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December 2019
A Peer-Reviewed Journal | cliniciansbrief.com
CASE: EYE
COLOR CHANGE
IN THIS ISSUE
IN A DOG
Socialization for
Puppies & Kittens
Top 5 Canine Biliary Diseases
Overview of
Mast Cell Tumors
Step-by-Step Urinary
Catheter Placement in Dogs
Differential Diagnosis List:
Hyperphosphatemia
Volume 17 Number 12
THE OFFICIAL CLINICAL PRACTICE JOURNAL OF THE WSAVA
HELP KEEP YOUR
PATIENTS STRONG
Hill’s Prescription Diet k/d1 is clinically shown in a recent GREAT TASTING
study2 to outperform Royal Canin3 at managing CKD.
SIX-MONTH CLINICAL RESULTS
Compared to Royal Canin Veterinary Diet Renal Support A Feline,3 cats with chronic kidney disease
(CKD) fed Prescription Diet k/d Feline1 with E.A.T (Enhanced Appetite Trigger) Technology:
1 Voluntarily consumed 23% more calories2
2 Increased their body weight by 5.8% while Royal Canin3 cats lost 13%2
3 Maintained their muscle mass while Royal Canin3 cats lost over 11%2
TAKE CONTROL TODAY — recommend the clinical strength of Prescription Diet k/d.1
1
Hill’s® Prescription Diet® k/d® Feline with chicken dry food. 2Data on file. Hill’s Pet Nutrition, Inc. 2018. Results are average values with statistical significance (p value less than
or equal to 0.05). 3Royal Canin Veterinary Diet Renal Support A Feline, dry food sold in the US market. ©2019 Hill’s Pet Nutrition, Inc. ®/™ Hill’s, Prescription Diet, k/d and
E.A.T. Technology are trademarks owned by Hill’s Pet Nutrition, Inc. Royal Canin is a registered trademark owned by ROYAL CANIN SAS.
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in veterinary
medicine
December 2019 cliniciansbrief.com 1
From Clinician’s Brief
on Social Media
WE ASKED …
What is the strangest thing a Do you prefer an open or closed technique
patient has regurgitated prior for routine canine neutering?
to surgery?
“A quarter and a penny. We took it off the owner’s
bill.”—Missie B
“A very fresh mouse. A cat was being kept overnight
and was being fasted before surgery the next
morning. Apparently, the mouse had gotten into the
43
kennel and the cat killed and ate it for breakfast.”
—Darlene J
%
“A doll head.”—Erin S
Open
57
“A whole hummingbird—not chewed. We could still
see the beak.”—Lilia W
%
“The patient’s own tail.”—Michael K
Closed
“The item we were planning to surgically remove.”
—Jennifer M
What is your favorite
team-building exercise?
“Ice cream Fridays.”—Lindsey A
“We went curling. It was actually a lot of fun!”
Do you use corticosteroid-containing
—Ciara R
sprays on hot spots?
“Pizza in the breakroom.”—Jenn P
55% Yes
“Escape room.”—Judy S
45% No
“Pug nail trims!”—Andrea B
FOLLOW US
facebook.com/cliniciansbrief @CliniciansBrief clinicians.brief
2 cliniciansbrief.com December 2019
Hidden Disease. Visible Answer.
As your experts in endocrinology, Dechra Veterinary Products
is proud to offer ZYCORTAL® Suspension
(desoxycorticosterone pivalate injectable suspension)
• Replacement therapy for mineralocorticoid deficiency in dogs
with primary hypoadrenocorticism (Addison’s Disease)
• FDA approved for subcutaneous use
• 4mL vial of 25mg/mL suspension
• Available direct from your preferred distributor
• Three year shelf life from the date of manufacture
FREE CE ON ADDISON’S DISEASE
Learn how to diagnose and treat Addison’s Disease from one of the top
minds in the field of Veterinary Endocrinology, Dr. Audrey Cook. This course
is approved by the AAVSB RACE to offer a total of 2.00 CE Credits for both
veterinarians and technicians. Each module earns you 1.00 CE Credit in the
Scientific category. This course is free to veterinarians and technicians through
Dechra Academy at dechra-us.com/CE.
NADA 141-444, Approved by FDA CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian.
Dechra is a registered trademark of Dechra Pharmaceuticals PLC. Zycortal is a registered trademark of Dechra Limited.
Z Y C O R T A L® CONTRAINDICATIONS: Do not use ZYCORTAL Suspension in dogs
that have previously had a hypersensitivity reaction to
ADVERSE REACTIONS: The field safety analysis included evaluation of
152 dogs. The most common adverse reactions reported are polyuria,
polydipsia, depression/lethargy, inappropriate urination, alopecia,
SUSPENSION (desoxycorticosterone desoxycorticosterone pivalate.
decreased appetite/anorexia, panting, vomiting, diarrhea, shaking/
pivalate injectable suspension) WARNINGS: Use ZYCORTAL Suspension with caution in dogs with trembling, polyphagia, urinary tract infection, urinary tract incontinence
congestive heart disease, edema, severe renal disease or primary hepat- and restlessness. Reports of anaphylaxis and anemia have been
Mineralocorticoid for subcutaneous use in dogs only. ic failure. Desoxycorticosterone pivalate may cause polyuria, polydipsia, associated with a different desoxycorticosterone pivalate injectable
increased blood volume, edema and cardiac enlargement. Excessive suspension product.
Z Y C O R T A L®
Brief Summary (For Full Prescribing Information, see package insert) weight gain may indicate fluid retention secondary to sodium retention.
Distributed by:
CAUTION: Federal (USA) law restricts this drug to use by or on the HUMAN WARNINGS: Not for human use. Keep this and all drugs out Dechra Veterinary Products
order of a licensed veterinarian. of the reach of children. Consult a physician in case of accidental human
SUSPENSION (desoxycorticosterone exposure.
