Sunday, February 20, 2011

Q & A: What's the Ideal Prednisone Dose for Dogs with Addison's Disease?

I'm writing to inquire if there is a consensus among the endocrine experts on the dose and frequency of administration of oral prednisone for an Addisonian dog on monthly Percorten injections.

i usually use about 0.1mg/kg SID, but some of my colleagues use 0.2mg/kg SID, whereas others using every other day (EOD) dosing at 0.1 - 0.2mg/kg each dose EOD).

i know each dog is different, and they may require more or less depending on "stressful" situations, but wanted to see if SID or EOD is the preferred frequency. I'd also like to know what dosage you recommend.

My Response:

For dogs with spontaneous hypoadrenocorticism (Addison's disease), it makes the most sense to me to give the glucocorticoid supplementation on a daily basis.

There is no reason to give alternative day steroids to avoid adrenal suppression in these dogs, because the adrenals are already permanently atrophied or destroyed in dogs with Addison's disease. If you give alternate day prednisone, they would have no glucocorticoid reserve on the off day.

I dose prednisone or prednisolone at 0.1-0.2 mg/kg/day. If the dog develops polyuria and polydipsia (PU/PD) or any other signs of iatrogenic Cushing's syndrome, I would lower the dose as needed.  I rarely, if ever, give a higher dose than 5-mg per day to ANY dog. The 5-mg dose is the average human maintenance dose, and we see very few dogs that weigh over 70 kg.


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Dr. Mark E. Peterson said...

The thirst will increase in a day or two, and lethargy might ocur (rarely), but other signs of Cushing's take much longer.

Every dog is different but almost all dogs with become Cushingoid on 0.4 mg/kg/day when given long term (and some will on 0.2 mg/kg).

Morgan said...

Hi Dr Peterson, following my previous question we were really worried today as he is still flat and was shuddering a little. Took him to vet for electrolytes test and they were worried about his pale gums so did full blood test. Electrolytes were fine but blood test showed severe anaemia, his HCT only just at 10%. They don't know why but their best guess is prednisolone may have affected bone marrow production of blood cells. WBC also slightly high which they think may be unrelated but due to pred lowering not immune system and him having small infection (suggested antibiotics).

We are going to go back to 2.5mg pred tomorrow and then 1mg the following day, alternating like this for the week and then hopefully stay at 1mg the following week. Even though they think the pred does is the problem, they are worried about dropping too quickly as he is currently so unwell.

Does this sound right to you? We are so worried, they want to do daily blood tests and said he may need blood transfusion if it doesn't pick up.

Dr. Mark E. Peterson said...

The anemia is not related to prednisone. This is life-threatening and someone needs to figure out what's causing it. If you vet doesn't know, get a referral to a internist who can figure out what's wrong!

Betsy A said...

Hi Dr. Peterson,
My 60 lb labradoodle was diagnosed with atypical Addison's last week. He was started on 15 mg of prednisone daily and I was told he'd stay on that dose for 6-8 weeks then we'd move toward a maintenance dose. I questioned my vet about the high dosage for such a long period but was told he had talked with and internal medicine vet at our local hospital and given the fact that my dog had very low protein, glucose, and cholesterol, that is what he recommended. He's been on the prednisone for 3 full days now and seems to be doing great, able to run up stair again and eating well. Do you thing 15mg for an initial 6-8 weeks sound like a lot? I was going to start reducing his doseage. Any insight is greatly appreciated!

Dr. Mark E. Peterson said...

It sounds like your vets aren't really sure what the problem is. That dose of pred is 3 times what you or I would need for Addison's replacement and I'm certainly not 60 pounds! If they are using it to treat another immune-mediated condition, that's another story.

If this were my dog, I'd taper down to 5 mg in a week - the energy level may not be hyper, but that is what excess prednisone does, at least initially.

Sherri's Strange said...

