C/E for the one who doesn’t have time for C/E

“Pearls” Trusted By of The Profession Veterinary Medicine Since 1981 “on veterinary therapeutics”

Volume 40 Number 4 July 2021

AT A GLANCE inventory of the home. Encourage clients to listen to all of the ambient noise in and around their homes to Aggression, canine, using SSRIs; P 5 pinpoint overlooked stressors. Once possible noise Alopecia and grooming; P 5 toxicities are addressed, the right music can create an Anesthesia, geriatric; P 2 Anesthesia, preventing hypothermia; P 4 enhanced, stress-free experience. To keep animals as Anesthesia, rough recoveries; P 3 calm as possible, instrumental music is best. Animals Biopsy tips; P 5 do not need the added stimulus of processing voices. C-section, based on fetal heart rate; P 2 At home, hearing calming music for as little as 30-60 Calcium oxalate uroliths; P 4 minutes a day will help reduce the sympathetic overdrive Cardiac cachexia; P 3 CBD, and noise-averse dogs; P 3 from the nervous system in pets. Susan O. Wagner, DVM, MS, DACVIM CHF; P 4 dvm360, Apr 2021 Constipation, cat; P 1 Cruciate disease, conservative management; P 5 Dry eye, treatment with pilocarpine; P 3 Constipation in the cat FHV-1 treatment; P 1 Radiographs can help evaluate the severity of con- FHV-1; P 2 stipation and assess for contributing factors such as Giardia, zoonotic potential; P 4 osteoarthritis, pelvic fractures, extralu minal masses, Heartworm antigen-negative dogs; P 2 Heartworm treatment protocol; P 3 and vertebral disease. Pelvic fractures and subsequent Increasing pharmacy income; P 5 narrowing of the pelvis are often cited as predisposing to Ketamine, alfaxalone myths; P 1 constipa tion. However, a study of cats with these injuries Music therapy; P 1 showed that only 20% had constipation and none had Noise phobia; P 2 megacolon. Additionally, the study found that the degree OA, treating with Omega-3 fatty acids; P 3 Palliated death; P 4 of narrowing was not related to the severity of constipa- tion. For severely impacted patients, additional treatment is usually required. Historically, manual disimpaction FHV-1 treatment has been the next step, but this author rarely resorts to Ophthalmologists have reported using a new (human- this procedure. The author has found that percutaneous label) oral anti-herpes product called famciclovir (Famvir) endoscopic gastrostomy (PEG) solutions administered in the treatment of feline herpesvirus-1. Results suggest via nasoesophageal (NE) tube is highly eff ective and this drug does have promise, but dosing information for safe. After the NE tube is placed and appro priate posi- cats has not been defi nitively established. Anecdotal tioning is confi rmed radiographi cally, the PEG solution reports from veterinarians in clinical practice suggest is administered over several hours. Most cats defecate that one-fourth to one-eighth of 125 mg tablet given within 6-12 hours. Typical doses are 100 mL/kg over 10 once daily for at least 10 days has resulted in decreased hours and can be titrated up over time or given for longer recrudescence of feline herpesvirus-1. The eff ects of time periods if needed. Anthony Carr, DrMedVet, DACVIM long-term administration of famciclovir are not known. dvm360, Apr 2021 Richard B. Ford, DVM, MS Diplomate ACVIM, DACVPM Midwest Vet Conf, Feb 2020 Ketamine and alfaxalone myths Music therapy Ketamine Myths: 1) Ketamine is an old drug that has More than 150 dogs were observed in home envi- no place in modern veterinary medicine. Fact. Ketamine ronments and kennels to see if they would sit down, is an excellent induction drug and can be used in an lie down, or even go to sleep when listening to certain infusion to help provide analgesia. 2) Ketamine cannot music. It was found that the simple piano with low tones be used in certain dog or cat breeds. Absolutely wrong. and a slow tempo is what made them most calm. When There is way too much inappropriate and incorrect infor- presented with a patient that displays signs of general mation on the internet! Alfaxalone Myths: 1) Alfaxalone anxiety or pain, this author suggests creating a sound is safer than propofol. Actually, the physiologic eff ects

