go along with that, too, is to talk to clients. And I love my clients sometimes, make sure that they understand to give the dose at the normal time.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. Yes!

Yvonne Brandenburg, RVT, VTS SAIM:
Because I've had clients be like, "well, you only had a 1 o'clock appointment. So instead of giving my trilostane at 4:00 in the morning, I gave it about 9:00." And you're like, "no!" So, you want to make sure that they give the medication at the normal time, they give it in the morning and that, you know, they give it with the food or whatever that they normally do and then do four to six hours. So, we have to be flexible with our scheduling for that.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. And to communicate with your receptionist too. If they're the ones scheduling of a recheck and they're just like, "hey, Fluffy needs to come in for a recheck A.C.T.H. stim." But it doesn't get realize they're supposed to get a medication and we got to try to time that it might turn into a drop off or you might miss that window if they scheduled at 4:00 p.m. So, that can be very frustrating for clients as well. So, it's just communication and record keeping. Try to make a communication in the client's chart saying, "hey, recommended rechecking A.C.T.H. stim. This needs to be four to six hours after the medication is given."

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. One of the other things I talk to my clients too about is brand versus generic. So, trilostane versus Vetoryl, right? So, my doctors prefer to use Vetoryl to trilostane.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, they prefer the brand name. So, that's one of the things that really important for us to remember when we're talking to a client is making sure that they stay with whatever it is they choose. Do not bounce back and forth between the generic and the brand because they react differently in the body. My doctors prefer Vetoryl, so when I'm calling it into a pharmacy, I will call it into Costco because Costco carries it. I specifically say Vetoryl brand only this strength, right?

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, that's just something really important to know, especially because Vetoryl in the last year has gone out of stock tons of time. So, you just want to make sure that if you've got a patient on Vetoryl, they're not switching back and forth between Vetoryl and trilostane without understanding that they may not work the same. And so, you may like if you're going from Vetoryl and trilostane because the Vetoryl brand is out of stock. They may see more of those symptoms again. And we probably don't want to do an A.C.T.H. and adjust dosages if we know we're just tiding over until we get back on to the Vetoryl.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
And then we kind of, you know, wait at least 10 days before switching again to test our A.C.T.H. that's just unfortunately, one of the things that we do have to deal with, because unfortunately if you don't, you have no idea we can be making dose adjustments that are inappropriate.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Because we're not consistent with the drug itself.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. And it does kind of break down too that there's a potential for wasting our clients' money, too. If you're unaware, you know you know that this test isn't gonna be accurate. But you don't ask the right questions to really kind of find out then there's a waste of money when it comes to that. So, unfortunately. So, it's just a matter of really kind of keeping tabs on what's happening with your patient.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
And then a functioning adrenal tumor. Those trilostane has little effect on a tumor size. Really, what's recommended for those is a unilateral adrenalectomy. And I'm so happy I don't work in surgery because that can be scary, especially if it's eating into the vena cava. And we've had several clients elect not to do that. I get it. It's a scary surgery. It takes a lot. Monitoring tumor size with ultrasound is important because then you can watch to see if it's how quickly it's growing, if it is going to start eating into the vena cava or not. But yes, surgery is really the top recommendation for that type of Cushing's.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
And these dogs do tend to have like a high triglycerides level and high cholesterol. So, just for general maintenance of these patients, a mild fat diet is recommended just to help kind of better control.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I think kind of the go to for my doctors is Royal Canin GI Low-Fat.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
That tends to be the one that they recommend the most.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, we recommend I/D low fat all the time.

Yvonne Brandenburg, RVT, VTS SAIM:
So I would say depending on which one they like. Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
It's like if you work for an internist you automatically just feed like low fat diet all the time.

Yvonne Brandenburg, RVT, VTS SAIM:
You're just like, "you just get low fat, everything.".

