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Monday, June 9, 2014

Catch-Up Blog #6: Are Multiple Issues Reason To Euthanize?

Susie brings a very difficult situation:

We have a ‘giant’ dog (Akita and possibly Leonberger mix,) Coco, about 8 years old, weighing in at 103#.  Several years ago, she tore the ligament around her left rear ‘knee’ and we had her operated on.  The vet repaired the ligament and installed a plate to help support her leg to the tune of $3,000+.  Since that surgery, she has been diagnosed with Atypical Addison’s Disease.  She is on a low dose of prednisone for this. Where a higher dose might provide better results, it causes her to pee, frequently, like a race horse, which means we prefer her to stay outside.  We live in Las Vegas, so this isn’t really feasible during the upcoming summer months. It would require the purchase of a $700-$900 swamp cooler to place on the patio to help keep her cool.

She also has a very crusty nose (bridge) and the inside of ear flaps are extremely crusted.  This crusting is now beginning to develop around her eyes.  There doesn’t seem to be blistering, just very rough, crusty tissue. The vet has taken a biopsy culture and nothing fungal has developed.

Last week, her right leg failed, another torn ligament requiring another $3,000+ surgery, and would require her an overnight stay because of possible Addison shock. Because of the Addisons, the vet wants her to be seen by a dermatologist, first, to rule out that the crusting isn’t anything autoimmune related, which could cause further complications…another $300-$500.

This girl is the sweetest dog you would ever hope to have in your life and does not seem to be ‘suffering’ in any way.  She has a good appetite (possibly due to the prednisone) and, while lethargic and down at the moment, is of good disposition. She is not an active dog, again, our fault due to our schedules. We hate the thought of putting her down, but I guess we just need a professional opinion as to when is enough enough.  We have considered just having her fit with a custom leg brace, but that isn’t cheap either.  Your opinion is respectfully appreciated.

I'm not going to address all of the medical issues, as it seems like there are numerous ones.  My advice and comments are going to be more about the timing of euthanasia rather than how to "fix" her.  But I will say that prednisone alone is not adequate treatment for Addison's disease.  That drug is a glucocorticoid, and Addison's results in a deficiency of both glucocorticoids and mieralocorticoids.  While prednisone is part of the treatment, in almost every case it is not the only treatment.

In veterinary medicine we have incredible capabilities to treat disease and injury, just about on par with our human counterparts.  Our limitations are not knowledge, technology, or skills.  In these areas I would put an average vet against an average physician any day of the week and consider them equals at minimum.  In virtually every case our ability to treat is limited by finances.  There are many cases that I end up euthanizing that might have a chance of treatment, or even a guarantee of full recovery, but the owners can't afford to do so.  So in a situation where money isn't an object, I would recommend pursuing as far as you can afford.

But sometimes it's not just a matter of money.  Since our pets can't make choices for themselves, they rely on us to face the hard decisions.  How many things do we put our pets through?  How far do we push before it becomes for our sake and not for theirs?  This is something I face frequently, as clients don't always know what the limit is.

To me it really comes down to one thing.  Do the "good days" outnumber the "bad days"?  With reasonable management does the pet seem "happy", have little difficulty doing normal functions, and has a normal appetite.  It's all about the quality of life.  If a pet with multiple health issues can be kept in the "good" category more often than not, then I think it's reasonable to keep going.  But if any of the health issues makes the bad outweigh the good, it's time to let go.

My prayers are with Susie and her dog.  That's not something easy to go through.

3 comments:

  1. Safe Uses of Cortasol by Dr. Jeffries. Used successfully on my dog. Otherwise right on post. Sorry to hear of this.

    ReplyDelete
  2. Just one quick note -- In dogs with atypical Addison's, supplementing with a steroid such as prednisone actually is the only support they need. It is the same with secondary Addison's -- the difference is that the atypical version is likely to progress into primary Addison's eventually.

    "Typical Addison’s, often called primary Addison’s, is caused by adrenal dysfunction that creates both glucocorticoid and mineralocorticoid deficiencies. The adrenal glands atrophy, usually because of an autoimmune response that may be hereditary. Other possible causes include granulomatous disease, tumors, injury, prescription drug side effects, infection, or inflammation. By the time symptoms appear, an estimated 85 to 90 percent of the adrenal cortex has been destroyed. Dogs with typical Addison’s will have electrolyte imbalances, but this alone is not enough to diagnose the disease, nor can normal electrolytes rule out Addison’s disease.

    In atypical Addison’s, the adrenal cortex continues to produce aldosterone but not cortisol. Patients with atypical Addison’s have normal sodium and potassium levels. Most eventually progress to typical Addison’s disease within a few months or, in some cases, years.

    In secondary Addison’s, the pituitary gland no longer produces ACTH because of immune-mediated damage, inflammation, trauma, or cancer. Similar to atypical Addison’s, only cortisol production is affected, but secondary Addison’s will never progress to the typical form of the disease. Because aldosterone is still produced by the adrenal cortex, secondary Addison’s disease does not cause electrolyte imbalances."

    http://www.whole-dog-journal.com/issues/14_10/features/Diagnosing-Addisons-Disease-in-Dogs_20365-1.html

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  3. As Karissa said, atypical Addison's often requires only prednisone, and monitoring, of course, to ensure the dog does not progress to typical Addison's. (I am a veterinarian.)

    ReplyDelete

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