A Matter of Opinion                         CONTINUED                                                  the profession’s hi...
Advancing One Health:                                                      Practical Tips for Veterinarians           Vete...
A Matter of Opinion                        CONTINUED A growing body                                                       ...
Dwight D. Bowman, MS, PhDW h a t ’s t h e Ta k e H o m e ?                                                  PA RA S I TOLO...
W h a t ’s t h e Ta k e - H o m e ?                                CONTINUEDCORRECT ANSWER                                ...
W h a t ’s t h e Ta k e - H o m e ?                               CONTINUEDSometimes                                     T...
Clarke Atkins, DVM, Diplomate ACVIM                                                                                       ...
H ow I Tre a t                     CONTINUEDConsensus was defined as all 10 panelmembers agreeing to a particular recom-  ...
S TA G E                    B2                                                 S TA G E                    Ca             ...
H ow I Tre a t                     CONTINUED  S TA G E                    Da                                              ...
How Clarke Atkins Does It    Stage A CVHD (At risk)                                                        Stage Cc CVHD  ...
The most commonly used drugs and protocols for immune-mediated diseases have been adoptedfrom human medicine, often withou...
Mechanical stretching of the skin by creating a                                and both had a healthy granulation bed. Ski...
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Cb july 11 web 3 navc clinician brief july 2011 capsule

  1. 1. A Matter of Opinion CONTINUED the profession’s history, some of the approxi- and most of this work was done in the absence mately 35 city-located veterinary colleges— of veterinarians.2 including those at Harvard University, New York University, and George Washington University— Instead, veterinarians continued to promoteOne of the pri- were associated with major medical schools. By human health by ensuring the safety of the foodmary goals of the the 1920s, however, all except one of our veteri- supply, preventing major zoonotic scourges suchOne Health Com- nary colleges (the exception being University of as salmonellosis and tuberculosis, and controllingmission is to Pennsylvania, which was an outgrowth of the the dreaded scourge of rabies. Unfortunately, medical school) were located in rural communi- there was less and less contact between physiciansadvance the ties such as Pullman, Washington, and Ithaca, and veterinarians, with each working in theirunderstanding, New York, or in small cities such as Columbus, respective spheres.prevention, and Ohio. The land grant’s agricultural priority gov- erned veterinary college curricula and entrance ZOONOTIC DISEASE MAKES Atreatment of requirements and, unfortunately, narrowed the COMEBACKzoonotic disease. veterinary community’s understanding of One By the mid-20th century, veterinary prophets Medicine to the (albeit important) priority for advocated for a resurgence of One Health. Among public health.1 them were Dr. James H. Steele, the father of vet- erinary public health, and Dr. Calvin W. Schwabe, Meanwhile, human medicine thrived in the who developed the parallel field of veterinary epi- population centers of the country and physi- demiology. Zoonotic diseases once again took cen- cians devoted their energy to advancing medical ter stage, and the comparative medical education diagnoses and treatments and developing clini- of veterinarians enabled many important clinical cal specialties that enhanced individual patient and research advances in human health. Dr. Tracey care. Ironically, starting as far back as the late McNamara’s groundbreaking work on West Nile 1800s, physicians also became experts in canine virus at the Bronx Zoo in 1999 helped solidify the physiology, pathology, and surgery. They devel- veterinarian’s role in the diagnosis, treatment, and oped important veterinary medical and surgical prevention of zoonotic disease. techniques decades before veterinarians did, even those who were working and teaching in In 2006 and 2007, Dr. Roger Mahr used his posi- veterinary colleges. The medical profession tion as AVMA president to advocate for a 21st used dogs as correlates for human medicine, century movement in One Health. He and col- leagues in veterinary medicine and other health professions have forged leadership alliances from THE ROOTS OF COLLABORATION The concept of One Health was a central theme in the early days of our profession. Cornell’s first veterinary dean, James Law, pro- moted the notion in an 1878 address to the Pennsylvania Department of Agriculture3: “Now that veterinary medicine has been established on a scientific basis, the time has come when the bonds that unite the students and practitioners of human and veterinary medicine should be knit more closely, and the two branches be brought into more intimate relationship. Both branches of medicine suffer from separation…. Each is necessary to the rapid progress and highest advance- ment of the other.” In the late 19th century, the fields of veterinary and human medicine were intertwined. For example, some of the great physicians and biomedical scientists, such as William Osler and Theobald Smith, were closely associated with veterinary medicine’s greatest leaders ( James Law, Daniel Salmon, and Alexandre Liautard). In fact, it was not uncommon for deans and some faculty of veterinary colleges to be physicians or to hold both MD and DVM degrees.1 42.......................................................................................................................................................................NAVC Clinician’s Brief / July 2011 / A Matter of Opinion