Jordan Porter, RVT, LVT, VTS SAIM:
Abscesses are gross. Their like, "the doctor forgot to give me a prescription." I'm like, "don't worry, it's probably this." Like we said, client communication is pretty big for this disease. Just because you want to express that the goals you're not going to, yes, it's a brain tumor or an adrenal tumor or caused by you. And all three of those options can be very stressful for a client. So, just trying to inform them that if it's a brain tumor, it's not malignant. Your patient will likely have a good quality of life. If it's an adrenal tumor. Yes. It can be scary. Yes, it can get worse. And if it's a steroid effect. Sorry, but it happens. It's a risk of steroids. So, you just want to tell them that, you know, the goals of treating Cushing's disease is just a minimize the effects of the disease and improve your pet's quality of life. We don't want them drinking and urinating all over a house. We don't want them eating the carpet randomly because the ravenously hungry. We don't want them having their skin come off because they got caught behind the couch. Oh, gosh. Can you imagine?

Yvonne Brandenburg, RVT, VTS SAIM:
No! That sounds horrible. Why do you even! Thanks for putting that in my head.

Jordan Porter, RVT, LVT, VTS SAIM:
The cat story. Like, stuck to my. I've heard stories of cats with Cushing's disease.

Yvonne Brandenburg, RVT, VTS SAIM:
It's just not.

Jordan Porter, RVT, LVT, VTS SAIM:
Being scruffed and then it just comes often. Oh.

Yvonne Brandenburg, RVT, VTS SAIM:
Oh. Okay. We just lost everyone listening to the podcast, their like switch off.

Jordan Porter, RVT, LVT, VTS SAIM:
Their techs, they get it. Half these techs, I'm certain like love a good abscess, like skin falling off shouldn't be too bad.

Yvonne Brandenburg, RVT, VTS SAIM:
Abscesses are gross.

Jordan Porter, RVT, LVT, VTS SAIM:
I know I'm not a big abscess person.

Yvonne Brandenburg, RVT, VTS SAIM:
I don't work in ER.

Jordan Porter, RVT, LVT, VTS SAIM:
So A.C.T.H. stimulation monitoring will be necessary. Yes, that test can be costly. Yes, it's necessary. So, informing your clients that rechecking that pretty frequently, especially in the beginning, is pretty important.

Yvonne Brandenburg, RVT, VTS SAIM:
And I was gonna say because the reason we're doing that is because we don't want to make our pets cortisol level too low.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Because there are there are concerns about becoming Addisonian, right? If we, if our dose is not correct then they can get vomiting, diarrhea. They don't want to eat it, become lethargic. And that can become you know, it works worse they can have an Addisonian crisis. Not super common for these guys to have it, but it is a potential, especially if you start really high and you're not monitoring. So, we just.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
You know, I usually tell my clients, if you're noticing vomiting, diarrhea, lethargy, not wanting to eat, skip the dose of the Vetoryl or the trilostane until they start feeling better and then, you know, maybe you need to figure out if we need to go a lower dose or, you know, what else is going on. But if you know, if it's just one day where they're doing that, you know, especially if it's like a new dosing increase. Try stopping the trilostane and see if they feel better. And then maybe we go, okay, we need to back off a little bit.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
Especially with our little kids, right? Because,

Jordan Porter, RVT, LVT, VTS SAIM:
Yes!

Yvonne Brandenburg, RVT, VTS SAIM:
There's only a 5, well thankfully there's a 5 mg now. There used to not be. And it goes from 5 to 10 and sometimes 5 isn't quite enough, but 10 is too much. So.

Jordan Porter, RVT, LVT, VTS SAIM:
And I think, too, you're going to have those noncompliant owners, so too, who don't schedule the recheck. And so, their dogs' bit on 30 mg for three months. And now the dog could potentially be having some kind of Addisonian like issues. So, because the clients didn't follow up and yes, there's only so much you can do but kind of trying to keep track of the clients and making follow up calls and be like, "hey, you know, how's Buddy doing? We really do recommend that you come back in for an A.C.T.H. stim", and finances can be an issue. So, I think it's just a matter of really communicating with your clients.

