Addison's Disease: The Great Pretender
Addison’s disease can mimic many other conditions; here’s how to positively identify it.
Article by CJ Puotinen and Mary Straus, published in the Whole Dog Journal, October 2011.
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Zala Bu (pictured at right) lost 30 pounds to Addison’s and her first owners gave up on her. Thanks to the right meds (and a more dedicated owner), she worked as a therapy dog and has an active life.
Something’s wrong with your dog but you’re not sure what. She seems listless, her eyes have lost their spark, and she just seems “off.” You might notice intermittent muscle weakness, tremors, and an inability to jump into the car or onto a sofa. Or your dog frequently ignores her dinner, vomits, or has diarrhea. These vague symptoms, which may improve and then return, could stem from a dozen canine illnesses – or they might point to Addison’s.
Addison’s disease, named for the 19th century physician who defined this adrenal gland dysfunction, is also known as hypoadrenocorticism or adrenal insufficiency. While fatal if left untreated, with appropriate treatment Addison’s can be managed so that affected patients lead normal, active lives. First diagnosed in dogs in the 1950s, it is considered an uncommon canine disorder, but veterinarians who routinely test for Addison’s often find it, suggesting that the illness is not really rare but rather under-diagnosed and under-reported. You don’t find Addison’s unless you look for it. Some veterinarians speculate that Addison’s disease occurs in dogs at a rate as much as 100 times the rate in humans.
Aiyana, a three-year-old Italian Greyhound who lives with Lydia Kunzler in Northern Utah, developed symptoms when she was nine months old, but none of the several veterinarians Kunzler consulted could find the cause.
“Last fall I noticed Aiyana was starting to lose weight,” she says, “and because I had a lot of things going on I attributed her loss of appetite to stress and tried to feed her more. But a week after one of my other dogs passed away she became very sick. She was vomiting, very lethargic, and her digestive system just shut down, sometimes going days without a bowel movement. A few weeks went by, and we had to keep her on intravenous fluids or she'd get really sick again. Finally I decided to change vets. I knew all this vomiting, alternating diarrhea and constipation, and other symptoms weren’t normal.”
Aiyana’s new veterinarian immediately recognized the signs of Addison’s and did an ultrasound test, saw how small the dog’s adrenal glands were, and ordered an adrenal hormone blood test to confirm the diagnosis.
Dogs of any breed, either sex, and any age can develop Addison’s. About 70 percent of Addisonian dogs are female, although in some breeds, including Standard Poodles and Bearded Collies, males and females are equally affected. The median age of dogs diagnosed with Addison’s disease is 4 to 6 years, but it has been reported in puppies and in dogs as old as 12.
Certain breeds may be predisposed to Addison’s, including Portuguese Water Dogs, Bearded Collies, Standard Poodles, Great Danes, Soft Coated Wheaten Terriers, Airedale Terriers, Basset Hounds, Springer Spaniels, West Highland White Terriers, Leonbergers, Labrador Retrievers, Rottweilers, Saint Bernards, Nova Scotia Duck Tolling Retrievers, Airedale Terriers, German Shepherd Dogs, German Shorthaired Pointers, other Poodles, and mixes of these breeds.
Commonly reported symptoms, which can vary dramatically from dog to dog, include loss of appetite, weight loss, depression, listlessness, vomiting, diarrhea, hind-end pain, muscle weakness, tremors, shivering, increased thirst, excessive urination, a painful or sensitive abdomen, muscle or joint pain, and changes in coat, which may become thicker, thinner, longer, or even curly. About 15 to 20 percent of Addisonian dogs will have dark, tarry stools (melena, caused by gastrointestinal hemorrhage) or blood in their vomit. Symptoms often wax and wane, with the dog getting worse, then better, for months or even years.
