Medical therapies for canine pituitary-dependent hyperadrenocorticism - Veterinary Medicine
  • SEARCH:
Medicine Center
DVM Veterinary Medicine Featuring Information from:

ADVERTISEMENT

Medical therapies for canine pituitary-dependent hyperadrenocorticism
Drug administration is usually the only option for treating dogs with PDH. Mitotane is the most common choice, but some alternatives are worth considering.


VETERINARY MEDICINE


Efficacy

The efficacy of L-deprenyl for treating PDH remains controversial. Because L-deprenyl is neither adrenocorticolytic nor an inhibitor of steroidogenesis, ACTH stimulation testing cannot be used to monitor efficacy. Owners' impressions of improvement have been used to measure treatment efficacy in several studies. Because a metabolite of L-deprenyl is a potent sympathomimetic and CNS stimulant, perceived improvements in the behavior of geriatric dogs with PDH may not be directly attributable to control of PDH.38,39 Improvements in clinical signs of PDH in up to 77% of dogs treated with L-deprenyl have been reported in studies sponsored by the manufacturer.36,40 In these same studies, low-dose dexamethasone suppression test results normalized at one or more time points in only 17% of patients. These studies have been criticized for relying largely on subjective data collected from many independent observers.4


2. Control of ACTH secretion from the pars intermedia portion of the pituitary gland differs from that of the pars distalis portion. Corticotrophs in the pars distalis are responsible for most ACTH secretion in health and for about 80% of all pituitary adenomas resulting in PDH. They are stimulated by both positive (corticotropin-releasing hormone) and negative (cortisol, ACTH) feedback. In the pars intermedia, serotoninergic and dopaminergic nerve fibers stimulate and suppress ACTH secretion, respectively. Theoretically, decreased serotonin concentrations (as induced by cyproheptadine) or increased dopamine concentrations (as induced by L-deprenyl or bromocriptine) should suppress ACTH secretion by the pars intermedia. Tumors of the pars intermedia are responsible for about 20% of dogs with PDH.
An independent investigation of L-deprenyl found that 20% of dogs with PDH exhibited a good response.38 This proportion is similar to the proportion of dogs with PDH resulting from a tumor of the pars intermedia rather than the more common pars distalis tumors (Figure 2). There is little evidence that dopamine plays a major role in suppressing ACTH secretion from the pars distalis, which may explain L-deprenyl's low efficacy in treating all dogs with PDH. Although dogs with pars intermedia tumors causing PDH may have a good response to L-deprenyl, no clinically applicable test exists to identify this subset of dogs.7 Because of its low efficacy, L-deprenyl is generally not recommended for treating PDH.4,5,7,24 In rare, select cases in which more effective treatments are contraindicated or when clinical signs are relatively mild, L-deprenyl therapy may be warranted.

Administration and monitoring

L-Deprenyl is administered at a dosage of 1 mg/kg/day given orally, preferably in the morning. If no response is observed after two months of therapy, the dose can be doubled for an additional month. If a good response is seen, normalization of low-dose dexamethasone suppression test results and urinary cortisol:creatinine ratios should occur. If remission is not attained within three months, alternative treatments should be investigated.6

Conclusions

Because of the cost of medication and monitoring and the risk of serious drug side effects, treating dogs with PDH can be challenging. Therapy should only be instituted when clinical signs (i.e. Cushing's syndrome) are present. Generally, treatment of PDH is undertaken to improve the quality of life for the pet and the owner (e.g. improving polyuria, resolving dermatopathy) rather than to increase the length of the pet's life. We do not advocate medical therapy of PDH based on endocrinologic test results alone. Usually, therapy should be undertaken when clinical signs of Cushing's syndrome adversely affect quality of life. Treatment should also be instituted in circumstances in which PDH is exacerbating or causing other serious illnesses (e.g. diabetes mellitus, hypertension, thromboembolic disease, protein-losing nephropathy).

While many treatment options exist, mitotane remains the most effective, readily available therapy for PDH in the United States. The protocol for selective adrenocorticolysis with mitotane remains our typical choice for therapy. Trilostane is gaining acceptance as an alternative to mitotane, but it is not readily available. The cost of trilostane is generally higher than that of mitotane. In our hospital, trilostane is nearly twice the cost for an average-sized dog with PDH. Ketoconazole therapy can ameliorate signs of PDH, but the therapy may have greater utility in the short-term treatment of dogs with adrenal-dependent disease, pending adrenalectomy, than for long-term management of PDH. If diagnostic tests become available to allow differentiation of PDH due to pars intermedia tumors from the more common pars distalis tumors, L-deprenyl may be the safest treatment for this subset of patients. Regardless of the treatment chosen, frequent monitoring is critical to allow adjustment of therapy while minimizing adverse effects.