Dr Peterson, I contacted you almost a year ago and you were very helpful. I have two Siberian huskies...a brother and sister. Both were diagnosed with Atypical Addisons disease right around their second birthday. The male was diagnosed first when he became imaciated and refused to eat and was having tremors. He was a bag of bones at 52 pounds. He has gained his weight back and then some, weighing in at 98 pounds. He was getting 3.25 mg of prednisone once a day. We cut him back to 2.5 mg and he seems to be doing great. He is a very laid back and calm dog. I continue to reduce his food but he acts like he's starving. His sister is not doing as well. She weighs 77 pounds and is also starving. She was also getting 3.25 mg of prednisone once a day. We reduced that to 2.5 mg and she started showing signs of not wanting to eat (being nauseated at the smell of food) and was having loose stools, so we bumped her back to 3.25 mg. She is a very active high energy dog. About 4 weeks ago, we noticed that she was beginning to have urinary problems. She was drinking lots of water but would have sudden urgent needs to urinate, sometimes every hour. We ran blood on her on Monday and everything came back normal. She did have some bacteria in her urine and it was dilute. Although her white blood count was normal, we started her on an antibiotic to treat a possible uti. She shows no change and is starting to have accidents in the house. Is it possible she is sensitive to the prednisone and we should try a different medication or do you think something else is going on? Thank you very much for your time

Dr. Mark E. Peterson said...

I'd try a different form of glucocorticoid to see if that helps.

Unknown said...

Hello! I have a 50 lb 6 year old female golden doodle who was diagnosed with Addison's disease 3 weeks ago. She presented with lethargy, vomiting and decreased appetite. During the crisis she had hyperkalemia and hyponatremia. An ACTH stimulation test confirmed the diagnosis of Addisons. She was treated as an inpatient with IV fluids and prednisone for 24 hours after her diagnosis. It took 3 additional days to receive the shipment of Percorten. Her electrolytes on the day of injection were back to normal, but 2ml (50mg) of Percorten were given anyway. She has since improved and is taking 5mg of prednisone daily. Her electrolytes were rechecked at 2 weeks and were again normal. She is now drinking water/eating like crazy and having night time incontinence. She is scheduled to have her electrolytes checked again at 25 days.

My questions are
1. Should I be concerned about a false positive ACTH stim test since electrolytes are now normal?

2. Is it too soon to decrease the dose of Prednisone to 2.5mg per day? Is this what you would do?

3. Since her electrolytes are normal now what would be your suggestion for proceeding with Percorten injections?

I really appreciate your insight! Your blog has been so helpful!

Dr. Mark E. Peterson said...

Certainly sounds like your dog has classic Addison's disease. The IV fluid therapy normalized the serum electrolytes but if you stop the percorten for a month or two, the crisis situation will definitely recur.

Yes, I'l lower the pred dose now. I'm not sure why vets always "load" up the glucocorticoids - not a reason to as far as I can tell.

Anonymous said...

Hi Dr Peterson
I have spoken to you about Scout before she is a 14 year old 60 pound shepherd/ collie mix. She has been on fludrocortisone for about a year and a half. She also had her spleen removed last year after it burst. She gets 6 pills of fludrocortisone a day and does well with her addisons. She is now having serious spinal arthritis that has been coming on and has recently gotten much worse. Our local vet is prescribing prednisone for the arthritis. 10 mg a day. Up until now she has been taking rymadyl for her arthritis. Of course he said to stop the rymadyl and start the prednisone. And maybe cut down the fludrocortisone to 4 or 5 pills. What are your thoughts on starting the prednisone and stopping the rymadyl?

Dr. Mark E. Peterson said...

I don't treat arthritis, but I wouldn't treat my dog with high-dose pred until the arthritis had an immune-mediated cause. I guess if nothing else works, the pred will help but with other side effects. I'd get another opinion from someone who deals with older dog with osteoarthritis.

Anonymous said...

What would be a recommended amount of prednisone you would recommend for Scouts Addison to go along with her fludrocortisone. She is 60 lbs. and she now takes 6- .1 mg of fludrocortisone?

Dr. Mark E. Peterson said...

Most dogs on that much florinef do not need any pred (florinef has quite a bit of glucocorticoid activity). If pred is needed, I would give between 2.5-5.0 mg per day.

Unknown said...

any harm with taking rymadyl with florinef ?

Dr. Mark E. Peterson said...

I don't know for certain. Many sources say not give both together but I know of no scientific studies.

Unknown said...

Dr. Peterson,

You are so kind to help everyone with their questions, hoping to get your thoughts.

Elle is a 4 year old cocker spaniel weighing 30lbs, diagnosed with Addison's a year ago. She is balanced now on 1.08 of DOCP and daily prednisone of 1/2 a 2.5mg tablet. She is very very thirsty and extremely hungry. She urinates every two hours excessively and also has accidents when she naps. I noticed other comments on this in the thread.

Should I decrease her pred to stop these symptoms? Appreciate your help!



Dr. Mark E. Peterson said...

I'd try cutting the prednisone in half for a few days to a quarter tab per day to see if that helps.

dachigo said...