Yvonne Brandenburg, RVT, VTS SAIM:
And with the client communication too, and this is something that unfortunately we can't dictate it, but we can talk to our doctors about is, I've seen so ideally your Vetoryl or trilostane is twice a day. You know, every twelve hours. We've seen a couple of pets come from some of our referring vets, where they're getting 30 mg once a day.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, the problem with that is, so let's say they give the 30 mg in the morning, you know, they drop down. Sometimes they drop down really low, so they get really lethargic and they feel like crap during the day. And then as it leaves their system at night all the time, they're PU/PD. And the doctors like, "oh, he's still PU/PD. Let's go up on the dose." Instead of realizing, you know, they'd be better off with 10 and 10. So, we can do less of the drug. But stabilizing that because it's meant to be a twice a day drug. Not every 24 hours.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
So, sometimes we have to be aware of that and talk to our doctors and be like, "hey, you know, why aren't we doing it twice a day?"

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, well, and too. I think some of those situations can be dangerous. I'm not home during the day. If my dog, if I were to give that medication once a day, my dog were to be lethargic middle of the day, I wouldn't be home to notice it. I would only be home to notice the symptoms of Cushing's. So, I think that, too, is like a matter of really just trying to get a thorough history and be aware of what's going on, because sometimes owners aren't gonna be aware that their dog is becoming lethargic, so.

Yvonne Brandenburg, RVT, VTS SAIM:
Mm hmm.

Jordan Porter, RVT, LVT, VTS SAIM:
And then just really minimizing those symptoms or to with the medication. So, you do want to ask your client, like, how is water consumption? How's urination? What time was the medication given? Because you do want to find out if it was given once or twice a day or if it was skipped because they were unaware that they needed to give it for the appointment.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
And how their appetite is, if their appetite is still ravenous or if they're still eating random objects out in the yard or in the house that they shouldn't be.

Yvonne Brandenburg, RVT, VTS SAIM:
Or they're getting super picky and don't want to eat.

Jordan Porter, RVT, LVT, VTS SAIM:
Exactly. Exactly. So, I think those are all pretty important. And then we kind of run in to the brand through the cautions. Don't cut the skin often. This disease, it seems pretty common, I think, in my world. But it's just it's easy to kind of forget how sick they really can be with the susceptibility of infections, and UTI's, and skin infections, and skin tearing.

Yvonne Brandenburg, RVT, VTS SAIM:
I think the other thing that we can monitor, especially when we're monitoring the adrenal gland size, is monitoring the gallbladder. Right? These guys are predisposed to getting a gallbladder mucocele, especially if they go untreated. Typically, once they start getting treated, it's not as much of a problem, but we still need to be very careful because the gallbladder mucocele what that is, is it's a plug basically in the gallbladder. And if they get a mucocele, the potential for the gallbladder rupturing is high. So, we just want to make sure that we're keeping an eye on that gallbladder, using the low fat food to help minimize the amount of gallbladder issues. So, that's something else to talk to our clients, just like, "hey, you know, we're going to keep an eye on the gallbladder, we're going to keep an eye on the adrenal glands and make sure there's not those problems."

Jordan Porter, RVT, LVT, VTS SAIM:
Another caution, I mean, with the gallbladder mucocele these dogs, and I think I don't think I've realized this for a long time, but Cushingoid dogs are really three prone to throwing clots. So, pulmonary thromboembolisms so they can throw clots in their lungs and, I mean, that can be severe.

Yvonne Brandenburg, RVT, VTS SAIM:
Oh, yeah! Yeah.

Jordan Porter, RVT, LVT, VTS SAIM:
It can be can be deadly. So, I think that needs to be remembered, too, especially when you have kind of a newly diagnosed patient and you're planning on doing anesthesia. It is ideal to try to stabilize them. But just understand, too, that if they start having respiratory symptoms, you might want to look into completing some radiographs and look for PTE.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And I mean, that makes sense because you have inflammation, inflammatory thing going on in the body, right? Plus, you have steroids and high dose of steroids, you're going to be also pro clot. Right? So, it makes sense that they're more predisposed to throwing clots. I didn't think about it, but that definitely makes sense. And one thing to remember, a patient that has a PTE, typically it's a sudden change in respiratory effort. And it sucks because you'll put him in oxygen. But they're still not oxygenating. Right? So, you're SpO2 isn't going up.

