Jottings from Dr. Dodds’ Webinar on Canine Hypothyroidism

Tags

canine health, canine hypothyroidism, dr. dodds, hemopet, thyroids, vet, veterinary endocrinology

On Sunday evening, I attended a webinar on “[Canine] Thyroid Disease and Autoimmune Thyroiditis” presented by Dr. W. Jean Dodds, DVM and sponsored by the Danish-Swedish Farmdogs USA.

As a pet person who has already read Dr. Dodds’ book and slogged through other peer-reviewed publications on canine hypothyroidism as best as I could, the vast majority of this was repeat information. I paid attention and took notes anyway as if it was all new to me. Perhaps I would’ve gotten more mileage out of the talk and Q&A opportunity if I was a dog breeder, because she had a lot of really thorough information directed towards breeders on how to screen and select for thyroid disorders. Her open liaison with breeders, in my opinion, is quite invaluable and one thing that sets her apart as a public spokesperson for canine health issues.

I also appreciated some of the detailed observations she presented with pictorial examples, which went beyond the level of description in her book (most of her pictures were already in there). Some of her comments about barrel-chested and front-loaded hypothyroid dogs made a lot of sense to me, based on what I’ve come to understand about Bowdu’s form and the range of movement he’s capable of.

She also talked a little about natural thyroid options. It’s hard to find good information about natural thyroid therapy for canines, so I would have liked to hear more about that. I wouldn’t say she embraces the idea, but she does mention it as an option, and she was willing to name-drop a few brands with a couple caveats: 1) it’s much more critical to get the dosage right and monitor reactions, since natural thyroid supplies BOTH T3 and T4 (whereas synthetic pet meds on the shelf right now just supply T4), and 2) it’s more expensive, and would probably be prohibitively so for dogs that weigh more than 60 pounds. This was covered in her book as well.

She mentioned a new double-blind clinical trial that she just wrapped up with Drs. Linda Aronson and Nicholas Dodman at Tufts (they’ve collaborated before). Results should be forthcoming in a veterinary behavioral journal. Thyroid function and aggressive/aberrant behavior were under investigation. I await the publication of that study to see what new information is presented.

In response to a good question from a trainer, who asked how she can talk to pet owners about Hemopet/Hemolife without disparaging the work of her clients’ regular vets as inadequate, Dr. Dodds clarified her organization’s position as a clinical research laboratory that needs to collect its own samples for publication purposes, using its own procedures. Hemopet is not meant to replace the work of conventional vets or compete with the handful of commercial labs that handle the majority of diagnostic tests for North American vets. Dr. Dodds’ lab is open to discussing their interpretations with conventional vets, and this would be an ideal professional relationship for the pet owner. If any part of this process is blocked, however, it’s really up to the client to decide if it’s in their best interest to work with what they have, or to seek another vet.

In all this, she hinted at some of her criticisms of the current state of the veterinary establishment. The talk was interlaced with other non-specific commentary that made it clear she understood her marginalized position, but I thought she was quite discreet. She’s been a lot more diplomatic than some vets have been to or about her, in my experience! She professed her love for the veterinary field and believes strongly in her line of work and research, though she found several things lacking in veterinary education. True to her word, that’s been one area in which she’s been campaigning for a long time. At times this does involve a bit of self-promotion that borders on oversell. But I think once you acknowledge how many questions remain in the vast, open and interconnected fields of canine health, genetics, behavior, breeding practices, pet culture, etc., then a lot of that kind of laboratory territorialism falls by the wayside as petty turf wars — particularly disadvantageous to pet people who have no stakes in that establishment, like myself.

Should the opportunity arise again, I’d recommend participating in one of Dr. Dodds’ presentations or webinars if:

• You want a quick overview of how hypothyroidism affects canine health, and you’re not inclined to spend the same amount of money on her book.
• Your own vet is unhelpful, dismissive, talks down to you, or oversimplifies explanations about thyroid issues.
• You’re a dog breeder and want to understand the dynamics of thyroid health and testing for your own breeding goals.
• You are a holistically-minded trainer who appreciates how genetics, overall health, diet, and living environment can affect a dog’s behavior, and you have some specific questions you’d like to ask.

New book on canine hypothyroidism

Tags

canine hypothyroidism, dog reference books, dogwise, hemopet, thyroids

I’ve never used one-click purchasing on Amazon before until I was alerted to this:

Dodds, W. Jean and Diane Laverdure. The Canine Thyroid Epidemic: Answers You Need for Your Dog. Wenatchee, WI: Dogwise, 2011.

Purchase from the publisher, Dogwise or on Amazon.com.

I’m aware that this is not a peer-reviewed veterinary publisher, and I’m not sure how I feel about the alarmist word “epidemic” in the title… Nevertheless, I’m sure I’ll make good use of this resource. As will the average pet owner trying to figure out what’s going on with their hypothyroid dog.