  2. 2. Advancing One Health: Practical Tips for Veterinarians Veterinarians can take a number of practical steps to promote One Health and forge collaborative bonds with their counterparts in human medicine: G Encourage prospective veterinary students to attend companies and politicians) to understand and undergraduate colleges and major in biological support the positive impact that pets play in sciences in conjunction with premedical students in enhancing human health. order to form lifelong personal and professional G Become active with local and regional departments bonds that will facilitate mutual understanding of of health. the health professions. G Encourage and support innovative roles for G Encourage veterinary colleges to accept MCAT appropriately selected animals in settings in which (medical college admission test) scores as well as animals are known to positively enhance the living GRE (general record examination) scores to experience, such as retirement and assisted-living accommodate students who may wish to consider homes, hospitals and hospice care facilities, either field. selected child care facilities, and prisons and G Encourage exchange programs between veterinary detention centers, among others. and medical students by inviting medical students G Encourage responsible ownership of pets to or family practice residents to visit your practice to minimize challenges such as noise (barking), observe the human–animal relationships that indiscriminant soiling, property and home damage, veterinarians encounter in clinical practice. and aggression/biting. G Become informed about and engaged with human G Encourage collaborative work between MDs health care needs and issues, including those with and DVMs in the management of any immuno- no direct relevance to pets or other animals. compromised person with pets. G Encourage physicians (as well as insuranceeducation, research, government, and industry to prevention, and treatment of zoonotic disease.promote comparative medicine in advancing During the past few years, the increasing number,human, animal, and ecosystem health. A perma- scope, and virulence of zoonotic pathogens; thenent administrative home for the One Health more rapid speed with which these pathogensCommission has recently been created at Iowa travel around the world; and the growingState University. immunocompromised human population have compelled us to keep this issue at the forefrontTHE GOALS OF ONE HEALTH of the One Health movement.Promoting Public HealthOne of the primary goals of the One Health CONTINUESCommission is to advance the understanding,A Matter of Opinion / NAVC Clinician’s Brief / July 2011.......................................................................................................................................................................43
  3. 3. A Matter of Opinion CONTINUED A growing body with pets. This is a field in which veterinarians undoubtedly can have a major impact on human of research is ONE HEALTH RESOURCES health. If these benefits can be proven to be tan- continually The following organizations offer gible and measurable, we have the potential to documenting informative resources to provide a decrease the cost of human health care and to broader understanding of the concept improvement in improve the quality of life for both people and and goals of One Health: animals. The term zooeyia (the positive impact of the physical, pets on human health) represents a cogent way to American Veterinary Medical social, and express and build upon this important founda- Association: mental health tional concept.4 Centers for Disease Control and Prevention: of people who BACK TO THE FUTURE share their The 21st century can and should become a “Back One Health Commission: homes and envi- to the Future” moment for the One Health ronments with movement. A number of valuable resources are One Health Initiative: available for veterinarians to better understand pets. One Health (see One Health Resources), and there are a host of constructive ways in which veterinarians can join the movement (see Advancing One Health: Practical Tips for Vet- erinarians, page 43). How marvelous would it be to celebrate the profession’s 150th anniversary in 2013 with the entire veterinary community com- mitting to a broader understanding of One Integrating Biomedical Research Health for the betterment of all species? A second primary intention of One Health is to exploit the strong correlation between human and animal health issues through biomedical research in such areas as oncology, nutrition, obesity, chem- ical and environmental risks, and aging. The field of comparative genomics, introduced barely a decade ago, provides us with the scientific tools to study diseases and conditions that have a genetic or inherited component, including certain cancers, endocrine and joint diseases, and even some degenerative and behavioral conditions. Because www.avma.org/onehealth human and animal genomes have so much in common and because correlates for some human www.cdc.gov/onehealth conditions are manifested in dogs and other ani- mals, more rapid research advances can be realized onehealthcommission.org through strong collaborative ties between veteri- narians and physicians. onehealthinitiative.com Exploiting “Zooeyia” The importance of pets to human health is well established and cannot be overlooked whenSee Aids & Resources, considering One Health. A growing body ofback page, for references research is continually documenting improve-& suggested reading. ment in the physical, social, and mental health of people who share their homes and environments 44.......................................................................................................................................................................NAVC Clinician’s Brief / July 2011 / A Matter of Opinion