Jordan Porter, RVT, LVT, VTS SAIM:
Those cases are difficult because it's like you try to throw Plavix or something. And it's just you're just waiting to see if it works.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, you want a fibrinolytic that works, hopefully fast enough. I mean, in theory, they can go in and take a clot out, which is expensive as a bit scary.

Jordan Porter, RVT, LVT, VTS SAIM:
I would not want to be a part of that.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah. And you might need to do a C.T. scan to look for it. If it doesn't show up on x-ray. But those are not very good.

Jordan Porter, RVT, LVT, VTS SAIM:
Scary. So yeah, I think that's one of those things too. I know I don't always remember that's a risk of Cushing's.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I totally. Honestly, I didn't even know it till we researched for this. So, I'm like, oh, geez.

Yvonne Brandenburg, RVT, VTS SAIM:
It's the Tip of the Week.

Jordan Porter, RVT, LVT, VTS SAIM:
So, a couple tips to kind of take away from this episode. It's an endocrine disorder. It's more common in dogs. Rare disorder of cats, but can happen. Rare. Clinical signs are PU/PD, similar in dogs and cats, with the exception that if you are going to see Cushing's disease in a cat, they're likely going to have concurrent diabetes mellitus with Cushing's disease and they're likely going to have diabetes first. And then just be sure, really be sure to know when and how the medications are being given and rechecking the stim. Just because we don't want to waste the client's money.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, I must say, the other tip of the week is our Snout versus Spin.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Yvonne Brandenburg, RVT, VTS SAIM:
So, I think that was a good tip of the week. And I will, I might make like a goofy picture for that because that's.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah. We'll have to make something and put it on Facebook.

Yvonne Brandenburg, RVT, VTS SAIM:
Yes. But to me that is always the hardest to understand: what is a highly sensitive but not since specific. like in my head I can never remember. So, I think we can simply try to try to remember that for us.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly. And we'll try to get that to you guys whenever we can figure out how to make it more simple to understand leading into our question of the week.

Yvonne Brandenburg, RVT, VTS SAIM:
And now for the Question of the Week.

Jordan Porter, RVT, LVT, VTS SAIM:
What is your favorite endocrine disorder? So, this is a pretty good endocrine disorder because so many things are happening within the body, I think, and people don't realize that it can lead to so many other things. So, I do personally like Cushing's disease, but I know there's a lot of people who prefer other endocrine disorders.

Yvonne Brandenburg, RVT, VTS SAIM:
Cushing's to me it is a fairly common one. And once you kind of understand it and know what to look for, I think it's kind of satisfying. Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Not as satisfying as Addison's because,

Yvonne Brandenburg, RVT, VTS SAIM:
Well, but I think it's satisfying in so far, well, we can argue this.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes.

Jordan Porter, RVT, LVT, VTS SAIM:
But I think, I always forget to do this is I'd love to take that before and after picture. Right?

Jordan Porter, RVT, LVT, VTS SAIM:
Oh yes.

Yvonne Brandenburg, RVT, VTS SAIM:
You see these animals come in and they look like they're old because, you know, they have the muscle wasting in their head and they're super potbellied, thin skin, and then, especially if they're really high when they're diagnosed, then you start treating them and they come in and they look like they have found the fountain of youth. Right? And the clients are like, "Oh, my God. I didn't realize how bad it was". Because it can be gradual. Right? In a lot of people go, "oh, he's just getting old." And you're like, "but it's not just getting old."

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly. So, I'll agree that the subtle changes are pretty good versus Addison's is like you can have a dog on death's door come in. And then you just give him some steroids and then they're like a puppy again.

Yvonne Brandenburg, RVT, VTS SAIM:
Okay, yes. You get instant gratification, fine I'll take you on that one.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, exactly.

Yvonne Brandenburg, RVT, VTS SAIM:
So, you guys want to tell us what your favorite endocrine disorder is and why that'd be really cool. Or if you absolutely hate endocrine. I don't know why.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah.