7015 College Boulevard, Suite 525
Overland Park, KS 66211
pivalateDesoxycorticosterone
DESCRIPTION: injectable suspension)
pivalate is a mineralocorticoid
PRECAUTIONS: Any dog presenting with severe hypovolemia,
hormone. Zycortal Suspension contains 25mg/ml of ZYCORTAL is a trademark of
desoxycorticosterone pivalate. dehydration, pre-renal azotemia and inadequate tissue perfusion Dechra Ltd © 2015,
(“Addisonian crisis”) must be rehydrated with intravenous fluid (saline) All rights reserved
INDICATION: For use as replacement therapy for mineralocorticoid
Z Y C O R T A L®
therapy before starting treatment with ZYCORTAL Suspension. The NADA 141-444,
deficiency in dogs with primary hypoadrenocorticism (Addison’s effectiveness of ZYCORTAL Suspension may be reduced if
disease). Approved by FD
potassium-sparing diuretics, such as spironolactone, are administered
SUSPENSION (desoxycorticosterone concurrently. 01AD-ZYC50104-0219
pivalate injectable suspension)
ERASING RABIES
ONE VACCINE AT A TIME!
Rabies is a deadly disease that can affect domestic animals, wild animals, and humans.
An estimated 59,000 people die from rabies each year.1 Children are at greatest risk from
rabies, with 40% of rabies deaths occur in children 15 years old or younger.2
Outbreaks can be controlled when more than 70% of an area’s canine population is
vaccinated.3 In 2015, the world called for action by setting a goal of zero human dog-
mediated rabies deaths by 2030, worldwide.4
Merck Animal Health, the makers of Nobivac® vaccines, is committed to making a
difference. Every purchase of Nobivac® vaccines helps contribute to the ability to provide
ongoing support and vaccine donations to non-profit organizations such as Rabies Free
Africa and Mission Rabies.
In honor of World Rabies Day, Gallatin Veterinary
Hospital brought awareness to this deadly disease by
participating in the Nobivac® Paw Print Campaign.
Gallatin Veterinary Hospital is proud to show
their commitment to the cause to help Erase
Rabies by 2030!
References: 1. Hampson K, Coudeville L, Lembo T, et al. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis. 2015;9(4):e0003709. 2. Rabies. World Health Organization website.
https://www.who.int/news-room/fact-sheets/detail/rabies. Accessed September 13, 2019. 3. Morters MK, McNabb S, Horton DL, et al. Effective vaccination against rabies in puppies in rabies endemic
regions. Veterinary Record. 2015;177:150. 4. Global Alliance for Rabies Control. Zero by 30: Our catalytic response. https://rabiesalliance.org/policy/united_against_rabies. Accessed September 13, 2019.
© 2019 Intervet Inc., d/b/a Merck Animal Health, a subsidiary of Merck & Co., Inc. All rights reserved. US-NOV-190800191
IN THIS
ISSUE
ON THE COVER
CASE IN POINT
Eye Color
Change in a Dog
Andrew Christopher Lewin,
BVM&S, DACVO
59
PG
NOTICE OF CORRECTION
In the article “Responsible
Antimicrobial Stewardship”
11 TOP 5
Top 5 Canine Biliary Diseases
Stefanie M. DeMonaco, DVM, MS,
62 PROCEDURES PRO
Urinary Catheter
Placement in Dogs
in the November 2019 issue DACVIM (SAIM) Lisa L. Powell, DVM, DACVECC
of Clinician’s Brief, the phrase
“and the patient does have
signs of antimicrobial resis-
tance” should have read “and
the patient does not have signs
22 CONSULT THE EXPERT
Puppy & Kitten Socialization
Leslie Sinn, CPDT-KA, DVM, DACVB
of antimicrobial resistance”
in the following sentence:
“Empiric antimicrobial therapy
should only be used to treat
other infections when the
31 CONSULT THE EXPERT
Mast Cell Tumors
Brooke Britton, DVM, DACVIM (Oncology)
infection is not life threatening,
57
the patient has not had an
infection in the past 3 months, DIFFERENTIAL DIAGNOSIS
skin infection is superficial, Hyperphosphatemia
the infection has a predictable Julie Allen, BVMS, MS, MRCVS, DACVIM
antimicrobial susceptibility, (SAIM), DACVP
and the patient does have
signs of antimicrobial resis-
tance.” Clinician’s Brief regrets
the error.
December 2019 cliniciansbrief.com 5
No More Double Plating
The Plate Large Enough for Giant Breed Dogs
The new Arthrex 4.5 mm TPLO locking plate was designed
after extensive research and includes several key features
that make plate placement easier and more consistent.
For dogs with severe stifle instability, surgeons have the
option to use a knotless anti-rotational lateral stabilization
technique (InternalBrace™ ligament augmentation).
■ High-quality, medical-grade material, quality
assurance, and superior craftsmanship
■ Locking screws both proximally and distally
■ Shape, contour, and additional features designed
to facilitate optimal plate positioning
■ Proximal screw trajectory to optimize bone
purchase safely for TPLO and TPLO with
InternalBrace augmentation
Cranial View
© 2019 Arthrex, Inc. All rights reserved
vAD1-000098-en-US_B ArthrexVetSystems.com
ON
THE
WEB
THIS MONTH’S FEATURED CLINICAL
CONTENT AVAILABLE ONLY ONLINE
QUIZ
Understanding GI Testing
M. Katherine Tolbert, DVM, PhD,
DACVIM (SAIM)
brief.vet/GI-testing
PODCAST
Managing Stress-Related
Aggression with Dr. Sung
Wailani Sung, DVM, MS, PhD,
DACVB, discusses managing fear-
related aggression and stress in dogs
and cats at the clinic, the physical
and mental impact severe stress can
have on patients, and how to provide
low-stress visits.
brief.vet/managing-stress
17
SYMPOSIUM CAPSULES
2019 American Veterinary Medical
Association Convention
08 OUR
AUTHORS
38 FROM PAGE TO PATIENT
Tips and techniques from
70
PRACTICE HOTLINE
The latest in products
and services
the research pages
71 ADVERTISERS
INDEX
02 GET SOCIAL
Currently on Clinician’s Brief
social media 72 QUIZ CORNER
Test your knowledge
Contact us at
editor@cliniciansbrief.com
Articles archived at
cliniciansbrief.com/journal
December 2019 cliniciansbrief.com 7
OUR
AUTHORS
JULIE ALLEN, BVMS, MS, MRCVS, ANDREW CHRISTOPHER LEWIN,
DACVIM (SAIM), DACVP, is a former BVM&S, DACVO, is an assistant
clinical assistant professor of clinical professor at Louisiana State Univer-
pathology at Cornell University. She sity. He earned his veterinary degree
earned her veterinary degree from Uni- from University of Edinburgh before
versity of Glasgow and her MS from Iowa completing an internship at a private
State University, where she completed a practice in the United Kingdom and
rotating internship in small animal medi- an ophthalmology residency at
cine and surgery and a residency in small University of Wisconsin–Madison.
