scott@vtx-cpd.com
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Hi Christina,
Thanks so much for sharing—what a tough case. I think Josep’s nailed this one and has covered all the key angles better than I could, so I’ll defer to him here!
Scott 🙂
Replying to Rachel H. 29/05/2025 - 15:18
No problem!
Let me know if there is anything else I can do to help.
Have an amazing weekend.
Scott 🙂
Replying to Raquel M. 27/05/2025 - 14:31
Thanks so much, Raquel.
Really insightful reflections
I think one of the key points you touch on is perception. Librela is often seen as safer than NSAIDs, especially among clients and some GPs, which can understandably shape prescribing behaviour. But I’d argue we’re simply more familiar with NSAIDs. We have decades of data on long-term effects, we know what adverse events tend to look like, and we’ve developed fairly robust strategies for monitoring and mitigation. Librela, by contrast, is still relatively new, and some of the serious concerns, while rare, are only becoming visible through post-marketing data and case-level reporting. So while neither drug class is risk-free, our comfort level and experience with NSAIDs is definitely more established.
Your point about reassessing clinical response over time is such an important one. I’ve also seen dogs on repeat Librela doses where it wasn’t entirely clear what the ongoing benefit was, and I do think it can be easy for monthly injections to become routine without always re-evaluating outcome. Regular follow-ups and clearer criteria for success would go a long way here, especially in the absence of objective pain scoring tools being used consistently.
Regarding neurological side effects, yes, there’s growing interest in this area, especially since the FDA included neurological signs like ataxia and seizures in their 2024 safety update. The Zoetis review still classifies these as “very rare,” but there’s certainly enough signal to warrant caution. To your neurologist’s point, bedinvetmab is not expected to cross the blood–brain barrier under normal conditions, but in cases of compromised barrier integrity (such as inflammation, trauma, or certain neurodegenerative diseases), we can’t be completely certain. The neurologist I work with now will avoid using Librela entirely in cases of inflammatory brain or spinal disease for exactly that reason. So I think your concern about potential misdiagnosis is well-placed, especially in settings without access to advanced imaging.
For now, I’d say careful neuro exams, a clear indication of OA based on physical exam (or ideally imaging), and caution in any dog with neurological history are all justified.
Thanks again!
Scott 🙂
Replying to Sybil Dryburgh 25/05/2025 - 23:23
Hi Sybil,
Haha, I honestly thought you were just making a very passionate point with those capital letters and I was completely here for it! And I totally agree, when you’re 48 hours post-op and they’re still not eating, NSAIDs can sometimes be the thing that turns the corner, especially when everything else feels a bit underwhelming.
Thanks for mentioning erythromycin. There’s a really helpful recent multicenter study out of WA looking at prokinetic use in hospitalized dogs, and it shows a clear shift toward erythromycin or dual metoclopramide/erythromycin therapy between 2018 and 2023. Interestingly, erythromycin alone or in combination became more common over time, and while efficacy wasn’t the primary endpoint, its increasing use suggests clinicians found it clinically helpful. No significant adverse effects were recorded, though obviously prospective studies would be ideal.
Erythromycin acts via motilin receptor stimulation in dogs (partly via 5-HT3 cholinergic pathways), and at low doses (0.5–1.0 mg/kg PO or IV) mimics the migrating motor complex (MMC) pattern, aiding coordinated gastric emptying. High doses (10–30 mg/kg), though, can actually trigger retrograde peristalsis, so careful dosing is crucial. I still default to 1 mg/kg IV q8h or oral where I can get it. Azithromycin is starting to crop up in the literature too, showing similar effects in manometric studies and possibly fewer antimicrobial resistance concerns long term.
On the metoclopramide front, I also wanted to share a study I came across recently by Wilson, Evans, and Mauer (Vet Anaesth Analg. 2006), which compared low and high dose metoclopramide infusions in dogs under GA. The high dose group—bolus 1 mg/kg IV followed by 1 mg/kg/hr CRI—had a 54% reduction in the relative risk of gastroesophageal reflux compared to placebo. That’s a huge difference, and it’s got me thinking more about dose escalation in critical GI cases.
I’ll admit, I’ve rarely gone above 2 mg/kg/day in my own patients, but I did try 4 mg/kg/day (CRI) in one recent regurg-heavy ileus case where erythromycin wasn’t available. It actually seemed to help. Silverstein and Hopper mention doses up to 7–8 mg/kg/day in their critical care book, though I’m still trying to find the primary reference. I’d be really curious to hear if anyone else has pushed the dose higher. Was it effective, and did you run into any neuro signs or other issues?