Veterinarians examining Addison’s patients may notice mental depression, a thin or emaciated body, muscle weakness, dehydration, patches of darkened skin, a slow and weak pulse, low body temperature, low blood pressure, and pale mucous membranes. Blood tests may show any of the following: elevated potassium, low sodium, elevated BUN and creatinine, elevated liver enzymes, low glucose (hypoglycemia is seen in about 30% of dogs with Addison's disease due to decreased levels of glucocorticoids), high calcium, low protein (albumin and globulin), nonregenerative anemia, low cholesterol, and metabolic acidosis. Urine may be dilute (low specific gravity). A sodium/potassium ratio of less than 27 with low sodium levels is strongly indicative of Addison’s, but a normal ratio does not rule it out as many veterinarians assume (one recent study found that only 76 percent of dogs with Addison's had sodium or potassium abnormalities). A sick dog with normal or elevated lymphocytes and eosinophils (lack of a stress leukogram) can point toward Addison’s. In fact, increased absolute lymphocyte counts may be more specific than the sodium:potassium ratio, even if the counts are still within the normal range (see Is there an easy screening test for canine hypoadrenocorticism? for more information).
Addison’s disease, called “The Great Pretender,” is often misdiagnosed because it resembles so many other illnesses. Patients with Addison’s are often erroneously diagnosed as having gastrointestinal diseases such as inflammatory bowel disease (IBD), infections, parasites, cancer of the gastrointestinal tract, or poisoning. Acute renal failure, liver disease, urinary blockage, pancreatitis, insulinoma, hyperparathyroidism, and protein-losing enteropathy are other common misdiagnoses.
The most dramatic Addison’s symptom is the endocrine emergency called Addisonian crisis. This occurs when the dog goes into shock due to circulatory collapse, and it can happen so quickly that a healthy looking dog is suddenly, within a few hours, close to death. In Addisonian crisis, the lack of adrenal hormones depletes sodium levels (hyponatremia) and body fluids (hypovolemia), resulting in potassium retention (hyperkalemia), bradycardia (slow heart rate), hypotension (low blood pressure), associated cardiac arrhythmias (abnormal heart beats), and physical collapse. In other diseases, hypovolemia and shock cause tachycardia (rapid pulse), but in Addison’s, the pulse slows. Low blood sugar levels (hypoglycemia) can cause seizures. Vomiting and diarrhea are common.
For many dog owners, the crisis is their first realization that something is wrong.
An estimated 30 to 35 percent of Addisonian dogs are initially diagnosed during a crisis. Patients treated in time with intravenous fluid therapy and glucocorticoid steroids show such rapid improvement that it seems a miracle cure, though some have to be monitored and treated for several days before their condition stabilizes. And the cure is only temporary, for without appropriate maintenance care, another crisis will follow.
As many as 90 percent of dogs in adrenal crisis will have elevated creatinine and BUN, which can lead to a misdiagnosis of acute renal failure. Dehydration and low blood pressure cause blood filtration to drop, resulting in “prerenal azotemia,” where waste products build up even though the kidney itself is functioning. Gastrointestinal bleeding can also cause increased BUN. The response to treatment is more dramatic for dogs with Addison’s disease than for those with kidney disease. (See Could it be Addison’s? for more information on differentiating between Addison's disease and acute kidney failure.)
The adrenals are two small glands positioned next to the kidneys. The center of each gland is called the medulla and the outer area is called the cortex.
The adrenal medulla secretes the “fight or flight” hormones adrenaline (also called epinephrine) and noradrenaline (also called norepinephrine). These hormones are generally not affected by Addison’s disease, which affects only those secreted by the adrenal cortex: glucocorticoid and mineralocorticoid hormones. Addison’s can cause deficiencies of both types of steroid hormones.
Glucocorticoids (primarily cortisol) affect nearly every tissue in the body. They help maintain blood pressure and cardiovascular function, activate the body’s stress response, regulate metabolism and blood glucose levels, stimulate appetite, modify red and white blood cell production, and promote a general sense of well-being. Glucocorticoid levels are controlled by adrenocorticotropic hormone (ACTH), which is produced by the pituitary gland.
Mineralocorticoids (primarily aldosterone) are responsible for regulating electrolytes (sodium, potassium, and chloride) and water balance, which affects blood pressure. Electrolytes also affect nerve and muscle function, including heart rate and rhythm.
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 cases 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.
Addison’s disease can be brought on by treatment for Cushing’s disease designed to suppress or destroy overactive adrenal glands. The anti-fungal medication ketoconazole is sometimes used to treat Cushing’s because it suppresses adrenal function. The sudden withdrawal of prednisone or other cortisone medications after long-term use can also trigger an Addisonian crisis.
