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Charlie's Guide to Addison's Disease

February 17, 2018

 

It was a typical Wednesday afternoon: come home from work, walk the dogs and then head to my horse barn across town. Except this time was different, Charlie, my 3 year old yorkie-poodle mix, was not himself.

 

Now let me explain Charlie. Charlie is the epitome of everything terrier. He has a zest for life that can only be matched by a bingeing Ozzy Osbourne snorting a line of fire ants off the pavement (apparently a true story) mixed with the man vs food guy at an all you can eat BBQ joint, but with a dash of just enough swagger that you find him cuddling with you when you need it most.

 

 

 

So I was naturally alarmed to find that he hadn’t eaten his breakfast, he was slow moving to exit his kennel, and then it happened, diarrhea everywhere. Vomit every few steps. Not good. I ran through my mental log of things this could be, suspecting perhaps leptospirosis or a similar infection. I checked his gums, but he happens to have those frustrating blackish colored gums which makes color checking difficult, capillary refill looked normal, but again hard to tell with his color. I grabbed the thermometer and checked his temp, expecting him to possibly be running a fever. Wrong. It was low, it was 98.2…..we needed to go to the vet right now.

 

Our regular vet said they could squeeze him in at the end of the day, but that if he needed hospitalization we’d have to go to the emergency vet. I got on the highway and started driving. I wrapped Charlie in my fleece jacket and turned on the heated seat for him. I began to get the feeling I was wasting my time driving all the way across town to the regular vet, when the animal ER was much closer. I turned the car around and was at the ER in minutes, breaking a few speed limits in between.

 

We arrived at Carytown animal hospital, I realized Charlie had some pretty vague symptoms with the only glaring thing being his low temperature. While I filled out paperwork, they took him back and immediately ran bloodwork and put him on fluids. They said the results from all the testing they ran would take a few hours and that I should maybe go and come back. Since this vet is in an area where you can walk to various stores and restaurants, I went for a walk. It was the longest 2 hours of my life. I made my way back to the vet, and that’s when they gave me news I didn’t want to hear.

 

“everything is negative except for his kidney values. He is going into kidney failure. Has he gotten into anything he wasn’t supposed to eat?”

 

“…..no” tears began to fill my eyes, no Charlie hasn’t gotten into anything. We don’t even allow foods like raisins in the house.

 

“So there are two possibilities. He may have acute renal failure, in which there is not much we can do at this point. Or he may have Addison’s Disease. Of the two, Addison’s Disease is what you want as a diagnosis, its very treatable once we can get a diagnosis…..” her words became inaudible to me. I started crying and couldn’t stop.

 

Addison’s Disease…..that’s what JFK had…..the only thing that came immediately to mind, but I remembered studying about it in school. Basically, the adrenal glands are responsible for making cortisol (needed for many hormones produced in the body but most notably, adrenaline), and the hormones that control the basics of kidney function, all gone. It is considered an autoimmune disease, which means his body attacks the adrenal glands, and is known to be carried in the poodle line among other breeds.

 

Apparently it would take a few days to get a conformation on his Addison’s disease but she went ahead and ran one of two tests used to diagnose. The first checks their current cortisol levels. And the second test is done where there is a baseline cortisol level taken, then the adrenal glands are stimulated to give a response to release cortisol, and the final cortisol result is measured (this is called the ACTH Stim test). Normal dogs have a huge increase in cortisol in the ACTH Stim test, and A-Dogs have small to zero response.

 

Charlie was going to have to be hospitalized over several days. It would take time to stabilize him and then to perform the ACTH stim test. His initial cortisol levels were basically zero, so it was promising that he may have Addison’s disease. But again, the vet continued to tell me, many dogs can have low cortisol but be completely normal, so I wasn’t to get my hopes up. The next few days were agonizing until I finally received the call.

 

 

 

 

(the vet techs at the Carytown animal hospital were sweet enough to send me these pictures of Charlie while I was at work, until I could get over there to visit him every day)

 

“his ACTH results are positive for Addison’s Disease” the vet’s voice said optimistically.

 

My feelings were mixed. While yes, I had prayed for this diagnosis over kidney failure, I had no idea what to expect for living with an A-dog.

