09Feb2023 Are you seeing these usual suspects in practice
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So, good afternoon from where I am. I'm Libby, as Anthony said, and it's great to see so many of you here from all different parts of the world, some early in the morning and late in the evening, I can see as well. We're going to talk today about canine crushing syndromes, and these are the objectives for today's presentation.

We're going to, at the end of this presentation, to be able to identify where your canine patients become prime suspects for having crushing syndrome. I'm also going to help you understand how to select and interpret appropriate initial tests, and then diagnostic tests for crushings. We'll develop the knowledge that we need to be effective in monitoring these patients once they're on veterile, and we're going to increase your confidence in managing those adjustments and potential complications.

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And finally, we'll help owners understand what to expect in their dog's crushings journey. Now, throughout this presentation, I'm going to ask you to interact with me, so I'm going to ask you a question, and I'd like you to reply using the chat function. If you've got any questions that you'd like to ask me, please pop them in the Q&A box, and I can answer them at the end of the session.

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So, the first question that I would like to ask you are, what are the biggest obstacles you face as vets, if you're a vet at the presentation today, when it comes to diagnosing crushings? So, one barrier many people find in patients, especially our older patients, is that owners can attribute clinical signs to just old age, and Margaret, exactly as you've said, owners may present them quite late on in the disease process. Today, we're going to explore the role that all the members of the practice team play in diagnosing these cases. So, another question that I have for you, what does a dog with crushings look like? Throw your answers into the chat.

So, we've got one reply saying that they can be quite normal. That's exactly right. Fat, hair loss with a pot belly, PUPD.

So, yeah, you might have described a dog exactly like that, with PUPD, polyphagia, panting, alopecia, a pot belly, poor exercise tolerance, and paper-thin skin. And crushings is more common in middle age to older dogs, and some breeds are predisposed, like Bichons or small terrier breeds. What's really interesting though, and I think we could all agree, is not all dogs present exactly the same.

They might only have one or two of these clinical signs, and what makes this even more complicated is that sometimes owners might not attribute these signs to a sign of illness at all. They might just think these are a sign of old age, and that's why we've developed this new campaign, which is called the Prime Suspects campaign. So, this is a campaign that we've launched to owners, and there's a website they can visit, which is suspecting-crushings.co.uk. When owners visit this website, they meet a selection of dogs who are prime suspects of having crushings.

So, my particular favourite is Greedy Gus on the right here, who's polyphagic. And owners can enter an online investigation room and explore which clinical signs might actually be a sign of illness, rather than just old age. And the aim of this campaign is to drive owners' awareness of the disease and to get them contacting their practice for further information.

You're going to suspect crushings in a lot more dogs than you'll diagnose. For every 100 cases of crushings treated, there are another 57 dogs where crushings are suspected but not confirmed, and this highlights just how many cases we could miss in practice. A little bit of owner communication at this early stage in the workup goes a long way.

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It takes an average of 3.4 visits to the practice to get a diagnosis of crushings, and at least two rounds of tests. It's important to explain to owners that the initial tests are useful to rule out other causes of their pet's symptoms, not just for identifying crushings. And making them aware of this before we run the tests helps get their buy-in right from the start, and we can make them aware of any costs involved.

So, some language I like to use when I'm suspecting crushings is, we're unlikely to make a diagnosis from these initial tests, but it will narrow down the list of possible causes and point us in the right direction with which test we need to perform next to get a diagnosis. So, once you've got your initial suspicion that a dog might have crushings, you're going to run some initial tests. I'd like you to put your answers in the chat box.

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In a dog where you're suspicious of crushings, what initial tests would you choose to run, and what findings would you expect to see? And we're going to give you 60 seconds to do this, starting now. Just encourage people to just go into the chat area and just write some comments down. The more comments we get, the more interactive and the more we're thinking about possible answers, the better.

So, just to help Libby on with some of the comments that you're making. So, that would be fantastic. So, thank you LOD and Colin and Gemma.

That's great. Thank you. Yeah, fantastic.

So, we're getting some really good answers in the chat box now. All right. So, there are lots of different initial tests that you could perform, but the ones that I would prioritize are haematology.

And on haematology, we would expect to see a stress leukogram. So, that's an increase in neutrophils and monocytes with a decrease in eosinophils and lymphocytes. Biochemistry, we would expect to see a raised ALKP and or ALT.

We can see raised triglycerides and cholesterol. We can also see a low total T4, as Cushing's acts as a non-thyroidal illness, causing sickly thyroid syndrome. We'd also expect to see a low or low normal urea and creatinine.