animal internal medicine. She also com- Dr. Lewin’s research interests include
pleted a residency in clinical pathology at ocular infectious disease and clinical
North Carolina State University. Dr. Allen veterinary ophthalmology.
focuses on cachexia/anorexia, endocri- case in point page 59
nology, and hepatobiliary and pancreatic
disease and has committed her career to LISA L. POWELL, DVM, DACVECC, is
improving the diagnosis of disease. an associate emergency medicine and
differential diagnosis page 57 critical care clinician at BluePearl
Veterinary Partners in Eden Prairie,
BROOKE BRITTON, DVM, DACVIM Minnesota. Her professional interests
(Oncology), is a veterinary medical include respiratory emergencies,
oncologist at BluePearl Veterinary mechanical ventilation, sepsis, and
Partners in New York City, New York. fluid therapy.
She earned her DVM from Cornell procedures pro page 62
University and completed a medical
oncology residency at University of LESLIE SINN, CPDT-KA, DVM, DACVB,
Pennsylvania. Dr. Britton has lectured maintains Behavior Solutions for Pets
widely and is active in oncologic research. in Leesburg, Virginia. She earned her
Her interests include hematologic malig- DVM from University of Georgia,
nancies, the biology of cancer metastasis, where she also completed an intern-
and combination drug therapy for the ship in small animal medicine and
treatment of various cancers. surgery. Dr. Sinn is a board-certified
consult the expert page 31 veterinary behaviorist and a certified
professional dog trainer. She has lec-
STEFANIE M. DEMONACO, DVM, MS, tured worldwide and is the author of
DACVIM (SAIM), is an assistant profes- numerous articles and book chapters.
sor of small animal internal medicine at consult the expert page 22 n
Virginia–Maryland College of Veterinary
Medicine, where she also earned her MS
in biomedical veterinary science and com-
pleted a residency. Dr. DeMonaco earned
her DVM from Kansas State University.
Her research interests include feline
medicine and hepatobiliary disease.
top 5 page 11
8 cliniciansbrief.com December 2019AAHA-RECOMMENDED
AND FDA-APPROVED
PRODATA
PROSUPPORT
PROZINC
Backed by the largest prospective study
in diabetic cats to date, PROZINC offers
predictable glycemic control and efficacy
proven to improve clinical signs associated
with diabetes.1-3 Another study shows that
remission rates with the use of PROZINC were
comparable to glargine. 2 Make PROZINC your
first-line treatment for diabetic cats.4–6
For more information, contact your
Boehringer Ingelheim representative.
Important Safety Information for Cats: For use in cats and dogs only. Animals presenting with severe ketoacidosis,
anorexia, lethargy, and/or vomiting should be stabilized with short-acting insulin and appropriate supportive therapy
until their condition is stabilized. As with all insulin products, careful patient monitoring for hypoglycemia and
hyperglycemia is essential to attain and maintain adequate glycemic control and to prevent associated complications.
Overdosage can result in profound hypoglycemia and death. Progestogen and glucocorticoid use should be avoided.
PROZINC insulin is contraindicated in cats during episodes of hypoglycemia and in cats sensitive to protamine zinc
recombinant human insulin or any other ingredients in the PROZINC product.
For more information, please see full prescribing information for cats.
References: 1. Data on file. Boehringer Ingelheim Animal Health USA Inc. 2. Gostelow R, Scudder C, Hazuchova K, et al. One-year prospective
randomized trial comparing effi cacy of glargine and protamine zinc insulin in diabetic cats. In: Proceedings from the American College of
Veterinary Internal Medicine Forum; June 8–10, 2017; National Harbor, MD. Abstract EN10. 3. ProZinc ® (protamine zinc recombinant human
insulin) [Freedom of Information Summary]. St. Joseph, MO: Boehringer Ingelheim Vetmedica, Inc.; 2009. 4. Rucinsky R, Cook A, Haley S, et
al. AAHA diabetes management guidelines for dogs and cats. J Am Anim Hosp Assoc. 2010;46(3):215–224. 5. American Association of Feline
Practitioners. AAFP practice guidelines. https://www.catvets.com/guidelines/practice-guidelines. Accessed September 19, 2018. 6. Sparkes
AH, Cannon M, Church D, et al. ISFM consensus guidelines on the practical management of diabetes mellitus in cats. J Feline Med Surg.
2015;17(3):235–250.
ProZinc® is a registered trademark of Boehringer Ingelheim Animal Health USA, Inc.
© 2019 Boehringer Ingelheim Animal Health USA, Inc., Duluth, GA. All rights reserved. PET-0887-PROZ0119. 18371
See page 10 for product information summary.NADA 141-297, Approved by FDA All cases of hypoglycemia resolved with appropriate therapy and if needed, a dose reduction.
ProZinc®
Three cats had injection site reactions which were described as either small, punctate,
red lesions; lesions on neck; or palpable subcutaneous thickening. All injection site
reactions resolved without cessation of therapy.
(protamine zinc recombinant human insulin) Four cats developed diabetic neuropathy during the study as evidenced by plantigrade
stance. Three cats entered the study with plantigrade stance, one of which resolved by
Caution: Federal law restricts this drug to use by or on the order of a licensed Day 45. Four cats were diagnosed with diabetic ketoacidosis during the study. Two were
veterinarian. euthanized due to poor response to treatment. Five other cats were euthanized during
Description: ProZinc® insulin is a sterile aqueous protamine zinc suspension of the study, one of which had hypoglycemia. Four cats had received ProZinc insulin for
recombinant human insulin. less than a week and were euthanized due to worsening concurrent medical conditions.