LINKS: Breeder sites on hypothyroidism

Tags

basenji, breeders, canine hypothyroidism, health tests, orthopedic foundation for animals, rhodesian ridgebacks, shetland sheepdogs, thyroids

Photo taken 1 March 2011

I first heard about canine hypothyroidism from Basenji people. With a current rank of #29 on the the list of breeds at risk for thyroid disease according to statistics compiled by the Orthopedic Foundation for Animals, and #35 according to Michigan State University, Basenji breeders had reason to be concerned. No, they don’t top the list, nor is that an enviable position to be in (that honor goes to the English Setter). But if even one out of every 10 dogs was showing abnormalities in a condition that could be screened, seems like it’s worth the test to me.

So it looks like responsible breeders were and have long been testing thyroids. And breeder websites have been where I have found some of the most informative, publicly-accessible information on hypothyroidism and canine thyroid health. Here are some of the links that I have found to be helpful.

Apu’s Basenjis: Basenji Health
– Karen Christensen, who provided the article on Apu’s page, also wrote up an article for the New York-based Rip Van Wrinkle Basenji club magazine, The Wrinkler. A .pdf is available here.

sinbajé basenjis: Thyroid Problems of the Basenji Dog.
– As far as breeder sites go, this is one of the most well done that I’ve seen, hitting a perfect mix of personal and professional, providing a ton of great information without cluttered design.

Revodana Ridgebacks: Talking About Thyroid: Everything you didn’t know you needed to know
– via a breeder of Rhodesian Ridgebacks. The article is directed primarily at breeders, but also useful in differentiating all the different available tests.

Moonstruck Meadows: Canine Health Testing: OFA Thyroid Tests
– via a breeder of Shetland Sheepdogs, what to look for in proof that a breeder has done proper testing on a dog.

I’m sure there are more out there, but this is enough for now.

Thyrogloblin AutoAntibodies (TgAA)

Tags

allergies, canine hypothyroidism, hair loss, health tests, hemopet, hyperpigmentation, orthopedic foundation for animals, tgaa, thyroglobulin autoantibodies, thyroids

One of the tests that we ordered from Hemopet/Hemolife labs as part of their Thyroid 5 panel was TgAA, or thyroglobulin autoantibodies. Yeah, say that one three times fast.

Well, we ordered it, but I didn’t really understand what the measure was for, nor how to match it against the reference range; I just wanted to be thorough. To rehash, Bowdu’s test numbers from Hemopet looked like this:

• T4: 0.87 (reference range 0.80 ~ 3.80 μg/dL)
• Free T4: 0.53 (reference range 0.55 ~ 2.32 ng/dL)
• T3: < 10, verified by repeat analysis (reference range 30 ~ 70 ng/dL)
• Free T3: 1.9 (reference range 1.6 ~ 3.5 pg/mL)
• Thyroglobulin Antibodies: <1% (reference range: negative [?])

TGAA CONFIRMATORY TEST INTERPRETATION
less than 10% = NEGATIVE 10 ~ 25% EQUIVOCAL greater than 25% = POSITIVE

I didn’t understand why the reference range was supposed to be “negative,” since a number that’s less than 1% is still a “positive” number. At any rate, Bowdu’s TgAA results fell within the reference range, while the others were low enough to diagnose him with hypothyroidism. How did his TgAA relate to the diagnosis?

Well, I’ve done some reading and poking around, and so I’m going to take a stab at rendering my understanding of what TgAA is and what those test results meant. If any experts are reading this and found that I’ve misunderstood what I’ve researched, please let me know. This is NOT my field by a long shot!

Photo taken 4 February 2011

Thyrogloblin AutoAntibodies (TgAA) are present in the system when the dog’s thyroid basically starts attacking itself, when something starts to go wrong with the thyroid glands. If a dog tests positive for TgAA, and other values are low, a dog is said to have autoimmune thyroiditis — the body is basically obstructing its own normal thyroid function. If other values are low, and TgAA is negative, it is labeled idiopathic thyroiditis — there’s some other reason that the thyroid production has atrophied. OR it could be that the condition has already progressed for some time such that you’re actually looking at the end stage of autoimmune thyroiditis, which is what I think is happening with Bowdu given his age and history of symptoms.

Some people called TgAA the “best” test in pinpointing thyroid dysfunction. As I understand it, it’s certainly not enough on its own. TgAA is the best advance indicator of possible thyroid disease further down the road, because if a dog is going to develop thyroid problems, he may test positive for TgAA as early as 1 year old, even without exhibiting other clinical symptoms or low T4 or T3 levels (subclinical thyroiditis). If TgAA comes back positive, it is “highly suggestive of later development of clinical hypothyroidism” (Ferguson, 658), though visible symptoms may not appear until years later. So it’s best to keep monitoring such a dog, and take into consideration all the other values from other thyroid tests.

In reality, the average pet owner is not going to ask for a TgAA test as part of annual bloodwork. But dogs intended to be used in breeding programs should have this measure on the record; it is one of the values that the Orthopedic Foundation for Animals (OFA) asks for when registering a dog in their database.

