Comparison of Survival Times for Dogs with Pituitary-Dependent Hyperadrenocorticism in a Primary-Care Hospital: Treated with Trilostane versus Untreated

Role of Prednisolone in Platelet Activation by Inhibiting TxA2 Generation through the Regulation of cPLA2 Phosphorylation

Glucocorticoids have been commonly used in the treatment of inflammation and immune-mediated diseases in human beings and small animals such as cats and dogs. However, excessive use can lead to Cushing's syndrome along with several thrombotic and cardiovascular diseases. Although it is well-known that glucocorticoids exert a significant effect on coagulation, the effect of cortisol on platelet function is much less clear. Thus, we aimed to study the effects of prednisolone, one of the commonly used glucocorticoids, on the regulation of platelet function using murine platelets. We first evaluated the concentration-dependent effect of prednisolone on 2-MeSADP-induced platelet function and found that the 2-MeSADP-induced secondary wave of aggregation and dense granule secretion were completely inhibited from 500 nM prednisolone. Since 2-MeSADP-induced secretion and the resultant secondary wave of aggregation are mediated by TxA₂ generation, this result suggested a role of prednisolone in platelet TxA₂ generation. Consistently, prednisolone did not affect the 2-MeSADP-induced aggregation in aspirinated platelets, where the secondary wave of aggregation and secretion were blocked by eliminating the contribution of TxA₂ generation by aspirin. In addition, thrombin-induced platelet aggregation and secretion were inhibited in the presence of prednisolone by inhibiting the positive-feedback effect of TxA₂ generation on platelet function. Furthermore, prednisolone completely inhibited 2-MeSADP-induced TxA₂ generation, confirming the role of prednisolone in TxA₂ generation. Finally, Western blot analysis revealed that prednisolone significantly inhibited 2-MeSADP-induced cytosolic phospholipase A₂ (cPLA₂) and ERK phosphorylation in non-aspirinated platelets, while only cPLA₂ phosphorylation, but not ERK phosphorylation, was significantly inhibited by prednisolone in aspirinated platelets. In conclusion, prednisolone affects platelet function by the inhibition of TxA₂ generation through the regulation of cPLA₂ phosphorylation, thereby shedding light on its clinical characterization and treatment efficacy in dogs with hypercortisolism in the future.

Survival of dogs with pituitary-dependent hyperadrenocorticism treated twice daily with low doses of trilostane

BACKGROUND

Twice daily low trilostane doses have proven to be effective to manage canine Cushing's syndrome. However, survival and prognostic factors in dogs treated with this protocol have not been evaluated. The aim of the study was to evaluate survival and prognostic factors, including systolic blood pressure (SBP) at diagnosis, in dogs with pituitary-dependent hypercortisolism (PDH) treated with low trilostane doses.

METHODS

Medical records of 91 dogs newly diagnosed with PDH initially treated with 0.2-1.1 mg/kg of trilostane twice daily were retrospectively included. Survival times were calculated using the Kaplan-Meier estimator. Univariable and multivariable analysis were performed using the Cox proportional hazard regression analysis.

RESULTS

Overall, median survival was 998 days (range 26-1832 days, 95% confidence interval = 755-1241 days). In the multivariable analysis, age (hazard ratio [HR] = 1.337, p < 0.001), presence of calcinosis cutis (HR = 5.271, p < 0.001), body condition score (BCS) ≤3/9 (HR = 8.100, p < 0.001) and higher platelet count (HR = 1.002, p = 0.022) were negatively correlated with survival. SBP was not associated with survival.

CONCLUSIONS

Low-dose trilostane treatment twice daily provides slightly longer survival than previously reported for dogs with PDH treated once or twice daily at higher doses. Older age, presence of calcinosis cutis, low BCS and higher platelet count, but not systemic hypertension, are predictive of poorer prognosis in dogs with PDH.

Frequency and risk factors for naturally occurring Cushing's syndrome in dogs attending UK primary-care practices

Objectives

To estimate the frequency and risk factors for Cushing's syndrome in dogs under UK primary veterinary care.

Materials and Methods

Dogs with Cushing's syndrome were identified by searching electronic patient records of primary‐care veterinary practices. Pre‐existing and incident cases of Cushing's syndrome during 2016 were included to estimate the 1‐year period prevalence. Incident cases were used to estimate the annual incidence and to identify demographic risk factors for the diagnosis of Cushing's syndrome in dogs, through multivariable logistic regression.

