NAVC clinician brief july 2011

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 promote
One of the pri-
were associated with major medical schools. By human health by ensuring the safety of the food
mary goals of the the 1920s, however, all except one of our veteri- supply, preventing major zoonotic scourges such
One Health Com- nary colleges (the exception being University of as salmonellosis and tuberculosis, and controlling
mission 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 physicians
advance the ties such as Pullman, Washington, and Ithaca, and veterinarians, with each working in their
understanding, 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 A
treatment of
requirements and, unfortunately, narrowed the COMEBACK
zoonotic 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. 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 insurance
education, 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; the
nent administrative home for the One Health more rapid speed with which these pathogens
Commission has recently been created at Iowa travel around the world; and the growing
State University. immunocompromised human population have
compelled us to keep this issue at the forefront
THE GOALS OF ONE HEALTH of the One Health movement.
Promoting Public Health
One of the primary goals of the One Health CONTINUES
Commission is to advance the understanding,
A Matter of Opinion / NAVC Clinician’s Brief / July 2011.......................................................................................................................................................................43

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 when
See Aids & Resources, considering One Health. A growing body of
back 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. Dwight D. Bowman, MS, PhD
W h a t ’s t h e Ta k e H o m e ? PA RA S I TOLOGY Cornell University
Peer 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 SCENARIO
In February, Jocko presents for a routine semian-
nual visit to his veterinarian in Sayre, Pennsylva-
nia, a small town located in the north-central
part of the state. The owner, Mrs. Jacobs, is a
widow who lives by herself in Lehigh Towers, a
retirement apartment complex maintained under
the Sayre community’s housing authority. Each
tenant is allowed to have a single pet cat or small
dog, but pets are forbidden access to the facility’s
grounds, so Jocko is truly an indoor cat.
When it comes to flea control, Mrs. Jacobs is
happy enough with how Jocko has been faring
over the past 6 months and would like to stay
the course on monthly Program (lufenuron,
program.novartis.us). During this visit, she needs
the veterinarian to complete the required annual
certification 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 Jocko
as well as protect the other elderly folks living in
Lehigh Towers?
CONTINUES
What’s the Take-Home? / NAVC Clinician’s Brief / July 2011 ................................................................................................................................................................47

5. W h a t ’s t h e Ta k e - H o m e ? CONTINUED
CORRECT ANSWER By giving 1 Capstar tablet to Jocko during this
D. Give Mrs. Jacobs 7 days of Capstar visit and having Mrs. Jacobs give him 1 tablet
and 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 in
erinary technician who has expertise ment), you should be able to sign the document
households today isn’t the cat flea or the dog flea
in resolving flea problems. with a clear con-
—it’s the human flea.
science2—but only
WEIGHING YOUR OPTIONS if there is proper
From the Case Scenario, it should be clear that follow-up.
this very likely is not a simple case of product
failure. Although that is always a possibility, Mrs. Managing this flea
Jacobs receives her product from you, and you problem is going to
have had no complaints from others about its use. require veterinary
Yes, 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 canis
is 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 bites
Obviously, 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 live
ers 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 places
Jocko 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 have
cidal 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. W h a t ’s t h e Ta k e - H o m e ? CONTINUED
Sometimes 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 in
managing flea
ovicidal, and larvicidal activities would likely pro- the neighbor’s apartment eclosed from their
problems tect Jocko and Mrs. Jacobs from being bothered pupal cases but had no host with the dog being
requires direct by fleas, the problem probably extends into the gone, so they started looking for a new blood
intervention 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 obtain
veterinary 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 challenging
flea 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 have
Advantage = 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 + pyriproxyfen
50 ................................................................................................................................................................NAVC Clinician’s Brief / July 2011 / What’s the Take-Home?