The diagnosis of “hypothyroidism” isn’t about a positive or a negative TgAA. But a positive or negative TgAA associated with hypothyroidism varies by breed. Hypothyroid English Setters and Golden Retrievers, for example, tend to test positive for TgAA more often than not, whereas hypothyroid Collies and Doberman Pinschers do not test positive for TgAA as often (Graham et. al, 624). Age at diagnosis was figured into those statistics somehow, which led researchers to suggest that the disease progresses differently, perhaps at a slower rate, in some breeds than in others. Overall, it’s about a 50/50 split across breeds whether you’re looking at autoimmune or idiopathic thyroiditis. You’ll have to consult the article or experts from your own breed club to see where your breed falls (there was no specific information for Shiba Inu, though Ferguson makes mentions the Basenji as one of the breeds with the highest prevalence of hypothyroidism based on some research done by Nachreiner at Michigan State University and others [649]).

This bit was interesting to me:

In a preliminary investigation of the influence of geography on the prevalence of thyroiditis in samples submitted to Michigan State University, some significant differences were observed. The prevalence of TgAA was significantly higher in samples submitted from North Dakota, Vermont, Wyoming, Minnesota, and Colorado compared with Michigan (range of odds ratios: 1.19 – 1.41; P < .05). The prevalence was significantly lower in samples from Massachusetts, Maryland, Virginia, North Carolina, Florida, South Carolina, Kentucky, Texas, West Virginia, Tennessee, and Alabama (range of odds ratios: 0.39 – 0.79; P < .05). There was no interaction with breed prevalence, but the underlying reasons (if any) for these observations have yet to be discovered. (Graham et. al, 623)

Tantalizing, isn’t it? Is it something in the water? Or the presence of puppy mills? Hunters? Urban sprawl? Mountain air? Who knows?!

At any rate, TgAA by itself is not an adequate test for diagnosing hypothyroidism. A dog can test positive for TgAA but still have T4 and fT4 levels within the normal range, which means the body is still producing enough hormone levels on its own, though the rumblings of worse to come are on the horizon. Likewise, a dog may not test positive for TgAA but the T4 and fT4 levels are low because the thyroids are already pooped; there’s nothing left worth attacking, so there’s no need to pump out more antibodies.

So I guess for the average pet owner like me, the TgAA was useful to suggest how far along Bowdu may have been in the disease. I’ll probably skip it next time, along with the T3 and fT3, and just order baseline readings of T4 and free T4 levels for the purposes of general monitoring.

Annotated list of References:
All articles come from The Thyroid special issue of Veterinary Clinics of North America: Small Animal Practice 37.4 (July 2007), edited by Cynthia R. Ward. I am disappointed to report that the veterinary college that delivered this title to my university library passed along a virtually pristine, unread copy. I sincerely hope that these articles are being accessed in electronic form by our future veterinary specialists in training!

• Graham, Peter A., Kent R. Refsal, Raymond F. Nachreiner. “Etiopathologic Findings of Canine Hypothyroidism.” Vet Clin Small Anim 37.4 (2007): 617-631.
  [too technical for me in some parts, and doesn’t really venture to offer any causes for the occurrence of thyroid disease though the authors tease their readers with intriguing statistics and suggestive avenues for further research; some illuminating charts which show some breed-specific information]
• Ferguson, Duncan C. “Testing for Hypothyroidism in Dogs.” Vet Clin Small Anim 37.4 (2007): 647-669.
  [clear, easy-to-understand survey of current available testing methods, their usefulness, limits, and attendant problems in diagnosis]
• Scott-Moncrieff, J. Catherine. “Clinical Signs and Concurrent Diseases of Hypothyroidism in Dogs and Cats.” Vet Clin Small Anim 37.4 (2007): 709-722.
  [also very technical, but covers a broad range and good for anyone who might be searching for answers on the relationship between thyroid disorders and other specific issues like cardiovascular and opthalmologic abnormalities, anemia, diabetes, bleeding disorders, etc.; good for mining additional sources]

Photo taken 3 February 2011

To bring this all back home, here are some pictures of Bowdu’s recent dermatological issues. He’s lost chunks of fur on his neck, one armpit, and a little bit on his belly, though he hasn’t been itching excessively nor does he seem to be in discomfort though he’s bald to the skin in some places, and there are patches of hyperpigmentation which come and go. We’re still monitoring him and treating him with medicated shampoo on affected areas, as well as Sulfodene on the hot spots, which seems to be keeping things from getting worse.

If this is just “allergies,” as I’m afraid the vet is going to say, then allergy season is really starting earlier and earlier each year… I’m still unwilling to admit that allergy season is year round, though this may be our punishment for living in the land of perpetual sunshine and no snow.

Shiba Inu & breed-specific profiles for aggression

Tags

aggression, akita, breeders, canine genetics, canine hypothyroidism, ethology, health tests, hemopet, shiba inu, thyroids, veterinary endocrinology, yukari takeuchi

I hope that breeders and those with any interest in behavioral issues in Nihon Ken are following and taking notice of Dr. Yukari Takeuchi’s work (武内　ゆかり, DVM, PhD). Takeuchi is at the University of Tokyo’s Laboratory of Ethology, and has done extensive research on genetic linkages and manifestations of aggression by breeds, with special attention to native Japanese breeds like the Akita and Shiba Inu.