  4. 4. Dwight D. Bowman, MS, PhDW h a t ’s t h e Ta k e H o m e ? PA RA S I TOLOGY Cornell UniversityPeer Reviewed What actions can be taken so the veterinarian can sign the required flea-free certification form—and Jocko can return to his home and previous flea-free status?Flea Management: A. Switch Jocko to an oral or topical adulticide. B. Switch to injectable Program because you suspect Mrs. Jacobs has not been religious in giving An Integrated Approach monthly Program in Jocko’s food. C. Give Mrs. Jacobs 7 days of Capstar (nitenpyram, capstar.novartis.us), tell her to continue with Program, and send her home. D. Give Mrs. Jacobs 7 days of Capstar and suggest a house visit by your veterinary technician who has expertise in resolving flea problems. E. Give Mrs. Jacobs 7 days of Capstar and a flea bomb to treat the premises. F. Give Mrs. Jacobs 7 days of Capstar and switch the Jocko, a 6-year-old neutered male cat to Revolution (selamectin, revolutionpet.com) along with applying Frontline Plus (fipronil + (S)- indoor-only cat, suddenly developed methoprene, frontline.us.merial.com) each a severe flea problem. month. G. Switch Jocko to Advantage (imidacloprid, bayerdvm.com) and use an additional carpet treatment. H. Stay the course and inform Mrs. Jacobs that she needs to rent a carpet steamer. ASK YOURSELF…CASE SCENARIOIn February, Jocko presents for a routine semian-nual visit to his veterinarian in Sayre, Pennsylva-nia, a small town located in the north-centralpart of the state. The owner, Mrs. Jacobs, is awidow who lives by herself in Lehigh Towers, aretirement apartment complex maintained underthe Sayre community’s housing authority. Eachtenant is allowed to have a single pet cat or smalldog, but pets are forbidden access to the facility’sgrounds, so Jocko is truly an indoor cat.When it comes to flea control, Mrs. Jacobs ishappy enough with how Jocko has been faringover the past 6 months and would like to staythe course on monthly Program (lufenuron,program.novartis.us). During this visit, she needsthe veterinarian to complete the required annualcertification that Jocko is flea-free.Unfortunately, Jocko is anything but flea-free.Thus the veterinarian is left with a conundrum:What can be done to help Mrs. Jacobs keep Jockoas well as protect the other elderly folks living inLehigh Towers? CONTINUESWhat’s the Take-Home? / NAVC Clinician’s Brief / July 2011 ................................................................................................................................................................47
  5. 5. W h a t ’s t h e Ta k e - H o m e ? CONTINUEDCORRECT ANSWER By giving 1 Capstar tablet to Jocko during thisD. Give Mrs. Jacobs 7 days of Capstar visit and having Mrs. Jacobs give him 1 tabletand suggest a house visit by your vet- daily for 6 days (total of 7 days of Capstar treat- One of the most common flea species seen inerinary technician who has expertise ment), you should be able to sign the document households today isn’t the cat flea or the dog fleain resolving flea problems. with a clear con- —it’s the human flea. science2—but onlyWEIGHING YOUR OPTIONS if there is properFrom the Case Scenario, it should be clear that follow-up.this very likely is not a simple case of productfailure. Although that is always a possibility, Mrs. Managing this fleaJacobs receives her product from you, and you problem is going tohave had no complaints from others about its use. require veterinaryYes, someone always must be the first to com- staff intervention—plain when problems arise, but in this case, Jocko as well as assistance from the building’s adminis- In fact, Pulex irritans is a Although Ctenocephalides canisis probably suffering from a shared affliction. trator. Jocko has obviously found himself in a One of the more abundant flea Ctenocephalides felis species is Ctenocephalides felis, situation in which fleas are breeding around him captured in an apartment species with a diversified host primarily lives off the blood of and have now sneaked into his environment. (male left, female right) spectrum, including both which is the cat flea. Its primary dogs, it also feeds on domestic domesticated and wild host is domestic cats, but it cats and sometimes bitesObviously, fleas must have slipped into the Tow- Thus a member of your team needs to use his or mammals and birds—dogs, is also a major player in flea humans. The dog flea can liveers and taken up residence, so a search for the her knowledge of flea biology to figure out the wild canids, pet cats, wild infestation of dogs. Although cat for months in carpets, couches,offending party or parties needs to be initiated.1 source for the large numbers of fleas moving into felids, pigs, monkeys in fleas will bite humans, they are not bedding, and other placesJocko is likely serving as a sentinel, as the flea Jocko’s apartment. captivity, wild rodents, free- a sustainable host. Therefore, without needing a blood meal.control product being used on him has no adulti- tailed bats, to name just a survival relies on infestation of However, the female must havecidal effect. CONTINUES few, and of course people. other mammals. a blood meal before it can produce eggs, which it lays on the host’s fur. Did You Know? To learn more about flea species and the infectious pathogens they can harbor, download a list at cliniciansbrief.com.What’s the Take-Home? / NAVC Clinician’s Brief / July 2011 ................................................................................................................................................................49