The Capsule Report® is published monthly for veterinarians who wish to maintain high standards of practice Copyright by William L. Collins, DVM© 64660 Picard Ct, Desert Hot Springs, CA 92240; (760) 671-6847, Fax (661) 821-8927 The caused by alfaxalone are very mg/kg, PO, SID-TID; CATS: 0.05-0.25 mg/cat, SID-TID. similar to those caused by pro- Wayne Hunthausen, DVM Fetch Kansas City, 08:19 pofol. Both drugs are excellent Capsule choices when the drugs are titrated ‘to eff ect’ to patients that Feline Herpesvirus-1 have been premedicated with Report ® Feline Herpesvirus-1 (FHV-1): FHV-1 infection com- drugs that lower the necessary monly causes feline ocular disease. However, estab- induction dose. 2) Alfaxalone is lishing a defi nitive diagnosis can be very frustrating in a great choice for IM administration in cats. Fact. It is an recurrent cases as very little virus is present. Treatment okay choice if used at low dosages in combination with can also be frustrating due to the “herpes is forever” other sedatives. The volume is too large if the IM label phenomenon. Some of our feline patients suff er more dose is used (10 mg/kg outside US – not on US label). commonly from recrudescent disease than others. Best IM use is for small mammals (‘pocket pets’) and Feline herpesvirus may also cause concurrent corneal small ‘exotic’ pets, not cats. Tamara Grubb, DVM, PhD, DACVAA ulceration. Corneal ulceration does not occur with other Atlantic Coast Vet Conf, 10:17 infectious causes of conjunctivitis. Therefore, if corneal ulceration and conjunctivitis are present, FHV-1 is most C-section based on fetal heart rate likely involved. DO NOT apply topical corticosteroids. Fetal heartrates (HR) are very easy to acquire, re- The Conjunctivitis may initially appear to improve, but gardless of the quality of the ultrasound machine and will worsen as will any corneal ulcers. A corticosteroid regardless of your imaging skills. Fetal HR will fl uctuate, is absolutely contraindicated. In cases of acute ocular especially in the last week of gestation, but there is cause infections or a recurrence, application of a tetracycline for concern when fetal HR is consistently <200bpm. It or erythromycin ophthalmic ointment four times daily is not uncommon to fi nd 1-2 fetal HRs <200bpm dur- will prevent secondary bacterial infections, will treat ing the last week of gestation, especially during subtle Chlamydophila and Mycoplasma if they are present, uterine contractions. The author’s benchmarks for and will help to cushion and coat the infl amed conjunc- proceeding to C-section are fetal HRs of 170 or less tiva. Often the infections are self-limiting and will clear at multiple time points. Fetal HRs of 150 or less usu- within 7-10 days. ally indicate fetal demise and require immediate surgical Wendy M. Townsend, DVM, MS, DACVO Emerald Coast Vet Conf, 07:17 intervention. When a dam is presented to the hospital and one or more puppies have already been delivered, Withholding meds prior to geriatric anesthesia it can be assumed that the remainder of the puppies are Most medications should be continued, with few under stress, and are likely in distress. If C- section is an exceptions. Angiotensin-converting enzyme (ACE) option for the owner fi nancially, it is preferred to proceed inhibitors (benazepril, enalapril) should be withheld directly to surgery for the best neonatal outcomes. Robyn R. Wilborn, DVM, MS,DACT the morning of anesthesia to reduce the incidence of Emerald Coast Vet Conf, 07:17 refrac tory hypotension; telmisartan, an angiotensin receptor blocker used increasingly for the treat ment of Noise phobias protein-losing nephrop athy, acts on the same pathway, Acepromazine may be helpful for very mild cases so withholding this drug may be prudent. The antithrom- but it is a sedative without any signifi cant anxiolytic botic medication clopidogrel should be discontinued eff ect. High doses required for severe problems may 10 days prior to surgery but can be continued for cause so much sedation that the pet is not functional. nonsurgical procedures. Patients receiving prednisone Benzodiazepines are very potent anxiolytics that can for hypo adrenocorticism should receive double their be very helpful for severe cases. Long term use may normal morning dose to help them tolerate the stress produce habituation. There may be withdrawal signs associated with anesthesia and surgery. which can be severe. Must slowly taper off . They may Molly Allen, DVM, DACVAA dvm360, May 2021 cause hyperphagia, ataxia, depression, and sometimes a paradoxical increase in activity/agitation. They may Heartworm antigen-negative dogs release inhibitions in fear aggression and disinhibit bite All positive