The ACTH (adrenocorticotropic hormone) response (or stimulation) test is considered definitive for Addison’s. Dogs must be off all corticosteroid hormones except dexamethasone for at least 12 to 36 hours (or more, if they’ve been on steroids for a long time) to prevent the drugs from affecting test results. The cortisol level of an initial blood sample is measured; then the dog is injected with a form of the pituitary hormone ACTH that signals the adrenals to produce cortisol. One hour later, the blood cortisol level is measured again. In healthy dogs, cortisol levels rise, indicating a normal adrenal response. If the dog’s initial cortisol level is low and there is little or no response after ACTH stimulation, the diagnosis is Addison's disease. If baseline cortisol is normal, Addison's is unlikely.
Synthetic ACTH (cosyntropin, Cortrosyn) is preferred for consistency; ACTH gels are not recommended for this test because results may not be accurate. An older protocol used one vial (250 mcg) of Cortrosyn for every dog, but 5 mcg/kg is all that is needed to achieve maximal adrenal stimulation when given intravenously. This can translate into a substantial cost saving for small dogs.
If the ACTH response test is positive and electrolytes are normal, then a separate test to measure endogenous ACTH levels can differentiate between primary and secondary Addison’s. Endogenous ACTH levels will be greatly elevated with primary Addison’s but low or undetectable with secondary Addison’s. Dogs with secondary Addison’s will never develop electrolyte abnormalities, making treatment and monitoring much less expensive.
Two situations can result in a misdiagnosis of Addison’s disease. Dogs from breeds originating around the Pacific Rim, including the Akita, Shiba Inu, and Jindo, often have elevated potassium values. This can be confused with Addison’s, particularly when symptoms are similar. Whipworms can create a syndrome nearly identical to Addison’s, including low sodium and elevated potassium. Fecal tests for whipworms are often negative because eggs are shed infrequently. In both cases, ACTH response tests will be normal. Always confirm a diagnosis of Addison’s disease before beginning mineralocorticoid supplementation.
In Addisonian crisis, treatment with intravenous fluids, glucocorticoids such as dexamethasone, and sometimes glucose as well can literally save a dog’s life. Once the patient’s condition has stabilized, treatment moves to the life-long replacement of adrenal hormones, along with careful monitoring of electrolyte levels for dogs with typical Addison’s.
Glucocorticoid hormones such as prednisone, prednisolone, methylprednisolone (Medrol), or hydrocortisone are needed for all Addisonian dogs. For atypical and secondary Addison’s, this is the only drug prescribed. Prednisolone and methylprednisolone have been converted to a bioactive form, a process which otherwise must be done by the liver, so these may be good choices for dogs with elevated liver enzymes. Methylprednisolone and hydrocortisone may be associated with fewer side effects. Hydrocortisone is synthetic cortisol, closest to the natural form.
The starting dose is 0.1 to 0.2 mg prednisone (0.4 to 0.8 mg hydrocortisone) per pound of body weight daily (recent recommendations say 0.1-0.2 mg per kg, which is about half as much). This is a physiologic dose, meant to mimic the amount of cortisol the body would produce itself if it were able. It should not cause the type of side effects associated with prednisone given at therapeutic levels for dogs with problems such as allergies or autoimmune disorders.
Many dogs do well on 0.05 mg prednisone (0.04 mg Medrol, 0.2 mg hydrocortisone) per pound of body weight daily. Even large dogs usually do not require more than 5 mg daily, except during times of stress. The dosage is best divided in half and given every 12 hours in order to keep cortisol levels more even, particularly when using hydrocortisone, which has a much shorter half-life.
Dogs with typical Addison’s also need mineralocorticoid supplementation. Two options are available: fludrocortisone acetate (Florinef) and desoxycorticosterone pivalate (DOCP, brand name Percorten-V).
Florinef is an oral medication that is given once a day in the morning or split into two daily doses. Missing even a single dose can be dangerous. Dogs taking Florinef can be difficult to regulate, and increases in the initial dosage are frequently required, especially during the first year, as any remaining adrenal tissue is destroyed.