  6. 6. W h a t ’s t h e Ta k e - H o m e ? CONTINUEDSometimes THE SOURCE & SOLUTION on flea prevention, for a week-long visit to his Although using various products with adulticidal, daughter’s house. During that time, the fleas inmanaging flea ovicidal, and larvicidal activities would likely pro- the neighbor’s apartment eclosed from theirproblems tect Jocko and Mrs. Jacobs from being bothered pupal cases but had no host with the dog beingrequires direct by fleas, the problem probably extends into the gone, so they started looking for a new bloodintervention by surrounding apartments.3 Thus, the best means source. The timing coincided with Jocko’s sched- of success in this scenario would be to send the uled wellness visit and the owner’s need to obtainveterinary staff clinic’s flea expert to the Towers to determine the a flea-free certification.with expertise in source of flea infestation. This can be challengingflea biology. because of the number of individual apartments Source found. Problem solved. that could be involved, but often the administra- tive staff in residence facilities is willing to work Although reviewing all viable approaches to inte- with concerned, knowledgeable individuals in grated flea management is beyond the scope of order to prevent problems from getting out of this article, a few options that can be considered control. for Jocko are outlined in Finding a Solution for Jocko: Flea Control Strategies. In this case, once the staff technician with expertise in flea management visited the Towers the problem was easily solved. The tenant in the See Aids & Resources, back page, for references next apartment had taken his dog, which was not & suggested reading. FINDING A SOLUTION FOR JOCKO: FLEA CONTROL STRATEGIES Many scenarios can be played out to bring Jocko’s flea problem under control. Following are 3 options to consider when devising an integrated flea control strategy. 1. Continue flea prevention with Program for Jocko or excellent integrated pest control by targeting different perhaps for the dog that created the problem, Sentinel life cycle stages. (milbemycin + lufenuron, sentinelpet.com), along with 3. Comfortis for Dogs (spinosad, comfortis4dogs.com) Capstar for both pets. The latter rapidly kills adult and Assurity for Cats (spinetoram, assurity4cats.com) fleas, and lufenuron prevents fleas from developing. are two products that were launched more recently for 2. Various adulticides contain built-in activities against flea control.5,6 These products target adult fleas with a eggs, larvae, or both. For example, Revolution, Front- once-a-month application, and in this scenario where line Plus for Cats and Kittens, Advantage II (imida- cats and dogs in the Towers never roam, these prod- cloprid + pyriproxyfen, bayerdvm.com), and Vectra ucts too would be likely to get this problem under for Cats and Kittens (dinotefuran + pyriproxifen, control and keep it away for an extended period. summitvetpharm.com).3,4 These products haveAdvantage = imidacloprid, Advantage II = imidacloprid + pyriproxyfen, Assurity for Cats = spinetoram, Capstar = nitenpyram, Comfortis for Dogs = spinosad,Frontline Plus = fipronil + (s)-methoprene, Program = lufenuron, Revolution = selamectin, Sentinel = milbemycin + lufenuron, Vectra for Cats and Kittens =dinotefuran + pyriproxyfen50 ................................................................................................................................................................NAVC Clinician’s Brief / July 2011 / What’s the Take-Home?
  7. 7. Clarke Atkins, DVM, Diplomate ACVIM (Internal Medicine & Cardiology), North Carolina State UniversityH ow I Tre a t CARDIOLOGYPeer Reviewed Bruce Keene, DVM, MSc, Diplomate ACVIM, Panel Chair Clarke Atkins, DVM, Diplomate ACVIM (Internal Medicine & Cardiology) John Bonagura, DVM, MS, Diplomate ACVIM Finding a Consensus on Stephen J. Ettinger, DVM, Diplomate ACVIM (Internal Medicine & Cardiology) Canine CVHD Philip R. Fox, DVM, MS, Diplomate ACVIM/ECVIM (Cardiology) & ACVECC Virginia Luis-Fuentes, VetMB, PhD, CertVR, DVC, MRCVS, Diplomate ACVIM & ECVIM Sonya G. Gordon, DVM, DVSc, Diplomate ACVIM (Cardiology) Jens Häggström, DVM, PhD, Diplomate ECVIM (Cardiology) Robert Hamlin, DVM, PhD, Diplomate ACVIM Rebecca Stepien, DVM, Diplomate ACVIMCanine chronic valvular heart disease (CVHD) is the most importantnonparasitic cardiovascular disease in veterinary medicine, butcontroversy remains about the best treatment.THE PLAYERSCanine CVHD, also known as endocardiosis, THE PANELmyxomatous valve degeneration, and mitralregurgitation (MR), affects approximately 85%of dogs 13 years of age or older and accounts for75% of heart disease in dogs.1 For such a sub-stantial disease, it may be surprising that therestill is controversy and general lack of agreementabout the appropriate medical management, bothbefore and after the onset of heart failure.To this end, the American College of VeterinaryInternal Medicine’s (ACVIM) Board of Regentsrecently selected a group of European and Amer-ican board-certified cardiologists to present aformal consensus for the diagnosis and treatmentof CVHD.1 The 10 panel members represented THE PROCESSdiverse points of view on cardiac therapeutics. Based on available evidence, the ACVIM panel determined whether the potential benefits of aThe consensus statements and recommendations given treatment option clearly outweighed theof the panel are not to be taken as “cutting edge” risk for adverse events and if the financial impactbut rather as a sampling of the “collective wis- on the patient and client would be justifiable.dom” that occurs when reasonable people reach a CONTINUEScompromise after reviewing published data andtheir own experiences.ACVIM = American College of Veterinary Internal Medicine, CVHD = chronic valvular heart diseaseHow I Treat / NAVC Clinician’s Brief / July 2011 .....................................................................................................................................................................................53