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And if we perform your analysis, the urine's often dilute with a USG of less than 1020. However, not all dogs will show all of these changes on the initial tests. But if we see any of these changes, then our suspicion that this dog might have Cushing's should increase.

Once we reach this stage of the workup, I would recommend taking a pause and considering the dog's signalment, clinical signs, and those initial test findings, and asking yourself these three questions. Has this case gone over the threshold to justify running a diagnostic test for Cushing's? Were there any findings on the initial tests that make Cushing's less likely? And is there a concurrent disease presence that's going to make this case more complicated to diagnose or treat? Let's take a look at Fred, for example. He's an eight-year-old male neutered chihuahua.

And for four weeks, he's been PUPD, scavenging on walks with a potbelly. We ran some initial tests, and we found that he had a raised ALKP and ALT, a low total T4, and a mild lymphopenia. On urinalysis, his urine was dilute.

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It was 10-0-6. The way I would approach this case is I would first look at his signalment. He's a middle-aged to older breed dog.

He's the right signalment for Cushing's. I then look at his clinical signs and examination findings. All of those symptoms, and you posted the vast majority of them in the chat box, can be attributed to Cushing's.

And there's nothing there, no symptoms that I can't attribute to Cushing's. When I look at those initial test results, again, they all make me more suspicious that Fred will likely have Cushing's. So my next question to you that I'd like you to answer is, would you run a diagnostic test for Cushing's on Fred? Yeah, fantastic, Emma, I agree.

I would run a diagnostic test for Cushing's on Fred. He's pretty much a textbook case with the right signalment, clinical signs, and initial test findings. So let's meet our second case.

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This is Beatrice. She's a seven-year-old female entire Labrador. She's got a two-week history of increased thirst and urination with some vomiting.

On the initial tests that we ran, we found that she has a raised ALKP, cholesterol, urea, and creatinine. Her urine was dilute with a USG of 1010. And I'm just going to give you 10 seconds or so to consider those initial test findings.

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Would you run a diagnostic test for Cushing's on Beatrice? Yeah, fantastic, lots of answers in the chat. No, we wouldn't run a diagnostic test for Cushing's on Beatrice. But I think we can agree she's not as straightforward a case as Fred is.

And that's why we've developed our new endocrinology app. If you're feeling unsure as to whether a dog has Cushing's or not, this new app allows you to plug in the dog's symptoms and it gives you a percentage likelihood that that dog has Cushing's, which can then give you the confidence to either recommend performing a diagnostic test or not. The app's fantastic.

It's also got resources for monitoring your dogs with Cushing's, and also diagnosis and monitoring dogs with Addison's as well. If we put Beatrice's details into the app, it comes up that she has a 28% likelihood of having Cushing's. And that's because of the presence of vomiting and azeotemia.

Both of those things make Cushing's less likely. But you're absolutely right, we wouldn't want to run a diagnostic test for Cushing's in Beatrice's case. So I'd be interested to know, which diagnostic test do you most commonly run to diagnose Cushing's? That's really interesting.

So we've got a mixture of answers in the chat. Some people run a low dose dexamethasone suppression test, and some run an ACTH stimulation test. Let's explore those different tests further.

But first, let's have a recap on how Cushing's occurs. So the hypothalamus, which is part of the brain, secretes a hormone called CRH, or corticotrophin releasing hormone, which then acts on the anterior pituitary, causing it to release a hormone called ACTH, adrenocorticotropic hormone, which then acts on the adrenal glands, which are a pair of glands in the abdomen. And it stimulates them to produce cortisol.

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Cortisol then feeds back on the anterior pituitary, causing it to produce less ACTH, and again on the hypothalamus, making it produce less CRH. Cortisol occurs due to a hormone producing lesion, either on the adrenal glands, or on the pituitary glands. And pituitary is much more common than adrenal as a cause.

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But the outcome's the same, the dog has high circulating levels of cortisol. There are two different diagnostic tests we can use to diagnose Cushing's. The first is the low dose dexamethasone suppression test.

So in this test, we give dexamethasone, and it acts in the same way as cortisol. So we give dexamethasone, it shuts off production of ACTH, and so the dog produces less cortisol in a healthy dog. If we give dexamethasone to a dog with Cushing's, this feedback system isn't working, because there's either a tumour on the pituitary gland producing loads of ACTH, and therefore the dog carries on producing cortisol, or there's a tumour on the adrenal glands which is producing cortisol.