Each mL contains: The following additional clinical observations or diagnoses were reported in cats during
recombinant human insulin 40 International Units (IU) the effectiveness field study: vomiting, lethargy, diarrhea, cystitis/hematuria, upper
protamine sulfate 0.466 mg respiratory infection, dry coat, hair loss, ocular discharge, abnormal vocalization,
zinc oxide 0.088 mg black stool, and rapid breathing.
glycerin 16.00 mg Extended Use Field Study
dibasic sodium phosphate, heptahydrate 3.78 mg Cats that completed the effectiveness study were enrolled into an extended use field
phenol (added as preservative) 2.50 mg study. In this study, 145 cats received ProZinc insulin for up to an additional 136 days.
hydrochloric acid 1.63 mg Adverse reactions were similar to those reported during the 45-day effectiveness study
water for injection (maximum) 1005 mg and are listed in order of decreasing frequency: vomiting, hypoglycemia, anorexia/
pH is adjusted with hydrochloric acid and/or sodium hydroxide. poor appetite, diarrhea, lethargy, cystitis/hematuria, and weakness. Twenty cats had
Indication: ProZinc (protamine zinc recombinant human insulin) is indicated for the signs consistent with hypoglycemia described as: sluggish, lethargic, unsteady, wobbly,
reduction of hyperglycemia and hyperglycemia-associated clinical signs in cats with seizures, trembling, or dazed. Most of these were treated by the owner or veterinarian
diabetes mellitus. with oral glucose supplementation or food; others received intravenous glucose.
One cat had a serious hypoglycemic event associated with seizures and blindness.
Dosage and Administration: USE OF A SYRINGE OTHER THAN A U-40 SYRINGE WILL
The cat fully recovered after supportive therapy and finished the study. All cases of
RESULT IN INCORRECT DOSING.
hypoglycemia resolved with appropriate therapy and if needed, a dose reduction.
FOR SUBCUTANEOUS INJECTION IN CATS ONLY.
Fourteen cats died or were euthanized during the extended use study. In two cases,
DO NOT SHAKE OR AGITATE THE VIAL. continued use of insulin despite anorexia and signs of hypoglycemia contributed to the
ProZinc insulin should be mixed by gently rolling the vial prior to withdrawing each deaths. In one case, the owner decided not to continue therapy after a presumed episode
dose from the vial. One mixed, ProZinc suspension has a white, cloudy appearance. of hypoglycemia. The rest were due to concurrent medical conditions or worsening of
Clumps or visible white particles can form in insulin suspensions: do not use the the diabetes mellitus.
product if clumps or visible white particles persist after gently rolling the vial. To report suspected adverse reactions, or to obtain a copy of the Material Safety Data
Using a U-40 insulin syringe, the injection should be administered subcutaneously Sheet (MSDS), call 1-866-638-2226.
on the back of the neck or on the side of the cat. Information for Cat Owners: Please refer to the Cat Owner Information Sheet for
Always provide the Cat Owner Information Sheet with each prescription. more information about ProZinc insulin. ProZinc insulin, like other insulin products,
The initial recommended ProZinc dose is 0.1 – 0.3 IU insulin/pound of body weight is not free from adverse reactions. Owners should be advised of the potential for
(0.2 – 0.7 IU/kg) every 12 hours. The dose should be given concurrently with or right adverse reactions and be informed of the associated clinical signs. Potential adverse
after a meal. The veterinarian should re-evaluate the cat at appropriate intervals reactions include: hypoglycemia, insulin antagonism/resistance, rapid insulin
and adjust the dose based on both clinical signs and glucose nadirs until adequate metabolism, insulin-induced hyperglycemia (Somogyi Effect), and local or systemic
glycemic control has been attained. In the effectiveness field study, glycemic control reactions. The most common adverse reaction observed is hypoglycemia. Signs may
was considered adequate if the glucose nadir from a 9-hour blood glucose curve include: weakness, depression, behavioral changes, muscle twitching, and anxiety.
was between 80 and 150 mg/dL and clinical signs of hyperglycemia such as polyuria, In severe cases of hypoglycemia, seizures and coma can occur. Hypoglycemia can
polydipsia, and weight loss were improved. be fatal if an affected cat does not receive prompt treatment. Appropriate veterinary
monitoring of blood glucose, adjustment of insulin dose and regimen as needed, and
Further adjustments in the dosage may be necessary with changes in the cat’s diet,
stabilization of diet and activity help minimize the risk of hypoglycemic episodes.
body weight, or concomitant medication, or if the cat develops concurrent infection,
The attending veterinarian should evaluate other adverse reactions on a case-by-case
inflammation, neoplasia, or an additional endocrine or other medical disorder.
basis to determine if an adjustment in therapy is appropriate, or if alternative therapy
Contraindications: ProZinc insulin is contraindicated in cats sensitive to protamine should be considered.
zinc recombinant human insulin or any other ingredients in the ProZinc product.
Effectiveness: A total of 187 client-owned cats were enrolled in a 45-day field study,
ProZinc insulin is contraindicated during episodes of hypoglycemia.
with 176 receiving ProZinc insulin. One hundred and fifty-one cats were included in
Warnings: User Safety: For use in cats only. Keep out of the reach of children. Avoid the effectiveness analysis. The patients included various purebred and mixed breed
contact with eyes. In case of contact, immediately flush eyes with running water for at cats ranging in age from 3 to 19 years and in weight from 4.6 to 20.8 pounds. Of the
least 15 minutes. Accidental injection may cause hypoglycemia. In case of accidental cats included in the effectiveness analysis, 101 were castrated males, 49 were spayed
injection, seek medical attention immediately. Exposure to product may induce a local females, and 1 was an intact female.
or systemic allergic reaction in sensitized individuals.
Cats were started on ProZinc insulin at a dose of 0.1-0.3 IU/lb (0.2-0.7 IU/kg) twice daily.