In a 2006 report surveying a broad range of breeds, “A Comparison of the Behavioral Profiles of Purebred Dogs in Japan to Profiles of those in the United States and the United Kingdom,” Shiba were found to be ranked higher than average in aggressive behavior towards other dogs, watchdog barking, territorial defense, and snapping at children. They were clustered in a group known to have “high aggression, high reactivity, and medium trainability” along with the likes of Pomeranians, American Cocker Spaniels, Yorkshire Terriers, Irish Setters, Maltese, Pugs, Mini Schnauzers, Mini Dachshund, and others. The tag “medium trainability” says to me that Shibas may potentially have these unfavorable behaviors trained out of them, bringing home the point that socialization is key.

In another article from 2009, “Association analysis between canine behavioural traits in the Shiba Inu and genetic polymorphisms,” (Takeuchi Y, Kaneko F, Hashizume C, Masuda K, Ogata N, Maki T, Inoue-Murayama M, Hart BL, Mori Y, Animal Genetics 40: 616-622), what I understood was that there are tentative causal links between certain genes and Shiba aggression. However, because there are many social factors that contribute to aggression, as well as many ways to define aggression, more research needs to be done.

It was also noted that the Shibas surveyed were all from Japan, where many are still kept as watchdogs, particularly in rural areas. In such cases, certain types of “aggression” as noted in the 2006 study are favorably linked to their function.

In the meantime:

The reasons and motivations for having dogs vary from owner to owner; some want a watchdog for security while others desire a companion for family members. If veterinarians working at clinics know the behavioral profiles of purebred dogs and the tendencies in gender differences shown in this [2006] study, they can more appropriately advise prospective owners. This can facilitate a better quality of human-animal bond and perhaps prevent behavioral problems due to a mismatch between dogs and owners. In addition, veterinarians should inform potential owners of the importance of understanding the pedigree line within a breed, the behavior of the dam, sire, and siblings from previous litters, and the early environment during the socialization period, as has been repeatedly emphasized in previous studies (p. 7 of the 2006 study).

Takeuchi seems to consider veterinarian expertise the first line of defense against uninformed dog owners acquiring a potentially volatile breed. This statement stems from his methodology, wherein he asked veterinarians to answer based on their familiarity with the breeds surveyed, instead of breeders and purebred dog owners. In practice, I doubt most owners consult with a veterinarian before bringing home their dog; you usually get the dog first, then bring him to the vet. But his very efforts to find a genetic basis for aggression is intriguing nevertheless. If such a clear, direct genetic factor could be located, this would put a lot more weight on the selective breeding of purebred dogs, as well as throw open a whole set of related cultural issues on why breeders select for the temperaments and the individual dogs that they do.

I also find it interesting that a number of breeds considered to be “highly aggressive” also rank relatively highly on the Michigan State University’s charts for breeds at risk for thyroid disorders. Specifically, I’m looking at Maltese (#9, 16.5% autoimmune thyroiditis), Beagles (#10, 16.5%), Dalmatians (#11, 16.3%), Cocker Spaniels (#13, 15.7%), Irish Setters (#25, 12.6%), all grouped in the same cluster as Shiba Inu. In another cluster of dogs with “high aggression, low reactivity, high trainability,” there are breeds like the Boxer (#6, 18%.0), Great Dane (#36, 10.1%), Akita (#46, 8.6%), and Doberman Pinscher (#50, 8.4%). A lot of the smaller breeds rank pretty far down the list, like Yorkies and Pomeranians, which matches what I understand about hypothyroidism usually affecting medium to large-sized dogs.

But the notable overlaps make me wonder if a statistical correlation between breeds documented to be “aggressive” and thyroid disorders could be made even clearer by someone else with more rigorous analytical methods. While there is a lot of online and anecdotal information about hypothyroidism as an underlying factor contributing to aggression and behavioral changes in dogs (I’m thinking in particular about the work of Dr. Jean Dodds who presented her findings at the 1996 International Symposium on Canine Hypothyroidism), American DVMs seem to downplay the link between hypothyroidism and aggression, and there hasn’t been much published information in peer-reviewed journals echoing Jean Dodd’s findings.

Considering that 1996 wasn’t that long ago, in my mind, and that was the first (and only!) large-scale conference on canine hypothyroidism to have appeared in my searches, I bet more work can still be done. I just hope the specialists are talking to each other, and not content to let endocrinologists do their own thing, while ethologists do their own thing, and dermatologists and neurologists and hematologists and so forth are not limiting themselves to the information immediately at hand.

Followup thyroid panel numbers from IDEXX

Tags

canine hypothyroidism, hemopet, idexx, levothyroxine, petmeds, soloxine, thyroids, virbac

Photo taken 13 October 2010

You’d think I was trying to play Collect-’em-All! with thyroid panel numbers from as many national laboratories as I could access. This latest one comes from IDEXX Laboratories, now that we’ve switched vets and they use a different system. For the blood tests they ran last week, this is what we got:

Free T4 (equilibrium dialysis) (ng/dL): 3.1000 (adult reference range 0.7 – 3.7 ng/dL)
Free T4 (equilibrium dialysis) (pmol/L): 39.9000 (reference range 9.0 – 47.4 pmol/L)
T4: 2.9000 (reference range, 0.9 – 3.9 ug/dL)
Interpretive Ranges: < 0.9 Low; 0.9 – 3.9 Normal; > 3.9 High; 2.1 – 5.4 Therapeutic

Dogs with no clinical signs of hypothyroidism and results within the normal reference range are likely euthyroid. Dogs with low T4 concentrations may be hypothyroid or “euthyroid sick.” Occasionally, hypothyroid dogs can have T4 concentrations that are low normal. Dogs with clinical signs of hypothyroidism and low or low normal T4 concentrations may be evaluated further by sumission of free T4 and canine TSH. A high T4 concentration in a clinically normal dog is likely variation of normal; however elevations my occur secondary to thyroid autoantibodies or rarely thyroid neoplasia. For dogs on thyroid supplement, acceptable 4 – 6 hour post pill total T4 concentrations generally fall within the higher end or slightly above the reference range.