So the dog will carry on producing a lot of cortisol, even if we've given dexamethasone. We rarely get a false negative result when we run this test, and therefore this is the test of choice when we're highly suspicious of Cushing's. The ACTH stimulation test works in a different way.

In a healthy dog, if we give ACTH, it causes them to produce more cortisol. That's a normal physiological response. In a dog with Cushing's, if we give ACTH, their adrenal glands are primed to produce cortisol, so they produce a massive amount more than a normal dog would.

The problem with this test is, it will miss a proportion of dogs that have Cushing's, and that can leave us with uncertainty, especially if we were pretty convinced already that the dog had Cushing's when they walked in the door, and it can leave the owner frustrated with which further tests need to be performed, and why we're still considering this diagnosis. Therefore, if you've built your suspicion of Cushing's based on the history, physical examination, and initial tests, you're going into your diagnostic testing being highly confident this dog has Cushing's, so we therefore run the test of choice, which is a low dose dexamethasone suppression test, and we can be confident in the results. If you had a patient with a known concurrent illness, for example unstable diabetes mellitus, then the ACTH stimulation test would be the test of choice in that circumstance, because it's less likely to be affected by non-adrenal illness.

Let's meet our case. This is Florence. She's a nine-year-old female entire crossbreed.

She's got a four-week history of panting and being slower on walks, along with drinking and urinating in the house. She's also been begging for food a bit more. On our initial tests, we found she's got a raised ALKP and ALT, with a low normal urea and creatinine.

She's also got an eosinopedia and neutrophilia, and her urine was dilute with a USG of 10-18. Again, I'm just going to give you 10 seconds or so to consider those findings. My next question is, would you run a diagnostic test for Cushing's on Florence? Lots of answers in the chat saying yes, and I agree.

I'm quite suspicious of Cushing's in Florence's case, so I would run a diagnostic test. If we put her details into the app, interestingly, it gives her a 71% likelihood of having Cushing's. Which test would you run? Fantastic.

Lots of great answers in the chat as well. We would run a low-dose dexamethasone suppression test, because we're pretty confident that Florence has Cushing's. Unfortunately, you were on annual leave when Florence came in for a low-dose dexamethasone suppression test, and your colleague ran an ACTH stimulation test.

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These were the results. Her pre-ACTH cortisol was 110, and her post-ACTH cortisol was 470. Your laboratory's reference range for a positive diagnosis of Cushing's is more than 600.

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Does this support your suspicion that she has Cushing's? Yeah, it doesn't, so we've got a negative result on an ACTH stimulation test. Florence, when she came into the reception, we looked at her, and we're pretty sure she had Cushing's. When we ran the initial tests, again, we were pretty sure.

We've done this diagnostic test, and it's come back negative, and we can feel uncertain, and it can leave the owner feeling frustrated. If this were you in practice, what would you do next? Fantastic. Lots of answers.

Colin, Rose, Margaret, Stein, straight off the mark in the chat, we would run a low-dose dexamethasone suppression test, and that's what we did in Florence's case. These were her results. At zero hours, her cortisol was 98.

At three hours, her cortisol was 75, and at eight hours, her cortisol was 90. Your lab's reference range for a positive diagnosis of Cushing's is that the eight-hour cortisol would be more than 40. Does this support our initial suspicion that Florence has Cushing's? Yes, spot on, Chris and Rose, it does, and Florence did have Cushing's, and we started her on treatment.

We can differentiate as to whether the dog has a lesion in the pituitary gland or adrenal gland. PDH is more common, so pituitary-dependent Cushing's is more common, but with adrenal disease, adenomas and carcinomas occur with equal frequency, and the medial survival time for adrenal carcinomas is short. Equally, if surgery is being considered, then you need to differentiate between the two.

You need to know where the lesion is. So once you have a diagnosis of Cushing's, it's important to explain this to the owner and give them the option of performing a differentiation test. Now, there are five tests that we can use to differentiate between pituitary and adrenal disease, and I'm going to give you 30 seconds to get them all listed in the chat box.

So Karen, absolutely right, we've got low-dose dexamethasone suppression test and ultrasound. There are three more. Perfect, Adriana, ultrasound.

So we can also use a high-dose dexamethasone suppression test, and we can use MRI as well as endogenous ACTH. The take-home messages for diagnosing Cushing's are build your suspicion based on signalment, clinical signs and initial test findings before running a diagnostic test. DECA can provide you with support if you're unsure via access to our app 24x7 or by contacting our technical team, and in a well patient where you're suspicious of Cushing's, then run a low-dose dexamethasone suppression test.

