May 9, 2023

#92: Cushing's: Diagnose like a pro, and treat it like you mean it. With Dr Sue Foster.

#92: Cushing's: Diagnose like a pro, and treat it like you mean it. With Dr Sue Foster.
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Season 1

Who feels like Cushing's is a nice disease to diagnose and manage? Like, how often do you feel like your hyperadrenocorticism patients are really doing REALLY well? My guess is: not that often. This episode will change that.

Dr Sue Foster is a registered specialist in Feline Medicine and Senior Lecturer in Small Animal Medicine at Murdoch University in Western Australia. She’s also a medical consultant for Vetnostics and ASAP Laboratory, where a large part of her role is interpreting cortisol test results and supporting veterinarians in their clinical decision-making. In this conversation, Dr Sue challenges the belief that Cushing's is to some degree a 'lifestyle' disease that doesn't always need to be treated, we discuss the subtle ways that it can present, and of course we take a deep dive into those slippery cortisol tests, which should feel a lot less slippery after this episode. Dr Sue also presents a paradigm shift in how we think about treating these cases.

 

Topics:

0:00 Understanding the cortisol lab tests. 

4:40 ACTH stim vs LDDT - which is better? 

10:28 The TRUE significance of ALP in diagnosing Cushing’s.

13:30 Fasting triglycerides - your friend in Cushing’s screening? 

16:26 Deciding when to test for Cushings .

18:27 More on triglycerides and lipaemia 

23:52 Why Cushing’s cases don’t all have to have pu/pd. 

26:04 The many different faces of Cushing’s - spotting the sneaky hyperA case .

29:42 Why we should consider treating Cushing’s even if they aren’t textbook cases. 

31:41 Cushing’s and anxiety.

35:40 The dog with the high ALP but no clinical signs of Cushing’s.

39:44 Treatment trials for the ‘undiagnosable’ Cushing’s case.

45:13 Monitoring Cushing’s therapy with ACTH stim testing. 

52:30 The quick and easy ACTH stim test. 

56:20 Treating Cushing’s like a pro. 

 

This episode is supported by the SVS Pathology Network.

QML/TML Vetnostics (QLD & Tas): 1300 838 765 vetnostics@qml.com.au

Vetnostics (NSW & ACT): 02 9006 7468 enquiries@vetnostics.com.au

ASAP Laboratory (VIC): 1300 838 522 admin@asaplab.com.au

Vetpath (WA): 08 9317 0777 admin@vetpath.com.au

 