This blood was drawn about six hours after his morning pill, six weeks into his thyroid supplement treatment. As Dr. Dodds mentioned in her test results, “Optimal therapeutic response should be in the upper 1/3rd to 25% above the upper limits of the resting optimal ranges at 4 – 6 hours post-BID thyroid medication.” So it seems that his numbers fall within acceptable range, though I was expecting a dosage adjustment since he remains so itchy. Approximately 50% of all dogs require a dosage adjustment after the second blood draw, according to one study I read.

Nevertheless, it was good to confirm that the hormone supplementation was working as it should, and that we could go ahead and order an entire bottle of Soloxine now that we knew the appropriate dosage. Once again, I placed an order with 1-800-PetMeds; my order was filled and shipped within 24 hours, thanks to the fact that the new vet was willing to fax the prescription, just like that!

Image from Drugs.com

Hello, little yellow label! Are we going to become good friends over the next several years?

One thing disappoints me is that the product information posted on Soloxine‘s own website offers no warning of the chemical properties of Levothyroxine sodium. The package insert PDF file, accessible at the above link, states that “Soloxine tablets may be administered orally or placed in the food.” Since these instructions come from Virbac themselves, I can’t exactly fault my previous vet for giving me inaccurate instructions. Could it be that the manufacturers of this drug are not aware of how thyroxine binds to soy and calcium? Or do they know something about canine absorption that magically nullifies the chemical property of this drug? Regardless, to be on the safe side, we’ve been giving Bowdu his pills one hour before or three hours after meals, on an empty stomach. At any rate, I intend to contact Virbac and ask, but I will have to make a phone call to follow up on this, since they do not post an e-mail contact.

One more thing on the Soloxine website — there’s a cheesily produced episode of a “People and Pets” show where they briefly discuss [rather, advertise] the use of Soloxine in the treatment of canine hypothyroidism. The vet on the show recommends retesting blood to ensure correct dosage two to three times a year. Given how traumatic every blood draw has been for Bowdu, this seems completely excessive. I hope we can stick to a schedule of annual blood tests at the most, if we have any say in the matter!

Thyroid testing, part 2 at the new vet

Tags

allergies, atopica, bordatella, canine hypothyroidism, comfortis, convenia, foot licking, Ketoconazole, lepto, rabies, rescue remedy, thyroids, vaccines, vet, yeast infections

We went to the vet today for Bowdu’s followup thyroid test, as instructed by both the previous vet and HemoPet. Standard Operating Procedure calls for hypothyroid dogs to get a repeat blood draw within 4 to 8 weeks of being diagnosed and starting supplements to make sure the dosage is correct. It has been six weeks since we started dosing Bowdu.

Here’s our bill from today’s appointment:

• Office call / examination fee — $53.00
• T4 and Free T4 bloodwork — $140.00
• Domitor / Antisedative reversal — $116.00
• Leptospirosis vaccine (annual) — $24.50
• Canine Rabies 3 year vaccine — $21.75
• Bordatella vaccine — $21.75
• Antibiotic Injection — Convenia (1.4 mL) — $78.60 $0.00
• Ketoconazole (Quantity: 20) — $24.80

Total before discount: $480.40
Minus student discount and free antibiotic: -$116.29
TOTAL: $364.11

I really appreciate the student discount and the free injection, though I’m not sure why they felt we deserved it given Bowdu’s total non-compliance, which is why they had to bust out the sedative, as expected. Even with four drops of Rescue Remedy on a marshmallow before we brought him in, he was fighting both the scale and the stethoscope — not exactly invasive procedures.

He was due for his rabies in November, so the vet recommended just getting it out of the way. When I asked about the necessity of Lepto and Bordatella, I was told that the clinic had already treated two Lepto cases this year from dogs who hadn’t left our city, and Bordatella is standard for any dog that comes in contact with other dogs. I haven’t done enough research on individual vaccines to know what to refuse, so we just got what they suggested.

We had to leave him at the vet in the “sedative queue” for a couple hours before we could come back and pick him up. The Doggy Daddy gets very anxious whenever he has to leave Bowdu in the hands of strangers, which has happened maybe a total of four times ever. So do I, but I try to mask my anxiety by telling myself it’s often part of the routine… They’re professionals… They handle screaming, squirmy, uncooperative pets every day. Still, when they called to notify us that we could retrieve him, I had this paranoid vision that they were going to tell us Sorry, but your dog broke out of his restraints and mauled one of our vet techs before charging through a window and into the street, where he was immediately hit by a passing SUV. [Yes, this is why I’m a crazy dog lady sometimes.] Instead, the report was that he was very good when he was not being prodded with needles, and they decided they liked him because “he has kind eyes.”

