Hyperadrenocorticism Flashcards
This drug has antiserotonin, anticholinergic, and antihistamine effects and is not a good way to control cushing’s but is an option. A) Mitotane/ Lyosdren B) Selegiline/ Anipryl C) Trilostane/ Vetoryl D) Ketoconazole E) Cyproheptadine
E increased serotonin levels may be associated with excess pituitary ACTH this drug is more commonly used as an appetite stimulant in cats AE= sedation, weight gain, increased appetite
Which form is most common in small breed dogs? A) PDH B) AT C) Iatrogenic D) A/B
A 85% of cases= pars distalis tumor most are microadenomas and do not cause CNS signs due to size
Which test is both diagnostic and differentiating? A) LDDST B)HDDST C) ACTH Stim D) Endogenous ACTH
A
Summary of treating adrenalcortical tumor hyperadrenocorticism
- TOC= surrgical removal of mass
- Trilostane
- Mitotane: at high doses
- Ketoconzole= palliative care
T/F: Some dogs may fit the exact description of a cushingoid, but all of the tests come back negative.
True some dogs may have a derangement of steroid pathway and overproduction of precursors –> increased levels of 17=hydroxyprogesterone have been found in dogs w/ Cushing’s
What does the SG of urine look like in a cushing’s dog? A) Well concentrated B) Isosthenuric C) Hyposthenuric D) A/B E) B/C
E dogs are PUPD
What form of cushing’s causes bilateral atrophy of the adrenal glands? A) PDH B) AT C) Iatrogenic D) A/B
C
An endogenous ACTH result of a dog with cushing’s comes back as 15 pg/ml. Normal= 20-100 pg/ml. Which of the following can be said based on this result? A) We cannot tell if the dog has PDH or an AT B) The dog has PDH C) The dog as an AT D) None of the above
C a result of <20 indicates a AT (PDH = 40-500 pg/ml)
Which form is most common in larger dogs? A) PDH B) AT C) Iatrogenic D) A/B
D: 50/50
T/F: Trilostane has an induction phase where higher amounts of the drug are given short term, and then the dose is decreased long term.
False- mitotane
What form of cushing’s causes unilateral enlargement with contralateral atrophy of adrenal glands? A) PDH B) AT C) Iatrogenic D) A/B
B
T/F: Selegiline/Anipryl is the only licensed therapy for cushing’s dz.
true-weird huh?! Idk if this is testable but what evs
Which of the following is recommended to perform prior to performing an adrenalectomy?
A) UPC ratio
B) Blood pressure
C) ATIII levels
D) All of the above
D
to ensure that they are not a high risk for thromboembolism
after sx recommendation: give dex, heparin, plasma, and hetastarch for 1st 5 days post op to decrease risk of TE
T/F: Mitotane is used primarily to treat PDH, while trilostane is used to treat PDH and AT.
True
(can use higher dose for adrenal tumors but not common)
Which of the following abnormalities has been linked to using trilostane and is the reason electrolytes should be monitored? A) hypernatremia, hypokalemia B) hyponatremia, hyperkalemia C) hypercalcemia D) hypocalcemia
B (I looked this up in plumb’s- it has something to do with aldosterone release)
Which of the following drugs listed is the BEST choice for medically treating Cushing’s caused by an adrenalcortical tumor?
A) Selegiline
B) Mitotane
C) Trilostane
D) Etomidate
C
When using mitotane to treat cushing’s, the owner needs to be able to report clinical signs. Why?
The drug can destroy too much of the adrenal gland and result in low cortisol levels that can manifest in clinical signs such as not drinking water. Should stop the drug if this occurs.
Which diagnostic test is best in patients that have only mild cs/lab abnormalities, have concurrent nonadrenal illness, or are receiving phenobarbital? A) LDDST B) HDDST C) ACTH Stim D) Endogenous ACTH
C
Draw backs of using US to differentiate bwtn PDH or AT
-AT are not always detected (and the finding of an AT does not mean the animal has Cushing’s–> use other BW+ cs to support diagnosis) -cannot differentiate malignant from benign unless there has been vena caval invasion and liver metastases
Which of the following inhibits only glucocorticoids and thus does not have an effect on aldosterone? A) Mitotane B) Ketoconazole C) Trilostane D) All of the above
B
Which of the following is often used to treat pituitary macroadenomas?
A) Transsphenoidal hypophysectomy
B) Bilateral adrenalectomy
C) Radiation
D) None of the above
C
can reduce tumor size, reducing CNS signs caused by size of the tumor–> often still have to use medical therapy to control cs of cushing’s
Which of the following is false regarding the LDDST? A) Is diagnostic and differentiating B) Cushingoids suppress at 8 hrs C) Elevated results at 8 hrs but 50% suppression at 4 hrs is diagnostic of PDH D) Test with highest false + E) 100% diagnostic with AT
B- THEY DO NOT SUPPRESS 95% diagnostic with PDH…5% may not read the book at suppress at 4 hrs
Which of the following biochemical values is increased in 90% of dogs? A) Cholesterol B) ALT C) ALP D) Bilirubin
C high sensitivity, low specificity may occur due to something else like nodular regeneration….must look at clinical signs to pursue PDH
Which of the following may occur due to treatment and control of hyperadrenocorticism?
