Insulin Errors How to avoid common errors that can impede treatment success in dogs and cats with diabetes. See page 29. Critical News, Expert Insights in Animal Health and Medicine 5.18 | V. 3 | N. 4 AVMA PURDUE Respiratory Unique Aspects Complications of Feline of Trauma Lymphoma raumatic injury can result in ymphoma is different in cats multiple respiratory complica- than in dogs, emphasized Jenni- Ttions, according to Lori Waddell, L fer Pierro, MS, DVM, DACVIM DVM, DACVECC, clinical professor of (Oncology), an oncologist at Veterinary critical care medicine Cancer Group in Los Angeles, Califor- at the University of nia. Presenting at the 2017 Purdue Vet- Pennsylvania School erinary Conference in West Lafayette, of Veterinary Medicine Indiana, Dr. Pierro discussed updates (PennVet) in Phila- in feline lymphoma and shared some delphia. At the 2017 unique aspects of how the disease dif- American Veterinary fers in cats compared with dogs. Natalie Stilwell, DVM, MS, PhD Medical Association In dogs, the typical presentation of Convention in Indianapolis, Indiana, lymphoma is high-grade multicentric Dr. Waddell drew from her years of nodal disease. However, cats more specialty training and clinical ex- commonly develop gas- perience to educate the audience trointestinal (GI) lym- on this important topic in emer- SPECIAL FEATURE phoma, typically with- gency medicine. out generalized lym- The various causes of thoracic In Time of Need: Veterinary Practices phadenopathy. Clinical trauma, whether accidental or inten- and Natural Disaster Preparedness signs of lymphoma in tionally caused by abuse, are gener- Nicola M. Parry, BVSc, cats also tend to be ally categorized as blunt or pene- By Don Vaughan MRCVS, MSc, DACVP, ELS nonspecific, mimicking trating, she said. Blunt trauma most s Hurricane Irma menaced South Florida in September 2017, Christina those of a range of other conditions commonly occurs from a fall or Wood’s thoughts turned to her dog, Loki. The 9-year-old mixed breed such as pancreatitis and renal failure. (continued on page 16) Awas so sensitive to loud noises that he would cower under the couch (continued on page 23) during thunderstorms. How, she wondered, would Loki react to hours of deafening wind and rain? “I was afraid it was going to be a rough ride,” recalled AVMA Wood, a freelance writer based in Delray Beach. “I had given Loki Xanax for the ACVC Why “Dental” (continued on page 25) Critical Care Is a Dirty Word INVMA PAIN MANAGEMENT Nutrition bout 75% of dogs and cats seen ritically ill animals require nu- in practice have dental disease, Managing Tramadol: tritional support. Patients with A but how many are receiving Invertebrates Limited Benefit Cchronic diseases also have nu- dental care? Dentistry is one of the for OA Pain tritional requirements that should be most overlooked and underappreciated in Practice addressed as part of their treatment plan. services in veterinary medicine. But it ccording to Jörg Mayer, DVM, ramadol is commonly used in “When patients are critically ill, they can also be one of the most profitable. MS, DABVP (ECM), DECZM, dogs to manage pain associated are constantly in a breakdown state,” At the 2017 American Veterinary A DACZM, associate professor of T with osteoarthritis (OA), a con- said David Liss, RVT, VTS (ECC, SAIM), Medical Association Convention in zoological and exotic animal medicine dition estimated to affect more than CVPM, in a presentation at the 2017 Indianapolis, Indiana, Kris Bannon, at the University of Georgia College 20% of the adult canine population.1,2 Atlantic Coast Veterinary Conference DVM, FAVD, DAVDC, owner of Vete- of Veterinary Medicine in Athens, in- Recent study findings, however, sug- in Atlantic City, New Jersey. Seriously rinary Dentistry & Oral Surgery of vertebrates are becoming increasingly gest that tramadol may offer limited ill patients burn calories constantly. If New Mexico in Albuquerque, urged popular as pets. therapeutic benefit. they do not receive adequate nutrients veterinarians to appreciate what it Presenting at the Indiana Veterinary Tramadol hydrochloride is a weak through feeding, their bodies begin takes to provide quality dental care. Medical Association’s 2018 annual μ-opioid receptor agonist that provides to break down skeletal muscle in an By doing so, she said, your prac- meeting in Indianapolis, Dr. Mayer centrally acting analgesia via 2 major effort to recruit