ACROMEGALIE

Bij doseringen Caninsulin® hoger dan 2 x daags 1,5 IE/kg lichaamsgewicht is het raadzaam
nadere diagnostiek naar acromegalie en het syndroom van Cushing uit te voeren. Hier informatie over deze twee ziekten.
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Jeanne
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ACROMEGALIE

Bericht door Jeanne » 12 mar 2010, 22:13

Wanneer de suikerziekte maar niet goed onder controle lijkt te komen, dan is het verstandig om stapsgewijs te zoeken naar de oorzaak. Nadat uitgezocht is of tijdens de behandeling alles volgens protocol is verlopen en er ook geen onderliggende infecties zijn zoals blaasontsteking, ontstekingen in de mond, moet toch gedacht worden aan Acromegalie.

Acromegalie is een aandoening waarbij er een teveel is aan groeihormoon in het lichaam is. Door het teveel aan groeihormoon is er een (forse) toename van botweefsel en weke delen weefsel. Het overmaat aan groeihormoon wordt vaak veroorzaakt door een goedaardige tumor van de hypofyse.

Hieronder tref je verschillende linken aan die Acromegalie behandelen.

* "Endocriene aandoeningen (okt. 2001)" van Felissana
* Acromegalie bij de kat - WHG-dierenartsen
* Acromegalie bij katten Universiteit Utrecht - Faculteit Diergeneeskunde (feb. 2010)
* Feline diabetes and acromegaly - University of London - Royal Veterinary College
* Amerikaanse site met forum voor lotgenoten met katten met acromegaly
* Merck Veterinary Manual
* Science Direct Succesful treatment of acromegaly in a diabetic cat..... (mei 2010)
* Science Direct Feline Acromegaly: An essential differential diagnosis for the difficult diabetic (januari 2010)
* World Small Animal Veterinary Association o.a. Acromegaly, Pancreatitis en bij Cushing Feline Diabetes Mellitus: How Relevant are Acromegaly, Hyperadrenocorticism and Pancreatitis as Underlying Disorders? (juni 2010)
* Suikerziekte bij 25% van de katten operatief te genezen. Katten met acromegalie

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Jeanne
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Re: ACROMEGALIE en HYPOFYSE

Bericht door Jeanne » 12 mar 2010, 22:15

Uit de folder: "Endocriene aandoeningen (okt. 2001)" van Felissana http://felissana.nl/dutch/text/index.htm

Hypofyse

De hypofyse van de volwassen kat is een klein (ongeveer 35 mg), vrijwel wit en ovaal weefsel aan de basis van de hersenen. Ruwweg kan onderscheid gemaakt worden tussen een voorkwab en een achterkwab. De achterkwab produceert hormonen die betrokken zijn bij de waterhuishouding (vasopressine = antidiuretisch hormoon) en bij de geboorte en de melkafgifte (oxytocine).
De hypofyse voorkwab bevat veel verschillende celtypen, die een reeks verschillende hormonen produceren, zoals bijvoorbeeld de hormonen betrokken bij de regulatie van endocriene klieren als de schildklieren (schildklierstimulerend hormoon: TSH), de geslachtsklieren (follikelstimulerend hormoon: FSH en luteïniserend hormoon: LH) en de bijnieren (bijnierschorsstimulerend hormoon: ACTH). Daarnaast geeft de hypofyse groeihormoon af dat een zeer belangrijke sturende rol vervult bij zowel de groei (van het jonge dier) als bij de stofwisseling. Langdurige overmatige afgifte van groeihormoon (GH) leidt tot acromegalie, een aandoening van de oudere kat, die wordt gekenmerkt door uitgroei van bot, bindweefsel en ingewanden.


Acromegalie

De overmatige hoeveelheden groeihormoon worden geproduceerd door een hypofysetumor die uitgaat van de GH-producerende cellen. Deze tumoren kunnen sterk in grootte variëren. Soms is de hypofyse nauwelijks of niet vergroot, terwijl in andere gevallen bij eerste onderzoek al een flinke tumor wordt aangetroffen.
De uitgroei van bot, bindweefsel en ingewanden manifesteert zich soms als een vergroving van de lichaamscontouren. De kat wordt forser met vooral een zwaardere kop en meer buikomvang. Het belangrijkste effect van de GH-overmaat is echter de invloed op de koolhydraatstofwisseling.

Katten met acromegalie worden meestal niet aangeboden vanwege de uiterlijke veranderingen, maar omdat er sprake is van een niet te reguleren diabetes mellitus. GH is een tegenregulerend hormoon voor insuline. GH-overmaat bewerkstelligt een sterke insulineresistentie. Dit wordt in eerste instantie nog gecompenseerd door een verhoging van de insulineproductie door de eilandjes van Langerhans in de alvleesklier, maar op termijn leidt dit tot uitputting van de insulineproducerende cellen.
Voor de behandeling staan in beginsel drie wegen open: medicamenteus, chirurgisch en bestraling. Met elk van de drie benaderingen is enige ervaring opgedaan. Per patiënt moet worden nagegaan wat de beste optie is.