Percorten-V is given by subcutaneous injection once every 25 days or so. Experts find that in addition to having fewer side effects, Percorten-V regulates electrolytes more effectively than Florinef. Dogs who have problems when taking Florinef, including excessive thirst, urination, or incontinence, may do better with Percorten-V.
Aiyana, the Italian Greyhound who was finally diagnosed with Addison’s disease, was initially treated with Florinef. “Her electrolytes wouldn’t stabilize, and she didn't respond as expected,” says Kunzler. “My vet switched her to Percorten-V injections, which has made a lot of difference.”
Dogs on Percorten-V require glucocorticoid supplements, such as prednisone, in addition to their monthly injections. Fludrocortisone has some glucocorticoid activity, so about half of the dogs who take this medication do not require regular glucocorticoid supplements, and others may need supplements every two or three days rather than daily.
All dogs with Addison’s need additional glucocorticoids during times of stress, injury, or illness. What constitutes stress will vary from one dog to another. Stress can be physiological, such as a medical procedure, injury, or even a particularly active play session. Stress can also be emotional, such as from a move, the loss of a human or animal companion, thunderstorms, fireworks, a visit to the vet’s office, or anything that disrupts familiar routines.
Stress increases the need for glucocorticoids from two to four times the maintenance level. A dog undergoing surgery may need even more, starting with a high dose and quickly tapering back to normal during the following week. An alternative would be to give an injection of dexamethasone during surgery, followed by oral steroids after. Fluid support should always be provided for Addisonian dogs during surgery.
With appropriate treatment, dogs with Addison’s share an excellent prognosis, with no anticipated disease-related problems affecting their life expectancy. Dogs usually feel better within days of starting treatment, and most symptoms are gone within two to four weeks. The main challenges to life-long treatment are its expense and the effort involved in monitoring electrolyte levels, administering medication, and keeping a close eye on the patient for signs of problems.
It’s important to monitor electrolytes through regular blood tests, especially when treatment begins. With Florinef, blood tests are initially done weekly, then gradually decreased once electrolytes reach normal levels, with continued monitoring two to four times a year after the dosage has stabilized. Dogs receiving Percorten-V are tested before each injection as the dosage is tapered to the lowest level needed, and then tested at least once or twice a year thereafter. Electrolytes should also be tested whenever the dog seems “off.” Dogs with atypical Addison’s require monitoring as well, in case the disease progresses to the typical form.
Dehydration or elevated potassium is indicative that the dosage may be too low. Dehydration causes tacky gums or shoulder skin that doesn’t snap back when pinched. Elevated potassium levels may slow the heart rate – a normal pulse for large dogs ranges from 60 to 100 beats per minute, and for smaller dogs 100 to 160 beats per minute. Severe muscle weakness may be due to low potassium from a dosage that is too high. Symptom changes should be reported as soon as they occur so that medication can be adjusted.
Cortisol levels are monitored not through blood tests but by observation of behavior. The goal is to give the lowest dose of glucocorticoids needed to keep your dog symptom-free, eating well, and happy.
Symptoms such as excessive thirst and urination, ravenous appetite, panting, hair loss, muscle atrophy, elevated liver enzymes, and frequent infections are indications that the glucocorticoid dosage is too high. Lack of appetite or energy, vomiting, diarrhea, and weakness or lethargy indicate that the dosage may be too low. Similar problems may be seen with too much or too little Florinef.
Zala Bu, a five-year-old Great Dane who lives with Jenny Schultz of Denver, North Carolina, was diagnosed with Addison’s at 18 months. “Her previous family did not follow up with their vet by doing continual blood testing to monitor her progress,” says Schultz. “To add to that, their vet was not prescribing a high-enough dose of Florinef, her first medication. As a result, Zala’s health declined. She came to me as a foster dog when she was in her second crisis and her family was fed up with dealing with her illness. She was anorexic, vomited frequently, and had chronic diarrhea. She had lost 30 pounds in six months.”
Schultz changed Zala’s medication to Percorten-V, which she says is “by far our preferred choice as it keeps the dog’s electrolytes consistent throughout the month and helps get a dog back to good health much faster.