Anyway, always love chatting GI motility. It’s one of those areas where a few subtle tweaks can make a huge difference to outcomes.
Scott 🙂
References
Teo EF, Sharp CR, Boyd CJ, Chee W. Use of erythromycin and metoclopramide in hospitalized dogs: a multicenter historical cohort study. Front Vet Sci. 2024;11:1206335. doi:10.3389/fvets.2024.1206335Wilson DV, Evans AT, Mauer WA. Evaluation of the effect of metoclopramide on the incidence of gastroesophageal reflux in anesthetized dogs. Vet Anaesth Analg. 2006;33(5):336–44
Mann FA, et al. Small Animal Critical Care Medicine. 2nd ed. Elsevier; 2015.
Replying to Jane Sedgewick 25/05/2025 - 14:54
Hi Jane,
Really interesting to hear that. Your audit findings are very much in line with what this new paper and others are pointing to. I must admit I often start around 1.5 mg/kg myself, based on the Sieber-Ruckstuhl et al. (JVIM, 2019) study which showed excellent electrolyte control with that starting dose. In fact, most dogs in that study ended up needing further dose reductions down to a median of 1.1 mg/kg to maintain stability over time, especially once they were past the initial stabilisation window.
It aligns nicely with the Vincent et al. (JVIM, 2021) trial too, which compared 1.1 mg/kg and 2.2 mg/kg and found no difference in electrolyte control, but much more biochemical evidence of overtreatment, including suppressed renin activity and lower urine specific gravity, in the standard-dose group. I do think we’ve probably been overtreating some dogs for a long time, largely out of convention.
Like you, we’ve also seen plenty of patients do well on extended intervals, 5 or 6 weeks for cost reasons in some cases, and even the ones with fairly inconsistent compliance seem surprisingly stable once they’ve had time to equilibrate. It does make you wonder how much of our rigid scheduling is about pharmacology versus calendar logic.
And yes, once they’re through that initial adjustment period, they really do just get on with things. Most of our long-term Addisonian dogs seem to die with the condition, not from it.
Thanks again for sharing!
Scott 🙂
Replying to Alys J. 25/05/2025 - 12:48
Hi Alys,
Thanks for your message.
That’s a great question, and it’s one we’re all increasingly mindful of in light of antimicrobial stewardship guidance. First, how was the urine sample collected? If it was free-catch, that’s important context, especially in asymptomatic dogs. A recent JSAP study (Mandese et al., 2024) showed that significant bacteriuria was far more likely in male dogs, and not meaningfully reduced by cleansing prior to collection. This reinforces that we need to be cautious about interpreting bacteriuria on sediment alone in patients without urinary signs.
Subclinical bacteriuria is defined as the presence of bacteria in a properly collected urine sample (ideally via cystocentesis) with no clinical signs of urinary tract infection. Terminology like “occult UTI” or “infection” without symptoms should be avoided. While cytological detection of bacteria or pyuria can be supportive, studies have shown poor agreement with culture results and poor predictive value for actual infection (McGhie et al., 2014; O’Neil et al., 2013). So a positive sediment alone, especially in an otherwise well patient, doesn’t justify treatment.
The recent Frey et al. (JAVMA, 2024) study followed dogs with untreated subclinical bacteriuria and found that it was typically persistent but non-progressive. Only one dog developed pyelonephritis, and that dog had multiple comorbidities and urinary calculi. This aligns with ISCAID’s 2019 recommendations to avoid treatment for SB, even in the presence of pyuria or high CFU counts.
Similarly, Siu et al. (JAVMA, 2022) followed post-op spinal surgery patients with SB and showed no adverse consequences from delaying antibiotics until clinical signs emerged—again supporting a symptom-driven approach to treatment.
A broader 2019 review by Weese and colleagues reinforces that subclinical bacteriuria is relatively common in dogs (up to 12% in healthy individuals and higher in those with diabetes, obesity, or neurologic disease), but treatment is rarely indicated. Culture should only be performed if a result would change your management, otherwise it risks leading to unnecessary antibiotics.
In your case, no LUTS, weight loss as the presenting concern, and bacteria seen only on sediment, I’d lean toward monitoring rather than treating, unless cystocentesis culture confirms infection and other signs develop. I think it will also depend on what other parts of your investigation tell you.
I hope that helps! Have a lovely week.
Scott 🙂
Replying to Samantha L. 24/05/2025 - 22:46
Hi Samantha,
Lovely to hear from you, I hope you are enjoying the course.
Thanks so much for your thoughts, I really appreciated your perspective.