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Re: ACROMEGALIE

Bericht door Jeanne » 12 mar 2010, 22:45

Bron: WHG-Dierenartsen http://www.whgdierenartsen.nl/html/docdb.asp?id=571

Inleiding
Suikerziekte komt vrij veel voor bij katten en we zien het ook eigenlijk steeds vaker (zie ook het artikel diabetes mellitus bij de kat). Reden hiervoor is het dikker worden van onze huiskatten in combinatie met een vaak beperkt bewegingspatroon. Voeding kan een rol spelen, door een overmaat aan koolhydraten. Maar ook chronische of terugkerende gezondheidsproblemen en medicatiegebruik vergroten de kans op suikerziekte. Klachten die kunnen voorkomen bij suikerziekte zijn bijvoorbeeld: meer drinken en meer plassen, vermageren ondanks goede eetlust. Wanneer u bij ons komt met een kat met deze klachten, dan zullen wij een urine onderzoek doen en een bloedonderzoek. Wanneer er in de urine glucose zit en de bloedspiegel zowel nu als afgelopen weken te hoog is geweest dan is er sprake van suikerziekte. Dit laatste testen we middels het fructosamine gehalte in het bloed. Vaak wordt er bij suikerziekte opgestart met een insulinetherapie, waarbij u als eigenaar thuis 2 keer per dag insuline injecteert onder de huid. Maar wat nu als de insuline niet voldoende werkt? En het suikergehalte in het bloed hoog blijft?

Oorzaken niet gereguleerde suikerziekte
Wanneer de suikerziekte niet goed onder controle lijkt te komen, dan is het verstandig om stapsgewijs te zoeken naar de oorzaak. Ten eerste kijken we hoe de behandeling thuis verloopt (wordt de insuline netjes in de koelkast bewaard, niet naast het vriesvak, hoe verloopt het injecteren?). Indien dit allemaal netjes verloopt, dan kijken we naar andere mogelijke oorzaken: is er een onderliggende infectie zoals bijvoorbeeld blaasontsteking, of een ontsteking de mond? Is er een ontsteking elders in het lichaam zoals een alvleesklierontsteking, of een darminfectie? Is er sprake van gebruik van andere medicatie, is er een hormonale afwijking of spelen er misschien andere ziektes een rol?
Wanneer er op al deze vragen een negatief antwoord kan worden gegeven is het belangrijk om te denken aan acromegalie.

Wat is acromegalie?
Acromegalie is het syndroom waarbij er een teveel is aan groeihormoon in het lichaam. Door het teveel aan groeihormoon is er een (forse) toename van botweefsel en weke delen weefsel. Het overmaat aan groeihormoon wordt vaak veroorzaakt door een goedaardige tumor van de hypofyse. De hypofyse is een klein orgaantje wat in het hoofd zit en allerlei hormonen aanmaakt. Op basis van het teveel aan groeihormoon en het hormoon dat door groeihormoon wordt aangemaakt (IGF-1, oftewel insulin growth factor-1) veranderen er een aantal zaken in het lichaam. Belangrijke klinische verschijnselen zijn naast de suikerziekte: gewichtstoename, verbreding van de gezichtsstructuur (zoals het ontwikkelen van een onderbeet) en het ontstaan van een snurkend bijgeluid. Het kan bijvoorbeeld heel informatief te zijn om foto’s te vergelijken tussen nu en een tot 2 jaar geleden. Tevens kunnen er afwijkingen aan de nieren en aan het hart ontstaan, een te hoge bloeddruk en neurologische verschijnselen.

Patiëntengroep
Suikerziekte komt in het algemeen meer voor bij katers van middelbare tot oudere leeftijd. Dit geldt dus ook voor de kat met acromegalie. Al is het wel zo, dat we pas sinds korte tijd hiermee rekening houden en het dus ook bij andere katten kan voorkomen. De meeste patiënten hebben een steeds groter wordende behoefte aan insuline en zijn dus in feite insuline resistent. Van de insuline resistente katten lijkt toch 1 op de 3 een acromegalie te hebben.

Diagnose
Wanneer we de managementzaken en andere onderliggende factoren voor de insuline resistentie kunnen uitsluiten, is het verstandig om te denken aan acromegalie. Om dit aan te kunnen tonen kunnen we bloedonderzoek doen naar de hormonen die bij acromegalie meer in het bloed zijn. Zoals de IGF-1 factor en het groeihormoon. De uiteindelijke diagnose kan gesteld worden door het maken van een CT-scan of MRI.

Behandeling
Vooralsnog is er een aantal mogelijkheden om de acromegalie te behandelen. Men kan denken aan het chirurgisch verwijderen van de hypofysetumor. Men kan ook denken aan bestraling (radiotherapie). Tevens is er recentelijk ontdekt dat er gebruik gemaakt kan worden van hormonen die de hypofyse remmen. Ook is het mogelijk om ons toch op de diabetes mellitus te richten, en met hoge doseringen aan insuline te werken. Er is dan wel altijd een risico op een te laag bloedsuiker en dit moet dus goed in de gaten gehouden worden. Bovendien moeten andere mogelijke complicaties bestreden worden (aantasting van de nieren, hoge bloeddruk en arthritis) om de levenskwaliteit zo optimaal mogelijk te krijgen en te houden.

Mocht u een kat hebben met diabetes mellitus die maar niet goed onder controle te krijgen is, dan is het verstandig om hieraan te denken.