Results

Analysis included 970 pre‐existing and 557 incident cases of Cushing's syndrome from a population of 905,544 dogs. The estimated 1‐year period prevalence for Cushing's syndrome in dogs under veterinary care was 0.17% (95% confidence interval 0.16 to 0.18) and incidence was 0.06% (95% confidence interval 0.05 to 0.07). In multivariable logistic regression modelling, the Bichon frise (odds ratio=6.17, 95% confidence interval 4.22 to 9.00), Border terrier (5.40, 95% confidence interval 3.66 to 7.97) and Miniature schnauzer (3.05, 95% confidence interval 1.67 to 5.57) had the highest odds of Cushing's syndrome. The Golden retriever (0.24, 95% confidence interval 0.06 to 0.98) and Labrador retriever (0.30, 95% confidence interval 0.17 to 0.54) were the most protected breeds. Increasing age, bodyweight greater than the breed‐sex mean and being insured also showed increased odds of Cushing's syndrome.

Clinical Significance

As Cushing's syndrome is predominately diagnosed and managed in primary‐care practice, this study provides valuable new information of its epidemiology in this setting. Demographics reported are supportive of previous work and additional novel associations identified, such as the Border terrier, could enhance the index of suspicion for veterinarians.

Machine-learning based prediction of Cushing's syndrome in dogs attending UK primary-care veterinary practice

Cushing’s syndrome is an endocrine disease in dogs that negatively impacts upon the quality-of-life of affected animals. Cushing’s syndrome can be a challenging diagnosis to confirm, therefore new methods to aid diagnosis are warranted. Four machine-learning algorithms were applied to predict a future diagnosis of Cushing's syndrome, using structured clinical data from the VetCompass programme in the UK. Dogs suspected of having Cushing's syndrome were included in the analysis and classified based on their final reported diagnosis within their clinical records. Demographic and clinical features available at the point of first suspicion by the attending veterinarian were included within the models. The machine-learning methods were able to classify the recorded Cushing’s syndrome diagnoses, with good predictive performance. The LASSO penalised regression model indicated the best overall performance when applied to the test set with an AUROC = 0.85 (95% CI 0.80–0.89), sensitivity = 0.71, specificity = 0.82, PPV = 0.75 and NPV = 0.78. The findings of our study indicate that machine-learning methods could predict the future diagnosis of a practicing veterinarian. New approaches using these methods could support clinical decision-making and contribute to improved diagnosis of Cushing’s syndrome in dogs.

Development and internal validation of a prediction tool to aid the diagnosis of Cushing's syndrome in dogs attending primary-care practice

BACKGROUND

Novel methods to aid identification of dogs with spontaneous Cushing's syndrome are warranted to optimize case selection for diagnostics, avoid unnecessary testing, and ultimately aid decision-making for veterinarians.

HYPOTHESIS/OBJECTIVES

To develop and internally validate a prediction tool for dogs receiving a diagnosis of Cushing's syndrome using primary-care electronic health records.

ANIMALS

Three hundred and ninety-eight dogs diagnosed with Cushing's syndrome and 541 noncase dogs, tested for but not diagnosed with Cushing's syndrome, from a cohort of 905 544 dogs attending VetCompass participating practices.

METHODS

A cross-sectional study design was performed. A prediction model was developed using multivariable binary logistic regression taking the demography, presenting clinical signs and some routine laboratory results into consideration. Predictive performance of each model was assessed and internally validated through bootstrap resampling. A novel clinical prediction tool was developed from the final model.

RESULTS

The final model included predictor variables sex, age, breed, polydipsia, vomiting, potbelly/hepatomegaly, alopecia, pruritus, alkaline phosphatase, and urine specific gravity. The model demonstrated good discrimination (area under the receiver operating curve [AUROC] = 0.78 [95% CI = 0.75-0.81]; optimism-adjusted AUROC = 0.76) and calibration (C-slope = 0.86). A tool was developed from the model which calculates the predicted likelihood of a dog having Cushing's syndrome from 0% (score = -13) to 96% (score = 10).

CONCLUSIONS AND CLINICAL IMPORTANCE

A tool to predict a diagnosis of Cushing's syndrome at the point of first suspicion in dogs was developed, with good predictive performance. This tool can be used in practice to support decision-making and increase confidence in diagnosis.