  8. 8. H ow I Tre a t CONTINUEDConsensus was defined as all 10 panelmembers agreeing to a particular recom- S TA G E A S TA G E B1mendation, but we also revealed when amajority of the panelists agreed on a rec- ACVIM classification ACVIM classificationommendation even if the criteria for G Patient at risk G Murmur presentconsensus were not met. G No clinical signs G No cardiomegalyHEALTH CARE SCHEME From the panel From the panelAlthough a number of classification G No drug or dietary therapy G Consensus: No drug or dietaryschemes that grade cardiac disease in recommended at this stage therapy recommended at thisdogs are already in place, we created a G Dogs used for breeding should be stage for dogs with hemodynam-novel scheme modeled after one used by removed from the breeding pro- ically insignificant MR, definedthe American Heart Association and the gram if MR is present here as radiographic or echocar-American College of Cardiology. Our diographic evidence of a normalsystem avoids the inclusion of progres- For my patients or equivocally enlarged leftsive exercise intolerance when grading For dogs with stage A CVHD, I atrium, left ventricle, or both, indisease severity and adds a category for make the dog’s owner aware of the addition to normal left ventricu-dogs that show no clinical signs but are need for annual examinations, what lar systolic function, normal ver-at risk for the disease (eg, cavalier King may lie ahead if the disease pro- tebral heart score on radiography,Charles spaniels, dachshunds, miniature gresses, and what an aggressive normal blood pressure, and nor-and toy poodles). diagnostic and therapeutic approach mal laboratory results might entail. I also discuss what canIn this article, I describe some of the be done for a patient if the owner For my patientsmore important consensus and majority has financial constraints. I discuss I suggest to owners that the dogfindings from the panel, as well as offer diet and exercise and the role of may benefit in the long-term from asome insights into how these findings dietary restrictions as heart failure diet that is mildly to moderatelycan translate into everyday patient care ensues. I also give the owners a restricted in sodium content, whilebased on my own practice. prognosis and inform them as to the dog’s appetite is presumably still how various predictable and unpre- good. I also suggest blood pressureNote: Not all consensus recommenda- dictable circumstances might alter control—most likely with the addi-tions would be appropriate for each the general expectation. tion of amlodipine and an ACEpatient. For example, it is unlikely that a inhibitor in the relatively unusualdog on pimobendan would also receive circumstance in which systemicdobutamine. hypertension accompanies CVHD. This is true at any stage of CVHD.ACE = angiotensin-converting enzyme, ACVIM = AmericanCollege of Veterinary Internal Medicine, CVHD = chronic valvularheart disease, IMPROVE = invasive multicenter prospectiveveterinary evaluation of enalapril study, MR = mitral regurgitation,RAAS = renin–angiotensin–aldosterone system54 .....................................................................................................................................................................................NAVC Clinician’s Brief / July 2011 / How I Treat
  9. 9. S TA G E B2 S TA G E Ca S TA G E Cc ACVIM classification ACVIM classification ACVIM classification G Murmur and cardiomegaly G Acute heart failure requiring G Chronic heart failure requiring present hospitalization at-home care From the panel From the panel From the panel: G Consensus: None G Consensus: Furosemide (PO, IM, G Consensus: “Triple therapy G Majority: ACE inhibitor IV, or CRI7,8) approach”—furosemide PO, G Majority: Highly palatable, G Consensus: Pimobendan ACE inhibitor,11-16 and mildly sodium-restricted diet G Consensus: Oxygen via cage or pimobendan17 G Majority: Against use of beta- nasal cannula G Consensus: Against beta-blocker blocker, pending clinical trials G Consensus: Mechanical removal in patients with signs of heart of thoracic or abdominal fluid failure For my patients G Consensus: Relieve dyspnea/ G Majority: Highly palatable, My viewpoint is controversial,2 as discomfort via appropriate mildly sodium-restricted diet I prescribe an ACE inhibitor at this humidity, environmental temper- G Majority: Spironolactone (see stage of the disease because of an ature, and body positioning Late-Breaking Data) abundance of supporting evi- G Consensus: Sedation with G Majority: Digoxin for cardiac dence.3,4 In an unpublished survey buprenorphine and/or acepro- inotropic support and to slow the of 100 board-certified veterinary mazine or morphine ventricular response to atrial fib- cardiologists, almost 60% prescribed G Consensus: Nitroprusside (a rillation in dogs so afflicted ACE inhibitors in small breeds of mixed vasodilator) and/or dobut- dogs and nearly 70% prescribed the amine (inotropic effect, afterload For my patients drugs in large breeds at this stage.5 reduction, reduction of mitral My personal approach to Cc orifice size) via CRI patients is to use triple therapy as For some of my more dedicated G Majority: ACE inhibitor, based well as spironolactone. This would owners, I often prescribe up-titra- on human research evaluating IV be accompanied by moderate tion of a beta-blocker and would enalaprilat (the active metabolite sodium restriction in a well- consider adding spironolactone. I of enalapril)9,10 and the results of balanced commercial canine diet. base the latter approach on recent the IMPROVE trial11 research conducted at North Car- olina State University College of For my patients CONTINUES Veterinary Medicine. This study I was in the minority in advocating indicates that “aldosterone escape” the use of nitroglycerin in patients at can occur when