Bronvermelding:
 Acromegalie bij de kat, Dr. Stijn Niessen, lezing Feline Symposium oktober 2009
 Acromegaly and pituitary dwarfism, Hans Kooistra, Ettinger, p. 1498-1500
 Clinical endocrinology of dogs and cats, A.Rijnberk, p. 22-24.


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Jeanne
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Re: ACROMEGALIE

Bericht door Jeanne » 12 mar 2010, 22:53

Bron: Faculteit Diergeneeskunde Universiteit Utrecht

Een ziekte van belang in de praktijk - Acromegalie bij katten
Tijdens het Feline Symposium op 10 oktober 2009 gaf Dr. Stijn Niessen, werkzaam aan het Royal Veterinary College te Londen, een lezing over acromegalie bij de kat. Acromegalie wordt over het algemeen beschouwd als een zeldzame aandoening bij katten.
Publicaties over acrogemalie bij katten zijn schaars en tot 2006 zijn er slechts zo'n 55 casuïstieken beschreven in Amerika en Europa. De prevalentie van deze aandoening ligt echter veel hoger dan aanvankelijk gedacht en diagnoses die in de praktijk worden gesteld zijn vermoedelijk het "topje van de ijsberg".

http://www.uu.nl/NL/faculteiten/diergeneeskunde/Actueel/media/2010/februari/Pages/Acromegaliekat.aspx
http://www.uu.nl/faculty/veterinarymedicine/NL/Actueel/media/2010/februari/Documents/201002%20In%20Praktijk.pdf


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Jeanne
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Re: ACROMEGALIE

Bericht door Jeanne » 12 mar 2010, 23:09

Bron: Royal Veterinary College - University of London http://www.rvc.ac.uk/CIC/Current/Internal.cfm

Internal Medicine
The Internal Medicine Service offers a comprehensive canine and feline medical referral service to veterinary surgeons in general practice. Clinics are run daily from Monday to Thursday with an emergency service available at other times.

Current Studies

Feline diabetes and acromegaly.
This particular study consists of examining the relationship between diabetes and acromegaly and also the role of cardiovascular disease in these patients.

Stabilising cats with diabetes can sometimes be very challenging, therefore clinicians at the Royal Veterinary College are studying the relationship between the control of this disease and Insulin-like growth factor (IGF).

Growth Hormone (GH) exerts an anabolic effec, which is mediated by insulin-like growth factor-1 (IGF-1) and plays a significant role in basal metabolic rate and developmental processes. Catabolic effects of GH include the development of insulin-resistance.Understanding the role between these conditions could improve the management of diabetic and acromegalic cats.

We are interested in receiving blood samples from all diabetic cats, including those that are proving difficult to stabilise. Newly diagnosed cats (diagnosis within the last 6 weeks) are eligible for follow up samples for 4 months.

Cats with a high IGF may be eligible for a free consultation at the Queen Mother Hopsital for Animals and a CT scan to try to confirm the presence of a pituitary mass. This can be of clinical value if owners wish to pursue radiotherapy which is still the treatment of choice for acromegalic cats. We are keen to continue long term follow up on these cats to objectively assess the long term response to treatment as well as consider other medical options should they become available.

-----------------------------------------------------------------------

Protocol Diabetes and Acromegaly in Cats

The RVC clinical medicine team has a number of individuals passionate about research into endocrine diseases such as diabetes in cats and who are well aware that stabilising cats with diabetes sometimes proves to be very challenging. Understanding the relationship between diabetic control and insulin‐like growth factor could improve management of difficult diabetics.

We are identifying a number of cats with pituitary tumours causing insulin resistance and we are keen to get long term follow up on these individual cats especially after treatment with radiotherapy.

Eligibility Requirements
* Cats where fructosamine is required at the point of diagnosis of diabetes mellitus or within 1‐2 weeks of that point. For these cats we are able to offer free fructosamine every 2‐4 weeks for the first 4 months on insulin.
* Cats with longer term diabetes that may be proving difficult to stabilise

Client Benefits
* Results for fructosamine, cholesterol, triglycerides and IGF will be provided free of charge
* Newly diagnosed diabetics (within the last 6 weeks) can have follow up samples run free of charge for 4 months
* Cats with IGF results > 900ng/ml may be offered further diagnostic imaging free of charge and long term follow up

Please note that only cats classed as newly diagnosed diabetics (within 6 weeks of first diagnosis) and acromegalic cats are entitled to send follow up samples.



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Re: ACROMEGALIE

Bericht door Jeanne » 21 jul 2010, 20:12

Bron: http://www.catacromegaly.com/573.html

What is acromegaly?

Acromegaly is long-term excessive secretion of growth hormone from a tumor of the pituitary gland in the brain. In felines, these tumors grow slowly and may be present for a long time before you notice any changes in your cat. The medical term for acromegaly is hypersomatotropism.


Clinical Findings

Feline acromegaly tends to occur in older (8-14 years) cats and appears to be more common in males. Most cats will first display signs of uncontrolled diabetes mellitus, namely, drinking water excessively, urinating excessively, and eating much more than usual. Unlike cats with long term uncontrolled diabetes, cats with acromegaly will gain lean body mass. Cats with acromegaly (which we like to call AcroCats!) often have enlargement of their kidneys, liver, and endocrine organs. In addition, some cats may get enlargement of extremities, body size, jaw, tongue, and forehead. The paws, chin, and skull may especially become enlarged. The heart can enlarge, heart murmurs develop, and congestive heart failure can occur late in the disease course. About half of cats with acromegaly will get a condition called azotemia where kidney dysfunction will cause nitrogenous wastes to accumulate in the blood. All cats with acromegaly have an impaired ability to process glucose and are resistant to the action of insulin and thus have diabetes mellitus. Generally, cholesterol levels and liver enzyme levels will be elevated. Protein is often present in the urine.