Let's talk about treatment. So there are various treatment options available, including things like surgery and radiotherapy, but for the purpose of the rest of this talk, I'm going to focus on medical treatment with Veteril. We treat Cushing's for three main reasons.

The first is to improve the dog and the owner's quality of life. The second is to prevent secondary complications, and the third is to reduce clinical signs. Some of the potential complications of untreated Cushing's include diabetes mellitus, urinary tract infections, urolithiasis, hypertension, pancreatitis, and thromboembolic disease.

What strikes me about this list is that although many of these complications can be treated, it can be difficult, time-consuming and a costly process, potentially more so than the original diagnosis of Cushing's. Veteril contains the active ingredient trilustane, which reversibly inhibits cortisol production, and that's a really neat fact to know. Because its effect is reversible, it means if you stop giving the medication, its effect wears off, and it's also titratable, so the more of it you give, the more of an effect it's going to have on that patient's cortisol, and you can use it to treat both pituitary and adrenal-dependent Cushing's.

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At the start of treatment, we need to set owner expectations. They need to know that the goal of treatment is to resolve their pet's clinical signs and improve their and their dog's quality of life, and this is information that we can only get from the owner, so we need them to be engaged. We need to manage their expectations of what treatment is going to involve.

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It's going to involve repeat visits to the practice, which will be quite frequent initially, but once we get the dose right, they'll likely be further apart. Their pet's likely going to be on lifelong medication, and we can give them an idea of what the ongoing costs are going to be. When we're recommending treatment options, we need to discuss the relative risks of each one and give them an idea of which of the pet's clinical signs are going to improve when.

We'll talk about this a little bit more later on. One question that we get asked a lot at the technical team is should veteran be given once or twice daily? The licensed starting dose is once daily, however it's on the data sheet that you can give it twice a day if you haven't achieved adequate control with once daily dosing. Some dogs are actually better controlled on twice daily dosing, whereas others manage just fine on once daily.

Some studies have actually shown that stabilisation could be more rapid with a reduced total daily dose on twice daily dosing, but twice daily dosing means an increased number of capsule sizes and the owner may struggle to medicate their dog twice a day. So the take-home message is that twice daily dosing is better for some dogs but not for all. How are we going to monitor these patients once they're on treatment? I'd like to ask you what are the most important things that you monitor in a dog that's receiving veteral? So Emma says Addison's crisis, so that's low cortisol, yeah that's a great answer.

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Karen says thirst and urination, fantastic clinical signs. Adriana says feedback on symptoms, these are fantastic answers. As you've alluded to, we need to focus on the clinical response, that's the dog in front of us.

Some of the most important things that we monitor are clinical signs and examination findings. At every recheck we're going to ask the following questions. Is the dog well or unwell? Do they have clinical signs of cushings and have they gotten better or worse? The answer to these questions guides us as to whether the dose is just right or whether it needs changing and we can then measure the dog's cortisol to back up our suspicion.

It can be really tricky to get the full picture during a standard monitoring appointment. Here in the UK our standard appointment time is 15 minutes and it can be understandably difficult for pet owners to remember all of their dog's symptoms since the previous visit. There can often be multiple vets involved in monitoring in one case as well which leads to some subjectivity in the interpretation of what owners are describing.

That's why we've developed these two validated tools. So on the left we've got the Cushing's clinical score. This is a short four question questionnaire that asks owners to grade the dog's most common clinical signs of cushings and allows you to track changes in the clinical signs over time objectively.

On the right we've got the Cush QOL Pet questionnaire. This questionnaire has been designed to monitor changes in quality of life over time and this allows you to objectively and quickly get this information during a consultation and these tools are validated and have been designed in conjunction with the Royal Veterinary College. As I said we need to give owners an expectation of what clinical signs are likely to improve when and it's really helpful for us to know this too when we're checking up on a dog that's on treatment.

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So by day 10 we would expect the PUPD and polyphagia to have improved and the dog should be panting less and a bit more energetic. By day 28 these symptoms should have resolved or mostly improved and their pot belly might be diminishing with some hairy growth. It can take three to six months for the clinical signs to resolve and the alopecia and pot belly tend to be the last signs to resolve.

This is our fourth case which is Bonnie. She's a 10 year old female neutered poodle cross. She's been on 20 milligrams of veteril once a day for 28 days and she's here to see you today for a medication review.