Amy E. DeClue, DVM
Leah A. Cohn, DVM, PhD, DACVIM
Marie E. Kerl, DVM, DACVIM, DACVECC
Department of Veterinary Medicine and Surgery
College of Veterinary Medicine
University of Missouri
Columbia, MO 65211

REFERENCES

1. Meij, B. et al.: Progress in transsphenoidal hypophysectomy for treatment of pituitary-dependent hyperadrenocorticism in dogs and cats. Mol. Cell Endocrinol. 197 (1-2):89-96; 1971.

2. Goossens, M.M. et al.: Efficacy of cobalt 60 radiotherapy in dogs with pituitary-dependent hyperadrenocorticism. JAVMA 212 (3):374-376; 1998.

3. Theon, A.P.; Feldman, E.C.: Megavoltage irradiation of pituitary macrotumors in dogs with neurologic signs. JAVMA 213 (2):225-231; 1998.

4. Feldman, E.; Nelson, R.W.: Canine hyperadrenocorticism (Cushing's Syndrome). Canine and Feline Endocrinology and Reproduction, 3rd Ed. W.B. Saunders, Philadelphia, Pa., 2004; pp 252-357.

5. Feldman, E.; Nelson, R.W.: Hypoadrenocorticism (Addison's Disease). Canine and Feline Endocrinology and Reproduction, 3rd Ed. W.B. Saunders, Philadelphia, Pa., 2004; pp 394-439.

6. Peterson, M.E.: Medical treatment of canine pituitary-dependent hyperadrenocorticism (Cushing's disease). Vet. Clin. North Am. (Small Anim. Pract.) 31 (5):1005-1015; 2001.

7. Peterson, M.E.: Medical treatment of pituitary-dependent hyperadrenocorticism in dogs: Should L-deprenyl (Anipryl) ever be used? J. Vet. Intern. Med. 13 (4):289-290; 1999.

8. Kintzer, P.P.; Peterson, M.E.: Mitotane (o,p'-DDD) treatment of 200 dogs with pituitary-dependent hyperadrenocorticism. J. Vet. Intern. Med. 5 (3):182-190; 1991.

9. Nelson, A.A. et al.: Severe adrenal cortical atrophy (cytotoxic) and hepatic damage produced in dogs by feeding 2,2-bis (para-chlorophenyl)-1,1-trichloroethane (DDD or TDE). Arch. Pathol. 48:387; 1949.

10. Schechter, R.D. et al.: Treatment of Cushing's syndrome in the dog with an adrenocorticolytic agent (o,p'DDD). JAVMA 162 (8):629-639; 1973.

11. Behrend, E.N. et al.: Treatment of hyperadrenocorticism in dogs: A survey of internists and dermatologists. JAVMA 215 (7):938-943; 1999.

12. Peterson, M.E.; Kintzer, P.P.: Medical treatment of pituitary-dependent hyperadrenocorticism. Mitotane. Vet. Clin. North Am. (Small Anim. Pract.) 27 (2):255-272; 1997.

13. Cai, W. et al.: Metabolic activation and binding of mitotane in adrenal cortex homogenates. J. Pharm. Sci. 84 (2):134-138; 1995.

14. Behrend, E. et al.: Medical therapy of canine Cushing's syndrome. Compend. Cont. Ed. 20 (2):679-696; 1998.

15. Arnold, D.L.: Mitotane. Compend. Cont. Ed. 23 (9):796-797, 815; 2001.

16. Plumb, D.C.: Mitotane, ketoconazole. Veterinary Drug Handbook (Pocket Edition), 4th Ed. Iowa State University, Ames, 2002; pp 588-590.

17. Kintzer, P.P.; Peterson, M.E.: Treatment and long-term follow-up of 205 dogs with hypoadrenocorticism. J. Vet. Intern. Med. 11 (2):43-49; 1997.

18. Nichols, R.: Complications and concurrent disease associated with canine hyperadrenocorticism. Vet. Clin. North Am. (Small Anim. Pract.) 27 (2):309-320; 1997.

19. Rijnberk, A.; Belshaw, B.E.: An alternative protocol for the medical management of canine pituitary-dependent hyperadrenocorticism. Vet. Rec. 122 (20):486-488; 1988.