Diagnosis

Feline acromegaly should be suspected in any diabetic cat that has severe insulin resistance (insulin requirement more than 20 units per cat day). Diagnosis can only be made by laboratory tests performed by your veterinarian. Tests that your veterinarian will perform include measurement of increased plasma growth hormone or insulin-like growth factor 1 (IGF-1) concentrations. Serum IGF-1 concentrations are often dramatically increased in acromegalic cats. Currently, the most definitive diagnostic test is computed tomography (CT) of the pituitary region of the brain. Results of computed tomography, combined with the exclusion of other disorders that cause insulin resistance (hyperthyroidism, hyperadrenocorticism) and clinical signs and laboratory abnormalities, support a diagnosis of acromegaly.


Treatment

Medications used in people includes the use of dopamine agonists, such as bromocriptine, and somatostatin analogs (octreotide). Treatment with octreotide has not been successful in acromegalic cats. Radiation therapy probably offers the greatest chance for success.


Prognosis

Diabetes mellitus can be controlled with daily injections of insulin. Mild heart disease can be managed with medications such as diuretics and vasodilators. The longterm prognosis of the cat with untreated acromegaly is not very good. Eventually, most cats die of congestive heart failure, chronic renal failure, or from growth of the pituitary tumor. The longterm prognosis may improve with early diagnosis and treatment.


References

Axiom Veterinary Laboratories Limited:
http://www.axiomvetlab.com/EF%207-0%20UC.html#Introduction%20to%20Feline%20Acromegaly

FelineDiabetes.com, "Acromegaly: A Case History and Discussion
http://www.felinediabetes.com/Acromegaly.htm

The Merck Veterinary Manual:
http://www.merckvetmanual.com/mvm/htm/bc/40508.htm


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Jeanne
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Re: ACROMEGALIE

Bericht door Jeanne » 21 jul 2010, 20:20

Bron: http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/40508.htm

Feline Acromegaly
Acromegaly, or hypersomatotropism, results from chronic, excessive secretion of growth hormone in the adult animal. Acromegaly in cats is caused by a growth-hormone-secreting tumor of the anterior pituitary. In cats, these tumors grow slowly and may be present for a long time before clinical signs appear.

Clinical Findings:
Feline acromegaly occurs in older (8-14 yr) cats and appears to be more common in males. Clinical signs of uncontrolled diabetes mellitus are often the first sign of acromegaly in cats; therefore, polydipsia, polyuria, and polyphagia are the most common presenting signs. Net weight gain of lean body mass in cats with uncontrolled diabetes mellitus is a key sign of acromegaly. Organomegaly including renomegaly, hepatomegaly, and enlargement of endocrine organs is also seen. Some cats show the classic enlargement of extremities, body size, jaw, tongue, and forehead that is characteristic of acromegaly in people. Some of the most striking manifestations occur in the musculoskeletal system and include an increase in muscle mass and growth of the acral segments of the body including the paws, chin, and skull. Cardiovascular abnormalities such as cardiomegaly (radiographic and echocardiographic), systolic murmurs, and congestive heart failure develop late in the disease course. Azotemia also develops late in the course of the disease in ~50% of acromegalic cats. Neurologic signs of acromegaly in humans, such as peripheral neuropathies (paresthesias, carpal tunnel syndrome, sensory and motor defects) and parasellar manifestations (headache and visual field defects), are not generally detected in acromegalic cats.

Impaired glucose tolerance and insulin resistance resulting in diabetes mellitus are seen in all cats with acromegaly. Measurement of endogenous insulin reveals dramatically increased serum insulin concentrations. Despite severe insulin resistance and hyperglycemia, ketosis is rare. Feline acromegaly should be suspected in any diabetic cat that has severe insulin resistance (insulin requirement >20 U/cat/day). Hypercholesterolemia and mild increases in liver enzymes are attributed to the diabetic state. Hyperphosphatemia without azotemia is also a common clinicopathologic finding. Urinalysis is unremarkable except for persistent proteinuria.

Lesions:
Gross necropsy findings in acromegalic cats may include a large expansile pituitary mass, hypertrophic cardiomyopathy with marked left ventricular and septal hypertrophy (early) or dilated cardiomyopathy (late), hepatomegaly, renomegaly, degenerative joint disease, lumbar vertebral spondylosis, moderate enlargement of the parathyroid glands, adrenocortical hyperplasia, and diffuse enlargement of the pancreas with multifocal nodular hyperplasia. Histopathologic examination of the endocrine glands reveals acidophil adenoma of the pituitary; adenomatous hyperplasia of the thyroid gland; and nodular hyperplasia of the adrenal cortices, parathyroid glands, and pancreas.