Development and evaluation of a health-related quality-of-life tool for dogs with Cushing's syndrome

Background

Clinical signs and consequences of Cushing's syndrome are likely to impact upon a dog's life. Quantification of this impact on a dog's health‐related quality‐of‐life (HRQoL) could contribute to optimized disease management.

Hypothesis/objectives

To develop a novel HRQoL tool to aid assessment of dogs with Cushing's syndrome and to evaluate factors that impact upon dogs living with this disease.

Animals

Two hundred and ten dogs with Cushing's syndrome and 617 dogs without Cushing's syndrome.

Methods

Cross‐sectional study design. Dog owners answered questions relating to the HRQoL of their dogs which were refined to develop the final tool. The tool was analyzed for reliability, validity, and interpretability, including Cronbach's alpha and principal components analysis. Factors impacting upon the HRQoL of dogs with Cushing's syndrome were assessed using appropriate nonparametric tests.

Results

The tool was refined from 32 questions to 19 and showed good internal consistency (α = .83). Owners rated questions related to “owner impact” as more important and those related to demeanor as less important. There was a positive correlation between the tool score of dogs with Cushing's syndrome and owner's assessment of their dog's quality‐of‐life (r = .41, P < .001). Dogs currently on treatment with trilostane had a statistically better HRQoL (.33, interquartile range [IQR] .23–.44) than those not receiving trilostane (.36, IQR .33–.54, P = .04).

Conclusions and Clinical Importance

The developed tool quantifies the HRQoL of dogs with Cushing's syndrome and could assist clinicians in the clinical assessment of dogs with Cushing's syndrome.

Survival analysis of 219 dogs with hyperadrenocorticism attending primary care practice in England

BACKGROUND

Hyperadrenocorticism is an endocrine disease routinely encountered within primary care practice; however, few studies evaluating survival beyond diagnosis have studied this population.

METHODS

This retrospective cohort study analysed the electronic patient records of 219 cases of hyperadrenocorticism from a sample of dogs attending primary care practices in England. Kaplan-Meier plots examined the cumulative survival and Cox proportional hazard regression modelling identified factors associated with the hazard of all-cause mortality.

RESULTS

In the analysis, 179/219 (81.7 per cent) hyperadrenocorticism cases died during the study period with a median survival time from first diagnosis of 510 days (95% CI 412 to 618 days). Trilostane was used in 94.1 per cent of cases and differentiation between pituitary-dependent and adrenal-dependent disease was made in 20.1 per cent of cases. In the multivariable analysis, dogs weighing greater than or equal to 15 kg (HR 1.51, 95% CI 1.06 to 2.15, P=0.023) and those diagnosed greater than or equal to 13 years of age (HR 3.74, 95% CI 2.29 to 6.09, P<0.001) had increased hazards of all-cause mortality. Dogs that had their initial trilostane dose increased had a favourable prognosis (HR 0.49, 95% CI 0.32 to 0.76, P=0.015).

CONCLUSION

This study shows that survival from diagnosis of hyperadrenocorticism appears fair for many dogs and provides primary care practitioners with relatable benchmark prognostic figures.

Clinical and Clinicopathological Features in Dogs with Uncomplicated Spontaneous Hyperadrenocorticism Diagnosed in Primary Care Practice (2013-2014)

The objective of this study was to report clinical and clinicopathological abnormalities in canine spontaneous hyperadrenocorticism (HAC) and assess the relationship between patient size and those findings. A questionnaire was made available to primary care veterinarians to gather information on cases diagnosed with canine spontaneous HAC. Inclusion criteria were an adrenocorticotropic stimulation test and/or low-dose dexamethasone suppression test consistent with HAC. Exclusion criteria included concurrent systemic diseases, any clinical sign (CS) not typically associated with HAC, a urinary corticoid:creatinine ratio within reference interval, administration of steroids during the 3 mo before diagnosis, treatment with any drug causing CSs of HAC, and ongoing treatment for canine spontaneous HAC. Sixty-two cases were identified. The prevalences of various CSs were similar to those historically reported. No association between the patient weight and CSs was identified. The platelet count was negatively correlated to the weight (P = .005, r² = 0.3). Alanine aminotransferase (P = .016, r² = 0.17) and alkaline phosphatase (P = .05, r² = 0.0014) activities were positively correlated to the CS ratio. In this group of dogs, CSs were not significantly different between dogs ≤20 kg and dogs >20 kg. The prevalences of various clinical findings appeared to be similar to those historically reported. Dogs with more CSs tended to have higher alanine aminotransferase and alkaline phosphatase activities.