benazepril is used in this stage of the disease. I believe healthy dogs that are undergoing that additional off-loading therapy furosemide-induced activation of is beneficial and can be used in place the renin–angiotensin–aldosterone of nitroprusside, which can be cum- system (RAAS).6 bersome (requires protection from light; CRI; shelf-life of 24 hours after reconstitution; blood pressure monitoring). Otherwise, my treat- ment approach is the same as that of the panel as a whole.LATE-BREAKING DATAThe consensus statement was prepared before the publication of a placebo-controlled, double-blind study that demonstrated thepositive impact of spironolactone when added to standard therapy in dogs with heart failure.18 The panel may have reached con-sensus on the use of spironolactone in dogs with stage C disease if this information had been available during our deliberations.How I Treat / NAVC Clinician’s Brief / July 2011 .....................................................................................................................................................................................55
  10. 10. H ow I Tre a t CONTINUED S TA G E Da S TA G E Dc ACVIM classification ACVIM classification G Refractory heart failure requiring hospitalization G Refractory heart failure requiring at-home care From the panel G Consensus: Maximum recommended or tolerated doses of furosemide, From the panel pimobendan, and an ACE inhibitor, assuming already in therapeutic regimen G Consensus: Continue triple therapy as G Consensus: When indicated, antiarrhythmic should be used before a patient adjusted in stage Da is considered refractory to standard therapy G Consensus: Increase dose of furosemide G Consensus: Additional furosemide (IV, IM bolus, or CRI) until respiratory as needed to ease pulmonary edema or distress has decreased or for a maximum of 4 hours if renal function is body cavity effusions adequate G Consensus: Monitor renal function Q 12 G Consensus: Fluid removal from chest or abdomen as needed to aid in to 24 H after dose increase to gauge respiration/comfort renal dysfunction G Consensus: Relieve dyspnea/discomfort via appropriate humidity, environ- G Consensus: Spironolactone, if not mental temperature, and body positioning (assumed from Stage Ca recom- previously initiated mendations) G Consensus: Against beta-blockade unless G Consensus: Sedation with buprenorphine and/or acepromazine or morphine signs of heart failure can be controlled (assumed from Stage Ca recommendations) G Consensus: Highly palatable, mildly G Consensus: Mechanical ventilation and oxygen supplementation sodium-restricted diet G Consensus: Vigorous afterload reduction in dogs that can tolerate arterial vasodilation (nitroprusside, hydralazine, amlodipine) For my patients G Consensus: Nitroprusside (a mixed vasodilator) and/or dobutamine (inotropic My approach to the refractory patient that effect, afterload reduction, reduction of mitral orifice size) via CRI has returned home would include maxi- G Majority: ACE inhibitor, based on human research evaluating IV enalaprilat mum dose of an ACE inhibitor, continua- (the active metabolite of enalapril)9,10 and the results of the IMPROVE trial11 tion of spironolactone, and higher doses of (Note: this applies to cases not receiving an ACE inhibitor when admitted to furosemide and/or additional diuretics, the hospital) such as hydrochlorothiazide or torsemide. For my patients Pimobendan would be continued and the My approach to Stage Da patients includes the already prescribed ACE dose increased as needed to maintain a state inhibitor and spironolactone. Oral furosemide would be replaced with free of clinical signs. An antiarrhythmic furosemide CRI, and heart rate and rhythm would be controlled with drugs agent would be prescribed when needed, as such as digoxin, lidocaine, and/or sotalol. Beta-blocker, if previously initiated, mentioned above, and sodium restriction would be continued but would not be instituted at this phase. may be intensified. Further off-loading therapy would include nitroprusside or the combination of Beta-blocker would be used only if initiated nitroglycerin and amlodipine, depending on severity of signs. Inotropic support prior to decompensation. I would use tho- might include pimobendan (with a dose increase if previously prescribed) and/or racentesis and abdominocentesis as needed, dobutamine CRI. Sedation, mechanical fluid removal, ventilation, and oxygen and I would add sildenafil to the regimen if therapy would be used as needed and described above. pulmonary hypertension is present. It is important to emphasize that each case is different and the therapeutic Nutraceuticals, such as fish oil, may be requirements vary. No cookbook formula can be provided other than the use of added to help avoid or reverse cardiac “triple therapy” here. It is also important to understand that while most patients cachexia. in Da stage will be on cardiac therapy, some will not.56 .....................................................................................................................................................................................NAVC Clinician’s Brief / July 2011 / How I Treat