“Her life started over the day she joined my pack,” she says. “Zala has been healthy for three years now and is a very active Dane. She takes an extremely low dose of Percorten-V as a shot that I give her at home, along with 1 mg prednisone daily. She gets her electrolytes checked every two to three months at the vet’s office to make sure the medicine is working well and that her electrolytes are balanced. Zala Bu started on 2.8 ml of Percorten-V and I have tapered her down to a .9-ml dose.”
According to Schultz, the most difficult challenge after an Addison’s diagnosis is finding a veterinarian who is wiling to fine-tune the dog’s medication. “When dogs are at their lowest effective dose,” she explains, “they feel their best. There are still many vets who do not know how to treat this disease. As a result, dogs in their care are not as healthy as they could be.”
If problems continue after electrolytes are stabilized and the appropriate glucocorticoid dose is determined, consider other concurrent causes, such as liver disease, spay incontinence, or gastrointestinal disease. Dogs with Addison’s may be particularly prone to other autoimmune diseases such as hypothyroidism.
Jenn, a chocolate Labrador Retriever belonging to Margaret Daunt of Modena, New York, developed typical Addison’s 10 years ago at age four. One year later she was diagnosed with hypothyroidism. At age 13 she survived bloat (“I believe quick action on my part saved her life,” says Daunt), and earlier this year, she was diagnosed with the tick-borne disease ehrlichiosis.
“Jenn has led an active life,” says Daunt. “She competed in agility, trained in obedience, and even dabbled in drug detection work. Now that she has recovered from ehrlichiosis, 14-year-old Jenn is back to her old self!”
It’s important to be alert, as Daunt was, to all symptoms. Don’t assume that every time your dog doesn’t feel well it must be due to Addison’s disease. Addisonian dogs develop illnesses just as other dogs do. If a dog with Addison’s disease is sick from something else, her prednisone dosage may need to be increased temporarily.
To make Addison’s treatment affordable, many caregivers purchase compounded fludrocortisone from a compounding pharmacy. “The compounded version is much more cost-effective for larger dogs than brand-name Florinef,” says Schultz, who participates in online forums for canine Addison’s. Most dogs who receive Percorten-V injections and about half of those who take Florinef require a small daily oral dose of inexpensive prednisone as well.
The online Addison’s groups share information about the disease and suggestions for reducing costs. “Our FaceBook and Yahoo groups help people understand lab test results and talk to their veterinarians about adjusting medications,” says Schultz. “We also help people find lower-cost options for treating their pets. In some cases owners were able to keep their pets when they couldn’t afford the prices their vets were charging. One single mom was paying $300 per month for her Great Dane’s shots until she switched to compounded medications that cost only $30 per month. Two years later, her Dane is still with her and doing well.”
Other money-saving strategies include giving shots at home to avoid having to pay for an office visit for each injection, purchasing medications online at a discount with the help of veterinarians willing to write the necessary prescriptions, or negotiating with veterinarians to keep office visit costs to a minimum. Schultz estimates her monthly expenses at $35 for Percorten-V and another $25 for electrolyte tests. “We test Zala Bu every other month now because we’re adjusting her dose downward,” she says. “She is small for a Dane, weighing in at 102 pounds. I get a large script for prednisone filled at a pharmacy for $4. Zala Bu is the poster child for low-dose effectiveness in big dogs.”
Elizabeth Andrews of Pleasantville, Nova Scotia, Canada, joined the online AddisonDogs Yahoo group in 2006, when Raider, her 75-pound Labrador Retriever, was diagnosed with typical Addison’s. Raider is now six years old and thriving, and Andrews is a list moderator. “The AddisonDogs group was founded in 2002 and currently has 4,594 members,” she says. “We also run a 501(c)(3) non-profit organization called AddisonDogs to educate and support the companion animal community about this condition, and the AddisonDogs website helps re-home dogs with Addison's disease and assists with vet bills and other expenses. I am also the owner of a new FaceBook Group, ‘Addison's Disease in Dogs,’ which has 559 members and is growing daily.”
Andrews explains that in the U.S., brand-name Florinef costs about $1 per 0.1-mg tablet, and the minimum starting dose is 0.1 mg per 10 pounds of body weight with dogs normally needing two to three times the starting dose. In Canada, Florinef costs about 27 cents per tablet when purchased at a drugstore. Florinef can also be purchased in the U.S. from compounding pharmacies, which reduces the total monthly cost regardless of dose to about $30.
