Monday, July 8, 2013

Managing Urinary Incontinence in Dogs Treated for Addison's Disease


I am the owner of Abbie, a 55 pound (25 kg) female spayed dog with Addison’s disease. She was diagnosed in January of this year; Abbie has been treated with daily prednisone (1.5 mg/day), as well as an intramuscular injection of Desoxycorticosterone pivalate (DOCP; Percorten-V, Novartis) given every 3 weeks (1.8 mg/kg).

All of Abbie's clinical signs have resolved but our problem is that she now has an ongoing issue with urinary incontinence. I just do not know whether this is due to too much or not enough prednisone or DOCP. We have tried increasing the prednisone dose for a day but it doesn't appear to help. Her routine serum chemistry panel done this week was normal with a sodium:potassium ratio of 35 (serum sodium, 149 mEq/L; serum potassium, 4.2 mEq/L).

This has been a rough ride for Abbie and us. There is not a lot of literature I can find. I would appreciate ANY helpful suggestions you may have.

My Response:

You don't mention if Abbie is drinking and urinating more or if she is only showing urinary incontinence.  Many dogs treated for Addison's disease will develop polyuria and polydipsia (increased thirst and urination) secondary to the drug they receive (1-3). Some of those dogs will develop an overflow incontinence (i.e., the bladder overfills and the dogs will leak urine, especially overnight when they haven't been walked for a few hours).

Why do dogs treated for Addison's disease develop a increased thirst and urination?
In dogs, treatment with any form of glucocorticoid (e.g., prednisone, prednisolone, methyprednisonlone, cortisone, dexamethasone) can lead to a form of nephrogenic diabetes insipidus (3). In simple terms, this means that the kidneys loose the ability to concentrate the urine, and this can result in large volumes of urine being produced.

To avoid this complication, it's very important not to give too much of any of these glucocorticoids — for prednisone or prednisolone, the maintenance dosage to replace the missing glucocorticoid hormones is about 0.1 mg/kg/day (or about 2.5 mg/day in Abbie) (1).  So, for Abbie, her dosage of 1.5 mg per day is not at all high, in fact, you might think that raising it could help — unfortunately, it could make her feel better if she is deficient, but giving more glucocorticoid will never help polyuria or urinary incontinence.

Treatment or control of polyuria, polydipsia or incontinence in dogs treated for Addison's disease
Unfortunately, some dogs (like Abbie) are simply overly sensitive to the "correct" dosages of glucocorticoid which are being given. Management of these dogs can be complicated, but may include one or more of the following steps (3):

1. Stopping all salt supplementation (if the dog is receiving any NaCl supplementation).

2.  Reducing the glucocorticoid dosage or stopping administration completely, if possible. Many dogs will do fine getting prednisone every 2 or 3 days. In some dogs, glucocorticoids can be discontinued without any ill effects and mineralocorticoid replacement alone will adequately control signs of hypoadrenocorticism.

3.  If glucocorticoid is required to prevent signs of hypoadrenocorticism, the glucocorticoid can be switched from prednisone or prednisolone to either cortisone acetate or methyprednisonolone (Medrol).

Cortisone acetate is a synthetic steroid that has equipotent glucocorticoid and mineralocorticoid activity (1,4). Therefore, it will provide more mineralocorticoid activity than other synthetic glucocorticoids, such as prednisone or prednisolone. In addition, its shorter half-life and lower overall activity means it is less likely to create polyuria or polydipsia. Generally, a daily dose of approximately 1.0 mg/kg provides adequate glucocorticoid coverage (1).

Methyprednisonolone (Medrol), the 6-methyl derivative of prednisolone, is also associated with less polyuria than that seen with prednisone or prednisolone (3). The daily maintenance dosage for this glucocorticoid is similar to prednisolone (0.2 mg/kg).

4. If all of the above fails, one can reduce the monthly dosage of DOCP and evaluate the effect.

5. Finally, if on Florinef instead of DOCP, then a switch to Percorten-V may solve the problem (obviously, this is not the case for Abbie).

Urinary incontinence without any increase in thirst
If Abbie's thirst is completely normal, however, it certainly is possible that she has estrogen-responsive incontinence (not uncommon in spayed female dogs) or a urinary tract infection (5,6). If you haven't already done so, I'd recommend that your veterinarian do a complete urinalysis and urine culture. If an infection is found, administration of an appropriate antibiotic may cure the incontinence.