 

Charlie was released on day 4 and $3,000 later (thank God for care credit). While the prognosis was good, he would have to be on medication for the rest of his life. He would have to take prednisone every day for the rest of his life, and a shot of percorten once a month to replace all of the mineral regulating hormones for his kidneys. But the good news was that A-dogs have the same life expectancy as regular dogs and never (as long as they are well controlled) die of their complications of Addison’s.

 

It was termed that Charlie had been in a “Addisonian Crisis” in which his adrenal glands had reached the point that they were no longer functioning, and suddenly kidney and cortisol control and function ceased. All at once. Unfortunately, this is how so many Addisonian dogs are diagnosed. It is known as the “great pretender” because its’ symptoms mimic so many other disorders that it may be too late before the thought to test for addisons comes to mind for a vet. Luckily, out ER vet had seen this before, and she followed her instincts.

 

Here’s where the real work began. I had to bring him back to eating and drinking regularly, and figure out the dosing of both medications that worked for him specifically. Each dog varies in what dosages of each of these medications they need to do best. Overdo the prednisone, and you’ve got a ravenous, agitated pup who’s urinating everywhere. Don’t give enough, and you’ve got a lethargic, listless pup who may not want to eat.

 

I discovered that since he received so many fluids at the vet, he probably wasn’t feeling thirsty, but it was imperative to get him to drink. He also wasn’t hungry. The vet sent me home with cans of something so vile I could never feed to him, so I decided to find something I could live with feeding him. Being the “dog foodie” that I am, I found an amazing brand of canned food that was bland enough for his tired tummy to digest, but an ingredient panel I could trust, and sourcing I could trust. I landed on “Dave’s Chicken and Rice” canned food. I took small amounts and diluted it in water. I was feeding him about 4-5 small meals a day for the first two weeks he was home. Some were more watery than others to make sure he was getting adequate water intake. This was crucial for many reasons, but restoring kidney function was the most important. I kept him on this food for about two months, as his stomach had been through hell.

 

I was basically considered the “poo police” by my husband. I was the one to walk Charlie at all times to go potty and I monitored for signs of improvement. It was about two weeks before I saw the first solid poo, but I sure did celebrate the first time I saw it. It meant he was on the way to recovery, and that he might be ok.

 

The percorten presented its’ own challenges.  You strive for a certain sodium to potassium ratio in their bloodwork based on what dosage of percorten you give. You want it as close to what is called homeostasis (what is normal for the body) as possible. But this becomes an art form, and checking it enough in the beginning comes with a price tag. But I promise it is all worth it. It takes time, as some doses may cause different ratios, never quite balancing out, and eventually you hit your stride with it, and don’t have to check the electrolyte panel so often.

 

After a while, Charlie returned to being his normal self. He went back to eating his regular food with his usual enthusiasm and also drinking at normal intervals. But there were several things about living with an A-dog that I did have to make sure I changed permanently.

 

Living with and A-Dog:

 

One thing you will learn when living with an A-dog is that you will end up knowing more about Addison’s disease than the vet will. It’s just natural. The vets spend maybe a chapter out of their entire schooling on this disease, as it is so rare, and end up relying on specialists to know more about it. Similar to human medicine except the specialists in the dog world are far more expensive (unless you have pet insurance), and are few and far between. So you must educate yourself to the point of nauseum, and be proud of it. I joined a facebook group comprised of owners of A-dogs, and vets that own A-dogs. The name of this group is “Addison’s disease in dogs” and they were immensely helpful.

 

 

Through personal contacts, I know a vet in Chicago who has an A-dog and is a board certified internist. We did several phone consults with my own vet for a basic understanding of his medication and where he needed to go from his initial diagnosis. This vet set the tone for how Charlie was to be cared for, and the more I became a self-proclaimed expert on the topic, the more my local vet trusted my judgment on medication adjustments.

 

One thing to remember is that the more stress or excitement your dog experiences, the more prednisone they need. But you also want to balance that with an overall low dose, as close to physiological dosing as possible, protocol. Sounds difficult? It actually isn’t. You taper down from where the ER vet put the dog on (usually high to compensate for the massive cortisol loss they had over the Crisis) and go down to the lowest dose in which your dog remains himself, without feeling listless or low in energy (for himself, obviously dogs vary considerable in energy level). So while a therapeutic dose of prednisone might be 10-20mg for an allergic dog or one needing prednisone therapy, Charlie, a 15lb dog, receives 0.3mg daily. BIG difference, and often a point of contention you might face with the holistic dog owners and vets out there since they hear the word prednisone and see red. Nothing against them, and I do my part of holistic care in my dogs, but there is a fundamental difference between the physiological need for prednisone (which is synthetic cortisol) and therapeutic doses. Ok, off the soap box.