Her owners reported that her PUPD has resolved but she's still got a thin hair coat over her tail. At her previous recheck her Cushing's clinical score was eight. Today the owners filled in the Cushing's clinical score and it's improved, it's decreased to two.

Her Cush QOL PET score is minus 0.10 which equates to a greatly improved quality of life since her previous recheck. I'm just going to give you 10 seconds to consider these findings. Okay my first question is, is Bonnie well? Yeah fantastic she is well.

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Does she have clinical signs of Cushing's? Yeah exactly so she's got a thin hair coat but we know that this can take three to six months to resolve and the PUPD is resolved as expected. Has she gotten better or worse since we last saw her? Exactly she's gotten better. And do you think you're going to need to adjust the dose of veteril? Perfect, no it seems to me like that dose of veteril is just right but we'll check her cortisol and come back to her a little bit later on.

This is Alfie, he's a 12 year old male neutered cocker spaniel. He's been on 30 milligrams of veteril once a day for six months and he's here to see you today for a routine medication review. He's been waking his owner up in the night to urinate and he's been sleeping and he's been stealing food from his owner's plate which isn't like him.

At his previous medication review his Cushing's clinical score was zero but now it's increased to four. When we reviewed his quality of life questionnaire his quality of life score was plus 0.05 which equals a reduced quality of life since his previous recheck. Is Alfie well? So Alfie would classify as well but he does have clinical signs of Cushing's so he's a generally happy dog but his clinical signs of Cushing's have recurred.

Has he gotten better or worse since the last review? Yeah he's gotten worse. So do you expect that you're going to need to adjust his dose of veteril? Yeah I think Alfie's going to need a dose adjustment so let's measure his cortisol and we'll come back to him later on. So given all this valuable information we've gathered just by assessing our patients hands-on and speaking to the owner why do we even need to assess cortisol? Well there are two main reasons.

The first are it acts as a safety check to make sure that there's no subclinical hypocortisolism so to make sure that the cortisol isn't subclinically too low and it also gives us the green light to make a dose adjustment that we'd already planned to do. There are two tests we can use to monitor cortisol in dogs receiving veteril. One is the pre-veteril cortisol and the second is the ACTH stimulation test.

For my interest just pop in the chat which tests or tests you currently use to monitor these cases. So we've got a mixture so some people using the ACTH stimulation test and a few people using pre-veteril cortisol. Let's run through which test is better if any.

So if you've not heard of pre-veteril cortisol before it works by measuring cortisol in a single sample at the time the pill is due. Because it's a single sample and you don't need to give synthetic ACTH or hospitalise the dog it's a lower cost than the ACTH stimulation test and less staff time required. Studies have shown there's a better correlation with clinical control and the test is more repeatable than the ACTH stimulation test.

However it's not mentioned on the veteril data sheets so it's considered off-label to use this test for monitoring dogs. The ACTH stimulation test most people are familiar with but it involves taking two blood samples four to six hours after the pill and giving synthetic ACTH after the first blood samples taken. The benefits of this test are it's suitable for unwell stressed or aggressive dogs.

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The owner usually needs to give the pill in the morning so the test can be run in the afternoon while your practice is open and it's on label it's on the veteril data sheets so we monitor dogs using this test. In summary pre-veteril cortisol has been shown to better correlate with clinical control and be more repeatable than the ACTH stimulation test but it's not suitable for monitoring all cases so look at the individual case and pick which test you think would be most appropriate for that case. Revisiting Bonnie and Alfie we measured their cortisol after their appointments and interestingly we measured their cortisol and it was the same in both cases they both have a cortisol of 97 nanomoles per litre.

That's well within the reference range the reference range is 40 to 138 plus or minus 15 but this just really highlights how important it is to examine the patient and speak to the owner about how they're doing because if we just looked at the cortisol value alone we might have chosen something completely different for either of these patients. So I'd be interested to hear your thoughts I'm just going to give you 10 or so seconds to put in the chat what worries you the most about managing Cushing's with veteril? It's really interesting so we've got owner compliance and Addison's, overdosing by the owner, comorbidities, they're all fantastic answers. So interestingly the most common and earliest complications of treatment with veteril are mild such as lethargy and inappetence and often more pronounced clinical signs are seen when better treatments continued for several days after seeing those first mild clinical signs.

So it's really unlikely that you'll put a dog into an Addisonian crisis with a single dose of veteril. Let's run through some of the more commonly seen complications that we can see with treatment. First is adrenal over suppression.

