Suzy’s Story: Kidney Failure Caused by Ingestion of Psoriasis Medication
Suzy, a 9 months old Boxer puppy, presented to VESCONE in February of 2003 for lethargy, vomiting and a poor appetite. She had been ill for 12 hours. While she had been known to chew on foreign objects, it was not believed she had been exposed to any toxins.
Suzy’s physical exam revealed that she was depressed, had a painful abdomen, and was dehydrated. She was admitted for abdominal radiographs and bloodwork to try to diagnose the cause of her illness.
While Suzy’s abdominal radiographs were non-remarkable, her bloodwork demonstrated that she was in kidney failure (her kidney enzymes were elevated and she wasn’t concentrating her urine well). Her calcium and phosphorus were elevated as well.
The owners were again questioned about possible toxin exposure as the laboratory results were consistent with kidney failure secondary to elevated calcium. Specifically, possible exposure to psoriasis medication was questioned. The Boxer was seen to ingest psoriasis medication 2 days prior. The owners did not mention it earlier as they didn’t think it was toxic. The dog had ingested about 1/8 of a 120 gm tube of Dovonex‚, a psoriasis medication.
Dovonex‚ is a popular human psoriasis medication. The active ingredient is calcipotriene. Calcipotriene is similar to vitamin D. While normal doses of vitamin D are beneficial to the body, overdoses of vitamin D can be toxic. When Suzy ate the Dovonex‚, it was as if she was ingesting a severe overdose of vitamin D.
In healthy amounts, vitamin D helps regulate the delicate balance of calcium and phosphorus in the body. Vitamin D works in the gastrointestinal tract, the bones, and the kidneys to help maintain the correct levels of calcium and phosphorus so the body can function properly. Not only did Suzy ingest enough toxin to disrupt this delicate balance, but she ingested an amount that was potentially fatal.
Suzy’s ingestion of Dovonex‚ was in essence an overdose of Vitamin D. Her calcium and phosphorus levels became unregulated. Most consequential was severe elevation in her calcium. The high calcium level caused kidney failure.
Suzy’s treatment was aimed at getting her calcium level to normalize. She was started in intravenous fluids to help “flush out” the calcium. The fluids were also beneficial to help re-hydrate Suzy. . In addition to the fluids, a special medication was given to better help get Suzy’s calcium down. This medication was pamidronate.
Pamidronate is a medication more often used in human medicine for elevated calcium associated with some forms of cancer. As VESCONE did not have pamidronate in our hospital, we contacted the Lahey Clinic in Burlington, MA. They were able to provide pamidronate for Suzy. A special gratitude is extended to the Lahey Clinic for providing the pamidronate in the early hours of the morning to treat Suzy.
In addition to the above, Suzy was treated symptomatically. Her nausea and vomiting was treated with metoclopramide. This helps promote forward motility of the gastrointestinal tract. She was also given Pepcid, an antacid. Suzy developed high blood pressure (not uncommon in animals with kidney failure). She was started on amlodipene to help treat her high blood pressure.
As Suzy was suffering from kidney failure, it was important to know if her kidneys were producing an appropriate amount of urine and were not shutting down. Thus, a urinary catheter was placed. This allowed for accurate measurement of her urine production.
During the 7 days of hospitalization, Suzy was continuously treated with intravenous fluids. She received one dose of pamidronate and 2 days later her calcium level started to drop and her kidney values started to improve. She also started to eat a little bit. By day 3 her attitude and appetite were back to normal. At the time of discharge the elevations in kidney enzymes, calcium, and phosphorus had all resolved. Suzy’s blood pressure remained a little high and thus she continued the amlodipene at home. Suzy’s kidney enzymes were monitored by her regular veterinarian for the first 2 weeks she was at home. These remained normal. During this time her blood pressure normalized and she was taken off the blood pressure medicine. Since then Suzy has been doing fine. She is a fighter and her owners were hoping she would pull through this crisis.
Dovonex‚ intoxication can sometimes require 2-3 weeks of intensive treatment and monitoring. Some animals initially recover but can die weeks to months later. While the prognosis for calipotriene intoxication is poor, aggressive and prompt medical therapy is imperative. In this case, intensive treatment started 48 hours after ingestion was successful. Special thanks to Dr. Chalfant and the Emergency and Critical Care nursing staff for their quick and accurate diagnosis and excellent care.
Suzy is doing well as a result her owners and the staff at VESCONE working as a team to save her life.
Suzy is a very lucky dog with a happy new beginning!