Percorten-V purchased online costs $150 to $190 per vial depending on the supplier. “Most AddisonDogs members buy it for $150 from the online pharmacy 1-800-PetMeds,” says Andrews, “because that company price-matches the lowest price online. However, many veterinarians in the U.S. refuse to give their clients a prescription for Percorten-V, arguing that the drug sold online may be counterfeit. A few vets will price-match. Veterinarians pay approximately $130 U.S. for a 4-ml (100-mg) multi-use vial directly from the manufacturer, Novartis, but this life-saving drug often has a high retail markup.”
The typical starting dose of Percorten-V is 1 mg per pound of body weight. Dr. David Bruyette, DVM, DACVIM, of VCA West Los Angeles Animal Hospital and an internal medicine specialist with an emphasis on Addison's disease, prefers to start large dogs (over 60 pounds) at half that amount, because their metabolism is slower. He points out that electrolytes should be measured more frequently when using a lower starting dose; he recommends checking at two, three, and four weeks after the first injection.
Julia Bates, DVM, of Veterinary Specialty & Emergency Care in Madison, Wisconsin, is a veterinary internist whose research during her residency involved the use of low-dose DOCP (Percorten-V) in the management of Addisons disease. She routinely treats dogs diagnosed with Addison's disease with a low dose of Percorten-V. In her experience, the majority of those dogs do very well.
Ideally, the dose is gradually tapered down until the lowest effective dose is found. “We know that lowering the dose works,” says Andrews, “as many in our Yahoo group have been doing so for over five years.”
As mentioned, dogs should be monitored while their drug dosages are being adjusted. “With Percorten-V, blood electrolytes should be tested at day 14 and then at day 25,” says Andrews. “The day-14 electrolytes show how well the Percorten-V is working, and the day-25 electrolytes show whether the dog will be ready at day 28 for more Percorten-V and whether the dose can be reduced. It is very common for a dog not to be ready for more during the first few months. Giving more Percorten-V before the dog is ready just drives potassium levels down. By waiting for potassium levels to rise and then reducing the dose, you ‘balance’ the electrolytes. Once the lowest effective dose has been found, you can test electrolytes every six months or whenever the dog’s behavior or symptoms seem different.”
Adjusting patients to Florinef requires much closer monitoring of electrolyte levels. “It’s important to test weekly until they stabilize,” says Andrews. “Most dogs need their dose increased frequently over the first few weeks and months. Once you find a dose that maintains stable electrolytes for a few weeks, you can move to biweekly testing and then monthly tests. After an effective dose has been found, testing every three months is recommended for life. Of course not everyone does this, and those who don’t generally end up having a dog go into crisis.”
All the experts agree that a properly treated dog can live a normal, happy, healthy life despite Addison’s disease.
“Since stress can be an issue for dogs with Addison’s,” says Jenny Schultz, “caregivers may have to cut back on stressful activities depending on their dogs’ temperament. My Great Dane used to make therapy dog visits to a nursing home. She enjoyed the activity and it didn’t seem to stress her too much. A little extra prednisone as a boost and a good nap was all she needed to continue on with her day. She is by far the most active dog in our pack. Some Addisonian dogs continue to compete in agility and obedience events with no problem after their condition has been stabilized.”
In her book Addison’s Disease in Dogs, Stephanie Kenrose describes the importance of long-term stress management and supplying extra prednisone whenever an Addison’s dog is stressed by injury, trauma, illness, or other events. She also discusses the stress created by annual vaccinations and heartworm prevention medications, noting that titer tests can be used to monitor immunity to common canine illnesses, and decisions about heartworm prevention depend on one’s location as well as the dog’s condition. “You’ll want to discuss these risk factors with your veterinarian,” she says, “so that you can decide whether it’s worth giving these medicines to your Addison’s dog.”
After eight months of treatment, Aiyana, the Italian Greyhound, is doing much better. “She was just spayed three weeks ago,” says Lydia Kunzler, “which caused her Addison’s to flare and her electrolytes to go a bit off again, but she was much easier to stabilize this time. The blood work we took last Wednesday was the best it's been since she was first tested!