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One of my favorite things about working as an emergency with is that I don't need to deal with all those tricky long-term diseases like Cushing's sometimes I do get to do the fun part of starting the investigation, but once we've stabilized, whenever they came in for and we're on a path to finding an answer, the real work of confirming the diagnosis and managing the disease begins with you guys.
My general practitioner Heroes and man.Oh man, concussion can be tricky, even just diagnosing and can be a real challenge managing it.Well, that's a whole different story but then we did this interview over on our clinical podcasts and now I'm a little bit sad that I don't get to be involved with Hyper a cases anymore because after listening to dr.
Sue unpack hyperadrenergic autism and all of its sneaky tricks in such a systematic way.I feel like I could totally take it on and make a big difference to these patients, like come here, you big fat.Adrenals.I'm going to shrink you Write down.So who is dr.
Sue in the zoo dr.Sue Foster, is a registered specialists in feline medicine and a senior lecturer in small animal medicine at Murdoch University, in Western Australia.She's also an internal medicine consultant for witness ticks, and ASAP Laboratories.And as you'll hear during this conversation in this role, she looked at a lot of Cushing's testing results and is probably help to diagnose and manage more Cushing's cases than you've expressed anal glands.
And that's even if you counted the left.In the right clients separately, basically you're in good hands with this conversation in which dr.Sue takes on the belief that Cushing's disease is not that bad a disease and that we don't really have to always treat it.She cruises into all these subtle ways that Cushing's can present.
That you might not pick up both clinically and on Lads and of course we get real deep on what dr.Sue does day in and day out those slippery.Cortisol stimulation test which hopefully after this episode will feel a lot less slippery.Also presents a paradigm shift in how we think about treating these cases.
I don't want to spoil it for you but basically go out there and treat it.Like you mean it, this episode was originally produced for the vet V, clinical medicine podcast series but we're sharing it far and wide thanks to the support of our friends at the SVS pathology network.If you're an Aussie practitioner you'll know them as witness ticks wait, Beth a separate laboratory and qml with gnostics depending on where you are.
And if you're not from these parts, well then I'm sorry, you missing.Hang out.As you'll hear from this conversation, all lab tests are not created equal.And when the repercussions of your results can make a huge impact on the patient in front of you, you want to be very sure that the people doing your Diagnostics are using the best that science has to offer.
So it's good to know that the SVS pathology Network lab that you use is doing just that.And they're not just splitting a bunch of numbers out and leaving it to figure out what they mean.They have people like dr.Sue and other Internal Medicine Consultants on the other end interpreting.Your results to support your clinical decision-making.
Okay, jumping in joy, and then get back out there and go make a real difference to these cases.Dr. Sue faster.Welcome to the vet felt bad cast.
Thank you very much.Yeah, Cushing's.We digging into Cushing's Cushing's.Pretty much your life.Now right.Well it does seem to be my life.I'm not sure that's what I planned.But case numbers dictate that most of my day is spent on Cushing's.Yes.So explain your role.
So you work for with gnostics as a medical consultant does that mean as GPS called you when we don't understand our test results or not, How exactly are you involved with Cushing specifically so much in the morning, all the cortisol results that have come in overnight?
Get put out by an internist rather than a pathologist.So we actually get to comment on those results and to look back and see what results.Have.Come previous, how dogs have presented?
Have they been diagnosed correctly?Is there any doubt?What's the treatment?How do they responding to treatment?So we Comment on I guess, diagnosis and treatment of Cushing syndrome and Addison's so okay.Bye adrenal disease in general so it's all.
So if that gives you busy full-time, how many are you seeing?I like how many adrenal function tastes just this one lab deal with in an average year.That's a very good question II.Probably comment on upwards of 5,000.I suppose.Whoa.Okay, so this is looking at the results looking at the history and then trying to help.
The GPU make sense of what is it actually mean?So in other words a have you got you diagnosis that you're looking for if not suggestions or of what else to do?All its own treatment.And yeah.Your treatments good or no little fiddle with your treatment?
Yeah, that's correct.So we do the validations and then gets can ring up during the day and discuss treatments Diagnostics what to do, okay?And mostly the stim test or low dose decks or Percentage-wise, what are you seeing when we're focusing on Cushing specifically, when we focusing on Cushing's for diagnosis?
I guess the majority of tests that come in are ACTH dentist.Yes.What do you think about that?Is that the in your opinion?Is that the test that we should be doing?Well, historically, the Lodi Stakes test has been regarded as the most sensitive test but of course it's the least specific test.
So if you're going to get a false positive, it's more likely on a low dose next test.So, So in many ways it's quite a good idea for an ACTH stimmt s to be running practice so that you don't get so many false positive diagnosis.
The other thing is that some of that historical data with different assays doesn't really pop probably apply in the Australian situation.So I think our ACTH didn't test, especially set at the cut-offs.We have at bet.
Gnostics is reasonably sensitive probably much better than The historical reported sensitivities for the ACTH dentist.So sorry.How is it different in Australia?We doing the test differently or what?We have a totally different dog population.
So unlike any other dog population in the world, our predominant breed is multis.We also have a million staffies and Australian cattle dogs and sure the oodles and Boodles.But if you look historically, it's been the poodles.
And Dax, he's and those sorts of great.So they've had quite a different breed list.So, I do wonder whether the sensitivity of these tests, is breed dependent.I mean, I pulled a heap of data on discrepant test, but of course, I haven't had time to go through it, but I probably got 1,000 tests that I need to actually look through to see whether tease out if there are any breed differences.
Because, historically, for example, Ed Feldman in the u.s. always supported the low dose text test, but his average size Dog in his population is 19 to 20 kilos.That's very different from the Australian dog population, which is somewhere between averages between five and seven kilos.
So, why does that matter when we talking about Cushing's Disease?Well, Cushing's syndrome.I guess he's more than one disease and we don't really have a full understanding of all the different types of Cushing's if you.
Like I mean, there's in Broad terms is I at regenexx, pituitary dependent and adrenal dependent.But for example, in Scottish Terriers, they have shown that it may be a decreased clearance of cortisol, that's actually contributing to Cushing's in that breed, that with the point of this broadcast, that's to make these things simpler Sue.
That's probably what we next time for with Cushing's.I'm sorry, but I think we've always looked at dog population as a whole and I think we know, This that isn't really the case and so it is possible that ACTH dim test sensitivity may vary in different populations.
It's just a hypothesis, really?I don't know, but that's one thing.The other thing is that really most commercial, Laboratories if not all apart from us don't validate their own essay so they use quite high cut offs for an ACTH stimulation test and they use historical textbook cut-offs.
They don't use their own validated cut-offs and we actually use a reference interval that was validated for healthy dogs in the lab.So that was that put us in a fairly unique position for by validating just to clarify.You mean, you ran the tests on a bunch of dogs that showed none of the symptoms of the Cushing syndrome and went?
Well, this these are cut offs for normals and then anything above that.So you basically you guys made your own range based on your taste and on the on the local population.We didn't actually have to make our own reference in trouble because what we did was back when Nick Russell looked at the emulator, I say we collected a whole lot of cortisol, 's and compared radioimmunoassay switch are now gone, which were the gold standard at Sydney uni and we looked at emulation against code account riaa and we found quite big differences.
But then when we ran the vet gnostics assay, which is quite a different essay from the from the, in your life.Right.They were interchangeable.So it actually meant we were really lucky and we could use the very very well validated and established Sydney uni reference intervals for their radioimmunoassay because we didn't have to do it, otherwise you couldn't really do it.
It's the sort of thing that University reference Labs could do because they had extensive workups to prove or disprove Cushing's and then that figured into their reference intervals.But you can't really do that with the commercial lab.Yet the only Way was comparing to a gold standard essay and as it happened the ad via Center a say at the time and now I teleca just happened to be virtually identical with the coat account.