antigen tests should be confi rmed with behavior. They may interfere with learning. They are microfi laria screening such as with a Modifi ed Knott’s contraindicated in animals with impaired liver function Test, or using a diff erent type of antigen testing prior Alprazolam: DOGS: 0.02-0.1 mg/kg, PO, SID-TID; CATS: to starting a patient on adulticide therapy. Be aware a 0.125-0.25, mg/cat, PO, SID-BID. Diazepam: DOGS: negative antigen test does not guarantee a dog is truly 0.55-2.2 mg/kg, PO, SID-TID; CATS: 1-2 mg/cat, SID- heartworm-free. It means that antigen was not detected BID. (**Acute, fatal hepatopathy documented in small in that sample. This can happen if the females are im- number of cats**) Lorazepam: CATS: 0.125-0.25 mg/ mature at the time of testing, or there is a “male-only” cat, BID. Clorazepate: (longer acting, more expensive) infection. In addition, if the in house antigen test kit in- DOGS: 0.55-2.2 mg/kg, PO, daily, SID-BID; CATS: 0.55- structions are not followed exactly, it is possible to get 2.2 mg/kg, PO, as needed. Clonazepam: DOGS: 0.1-1 false negative results. The AHS recommends yearly test- Page 2 ing for all dogs, even if they are on regular preventives. intake. In addition, reduction of Douglas Mader, MS, DVM, DABVP, DECZM cytokines has been cor related TThehe VPN, Apr 2021 with survival in dogs and cats with CHF. CCapsuleapsule Pain as a cause of rough anesthetic recoveries Lisa M. Freeman, DVM, PhD Clinical signs of pain include vocalization, restless- N Amer Vet Conf, 02:17 ness, hyperventilation or panting, and aggression, RReporteport ® especially when painful areas are touched. Pain can be Heartworm treatment protocol diagnosed using a pain scale (e.g., short-form Glasgow The timing of each component Composite Measure Pain Scale, Colorado State Univer- of heartworm dis ease treatment is detailed by the AHS. sity Acute Pain Scale). Knowledge of the analgesic pro- Macrocyclic lactone and 4-week doxycycline treatment tocol used, duration of action, and time of administra tion should be initiated at the time of diagnosis. After 1 can also help reach a diagnosis. An analgesic trial with month and then monthly, a macrocyclic lactone should opioids (e.g., methadone or hydromor phone [0.1 mg/ be administered unless a sustained-release moxidectin kg, IV], buprenorphine [0.02 mg/kg, IV]; cats and dogs) product was chosen as the macrocyclic lactone in the or other analgesic agents (e.g., ketamine [0.6 mg/kg/ beginning of the treatment protocol. Two months after hour, CRI; cats and dogs]; NSAIDs) should be instituted diagnosis, the fi rst dose of melarsomine should be and the patient reassessed if there is uncertainty on administered, followed 1 month later by a second and whether the patient is still painful. third dose given 24 hours apart. It is thought that the Renata S. Costa, DVM, MPhil, MANZCCVS, DAVCAA month in between the end of doxycycline and the start Clinician’s Brief, Apr/May 2021 of melarsomine therapy is necessary for worm-mediated degradation of Wolbachia spp killed by doxycycline, en- Noise-averse dogs not calmed by CBD suring no immunogenic Wolbachia spp surface proteins A cannabidiol supplement did not reduce anxiety in are released into the bloodstream. Because Wolbachia dogs exposed to loud sounds, according to a Fron- spp is an endosymbiont, killing the bacteria should also tiers in Veterinary Science study. For seven days, 16 weaken the worm, as Wolbachia spp is required for mixed- breed dogs were given CBD, trazodone, a com- worm survival. bination of CBD and trazodone, or no drug. The CBD Andrew R. Moorhead, DVM, MS, PhD, DACVIM consisted of a proprietary industrial hemp extract that Clinician’s Brief, Mar 2021 was incorporated into treats and administered as one treat twice a day. The daily dose of CBD was 1.4 mg/ Treatment of dry eye with pilocarpine kg. After seven days, researchers exposed the dogs The most commonly used cholin ergic agent is pilo- to a 3-minute fi reworks sound track. Blood samples carpine. It is a direct-acting parasympathomimetic drug were collected to measure cortisol concentrations, and commonly used in cases of neurogenic KCS. Because the dogs’ behavior was videotaped and analyzed for topical administration of pilocarpine is irritating due to its movements associated with fear, or relaxation. Each acidic pH, oral administration of the ophthalmic formu- dog was also fi tted with a heart monitor. Researchers lation is