  11. 11. How Clarke Atkins Does It Stage A CVHD (At risk) Stage Cc CVHD Stage Dc CVHD G No treatment ( Fa i l u r e o r h i s t o r y o f (Refractory: at home) G Remove from breeding stock failure: at home) G Diuretic & MRB (furosemide G Advise client about disease progress G ACE inhibitor [higher doses] & spironolactone & what to expect G Diuretic (furosemide) and/or additional hydrochloro- G MRB (spironolactone) thiazide or torsemide) Stage B1 CVHD G Pimobendan G ACE inhibitor (perhaps increased (Murmur and no G Moderate sodium restriction dose) enlargement) G Pimobendan, typically at an G Diet: Mild sodium restriction Stage Da CVHD increased dosage G Antiarrhythmic as previously G Blood pressure: Possible hyperten- (Refractory: hospitalized) sion control (eg, ACE inhibitor, G Diuretic (furosemide CRI) as described usually with amlodipine) G Monitor renal function needed G Spironolactone G ACE inhibitor (continue or G Greater dietary sodium restriction Stage B2 CVHD institute) G Beta-blocker continued (but not (Murmur & enlargement) G MRB (spironolactone) G Inotropic support (pimobendan or initiated) G ACE inhibitor G Sildenafil with pulmonary G Beta-blocker dobutamine CRI) G Antiarrhythmic agent as indicated hypertension G Possibly MRB (spironolactone) G Nutraceuticals for cachexia (digoxin, diltiazem, lidocaine, G Thoracentesis or abdominocentesis Stage Ca CVHD sotalol) G Relieve dyspnea ( Fa i l u r e o r h i s t o r y o f G Sedation failure: hospitalized) G Nitroprusside or nitroglycerin G Nitroglycerine therapy G Diuretic (furosemide) & amlodipine G Oxygen G ACE inhibitor G Ventilation G Pimobendan G Beta-blocker continued (but not G Oxygen G Dobutamine initiated) G Thoracentesis or abdominocentesis G Thoracentesis or abdominocentesis G Sedation G Relief of dyspneaCANINE CVHD—IDEALLY A SURGICAL DISEASEIdeally, severe canine CVHD is a surgical disease, but valve repair or replacementefforts have not been met with adequate success. Recent case studies have shown that ACE = angiotensin-converting enzyme,surgical mitral valve repair has resulted in high perioperative mortality19 and surgical CVHD = chronic valvular heart disease,valve replacement has resulted in postoperative thrombus formation,20 but there have IMPROVE = invasive multicenter prospective veterinary evaluation of enalapril study,been some individual successes. However, the cost, small number of participating MRB = mineralocorticoid receptor blockerhospitals, and limited success have rendered surgical correction of canine CVHDimpractical, leaving it as a medically managed disease in veterinary medicine for theforeseeable future.How I Treat / NAVC Clinician’s Brief / July 2011 .....................................................................................................................................................................................57
  12. 12. The most commonly used drugs and protocols for immune-mediated diseases have been adoptedfrom human medicine, often without the benefit of prospective studies in dogs and cats. This in-depth review details current understanding of the immune system with respect to autoimmunity.The authors then extensively review published data on the treatment of 5 important immune-mediated diseases in dogs: immune-mediated hemolytic anemia (IMHA), immune-mediatedthrombocytopenia (IMTP), acquired myasthenia gravis (AMG), glomerulonephritis, and inflamma-tory bowel disease (IBD).The pathophysiology of IMHA is complex. Case studies indicate that the thromboembolic state thatoften accompanies or follows IMHA is a major cause of death. Prospective clinical studies fortreatment of IMHA have evaluated cyclosporine, danazol, and azathioprine in IMHA used in con-junction with glucocorticoids and shown no benefit over prednisone alone. Azathioprine has notbeen used in prospective studies, but retrospective studies suggest a beneficial effect over pred-nisone alone. By contrast with IMHA, clinical signs of IMTP can be fairly mild and most patientsrespond well to glucocorticoid therapy. The only additional drugs evaluated prospectively in con-trolled studies were vincristine and intravenous immunoglobulin (IVIG), both used in combinationCapsuleswith glucocorticoids. Dogs receiving prednisone and IVIG had significantly higher platelet counts C O N T I N U E D F R O M PA G E 3 9and shorter hospitalization stays than those receiving prednisone alone. A small study showedvincristine to be an effective adjunctive therapy for stimulating platelet production. Leflunomideand cyclosporine were separately shown to have some efficacy; however one dog receivingcyclosporine died of systemic aspergillosis, possibly secondary to immunosuppression.Drug Efficacy in Immune-Mediated DiseasesAMG is frequently associated with other immune-mediated and neoplastic diseases. The authorspoint out that it has the potential for spontaneous remission, creating a significant confoundingfactor in clinical studies. Glucocorticoids have been used but the side effects are of significantconcern (muscle weakness, aspiration pneumonia). Azathioprine alone or with prednisone hasbeen associated with better survival rates. Cyclosporine has also been used in a small number ofcases as part of combination therapy or following glucocorticoid therapy. Canine glomerulonephri-tis is an immune-complex–mediated disease. True autoimmune glomerulonephritis is rare. Thereis no evidence that immunosuppressive therapy is of benefit and it may be detrimental. IBD is acomplex disease and little evidence exists that this is a true autoimmune disease. Manipulation ofexogenous antigens in contact with the mucosa and control of the inflammatory response arecornerstones of treatment.Commentary: These drugs represent what is available today to treat immune-mediated diseases.Their overall effect on the immune system is nonspecific, which can lead to compromise of otherareas and unfortunate complications (ie, susceptibility to infection). New technologies from humanmedicine that are more target specific are being studied. One example is canine recombinantinterferon-gamma that “rebalances” the activity of Th1 and Th2 lymphocytes for the managementof canine atopic dermatitis. Another example is the use of a peptide vaccine to treat dogs withspontaneous myasthenia gravis.—Karen A. Moriello, DVM, Diplomate ACVDImmunomodulatory drugs and their application to the management of canine immune-mediated disease. WhitleyNT, Day MJ. J SMALL ANIM PRACT 52:70-85, 2011. CONTINUES58 ..............................................................................................NAVC Clinician’s Brief / July 2011 / Capsules
