Canine Cushing’s Case Files: THE INS AND OUTS OF DETECTION AND TREATMENT SPONSORED BY DECHRA VETERINARY PRODUCTS Canine Cushing’s Case Files: THE INS AND OUTS OF DETECTION AND TREATMENT CLINICAL ARTICLES PRACTICE-RELATED ARTICLES 6 DALI 26 Your veterinary team’s role in identifying by Audrey K. Cook, BVM&S, MRCVS, DACVIM dogs with hyperadrenocorticism 8 PRINCESS 28 Your veterinary team’s role in by Lori Thompson, DVM, DACVD treating and monitoring dogs with hyperadrenocorticism 10 MITCH by David Bruyette, DVM, DACVIM 30 The economics of managing hyperadrenocorticism in dogs 12 HOLLY by Fritz Wood, CPA, CFP by Christopher G. Byers, DVM, DACVECC, DACVIM 32 Avoiding practitioner pitfalls 14 LIBBY with canine Cushing’s cases by Todd M. Archer, DVM, MS, DACVIM by Andy Roark, DVM, MS 16 BOCA by Cynthia Nichols, DVM DECHRA VETERINARY PRODUCTS 18 HOWIE SUPPLEMENTAL RESOURCES by Christopher G. Byers, DVM, DACVECC, DACVIM 34 Diagnosis, Treatment and Monitoring 20 CALLIE of Hyperadrenocorticism by Orla Mahony, MVB, DACVIM, DECVIM 37 Technical Brochure for VETORYL® 22 Dogs with recurring pyoderma Capsules (trilostane) by Thomas Lewis, DVM, DACVD 24 5 questions veterinarians ask the Dechra Veterinary Products Technical Services Team hen you know the ins and outs of something, it Dechra Veterinary Products, the manufacturer of VETORYL® W Capsules (trilostane), understands how challenging the diag- peculiarities, or technicalities of a certain subject. The nosis and management of canine hyperadrenocorticism, or phrase the ins and outs also has a second meaning — the Cushing’s syndrome, can be. The disease can manifest in many windings of a road or path. When faced with a case of hyperadrenocorticism in a dog, you may feel you are on a best treatment for these patients, Dechra Veterinary Products winding path. Often the diagnosis is not straightforward sponsored a 12-article series for your reference, Canine Cush- or obvious. The clinical signs can be subtle or have a ing’s Case Files: The Ins and Outs of Detection and Treatment, that was inserted in dvm360 magazine throughout 2013. That series gradual onset. And because hyperadrenocorticism is the core of this e-book, along with two bonus case reports, available only here. changes they’re observing to “normal aging.” The veterinarians who managed the eight clinical cases in 2 | CANINE CUSHING’S CASE FILES H pituitary-dependent (80% to 85% of spontaneous cases) or adrenal- dependent (15% to 20% of cases), the clinical and laboratory abnormal- ities associated with it result from chronic hypercortisolemia. Clinical this e-book describe their diagnostic process and their treat- signs of hyperadrenocorticism at the time of diagnosis can vary widely, ment protocol and share their personal perspective on each and they develop so gradually that owners often mistake the signs for case. In addition, a veterinary dermatologist provides insight “normal” aging. Being aware of the more subtle signs of canine hyper- on why practitioners should consider hyperadrenocorticism in adrenocorticism can be key to early diagnosis and initiation of therapy. dogs that have recurring pyoderma. Whenever possible, pituitary-dependent hyperadrenocorticism As with any type of case, client communication, involvement of the entire veterinary practice team, and understanding the and patient monitoring. Early diagnosis and management of canine - hyperadrenocorticism may not only improve the patient’s clinical ing patients with chronic diseases such as Cushing’s syndrome. To signs but may also keep the more severe consequences of Cushing’s address such issues, this e-book also includes articles on: syndrome from developing. • A the Dechra Veterinary Products Technical Services Team Common clinical signs of canine hyperadrenocorticism about canine hyperadrenocorticism and VETORYL® Capsules (trilostane). Polyuria (owners may complain Alopecia T he veterinary practice team’s role in educating and com- • • • of housesoiling) • Recurrent skin disease municating with clients about identifying, treating, and • Polydipsia • Lethargy monitoring dogs with hyperadrenocorticism • P olyphagia (owners may • Pendulous abdomen • - complain of food stealing or • E xcessive panting ing’s patients on your practice’s bottom line excessive begging) • Thin skin • Ways to avoid common practitioner pitfalls when providing long-term healthcare for a patient with a chronic disease Other clinical signs may include hypertension, comedones, sebor- rhea, heat intolerance, hyperpigmentation, calcinosis cutis, bruising, At the back of this e-book, we have included additional algo- facial paralysis, failure to cycle, clitoral hypertrophy, testicular atrophy, poor hair regrowth after surgery, recurrent urinary tract infections, helpful — Diagnosis, Treatment, and Monitoring of Hyperadreno- pyoderma in an older dog. corticism (p. 34-36), and the full Technical Brochure for VETORYL® Capsules (trilostane) (p. 37-52). Beyond this e-book, we provide a number of Cushing’s-relat- ed online resources at www.dechra-us.com and Continuing Education modules in our Dechra Academy (click on the Dechra CE tab on the Dechra website). The Dechra Academy contains VETORYL® Capsules (trilostane) are the only FDA-approved drug multiple complimentary RACE-approved CE modules on indicated for the treatment of pituitary-dependent and adrenal- endocrine diseases presented by key opinion leaders. dependent hyperadrenocorticism (PDH and ADH) in dogs. Trilostane, Diagnostic and treatment algorithms, client brochures, patient the active ingredient, blocks hormone production in the adrenal cortex monitoring forms, case studies and more can be found on the Dechra US website. To order printed copies of any of the dogs with PDH and ADH resources contact Dechra Customer Support at (866) 683-0660. For case consultations please contact our highly skilled • T he use of VETORYL Capsules is contraindicated in dogs that have Veterinary Technical Support Team at (866) 933-2472. demonstrated hypersensitivity to trilostane. The main purpose of this e-book and all of our other • D o not use VETORYL Capsules in animals with primary hepatic resources is to let you know that we are here to help you be • successful when you are faced with canine Cushing’s patients. D o not use in pregnant dogs. Studies conducted with trilostane We want to help guide you along the sometimes winding path pregnancy loss. of diagnosing and managing dogs with hyperadrenocorticism • T he most common adverse reactions reported are poor/reduced and provide you with the information and tools you need to appetite, vomiting, lethargy/dullness, and weakness. • Occasionally, more serious reactions, including severe depression, canine Cushing’s syndrome. hemorrhagic diarrhea, collapse, hypoadrenocortical crisis or adrenal necrosis/rupture may occur, and may result in death. —Dechra Veterinary Products SPONSORED BY DECHRA VETERINARY PRODUCTS ©2018 | 3 Treat their Hyperadrenocorticism. Help restore their vitality. VETORYL® Capsules (trilostane) are the only FDA veterinary- approved treatment for pituitary-dependent and adrenal-dependent hyperadrenocorticism in dogs (Cushing’s syndrome). They contain the active ingredient trilostane, which blocks the excessive production of cortisol. Daily administration of VETORYL Capsules can greatly reduce the clinical signs associated with Cushing’s syndrome, helping to restore the dog’s vitality. Clinical studies demonstrated that treatment with VETORYL Capsules resulted in decreased thirst, decreased frequency of urination, decreased panting, and improvement of appetite and activity.1 Activity levels began to show improvement within 14 days of treatment. anorexia, lethargy/depression, vomiting, diarrhea, elevated liver enzymes, elevated potassium with or without elevated sodium, elevated has been reported as an outcome of these adverse events. VETORYL Capsules are not for use in dogs with primary hepatic or renal disease, or in pregnant dogs. Refer to the prescribing information for complete details or visit www.Dechra-US.com. 24 Hour Technical Support: 866-933-2472 | www.dechra-us.com | [email protected] VETORYL is a trademark of Dechra LTD. ©2018, Dechra Ltd. NADA 141-291, Approved by FDA CAUTION: Federal law restricts this drug to use by or on the order of licensed veterinarian. Dechra is a registered trademark of 1http://www.fda.gov/AnimalVeterinary/Products/ApprovedAnimalDrugProducts/FOIADrugSummaries/ucm049823.htm Dechra Pharmaceuticals PLC. Canine Cushing’s Case Files: THE INS AND OUTS OF DETECTION AND TREATMENT CONTRIBUTING AUTHORS Todd M. Archer, David Bruyette, Christopher G. Byers, Audrey K. Cook, Thomas Lewis, DVM, MS, DACVIM DVM, DACVIM DVM, DACVECC, DACVIM BVM&S, MRCVS, DACVIM, DVM, DACVD DECVIM, DABVP Orla Mahony, Cynthia Nichols, DVM Andy Roark, DVM, MS Lori Thompson, Fritz Wood, CPA, CFP MVB, DACVIM, DECVIM DVM, DACVD © 2018 Dechra Veterinary Products http://www.dechra-us.comwww.dechra-us.com • www.dechra-us.com/CEhttp://www.dechra-us.com/CE Dechra Veterinary Products 7015 College Blvd., Suite 525 Overland Park, KS 66211 Veterinary Technical Support: (866) 933-2472 Customer Support: (866) 683-0660 SPONSORED BY DECHRA VETERINARY PRODUCTS ©2018 | 5 DALI 10-year-old, spayed female dachshund weighing 9 lb (4.1 kg) Presenting complaint and history Dali was referred to Texas A&M’s Veterinary Teaching Hospital for evaluation of a mammary mass that had progressively enlarged over a three-month period. Several years before refer- ral, Dali had two malignant mammary masses removed. Dali