References and Suggested Reading:
  1. Church DB. Canine hypoadrenocorticism In: Mooney CT, Peterson ME, eds. BSAVA Manual of Canine and Feline Endocrinology. Fourth ed. Quedgeley, Gloucester: British Small Animal Veterinary Association, 2012;156-166.
  2. Kintzer PP, Peterson ME. Treatment and long-term follow-up of 205 dogs with hypoadrenocorticism. J Vet Intern Med 1997;11:43-49.
  3. Nichols R, Peterson ME. Investigation of polyuria and polydipsia In: Mooney CT, Peterson ME, eds. BSAVA Manual of Canine and Feline Endocrinology. Fourth ed. Quedgeley, Gloucester: British Small Animal Veterinary Association, 2012;215-220.
  4. Plumbs DC. Plumb's Veterinary Drug Handbook. Seventh edition. Wiley-Blackwell; 2011.
  5. Forsee KM, Davis GJ, Mouat EE, et al. Evaluation of the prevalence of urinary incontinence in spayed female dogs: 566 cases (2003-2008). J Am Vet Med Assoc. 2013;242(7):959-962.  
  6. Stöcklin-Gautschi NM, Hässig M, Reichler IM, et al. The relationship of urinary incontinence to early spaying in bitches. J Reprod Fertil (Suppl) 2001;57:233-236. 

25 comments:

Dr. Mark E. Peterson said...

A follow-up note from Abbie's owner:

Dr. Peterson, thank you SO much for your response!! The inability to concentrate the urine and the D.I. effect, I feel, has been what happened to Abbie. Sorry, but she was drinking more!

We had great labs this last time and her DOCP dose was decreased. She is getting Prednisone about every 3-4 days now. Once we stopped the Prednisone, we had 3 dry days in a row.

Everything you mentioned makes perfect sense to what we have experienced. I thank you again.

La tuluseña said...

Would you recommmend the use of Propalin to deal with this incontinence issues? My dog Killa, a mixed 5 year old was diagnosed with Addison's disease a year ago. Her incontinence problem was controlled at first with pro-in, then propalin, but now, it doesn't seem to work anymore. We don't know what to do next. We are from Mexico and there are no specialists on Addison here to help us.

More data:

16kg
Percorten-V every 2 months 1.2ml
Prednisone 5mg daily (1 dose in the morning)
Propalin 1.5ml daily (1 dose in the morning)

Dr. Mark E. Peterson said...

How much does your dog Killa weight?

La tuluseña said...

She weights 16 kg or 35.27 lbs.

Dr. Mark E. Peterson said...

That's what I was hoping you would say (about the weight). The dose of prednisone or prednisonlone that I recommend for dogs with Addison's is between 0.1-0.2 mg/kg/day. That calculates to 1.6-3.2 mg per day.

So first try lowering the dose to 2.5 mg per day. That alone may help the incontinence.

Has your vet done a complete urinalysis and urine culture. If not, that should be done too.

Dr. Mark E. Peterson said...

That's what I was hoping you would say (about the weight). The dose of prednisone or prednisonlone that I recommend for dogs with Addison's is between 0.1-0.2 mg/kg/day. That calculates to 1.6-3.2 mg per day.

So first try lowering the dose to 2.5 mg per day. That alone may help the incontinence.

Has your vet done a complete urinalysis and urine culture. If not, that should be done too.

Matt M said...

What is the current view of using salt supplementation in Addison dogs?

We have a newly diagnosed basset hound and the vet suggested we add salt to diet (in addition to pred/florinef).

I haven't come across much about using salt supplementation

Dr. Mark E. Peterson said...

Adding salt to the treatment may allow for a lower dose of the florinef. The disadvantage in some dogs, however, is that it may increase thirst and lead to increased urination.

So it's not right or wrong to lightly salt the food; you will just have to see what works best for you and your dog.

froggeez said...

HI,
Thank you so much for having a sight with information on Addison's Disease. I have a 13 pound, 11 year old toy rat terrier that has addison's. She takes 1/4 of a 5mg predisone daily and gets a percorten shot at the vet every 25 days. She has an incontinence issue and we take her out as much as possible and this helps but she does have an accident in bed every 3-4 nights. We get her regularly tested and she does not have a UTI. Our vet gave us proin, but we are really worried about giving her another med since she is already on some. Also I read that it can cause strokes. Any suggestions would be greatly appreciated!

Dr. Mark E. Peterson said...

I'd try cutting back on the dose of the pred. At 13 pounds (5.98 kg), the maintenance dose would be 0.6-1.2 mg per day. So right now you are giving the upper limit of that dose. Pred is available as a liquid or as 1-mg tablets, which would make it easier to give a lower dose. That could help with the incontinence.

froggeez said...

Thank you!

Jamie Cartelami said...

I know this is an old post but I am becoming desperate for some answers or advice. I have a 3year old 165lb english mastiff who was diagnosed with addisons about 7 months ago. She is on 20mg of prednisone p/day and recieves the percorten shot every 25 days (I think 4.5ml). Yesterday she began leaking urine, this actually started months ago but it was only ever so often, it has been constant dripping since yesterday. What are our options? In addition she has hip dysphasia as well as authritis. At this time I am fearing that I am making her hold on when she really just doesn't want to. I am quite emotional and just not really sure what to do.

Dr. Mark E. Peterson said...

Your dog is on a massive dose of prednisone, which would be expected to cause polyuria and could lead to overflow incontinence. The maintenance dosage of prednisone for an adult human patient is 5-mg, so your dog should not be on more than that dosage if the drug is being given just for Addison's replacement. You cannot base the pred dose of a kg basis in dogs that weight more than I do!