I agree, it’s definitely something that feels more psychological and individual than anything else. Like you, I hadn’t really given much conscious thought to the owner’s body condition in relation to how we approach weight discussions until I read this paper. But once you start reflecting on it, you can see how these subtle dynamics might play out in the background, especially when tensions rise or when an owner becomes defensive. It’s often in those moments that we start noticing more about the interaction and maybe even making unconscious attributions without realising.
I also completely agree that the owner’s attitude has a much bigger impact on our perception of their caregiving than their appearance. In any case, I think the paper is a useful reminder to stay self-aware and make sure our communication is always grounded in compassion, not assumptions. At the end of the day, it’s about doing what’s best for the pet and finding ways to support the owner in that without making it personal.
Thanks again for engaging with it.
Scott 🙂
Hi Laura,
Great question and I’m completely with you on the love for maropitant. It’s one of those game-changing drugs I’d now struggle to practise without.
I do use maropitant routinely in premeds (especially for opioids), and I’ve also used it in plenty of jaundiced or hepatopathy patients. The theoretical concern stems from the fact that maropitant is primarily cleared by hepatic metabolism (CYP3A), and plasma levels can be higher and clearance slower in dogs with moderate to severe liver disease. But in practice, short-term use—even in the face of elevated liver enzymes, hasn’t been shown to cause harm, and I’d consider it a reasonable choice if the clinical benefit is there (e.g. vomiting, nausea, perioperative antiemesis).
I think it’s also important to remember the difference between liver enzyme increases and true liver dysfunction. Maropitant is metabolised in the liver and should be used with caution in patients with hepatic disease—particularly when treating over longer periods. As it accumulates during a 14-day course due to metabolic saturation, careful monitoring of liver function and any adverse effects is sensible during extended use.
Really interesting question!
Warm wishes,
Scott 🙂
Replying to Jane Sedgewick 25/05/2025 - 14:25
Hi,
I don’t use it often either, but I agree it can be really helpful in those relapsing colitis cases where owners just need something practical they can do early. And totally with you on being confident it’s not NSAID-related before combining.
The evidence for sulfasalazine is definitely disappointing, and the human data is also a bit all over the place. It feels like one of those drugs that’s hung around more through tradition than strong trial data.
Have a great week!
Scott 🙂
Replying to Jane Sedgewick 25/05/2025 - 14:34
Hi,
Yes, I completely agree with your point about the <2-hour window, I’ll still often give it a go with emesis if the object is known and hasn’t progressed. I’ve definitely seen things like socks or bits of toy sit quite happily in the stomach for a couple of days before they start to cause trouble.
Like you said, it’s got to be something soft and safe enough to come back up, but when the circumstances are right, those success rates are very encouraging.
Scott
Hello Amy,
Entyce (capromorelin oral solution) is indeed available in the UK through Raman Pharma, a licensed veterinary pharmaceutical wholesaler. They specialize in sourcing difficult-to-obtain medications and are MHRA and VMD licensed .
Let me know if you need any further assistance! I hope you are enjoying the course. We would love to hear any feedback you have.
Best regards,
Scott
Replying to Rachel H. 21/05/2025 - 12:09
Hi Rachel,
Great question.
In terms of timing neutering in acromegalic bitches with diabetes, the general principle is to prioritise spaying as soon as it’s safely possible, rather than waiting for full diabetic control first. The reason is that as long as progesterone is circulating, growth hormone remains elevated, and the insulin resistance will persist no matter how much insulin we throw at it. So, while some degree of stabilisation is helpful for anaesthetic safety, trying to fully regulate diabetes before spaying can become a bit of a futile cycle.
What I typically aim for is at least partial stabilisation, meaning the dog is eating reasonably well, we’ve ruled out ketones, hydration is okay, and blood glucose is starting to come down with insulin support. That can often be achieved in a few days to a week. Then I would move ahead with spaying, earlier if she’s in overt dioestrus, and a little later if we’re able to catch her before the progesterone surge.
Once the ovaries are removed, the source of growth hormone disappears fairly rapidly, and we usually see a steady improvement in insulin sensitivity over the following couple of weeks. Insulin doses often need adjustment after surgery, so close monitoring is important.
If there are any concerns about anaesthesia, or if she’s particularly unstable, we’ll sometimes work with the surgery team to delay briefly while addressing acute issues, but I wouldn’t aim for weeks or months of pre-op diabetic control in these cases. That just delays resolution of the underlying driver.
Have you got a case currently?