protein. Catabolism tice will see an increase in compli- discussed some common problems in metabolites: O-desmethyltramadol and of protein adversely affects wound ance, staff satisfaction, and revenue. invertebrates and shared some basic N,O-didesmethyltramadol. Although healing, immune function, and strength. (continued on page 19) (continued on page 20) (continued on page 28) (continued on page 14) AmericanVeterinarian.com Jimmer-focused on soaring to new heights. PROZINC-focused on Jimmer. No matter what your patients are focused on, PROZINC is the ideal insulin choice that meets their individual needs. That’s because PROZINC puts diabetic cats fi rst with e cacy proven to improve clinical signs,1 a duration of action appropriate for felines,2,3 and expert veterinary support. Plus, PROZINC is the only veterinary insulin recommended by the AAHA for the initial treatment of diabetic cats.3 Make PROZINC your fi rst choice. Visit PROZINC.us. Important Safety Information: For use in cats 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. References: 1. Nelson RW, Henley K, Cole C; PZIR Clinical Study Group. Field safety and e cacy of protamine zinc recombinant human insulin for treatment of diabetes mellitus in cats. J Vet Intern Med. 2009;23(4):787–793. 2. Nelson RW. Disorders of the endocrine pancreas. In: Nelson RW, Cuoto CG, eds. Small Animal Internal Medicine. 4th ed. St. Louis, MO: Mosby Elsevier; 2008:764–802. 3. Rucinsky R, Cook A, Haley S, Nelson R, Zoran DL, Poundstone M; American Animal Hospital Association (AAHA). AAHA diabetes management guidelines for dogs and cats. J Am Anim Hosp Assoc. 2010;46(3):215–224. PROZINC is a registered trademark of Boehringer Ingelheim Vetmedica, Inc. © 2018 Boehringer Ingelheim Vetmedica, Inc. PRO0315001 18212 NADA 141-297, Approved by FDA ProZinc® (protamine zinc recombinant human insulin) Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Three cats had injection site reactions, which were described as either small, punctate, red Description: ProZinc® insulin is a sterile aqueous protamine zinc suspension of recombinant lesions; lesions on neck; or palpable subcutaneous thickening. All injection site reactions human insulin. resolved without cessation of therapy. Each mL contains: Four cats developed diabetic neuropathy during the study as evidenced by plantigrade recombinant human insulin 40 International Units (IU) stance. Three cats entered the study with plantigrade stance, one of which resolved by protamine sulfate 0.466 mg Day 45. Four cats were diagnosed with diabetic ketoacidosis during the study. Two were zinc oxide 0.088 mg euthanized due to poor response to treatment. Five other cats were euthanized during the glycerin 16.00 mg study, one of which had hypoglycemia. Four cats had received ProZinc insulin for less than dibasic sodium phosphate, heptahydrate 3.78 mg a week and were euthanized due to worsening concurrent medical conditions. phenol (added as preservative) 2.50 mg The following additional clinical observations or diagnoses were reported in cats during hydrochloric acid 1.63 mg the effectiveness field study: vomiting, lethargy, diarrhea, cystitis/hematuria, upper water for injection (maximum) 1005 mg respiratory infection, dry coat, hair loss, ocular discharge, abnormal vocalization, black pH is adjusted with hydrochloric acid and/or sodium hydroxide. stool, and rapid breathing. Indication: ProZinc (protamine zinc recombinant human insulin) is indicated for the Extended Use Field Study reduction of hyperglycemia and hyperglycemia-associated clinical signs in cats with Cats that completed the effectiveness study were enrolled into an extended use field diabetes mellitus. study. In this study, 145 cats received ProZinc insulin for up to an additional 136 days. Dosage and Administration: USE OF A SYRINGE OTHER THAN A U-40 SYRINGE WILL Adverse reactions were similar to those reported during the 45-day effectiveness study RESULT IN INCORRECT DOSING. and are listed in order of decreasing frequency: vomiting, hypoglycemia, anorexia/ poor appetite, diarrhea, lethargy, cystitis/hematuria, and weakness. Twenty cats had FOR SUBCUTANEOUS INJECTION IN CATS ONLY. signs consistent with hypoglycemia described as: sluggish, lethargic, unsteady, wobbly, DO NOT SHAKE OR AGITATE THE VIAL. seizures, trembling, or dazed. Most of these were treated by the owner or veterinarian ProZinc insulin should be mixed by gently rolling the