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So in adrenal over suppression cortisol levels have been suppressed and become too low. These dogs can present with GI signs, vomiting, diarrhea, lethargy or appetite. Generally they're the most common ones and if an owner reports any of those symptoms to you you should recommend that they stop giving veteril and that they pop the dog into the practice for you to do some further tests because these symptoms can occur with other conditions as well so we need to find out whether this is related to the veteril or whether this is something else entirely.

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Once the dog's in the practice you perform biochemistry, electrolytes and an ACTH stimulation test. With over suppression we'd expect to see a non-stimulatory ACTH stimulation test. Because veteril is a reversible enzyme inhibitor the vast majority of patients improve within 24 hours stopping veteril and again causing true iatrogenic adrenal over suppression is pretty rare.

(37:12 - 38:35)
Wait until the dog's clinical signs of Cushing's recur and or the post ACTH cortisol is more than 140 and then start the veteril again but at a 50% dose reduction. The second complication that we can see is something called cortisol withdrawal syndrome. What's really interesting is those dogs can present very similarly to dogs with adrenal over suppression.

The reason this happens is those dogs are used to walking around with really high levels of cortisol and when we start treatment it can drop and although it's within a normal range the dog can sometimes struggle to cope with that new normal. Again the owner is probably going to phone you and report very similar signs to adrenal over suppression so you're going to give the same advice you're going to get and you're going to ask them to stop veteril and bring the dog in so you can do biochemistry, electrolytes and an ACTH stimulation test and these test results will likely be normal and if that's the case you just give the dog a treatment break for a week and then start the veteril again at a 50% dose reduction. It's really handy to advise the owner that the final dose of veteril that the dog ends up on might be higher than this original dose where they saw these symptoms occur in their dog and if you explain that to them in advance the owner's unlikely to be concerned when you end up increasing the dose.

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The third complication we can see is unmasking steroid responsive disease so as we decrease the dog's level of cortisol we can unmask other conditions that were already there like atopic skin disease or inflammatory bowel disease and in this case we might need to consider non-steroid therapies for these treatments. The bottom line is if a patient on veteril presents unwell recommend that the owner stops veteril. Its effect is reversible so most of patients most patients will recover within 24 hours of stopping treatment.

(39:15 - 45:17)
You're going to ask them to come in and you're going to do some further tests like an ACTH stimulation test, biochemistry and electrolytes and this is going to allow you to ascertain whether the problem is related to the veteril or whether it's something completely different and the dog's presented unwell and finally provide supportive treatment as necessary. There are some key things we need to communicate with owners at this stage and it includes if their dog's unwell on treatment it may or may not be related to veteril so stop and contact the practice for further advice. Advise what we'll do if complications do arise so they'll need to bring their dog to the practice and advise them that most complications that we see are mild like things like lethargy and reduced appetite so they're the things that they need to alert us for.

The take-home messages of monitoring these patients are some dogs are better controlled on twice daily dosing but not all. Adverse effects of veteril are usually reversible but if you're unsure stop the veteril and get the patient in for assessments and you need to focus on the clinical response to treatment and that's what's going to guide you as to whether a dose adjustment is needed and finally by treating dogs with Cushings we really believe at Decra it's an opportunity to bring back health and vitality for their patients but also the owner too. If you need any help with individual cases we're here along the way so for in-person individual case-based advice you can speak to our technical team which includes me and my colleagues, you can reach us by email on the email address shown on screen, by phone or you can fill in one of our inquiry forms on the website and we're also available online via Cushings Connect.

This is our brand new website for veteran professionals and it's designed to ensure that you can find all the answers you need about veterinol and Cushings at the click of a button so it's got all of the information that we discussed here today together with some other information that you might find helpful as well. So thanks very much for listening everyone that's everything I had for you this afternoon and I'm just going to stop sharing my screen and we can move to questions and answers Anthony if that's all right for you. That's great Libby, thank you so much for that, that was really clear and concise I think it is sometimes problematic treating Cushings and you went through the various scenarios really well so thank you for that great recap on Cushings disease.

Just listening, just watching on the chat we've got some people in from America, from Trinidad, obviously the UK, Guernsey, those of you who haven't put in do put in where you're listening in from it's always interesting and thank you for those who participated in the chat otherwise it would have been a less enjoyable webinar for Libby if she'd have had no feedback so thanks for doing that for us and of course thank you to to Decra for making this possible and also for those great resources the website and the app which I think will be really useful for practices as well and for vets and nurses obviously. Oh Florida, USA a bit warmer there than here probably and Tamworth in Australia which is bound to be warmer so Claire's been coming on a lot of these and it must be quite late in the night early morning there so well done Claire for that. Barry Bados, I presume that's Barry down in South Wales, Norfolk, yes warm Karen was saying in Florida so that's that's all good so yeah let's just see if there's any questions and thank you for oh in Miami as well this is yeah getting me thinking of warmer climes 72 degrees in Miami today Libby.