"She still struggles with muscle weakness especially in her rear from time to time, and she needs a little extra prednisone some days, but getting her spayed so those hormones weren't complicating things seems to have made a big difference. I've also stopped feeding any dry food, per my vet’s advice, as we were having a hard time maintaining her hydration levels. She mainly eats raw now, or canned food if I'm going to be traveling, and I feed her three to four small meals a day instead of two big meals to make it easier on her GI system.”
Caring for a dog with Addison’s disease can seem overwhelming at first, both financially and emotionally. But properly treated, your Addison’s dog can live just as long and just as well as her disease-free counterparts.
While treatment of Addison’s disease focuses on prescription drugs and electrolyte tests, holistic veterinarians add various support therapies to help their patients.
Nutrition is the cornerstone of every holistic therapy, and while diet cannot cure Addison’s disease, foods made of poor-quality ingredients or diets that lead to nutritional deficiencies are a significant source of stress, and additional stress is just what dogs with Addison’s don’t need. Because wheat, corn, and soy are problem ingredients for some dogs, many holistic veterinarians recommend avoiding them. Some tell their clients to avoid grains altogether. In general, foods made from high-quality animal-source ingredients that are easy to digest work best, but because individual responses vary, caregivers should observe their pets’ responses and avoid ingredients that seem to trigger symptoms.
Veterinarians used to recommend adding salt to the food of dogs with Addison’s, but the benefits of the practice are not supported by research. Dogs with Addison’s do not require additional salt, which may lead to excessive thirst and urination.
The addition of probiotics can improve any dog’s diet, whether home-prepared, raw, cooked, canned, frozen, or packaged. Digestive enzyme powders are a sensible addition for any dog with digestive problems if they seem to help. These products are widely available in pet supply stores and online. Follow label directions.
Prior to the development of synthetic adrenal hormones, Addison’s disease was treated with glandular extracts. Adrenal cortical extracts given orally or injected are still available, though because synthetic versions have so thoroughly replaced them, few veterinarians are familiar with their use. Those who are often prescribe Standard Process Canine Adrenal Support, a powdered supplement that contains animal tissue extracts and other ingredients that support the adrenals. “The goal of Canine Adrenal Support,” explains the manufacturer, “is to help maintain the adrenal glands’ response to metabolic demand, normalize adrenal function, support the body’s ability to handle stress, and promote the adrenal glands’ ability to rebuild and regenerate.” Adrenal glandulars may reduce the amount of medication needed or just help the dog feel better, but their use requires close supervision from a knowledgeable veterinarian.
Some medicinal herbs are known for their effect on the adrenals. Six years ago, the New Zealand Veterinary Journal published a case report by R.H. Jerrett, et al, that examined the effect of whole, natural liquorice (Glycyrrhiza glabra, or what we call licorice) on a dog with Addison’s. The subject, a four-year-old neutered male, had persistently high potassium levels despite receiving a moderate dose of fludrocortisone. “Financial considerations and the potential for adverse effects made increasing the dose of fludrocortisone undesirable,” wrote the researchers, “so liquorice was added to the dog’s diet in hopes that the hyperkalemia would be corrected.” The dog’s potassium levels returned to normal, where they remained for the duration of the 14-month study. “Given these very preliminary findings,” the authors concluded, “we believe it is possible that licorice may, in future, prove to be a useful adjunct in the management of canine hypoadrenocorticism.” It may also prolong the effect of corticosteroids.
Licorice is an adaptogenic herb, a category that describes medicinal plants that help the body deal with stress. Relaxing or sedative herbs help Addison’s patients, too. Oatstraw (Avena sativa) and German chamomile (Matricaria chamomilla) brewed as teas separately or together can be added to food or even applied to the skin and coat to help dogs feel relaxed. Other herbs may be beneficial for gastrointestinal upset and liver support.
Aromatherapy’s essential oils are more concentrated than herbal teas, so they should be diluted with vegetable oils before being applied to the skin, coat, or paw pads. For details see “Smell This, You’ll Feel Better,” WDJ December 2004.
