Hiperadrenokorticizam u pasa. II dio: Dijagnostika i terapija. (Bosnian)

Canine hyperadrenocorticism (Part II: Diagnostics and therapy). (English)

The clinical syndrome of naturally occurring hyperadrenocorticism (HAC) in dogs is one of the most common endocrinopathies in veterinary medicine. The clinical manifestations and laboratory findings reflect the influence of a chronically increased concentration of circulating cortisol. The diagnosis is based upon a compatible history and the presence of one or more clinical signs. The greater the number of clinical symptoms and laboratory changes, the stronger the suspicion of HAC. According to a consensus in veterinary medicine, diagnostic tests should be carried out only in patients with appropriate clinical signs, results of diagnostic imaging and in patients with comorbidities not responding to adequate therapy in order to enhance the positive predictive value of endocrinological tests. None of currently available adrenal function tests are reliable due to frequent false-positive and falsenegative results mainly originating from non-adrenal diseases or medications that can influence the results. The diagnostic tests for HAC are based on proving either increased production of cortisol or decreased sensitivity of the hypothalamic-pituitary-adrenal axis to negative glucocorticoid feedback. The available tests are subdivided into screening tests (ACTH-stimulation test - ACTHST, low-dose dexamethasone suppression test - LDDST, and urine corticoid-to-creatinine ratio - UCCR) and differentiating tests (endogenous ACTH concentration - eACTH, LDDST, high-dose dexamethasone suppression test - HDDST, and dexamethasone suppression with UCCR). The best diagnostic yield is achieved with a combination of adrenal function tests and diagnostic imaging (DI). All modalities of DI can be used, though the methods differ in specificity and sensitivity, much like the adrenal function tests. Suitable DI methods for adrenal diseases are ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen, while CT and MRI of the head are taken to determine pituitary diseases. Usually, abdominal ultrasound is used in combination with a screening test to establish a definitive diagnosis. To determine the optimal therapy, it is necessary to distinguish between pituitary dependent HAC (PDH) and adrenal tumours (ADH). Available treatment options are radiation, medical or surgical therapy. The surgery of the hypophysis or adrenal tumour, and radiotherapy in cases of PDH, are aimed at removing the cause of the disease, and although they are potentially curative, they are expensive, not widely available, and include inherent risks. Medical therapy consists of either the adrenocorticolytic drug mitotane or trilostane that inhibits steroidogenesis. Both medications are also expensive, are taken life-long, and have their own inherent risks. This review considers the current treatment options regarding availability, efficacy and adverse effects of therapy, while also taking into account the form and spread of the disease, and the age and comorbidities of the patient, with the goal of the selecting the most optimal treatment plan. [ABSTRACT FROM AUTHOR]

Klinički sindrom hiperadrenokorticizma u pasa (HAC) je jedna od najčešćih endokrinopatija u veterinarskoj medicini. Kliničke manifestacije i laboratorijski nalazi odražavaju utjecaj kronično povišene razine cirkulirajućeg kortizola. Dijagnostika započinje utvrđivanjem odgovarajuće anamneze i prisustva jednog ili više karakterističnih kliničkih znakova pri čemu što je broj simptoma veći to je sumnja na HAC utemeljenija. Prema preporukama konsenzusa u veterinarskoj medicini, da bi se povećala pozitivna prediktivna vrijednost endokrinološkog testiranja na HAC, ona bi se trebala provoditi samo u pacijenata s odgovarajućim kliničkim znacima, rezultatima slikovne dijagnostike i u pacijenata s komorbiditetima koji ne reagiraju na adekvatnu terapiju. Radi lažno negativnih i lažno pozitivnih rezultata koji su obično posljedica prisustva drugih bolesti ili uporabe nekih lijekova, niti jedan od trenutno raspoloživih testova nije posve pouzdan. Dijagnostički se testovi za HAC zasnivaju na dokazivanju ili povećane proizvodnje kortizola ili smanjene osjetljivosti osovine hipotalamus-hipofiza-adreni na negativnu povratnu spregu glukokortikoidima. Dostupne testove dijelimo na dijagnostičke testove (ACTH-stimulacijski test, test supresije niskom dozom deksametazona i omjer kortizola i kreatinina u urinu) i razlikovne testove (određivanje koncentracije endogenog ACTH, test supresije niskom dozom deksametazona, test supresije visokom dozom deksametazona i supresija deksametazonom s omjerom kortizola i kreatinina u urinu). Najbolji se dijagnostički rezultati postižu uporabom kombinacije testova adrenalne funkcije i slikovne dijagnostike. Svi se modaliteti slikovne dijagnostike mogu rabiti no razlikuju se, kao i testovi adrenalne funkcije, po svojoj osjetljivosti i specifičnosti. Raspoloživa slikovna dijagnostika za bolesti nadbubrežnih žlijezda uključuje ultrazvučnu pretragu te kompjuteriziranu tomografiju (CT) ili magnetsku rezonanciju (MR) abdomena, dok se za bolesti hipofize najčešće koriste CT ili MR glave. Da bi se došlo do definitivne dijagnoze najčešće se koristi kombinacija ultrazvučne pretrage abdomena s jednim od dijagnostičkih testova adrenalne funkcije. U odabiru optimalne terapije na raspolaganju su zračenje te kirurška i medikamentozna terapija. Operativni zahvati na hipofizi i adrenalnim tumorima, kao i radioterapija hipofize etiološki su oblici liječenja i iako su potencijalno kurativni nisu široko dostupni, skupi su i nose svoje vlastite rizike. Medikamentozna se terapija sastoji ili od davanja adrenokortikolitičkog lijeka mitotana ili inhibitora steroidogeneze trilostana. Oba su lijeka relativno skupa, a njihova primjena podrazumijeva i neki oblik doživotne terapije, a nose i neke vlastite rizike. Da bi se odabrala optimalna terapija ovaj pregledni rad razmatra terapijske opcije HAC-a s obzirom na dostupnost, učinkovitost i moguće nuspojave te uzevši u obzir oblik bolesti, moguće napredovanje te dob i komorbiditete pojedinačnih pacijenata. [ABSTRACT FROM AUTHOR]

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