generally preferred. The initial dose applied to reported that dogs in the trazodone group had lower food is 1 drop of 2% pilocarpine per 10 kg, twice daily. plasma cortisol concentrations after the track was The drug may be unpalatable, and the dose is rather played, whereas the dogs in the CBD, trazodone-CBD, small, therefore owners should be instructed to apply the and control groups did not. Moreover, the CBD didn’t drops to a spoonful of tasty moist food and feed that to reduce the dogs’ fearful behavior during the fi reworks. the patient. The dose is increased in 1-drop increments Future studies should investigate higher doses of CBD. every 2 to 3 days until tear production increases or signs The study is available at jav.ma/Noise. of systemic toxicity (including inappetence, hypersaliva- JAVMA, Jun 15, 2021 tion, vomiting, diarrhea, or bradycardia) develop. If systemic adverse effects are observed, pilocarpine Cardiac cachexia should be discontinued for 2-3 days until systemic signs Cardiac cachexia is typically recognized only after abate, and then renewed at a lower dose. Some patients CHF has developed. Loss of lean body mass is most tolerate the drug better if the total daily dose is divided readily evi dent in the epaxial, gluteal, scapular, or tem- into 3 treatments rather than 2. In the author’s experi- poral muscles. Nutritional considerations for cardiac ence, the drug is eff ective in about 90% of patients with cachexia should in clude management of anorexia, if unilat eral neurogenic KCS and ipsilateral xeromycteria. present and nutritional modulation of cytokine produc- Treatment duration is variable (from 3-5 months), but in tion also may be helpful. One method of decreasing some cases long-term administration may be needed. the production and eff ects of cytokines is with omega-3 Topical immuno modulating agents may be prescribed fatty acid supplementation. Supplementation of fi sh simultaneously to reduce ocular surface infl ammation. oil, which is high in omega-3 fatty acids can decrease Ron Ofri, DVM, PhD, DECVO cytokine production in dogs with CHF and improve dvm360, Apr 2021 cachexia. In some, but not all dogs with CHF- induced Omega-3 fatty acids for OA anorexia, fi sh oil supplementation can improve food Mild and moderate osteoarthritis can be managed

Page 3 eff ectively using nutritional supplements, delaying the unproven, and likely to be of minor importance compared need for treatment with NSAIDs. When managing severe to person-to-person transmission.”— Center for Food cases, the veterinarian can combine a NSAID with a nu- Security & Public Health. tritional supplement enabling the dose of NSAID needed Michael W. Dryden, DVM, PhD, DACVIM dvm360,m Mar 2021 to be minimized. In this study the most important fi nding was dogs that received a diet enriched with omega-3 Preventing hypothermia during anesthesia fatty acids experienced a statistically signifi cant improve- Active techniques apply heat to the surface of the ment in peak vertical force generation, while dogs that patient in an at tempt to reduce the heat gradient from received the control diet did not experience any improve- the patient to the environment and slow the rate of heat ment in this parameter. Dogs receiving omega-3 fatty loss. Some of the more common active techniques in- acid supplementation also experienced improvements clude forced warm air blankets, circulating warm water in subjective parameters such as lameness and weight pads, and electric blan kets. It is important to understand bearing capacity, and trends toward improvements in that these techniques do not warm the patient. Instead, pain and reluctance to hold up the contralateral limb they reduce the gradient al lowing the patient’s own heat were also observed. Neerav Dilip Padliya, PhD production to be more eff ective. Metabolic techniques, VPN, Jun 2021 although well described in hu man medicine, are still mostly in a research phase in veterinary medicine but Calcium oxalate uroliths have shown promise. This method provides a substrate Oxalate is primarily derived from dietary intake. High to the patient that when utilized, induc es the patient to oxalate containing foods include certain vegetables (e.g., produce more endogenous heat. Amino acids and pro- spinach), legumes, and fermentable fi bers (e.g., beet teins appear to be the most thermogenic sub stances pulp). The endogenous hepatic metabolism of glycine as they result in a large