Dear Editor:
Concerning Dr. Bernard Rollin’s reply to the ethical question of September 2012, published in the December 2012 issue of The CVJ (Can Vet J 2012;53:1246). I hesitate to write this because I expect there will be more eloquent counters to Dr. Rollin’s poorly considered commentary on the “Dog with Cushing’s,” but the entire tone of his reply was condescending, mildly ignorant, and missed the point completely.
Practically every veterinarian in practice has faced the “healthy” dog with overt Cushing’s disease. These dogs are usually happy, relatively inflammation-free, and often have great appetites. If the owner can tolerate the dramatically increased frequency of urination, these dogs are still good pets with a decent quality of life. They do have a serious disease that will likely kill them, but they will not die immediately and they are not “suffering” from the disease. The dog in this situation was 15 years of age, 3 years past his expected life span. We need not treat everything, nor must we euthanize every dog with Cushing’s disease when owners cannot treat. The moral conundrum was what to say to the SPCA so they don’t insist on immediate euthanasia.
My second point is that Dr. Rollin’s suggestion of treating the dog with Trilostane without confirming hyperadrenocorticism, whether it is PDH or ADH, is not serving anyone well. Based on pure arithmetic, it is a poor solution; furthermore, medically it is foolish. It is bad medicine to treat a Cushing’s disease dog just because it looks like it has the disease. If diagnosing Cushing’s disease was just that easy, there would not be entire books written on the subject.
Dr. Feldman, an expert on endocrine disease, noted that trilostane is NOT a benign drug; adverse reaction rates are as high as 25%, death being one of those adverse reactions. Dr. Rollin suggests that we should put a dog on a potentially fatal drug without confirming our diagnosis; this may work for him, but it’s the veterinarian’s license that takes the hit if the dog dies.
While Trilostane does work regardless if the HAC is PDH or ADH, it is more effective if the disease is PDH. The same is true for the older drug Mitotane. The difference would be cost.
Diagnostics for the safe use of each drug are about the same. Diagnosis is based on staged use of appropriate blood tests and imaging studies and is costly. An ongoing cost comparison between the drugs is important.
Assume a 10–kilogram dog is involved. Mitotane costs about $5.00 per 500 mg pill, veterinarian’s wholesale cost. Assuming the dog stabilizes in 7 days on the loading dose, the first month of chemotherapy alone for this dog is going to be about (assuming he is an “average dog”) $50.00. Subsequent months will be about $20.00. Trilostane, at wholesale cost and assuming, again, that this dog is “average” will cost at least $85.50 per month every single month the dog survives. There is quite a cost differential between the two.
Then there is the monitoring of the dog. We skipped the diagnostics when we followed Dr. Rollin’s suggestion, so why we would bother with monitoring the dog, I have no idea. Let’s just assume we regained our senses and decided to actually practice medicine. Again, let’s assume we are doing this at cost and not charging anything for our services or handling costs. The monitoring requirements are repeated ACTH–stimulation tests. Each follow-up test is going to wholesale at $94.05. The standard protocol for both Mitotane and Trilostane suggests a minimum of 3 follow-up tests (cost $282.15), and I have never seen an HAC dog safely managed using “the absolute minimum.”
So Dr. Rollin suggests that the veterinarian should give a client he has not seen in 3 years services that cost him, out of pocket, $282.15 in the first year alone. This number just reflects the drug and lab fees and ignores the fact that there are all sorts of services involved. This brings up a new moral question: why should this client get “free” service while other clients pay? Why should the clinic owner and his family suffer deprivation to help this particular “sometime” client? Do we have proof that it will generate goodwill in the community? Or is it more likely to just attract more clients who want free service?
It has been my experience that giving free service goes unappreciated and just attracts more clients who want to ride the free gravy train while alienating the good clients who are willing to pay for good service. Dr. Rollin does not seem to appreciate the reality of veterinary practice, but then that would be because he is not a veterinarian.