7. Clarke Atkins, DVM, Diplomate ACVIM
(Internal Medicine & Cardiology),
North Carolina State University
H ow I Tre a t CARDIOLOGY
Peer 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 ACVIM
Canine chronic valvular heart disease (CVHD) is the most important
nonparasitic cardiovascular disease in veterinary medicine, but
controversy remains about the best treatment.
THE PLAYERS
Canine CVHD, also known as endocardiosis, THE PANEL
myxomatous valve degeneration, and mitral
regurgitation (MR), affects approximately 85%
of dogs 13 years of age or older and accounts for
75% of heart disease in dogs.1 For such a sub-
stantial disease, it may be surprising that there
still is controversy and general lack of agreement
about the appropriate medical management, both
before and after the onset of heart failure.
To this end, the American College of Veterinary
Internal Medicine’s (ACVIM) Board of Regents
recently selected a group of European and Amer-
ican board-certified cardiologists to present a
formal consensus for the diagnosis and treatment
of CVHD.1 The 10 panel members represented THE PROCESS
diverse points of view on cardiac therapeutics. Based on available evidence, the ACVIM panel
determined whether the potential benefits of a
The consensus statements and recommendations given treatment option clearly outweighed the
of the panel are not to be taken as “cutting edge” risk for adverse events and if the financial impact
but rather as a sampling of the “collective wis- on the patient and client would be justifiable.
dom” that occurs when reasonable people reach a CONTINUES
compromise after reviewing published data and
their own experiences.
ACVIM = American College of Veterinary Internal Medicine, CVHD = chronic valvular heart disease
How I Treat / NAVC Clinician’s Brief / July 2011 .....................................................................................................................................................................................53

8. H ow I Tre a t CONTINUED
Consensus was defined as all 10 panel
members agreeing to a particular recom-
S TA G E A S TA G E B1
mendation, but we also revealed when a
majority of the panelists agreed on a rec- ACVIM classification ACVIM classification
ommendation even if the criteria for G Patient at risk G Murmur present
consensus were not met. G No clinical signs G No cardiomegaly
HEALTH CARE SCHEME From the panel From the panel
Although a number of classification G No drug or dietary therapy G Consensus: No drug or dietary
schemes that grade cardiac disease in recommended at this stage therapy recommended at this
dogs 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, defined
the American Heart Association and the gram if MR is present here as radiographic or echocar-
American College of Cardiology. Our diographic evidence of a normal
system avoids the inclusion of progres- For my patients or equivocally enlarged left
sive exercise intolerance when grading For dogs with stage A CVHD, I atrium, left ventricle, or both, in
disease 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 can
In this article, I describe some of the be done for a patient if the owner For my patients
more important consensus and majority has financial constraints. I discuss I suggest to owners that the dog
findings from the panel, as well as offer diet and exercise and the role of may benefit in the long-term from a
some insights into how these findings dietary restrictions as heart failure diet that is mildly to moderately
can translate into everyday patient care ensues. I also give the owners a restricted in sodium content, while
based 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 pressure
Note: 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 ACE
patient. For example, it is unlikely that a inhibitor in the relatively unusual
dog on pimobendan would also receive circumstance in which systemic
dobutamine. hypertension accompanies CVHD.
This is true at any stage of CVHD.
ACE = angiotensin-converting enzyme, ACVIM = American
College of Veterinary Internal Medicine, CVHD = chronic valvular
heart disease, IMPROVE = invasive multicenter prospective
veterinary evaluation of enalapril study, MR = mitral regurgitation,
RAAS = renin–angiotensin–aldosterone system
54 .....................................................................................................................................................................................NAVC Clinician’s Brief / July 2011 / How I Treat

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 DATA
The consensus statement was prepared before the publication of a placebo-controlled, double-blind study that demonstrated the
positive 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. 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. 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 dyspnea
CANINE CVHD—IDEALLY A SURGICAL DISEASE
Ideally, severe canine CVHD is a surgical disease, but valve repair or replacement
efforts 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 blocker
hospitals, and limited success have rendered surgical correction of canine CVHD
impractical, leaving it as a medically managed disease in veterinary medicine for the
foreseeable future.
How I Treat / NAVC Clinician’s Brief / July 2011 .....................................................................................................................................................................................57