Photo taken 22 February 2008

They gave us a round of Ketoconazole after determining that the fermented tofu smell coming from his ears and feet (which I hadn’t detected from the latter, though I’d noticed the scaling for sure!) was a yeast infection. This isn’t a drug he’s tried before, so hopefully it’ll be effective in keeping Bowdu’s paws under control. Meanwhile, we’ve been advised to bathe him more frequently with a good antibacterial/antifungal shampoo, and switch to an oral flea medication like Comfortis to help enable this process.

So we’ve gotten a lot of “new” professional recommendations today, though they’re still considering his case from the angle of allergies, not so much physical conditions that hypothyroidism might predispose him to. It’s comforting just to try something different at all, and I feel like this vet actually listened to me when I said I didn’t want to use Temaril-P. She drew up a cost estimate for Atopica, which we have considered and may still consider in the future.

Meanwhile, we’ll await Bowdu’s thyroid test results and I’ll continue to process the events of the day.

Finally refilled

Tags

canine hypothyroidism, drugs, levothyroxine, pet internet pharmacies, petmeds, pharmacies, soloxine, thyroids, vca, vet, walgreens

So after all my running around trying to get thyroid meds for Bowdu, we finally got the prescription filled at…

Drumroll, please…

My original VCA.

Yeah, that’s how it worked out.

On Monday, I finally picked out a new vet. I went in and scheduled a follow-up blood draw for Bowdu’s thyroid panel, to be done in a couple weeks. Bowpi’s also going in for a tech appointment, during which they’ll evaluate her teeth and offer an estimate for dental work. Then I showed them the written prescription from my old vet, and asked if they said they would be able to fill it. The vet tech was sympathetic to my explanation, but after consulting with the doctors, had to tell me that legally, they could not fill my prescription because they had not yet seen Bowdu. I’m not sure if they were following AVMA guidelines, state law, or some other policies, but since I was already mentally prepared for rejection, it came as no shock.

They suggested I try a human pharmacy. So I went to Walgreen’s. Surprisingly, they presented the least resistance, and were all set to send me out the door with sixty pills of Levothyroxine until I realized they were going to sell me a generic brand for $32.99 (or, I could sign up for their pharmacy savers program for $20, then the price would be $10.99). I had been advised not to get the generic version, as dogs don’t seem to absorb it very well. As I soon realized, Soloxine is a brand name manufactured by Virbac that is specifically formulated for animal absorption. That is what is written on my prescription, and even though it wasn’t coming up in Walgreen’s database of drugs, the pharmacist just took my word that Levothyroxine was the same drug.

So even a human pharmacy was no use. Today, we trekked back up to the old VCA one last time. I had no intention of entering the clinic again after I “broke up” with them, but the Doggy Daddy was willing to oblige. Meanwhile, I took the dogs around the block for their daytime walk. Bowdu remembered the neighborhood, as he was moving cagily the entire time and pooped within a block, which he does when he’s anxious. He CHARGED the car when the Doggy Daddy came back and I gave the cue to pack up and go home.

The Doggy Daddy said that the VCA receptionist was surprised that the prescription was so hard to fill. Har, har, har. If they had just faxed the prescription to PetMeds in the first place (a Vet-VIPPS approved online pharmacy), NONE OF THIS WOULD’VE BEEN HARD AT ALL! PetMeds cannot legally accept faxed copies from private customers, only veterinary clinics, so I would have had to mail the paper prescription in. By the time I realized that every clinic in town was going to refuse to fill my prescription, we were down to four days worth of meds. Four days (including Sunday) to get a piece of paper across the country, an order processed, and shipped from whatever originating warehouse to my dog who needed his daily thyroid medication. The funny thing is that even if we had requested next day air shipping, the total cost would have been less than the $24.70 that the VCA charged us again.

And this time, they weren’t even good enough to put an expiration date on the bottle. It just says **/** where a date should be. I wonder if this batch is coming from the same bottle that is set to expire 10/10 like the batch they gave us last month, and so they just “conveniently” forgot to enter the expiration date on the label. I wouldn’t put it past them.

Photo taken 21 August 2010

Vet frustrations make me want to chew *my* paws off, too

Tags

canine hypothyroidism, drugs, grooming, soloxine, thyroids, vca, vet

Due to my schedule this semester, I thought I would be too exhausted most Wednesdays to make any significant posts. However, I’ve just spent a good chunk of my evening fuming with anger after I received a voicemail message from my soon-to-be ex-vet. Apparently, I deleted it in frustration so I can’t transcribe it here. Basically, they called to tell me —

1. They “don’t deal directly” with 1-800-PETMEDS, with whom I just placed an order for a mere 60 more pills of Soloxine (0.2 mg). My vet could hand me the prescription and I could fax it in myself, but their policy is not to deal with these online pharmacies.

2. Their price on Soloxine is actually “pretty good,” they said. In fact, they could sell us 250 pills of what I want — the whole bottle — for about $24.XX. So this is something I might want to consider.