Hi Dr Peterson,
I have a year and four month old lab that was started on prednisone 10 mg bid for ear itching due to bad bact/fungal infection. She's also given antifungal/antibacterial Rx too. But on day 2 onwards she's been so restless been drinking a lot and urinating a lot. Crazy hungry too.
I stared her 1st dose last Wednesday. The course was 10 mg bid X 4 days, 5 mg bid 4 days, 5 mg od X 4 day then off.
I just think she should not have been on it to begin with but I didn't expect she would feel this miserable or have such adverse effect in such short time as she was never on one before.
I gave her the instructed dose on weds thrus and Friday but decided to taper on Saturday from 10 mg bid to 5 mg bid and plan to reduce to 2.5 mg bid tomorrow and 2.5 mg od tues and off weds.
Will that be ok or should I take longer time to taper the dose.
I'm sorry I know my qs is not Addison related but I hope you could Help as glucocorticoid is endocrine related.
Thanks a lot

Dr. Mark E. Peterson said...

Your vet knew this could happen. Talk to them about what to do.

Jess McTaggart said...

Hi Dr Peterson,

Our nine-year-old border collie has Addisons, and we've had him stable for the most part for a number of years. But today we've had a downer and he's been at the vet's with his levels out of whack. I've no reason to believe we won't get him stable again. But in the long run, looking towards the inevitable, do most owners of Addison's dogs see their dogs die of old-age associated conditions? Or do issues with Addison's usually end up playing a part in triggering the palliative phase? We have always been prepared that our BC may not live as long as a non-Addison's dog. But there doesn't seem to be much info around as to how things tend to pan out at the end of life. Of course every case will be unique, but I wonder if there are any patterns you have observed.

Appreciate your valuable comments thread, and apologies if there's a relevant posting above that I've missed.


Dr. Mark E. Peterson said...

Most dogs with Addison's, when treated, live a relatively normal life and die of unrelated, old age issues. If adequately controlled, these dogs do not die of their disease.

carol said...

Hi Dr Peterson,
My little poodle (10lb) was diagnosed with Addisons 1 yr ago at age 7 (several years of misleading diagnoses preceded the'crash' in Aug 2015). After gradually tapering her Prednisolone, she has been maintained on Percorten-V every 26 days and Prednisolone 0.4mg daily. All was well until 2 weeks ago when she (and companion dog who does not have Addisons) developed colitis (treated with Cerenia and Metronidazole).
The colitis cleared up but now she is vomiting bile at about 6.30 AM. if I give her regular doese of Pred she seems fine until the next morning when she vomits bile again. Complicating the picture is that she seems to have persistent PD/PU (a change seen in the last 4 months). Her appetite is a little excessive so the vet agreed to lower the dose and we went down to 0.3ml Prednisone a day but that is when she developed colitis.
My questions are 1).can I split the dose of Prednisone to BID to see if that prevents the vomiting in the morning by supplying a continuous lower level dose? 2) The PD/PU and hefty appetite makes it seem like we should lower the dose of Prednisolone but the vomiting and recent colitis makes it seem like she needs more Prednisolone...which is more accurate an assessment? The vet says she would not divide a dose of Prednisolone. Thanks so much for an answer....Carol L.

Dr. Mark E. Peterson said...

BID administration is fine. The pred dose needed for Addison's would not change after all this time so the signs are NOT related to Addison's or pred deficiency. Talk to your vet.

Unknown said...

Hi dr Peterson-
I noticed this is a fairly old blog post so I hope you still check this.

My 76# Weimaraner was just diagnosed with Addison's five days ago. He was exhibiting some of the typical symptoms-i.e. Shaking, depressing, lethargy, and anorexia. No episodes of vomiting or diarrhea. His potassium sodium ratio was 21 with a slightly elevated BUN at 34. ALT was 41 AST 31. His AMYL was 1199, but we recently treated a yeast and bacterial infection for a long period of time. After receiving IV fluids, 20 mg of prednisone and completing the acth Challenge test he came home that evening and seem to be much improved.

After receiving our positive diagnosis we returned to the vet the following day for 2.75
mL of percorten and we were told to do 7mg of prednisone QD. I knew from reading your blog post that that was a really high dose and my veterinarian even admitted he's only seen a couple of cases of Addison's in his long career and has never actually diagnosed one until now. I decided that a 5mg dose divided into 2.5mg bid was a better option. However I'm noticing my dog is having PU/PD and seems to be painting a lot more frequently doing simple activities like running up the stairs. He was a very active dog up until a couple of weeks ago. I've also noticed he is struggling to get all of his urine out. The only other time he had trouble urinating was when he was taking Temaril P for allergies at 3 tabs bid then on a tapering dose of 3tabs QD. His urination problems resolved quickly after stopping this medication.