So just to clarify on the choice of tasting.So my understanding from a previous discussion was that exactly?As you say ACH system is great when it's positive because it's it means that it is yes, right?The there's a Tiffy Gray Zone.That jeep is hate so much and certainly in Australian Revelations.
I've had plenty of Gray Zone results over the years and then the loaders Dex is is much more sensitive.So it's it's not going to have you give you that Gray Zone if the dog It's Cushing's.It's more likely to give you a positive test result, but it is more influenced by any other disease, anything else that's wrong with the animal is going to mess with the low dose sticks suppression test.
So then you get those false positives, much more like for that reason.Our understanding was that those decks should probably, it's probably the one to go for unless you got a sick animal, but that was my takeaway, but you saying that you feel like a snitch them is straightforward enough for that.
It's worth it.I think that that is very valid because I think that that is helpful.I just think we see a lot of dogs that have a negative low-dose next test and they can stimulate to a thousand thousand animals per liters and vice versa.
We see ACTH stems that go just into normal range, 200 nanomoles per liter and they totally fail a low dose text test and they do not have concurrent disease.You know, if I wanted to be really blunt about this, I would say what come on Muni does is that Cushing Is is a to test disease and we shouldn't be worrying about the semantics of which is the most sensitive.
We probably should just be as you say, not running a low dose text test in an ill dog.And then start off with either test, really it?It sort of doesn't matter.So long as if you think you have Cushing's you follow up with a second.That would be my take home message, ACTH deems, it depends which lab you're running them through as to how sensitive because that Gray Zone really depends on how likely Something used to have Cushing's or not whereas we tend to look at what should happen in a healthy dog.
And then we compare it with the age, the breed the technical history, the veterinarian has provided us with and then put it together and say on the basis of this.We think it is more likely that this is a true positive than a false positive or we think it's more likely, it's a false positive.
So we don't actually put out gray zones.We interpret each on.A pretest probability situation.Okay, cool.You say that's not we have a lot of listeners from the UK and the US and all over.So that's not necessarily the case in the UK lab or something like that.
And as you say, the dog, populations that do not know and I think the many commercial Laboratories.I think, probably low dose text test will be the most sensitive test, you know, depends really where you fine-tune your ACTH dim test as to how sensitivities.Okay, great.
So when over the years from looking At all those results and taking all those phone calls, one of the most common stumbling blocks and questions that you get regarding Cushing's testing I guess.The big stumbling blocks for most people is I have a dog, it looks like it has Cushing's, but it doesn't have a high a, or P.
So it can't be Cushing's, right?Well, that's not the case and likewise I have a dog, it looks really crushing.All right, I'm sure it's got Cushing's age.Breed everything, right, but it's concentrating, its urine.Do I have to test for it?
And I really think we have to move away from historical 50 year old data that said something had to be Polly.Deb seek or have a high Alp to have Cushing's.Probably they do when they're historically presenting, you know, with severe bilateral.
Alopecia and belly dropping in the floor and tearing every cupboard down and drinking everything.But I think we can pick Cushing's a lot earlier than that.And I don't think it's a prerequisite that you need an increased Alp or a decreased urine specific gravity.
And I actually wish people would do more fasting.Try Suraj.I think that would be potentially far more interesting because we do those as routine.What we do triglycerides as routine, we can't guarantee there faster that's not out of our control.And many Christians.
Dogs will have an increased triglyceride regardless of the Alp or the USG.All right, so many as in 80% 90% or a, no, not asking for specific data but you're you're feeling that I can't say, because remember a lot of people do in-house testing.
And that doesn't come with triglycerides and that's been done.Before I see the ACT HD more, the low dose text test, okay.And that's not going to be to the level of visually, seeing a light beam examples, not like a pancreatitis blood sample.Well, it may not cause like pina, it depends on the degree of hypertriglyceridemia.
But certainly, I mean, we're all used to plenty of Cushing's.Dogs, do have those strawberry milkshake by P.Make Bloods.Okay.And you saying that, you think that might actually be Be a good fairly sensitive Trigger or clue to say, well, I've got high triglycerides.
If I send an external LED screen off, and it comes back with high triglyceride levels and I've got two nickel-sized as well, that might be a trigger for you to go, even if your LP is not high, consider Cushing's testing.I think if you have a consistent fasting, hypertriglyceridemia bushings has to be one of the differentials, even even and I daresay controversially in miniature schnauzers, I've because they they have the sort of expect them to have it, right?
Yeah.They get written off as having primary hypertriglyceridemia often without adrenal function testing.And I do believe they should get adrenal function testing because primary hypertriglyceridemia is a diagnosis of exclusion.So helping you because we in other discussions we've had as well.
Sort of said that Cushing's is a syndrome.So a high LP or a them test that's out of whack or Or anything else doesn't make a Cushing's patient if it's not showing the signs of.So the PPD the hair lice, all all the things that we expect to see in Cushing's disease is that, that doesn't quite jell with what you're saying here.
That, you know, let's say, I've got a Schnauzer, I get this gets free jablin screen or it's got something else wrong we run.Bloods.It's got fancy blood but nothing else.No alarm bells are going off for me that it looks awake squish annoyed.Am I still going to investigate that?
Or is it okay to say, well, you just now is that you at the new blood?So, what Well, I guess I personally believe you should.You should check for it yet.It's quite difficult to manage primary, hypertriglyceridemia and miniature, schnauzers.It's difficult to get the trees down and those dogs can go on to have pretty miserable lives with recurrent pancreatitis gallbladder, mucosal diabetes mellitus and I see them through the lab.
I pulled quite a few miniature.Schnauzer cases that came through and looked at the history is which we get to do because we can often follow these dogs out for them.Lifetime and those hypertriglyceridemia Miniature Schnauzers.Some of them LED pretty terrible lives.So if we can do something to really try and find an underlying cause and treat that then it may give us a better chance of addressing the hypertriglyceridemia.
So yes I do think it's worth it in a miniature Schnauzer and of course that flies in the face of really what everyone else thinks but there was some fabulous work done by my colleagues Troy bun in Australia and From langner and Gabrielle Rossi, they did amazing research project.
With miniature schnauzers that has been presented at European Society Veterinary endocrinology.And is now obviously, either in press or in the process of going to publication, I didn't intend to talk about fatty blood, but it's actually something that often does bother you in practice.
So just to recap, you say, persistent hypertriglyceridemia triglyceride emia it will cause, or can cause pancreatitis.We know the dressed for that and you decide diabetes as well.Just play into diabetes.I think when dogs have many recurrent bouts of pancreatitis, diabetes, is, is a possible in stage.
It's not diabetes directly.And you mentioned the third thing, they get a lot of gall bladder, mucus heels.I don't know whether it's to do with the Triggs, or it's to do with the untreated Cushing's, but regardless they get hurt and so they just have miserable lives.
I mean, some of the dogs that Head through bit gnostics, head, 50 and 60 submissions for Bloods for various illnesses, over 45 years, and it's just these poor people and they said yeah, yeah, well, anything better there and we might not be able to but I certainly some dogs that I personally have been involved with and we've treated actually with might attain.
So we've had very tight control of the hypertriglyceridemia they have resolved.This is Miniature Schnauzers.I'm talking about they have resolved.The Reagan Sardinia, but it takes quite a few months.Well, and is it just the schnauzers?Do we ever get it?I know I shouldn't ask ever because he is, there's always a choice, dad lies, but routinely do we expect it to see it sometimes and other breeds as well?
Or is it really just a Schnauzer or?Yes, there are some other breeds as well.Lipids aren't really my forte apart from very sort of pushing these lipid dad but she'll tease ring a bell.But you know I honestly can't remember.There are a list of breeds that have been reported to have Abnormalities and just to put a point on a, might be more of a pathologist question because it often happens, you draw blood and then it is fancy or you get an abnormal result from the lab.
How long since eating should it be until you could say well that's abnormal.Where do we draw the line to say you should definitely shouldn't happy having fatty Blood by this stage of the game.To my studies.We use 12-hour fasting for our Miniature Schnauzers.We used 15, but I think fairly Stickley.