Animal Safety: Owners should be advised to observe for signs of hypoglycemia (see Cats were evaluated at 7, 14, 30, and 45 days after initiation of therapy and the dose
Cat Owner Information Sheet). Use of this product, even at established doses, has been was adjusted based on clinical signs and results of 9-hour blood glucose curves
associated with hypoglycemia. An animal with signs of hypoglycemia should be treated on Days 7, 14, and 30.
immediately. Glucose should be given orally or intravenously as dictated by clinical
Effectiveness was based on successful control of diabetes which was defined as
signs. Insulin should be temporarily withheld and, if indicated, the dosage adjusted.
improvement in at least one blood glucose variable (glucose curve mean, nadir,
Any change in insulin should be made cautiously and only under a veterinarian’s or fructosamine) and at least one clinical sign (polyuria, polydipsia, or body weight).
supervision. Changes in insulin strength, manufacturer, type, species (human, animal) Based on this definition, 115 of 151 cases (76.2%) were considered successful.
or method of manufacture (rDNA versus animal-source insulin) may result in the need Blood glucose curve means decreased from 415.3 mg/dL on Day 0 to 203.2 mg/dL
for a change in dosage. by Day 45 and the mean blood glucose nadir decreased from 407.9 mg/dL on Day 0
Appropriate diagnostic tests should be performed to rule out other endocrinopathies to 142.4 mg/dL on Day 45. Mean fructosamine values decreased from 505.9 μmol/L
in diabetic cats that are difficult to regulate. on Day 0 to 380.7 μmol/L on Day 45.
Precautions: Animals presenting with severe ketoacidosis, anorexia, lethargy, and/or Cats that completed the effectiveness study were enrolled in an extended use field
vomiting should be stabilized with short-acting insulin and appropriate supportive study. The mean fructosamine value was 342.0 μmol/L after a total of 181 days
therapy until their condition is stabilized. As with all insulin products, careful patient of ProZinc therapy.
monitoring for hypoglycemia and hyperglycemia are essential to attain and maintain How Supplied: ProZinc insulin is supplied as a sterile injectable suspension in
adequate glycemic control and to prevent associated complications. Overdosage can 10 mL multidose vials. Each mL of ProZinc product contains 40 IU recombinant
result in profound hypoglycemia and death. Progestogens, certain endocrinopathies human insulin.
and glucocorticoids can have an antagonistic effect on insulin activity. Progestogen
Storage Conditions: Store in an upright position under refrigeration at 36-46°F
and glucocorticoid use should be avoided.
(2-8°C). Do not freeze. Protect from light. Use within 60 days of first puncture.
Reproductive Safety: The safety and effectiveness of ProZinc insulin in breeding,
Manufactured for:
pregnant, and lactating cats has not been evaluated.
Boehringer Ingelheim Vetmedica, Inc.
Use in Kittens: The safety and effectiveness of ProZinc insulin in kittens has not St. Joseph, MO 64506 U.S.A.
been evaluated.
ProZinc® is a registered trademark of Boehringer Ingelheim Vetmedica, Inc.
Adverse Reactions: Effectiveness Field Study
© 2017 Boehringer Ingelheim Vetmedica, Inc. All Rights Reserved.
In a 45-day effectiveness field study, 176 cats received ProZinc insulin. Hypoglycemia
(defined as a blood glucose value of < 50 mg/dL) occurred in 71 of the cats at 449901-03
various times throughout the study. Clinical signs of hypoglycemia were generally Revised 09/2017
mild in nature (described as lethargic, sluggish, weak, trembling, uncoordinated,
groggy, glassy-eyed or dazed). In 17 cases, the veterinarian provided oral glucose
supplementation or food as treatment. Most cases were not associated with
clinical signs and received no treatment. One cat had a serious hypoglycemic event
associated with stupor, lateral recumbency, hypothermia and seizures.TOP 5 h INTERNAL MEDICINE h PEER REVIEWED
Top 5 Canine
Biliary Diseases
Stefanie M. DeMonaco, DVM, MS,
DACVIM (SAIM)
Virginia–Maryland College of Veterinary Medicine
d FIGURE 1 Ultrasonographic image of a GBM
showing the classic kiwi-like appearance
The number of dogs diagnosed with biliary Following are 5 of the most common canine
biliary diseases according to the author.
disease is increasing.1-5 Clinical signs and physical
1
examination findings in dogs with biliary disease Gallbladder Mucoceles
tend to be nonspecific and overlap with clinical Gallbladder mucoceles (GBMs) result
from an accumulation of semisolid mucus
signs of GI and systemic diseases; these can include
masses and inspissated bile in the gallblad-
anorexia, vomiting, abdominal pain, jaundice, and der and are associated with high morbidity and
fever. Clinicopathologic abnormalities are similarly mortality.3,6-11 Affected dogs are typically older
nonspecific and can include cholestatic to mixed
liver enzyme elevations, hyperbilirubinemia, TOP 5 CANINE BILIARY DISEASES
hypercholesterolemia, and neutrophilic 1. Gallbladder Mucoceles
leukocytosis.1,2,6-8 Diagnosis of biliary disease 2. Extrahepatic Biliary Obstruction
usually involves ultrasonography with or without 3. Cholecystitis
collection of liver and bile samples. Treatment with 4. Cholelithiasis
urgent surgical care versus conservative medical
5. Biliary Neoplasia
management should be determined based on the
cause and severity of disease. GBM = gallbladder mucocele
December 2019 cliniciansbrief.com 11TOP 5 h INTERNAL MEDICINE h PEER REVIEWED
(median age, 10 years) and of a predisposed breed appearances of GBMs include echogenic immobile
(ie, cocker spaniel, Shetland sheepdog, miniature biliary sludge filling the gallbladder or a stellate
schnauzer, border terrier, Pomeranian).2,3,6-16 pattern (Figure 2).6,10,11 These different GBM
Additional risk factors for GBMs include gallbladder appearances on ultrasonographic images likely
dysmotility, dyslipidemias, and endocrinopathies represent a continuum of early to mature mucoce-
(eg, hyperadrenocorticism, hypothyroidism).14,17,18 les.6 Ultrasonography cannot be used alone to
determine the clinical significance of GBMs or
Abdominal ultrasonography is key to diagnosis of guide treatment decisions unless there is clear
GBMs. The classic description of GBMs is a kiwi- evidence of biliary rupture or obstruction that
like appearance of intraluminal gallbladder warrants urgent surgical intervention (see
contents with hyperechoic immobile striations Gallbladder Rupture).1,3,10
of inspissated bile in hypoechoic mucus structures
(Figure 1, previous page). Other ultrasonographic Preoperative biliary rupture and bile peritonitis
can increase the risk for death, but some studies
have shown that long-term survival (ie, 2-5 years)
is possible in patients that survive the peri-
operative period.3,7,8,19,20 Common postoperative
complications include pancreatitis and bile
peritonitis.2,7,19 Patients with biliary infection at
the time of rupture tend to have a higher mortality
rate.