So, my question to you is, given the SX I am sharing does it sounds as though a lower dose of prednisone would be better? And how do you know if your dog is one that does not require any prednisone supplementation unless in a stressed environment?

I really appreciate you taking the time to answer all of these questions. I've learned so much in a very short period of time with your help.

(Not the same Morgan as above)

Dr. Mark E. Peterson said...

I'd try lowering the dose to 2.5 mg once daily and see how he does. If the appetite decreases, the go back up on the dose.

Unknown said...

Thank you for your reply. One last question, my dog (76#) appears to be breathing at much more rapid pace. Could that also be a sign of too much prednisone. He has never had this SX before stating prednisone. He is not in pain or othwr wise stressed. Other than the rapid breathing, and the symptoms I previously listed he is doing well. We did cut him down to 2.5mg today.

Thank you again, Morgan

Dr. Mark E. Peterson said...

Yes, rapid breathing could be due to too much prednisone.

Aridgebackowner said...

Dear Dr. Peterson,
Thank you for this invaluable resource and your time. from what we've found, Addison's disease is not quite well understood and we've had a bit of agonizing course coming to this diagnosis. We have a 16 mos old intact Rhodesian Ridgeback who presented at 9 mos of age with sudden loss of appetite, nausea, which quickly progressed to diarrhea, and ileus confirmed by Barium swallow. Ex Lap was even performed to r/o obstruction and, of course, there was no FB, final diagnosis was ileus. Inflamed lymphnode was noted. Intestinal biopsy to r/o IBD was NOT done. Fast forward several month, GI issues continued, periods of nausea, lethargy and anorexia with weight loss followed and finally another vet proposed Juvenile Addison's diagnosis. Basal cortisol was 1.4 a month later ACTH stim test was done: PRE level 2.7; POST level 4.1. Electrolytes and CBC were completely normal. Atypical Juvenile Addison's diagnosis was made. He was started on 10 mg of Prednisone in end of Nov 2016. He also received Percorten (don't know dose) x 2. Last Percorten on Jan 9. His anorexic weight was 83, he is back to 90. Pre-illness weight was 95. good appetite.
But his GI symptoms with frequent loose stools, not frank quite diarhhea continued. He is on Vetriscience BD probiotics, Standard Process Enteric and Adrenal Support. He eats high quality dehydrated foods from Honest Kitchen.

IN the last week he has developed blood tinged intermittent diarrhea. Saw the vet again today and he started Flagyl and advised Clavamox. But we are very concerned!
Having read your blog and researched Addisosns, we are terrified. He has now been on 10 mg of Prednisone for almost 3 months! He had 2 unneeded Percorten shots (after which he had tremendous PU/PD, which subside by week 3 post injection). we have initiated the Pre taper with the vet at our request and last 2 days have given him 7.5 mg (5 in am and 2.5 in pm).
We don't know if we have cause serious problems by long term high dose pred by now, or if his likely colitis is related to the medicatios, or is this IBD in addition to addisons or if this is a misdiagnosis somehow and we are doing everything wrong?! We would be so grateful for any insights . Thank you again for your time.

Dr. Mark E. Peterson said...

The ACTH stimulation tests rules out Addison's disease, which explains the lack of response. I'd taper off the prednisone and get a referral to see a GI specialist. Obviously, the Percorten should be stopped now. Sorry, but you need a new endocrine vet!

Aridgebackowner said...

Thank you fort such a prompt reply! I am sorry to bother you with more questions. We were explained by our vet that in a 1 year old dog the cortisol level after ACTH stimulation would be expected to be notably higher. His cortisol sample 1 was 2.7 micrograms/dL and Cortisol 2 was 4.1 micrograms/dL. because the response was lower than expected value of say 15, he diagnosed atypical juvenile addisons. Could you please help us understand - are these values not in line with hypoadrenocortisism? Could this be iatrogenic form? in one of the bouts of lethargy he was given a steroid shot - don't know the drug or dose. I am not a vet, I am an MD, and I am not an endocrinologist :( all i can say is this is an extremely confusing clinic picture to me :( I just know enough to be thoroughly confused. I would be grateful for any help!

Dr. Mark E. Peterson said...