20. den Hertog, E. et al.: Treatment of pituitary-dependent hyperadrenocorticism in the dog by non-selective adrenocorticolysis with o,p'-DDD. Vet. Q. 19 (suppl. 1):S17; 1997.

21. Rijnberk, A. et al.: O,p'-DDD treatment of canine hyperadrenocorticism: An alternative protocol. Kirk's Current Veterinary Therapy Small Animal Practice XI (R.W. Kirk; J.D. Bonagura, eds.). W.B. Saunders, Philadelphia, Pa., 1992; pp 345-349.

22. den Hertog, E. et al.: Results of non-selective adrenocorticolysis by o,p'-DDD in 129 dogs with pituitary-dependent hyperadrenocorticism. Vet. Rec. 144 (1):12-17; 1999.

23. Potts, G.O. et al.: Trilostane, an orally active inhibitor of steroid biosynthesis. Steroids 32 (2):257-267; 1978.

24. Neiger, R.: New treatments for Cushing's disease. Proc. Br. Small Anim. Vet. Assoc., BSAVA, Birmingham, U.K., 2003; pp 475-477.

25. Braddock, J.A. et al.: Trilostane treatment in dogs with pituitary-dependent hyperadrenocorticism. Aust. Vet. J. 81 (10):600-607; 2003.

26. Neiger, R. et al.: Trilostane treatment of 78 dogs with pituitary-dependent hyperadrenocorticism. Vet. Rec. 150 (26):799-804; 2002.

27. Ruckstuhl, N.S. et al.: Results of clinical examinations, laboratory tests, and ultrasonography in dogs with pituitary-dependent hyperadrenocorticism treated with trilostane. AJVR 63 (4):506-512; 2002.

28. Neiger, R. et al.: Trilostane therapy of canine hyperadrenocorticism. Proc. ACVIM, ACVIM, Dallas, Texas, 2002; pp 544-546.

29. Braddock, J.A.: Medical treatment of hyperadrenocorticism in the dog. Aust. Vet. J. 81 (1-2):31-33; 2003.

30. Bruyette, D. et al.: Ketoconazole and its use in the management of canine Cushing's disease. Compend. Cont. Ed. 10 (12):1379-1385; 1988.

31. Queiroz-Telles, F. et al.: Adrenal response to corticotrophin and testosterone during long-term therapy with itraconazole in patients with chromoblastomycosis. J. Antimicrob. Chemother. 40 (6):899-902; 1997.

32. Feldman, E.C. et al.: Plasma cortisol response to ketoconazole administration in dogs with hyperadrenocorticism. JAVMA 197 (1):71-78; 1990.

33. Kemppainen, R.J.; Sartin, J.L.: In vivo evidence for dopaminergic regulation of the canine pituitary intermediate lobe. Acta Endocrinol. 113 (4):471-478; 1986.

34. Peterson, M.E. et al.: Plasma immunoreactive proopiomelanocortin peptides and cortisol in normal dogs and dogs with Addison's disease and Cushing's syndrome: Basal concentrations. Endocrinology 119 (2):720-730; 1986.

35. Zerbe, C.A. et al.: Domperidone treatment enhances corticotropin-releasing hormone stimulated adrenocorticotropic hormones release from the dog pituitary. Neuroendocrinology 57 (2):282-288; 1993.

36. Bruyette, D.S. et al.: Treating canine pituitary-dependent hyperadrenocorticism with L-deprenyl. Vet. Med. 92 (8):711-727; 1997.

37. Cohn, L.A. et al.: Effects of selegiline, phenylpropanolamine, or a combination of both on physiologic and behavioral variables in healthy dogs. AJVR 63 (6):827-832; 2002.

38. Reusch, C.E. et al.: The efficacy of L-Deprenyl in dogs with pituitary-dependent hyperadrenocorticism. J. Vet. Intern. Med. 13 (4):291-301; 1999.

39. Milgram, N.W. et al.: Effects of chronic oral administration of L-deprenyl in the dog. Pharmacol. Biochem. Behav. 51 (2-3):421-428; 1995.

40. Bruyette, D.S. et al.: Management of canine pituitary-dependent hyperadrenocorticism with l-deprenyl (Anipryl). Vet. Clin. North Am. (Small Anim. Pract.) 27 (2):273-286; 1997.


ADVERTISEMENT

Source: VETERINARY MEDICINE,
Click here