Best,
Scott 🙂
Replying to Christina Frigast 23/05/2025 - 13:29
Hi Christina,
I think many of us have felt that same hesitation when it comes to NSAIDs post-GI surgery, especially with the historic emphasis on avoiding them. It does seem like we’ve maybe swung a bit too far in the opposite direction, and this paper helps shift the balance back toward a more nuanced, risk-based approach.
I’m also a bit of a paracetamol fan (probably helped by how many of my cases are already on steroids), but I completely agree—it often feels like it doesn’t quite cut it after ex-laps. Your case from last weekend is exactly the kind of situation where I’ve found myself second-guessing too. I often wonder if we end up prolonging opioid use (and all the issues that come with it) by holding off on NSAIDs a bit too much.
For straightforward, non-septic GI surgeries that are recovering smoothly, I think this data gives us some reassurance. Like you, I might still go cautiously in anything with active diarrhoea or signs of mucosal fragility, but it’s definitely helped reframe my comfort level with a single dose or short course when appropriate.
Really appreciate your thoughts as always.
All the best,
Scott 🙂
Hi Cristina,
Thanks so much for your message, and I’m really glad to hear you’re enjoying the course! I would love to hear any feedback/improvements you have!
That’s a great question about antibiotic duration for pyothorax. You’re right that 4–6 weeks can sound like a long course, particularly if surgical drainage or debridement has been carried out effectively. The recommendation for a 4–6 week duration is based largely on expert consensus and limited veterinary evidence, with some extrapolation from human medicine, where protracted courses are also common due to the complex nature of pleural infections.
A few practical points to consider:
Even with surgical drainage, the pleural space can be a difficult site to clear, and anaerobic or mixed infections are common, especially in cats.
In dogs, pyothorax is often due to inhaled or migrating foreign bodies, while in cats, oropharyngeal anaerobes (e.g., Fusobacterium, Prevotella, Porphyromonas) are frequently involved, sometimes with Actinomyces or Nocardia.
Because of the fastidious nature of many of these organisms, culture can underestimate what’s truly there, so a course that covers anaerobes (e.g., clindamycin + enrofloxacin) is often continued empirically even if cultures are negative.
The ACVIM consensus working group recommends:
Prompt drainage with chest tubes (intermittent or preferably continuous), with or without lavage
Empirical combination therapy pending culture: typically a penicillin or clindamycin plus a fluoroquinolone (e.g., marbofloxacin or enrofloxacin)
Continued anaerobic cover regardless of culture outcome
No intrapleural antimicrobials, given the lack of evidence and potential for irritation
Minimum 3–4 weeks, often 4–6 weeks total antimicrobial course, with imaging at 10–14 days and again at treatment completionThat said, you’re completely right that treatment needs to be individualised. In surgical cases where drainage is complete and clinical recovery is rapid, a shorter course may be justifiable, but we still tend to default to caution. Serial imaging and clinical response are key to monitoring.
Let me know if you’d like a copy of the full consensus summary or any additional reading on this topic!
Warm wishes,
Scott
Replying to Jane Sedgewick 20/05/2025 - 18:01
Hi Jane,
I totally agree that we do end up medically managing more of these than we probably realise. And I also found the low numbers of medical cases in the JAVMA study surprising given the overall caseload. Like you, I couldn’t easily tell if the decision for medical management was strategic (e.g. known soft/smooth FBs) or driven more by financial barriers. It’d be interesting to know how many of those “conservative” cases ended up needing serial imaging, Entyce, fluids, or creative medical therapy.
The cost side is a real factor—between 2–3 days of hospitalisation, repeated imaging, and increasingly elaborate outpatient meds, surgery might still be cheaper and more definitive in selected dogs. And as you said, short enterotomies or straightforward gastrotomies do so well in most cases.
On the emesis side, I found two recent studies that really help guide us:
Zersen et al., JVEC 2020: 61 dogs given IV apomorphine—97% vomited, 78% produced the foreign body, and no complications were reported. About 20% still needed endoscopy.
Kirchofer et al., JAVMA 2020: 495 dogs evaluated after apomorphine-induced emesis. Vomiting occurred in 95.6%, and 76% had successful foreign body removal. Outcomes were best when vomiting was induced <2 hours post-ingestion, in younger dogs, and when the item was fabric, leather, or bathroom waste. Success dropped if opioids/sedatives/antiemetics had been given beforehand. Adverse effects were rare (0.8%).
I tend to use emesis only for recent ingestions of soft, non-caustic, non-sharp materials in dogs with good mentation and no risk factors (e.g. laryngeal paralysis, megaoesophagus). These studies help reinforce that with the right case selection, it can be very safe and effective.
Would love to hear your decision making thoughts!
Have a lovely weekend!
Scott 🙂
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