Most dogs, don't have a huge postprandial Spike, they'll have a bit but not into the numbers that are going to be twelve, thirteen, fourteen fifteen, sort of numbers that we can see with some of these dogs.If they eat a big fat and shank bone or something, they might go up to 5 but I don't know because really the work hasn't been done but idea.
Ali a 12-hour fast if you had a tower.I guess that's probably pretty good.But if you're looking at it from a persistent level, you'd want fasting triglycerides and 12 hours or more.Quick Interruption to tell you about something semi-secret that we plan.So in the last week of May, a lot of you might be hanging around in Adelaide for the a VA National Conference will be hanging around the to and we planning something really fun.
We are partnering with our friends from very the very clever.Guys, you've figured out a way to link patient data to your patients, existing microchip, and we've booked a very funky venue right across the road from the conference.We will do a live podcast recording with you guys.Eyes as an audience and as possible, participants, and possibly ever drink or two together.
And the reason I said that it's semi-secret is because we not giving away any details or tickets or anything like that before hand, you have to come and find us at the very least and on the trade flow to get your ticket which point all will be revealed.Oh the event is planned for Wednesday, the 31st which also happens to be my birthday.
So that works out well.So make sure you come and find us on those first three days.Can't wait.It.Okay, back to overexcited adrenal glands with dr.Sue Just to go back to those two sticking points.So you said Alp not being a doesn't drill it out which I would like really it.
I feel like it should.I would be very uncomfortable.Jason Cushing's.If I don't my LP Avenue said man not necessarily you what you can see them with normal LP.Yeah I must definitely and I guess if you look at the calls I get they're skewed to the ones that don't match the textbook.
So again and this is where the problem is in cases being Potentially over-represented in my consult load, as opposed to what happens out there because things within our price increase a far simpler.So it's if it doesn't increase that people often often call me.
So I would see a higher number of them relative to what's really happening out there.But yeah, sure again I wonder if it's a breed thing, it's unusual to see a maltese.For example, that has a normal out floss and probably subjectively more of my large.
Dogs don't have the out Force increase but that's a really subjective comment you know she don't all this data but I need someone to I need a resident to actually look through it all really.That's why I love this discussions that because we all know that there are limitations to what research hasn't hasn't been done and it's nice to speak to people who do it all the time, we have a feel for it and and we will put in there and say, oh look, it's not doesn't mean it's a fact, it's not proven, but we're talking to somebody who looks at 5,000 a year.
You should probably have a bit of Feel for it in me and any of us, I think it's a valid thing.And then the concentrated urine, I just want to double click on that.Because again, when I went through uni, it was taught under the banner of Cushing's Disease.Was taught under the banner of diseases that cause the upd have a sort of the primary thing that's going to trigger you to start looking for.
It is is PPD which you would expect a minimally concentrated urine and I've learned in The Last 5 Years, no, not necessarily.It's great.Yeah, correct and I don't know that it ever has been.Again it was this lovely textbook package that came with it but if you looked at the early studies, the studies back in the 80s, there was always an 80 to 85 percent polydipsia rate that meant 15 to 20% wound.
And it was unlikely that those 15 to 20% also would have a dilute USG.So I think it's been there.But it's we've concentrated Aunt rated.So heavily on Cushing's being a differential diagnosis for polydipsia that.We forget the Cushing's can present without polydipsia in a very long time ago, there was a study in, I think that Dermatology where the dermatologist said, well, our cases don't conform to that and of course, they didn't because the dermatologist were getting the cases that weren't automatically identifiable in primary practice because they weren't polydipsia Of skin diseases because there was no polydipsia and people hadn't chased the the Cushing syndrome in it.
So because it's a syndrome, all those things do not have to be in place for it to be cushions and that would be my real.Take-home message.We have dogs that have just skin disease.We have dogs at present with calcium oxalate, you release as their only son and the schnauzers.
For example, never become LP chic.Even when they have pay upd, polyphagia Alp and whatever you can, their code changes a little bit and you get used to picking that change, but they never present as that textbook.Bilateral, alopecia, I've never seen that completely.
Alopecia miniature schnauzer, so they just don't present that way.It's a multifactorial syndrome, right?Like the more I do these podcasts, that every now and again, we'll do an episode on something and then it will be mentioned as oh not forget about Cushing, is because that's going to mess with your results.
So I want to order to try and to recap trying to put these into one place.So let's talk about the syndrome.So there's the classic one, it's the pot-bellied, dog, that eats and drinks a lot and pants all day and has code changes.The classic you walk through the door and I go yeah I know what you've got.
That's it, that's easy.But then the more sneaky things that we might miss for the way, especially as you said, as we get better and better, at picking this up, and we don't let them get to that extreme very obvious Kush annoyed stage calcium oxalate because that's a new one to me.
Customer oxide crystals with cushy.How does that how he mocks?Let your roommates not just Crystal excess, corticosteroids cause increased excretion of calcium.That's why we use prednisolone as one modality to.Hypercalcemia to try and increase the urinary expression of it.
And that's an old one that's tucked away in the first edition of Feldman and Nelson.Obviously key things are they what?That are not the typical ones.What do we see clinically?And then and then maybe on blades as well, Bloods.Or let's say General testing Beyond a LP.
Yeah, I think the failure to regrow after the cruciate surgery is a big one.Failure to regrow hair, it cruciate, ligament rupture of Course is is something that can occur when you have excess corticosteroids and hypercortisolism.So when we get older dogs with cruciate ligaments, we should just like we do for polydipsia have Cushing's there in the d/dx list and we don't, you see them three months or four months later for their vaccinations.
And they still haven't really regrown their hair over that surgery site.That's a real red flag and for example you're talking about subtle Cushing's but in Australia with Australian Cattle, Dog, For example, like the schnauzers, they never ever present with our patient.
I've never seen one present with alopecia, but they do get a lot of cruise ship rupture.And one of the main reasons they get picked up, is the failure to regrow hair over that site.Now when you look at them, yeah, sure.They're panting a little bit more.They may or may not be drinking more but really one of the first signs in that breed can be there cruciate rupture in the failure to regrow and the tricky because they kind of barrel-shaped anyway.
Like I know a normal nose, here is a novel cattle dog have that they take Harry and broccoli rounds that I it will take a while for them to get pot-bellied to the point where we go.You actually abnormal.Well it's interesting I had a very high-level military nurse come in with her Australian Cattle, Dog and many years ago.
And her complaint was the dog's weight hadn't changed but she was pretty sure that the body shape and changed.Now, we're talking about a very observant, highly intelligent, and very keen.China.And what she'd noticed was that the dog used to have a lovely tucked up belly and now it was the same way but it was almost a flat line.
You know, I use that dog in lectures routinely because if you looked at it it had a slightly singed hair coat around the collar region and in the inter scapula region, it just looked a little bit brownie on a blue cattle, dog.And it had the flat belly as opposed to a tucked up belly that the dog had always had and it panted on Winters.
Day.And so it's sort of lovely but and induced very quickly with might attain in those days and everything resolved just so textbook wise, you never would have treated that dog.But this was an owner who wanted the best for that dog.And in the days of my detained, it was a slightly scary proposition, but this was a dog that really you would not as having cushions And should you treat it?
Of course because again that prevailing Dogma has been don't treat you to get clinical signs, but there's there was a study in JSF in 2016 and 26% of those dogs died at their hypercortisolism.If there were other complications, for example, if you included things like pancreatitis Etc, up to 32 percent of dogs actually died from sequentially or directly from hypercortisolism, so directly how I get it.
If you get an infection and you can't fight it or you're not healing or but, how does hypercortisolism kill you directly pulmonary?Thromboembolism, overwhelming infections, pancreatitis, Etc.Mmm, and of course that study had adrenal tumors so adrenal tumors played into that number okay?
Gotcha.Yeah.So said to me, that had some sort of malignancy That Grew into a vessel or something like that, but it really if we look at the study by there was an honor.Euthanasia studied by Nagata a Japanese study in 2015 and I guess this will never be repeated because it's unlikely that we would have an on euthanasia in point.