The best approach to treating GBMs (medical vs
surgical) in dogs is controversial. When clinical
signs and serum chemistry abnormalities (eg,
increased ALP, γ-glutamyl transferase, ALT, and
total bilirubin) are supportive of GBMs, cholecys-
tectomy is generally recommended over medical
management.1,6,10,21,22 A retrospective study found
a longer survival time in dogs that underwent sur-
d FIGURE 2 Ultrasonographic image of a GBM displaying a gery as compared with those that received medical
stellate pattern
management.20 Medical therapy is best reserved
for clinically inapparent cases of GBMs and when
surgery is not an option. Medical therapy includes
ursodiol, a low-fat diet, antibiotics, and treatment
GALLBLADDER RUPTURE of concurrent diseases associated with GBMs (eg,
hyperadrenocorticism, hypothyroidism, dyslipid-
Ultrasonography can help determine the presence of emias) and, in most cases, is unlikely to resolve
concurrent gallbladder rupture and/or extrahepatic
GBMs. A few cases of resolution or improvement
biliary obstruction. Pericholecystic hyperechoic fat,
with medical management have been reported,
pericholecystic fluid, a discontinuous gallbladder wall,
with other cases having static disease.2,10,23 Follow-
and an unidentifiable discrete gallbladder with free-
floating mucoceles in the peritoneum are supportive of up ultrasonography and serum chemistry profile
gallbladder rupture.1,6,7 The specificity and sensitivity of performed within 2 to 3 months of diagnosis to
ultrasonography in determining gallbladder rupture in assess response to treatment and identify complica-
dogs with GBMs varies from 91.7% to 100% and 56.1% to tions are recommended, regardless of whether the
85%, respectively.3,10 patient is treated medically or surgically.
12 cliniciansbrief.com December 20192 Extrahepatic Biliary Obstruction
The most common cause of extrahepatic
biliary obstruction (EHBO) in dogs is
pancreatitis. In acute pancreatitis patients,
atitis, which is typically characterized by chronic
neutrophilic inflammation.4,5 Abdominal radiogra-
phy can aid in the diagnosis of cholecystitis, partic-
ularly if emphysematous cholecystitis is present
pancreatic edema and/or inflammation affecting with a gas-filled gallbladder or gas opacities in the
the bile duct results in obstruction, whereas in pericholecystic region. Nonspecific radiographic
chronic pancreatitis patients, fibrosis results in duct findings may reveal a right quadrant abdominal
obstruction. Other causes can include GBMs, chol- mass effect, poor serosal detail, and/or
angiohepatitis, neoplasia, and cholelithiasis.4,13,24 choleliths.9,27 The following abdominal ultrasono-
graphic findings can be suggestive of cholecystitis
Diagnosis of EHBO is usually made via ultra- and/or cholangiohepatitis: thickened, hyperechoic,
sonography and/or exploratory laparotomy. irregular and/or laminar gallbladder wall; echo-
Ultrasonographic characteristics of EHBO include genic intraluminal contents; pericholecystic fluid
gallbladder enlargement, dilation of the cystic or echogenic abdominal effusion; distended bile
and/or bile ducts, and, in cases of obstruction last- duct; and/or heterogeneous or hyperechoic hepatic
ing >5 days, intrahepatic duct dilation.9 Because parenchyma.4,9 Bile samples can be obtained with
ultrasonography may not always discern the cause percutaneous ultrasound-guided cholecystocente-
of obstruction, surgery may be necessary to con- sis to assess for inflammation, infectious agents,
firm biliary obstruction and further characterize and culture and susceptibility. Culture and suscep-
and address the cause.9 tibility testing is particularly important, as resis-
tance can occur with empiric broad-spectrum
Treatment of EHBO should be aimed toward antimicrobials.5 Common bacterial isolates include
addressing the underlying cause of obstruction Escherichia coli, Enterococcus spp, Klebsiella spp,
and, if necessary, include biliary decompression. Clostridium spp, and Bacteroides spp.4,5,25,28
Whether surgical or ultrasound-guided percutane-
ous biliary decompression is necessary in patients Treatment of cholecystitis includes medical manage-
with EHBO secondary to pancreatitis is controver- ment, but surgical intervention may be necessary
sial. Most dogs with EHBO secondary to pancreati- depending on the severity of signs and gallbladder
tis improve with medical management as acute rupture. Cholecystectomy can reduce morbidity and
pancreatitis resolves. Serum chemistry abnormali- mortality in dogs with cholangiohepatitis and/or
ties (eg, liver enzymes, bilirubin) can worsen cholecystitis.4 Medical therapy includes antimicro-
despite improvement in clinical signs and should bial administration guided by either culture and
not be confused with worsening of the patient’s con-
dition. Unpublished data suggest that bilirubin lev-
els peak in dogs with pancreatitis-associated EHBO
when clinical signs of pancreatitis are improving.
Cholecystectomy can reduce
3 Cholecystitis
Cholecystitis can have acute or chronic pre-
sentations. Anorexia, vomiting, abdominal
pain, and fever are typical signs of acute
morbidity and mortality in dogs
with cholangiohepatitis and/or
cholecystitis.4
cholecystitis.25,26 Patients with chronic cholecysti-
tis may have milder signs of chronic intermittent
vomiting, anorexia, weight loss, and/or abdominal
EHBO = extrahepatic biliary obstruction
pain or no clinical signs at all. Cholecystitis may be
GBM = gallbladder mucocele
present alone or in combination with cholangiohep-
December 2019 cliniciansbrief.com 13TOP 5 h INTERNAL MEDICINE h PEER REVIEWED
susceptibility results or, when culture and suscepti- Ultrasonographic findings are nonspecific but
bility results are unavailable, empiric treatment can include a solitary mass or diffuse nodules
against common isolates (eg, amoxicillin/clavulanic with or without target lesions.38 Histopathology
acid and enrofloxacin). Additional treatment with or without immunohistochemical markers
options include ursodiol and supportive care.9,25 is necessary to confirm diagnosis.