Canine hyperadrenocorticism associations with signalment, selected comorbidities and mortality within North American veterinary teaching hospitals

OBJECTIVE

To describe a large population of dogs with a diagnosis of hyperadrenocorticism at the time of death in North American veterinary teaching hospitals, and to identify comorbid conditions associated with hyperadrenocorticism.

MATERIALS AND METHODS

Retrospective cohort study of 1519 dogs with hyperadrenocorticism from a population of 70,574 dogs reported to the Veterinary Medical Database. Signalment, presence or absence of hyperadrenocorticism, aetiology of hyperadrenocorticism (if described), frequency of select comorbidities and causes of death were evaluated in dogs with and without hyperadrenocorticism.

RESULTS

Hyperadrenocorticism was more frequent in females. Neutering was associated with a minor, but significant, increase in the odds of hyperadrenocorticism. Hyperadrenocorticism was the presumed cause of death of 393 (25∙9%) of affected dogs. When aetiology was specified (527 dogs, corresponding to 34∙7% of the cases), pituitary-dependent hyperadrenocorticism [387 (73∙4%) out of 527 dogs] was more common than functional adrenocortical tumour [136 (25∙8%) out of 527 dogs). Hyperadrenocorticism was over-represented in certain expected (miniature poodle, dachshund) and unexpected (Irish setter, bassett hound) breeds compared with the population at large. Of the select comorbidities investigated, dogs with hyperadrenocorticism were at increased risk for concurrent diabetes mellitus, urinary tract infection, urolithiasis, hypertension, gall bladder mucocoele and thromboembolic disease compared with dogs without hyperadrenocorticism.

CLINICAL SIGNIFICANCE

Hyperadrenocorticism is significantly associated with certain comorbid conditions but is not a major cause of mortality in affected dogs. Documented patterns now provide targets for prospective clinical research.

Treating canine Cushing's syndrome: Current options and future prospects

Naturally occurring hypercortisolism, also known as Cushing's syndrome, is a common endocrine disorder in dogs that can be caused by an adenocorticotrophic hormone (ACTH)-producing pituitary adenoma (pituitary-dependent hypercortisolism, PDH; 80-85% of cases), or by an adrenocortical tumor (ACT; 15-20% of cases). To determine the optimal treatment strategy, differentiating between these two main causes is essential. Good treatment options are surgical removal of the causal tumor, i.e. hypophysectomy for PDH and adrenalectomy for an ACT, or radiotherapy in cases with PDH. Because these options are not without risks, not widely available and not suitable for every patient, pharmacotherapy is often used. In cases with PDH, the steroidogenesis inhibitor trilostane is most often used. In cases with an ACT, either trilostane or the adrenocorticolytic drug mitotane can be used. Although mostly effective, both treatments have disadvantages. This review discusses the current treatment options for canine hypercortisolism, and considers their mechanism of action, efficacy, adverse effects, and effect on survival. In addition, developments in both adrenal-targeting and pituitary-targeting drugs that have the potential to become future treatment options are discussed, as a more selective and preferably also tumor-targeted approach could have many advantages for both PDH and ACTs.

Transsphenoidal surgery: accuracy of an image-guided neuronavigation system to approach the pituitary fossa (sella turcica)

OBJECTIVE

To determine the accuracy of locating the pituitary fossa with the Brainsight neuronavigation system by determining the mean target error of the rostral (tuberculum sellae) and caudal (dorsum sellae) margins of the pituitary fossa.

STUDY DESIGN

Experimental cadaveric study.

ANIMALS

Ten canine cadavers.

METHODS

Computed tomography (CT) and MRI were performed on each cadaver with fiducials in place. Images were saved to the neuronavigation computer and used to plan the drilling approach. The cadavers were placed in the surgical head clamp of the Brainsight system and positioned for a transsphenoidal approach. On the basis of the planning, 2 localization points were drilled, 1 each at the rostral and caudal margins of the pituitary fossa, and CT was repeated. Error was assessed from the difference in millimeters between the targets identified during Brainsight planning and the actual location of the 2 points drilled on each cadaver skull as identified by postdrilling CT.