Yvonne Brandenburg, RVT, VTS SAIM:
If you like internal medicine, I feel like you're obligated to like endocrine even though you may have a love-hate relationship with it.

Jordan Porter, RVT, LVT, VTS SAIM:
Maybe people were just getting into internal medicine so they still hate it.

Yvonne Brandenburg, RVT, VTS SAIM:
Yeah, they're still hating it because they're like, "I don't understand it at all." That was me for a long time. I totally understand.

Jordan Porter, RVT, LVT, VTS SAIM:
Yes, exactly. So, please answer our question of the week at InternalMedicineForVetTechs.com/podcastshownotes and you can leave us a comment. Or at imfpp.org/shownotes.

Yvonne Brandenburg, RVT, VTS SAIM:
So, definitely check it out there. Go check out the Continuing Education questions and get your certificate for maybe listening to podcasts while driving or, you know, doing chores around the house, because that's also a great time to listen to a podcast. That way you can, you know, get smart and show your work that you're, you know, learning on your own time. And then we've got the resources that will be on the website. So, you can see the, you know, the books that you like to check out and learn from. We'll have those resources up for you, too. And just a reminder that we have the Technician Treasure Trove. So, if you haven't signed up for our Web site and you haven't gotten your password, definitely do that so you can get all the fun handouts that we're talking about in the resources. And like we've said, we'll keep that updated and keep adding more to it. So, it's a little bit more of like a horde of treasure for you. And if you guys have any suggestions for things that you'd like us to add in there, just let us know because we'll make stuff. We're happy to do that.

Jordan Porter, RVT, LVT, VTS SAIM:
We do love hearing from people. Yes, and I do. Gosh, I love making handouts.

Yvonne Brandenburg, RVT, VTS SAIM:
So do I.

Jordan Porter, RVT, LVT, VTS SAIM:
It is, yeah. There's just something like. I just I don't. I like it.

Yvonne Brandenburg, RVT, VTS SAIM:
I like it, it's rewarding because you're sharing that information with someone, with your client.

Jordan Porter, RVT, LVT, VTS SAIM:
And when your doctor's like, "God, I wish I could just give my client something." And I'm like, "here. I made it."

Yvonne Brandenburg, RVT, VTS SAIM:
I'm the one that does that for my clinic. So, I guess.

Jordan Porter, RVT, LVT, VTS SAIM:
Yeah, me too. I make feeding guidelines. It's great.

Yvonne Brandenburg, RVT, VTS SAIM:
All right, guys. Well, is there anything else that you can think of we should talk about before we head out for the week?

Jordan Porter, RVT, LVT, VTS SAIM:
I don't think so. Just keep listening. Rate, review. Leave us a comment. Please send us an e-mail if you have suggestions or just comments about something that we talked about that you want to mention. We're always happy to hear from you. So, thanks again for listening.

Yvonne Brandenburg, RVT, VTS SAIM:
It amazes me how many people are listening and makes me feel like we're doing good getting some knowledge out there for you guys. All right. Well, I hope you had a wonderful Thanksgiving last week. Hopefully, you know, you're awake enough to listen to this episode. Stay sane until next week. I'm sure the holiday rush has already started.

Jordan Porter, RVT, LVT, VTS SAIM:
Oh, definitely.

Yvonne Brandenburg, RVT, VTS SAIM:
I got go Christmas shopping. Ugh. Oh crap.

Jordan Porter, RVT, LVT, VTS SAIM:
Right?

Yvonne Brandenburg, RVT, VTS SAIM:
All right, guys, have a wonderful week. Keep learning and go save some pets and we'll talk to you next week.

Thank you for listening to today's episode of the Internal Medicine For Vet Techs Podcast. If you like what you heard, we'd love for you to share with someone you think might enjoy the podcast. And make sure to subscribe so you never miss an episode. Want to give us a boost? Please leave a review on i-Tunes or your favorite pod catcher and we'll be sure to say thank you. Find out everything about us at InternalMedicineForVetTechs.com. Talk to you next week. Bye.

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Question of the Week:

What is your favorite endocrine disorder?

Leave a comment below!