Cholecystectomy is typically the surgical treatment
of choice when surgery is required and in cases in The treatment of choice for biliary carcinomas is
which only the gallbladder is affected.9,29 surgical resection unless the disease is diffuse or
4
multifocal in nature. Overall survival is generally
Cholelithiasis poor, with survival times typically being ≤6
Choleliths are stones in the biliary system months.34,39 Metastasis to regional lymph nodes
and can have varying presentations (ie, and lungs occurs in ≤88% of dogs.35,36 Cholecysto-
mixed stones, pigment stones, cholesterol duodenostomy can be performed in patients with
stones). In dogs with mixed stones, pigment stones secondary EHBO as a palliative option. n
are most commonly seen, with cholesterol stones
being less frequent.9,30,31 Middle-aged to older,
female, small-breed dogs are predisposed to
choleliths, and an increased incidence of cholelithi-
asis has been observed in miniature poodles and
miniature schnauzers.9,26,29,30,32,33 Choleliths are POLL
usually found incidentally on abdominal ultrasono-
graphic images or necropsy and can lead to EHBO Have you ever suspected or diagnosed any
or cholecystitis. of the following biliary diseases via ultra-
sonography? Check all that apply.
Diagnosis is made via ultrasonography, which can A. Gallbladder mucocele
detect stones >2 mm in size.9,26,27 Medical dissolu- B. Extrahepatic biliary obstruction
tion of choleliths is usually unsuccessful. Medical C. Cholecystitis
therapy includes ursodiol, S-adenosylmethionine, D. Cholelithiasis
antimicrobials, vitamin E, and anti-inflammatory E. Biliary neoplasia
medications based on liver histopathology results F. I have never suspected/diagnosed any
(eg, chronic nonsuppurative hepatitis). Surgery is of these via ultrasonography.
the treatment of choice in patients with concur-
rent cholecystitis and/or bile duct obstruction. Scan the QR code to submit your answer and see the
5
other responses! The poll is located at the bottom of
Biliary Neoplasia the article.
Hepatobiliary neoplasia accounts for 0.6%
Using QR codes from your mobile
to 1.3% of all canine neoplasms.34 Hepato-
device is easy and quick!
cellular carcinoma is the most common
form of hepatobiliary neoplasia, followed by bili- Simply focus your phone’s camera on
ary carcinoma. Labrador retrievers and female the QR code as if taking a picture (but
don’t click!). A notification banner will pop up at the
dogs are predisposed to biliary carcinomas.34-37
top of your screen; tap the banner to view the linked
EHBO = extrahepatic biliary obstruction content.
14 cliniciansbrief.com December 2019References
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2004;224(10):1615-1622. and risk factors associated with biliary surgery in dogs: 34 cases
2. Aguirre AL, Center SA, Randolph JF, et al. Gallbladder disease in (1994-2004). J Am Vet Med Assoc. 2006;229(9):1451-1457.
Shetland sheepdogs: 38 cases (1995-2005). J Am Vet Med Assoc. 20. Parkanzky M, Grimes J, Schmiedt C, Secrest S, Bugbee A. Long-term
2007;231(1):79-88. survival of dogs treated for gallbladder mucocele by
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6. Besso JG, Wrigley RH, Gliatto JM, Webster CR. Ultrasonographic 1688-1693.
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7. Worley DR, Hottinger HA, Lawrence HJ. Surgical management of 1995;31(6):478-482.
gallbladder mucoceles in dogs: 22 cases (1999-2003). J Am Vet Med 25. Rivers BJ, Walter PA, Johnston GR, Merkel LK, Hardy RM. Acalculous
Assoc. 2004;225(9):1418-1422. cholecystitis in four canine cases: ultrasonographic findings and use
8. Crews LJ, Feeney DA, Jessen CR, Rose ND, Matise I. Clinical, of ultrasonographic-guided, percutaneous cholecystocentesis in
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gallbladder disease and rupture in dogs: 45 cases (1997-2007). J Am 26. Aguirre A. Diseases of the gallbladder and extrahepatic biliary
Vet Med Assoc. 2009;234(3):359-366. system. In: Ettinger SJ, Feldman EC, Côté E, eds. Textbook of
9. Center SA. Diseases of the gallbladder and biliary tree. Vet Clin North Veterinary Internal Medicine. St Louis, MO: Elsevier; 2010:1689-1695.
Am Small Anim Pract. 2009;39(3):543-598. 27. Partington BP, Biller DS. Hepatic imaging with radiology and
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ultrasonographic and clinical findings in 43 dogs with gallbladder 28. Wagner KA, Hartmann FA, Trepanier LA. Bacterial culture results from
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11. Uno T, Okamoto K, Onaka T, Fujita K, Yamamura H, Sakai T. ary disease: 1998-2003. J Vet Intern Med. 2007;21(3):417-424.
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30. Kirpensteijn J, Fingland RB, Ulrich T, Sikkema DA, Allen SW.
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13. Newell SM, Selcer BA, Mahaffey MB, et al. Gallbladder mucocele
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15. Gookin JL, Correa MT, Peters A, et al. Association of gallbladder
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16. Allerton F, Swinbourne F, Barker L, et al. Gall bladder mucoceles in 36. Patnaik AK, Hurvitz AI, Lieberman PH, Johnson GF. Canine bile duct
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17. Kutsunai M, Kanemoto H, Fukushima K, Fujino Y, Ohno K, Tsujimoto 37. Hayes HM, Morin MM, Rubenstein DA. Canine biliary carcinoma: epide-
H. The association between gall bladder mucoceles and miological comparisons with man. J Comp Pathol. 1983;93(1):99-107.
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18. Tsukagoshi T, Ohno K, Tsukamoto A, et al. Decreased gallbladder 39. Fry PD, Rest JR. Partial hepatectomy in two dogs. J Small Anim
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December 2019 cliniciansbrief.com 15SYMPOSIUM CAPSULES
SYMPOSIUM
CAPSULES
What Breeds Are makeup. Other coat traits (eg, furnishings, hair
length, curl) also involve multiple genes. The
2019 American in My Mixed-Breed list of polygenic traits is long, and environmen-
tal factors can impact some polygenic traits;
Veterinary Medical
Association Convention
Dog? therefore, these traits should not be used to
make breeding choices. Although crossbreed
dogs may theoretically benefit from a lesser
concentration of disease-causing recessive
August 2-6, 2019 Visual identification of the breed makeup of genes, it is important to consider diseases
Washington, DC crossbreed dogs is imprecise. There is often of genetic origin when creating a differential
little agreement regarding breed-makeup diagnosis list for patients. When a genetic
assumptions among professionals in dog- disease database is being used, however, the
related professions, and DNA identification, search should be based on clinical signs rather
which is based on gene identification and than breed.