  13. 13. Mechanical stretching of the skin by creating a and both had a healthy granulation bed. Skin Commentary: Preoperative skin stretching is aconstant load over time results in cellular stretchers were placed on the patient’s back, technique that has been used in human recon-growth and tissue regeneration. This phenome- and the owners were instructed to gently tighten structive surgery for procedures as varied asnon is typically seen in pregnancy, skin growth the cables daily if there was a loss of tension. extensive oncologic resections to the separationover benign tumors, and obesity. Preoperative After 4 days, the dog was admitted for wound of conjoined twins. The system mentioned in thisskin stretching has been described in dogs and repair. The skin stretchers had created approxi- case report was originally described by Pavleticcats. In this report, a 7-year-old male dog was mately 8 to10 cm of additional skin. The flap for more than a decade ago. It is easy to use andevaluated for 2 wounds—1 in the right cervical wound reconstruction was created over the right avoids the significant expense and increasedarea, the other on the right antebrachium— caudal shoulder area, allowing preservation of morbidity of temporary inflatable subcutaneoussustained during a dog fight. The wounds were local blood supply and the right thoracodorsal implants. Although the theory is a little complex,severe. The right cervical wound was 8 cm long artery and vein. The flap was then rotated 180° the application of skin stretching is a relativelyand extended 10 cm ventrally from the dorsal into the wound and sutured to the distal ante- simple technique that is undoubtedly underuti-midline. The right antebrachium was devoid of brachium. Drains were placed under the base of lized in veterinary surgery.—Art Fettig, DVM,skin from the elbow to the carpus except for a the flap exiting caudal to the elbow and were Diplomate ACVSsmall piece extending distally from the elbow removed 4 days after surgery. The dog was dis-and another thin strip on the craniomedial charged 5 days after surgery and at 5 monthsCapsulesaspect of the limb. Neither wound was infected the flap was intact and completely healed. CONTINUED Use of skin stretchers to elongate a peninsular thoraco- dorsal axial pattern flap for antebrachial wound closure in a dog. Holt DE, Runge J. VET SURG 40:352-356, 2011.Skin by a StretchCefpodoxime proxetil (Simplicef, pfizer.com) is a excreted essentially unchanged in the urine with further evaluation. This study also suggests thatonce-daily orally absorbed antibiotic with a wide cumulative percentages of unchanged cefpo- cefpodoxime rapidly achieves good penetrationspectrum of activity that is widely used to treat doxime at 72.2% and 95.8% at the 5 mg/kg and of the skin, has a half-life of 3 to 5 hours, andskin infections. It is a third-generation cephalo- 10 mg/kg doses, respectively. Based on these persists in the tissue for up to 22 hours followingsporin that in the intestine is cleaved into the studies the authors recommend a dose of 10 administration. Pharmacokinetic data indicateactive metabolite cefpodoxime. In this study, the mg/kg for skin infections for bacteria with an that cefpodoxime should be effective againstcefpodoxime concentrations in plasma, subcuta- MIC50 (minimum inhibitory concentration) up to certain microbes (MIC50 < 0.5 mcg/mL); how-neous (SC) tissue, and urine were determined 0.5 mcg/mL. Higher and more frequent dosing ever, for microbes with a higher MIC50, cefpo-using a crossover design. Dogs received 2 dose would be needed for bacteria with higher MIC doxime should be administered at a higher doselevels of cefpodoxime proxetil (6.5 mg/kg and values. These data suggest that this drug would or with increased frequency for effective treat-13.0 mg/kg; the equivalent of 5 mg/kg and 10 be useful in treating urinary tract infections ment. The importance of pharmacokinetic stud-mg/kg cefpodoxime, respectively) with a 1-week (UTI). Supported by Pfizer Animal Health ies to optimize antimicrobial therapy and ofwashout period between doses. Blood samples obtaining culture and sensitivity data to makewere collected from a cannulated cephalic vein, Commentary: The pharmacokinetics of cefpo- the most appropriate choice of antibiotic andurine was collected via a Foley catheter, and a doxime in dogs was evaluated in this study, dosing schedule are highlighted here.—Jennifersterile microanalysis probe was used to obtain focusing specifically on plasma and SC distribu- Ginn, DVM, Diplomate ACVIMsamples from the SC tissue. The mean maxi- tion after a single oral dose. The concentrationmum concentration in plasma was 13.66 of cefpodoxime in urine was also measured tomcg/mL and 27.14 mcg/mL at 5 mg/kg and 10 determine whether the drug might be useful inmg/kg cefpodoxime, respectively. Cefpodoxime treating UTI in dogs. Cefpodoxime was elimi-was widely distributed to the skin with maximum nated mostly in the urine and in high concentra- Pharmacokinetics of cefpodoxime in plasma and subcu-concentrations of 1.70 mcg/mL (5 mg/kg dose) tions, which suggests that it may indeed beUtility of Cefpodoxime taneous fluid following oral administration of cefpodoximeand 3.06 mcg/mL (10 mg/kg dose). The drug was effective for UTI in dogs, although this requires proxetil in male beagle dogs. Kumar V, Madabushi R, Lucchesi MBB, Derendorf H. J VET PHARMACOL THER 34:130-135, 2011. CONTINUES60 ........................................................................................................................................................................................NAVC Clinician’s Brief / July 2011 / Capsules

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