amount of heat to be pro duced and vitamin C will also contribute to oxalate formation. as a by-product of the metabolic processes neces sary Excess intake of vitamin C should be avoided as this is to utilize them. a precursor to oxalic acid. Cats and dogs do not have a Stuart Clark-Price, DVM, DACVIM, DACVAA VMX, Jun 2021 dietary requirement for vitamin C, therefore additional supplementation is unnecessary. Cranberry supplements Palliated death are also not recommended as these contain both vita- While most veterinary professionals would prefer a min C and oxalates and contribute to urine acidifi cation. pet in the end stages of disease to be euthanized, not Vitamin B6 defi ciency has not been reported with spon- all owners are comfortable with or ready to make that taneously occurring CaOx urolithiasis in dogs and cats. decision. A palliated death allows the pet to die from Supplementation may be needed in patients consuming the disease, but with interventions to control pain dur- an unbalanced home prepared diet (2-4 mg/kg, q24hr) ing the end stages. In many cases, palliative sedation but is unnecessary in patients consuming a complete and is used, which maintains life while providing pain relief balanced commercial diet. ACVIM consensus guidelines and keeping the patient subconscious to uncon scious recommend to avoid a high protein intake as ingestion for the remainder of the disease course. It is important of high quantities of animal protein (>10 g/100 kcal) to discuss with owners that for many palliated deaths, increase urine calcium excretion and decrease urine 24-hour recumbent care and extensive nursing care citrate excretion. Martha G. Cline, DVM, DACVN are needed. In this author’s experience, once owners Emerald Coast Vet Conf, 07:17 are educated on this process, many elect euthanasia for their pet. Zoonotic potential of Giardia Lynn Hendrix, DVM, CHPV dvm360, May 2021 The most popular parasite on pup playgrounds? Giardia. It was found in more than 70% of dog parks. CHF Considering how ubiquitous it is in nature, how worried Outpatient Management when fi nancial constraints should veterinarians be about Giardia from a zoonotic preclude hospitalization: 1) Reduce Preload: First, give standpoint? According to this author—not very. As under- an IV furosemide bolus (2-4 mg/kg) ideally, via IV cath- standing of Giardia has increased, its zoonotic potential eter. 2) Reduce Afterload: Second, give hydralazine, has decreased. The author provided quotes from a few 1-1.5 mg/kg, PO. 3) Administer Pimobendan (Inodila- organiza tions as evidence. “Human infection from a dog tor therapy): Third, give pimobendan, 0.3 mg/kg, PO. or cat source has not been conclusively demonstrated in 4) Supplement O2. 5) Record ECG if tachycardic or North America.”—Companion Animal Parasite Council. arrhythmic. 6) Tap chest if severe pleural eff usion is “The risk of humans acquiring Giardia infection from dogs present. 7) Measure Systolic BP and Creatinine (Ideally, or cats is small. The exact type of Giardia that infects to guide further therapies- Note, skip or delay if dog is humans is usually not the same type that infects dogs extremely dyspneic and in critical condition). Repeat and cats.”— Centers for Disease Control and Preven- steps 1, 2, 4, 5, 7 hourly until respiratory rate and ef- tion. “Several recent reviews conclude that zoonotic fort and lung crackles substantially diminish. Skip one transmission from domesticated animals is possible but Page 4 or more treatments if hypotension occurs and reassess of the city or a social tour. Ideally, we want to start with the following hour. 10 minutes, 2-3 times daily and add 5 minutes weekly Philip R. Fox, DVM,MS, DACVIM/ECVIM-CA to each walk. The goal is to start on fl at surfaces with Emerald Coast Vet Conf, 07:17 good traction to preventing slipping. Don’t add inclines or uneven terrain till at least the patient is at 20 minutes Biopsy tips of comfortable walking or has reached 4-6 weeks. Re- When using the punch biopsy technique, it is important member pace is the key, it should be slow to promote to use a fresh biopsy punch and to rotate the punch in a leg usage so you may have to adjust your pace. Ideally, single direction (clockwise or coun terclockwise) rather walking should start after 5-7 days of being on an NSAID. than oscillating back and forth. Other than biopsies ob- The author usually says no to daycare, as it is free play. tained near the