comparison, often does not match these
assumptions. Implications of misidentification Because visual breed identification is so
exist from both legal (eg, breed-related legisla- unreliable, it is recommended that non-
tion) and medical standpoints (eg, testing for breed–based terminology be used when
genetic disease). describing a dog. Use of generic terms (eg,
crossbreed), along with a description of the
Breed-related traits that can be visually iden- dog’s characteristics (eg, brindle, short-
tified include chondrodysplasia, hair ridge, haired, neutered male dog with upright ears),
and hairlessness. Coat colors are determined is preferable to breed-based identification
by many different possible gene combinations (eg, pit bull cross).—Ekenstedt KJ
and thus cannot be used to ascertain breed
Hypertonic Saline vagally mediated hypotension and brady-
cardia; electrolytes should be monitored.
In cases of shock, HTSs can interrupt the cycle
Hypertonic saline solutions (HTSs) are crystal- of reduced perfusion, ischemia, vasocon-
loid solutions with NaCl concentrations ranging striction, and endothelial swelling. Cerebral
from 3% to 23.4%. Administration of HTSs can blood flow may also be enhanced by the abil-
cause water to immediately shift from the inter- ity of HTSs to decrease endothelial swelling.
stitial space to the intravascular space due to Administration of HTSs can lower intracranial
SAVE THE DATE increased osmolarity, expanding the intravas- hypertension and is generally preferred over
cular volume by 2 to 3 times the volume admin- mannitol. HTSs have shown some promise
2020 American istered. Although this effect may only last 1 to in nebulization for patients with respiratory
Veterinary Medical 3 hours, it is a desirable effect in patients with disease. Although seemingly counterintui-
Association Convention hemorrhagic and/or traumatic shock, in which tive, administration of HTSs with high-dose
excessive fluid resuscitation can exacerbate furosemide to patients that have congestive
hypothermia, acidosis, and coagulopathy. heart failure has also proven beneficial. HTSs
Small volumes of HTSs can improve preload, are inexpensive and easy to administer, and
July 31-August 4, 2020
cardiac output, and mean arterial pressure although more clinical studies are needed to
San Diego, California
and decrease peripheral vascular resistance. investigate their potential role in veterinary
Dehydration is not a contraindication of HTS medicine, there are numerous documented
administration. A rate ofSYMPOSIUM CAPSULES
Tips & Advanced the process, as owners will often take
their emotional cues from the staff.
double the dose can also be squirted
into the mouth.
Techniques for Sedatives, often at high doses, can Smaller patients, obese cats, and
Challenging help ensure a smooth, less stressful patients with poor venous access may
Euthanasias procedure. Overdosing is not a concern,
although the possibility of death via
require alternative euthanasia routes
following sedation; these can include
sedative should be communicated. intrahepatic, intrarenal, or intraperito-
Sedation prior to IV catheter placement neal injections, although these routes
is ideal; vitamin B12 in the sedative generally require larger volumes of
Although some euthanasias can present syringe can help reduce stinging on the euthanasia agent and usually take
unique challenges, veterinary staff can injection. longer to achieve full effect. Alterna-
provide a smooth experience through tive veins (eg, dorsal pedal, sublingual,
good planning and communication. Oral premedication at home with ear) can also be considered. Clinicians
gabapentin, acepromazine, or should gain experience with alternative
Euthanasia appointments should trazodone can be helpful for reactive euthanasia routes to be prepared for
be scheduled with plenty of time patients; gabapentin (30 mg/kg) with when a secondary plan is needed; alter-
allowed to ensure that all questions crushed acepromazine (10 mg/kg PO) native routes can first be attempted in
and concerns are fully addressed. administered in treats on presentation fully sedated patients of owners who
Staff members should be calm and will often be effective within 10 to 15 choose nonwitness euthanasias.
reassuring to pet owners throughout minutes. Injectable premedication at —Naun C
Anesthesia compressed gas, although some use
both. The drive mechanism is usually
cavity, and/or patients with increased
intracranial pressure that also require
Ventilators: compressed gas, and most ventilators
are dual circuit. With dual-circuit venti-
strict regulation of end tidal CO2. Obese
patients or those with intra-abdominal
How They Work lators, a driving gas provides the pneu- masses may also benefit from ventila-
& When to Use matic force that compresses the bellows,
which then releases its contents (ie,
tion. Debilitated patients may not be
good candidates for ventilation due to
Them the breathing gas) that are delivered to
the patient. The major control variable
decreased preload, which may affect
cardiac output, and increased thoracic
delivers the breath and can be volume positive pressure.
or pressure controlled; most are volume
Anesthesia ventilators are simpler in controlled and have an alarm and/or Delivery of tidal volume that is greater
function than intensive care ventilators pressure relief valve. The cyclic mech- than what is recommended may cause
and are intended to provide support to anism generally uses an electric timing barotrauma and lead to interstitial
healthy patients. Because veterinary mechanism to cycle from the inspira- emphysema and pneuomothorax; maxi-
models are not regulated like human tory to expiratory phase. Most modern mum values for peak inspiratory pressure
models are, clinicians are responsible ventilators have ascending or standing should not be exceeded. Minute volume
for understanding how to use them. bellows (vs hanging bellows) based on (ie, tidal volume multiplied by respiratory
Ventilators are typically classified based the direction of the bellows during expi- rate), positive end expiratory pressure,
on power source, drive mechanism, ration. Smaller patients require smaller and peak inspiratory pressure values
major control variable, cyclic mecha- bellows. should all be monitored and maintained
nism, and bellows. in the appropriate range.—Barletta M
Indications for mechanical ventilation
The power source in most ventila- include use of neuromuscular blocking
tors is electricity or, less commonly, agents, patients with an open thoracic
18 cliniciansbrief.com December 2019You can also read