At 165 lb, weight loss is strongly recommended to help the arthritis. The high prednisone doses would likely make that impossible.

I'd recommend that you talk to your vet or get a referral to a specialist.

Jennimcg said...

My 9 year old 85 lb Weimaraner was diagnosed with Addison's at the beginning of the year. We've adjusted his prednisone up and down several times. Our vet ultimately determined that he doesn't need the predisone at all and d/c'd the dose about 2 months ago. This was after some eratic manic behavior ( racing around, panting, shredding trash, etc..) Off the predisone, this behavior has stopped. He gets 3 vials of Percorten every 30 days. We're having a terrible time with his urinating in his bed. I've never seen him do it and it doesn't happen at night, so I don't think it's necessarily incontinence. We usually come home at the end of the day to find it. He doesn't sleep in his bed during the day, he usually sleeps on the sofa or our bed. I'm wondering if his percorten dose is too high. He drinks ALOT and goes outside frequently. His appetite seems fine and is weight is stable. His labs are good. At his lowest point in crisis he was 60lbs. Any insight is welcome.

Dr. Mark E. Peterson said...

I've never heard of a percorten dose this high and I would lower it to the recommeded dosage. Percorten doesn't cause massive drinking or urinating so that needs to be worked up. You probably are going to need to see a specialist to get this all figured out.

CC said...

My Aussie was diagnosed with Addisons almost 5 years ago & he'll be 10 in May. He started leaking shortly after starting on the percorten shots (1.4 mg every 23 days, no prednisone). He stopped after we switched him to a grain free diet & has been fine for about 4 years, but has started leaking again (dosage is the same). He doesn't seem to be drinking anymore & he doesn't do it all the time. Any ideas would be helpful.

Dr. Mark E. Peterson said...

Sorry, no idea. My guess is that it's not related to the Percorten.

Jack Alltucker said...

My dog is 8 years old 64 pounds has had addisons for about 3 years now. After each percorten injection, he drinks a ton of water for about 2-3 weeks. He is not on predisone at all anymore we determined he didn't need it. After a couple weeks his drinking and urination is back to normal until his next percorten injection. Currently he is on 1.9 every 40 days. He was at 2.1, then 2.0. His drinking got better when we went to 2.0, we just changed to 1.9. His blood tests are always good. Other than the drinking/urination he is completely healthy as far as we can tell. Vet thinks he is just really sensitive to steroids ( he had other side effects from the predisone )

Unknown said...

Hello my dog has had Addison's since this past winter. She takes 3 and a half .1mg Fludrocortisone a day with half teaspoon of salt twice a day.
She now is leaking pee. She can't seem to get enough water. I've limited her water but she can't control her bladder at all. She weights 61lbs. Please help...

Dr. Mark E. Peterson said...

First of all, you need to rule out renal disease, urinary tract infection, and other causes of increased thirst and urination. Then you can try stopping the salt. If that doesn't help, you may have to switch from florinef to percorten. Talk to your vet.

Stacy said...

Doctor,

My 30lb dog (Jack Russell/Pug mix) was diagnosed with Addisons at 5. He has 9 now. He gets 1 mil. Percorten injection every 25 days and after his initial "Addisonian crisis" at 5, has never had to be on any prednisone. That all changed about a month ago. He had diarrhea, vomiting, lethargy, shaking, and was laying his belly on the floor. Vet did full blood workup, all came back normal, they gave him a prednisone injection and prednisone for him to take 2.5 mg every 12 hours so twice a day. After a week of that dosage, I was supposed to decrease it to 2.5 mg once a day. After one day of that, he went right back to his old ways - shaking, etc. He has been drinking a lot and having the incontinence issue. I'm worried he will need to be on this high dosage of pred for the rest of his life. Does this sound normal? Some days are good - he eats, has a normal bowel movement, etc. Other days, he throws up his food, blood in stool, etc. Vet said this is normal as we try to regulate his hormones and levels. Should I be checking for something else? Worried in NJ. Thank you for any advice!

Dr. Mark E. Peterson said...

Dogs with long-term addison's disease don't suddenly need a big change in pred dosage unless something else is going on. Ask your vet for a referral to an internist who can work up your dog and figure out what is wrong.

Christa Stewart said...

My 61 lb. Collie is 4 yrs old and was diagnosed Addisons in Jan. After several months of treatment he is currently on 1.25mg Prednisone each day and the max dosage of Percorten for his size every 25 days. He had incontinence issues while on a higher dose of Pred but since lowering it, and allowing him ample time to relieve himself in the morning, that has resolved. However, a few weeks ago he started dripping blood from his penis after his morning urination. Only a few drops, only that time of day, most but not all days. Our vet ran urine cultures and urinalysis, and did xrays and nothing is evident. He has taken 500 mg Amoxicillin twice a day since seeing the vet. She believes the next step is an ultrasound to look for cancerous growth in the bladder. Has there been any correlation between Addison's, Pred or Percorten that you know of that could explain this blood?

Dr. Mark E. Peterson said...

No correlation... Do the ultrasound.

Romilda Gareth said...

thanks