Oh that sounds lovely. Yeah this was an interesting one from Katerina because actually it's a really interesting story for me what about the urine cortisol creatinine test? Yeah that's a fantastic question actually Katerina so the urine cortisol to creatinine ratio for those who aren't familiar with it measures the amount of cortisol in urine and compares it to creatinine so in a dog with Cushing's or a dog that's stressed or ill we would expect them to have more cortisol in their urine but therein lies the problem. Dog it can be really difficult to tell whether a dog with high cortisol in its urine is ill or with another condition or whether it has Cushing's so I think as vets we're pretty good at only running tests on sick animals so if you think about the proportion of the population of dogs that you run this test on they're probably sick or got something wrong with them so they've probably got high cortisol in their urine so what can happen is you can get this positive result back and you still don't really know whether the dog has Cushing's or whether it has some other illness and you then end up having to go on to do an ACTH stimulation test or a low dose dexamethasone suppression test anyway so often you can skip this test you've already built your confidence based on clinical signs, signalment and initial test findings you can go straight to an ACTH stim or a low dose dex if you're still suspicious of Cushing's.

(45:18 - 51:10)
That's a great answer Libby, I remember this was the first time after the qualifying that I realised pathologists weren't gods because I think I'd been advised you know I was speaking about a case and the pathologist said yeah send me a urine sample I'll do a cortisol creatinine ratio on it and then I can't remember if it was he or she but they came back and said yeah this dog has Cushing's disease and obviously as I then investigated and went into more detail read a few textbooks I realised that you know whilst it very much could have Cushing's it could also have a number of other diseases as you've said so it made me just that little bit more thoughtful when I spoke to pathologists that I didn't think that necessarily they would have all the answers and I think this is where the relationship between between vets and pathologists you know clinical pathologist histopathologist is is really important because if we look at it in isolation we don't get the same benefits as if we work together as a team. Yeah exactly. Margaret is saying tell me more about steroid responsive disease.

Yeah I certainly can Margaret so and I hope this answer helps and let follow up with another question actually if it doesn't answer quite what you what you meant so dogs with uncontrolled Cushing's have really high circulating levels of cortisol and this can mask certain other health conditions so for example if you've got atopic skin disease and you develop Cushing's that high circulating level of cortisol will in a way self-medicate your atopic skin disease and when you drop the cortisol those clinical signs like pruritus can return. If you gave that dog steroids as part of its treatment plan then you're kind of undoing the effect that better or has so you might want to consider an alternative therapy option in in that case and the same goes for conditions like inflammatory bowel disease so having a high circulating level of cortisol can self-medicate that condition and once you begin treatment you can unmask it. Well that's great thanks for that thanks for that Libby.

April is asking do you know if and when the app will be will be available in the USA? April that's a great question and I don't actually know the answer to this and I might check with my colleague Sarah who I think's on the call. Yeah Sarah is here if Sarah wants to unmute and and start her video you can you can let us know if if that's available or not Sarah. I will have to double check but I can follow that up because obviously we deal with the UK I'm from the UK as well as you can tell from my voice so I can double check with our colleagues in America and see if it's available there for you and we can include that as part of our follow-up for you so you're aware.

Thanks Sarah. April it's always worth going on to the app store because it it might show up just from that as well but a nice bit of feedback Sarah from just let me just find this I can't see actually it's just moving around on the questions but Sarah I think as she said for owner information suspecting-cushings.co.uk is the best website for owners looking for information so that's another resource for people as well. So that owner website just to answer your question Karen that has got various bits of videos, tools, content for owners to be able to understand the disease and the diagnosis and treatment routes obviously that Olivia's outlined as well today so that's all available on that one place.

That's useful for the owners so worth looking at. Somebody said can a dog have cushings with a normal ACTH and low-dose dexamethasone suppression test? We have a 10-year-old Welsh Terry with PUPD thinning coat, high alcohol and cholesterol and all other blood parameters normal. Yeah that's a really interesting question.