 

 

 

Now managing the “mineralocorticoids” which are the hormones that control kidney function, specifically sodium and potassium levels, is a bit tricky. There are two ways to go about it. The first, and gold standard, is a monthly injection given either SubQ or intramuscular. You only need to give the injection in the muscle if the dog is about to go into crisis, and as long as he is well maintained and you haven’t forgotten a shot, this shouldn’t ever be necessary. SubQ is given between the shoulder blades, under the skin. There are two protocols for giving percorten, and the first is not the best. It goes by the weight of the dog and that’s it. This is often costly, uses too much percorten, and can cause damage to the kidneys long term. The second protocol is newer and based off of more accurate research and data. It is termed the “low dose protocol.” The dog starts off on a lower dose, but still weight dependant, and then the dose is dropped until the sodium to potassium ratios, run via electrolyte blood checks, is at the ideal range. For an example, Charlie initially was at 1.5cc of percorten monthly, and dropped to 0.23cc in which he is at ideal ratio.

 

I know this sounds challenging and expensive but it isn’t really. Percorten can be purchased from stores like Costco or 1800 petmeds, and one vial is 4mL (cc), so for Charlie it lasts about 14 months. It runs about $200 for one vial. The good news is that if you are comfortable giving injections at home, then you can have your vet teach you how to give it and you save yourself money and your dog stress by going to the vet. In fact, as I type this, I just gave Charlie his monthly shot while he was laying on the couch, obviously followed by some really tasty treats.

 

Another option for those a little more squeamish is to buy the vial and have the vet give it monthly, or even the vet tech. Usually they don’t charge office visits for this sort of thing, so again it is economical.

 

There is also the option of Florinef tablets. It is the only option for those in Europe as percorten is not available there. Florinef combines the action of prednisone and percorten in a tablet. It is less ideal as you cannot independently fine tune the prednisone and mineralocorticoid function independently and is far more costly. For human medicine, it is the chosen drug for maintenance of Addison’s disease, mostly due to convenience of taking a pill over a shot, but percorten is still considered more effective in canines.

 

So when you boost the prednisone, how do you do it? And how do you get such low doses to begin with? I order from CVS for prednisone in liquid form. Make sure to ask for xylitol free prednisone. It is a sweetner used to help kids take it but is absolutely deadly to dogs. The pharmacist knows the difference and will give you the regular, non sweetened medication. Sometimes it can be sweetened with regular sugar if you need. I always, without question, give Charlie a treat following his squirt of pred in the morning. This is for two reasons: obviously we want Charlie to like getting medicine, easy enough. He comes running at 7:30am every morning to the bathroom and waits for his meds. But because prednisone can be hard on an empty stomach, if you aren’t ready to feed breakfast yet, a tasty treat will do the trick.

 

 Now on to boosting. When you know your dog may need to have a boost for say an agility round or maybe you’re headed to the groomer, I boost by 0.1mg at a time. Usually that is more than adequate. For Charlie, I have never had to take him higher than a grand total of 0.5mg total for the day. In most cases, he doesn’t even need a boost. You end up knowing your dog very well, and what his stress triggers are (positive or negative) and compensate for that.

 

A-Dogs have compromised immune systems. This is part of it being an autoimmune disorder, they do not handle getting infections as well as other dogs. I am one to use many supplements in my dogs regardless, but I find it paramount in Charlie’s diet. Boosting his immune system gives him every fighting chance when a bout of kennel cough goes around, or he is exposed to something. For a normal dog kennel cough could last a few days, maybe a week, but in Charlie I’ve seen it last almost a month. Sadly, that can be normal for these guys.