I think one dog out of the whole study was euthanized and that study showed that there was a really significant increase in survival time in dogs, treated with child State versus dogs, that are left untreated.So again, it backs up the fact that this disease, which we've already guarded as almost being a luxury disease.
While you can treat it or you don't have to is not really such a luxury disease.I mean, we're very keen to get in early on cardiovascular disease and all sorts of other diseases, but we still have this textbook reluctance to go after cushions and I know if they've Church talked about just neurologically mentally also feeling shitty which is a hard to put your finger on it.
But yeah people with did say that they don't feel well if you're agitated Field.Yeah, absolutely and I think this is again there's very little about this in the literature but Dave and star nice and and the RV C group, with image and Scofield, showed that the quality of life was really quite poor with Cushing's and that improved with treatment.
Now, anything else in bet that had for quality of life would want to treat.But somehow again we have this reluctance with Cushing's I mean I'd rather risk Addison's any day and have An improved quality of life, then prematurely aging, get all that horrible quality of life issues that these dogs have, and you mentioned the mental things.
We did a study with very tight control.It's it's, it's still in preparation.It's not far off being submitted, but interestingly out of the dogs that had anxiety did over 25% of them actually had complete resolution at the anxiety with tight control of the cushions.
Early.Yeah, and I mean some got worse, some stayed the same, so it's not a Panacea for anxiety, don't get me wrong, but it is one of the causes of anxiety, and if you control it, tightly, these dogs result.I mean, I had a vet who's own dog.
Had a thunderstorm phobia and had serious canine cognitive dysfunction and and those things essentially resolved, or at least dramatically improved once we treated the crushing.So the mental aspects of this disease, which we Have so long ignored even though his fact we know that the owners come in really delighted that they've got a young puppy again, sometimes after treatment.
We just ignore these significant behavioral issues.And and Dave church has always been a very strong proponent and as am I, that the polydipsia is a behavioral issue.In these dogs, that USG, for example is, it might be affected by a couple of point 0 0, 1, 2, 3, Whatever by the To fix a corticosteroids on the nephron.
But really what drives the dog to polydipsia polyuria is this incessant polydipsia and they can turn it off in hospital, which they couldn't, if it was a primary polyuria, followed by a secondary polydipsia.So if you take water away from them, then they can concentrate just fine.
Nothing wrong with it with the concentration.It's like they're just crazy.Yeah, they're crazy.It kind of makes sense though.If you think it was a stressful moment out of everybody's artificially saying constantly, hey, We're in Strays, we're in stress, get ready for action, get ready to fight, or flight, or do something.It would make sense that it will impact you neurological going to be anxious all day.
Absolutely.And when I was looking after putting this question in the survey, in the study, I did, there's a number of papers on pred and all the things they described on secondary effects of prednisolone.In dogs, were exactly the same.As I had seen historically coming in, on submission, after submission.
After submission, over The years through that gnostics, nocturnal, restlessness anxiety, vocalizing thunderstorm, phobias aggression.They're all listed in print papers, but again, that's sort of gone into the behavioral stream and it seems to have been separated out from the endocrine stream.
Go, right?Like it when I have a blood Bob go because it's not something I've ever really thought about you.You sort of put things in Little Boxes and those two boxes didn't really make.So thank you that's a good thing to think about.So you mentioned, let's get back to testing and confirming the.
So I think what that conversation did for me was to make sure that you think about it in more than just the screamingly obvious case put it, put it on the list and talk to the owners about why you should change the diagnosis.So you mentioned LP, you're an SG, other common questions that people struggle with or those the to to stand out funnily enough.
The flip side is one of the most common questions I have a dog that's completely normal, but I've watched its Alp go up.Every year on its Wellness profiles or I have a dog that's coming in for dent or something.And it's got a really high, or p-dogs completely normal, not drinking whatever.
What do I do, and that would probably be the most common question.Because again, textbooks would suggest that you shouldn't go chasing these dogs for Cushing's and how I address these is, I obviously look carefully at the age, the breed probe into all the clinical things I can assess from The distance because I don't have the dog in front of me and discuss it with the vet, but often it comes down to these dogs.
Have if they don't have polyphagia, they at least have a robust effort.Nearly always.That's what I'm going to say for myself, from now on and sidewalk.So they have a really robust appetite, how many conditions that cause really high LPS?
And I mean, we're talking up to 9,000. 10,000 12,000 units per liter, but it could also be 200 units per liter or 400 units per liter.But how many pathological conditions other than Cushing's cause these high a LPS, but still a dog that has come in completely healthy.
Yeah, I can only think of one, okay.You think of the one are there?Any others?Well, I guess it could.I mean you could have I mean Alp have come from a number of areas I suppose you can have the And to me that hasn't yet manifest, you could have a caller static lesion that isn't at the stage it's causing obstruction, but then most of those people, most of those vets then do the right thing and they've taken the dogs out to abdominal ultrasound and they still can't find any lesion to explain their Alp of 800 900 1000 or or Worse 10,000.
And they have this Healthy dog with a robust to East appetite.And I'd say test for the reasons that Dave Church discusses that I think it has a really significant quality of life effect and and I don't need it to go to polydipsia and I like Phaedra and a potbelly and alopecia to make me want to treat it.
I would point out, that puts me at odds with nearly everyone else in the world who say hold off until its clinical.Yeah.Right.It is confusing talking about this disease because you're right they are different.Opinions on it.But the way you described it make sense to go, if it was me, never mind my dog.
If it was me, I'd probably want to know if there's something majorly wrong with my metabolism.If I've had my own dog that I've thought has early Cushing's, I'd far rather get a diagnosis early and get on to it.I don't want it to rupture, appreciate, or end up with pancreatitis.I don't want either of those things.
Did you have a question or a dog?I had a dog that I couldn't pray because she's, which is just the complete Army.I mean, you know, I used to get stuck in the pub and ask with my dog had mange for God's sake and it looked like it smelt like it tasted like it.
I do.They see th dim after low-dose sex after a sea change them, after low dose 64's, CK sh free tea for us.You name it?I did it.And unfortunately, most of it was pretrial stain.And I just started her.I'm a trailer stain treatment trial in desperation and then she deteriorated with some neurological disease and I had to euthanize it so I never got to do it in my own dog.
But we're I in the situation I am now where I've done numerous treatment trials, and have been involved in numerous treatment, trials and dogs with AC, th dim and low dose decks test negative results.I would have actually given her a treatment trial Okay.
So if you said treatment trials, you mean individual patients, you know, you talking about trials, on a research basis, I know where we did incorporate the possibility of a treatment trial into the European Society Veterinary, Endocrinology, alive, definitions, they basically state.
That if you've got double negative test and you think that you have Cushing's and that the consequences of Cushing's will be life threatening that you could consider a treatment trial.I prefer to myself Why do them before complications become life-threatening?
But that is at least it.Now at least has a place in the literature in the possibility of doing one is there.And that is because you mentioned that you were involved in the consensus statement creation.Does that part of the consensus statement to say, look, if it looks and acts and smells like Cushing's and you can't find any other reason for it and it has a lot threatening consequence, which wasn't my addition.
But you know, this is a consensus statement.And some of them are, I mean, if you look at these dogs that are just incontinent all day every day, that's really horrible for the dog and Parable for the owner.And if you've done test after test, and then - what have you got to lose, they're going to be euthanized for their incontinence, putting them on a trailer stain treatment trial, a quartus well-managed treatment trial You've got nothing to lose at all.
So what is it?Cautious well-managed treatment trial look like.Well I guess it's not to be taken lightly.So the owners have to be fully counseled as to the things that you might make worse than they already, are that you could cause a life-threatening disease, you could cause Addison's me, I would always start on half the routine dose that I was using.