In her book Holistic Aromatherapy for Animals, Kristen Leigh Bell describes her Calm Canine Essential Oil Blend, made with ½ fluid ounce (1 tablespoon) hazelnut, sweet almond, or other vegetable oil, 3 drops valerian (Valeriana officinalis), 2 drops vetiver (Vetivera zizanoides), 4 drops petitgrain (Citrus auranthium leaf), 3 drops sweet marjoram (Origanum morjorana), and 2 drops sweet orange (Citrus sinensis) essential oils. Combine and store in a dark glass bottle.
“This is my standard calming blend,” says Bell, “which has had a very impressive track record for dogs in numerous situations. The calming effect ranges from ‘taking the edge off’ to soothing a dog to the point where it gets very mellow and takes a nap.”
For best results use therapeutic-quality essential oils. Several pet aromatherapy companies make their own calming sprays and oils.
Melatonin, a hormone produced by the pineal gland, is sold as an over-the-counter supplement to help people with insomnia sleep through the night. Veterinarians have found that when given to dogs, melatonin helps manage separation anxiety and fearful reactions to thunder, fireworks, and other noises. In other words, it helps reduce stress levels.
Melatonin is recommended (one 3-mg tablet or capsule for a medium-sized dog) 20 to 30 minutes before stressful events. Although some experts warn that melatonin may interfere with corticosteroids and other medications, others consider the benefits of occasional use to outweigh the risks. Consult your veterinarian as to whether melatonin is appropriate for your dog.
Calming pheromones provide stress relief, too. The product Comfort Zone contains "dog appeasing pheromone" (D.A.P.), which may significantly reduces destructive behavior, fears, and phobias, and help some dogs deal with stressful environments. Comfort Zone is sold in pet supply stores as a spray or with a plug-in electric diffuser.
- 1-800-petmeds.com, (800) 738-6337. Discount pet pharmacy, will match prices.
- Pet Health Pharmacy, (800) 742-0516. Compounding pharmacy.
- Tiffany Natural Pharmacy, (908) 233-2200. Compounding pharmacy.
- Canine Adrenal Support from Standard Process, (800) 558-8740.
- Nutri-West offers adrenal glandular supplements designed for people, (800) 443-3333.
Comfort Zone canine pheromones
Addison’s Disease Study at the University of California, Davis
Blood samples are requested for the following breeds: Bearded Collie, Great Dane, Leonberger, Portuguese Water Dog, Standard Poodle, & West Highland White Terrier.
David Bruyette, DVM, DACVIM, VCA West Los Angeles Animal Hospital, 310-473-2951
Julia Bates, DVM, Veterinary Specialty & Emergency Care, Madison, WI, 608-845-0002
Also see The Fascinating Story of Percorten-V for interesting information about this drug and additional links on the right side of the page.
Addison’s Disease in Dogs
by Stephanie Kenrose. Published by the author, 2009, paperback, 78 pages, $12
Addison’s Disease: Uncommon or Underdiagnosed?
A roundtable discussion with Ellen Behrend, VMD; Catharine Scott-Moncrieff, MA, VetMD; Deborah Greco, DVM; and Peter Kintzer, DVM. Novartis Animal Health U.S., 2003
Liquorice and canine Addison's disease
by RH Jarrett, EJ Norman, and RA Squires. New Zealand Veterinary Journal 2005 Jun;53(3):214
Blog posts by Dr. Mark E. Peterson, veterinary endocrinologist:
- How Is Canine Addison’s Disease Best Diagnosed?
- Interpreting the ACTH Stimulation Test in Dogs with Suspected Addison's Disease
- Confirming the Diagnosis of Addison's Disease in Dogs on Corticosteroids
- Treating Dogs with Hypoadrenocorticism (Addison's Disease)
- What's the Ideal Prednisone Dose for Dogs with Addison's Disease?
- How to Adjust the Glucocorticoid Dose in Dogs Treated for Addison's Disease
- Performing an ACTH Stimulation Test in Dogs Treated with Fludrocortisone (Florinef)
- More posts on Addison's disease
You can contact me if you have any comments, but I regret to say that I can no longer respond to questions about individual dogs. See my Contact page for more information. My name is Mary Straus and you can email me at either or