 

 

So how does raw feeding fit in? Dogs need a healthy microbiome in their gut for optimal immune system activity. Raw feeding is directly correlated to a diverse intestinal flora. Look for a separate blog on this topic. Charlie (as well as all of our dogs) eats a raw diet of Oma's Pride Woof, and a rotation of the signature mixes. When time allows, I will make up a prey model diet of 80/10/5/5 from various items at Oma's Pride including the beef organ mix, exotic proteins, and raw meaty bones. I don't always have the time to create a diet like this, so I tend to rely on premade diets. 

 

For the supplements I use, I research companies down to where they source ingredients and if they are third party tested. If they don’t have data to back up what they say is in their supplement, it isn’t worth my time, or my dog’s. I wanted Charlie on a set of probiotics, which had multiple bacterium present, prebiotics, as well as omega-3 fatty acids. I also wanted him on a wellness supplement which was clinically proven to support the immune system, gut and joints. Here’s what I settled on:

 

  1. Nordic naturals fish oil for dogs. Must be the pet specific one as cod liver oil for humans may contain too high of vitamin A levels. It is the same quality as the human version, but third party tested for the correct ratios.

  2. Platinum Performance Canine. This one speaks for itself to a certain extent. The clinical research surrounding the immune boosting properties of their proprietary ingredient, “bio sponge” which works in the gut to remove toxins that may cause allergic and immune reactions. It also gives you glucosamine, MSM and chondroitin, as well as other essential amino acids and vitamins and minerals for overall wellness.

  3. Nutrivet Probiotics and Digestive enzymes. This product is tasteless, and provides a good swath of bacterial cultures as well as digestive enzymes to aid in food digestion.

 

But there is one more thing. A-dogs are technically not considered healthy enough to be vaccinated. While vets will vaccinate them, they do not handle the vaccines like normal healthy dogs do. Vaccine reactions are much more common in A-dogs, and their immune systems remain very low following  I  made the choice to titer test Charlie for the core vaccines (minus rabies – it’s the law) and opt out of the non core vaccines such as leptospirosis and Lyme. Many people may argue that if he is exposed to these diseases he could become sicker or die, but the reality is, Charlie is a house dog and has never been in an environment where his is exposed to these diseases. Titer testing allows me the autonomy to know what his immune levels actually are to these diseases, and if he is showing strong immunity to them, then we can postpone by a year and recheck the titers.

 

His stress level also has to be closely monitored, as well as excitement level. Both require cortisol for him to cope with either, and at times he may need a boost in prednisone to deal with something stressful like a grooming appointment or exciting like going to a dog friendly festival. Boarding is basically out of the question for him at this point. We have had success in having him stay in other people’s homes for pet sitting, but because he is a small dog (15lbs) he fits very nicely underneath airplane seats. We typically take Charlie everywhere with us. He is a more well travelled dog than most, and his stress and excitement levels remain pretty constant as long as he is with us, which means less prednisone boosting for him. He handles turbulence like a pro, and I’ve literally caught him snoring while taking off and landing in turbulent winds. I at times envy his naiveté.

 

To date, Charlie has travelled to Washington DC (and had an accidental romp across the Vietnam war memorial, which is another story for another day!), Naples, Tampa, Tallahassee, North Carolina, Atlanta, New Orleans, Ft Lauderdale, Orlando, Chicago and the list goes on. The fun thing about taking him places is that TSA turns totally mushy when they see his crazy cute terrier face, and I don’t have to go through the X-Ray thingey and instead carry him through the old metal detector like the old days. He is also allowed to walk on leash through the airport (must be in carrier bag to board), so I have taught him how to run on moving side walks, which he thinks makes him super dog! He has also learned to pee exactly on command in an exact location (unfortunately on concrete) when we are in the airports for a quick potty break.

 

I won’t lie, taking on the challenge of an A-dog has had a huge learning curve, and at first can be a financial burden. The initial diagnosis is very expensive, as they usually are only discovered when they are in a “crisis” but once properly diagnosed, they really do live like normal dogs, and can do normal doggie things. Charlie now seems no different than he was before his diagnosis, which means to me he is living his life to the fullest. There are many A-dogs I know of who compete in Agility and obedience as well as dock diving. While Charlie doesn’t compete, he finds that world travelling is more his speed, and he hopes to get many more stickers on his puppy passport. Today we celebrate Charlie's 9th birthday, he was diagnosed at the age of 3. Six years post diagnosis, I am grateful to have the moments I have had with Charlie and look forward to the many more adventures ahead.

 

 

 

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