For that particular dog size just to make sure they were going to tolerate the drug before I then made those changes because obviously I want to get it into a range that I would expect.See clinical resolution of signs.Otherwise, I can't judge my treatment trial.But for that first 10 days, I put them on a reasonably low dose, just to make sure that they can actually tolerate it.
And in Australia, at least, and I do preface this is being Australian.We do have the option of using Court 8, which is cortisone acetate, which is essentially identical to cortisone.And that means that I give those owners caught eight at one milligram per kilogram to take home and if the dog even vaguely might have an adverse reaction or effect from The Trial of staying.
I instruct the owners to give quarter, so vaguely, what are they looking for?You're all your discharge instructions, look out for.What I certainly, don't want them to get to the stage of vomiting and diarrhea and collapse.So I'd rather get them that the dog didn't want to walk.As well.
This morning, a dog seemed a little bit lethargic perhaps, it wasn't quite eating as much as it should.Which of course could be because it's responding to the trailer Stan.I'd rather see what happens adding in the court 8 and assess the response, because dogs do respond very quickly to court.
A, I've had dogs, literally collapsed.It will get up within 3045 minutes, so not not with a treatment trial, I might add, but with normal normal.Listen, if you're talking about other countries, Your options are, I guess to use pred, but there's a 24-hour withholding on pred before you do an ACTH DM.
So that does make it a little bit long if you're trying to see what's happening with your trial estate and the other possibility, if you don't mind giving it, I suppose is decks because that doesn't cross-react with the cortisol assays.So you could get the owner to give decks and then bring it in and do an ACTH stem sa to assess whether the dog is too tight or not without any weight on Deck.
X, it's 12 hours, 12 hours of Court, 8, 24 hours, I'm prayed and nothing on decks, but of course, caught eight is virtually a physiological steroid decks and Prager are quite potent.Okay?So you start your treatment trial.Half of those for about 10 days.
You said, if during that period dogs?No.Well, it's sick.Then you say yet, give it a steroid of sort.Ideally courted.Come in, Let's do an ACTH them test and if if you add overzealously, treating or treating with didn't need to When you're going to have a white up, Flatline stem taste, or what are they going to do?
I have to say, it almost gonna jinx myself, but it's never actually happened to me in a treatment trial.So, usually we're only doing treatment trials in dogs, where vets, or me, personally, are very sure that these dogs have caught have Cushing's syndrome and we can't prove it on the test and again, the alive consensus statement.
So the alive definitions for Cushing's acknowledge the At that, there are problems with the sensitivity of the testing that we use for diagnosing questions.Okay, so flip side, you start on the, on the dose, it's a half a dose, then there's in nothing, really changes.
But how are we monitoring?Because we just said that the test didn't give us the answer.We just looking at what the dogs doing like in that 10 day period, are you sort of not expecting Improvement?You just want to make sure they don't fall apart.Exactly.And then, and your question is a really One and I get asked a lot with treatment Trials.
Of course, you still monitor with an ACTH dim because you still want to make sure that they're not going at a Sonja.So it's really important that you monitor with an ACTH DM and don't just do it uniquely so that, you know, that you're not going to tight.But the flip side is we all know that dogs have huge different range of trial or standards required for their Cushing syndrome control.
We also can't measure the clinical response.If we haven't got to a post in cortisol, that at least, would give control in a conventional dog.So, for me, on the vet gnostics, a say, I want dogs to be between 30 to 70 nanomoles per liter, post stimulation.
When the test is performed four to six hours after travel-stained dosing, and I'd at least like it to be under 100 foremost, emulate essays.And I do consult on some emulate, essays probably between 40 and And 100 so stimulation and I have to have it somewhere in that range before I can assess whether it's been effective to control the signs because if the dog is still stimulating to 250 or 300 then I don't expect any clinical resolution of a dog, that's proved positive on an ACTH diem low-dose decks or on - on both.
So just to make it applicable for people who use a different lab.What sort of Percentile of the range.Are we aiming for?So let's say the dog, stimulated normally, but top-end normal.But within the expected reference range pretreatment, now we're treating it.
Where do we want to see it?Stimulate to like the bottom half or what, as a generality, whatever, the labs reference interval for Basil cortisol.He's you don't want it stimulating any higher than that, at least.Basil.Cortisol by supporting what we're aiming for is subclinical.
What we are always aiming for in Cushing's treatment is healthy subclinical.Hypo allergenic water system.We don't want to crash them, we just want to have a dog that has enough cortisol to live but can't be producing excess cortisol throughout that day.
And the only way to do that is to ensure that after ACTH it can't stimulate much higher than what the basal cortisol is for any given layer.So a well-treated Cushing's patient will have lower cortisol levels, even under stress, then then an untreated, Emel healthy animal.
Yeah absolutely and well-controlled Cushing's dog again should have supplemental corded corticosteroids when it is in during periods of stress.So when it's boarding, when it's going in for surgery, when it's having its GA in order to make sure a dog doesn't have hypercortisolism, you really have to eliminate a stress response to a degree.
All right.So you can have enough quarters in to live but not enough to actually be stressed.If you More than that, I'm going to have to give it to you externally.Yeah, exactly.And that's what caught and again, is very handy.So, I mean, caught eight.I would advise routinely for every trial of stain treatment every single one.
And then, I tell owners of, well, you've got to be their adrenal gland.If you think they're going into boarding, give them half an egg Paquita of core.Take every day while they're boarding and just leave the trailer, staying the same and adding support eight.That will make sure they have enough stress to deal with it.Yeah, I'm trying to think of other scenarios but I'm thinking of my dogs but I'll just realizing my dogs have the most stress-free life.
Well that's been think they need that adrenal glands living on the interesting thing is when I did my Master's research back in the 90s, I had all these dogs.That thought they were my pets, they were kept in very elaborate Stables, not kennels, you know, they could see out.
They had tables that covered with hash.And, you know, they were in the days, pre anyone worried About Animal Welfare.These guys had palatial accommodation and exercise and that got them like pets.And the vast majority of those dogs had basil, quarters olds that are less than 10 on the old, radioimmunoassay all the time.
And that's a situation, we don't see or get to see in a clinic, because an animal walks across the car park.They get cortisol increase in minutes.And so a basil.Cortisol measured at a vet clinic is quite different from my dogs, which were at home.Essentially.And so they were less than 10.
Astounding how liar and I found one other reference in the literature, A Very Old Paper where they found.They just commented that well-conditioned research, dogs had almost no basil courtesan and so I don't think dogs need a lot of cortisol from day to day.
They need it.Of course, when they get sick when they get stressed, when they run behavioral stress disease stress, just like we do, it's another shift that's happening for me in the last year or so is with several Diseases but this one of them in my headed used to be called his old bull.
You're going to have a level that's going to not fluctuate too much.It was like a blood glucose going to sit there, but it's more like a diabetic blood glucose.So it's gonna go up and down in response to whatever they have is happening.And we just taking pinpoint at random locations.When we do, when we just do non stimulated, like cortisol levels.
Absolutely.Absolutely.I mean, Cushing's itself is defined by an overall accumulation of corticosteroids it.Hypercortisolism that goes across days months rather than a single point.So we it's not rare.
I suppose that we would see dogs that might have basil.Cortisol of 3040 say on a low dose decks test but they just don't suppress.So they go 40 40. 40.Well, an average dog coming into a clinic might be 140.
So, a 40 per se isn't particularly exciting for a basal cortisol.But when that Dog, if you take it in another time point, it might be 140, maybe it's 200, maybe it's 300, and it's how many fluctuations of cortisol in in that day that add up to this cumulative pattern that we see that causes Cushing's.
It's not just a single point Quarters on.Hmm, that's very cool.So when we're doing those treatment trials and really just for treating, the more obvious cushion Red.Dog, at what point are we doing those ACH System test?To check response to treatment, how long after starting treatment and how frequently beyond that to run to test them.
Yeah, well I'm I'm pretty rigid about about follow-ups.I'd rather do more monitoring tests and control tighter.I want to check in 10 to 14 days, unlike them Decorah recommendations, I will change the dose at 10 to 14 days, based on the result simply because my clients don't seem to have an endless supply of money to do.