Diagnosis:
A definitive diagnosis requires measurement of increased plasma growth hormone or insulin-like growth factor 1 (IGF-1) concentrations in suspected cases. Unfortunately, feline growth hormone assays are no longer available. Serum IGF-1 concentrations are often dramatically increased in acromegalic cats (as in affected people). Currently, the most definitive diagnostic test is computed tomography of the pituitary region. Results of computed tomography, coupled with the exclusion of other disorders that cause insulin resistance (hyperthyroidism, hyperadrenocorticism) and clinical signs and laboratory abnormalities, support a diagnosis of acromegaly.

Treatment and Prognosis:
Medical therapy in people includes the use of dopamine agonists, such as bromocriptine, and somatostatin analogs (octreotide). Treatment with octreotide has been unsuccessful in acromegalic cats. The lack of efficacy of the long-acting somatostatin analogs may result from species-specific tissue binding. Radiation therapy probably offers the greatest chance for success with low rates of morbidity and mortality. The disadvantages include the slow rate of tumor shrinkage (>3 yr) and the occurrence of hypopituitarism, cranial and optic nerve damage, and radiation injury to the hypothalamus.

The short-term prognosis in cats with untreated acromegaly is fair to good. Insulin resistance is generally controlled satisfactorily by using large doses of insulin divided into several daily doses. Mild cardiac disease can be managed with diuretics and vasodilators. The longterm prognosis is relatively poor, however, and most cats die of congestive heart failure, chronic renal failure, or signs of an expanding pituitary mass. The longterm prognosis may improve with early diagnosis and treatment.

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Re: ACROMEGALIE

Bericht door Jeanne » 21 jul 2010, 20:49

Bron: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WJC-4YXJNYK-7&_user=10&_coverDate=05%2F31%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1407649517&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=27c2a58d4523a5b78944a7188c298b31

Successful treatment of acromegaly in a diabetic cat with transsphenoidal hypophysectomy


References and further reading may be available for this article. To view references and further reading you must purchase this article.


Björn P. Meij DVM PhD[1], , , Edoardo Auriemma DVM[2], Guy Grinwis DVM PhD[3], Jenny J.C.W.M. Buijtels DVM1 and Hans S. Kooistra DVM PhD[1]

[1] Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 108, Utrecht, The Netherlands
[2] Division of Diagnostic Imaging, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 108, Utrecht, The Netherlands
[3] Department of Pathology, Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, Utrecht, The Netherlands

Accepted 4 February 2010. Available online 23 April 2010.


Patient and surgical treatment
An 11-year-old, castrated male cat was referred for insulin-resistant diabetes mellitus. It had a ravenous appetite, increased body weight, polyuria/polydipsia and a dull hair coat. The cat was receiving 25 IU insulin four times daily but blood glucose concentrations remained elevated. Plasma concentrations of growth hormone (GH) (51 μg/l, reference range 0.8–7.2 μg/l) and insulin-like growth factor 1 (IGF-1) (3871 μg/l, reference range 39–590 μg/l) were highly elevated, whereas those of alpha-melanocyte-stimulating hormone, adrenocorticotropic hormone and cortisol were normal. Computed tomography revealed a thick palatum molle and an enlarged pituitary gland, indicating a pituitary neoplasm. Microsurgical transsphenoidal hypophysectomy was performed and microscopic examination of the surgical specimen revealed an acidophilic, infiltrative pituitary adenoma that showed positive immunostaining for GH.

Outcome
The clinical signs resolved and 3 weeks after surgery the cat no longer required insulin administration. One year after hypophysectomy the plasma concentrations of GH and IGF-1 were 2.4 μg/l and 113 μg/l, respectively.

Practical relevance
This is the first report detailing transsphenoidal hypophysectomy as a feasible and effective treatment for feline acromegaly due to a pituitary somatotroph adenoma. Moreover, in this patient, concurrent insulin-resistant diabetes mellitus resolved completely. The surgery is discussed in the context of human and other feline therapies for acromegaly.


Corresponding author.

--------------------------------------------------------------------------------
Bron: Journal of Feline Medicine & Surgery
Volume 12, Issue 5, May 2010, Pages 406-410



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Jeanne
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Re: ACROMEGALIE

Bericht door Jeanne » 21 jul 2010, 21:03

Bron: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WJC-4Y0TTCH-4&_user=10&_origUdi=B6WJC-4YXJNYK-7&_fmt=high&_coverDate=01%2F31%2F2010&_rdoc=1&_orig=article&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=8b9c8fce93ff316cac97748b874c2c2c

Feline Acromegaly: An essential differential diagnosis for the difficult diabetic


References and further reading may be available for this article. To view references and further reading you must purchase this article.

Stijn J.M. Niessen DVM DipECVIM-CA MRCVS[a,] [b,]

[a,] Department of Veterinary Clinical Sciences, Royal Veterinary College, Hatfield, Hertfordshire, UK
[b,] Diabetes Research Group, Newcastle University Medical School, Newcastle-upon-Tyne, Tyne and Wear, UK

Available online 24 December 2009.



Practical relevance
Clinicians who deal with diabetic cats can have mixed experiences. Some patients are ‘textbook cases’, responding very well to insulin administration; others prove to be more challenging. Recent studies have shown a significant proportion of problem diabetic cats to have underlying acromegaly (hypersomatotropism). Recognising this syndrome in these cats will be key to successfully managing the concurrent diabetes.