A) Emergence of allergies
B) Unmasking of osteoarthritis
C) Increase in BP
D) Increase in risk of PTE
A/B
(C/D= occur more likely with uncontrolled cusghin’s)
Why is using the HDDST to differentiate PDH from AT not an ideal test?
a 50 % reduction after 8 hrs means suppression which indicates PDH, HOWEVER, 30% of PDH dogs do not suppress so cannot definitely diagnose AT
PDH causes what in the adrenal glands? A) Bilateral atrophy B) Bilateral enlargement/hyperplasia C) Unilateral atrophy, unilateral hyperplasia D) None of the above
B
Disregarding practicality, sample handling, and cost, which test is most likely the best differentiating test? A) LDDST B)HDDST C) ACTH Stim D) Endogenous ACTH
D
A dog being treated with trilostane has been stable for 6 months. It has begun to show signs of PUPD. Which of the following is the best route to begin discovering the cause of the cs? A) ACTH stim test B) Electrolytes C) Urinalysis D) None of the above
B- first perform electrolytes (cheaper/easiest route)- the animal may be drinking more because an electrolyte imbalance and not necessarily too much cortisol, if these are normal then most likely proceed to the ACTH stim test this question is from my interpretation from something she said in class- wasn’t listed on the slides
What response to ACTH stim do we expect to see in a PDH or AT cushingoid? A) No response B) Physiologic increase in cortisol C) Exaggerated increase in cortisol D) Cortisol levels remain the same in the pre and post samples
C
List some causes other than overproduction of cortisol that can cause cushingoid signs
-Increased progestins (have glucocorticoid like- activity) -Noncortisol hormones can displace cortisol from its binding protein resulting in increased free cortisol levels even if total levels are normal
Which of the following combinations can be seen in Cushingoid dogs and does not require treatment? A) High T3/T4, low FT4 and TSH B) Low T3/T4, normal fT4 and TSH C) Low T3/T4, low fT4, high TSH D) High T3/T4, low FT4, low TSH
B
Other than a low SG, what else may be seen on the dip stick of the urine?
Proteinuria–> follow up to rule out UTI, urine culture and UA
If a LDDS test comest back positive for cushing’s but not definitive for PDH, which of the following is the best choice to determine whether it is AT or PDH?
A) HDDS test
B) Endogenous ACTH
C) ACTH stim
D) Ultrasound
D
List the two surgical therapies for cushing’s dz
- transsphenoidal hypophysectomy= difficut to perform, lifelong thyroid and prednisone replacement required( can accidentaly remove entire pituitary gland); perform CT first, if tumors are >12 mm= not good candidates
- bilateral adrenalectomy= difficult to perform, require lifelong replacement
Which of the following drugs is a selective irreversible inhibitor of monoamine oxidase type B and helps to restore central dopamine concentration (improves cognitive function)? A) Mitotane/ Lyosdren B) Selegiline/ Anipryl C) Trilostane/ Vetoryl D) Ketoconazole E) Cyproheptadine
B
The urine cortisol:cre in a dog you suspect may have cushings is found to be elevated. Which of the following is true? A) The dog has cushing’s B) The dog does not have cushing’s C) The dog may have cushing’s D) This test is useless in diagnosing cushing’s
C– this is a good screening tool, if the test is negative for cortisol in the urine…the dog is less likely to be cushingoid but just because the there is cortisol in the urine this does not mean it has to be due to hyperadrenocorticism
What test should be performed 5-10 days after starting mitotane? A) LDDST B) ACTH Stim test C) Endogenous cortisol D) Ultrasound
B, want cortisol to be less than 5 then perform at 1 and 3 months after diagnosis and then every 3-6 months
Which of the following are advantages to performing the ACTH stim test to diagnose cushings? A) The animal only needs to stay in the hospital one hour after the injection B) Response will be flat line for iatrogenic cushing’s C) Can refrigerate/freeze extra cortrosyn D) All of the above
D disadvantage= expense! diagnostic of pdh= 85% of the time, 70% in AT–> overall accuracy= 85%
T/F: Ketoconazole is used in pts whose owners are reluctant to use mitotane because of the side effects or because of the cost of trilostane. This drug works by altering cognitive function and helping dogs to “pee in the right places”.
False- this is selegiline
Other medical therapies to treat cushing’s that are not commonly used
What is the monitoring schedule for starting trilostane? A) ACTH stim test 3-7 days after start and then 1 month and 2 months into treatment B) ACTH stim test 10-14 days after start and then 1 months and 3 months into therapy C) LDDST 3-7 days after start and then 1 month and 2 months into treatment D) LDDST 10-14 days after start and then 1 months and 3 months into therapy
C- then monitor every 3-4 months once stabilized testing pts when on mitotane and trilostane is the same except because mitotane is more risky, it is performed 5-10 days after the start of tx instead of 10-14
What is the purpose of dispensing prednisone to a chushingoid on mitotane?