Dogs with Addison's (at least those with clinical signs) have low cortisol levels (certainly a post-ACTH cortisol level less than 2-2.5 ug/dL). Any past steroid use could have blunted the ACTH response, but that is not an indication for high-dose pred treatment (and certainly not Percorten).

Dogs with Addison's don't need more than a dose of 0.1-0.2 mg/kg/day.

You need to figure out what the underlying problem is, not cover up the signs with so much steroids. I would recommend getting another opinion from a specialist that can do a further workup.

oneros777 said...

Greetings Dr Peterson. We are having great difficulty in our country getting hold of prednisolone or prednisone tablets for that matter. My dog has been on prednisolone 3mg for 2 years now and very stable.The only alternative available to our vet for now is the prednisolone sodium phosphate in liquid form.
Would this be OK to use and just swap over? And would we still give him the equivalent dose of 3mg but in ml conversion?
Your input would be greatly appreciated
Kind regards

Dr. Mark E. Peterson said...

That should be fine. No difference between tablets and liquid.

Unknown said...

Our dog, a female Lab about 69 pounds has been doing pretty good on Percorten V, but the Predisone seems to charge up her eating/ drinking substantially. By switching her to Florinef could she be more likely taken off the Prednisone?

Dr. Mark E. Peterson said...

Florinef frequently causes PUPD so that's not the answer. Why not lower the dose of prednisone?

Unknown said...

Hi Dr. Peterson, I have a 3-year-old Great Dane who was diagnosed with Addison's about a year ago. He weighs about 150 pounds. He currently gets 4 mls of Percorten every 6-7 weeks & gets 5 mg of Prednisone every morning. We have a very active household with 2 young children & he used to love it! He was always very playful & present, but now he hides in a closet & always seems stressed/nervous. I thought the Prednisone was supposed to help with stress? Am I giving too much or not enough? He does not exhibit any signs of too much Prednisone, (no panting, drinking/urinating frequently.) I have spoken to my vet about my concerns, but he does not have a lot of experience with Addison's & does everything by the book. What are your thoughts? Thank you for your time.

Dr. Mark E. Peterson said...

I've never heard of this before in a dog with Addison's. Is everything ok on routine blood work and urinalysis (CBC, chemistry panel, etc). The doses you are giving should be adequate. You may want to get a consult with a behaviorist.. again, may not be due to Addison's at all.

Unknown said...

Thank you for your reply. Yes, he had blood work done this past Wednesday prior to his Percorten injection & everything was within normal limits. (Sodium was on the low end of normal) Do you prefer giving a lower dose of Percorten & keeping within a 28 day cycle vs. giving a larger dose and stretching it out 7 weeks between injections? I am not sure if there is a difference & maybe his levels are up & down within that time period? Also, we have started decreasing his Prednisone from 5 mg to 3.75 mg & I can already see an improvement in his behavior, but it is hard to say if it is from the reduced Prednisone or if the Percorten he just received is making him feel better. I was just wondering if his doses were too high possibly causing his nervous behavior, but I can certainly contact a behaviorist so that we can figure out how to help him lead a happy, normal life. :)

Dr. Mark E. Peterson said...

I'd recommend that you keep adjusting the prednisone dose to see it that helps. I'd give the percorten once monthly. That will help avoid huge fluctuations in the blood levels. If none of this helps, then go to a behaviorist and get their thoughts.

Unknown said...

Summer dosing in out 45 lb goldendoodle with atypical: he has done well on 1.25 mg pred QD in winter/Spring but no appetite and more lethargic since it's been hot outside. Upped dose to 2.5 QD and doing better now. We also have found that for days with lots of activities (long hikes in Adirondacks or Vermont) we add 1.25 mg In the evening the night before with good result next day. Our local vet is - well - not up to speed on this topic. She was dosing him much higher (10 mg QD) so I wrote Rx myself (I'm a family doctor) and we're on our own for this. Not on mineralocorticioids and vet still wants to check lytes regularly since "it's when and not whether" he will need mc. Seems like the literature on this is scant, but I question her assumption based on my lit review. Agree?

Unknown said...

Hi doctor,
I have a question because I am very confused about if to raise or to lower the cortisone that I give to my dog with Addison...she weights 49 pounds and takes 1 to 1.25mg a day
The thing is that she pants a lot and at times she becomes so scared for no reason at all, drooling and with a high anxiety, pacing restless in and out...i know that when dog pants you have to reduce the dosage but in her case I do not know if this panting is for anxiety or for high dosage of cortisol...
What should I do ? Raise or lessen the dosage? thank you very much, I am really soooo confused.....

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