Patient group
Just like the ‘normal’ (non-acromegalic) diabetic cat, the acromegalic diabetic cat tends to be a middle-aged to older male neutered domestic short hair. However, with increasing case experience, this signalment may change. Most patients are insulin resistant, although this may not be the initial presenting sign. No breed predispositions have been recognised to date.

Clinical challenges
There is no single diagnostic test for feline acromegaly – a confident diagnosis relies on a combination of clinical signs, feline growth hormone and insulin-like growth factor 1 levels, and intracranial imaging. Additionally, the ideal treatment protocol has yet to be established. Currently, radiotherapy is considered by many to be the best treatment; however, costs, the need for multiple anaesthetics, and the often delayed and unpredictable treatment response represent serious limitations of this modality. Previously, medical treatment has proven unsuccessful. Recent studies provide some evidence in favour of, and some against, the use of newer long-acting somatostatin analogue preparations in a proportion of acromegalic cats.

Evidence base
Two recent studies have revealed a relatively high prevalence of acromegaly among diabetic cats. One also specifically assessed the value of hormonal tests, computed tomography and magnetic resonance imaging during the diagnostic process.


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Bron: Journal of Feline Medicine & Surgery
Volume 12, Issue 1, January 2010, Pages 15-23



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Jeanne
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Re: ACROMEGALIE

Bericht door Jeanne » 06 feb 2012, 14:51

Feline Diabetes Mellitus: How Relevant are Acromegaly, Hyperadrenocorticism and Pancreatitis as Underlying Disorders?
Claudia E. Reusch, Dr.med.vet, DECVIM-CA
Prof., Zurich, Switzerland
2010 WSAVA Congress - Geneva, Switzerland - June 2-5, 2010

Introduction

Traditionally, the classification of diabetes mellitus in cats has more or less followed the model used in human medicine. Although the etiopathogenic mechanisms may not be identical, the human model provides a guide for the characterization of various forms of the disease. While type-1-like diabetes seems to be rare it is currently assumed that up to 80% of cats suffer from a type-2-like diabetes. Other specific types (formerly called secondary diabetes mellitus) may occur in approximately 20% of diabetic cats. They develop as a sequela of another disease, the most important of which are pancreatitis, hyperadrenocorticism and hypersomatotropism (acromegaly). Diabetes may also be drug-induced (glucocorticoids, progestins). Usually, the presence of those diseases is only considered in cats in which regulation of diabetes is difficult.

Work-Up in Diabetic Cat with Persistence of Clinical Signs

Recurrence or persistence of clinical signs is a frequent problem in diabetic cats. The first step is to confirm that the cat is indeed poorly regulated (i.e., has clinical signs of diabetes). High blood glucose levels may be incorrectly interpreted to be the result of poor glycemic control when, in fact, they are stress induced. Fructosamine concentration is also not always a reliable parameter and is sometimes moderately to markedly increased although the cat is clinically well.

In cats in which the insulin dose has been increased to approximately 1 U/kg BID a stepwise approach should be taken to exclude technical errors, insulin underdose, insulin overdose and Somogyi effect, short duration of insulin effect or prolonged duration of insulin effect. If no problem is identified thus far diagnostic work-up for diseases causing insulin resistance should be pursued. In principle any other concurrent disease (e.g., inflammatory, infectious, neoplastic) may cause insulin resistance. The most relevant are: pancreatitis, pancreas adenocarcinoma, hyperadrenocorticism, hypersomatotropism, infection of oral cavity, chronic renal failure and obesity. As a last resort, poor absorption of insulin and circulating insulin antibodies should be considered, although the relevance of the latter is controversial.1 The review will focus on pancreatitis, hyperadrenocorticism and hypersomatotropism.

Hyperadrenocorticism (Cushing)

Approximately 80% of cats with hyperadrenocorticism (HAC) will develop diabetes mellitus. Insulin resistance is often severe, however, there are cases with only mild or moderate insulin resistance. HAC is considered to be a rare disease in cats. 75-80% of cats have pituitary-dependent disease and 20-25% have cortisol-secreting adrenocortical tumors. In rare circumstances, adrenocortical tumors secrete other steroid hormones (e.g., progesterone). However, clinical signs are identical to those of hypercortisolism, and diabetes mellitus may develop as well. In addition to pu/pd and weight loss, which are usually due to concurrent diabetes mellitus, typical clinical signs are abdominal enlargement, an unkempt seborrheic hair coat, thinning of the hair coat, failure of hair to regrow or alopecia and muscle weakness. Severe cases may have thin fragile skin that tears easily. Cats with large pituitary masses may have CNS disturbances. However, clinical signs may also be mild and HAC is often not suspected until it becomes evident that the diabetes is difficult to regulate.