In case the drug puts the dog into a hypoadrenocorticism crisis (basically an overdose of the drug that kills off too much of the adrenal gland), the owner can give prednisone to treat this in an emergency –> but iatrogenic addison’s dz is rare (<5%)
Cushing’s dogs tend to be hypercoagulable. Which of the following is linked to this statement? A) PUPD B) Polyphagia C) PTE D) Seizures E) Circling
C= pulmonary thromboembolism
Which of the following drugs is a synthetic orally acting steroid analog that competitively inhibits the 3-B-hydroxysteroid dehydrogenase system, thereby inhibiting synthesis of several steroids including cortisol and aldosterone? A) Mitotane/ Lyosdren B) Selegiline/ Anipryl C) Trilostane/ Vetoryl D) Ketoconazole
C overdose can cause addisonian crisis
List as many breeds that you can think of that most commonly develop Cushing’s (6)
Poodles Boxers Dachshunds Schnauzers Bostons GSH
When using trilostane and testing for cortisol levels using the ACTH stim test, how long after the dose of trilostane is the test performed?
4-6 hours
What are the drawbacks of using ketoconazole to treat cushing’s? A) 20-25% patients fail to respond B) The drug is expensive C) Can cause elevated liver enzymes along with V/D/A D) all of the above
D -similar to other drugs it can cause a steroid deficiency -different from other drugs this does not effect mineralcorticoid production V/D/A= vomiting diarrhea anorexia
Of the drugs listed, what two are used most commonly in the treatment of cushing’s? (trade name listed 2nd) A) Mitotane/ Lyosdren B) Selegiline/ Anipryl C) Trilostane/ Vetoryl D) Ketoconazole E) Cyprohepatadine
AC (Didn’t even discuss E or bromocriptine)
T/F: 40-50% of dogs with cushings are hypertensive which is why monitoring of BP is recommended.
True another slide said 50-80% are hypertensive…either way monitor BP!
Which of the following drugs can be effective in dogs that have mild cushing’s resulting in slow progression of clinical signs and are often negative on lab tests? A) Mitotane/ Lyosdren B) Selegiline/ Anipryl C) Trilostane/ Vetoryl D) Ketoconazole E) Cyproheptadine
B- switch drugs if not responding after 2-3 months
Which of the following drugs destroys the zona fasciculata and reticularis of the adrenal gland causing permanent adrenal atrophy? A) Selegiline B) Mitotane C) Trilostane D) Ketoconazole E) Cyproheptadine
B
Which diagnostic test is best to use in patients with severe cs and no evidence of nonadrenal illness and pts with suspected adrenal tumors? A) LDDST B)HDDST C) ACTH Stim D) Endogenous ACTH
A
Why may proteinuria indicate hypercoagulability in a cushingoid dog?
They could be losing antithrombin III into the urine
What is the treatment of choice for treating an adrenocortical tumor?
A) Mitotane or trilostane
B) Radiation
C) Unilateral adrenalectomy
D) Selegiline
C- but it is difficult because they are often highly vascular and invasive even if they are benign
supraphysiologic doses of steroids are required initially because the other adrenal gland is atrophied and needs time to recover
increased risk of thromboembolism bc cushingoids are hypercoagualable
What drug’s MOA is described -inhibitor of cholesterol side-chain cleavage enzyme (P450scc) and also of 11B-hydroxylase, 18- hydroxylase (aldosterone synthase), and 3B-hydroxysteroid dehydrogenase to a lesser extent
Mitotane
Which tests are used to diagnose cushing’s? A) LDDST B)HDDST C) ACTH Stim D) Endogenous ACTH
A and C the others are used after the diagnosis has been made to differentiate PDH from AT D is not performed often due to the need of careful handling, dogs with cushing’s can have a normal result so perform only after a diagnosis has been made
What is the test of choice for iatrogenic cushing’s and also addison’s, but can also be used to diagnose PDH and AT? A)HDDST B) LDDST C) ACTH Stim test D) Endogenous cortisol
C
T/F: 80% of AT are benign.
False- it is 50/50
Which of the following are commonly seen on the CBC of a dog with cushings? A) Anemia B) Polycythemia C) Inflammatory leukogram D) Stress leukogram E) All of the above
B/D
T/F: Cortisol can be released when an animal is stressed and cause a false + LDDST.
TRUE
Both mitotane and trilostane cause decreases in cortisol levels. Which is reversible?
Trilostane= reversible + dose related
Which of the following may be seen on a radiograph of a cushingoid dog? A) Large bladder B) Hepatomegaly C) Mineralization D) Osteopenia E) All of the above
E malignant metastatic tumor= mineralization
This drug is an imidazole antifungal drug that works by lowering circulating cortisol concentrations by inhibiting steroid biosynthesis. A) Mitotane/ Lyosdren B) Selegiline/ Anipryl C) Trilostane/ Vetoryl D) Ketoconazole
D
Which of the following is true regarding collecting the urine sample for the urine cortisol:cre test? A) Should be done in the afternoon B) Should be taken in the clinic C) Best to collect the sample from their first morning urination at home D) It doesn’t matter when or where you take the sample
C many dogs are stressed at the vet clinic and this can cause cortisol to spike and result in false readings