The second part is what set me off. I call bull. It’s absolutely ridiculous that they sold me 60 pills of Soloxine last time for $24.70, and they turn around and tell me they can offer me the whole bottle for that price only after I decide to go elsewhere to get the prescription filled, as is entirely within my rights by law. They’re probably going to tell me that it’s a different price for loose pills versus the entire bottle, but I still find it absurd that they would charge over eight times more per pill than the cheapest place I was able to find it online (which, for the record, was not 1-800-PETMEDS, but I had some other things I wanted to buy and they price match, which is why I chose them). Oh, by the way, the pills that the vet sold me the first time were set to expire in a month, according to the label.

[EDIT 16 September 2010: Their answer as to why there’s such a large difference in price — one is an “introductory price” for a first- or one-time dose. The second, where they offered me the whole bottle, is a “chronic med price”. I find this explanation inadequate. My response was that the first dose is basically a chronic dose, since you’re expected to keep the dog on thyroid medication once you start. Hormone supplementation will result in his own thyroids shutting down, if they weren’t already mostly non-functional to begin with. If they had actually considered the medication they were offering as more than something to look up on a price chart and ring into the register, they would’ve known that and have been able to deal with his case in a reasonable, rather than mechanical (dare I say corporate and anonymous?) manner.]

The thing is, we don’t know that we even need 250 pills yet. The standard procedure, as I understand it from Hemopet, from chatting with other hypothyroid dog owners, and as I’ve read in the veterinary literature, is for the dog to go on a 6-8 week therapeutic trial and then return for another blood draw to make sure that the dosage is correct. After the initial dose, thyroids can be retested after 2 weeks, and should be retested after no more than eight weeks at most, as about half of all dogs require a dosage adjustment. One article I read specifically said that dogs with “borderline” levels (as our vet proclaimed them to be) would be fine waiting 6-8 weeks before retest [citation forthcoming]. Given all this, the four weeks that our vet initially gave us seemed conservative, like they were in a hurry to get us back (as if our monthly visits since the month of May weren’t enough!).

However, you might recall that Bowdu was extremely stressed out by the previous blood draw. When I asked specifically what we could do to ease his anxiety before the next visit, if they had any mild relaxants that wouldn’t interfere with the heavier sedatives they’d most certainly have to give him, they professed to have nothing to offer.

It was disappointing to hear them say that they had no suggestions to help either us or themselves. I’m at a loss as to what to do in this situation. The only thing I can think of is to hang out with the vet and a behaviorist in the weeks leading up to the dreaded blood draw. Obviously this is not practical for anyone involved. Bowdu is unfortunately a high maintenance Shiba who does not like being handled by strangers, and every subsequent visit has just escalated into greater anxiety. The next visit is not going to make things any easier, nor help his impression of vets in general.

So we want to push the next visit back as far as possible, and we need more thyroid drugs in the meantime. That’s why I ordered from an online source. I sure as hell didn’t want to get gouged for another vial of drugs that he’s likely going to be on for the rest of his life.

But this vet is not going to make it easy for me to get my prescription filled where I want. Just like they didn’t make it easy for me to get his blood tested where I want. If it’s their policy not to deal with labs or pharmacies outside of their own VCA network, fine. I’m not asking them to bend any rules for us. We’ll just have to find a vet with different policies.

Searching for a good vet is tiring. This is not a personal judgment against the receptionists and vets, as they all seemed genuinely friendly and our interactions were always professional. As far as facilities go, they have some of the nicest I’ve seen (it feels rather unclinical, not like a hospital). Every DVM on staff graduated from top veterinary schools, and there are a couple reputable surgeons among the group. But I don’t need a surgeon. I need someone who knows thyroids and maybe a little bit about my relatively “rare” breeds. I want policies that permit client input. I want a vet with whom I see eye-to-eye on some core principles, like the value of holistic and natural treatments, and is willing to dole out such advice without prodding (fish oil, Epsom salt baths, over-the-counter Benadryl, apple cider vinegar, kelp supplements, baby wipes — not a word of these were ever mentioned by my vets). And I am hoping for a team of more creative diagnosticians, vets who can look outside their tunnel vision (i.e., regarding Bowdu’s problems as merely dermatological the entire time) and stay abreast of the constantly changing field of veterinary medicine.

This is what I’m prepared to tell them tomorrow in my “break up speech” when I get Bowdu’s prescription so we can get it filled elsewhere.

For old time’s sake, here’s a video of what Bowdu used to be like when he was permitted to lick himself freely:

Video taken 15 August 2008

More thyroid numbers from Hemopet

Tags

canine hypothyroidism, hemopet, michigan state university, orijen, skin care, thyroids, vet

I didn’t mention that a couple weeks ago, we heard back from Hemopet, Dr. Jean Dodd’s veterinary institution and lab. I sent everything out on a Monday afternoon. We’re in the same state, so it didn’t take long for the sample to get there. I had results e-mailed to my inbox on Thursday.

Here are Bowdu’s numbers:

T4: 0.87 (reference range 0.80 ~ 3.80 μg/dL)
Free T4: 0.53 (reference range 0.55 ~ 2.32 ng/dL)
T3: < 10, verified by repeat analysis (reference range 30 ~ 70 ng/dL)
Free T3: 1.9 (reference range 1.6 ~ 3.5 pg/mL)
Thyroglobulin Antibodies: <1% (reference range: negative [?])