As in dogs the work-up is a two step procedure. First, the diagnosis of HAC should be confirmed by means of screening-tests. The urine cortisol-to-creatinine ratio has been described to be a sensitive screening-test. It should be remembered that reference values are strongly laboratory/assay dependent, and that the test's specificity is only moderate. We recently investigated the dexamethasone test in a group of diabetic cats 6 weeks after initiating insulin therapy. In 20 of 22 cats, the cortisol concentration was completely suppressed at 4 and 8 hours after the application of 0.1 mg/kg dexamethasone IV. The results did not differ between cats with good glycemic control and those with moderate to poor control. In 2 cats, the test was abnormal and hyperadrenocorticism was confirmed by histopathology.2 Based on our results, the dexamethasone test appears to be a suitable part of the diagnostic work-up in diabetic cats suspected of having hyperadrenocorticism. In our hospital, the test is carried out 6-8 weeks after initiating insulin therapy. The ACTH stimulation test is a test to investigate adrenal reserve, and therefore a test which is more appropriate for the diagnosis of hypo- than hyperadrenocorticism. Ultrasonography may be used as a discriminating test, whereas, interpretation of the adrenal gland findings appear to be more difficult than in dogs. In general terms bilateral symmetrical appearance of the adrenal glands in cats with confirmed HAC is indicative for pituitary disease, unilateral enlargement or differences in size for an adrenal tumor. Further discriminating tests are measurement of endogenous ACTH and pituitary imaging by means of CT or MRI.

Treatment of feline HAC is difficult and none of the treatment modalities have been used in a large enough number of cats to allow reliable recommendations. Microsurgical transsphenoidal hypophysectomy is an effective method, and may become the treatment of choice in the future. Currently, expertise is lacking in most centres. Pituitary radiation has been described in only very few cats with mixed results. Bilateral adrenalectomy has long been considered the treatment of choice, however post surgical complications are common and lifelong treatment with mineralo- and glucocorticoids is required. The response to medical treatment as mitotane or ketokonazole has been poor. Recently, trilostane has been used with some success and may become the medical treatment of choice. Initial dosage usually is 30 mg/cat SID.3,4 In cats with unilateral adrenal tumor removal of the affected gland should be recommended.


Hypersomatotropism (Acromegaly)

Nearly all cats with hypersomatotropism will develop diabetes mellitus. Hypersomatotropism in cats is caused by a growth hormone (GH)-producing tumor (usually an adenoma) in the pars distalis of the pituitary gland. GH has catabolic and anabolic effects; the latter are in part mediated by insulin-like growth factor-1. The catabolic effects are mainly due to insulin antagonism and are the reason for the diabetes mellitus. The anabolic effects include proliferation of bone, cartilage, soft tissue and organs resulting in a large body size, broad head and large paws, weight gain, prognathia inferior, respiratory difficulties because of thickening of pharyngeal tissues, degenerative arthropathy and organomegaly with potential organ dysfunction. Growth of the tumor may lead to signs of CNS disease. As previously mentioned for hyperadrenocorticism, clinical signs may also be very subtle or even absent.

Acromegaly has long been considered a rare disorder. It was recently suggested that acromegaly occurs more frequently than previously thought and is most likely underdiagnosed.5 However, more studies are needed to evaluate the true incidence of the disease. According to currently available data it seems that acromegaly is relatively frequent in cats with insulin resistance6 but uncommon in uncomplicated cases. Since the availability of a validated GH assay for cats is a problem, diagnosis is usually based on the finding of high IGF-1 concentration. Two important points should be kept in mind. First, circulating IGF-1 is bound to proteins, which must be removed before measurement. However, not all methods are equally effective, and intra-assay inference of binding proteins may lead to false high IGF-1 levels.7 Therefore, only assays validated for the cat should be used. Second, IGF-1 concentrations are often low in newly diagnosed diabetic cats and increase markedly after initiating insulin therapy. Low IGF-1 levels have also been seen initially in untreated diabetic cats with acromegaly.8 This observation is explained by the fact that relatively high insulin concentrations are required in the portal vein for the expression and function of GH receptors on hepatocytes, and this mechanism is impaired in insulin-deficient states.9 In our hospital, IGF-1 is therefore usually only measured 6-8 weeks after initiating insulin therapy.

Experience with treatment is limited. As in cats with hyperadrenocorticism microsurgical transsphenoidal hypophysectomy may become the treatment of choice at some time in the future. The most frequently reported modality currently is radiation therapy. We and others have seen clinical improvement, reduction of insulin requirement and decrease in size of the pituitary tumor. Interestingly, IGF-1 does not seem to be a suitable method to monitor treatment success, i.e., it may remain high despite improved glycemic control.10,11,12 Medical treatment with somatostatin analogues may be successful in some cases.

Pancreatitis

The association between diabetes mellitus and pancreatitis is complex and far from being clear in humans as well as in small animals. Although the endocrine and exocrine pancreatic tissues have traditionally been viewed as separate systems it is now clear that they are anatomically and functionally related. There is cell-to-cell contact between exocrine and endocrine cells and an islet-acinar portal system communicates between the two parts. It is assumed that blood coming from the islets flows into the acinar capillaries before leaving the pancreas and that islet hormones have a role in regulating the exocrine pancreas.