I think for this one if you're in the UK then feel free to contact me or one of our team and then we can review the full case for you and give specific case-based advice on this one. A low-dose dexamethasone suppression test is very unlikely to miss a case of cushings so it would be unusual for a dog to have cushings with a negative low-dose dexamethasone suppression test but yeah if you're in the UK reach out to me or one of our technical team you can find the information on the DECFA website or if you're abroad then you can reach out to your technical team in whichever country you are and they can help work this case through with you. That's great.

Just to remind everybody it is in the chat this will be available as a recording as will all of the webinars from the Virtual Congress on the 19th of February and also you can download certificates from the 19th. Do go and have a look in the the goodie bag there's various exciting prizes you can win by going to look at the goodie bag and I think again Rebecca or Kyle will put that link into the chat box so that you can look at that as well. So let me see if there are any more questions that have popped up while we're doing that.

(51:11 - 51:56)
Eleanor is asking a question about lysodrin is that a product that's still available and is a licensable well it's not it's not licensable I know but is it available is it still being used in the UK or further appealed? I'm not sure on the answer to that question and I'm not sure I'm honestly not sure on the data sheet or SPC so maybe Eleanor if you could email that one into us the email is technical at decra.com and we can look into that one for you. Yeah Sabrina is saying thank you for a great webinar. Katie's saying would it be possible to see the last two slides with contact details so we want to share screen again.

(52:01 - 54:19)
It's interesting with the lysodrin question I remember treating quite a lot of dogs with Cushing's disease in the 90s and the 2000s and while you could get some good results with it it was a drug that you know could kill dogs as well so it's a drug that you really have to use terribly carefully if you are listening in from somewhere where you can get hold of it. My understanding which is a little bit more old is that it was becoming increasingly more difficult to get hold of because it wasn't obviously on the cascade in the UK so I think it is it is pretty difficult to get hold of it in the UK but obviously in other areas you may have more success but it's a drug not for the faint-hearted because it can lead to some really quite nasty side effects as well. Rebecca is saying if you have a dog on treatment who comes in for their routine medication review if they are clinically well with no clinical signs of Cushing's disease how often do you advise checking haematology and biochemistry? That's a really good question Rebecca so if you look at the veterile data sheet it recommends performing an ACTH stimulation test and checking things like biochemistry and electrolytes at each medication review so that's the on label thing to do however if you've opted to use pre-veterible cortisol monitoring and to do that that would be off label because it's not on the data sheet even though we know it's been shown to better correlate with clinical control you would have obtained owner consent to monitor their dog in an off label way and if you're going to do that you may consider altering the frequency at which you check things like haematology and biochemistry if it's going to differ from the SPC so if you were going to monitor these things any less frequently than on the data sheet you would have to obtain written consent from the owner because it would be off label but you may already be doing that anyway if you've chosen to use pre-veterible cortisol to monitor that dog.

(54:22 - 57:02)
Libby that's fantastic thank you for that extra question I suppose sometimes you know we have to look at what people can afford to do as well can't we so looking at potential savings is something that we you know we always must consider so thank you for clarifying that for us. Right I think that they are all the questions we've got actually one more just coming from Julie who says what is the maximum dose of veterol in dogs is there a high dose you could go to? A good question so there isn't a maximum dose and because it's a reversible enzyme inhibitor it's effectively titratable so the more of it you give the more you're going to reduce that patient's cortisol. On the data sheet it says that dogs requiring some dogs a significant proportion of dogs require in excess of 10 mg per kg per day and that those dogs should have appropriate additional monitoring implemented and it doesn't give you any further guidance than that so some dogs will require there's no maximum dose some dogs will require in excess of 10 mg per kg and if you've got one of those dogs in front of you you might want to either do additional monitoring tests or shorten their monitoring interval.

And again that's where they could potentially ring you up and ask for extra advice on the exactly the care line. Great is that have we got another slide just for the person who was asking for because they said two slides is there another one after this or one before that? Yeah this is our vet website. Great so people can just get the decra.co.uk forward slash Cushing's hyphen connect.

Thank you so much Libby for a fantastic talk thank you also to Sarah and obviously to Decra for making this this possible. Libby is one of the veterinary advisors at Decra so if you do ring up or email who knows you might be able to speak to Libby in person but thank you so much Libby that's been a really clear walk through the the challenges of diagnosis but also of treatment with Cushing's. But they're also very satisfying cases because I think if we catch them early these are dogs that can live for really a very long time with their Cushing's disease can't they? Exactly and it's that improvement in dog and owner quality of life that we see I think it makes it a really rewarding condition to treat.