TGAA CONFIRMATORY TEST INTERPRETATION
less than 10% = NEGATIVE 10 ~ 25% EQUIVOCAL greater than 25% = POSITIVE

Elevated TGAA levels confirm autoimmune thyroiditis. False positive results can occur if the dog has been vaccinated for rabies within 30 to 40 days. Thyroid hormone supplementation can decrease TGAA levels. Performed using the Non-Specific Binding (NSB) Method. 8/26/10

Dear [name of my vet]: Thyroid levels are too low here, and support the clinical issues. The very low T3 reflects concurrent non-thyroidal issue(s). Jean

Adult optimal levels:
T4: 1.40 ~ 3.50 μg/dL
FT4: 0.85 ~ 2.30 ng/dL
T3: 35 ~ 70 ng/dL
FT3: 1.6 ~ 3.5 pg/mL

X Thyroid levels are below minimal expectations for a healthy performing adult

X Thyroid levels are too low. Recommended 6 ~ 8 weeks of Soloxine (R) or equivalent product at 0.1 mg per 12 – 15 lbs twice daily (e.g. 0.2 mg BID), followed by retesting thyroid profile 4 – 6 hours post-pill to monitor response levels. Dose at optimum weight.

X Optimal therapeutic response should be in the upper 1/3rd to 25% above the upper limits of the resting optimal ranges at 4-6 hours post-BID thyroid medication.

To ensure proper absorption, thyroxine is best given by mouth, at least 1 hour before or 3 hours after a meal.

So there we have it. Nothing here came as a real surprise, except for the last bit about timing the thyroid supplements. I had specifically asked the vet if timing around meals mattered for this medication, and they said it didn’t. As I soon learned, thyroxine binds to calcium and soy, so slipping the drug in with food or treats impairs its absorption. Apparently, this is something that human physicians tell their patients all the time, but veterinary clinicians are generally ignorant of this property. Dr. Dodds recommended administering the drug with a tiny marshmallow, smooth peanut butter, or other soy and calcium-free snacks, like some kinds of German sausage.

I was initially disappointed by the brevity of the analysis, as I thought I would get more breed-specific information about hypothyroidism. So I e-mailed back with specific questions late on a Saturday night. The prompt response satisfied me in the end. Dr. Dodds wrote back on a Sunday, which I was not expecting. Aside from informing me as to why thyroxine is not to be given with meals, she also let me know that Hemopet’s database currently only contains about 100 Shiba Inu, which frankly isn’t enough to give a statistically accurate portrait of the breed as a whole. By contrast, there were at least 300 Shiba Inu in Michigan State University‘s Canine Thyroid Registry through 2005 — but I imagine the motivations for going to either lab are very different. My wild guess is that MSU’s numbers are tipped in favor of healthy dogs who are being registered by conscientious breeders, particularly for a breed like Shiba Inu whom are not typically tested or registered for thyroid health. Hemopet, on the other hand, seems to be a lab where concerned pet owners actively request to have their samples sent, and so may be skewed towards dogs that are strongly suspected to have issues.

In our case, hypothyroidism was never even mentioned as a possibility by my vet. I had to push for the thyroid tests myself. When I first asked for the blood sample to be sent to an “outside” lab, my request was met with considerable resistance. In the end, I was able to have my vet pull an extra vial of blood for me to handle on my own. Given how reluctant they were to deal with Hemopet in the first place, it seems like I would’ve been asking too much to ask them to prepare it for proper shipping — which is what so concerned the FedEx employee whom I first approached about sending out the sample. In her mind, if the sample hadn’t been packaged by a “professional,” I was sending out some kind of rogue specimen that must contain all sorts of unspeakable ills. Oh heavens!

The USPS clerk, on the other hand, was much more lenient. He did ask if I had anything “fragile, liquid, perishable, or potentially hazardous.” I couldn’t flat-out lie, so I started to go into detail about how I wrapped the vial in swathes of absorbent paper towel and how that bundle was slipped into a plastic bag, which was then placed in a padded envelope, which was then boxed up. The clerk was overwhelmed by my details, and interrupted to confirm that the item was not hazardous before he slapped the postage on my priority mail box and sent it on its way. I’ve heard that other USPS clerks have refused to mail out bio-specimens, or at least gave others a hard time, so I guess it’s luck of the draw.

Front left paw (left) and right paw (right), pictured above, with notes

So here we are, weeks later, still nursing him along. As of Aug. 30th, we’ve switched Bowdu to Orijen Six Fish in the morning and Primal Raw in the evening, with various supplements in both meals. This is mainly for the sake of convenience now that school has resumed, but I don’t think food is really our focal problem anymore. If we can continue to give him a good diet to boost his skin barrier functions, all the better. Hence, lots of Omega-3s in the form of fishy fish (which is probably his favorite meat anyway) and Omega-6s as well. Unfortunately, I guess hypothyroid dogs experience a thinning of the epidermis (visible on a microscopic level) and slow healing of lesions. So even though he’s on thyroid supplements, those scabs on his paws persist.