In humans it has long been thought that diseases of the exocrine pancreas account for about 0.5-1.7% of all cases of diabetes. However, recent papers suggest that the prevalence is underestimated and may in fact comprise 8% or more.13 In around 50% of human patients with acute pancreatitis temporary hyperglycemia can be observed, diabetes may persist in 1-15% of them. In chronic pancreatitis the prevalence of diabetes varies between 30 and 83%. The longer the duration of chronic pancreatitis the higher the number of patients who develop diabetes. To make the issue even more complex it is now known that approximately 40% of patients with type 1 and type 2 diabetes have impaired exocrine pancreatic function.14

In diabetic cats pancreatitis may also be common, however, it is not known whether the former triggers the latter or vice versa. In one retrospective post mortem study pancreatitis was present in 19 of 37 (51%) diabetic cats (chronic pancreatitis in 17, acute-subacute in 2).15 In a recent laboratory study increased fPLI was found in 24 of 29 (83%) samples from diabetic cats. Unfortunately nearly no clinical information was available due to the nature of the study (evaluation of submitted samples). Interestingly in the same study fPLI was also increased in 15 of 23 (66%) of samples from non-diabetic cats.16 We are currently investigating the relationship between pancreatitis and diabetes mellitus and the various diagnostic tests in a prospective manner. In cats with newly diagnosed diabetes without any obvious complications the prevalence of increased fPLI is much lower than in the study mentioned above. Only 2 out 13 (15%) cats had mildly increased fPLI (between 12 and 20 µg/dl), in all other cases it was normal.

Clinical signs of pancreatitis are unspecific and may range from mild to life-threatening. The most common signs are anorexia, lethargy, less common are vomiting and diarrhoea. Others such as tachypnoea/dyspnoea, hypothermia or fever, tachycardia, abdominal pain and a palpable abdominal mass may also be seen. Glycemic control can be extremely difficult in cats with pancreatitis and glucose concentrations may show wide fluctuations with unpredictable episodes of hypoglycaemia. Treatment of acute pancreatitis includes fluid therapy, pain management, antiemetics, nutrition, antithrombotic prophylaxis, antibiotics. In chronic pancreatitis treatment is mainly limited to dietary management.


References
1. Reusch C in Ettinger & Feldman 2010, 1796.
2. Kley S, et al. SAT 2007;149:493.
3. Skelly BJ, et al. JSAP 2003; 44:269.
4. Neiger R, et al. JVIM 2004;18:160.
5. Niessen SJM, et al. JVIM 2007;21:899.
6. Slingerland LI, et al. Dom Anim Endocrinol 2008; 35:352.
7. Tschuor F, et al. SCE meeting 2007.
8. Reusch CE, et al. Vet Rec 2006;158:195.
9. Bereket A, et al. Horm Metab Res 1999;31:172.
10. Kaser-Hotz B, et al. JSAP 2002;43:303.
11. Brearley MJ, et al. Vet Comp Oncology 2006;4:209.
12. Dunning MD, et al. JVIM 2009; 23:243.
13. Hardt PD, et al. Diabetes Care 2008;31:165.
14. Czako L, et al. Pancreatology 2009;9:351.
15. Goosens MM, et al. JVIM 1998 ; 12:1.
16. Forcada Y, et al. JFMS 2008;10:480.


Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)
Claudia E. Reusch, Dr. med.vet., Prof., DECVIM-CA
Zurich, Switzerland



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Emmie
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Suikerziekte bij 25% van de katten operatief te genezen

Bericht door Emmie » 08 apr 2013, 16:12

Ik kreeg zojuist van mijn dierenarts onderstaand bericht:
******************
Uit nieuwsbrief MCD (Medisch Centrum voor Dieren te Amsterdam)

Chirurgische behandeling suikerziekte kat
Een operatieve ingreep, waarbij de suikerziekte verdwijnt, dat zou toch fantastisch zijn? Er komen steeds meer bewijzen dat suikerziekte bij ongeveer 25% van de katten operatief te genezen is.
Uit recent onderzoek blijkt dat bij ongeveer 1 op de 4 katten met diabetes mellitus acromegalie heeft, een groeihormoon producerende hypofysetumor. In Nederland zijn inmiddels 7 katten succesvol geopereerd, waarna ze geen insuline meer nodig hadden.
Als de suikerziekte slecht te reguleren is (insuline resistentie), kan dat een aanwijzing zijn voor acromegalie. Een andere verschijnsel van acromegalie is reuzengroei: de kat komt ondanks de suikerziekte aan, heeft een vergrote lever, vergrote nieren, een bredere kop, een grotere afstand tussen boven en onder hoektanden en een stridor (allen door weefseltoename). Ook de voeten van de kat kunnen breder worden en hij/zij kan kreupel zijn. Helaas is het niet altijd zo duidelijk: sommige katten met acromegalie hebben een goed in te stellen suikerziekte, en 75% van de katten met acromegalie heeft geen “reuzengroei” verschijnselen. In principe kan elke kat met suikerziekte acromegalie hebben.
Omdat groeihormoon pulsatiel wordt afgegeven en er vaak veel insuline nodig is, is de kans op een fatale hypoglycemie bij acromegalie verhoogd.
De diagnose acromegalie wordt gesteld op basis van een groeihormoon of IGF-1 bepaling, gevolgd door een contrast-CT onderzoek. Het bloedonderzoek moet gedaan worden bij een kat die al minstens 6 weken wordt behandeld met insuline.
Op dit moment is de hypofysectomie de enige behandeling voor deze aandoening. Na de behandeling is de kat insulinevrij, maar niet medicatievrij. De ex-suikerziekte patiënt dient de rest van zijn leven orale medicatie te krijgen (L-thyroxine en cortisonacetaat) en mogelijk oogdruppels (Minrin). De behandeling is dus alleen geschikt voor klanten met voldoende financiële middelen en bij katten die te pillen zijn.
Als u een patiënt met de verdenking op acromegalie wilt verwijzen, kunt u de eigenaar een afspraak laten maken voor de poli interne bij het MCD.

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