12. The most commonly used drugs and protocols for immune-mediated diseases have been adopted
from 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-mediated
thrombocytopenia (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 that
often accompanies or follows IMHA is a major cause of death. Prospective clinical studies for
treatment 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 not
been 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 patients
respond well to glucocorticoid therapy. The only additional drugs evaluated prospectively in con-
trolled studies were vincristine and intravenous immunoglobulin (IVIG), both used in combination
Capsules
with 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 9
and shorter hospitalization stays than those receiving prednisone alone. A small study showed
vincristine to be an effective adjunctive therapy for stimulating platelet production. Leflunomide
and cyclosporine were separately shown to have some efficacy; however one dog receiving
cyclosporine died of systemic aspergillosis, possibly secondary to immunosuppression.
Drug Efficacy in Immune-Mediated Diseases
AMG is frequently associated with other immune-mediated and neoplastic diseases. The authors
point out that it has the potential for spontaneous remission, creating a significant confounding
factor in clinical studies. Glucocorticoids have been used but the side effects are of significant
concern (muscle weakness, aspiration pneumonia). Azathioprine alone or with prednisone has
been associated with better survival rates. Cyclosporine has also been used in a small number of
cases as part of combination therapy or following glucocorticoid therapy. Canine glomerulonephri-
tis is an immune-complex–mediated disease. True autoimmune glomerulonephritis is rare. There
is no evidence that immunosuppressive therapy is of benefit and it may be detrimental. IBD is a
complex disease and little evidence exists that this is a true autoimmune disease. Manipulation of
exogenous antigens in contact with the mucosa and control of the inflammatory response are
cornerstones 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 other
areas and unfortunate complications (ie, susceptibility to infection). New technologies from human
medicine that are more target specific are being studied. One example is canine recombinant
interferon-gamma that “rebalances” the activity of Th1 and Th2 lymphocytes for the management
of canine atopic dermatitis. Another example is the use of a peptide vaccine to treat dogs with
spontaneous myasthenia gravis.—Karen A. Moriello, DVM, Diplomate ACVD
Immunomodulatory drugs and their application to the management of canine immune-mediated disease. Whitley
NT, Day MJ. J SMALL ANIM PRACT 52:70-85, 2011.
CONTINUES
58 ..............................................................................................NAVC Clinician’s Brief / July 2011 / Capsules

13. Mechanical stretching of the skin by creating a and both had a healthy granulation bed. Skin Commentary: Preoperative skin stretching is a
constant 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 as
non is typically seen in pregnancy, skin growth the cables daily if there was a loss of tension. extensive oncologic resections to the separation
over benign tumors, and obesity. Preoperative After 4 days, the dog was admitted for wound of conjoined twins. The system mentioned in this
skin stretching has been described in dogs and repair. The skin stretchers had created approxi- case report was originally described by Pavletic
cats. 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 and
evaluated for 2 wounds—1 in the right cervical wound reconstruction was created over the right avoids the significant expense and increased
area, the other on the right antebrachium— caudal shoulder area, allowing preservation of morbidity of temporary inflatable subcutaneous
sustained 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 relatively
and 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 ACVS
small 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 months
Capsules
aspect 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 Stretch
Cefpodoxime proxetil (Simplicef, pfizer.com) is a excreted essentially unchanged in the urine with further evaluation. This study also suggests that
once-daily orally absorbed antibiotic with a wide cumulative percentages of unchanged cefpo- cefpodoxime rapidly achieves good penetration
spectrum 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, and
skin infections. It is a third-generation cephalo- 10 mg/kg doses, respectively. Based on these persists in the tissue for up to 22 hours following
sporin that in the intestine is cleaved into the studies the authors recommend a dose of 10 administration. Pharmacokinetic data indicate
active metabolite cefpodoxime. In this study, the mg/kg for skin infections for bacteria with an that cefpodoxime should be effective against
cefpodoxime 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 dose
levels 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 of
washout period between doses. Blood samples obtaining culture and sensitivity data to make
were collected from a cannulated cephalic vein, Commentary: The pharmacokinetics of cefpo- the most appropriate choice of antibiotic and
urine was collected via a Foley catheter, and a doxime in dogs was evaluated in this study, dosing schedule are highlighted here.—Jennifer
sterile microanalysis probe was used to obtain focusing specifically on plasma and SC distribu- Ginn, DVM, Diplomate ACVIM
samples from the SC tissue. The mean maxi- tion after a single oral dose. The concentration
mum concentration in plasma was 13.66 of cefpodoxime in urine was also measured to
mcg/mL and 27.14 mcg/mL at 5 mg/kg and 10 determine whether the drug might be useful in
mg/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 be
Utility of Cefpodoxime
taneous fluid following oral administration of cefpodoxime
and 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.
CONTINUES
60 ........................................................................................................................................................................................NAVC Clinician’s Brief / July 2011 / Capsules