RESULTS

The rostral and caudal margins of the pituitary fossa provided 2 target points per cadaver. The median target error (interquartile range) for all target sites (n = 20) was 3.533 mm (range, 2.013-4.745).

CONCLUSION

This stereotactic system allowed the surgeon to locate the rostral and caudal margins of the pituitary fossa with clinically acceptable accuracy and confidence.

CLINICAL SIGNIFICANCE

Using the Brainsight neuronavigation system for localization during transsphenoidal hypophysectomy may decrease morbidity and surgical time.

Evaluation of individual low-dose dexamethasone suppression test patterns in naturally occurring hyperadrenocorticism in dogs

BACKGROUND

Dogs with hyperadrenocorticism (HAC) may be more mildly affected at the time of diagnosis today, which could influence the prevalence of associated clinical and clinicopathological abnormalities and diagnostic test performance. Different low-dose dexamethasone suppression test (LDDST) result patterns have not been evaluated individually.

OBJECTIVES

To assess the current features of HAC and evaluate if the diagnostic test performance of individual LDDST result patterns differ.

ANIMALS

One hundred and twenty-three dogs undergoing investigation for HAC.

METHODS

Retrospective evaluation of dogs in which a LDDST was performed and HAC confirmed or excluded by alternative means. Cases with basal cortisol concentrations (t0 ) < 1 μg/dL were excluded. Each LDDST result was classified as (a) complete suppression (t3 and t8  < 1 μg/dL), (b) lack of suppression (t3 and t8  > 1 μg/dL and both > 50% t0 ), (c) partial suppression (t3 and t8  > 1 μg/dL but either < 50% t0 ), (d) escape (t8  > 1 μg/dL and t3  < 1 μg/dL) or (e) inverse (t3  > 1 μg/dL and t8  < 1 μg/dL) pattern.

RESULTS

Fifty-nine (48%) dogs were diagnosed with HAC and 64 (52%) with non-adrenal illness. Hyperadrenocorticism cases had similar clinicopathological abnormalities compared to previous reports. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) (95% confidence interval [CI]) of the LDDST for diagnosing HAC were 96.6 (91.9-100)%, 67.2 (55.7-78.7)%, 73.1 (63.2-82.9)%, and 95.6 (89.5-100)%, respectively. Lack of suppression pattern had the highest PPV (93.9 [85.8-100]%) followed by the partial suppression pattern (67.9 [50.6-85.2]%) and escape or inverse pattern (36.8 [15.1-58.5]%).

CONCLUSIONS AND CLINICAL IMPORTANCE

A lack of suppression LDDST pattern has the highest PPV for diagnosing HAC followed by a partial suppression pattern. By contrast, the escape or inverse pattern provided limited support of HAC.

Update on the use of trilostane in dogs

Many articles published in the past few years have contributed to a better understanding of the use of trilostane in dogs. Trilostane is a competitive inhibitor of 3β-hydroxysteroid dehydrogenase, the enzyme essential for synthesis of cortisol and all other steroids. Trilostane is reported to be safe and effective in the treatment of pituitary-dependent hyperadrenocorticism (HAC), adrenal-dependent HAC, and alopecia X. While trilostane controls most of the clinical signs associated with HAC, abnormalities such as hypertension, hypercoagulability, and proteinuria may persist despite therapy. Because the duration of cortisol suppression after a dose of trilostane is often less than 12 hours, many dogs with HAC could benefit from low dose trilostane treatment every 12 hours. Many controversies regarding trilostane still exist. This review provides a comprehensive commentary on trilostane's indications, mode of action, dose, monitoring, efficacy, and adverse effects.

Transsphenoidal Surgery for Pituitary Tumors and Other Sellar Masses

Transsphenoidal surgery is an option for dogs and cats with functional and nonfunctional pituitary masses or other sellar and parasellar masses. An adrenocorticotropic hormone-secreting tumor causing Cushing disease is the most common clinically relevant pituitary tumor in dogs, and the most common pituitary tumor seen in cats is a growth hormone-secreting tumor causing acromegaly. Transsphenoidal surgery can lead to rapid resolution of clinical signs and provide a cure for these patients. Because of the risks associated with this surgery, it should only be attempted by a cohesive pituitary surgery group with a sophisticated medical and surgical team.