ACTH, Jim testing, Time After Time After Time.So if I miss one opportunity to change a dose, that might mean another ACTH dim test, which in Australia could be anywhere between five or six hundred dollars depending on which communiques running at.So I'll do 10 to 14 if I have it perfect.
Then I'll check it in three to four weeks to, make sure it's stable and then every three months and I really don't bury 8 very much off every three months monitoring.I'm quite happy just to run a post.Stimulation cortisol do I do?Necessarily Lambda 0 and I think that's also really handy for those dogs that are really anxious.
I'm happy to use I am or sub-cut ACTH and send the owners awake.Do it in the car park, send the owners away for a coffee for an hour and get them back and do my one, our blood draw.And that makes it a lot less stressful for some of these owners and their dogs.
So I'm quite happy to make all sorts of compromises to make it work so that I can monitor as much.As I want to and that does, I guess.Also, when you were talking about ACTH dim versus low dose sticks, there is a reason why General Practitioners like the ACTH team because they have a dog in, for 1 hour, not eight hours.
They don't have to get it in at 8:00 in the morning but also for really anxious dogs.I think it's a real Advantage just to be able to do a modified.ACTH dim test and not to even have the dog in hospital.See them in the car park, send them away.
Get them back in for one hour.Lovejoy and who cares about the zero hour?Yeah, which makes sense.But what dose are you giving that I am sub-cut dose?Just to make sure we like five micrograms per kilo.I am, I mean, I even had to use it on my neighbor's, dog, be able day because it was a miniature Schnauzer.
And it was being slightly difficult and it jumped and didn't want to didn't want to do anything, of course, because it was the neighbor's dog and a half, but when I am half, but when some cup, fortunately both have been validated for ACTH.And I just did a one-hour blood draw and confirm.
It's Cushing's.I'm just going to jump in here with a little boast recording edit.So after this episode came out on the clinical Bond casts dr.Sue got back to me and said that, she was aware that in a previous podcast episode with us talking about Cushing's.
We had a fact at there that said that we should maybe not freeze sign actin, is she go back to me to say that?That is incorrect there.Has been proven.It has been validated that you can store, so nekton safely up to six months, they just never tested it past six months, but we know that a frozen up until six months, it is still going to be effective.
So how would we do that?You would open the vial, draw a cute house and give it.And the remainder you draw it into small aliquots like 0.2 Mills, or if you're going to be using the same vial for the same dog in future and you building that same file to the animal, you draw it up in the dose, that you're going to be needing for that animal in future.
ER, and then you put those little doses in the freezer and you can keep them Frozen for up to six months.We know and when you need to do your next test, you thought and use it immediately single thought only, so don't refreeze it, so you can't freeze a whole vial defrosted, draw some out, put it back in the freezer, just that dose, do it, inject it and then don't store it in the refrigerator doctor.
She says, in her experience, what happens is?We put it in the fridge to use later and we forget to use it and it's definitely not validated for use.It's opened after storing just in the fridge.Hope that helps.You mentioned earlier, he said you will attain to 14 days.You will change your dose based on that Tim result, unlike Decorah.
So what is the current command?I just recommend that you make sure that the dog isn't a disowning at that time and keep on going and make any changes at the next test.But as you look at the 10 to 14, day, Martin go, now, that's the stimulating, way too much, but my days, if it's not any just out of do, I won't bother.
Changing it, because some dogs increase their trial stain requirements over time and some dogs decrease.So, there is a reason for not changing at 10 to 14 days, but, you know, a dog that still stimulating to 500 is going to be stimulating any better in three weeks time, that's for sure.
And then, what increments do you increase your dose?It does, it depend on the on the degree of the system relation or is it a standard?I'm up by 20% or 50% or what?No, I literally will make the decision based on how high it stimulating.I don't actually use milligrams per kilogram for my starting doses.
I use empirical doses, which I've always used before, that are all was even released as a drug.And we've had trouble staying as part of experimental work.And in those days, everyone did everything in the increments of 30 60 120 because that was all that was available in capsules.
And I still find empirical dosing.Works for me and I find it easy to juggle.Those changes based on what those they're already on as an empirical do.So I really don't care how many kilos.They are explain empirical dosing so it's dead of.So how do you do?
So let's say my I've got 220 kg dog and it's got Cushing's, okay?So at 20 kilo dog, probably 50 to 60, mig's the ID and then a 10 kg dog, 10 kilo dog. 20 weeks, 20 weeks PID, don't understand your thinking If you say you're not using mg per kg.
So then how do you make a decision on of you guys?You know, days in the all the original studies anything less than five kilos or up to five kilos, got 30 milligrams a day that was when we were using once daily dosing and then anywhere, between 5 and 20 got 60 mg and everything over. 20 kilos, got 120 milligrams.
Now I certainly think that in itself is a little bit too broad these days knowing what we know and large breed dogs to be honest.Like almost nothing.So if I have a giant breed of 50 kilo dog, I might started on 30 milligrams once a day just to make sure it's not going to crash.
You know, whereas we have multis that end up taking 180 milligrams, PRD, 45, kilo dogs.So it's not a linear scale for me, and that's why I don't like mix mckeague.That's why I wrote a letter to Gemma.I think the only thing I've ever got into Java discussing.
A paper of Ed Feldman's on how I felt dosing wasn't related to kilos.It was more related to breeds and sizes with some breeds particularly resistant.So the Maltese and the multi Shih Tzus and potentially the or chi silk is being being more resistant and some of the giant breed dogs, literally, always only have to open the bottle in that crash so I just use, still use that scale.
If I have a 5 kilo dog, I'll use 15.Now, use more be ID.So I'll use 15b, ID or 30s, ID 10, kilo dog, 40 milligrams, or 20b ID, 15 kilo dog up to 20 sort of almost a linear scale, but once I go over 20, I look at how big the dog actually is and whether it's just one of those 20 to 25 kilo type dogs vs.
The giant breeds, which I really think it can be really sensitive.And you said, you're starting does for.Those guys is no more than 30 Meeks be ID, I start really like and letting Greyhounds I suppose.They're not really what I call.A giant breed Greyhounds seem to have a very good trailer, stain tolerance, which is always interest me.
So I start them just like I would any 20 to 30 kilo, dog and plenty of greyhounds, do get Cushing's.Now they live long enough in Australia.Okay, and then we chatted to again, back to today.
A church and he, well, there's some new developments in the space of treating Cushing's disease, that he mentioned that.I heard somebody else talk about the other day as well, beyond trailer stain.What's happening word?What are you recommending or saying or seeing, or what?What's new?
Well, I guess there's a number of things in the pipeline but none of them yet here.So, and I'm a very clinical person that I don't have a lot of research capacity in my current job, apart from looking crunching big.It's like, I do, I think as soon as we can get rid of trial statement better, all be sorry doctor but you know, that's the way it's a really difficult drug.
It was supposed to be the Panacea, it wasn't supposed to cause Addison's.I like the drug because I can say use it with my treatment trials and I can use it in sick dogs, that I was scared about using might attain in, but overall, I don't think it's actually as good as drivers might have changed.
And it's certainly a lot more expensive and And if I were doing a lot of clinical practice, now, to be honest, I'd be going back to my determine what we have available because I just think it's so much cheaper.You get a much more consistent effect you have much less monitoring a stable.
Wishing's on might attain is every six months and and I know for many places in the world that's not an option because you have to use the drug that's registered for treatment, which is federal but in Australia, that's not the case.And a lot of our rural practitioners use might attain very effectively because The clients simply can't afford travesty and I think if we're all mixed practitioners can use might attain successfully then then really.
It's it's an okay drugstore.So you can still get it.It's still available.It's difficult in Australia.You have to get it through Decorah interestingly.I'm sure they don't like the product.The apvma won't register it here.So that's the Australian registering body without a full set of registration registration data, which is just to be frank Ludacris, I mean this drugs being around forever and we've used it forever but in order to get registration, you'd have to do full trials which no one's ever going to do on an old-fashioned drug.
So that means they have some sort of provisional registration and you actually have to apply to Decorah with the script.You can't get it through a wholesaler and you get your my steamed through Declan.So if you had a question or a dog, now, if the specially if you actually could confirm it or not, you're one that dress.