eye, pinnae, nasal planum, or foot pad of The only way they are allowed to go to daycare is if they small dogs and cats (in which a 4-mm punch may be most will isolate the dog and then walk them. feasible), a 6- to 8-mm punch should be used to provide David Dycus, DVM, MS, CCRP, DACVS a suffi cient number of follicles and enough surface area 25th IVECCS, 09:19 to be informative. Punch biopsies 2 mm in diameter are of negligible diagnostic value. Location also matters. SSRIs to treat canine aggression Biopsies from the periphery of lesions are often more Inhibition of serotonin reuptake resulting in increased diagnostic than those from the center, which may be more serotonergic neurotransmission by allowing serotonin necrotic. The edges of ulcers tend to include crusts. It is molecules to act for extended periods of time. In dogs also important to biopsy areas on the nose showing loss common uses include anxiety and fear issues. Sero- of cobblestone appearance and areas of depigmentation tonin is involved in modulation of aggression, therefore, where there is still some gray coloration. When sampling medications which increase central serotonergic activity paw pads, the carpal pad is a good choice because it is should produce a decrease in aff ective aggression and not weight-bearing. When shipping in cold temperatures decrease the tendency to engage in sudden outbursts. where freezing is a concern, add 1 part isopropyl alcohol Side-eff ects of SSRIs include GI signs - decreased ap- to 9 parts 10% neutral buff ered formalin to prevent freez- petite, vomiting, diarrhea/constipation, anxiety, irritability, ing and its associated artifact. insomnia, anorexia, and aggression. Contraindications Karen Trainor, DVM, MS, DACVP include diabetes mellitus and hepatic disease. Do NOT dvm360, Apr 2021 use with an MAOI or TCA as it may result in serotonin syndrome. SSRIs have a slow onset of action and result Increase pharmacy income with reminders in neurotransmitter/receptor changes. They are metabo- Many veterinarians are making the No. 1 mistake in lized in the liver and excreted through kidneys. They have pharmacy operation: Failure to remind clients to reorder 1-4 week latency to eff ect and a long t1/2. Start at the medications and food. Online polls of nearly 400 hospi- lower dose and work up to avoid side-eff ects. Fluoxetine tal managers and veterinarians found 86 percent don’t dose: Dogs 1.0-2 mg/kg, PO, q24h; Paroxetine dose: send refi ll reminders. Relying on clients to remember to Dogs 1.0-1.5 mg/kg, PO, q24h; Sertraline dose: Dogs reorder is a horrible business strategy. Hospitals could 0.5-4.0 mg/kg, PO, q24h. secure and grow more pharmacy income by performing Terry Marie Curtis, DVM, MS and Laurie Bergman, VMD one simple strategy: Turn on refi ll reminders. Pharmacy VMX, 01:19 sales represent 25-30 percent of revenue in companion animal practices. Here are smart pharmacy operational Alopecia and grooming strategies: 1) Send reminders 30 days ahead. 2) Send Alopecia or thin hair is noticed when many hairs have lab test reminders when required for medication refi lls. been shed and not regrown for many months, the re- 3) Use “blood work required before next refi ll” stickers. maining unshed hair (which is not cycling normally) may 4) Set up auto shipments. be faded, dull, or matted. The owner may not notice the Wendy S. Myers, CVJ problem until the pet is groomed or clipped, and they will Vet Pract News, Jun 2021 blame the groomer for the hair condition because “there was no problem until he was groomed.” It is important Conservative management of cruciate disease to educate owners that the grooming or clipping did not The most important part of the conservative manage- cause the underlying issue with hair cycling. Giving a ment is the at home exercises and the most critical part diagnosis of “post clipping alopecia” is not recommended of this is walking. However, to be able to walk, the patient as it implies the act of clipping was somehow involved has to be comfortable. The author wants the owners to in the disease. “Hair cycle arrest” is more appropriate. use a 4 ft. leash, not a retractable leash. There should Melissa Eisenschenk, DVM, DACVD be no pulling and they should be allowed to eliminate VPN, May 2021 fi rst. The goal here is to focus on walking, not a sniff tour

www.CapsuleReport.com; [email protected]

Forwarding or Copying is a Violation of U.S. and International Copyright Laws Page 5