That dress the unprovable Christian or don't we?Apply for meditate.Absolutely.I'm doing it for my neighbor's dog.That can they can't afford Charles thing.I've found a local vet, who's happy to go along with using my detained for them.I'm talking about, it's actually my mother's neighbor.
So, in a different state for large breed dogs, I still prefer a travesty.They used to crash with might attain and sometimes I never got up again, to be honest.So for the large and giant breed dogs especially since a smaller meat per gig doses.Often used, it's perfectly reasonable to use trial.
Jane, but for the 5 to 10 kilo dogs, she don't know, I'd be treating the majority with my team because I've never actually used it.I know we learned about it but I can't quite remember what it actually does.So the difference is trailers, then it's a temporary separation of cortisone production.
I know some of the area that sometimes it could be Hemorrhage in the adrenal cortex and it can actually cause permanent changes, but where's might attend?You actually take out the adrenal cortex that dried or what does it do?Ya.None of its It came a therapeutic drug so it causes adrenal cortical license and you can either use it selectively to try and sort of just shave off enough of the cortex to produce the right amount of cortisol, or you can wipe it out completely and just treat them as Addison's.
And for those of us that are old enough that have used, a lot of Might attain inadvertently.We do end up with Addison's.Of course, I might attain and those owners always seem to be much happier and you can ask almost any old button over here that dog.That I cook the adrenals, it did much better because Addison's is relatively easy to treat and Cushing's is really quite hard to treat and that goes along with with they church.
I'm sure you've discussed this with Dave Church.His preference is to is to surgically remove both adrenals.I'm not as Brave as that and I've seen things go wrong with surgery but I'd be more than happy to ablate adrenals.And I've advised on protocols again, mainly in rural areas, where people have a lot of trouble coming back and forth to the clinic to get rechecks.
Because I might have to travel 300 case each way and a number of Rural clinics, have managed the non-selective adrenocortical, Isis protocol, very easily, and very effectively.And the dogs just stay on court, 8 and floor, and therefore, caught eight a court in for the rest of their lives.And then the, how much do you know about the talk that I've listened to recently about scooping out the pituitary gland.
For the pituitary dependent is that something we're aware of it all?Yeah, I'm not a huge fan.I guess for me, it seems a rather drastic treatment for Cushing's to end up with hypothyroidism Central diabetes, insipidus Addison's, and dryer.
And, you know, just to swap for Cushing's that and not to mention.We're talking a surgery that probably cost somewhere between 25 and 30 thousand dollars.I also have another theoretical problem with it and I don't know because I haven't Haven't been involved in these programs, but certainly when I was in the Netherlands, the comment I heard, was that most dogs that live, 5 years, with their Cushing's.
Even with a hypothesis, ectomy will need a second one because it regrows again.I don't know that many people have got 60,000 dogs, and, and we have especially in Australia where we have a high Maltese population in our Cushing's population.They have quite young ages presentations, so it's not so uncommon to get All taste coming in at 3, 4, 5 May 3.
Not so much but four-year-old five-year-old Maltese and they're still sometimes live at 17.So if they had a hypothesis ectomy at for, they would need another one again at 9 and another one again at 14, if that's right.And as I say, I don't know because I've never been involved with those programs but it was a comment that I was given it.
You checked that it's not a permanent solution if a dog actually lives long enough.Now they may have I've refined that since then, I don't know.But it's not something I would ever do on my own.Well, I couldn't do it, anyhow because I wouldn't have the skills, but it's not something I would refer my own dog to have done.
I just don't see that having a hypothyroid edisonian dog with Central diabetes and also on ddavp as well.And dry eye is really what I want for my patient.No, no, I remember seeing anything.
There was there's a lot to think about that.A lot of shifts in a lot of deeper understand.This is why we took the specialist, it's from your really controversial but it's just the different type because of the numbers game.No I do.But this is what we try and get to because these diseases are complicated and it helps to I actually kind of like having different opinions on the podcast because we the end we have to make our own decisions as clinicians.
It's nice to speak to people with opinions and then you can formulate your own idea.Are we missing anything to do?You could probably use one comment.I'd like to make.Yeah, one take home.There's only been one study of survival rates in GP hospitals and it was done in Britain on BET Compass data and it's pretty woeful like 500 days or something.
We've just finished an Australian study where these dogs will control really tightly.So to the vet gnostics between 30 and 70 posting, and they're knocked the survival figures in the literature out of the port bow.Now, that could be because of our population, could be our different breeds.
It could be all sorts of things.We might have longer, living braids.I'm not claiming that it's due to the tight control of Cushing's.But what it does say, and these dogs were all in general practice, they weren't referral practice.So compared to all the other referral studies out there.
So they were managed by GPS admittedly with, help in some cases from that gnostics Consultants.But within that oversight and within that framework, we managed to have really long survivals, which is pretty exciting because it means that GPS are managing these.
Well, they're managing them tightly and they're managing them safely and they have long survivals.And I think that's a real, take-home message because I think GPS are often assumed not to manage as well as specialist.Something I think is a little bit arrogant, but anyhow that GPS can manage these.
Well, they have good client relations and if they have the right support tight control, caught eight in the cupboard, then these dogs can have very long survival times with very good quality of life. so do you think the the woeful survival times in the previous study was because we were being too, Pussy footing around the disease and trying so hard, not to make them at a stone in that we didn't really treat the Cushing's effectively.
Yeah, I do think that's the case and I do think the veterinary profession as a whole is obsessed.With the avoidance of Addison's, Madison's is really easy to treat and pancreatitis is not a ruptured.
Crew should is not getting calcium oxalate, your ellipse is not pulmonary thromboembolism can kill them.I'm not quite sure why our risk analysis is so skewed onto one disease that we can all treat.Sure it might make the dog sick and yes it can be life-threatening but much less life-threatening if we're expecting it, anticipating it and have steps in place to prevent it.
Then all these things that I can't control with uncontrolled Cushing's.I can't stop getting pancreatitis and, and the saddest case for me ever, Is a dog that was actually diagnosed and was under specialist control in Germany.
And and one of the my colleagues there said, why don't you ring see that dog?Got Cushing's myotonia on recommended Decker control rates, and that is tragic because that dog lived another five or six years.With a totally dedicated owner with a terrible condition that is not reversible in any way, shape, or form, Cushing Sudan, Mauritania is not reversible and yet, if that dog had been Tightly.
Hopefully, it would never have got in the first place.So I just think our risk assessment is wrong.I'll Hazard a guess.I think it's a psychology thing in that as a liable, professional.Whatever happens because if your dog's cushion or it isn't my fault, it's the Christians fault.
So if you get a green shade or something, I didn't cause that, whereas, if I give you dr.Edison's, I did that.So, is there a question about whether it's genuine T or the feeling of liability of saying?Well I don't want to First Do no harm, I suspect that's probably it.
It absolutely is an end often.I get that same to me but you know I don't want to, I mustn't Do no harm but that could treatment if because he is not doing no harm either.Yeah, hopefully this episode will shift that but but yeah, it is and I mean I and I totally understand where people are coming from and I also understand that it's a major textbook shift and it's what's Driven weather.
We even treat Cushing's or not, but I just think we need to look better at the risk analysis.Yep, it sounds like a communication thing, just finding a way to communicate this.In a succinct way to an owner to say as we are going to tangle with this other disease.But you know, the reasons if I overstepped the Line This is what it's going to look like.
But if I under tree, this is what it's going to look like.Which way do you want to go?Yeah, I think that's really right.And I don't think we do that at the moment and it should be that whole domestic concept, you know, I could cause this life-threatening disease, but you could get a life-threatening disease, anyhow, if you don't treat it and So I think it is a matter of communication and and at least in Australia as I say, we have caught out in the cupboard.
And I often take the extra step of writing in red, on it antidote, which Dave Church, you said she doing with friend might attain for what it's worth.So, I learned from the master and it's helpful when owners know they have the antidote in the cupboard they reach for the antidote.
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