scott@vtx-cpd.com
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This is really interesting Simon!
I think Andy’s question about intralipid is a really good one… I might indeed be a consideration in these cases.
Why have the human medics moved away from gastric lavage? Is there evidence to support worse outcomes? I wonder if the outcomes are worse in these cases because they have the more severe toxins to begin with?
It is always a worry inducing emesis in the cases that are neurological or likely to become neurological. If they are obviously neurological on presentation when I would not induce emesis. If they are clinically normal on presentation I often will.
Scott 🙂
I feel your pain! Hope things settle down a bit! 🙂
Thank you Gemma.
This is really useful. Thank you so much for this.
Scott 🙂
Andy…
I think this actually raises a really good point. Is an epidural something a nurse can do?!
I dont know the answer?!
Anyone?
Scott 🙂
Hey Charlotte.
Hope that sounds OK. If your clinics are anything like mine at the moment, I understand why you are a bit behind!
The discussion forum will be live till then, so feel free to keep asking questions.
Scott 🙂
Thanks again for all of this discussion.
I think this is why it so interesting/important to look what is actually included in the products we have on the shelve!
I had a question for our friends at Protexin. Why have you included SAMe over DL-methionine in Denamarin?
Loving asking the questions for a change! 🙂
Sure.
Do you worry about toxicity?
Scott 🙂
Sorry!
I did not answer the bit about the chlorambucil! It was added as a second agent from the start to deal with the inflammatory changes particularly in the GI tract, the aim being that we would be able to reduce the dose of steroid sooner.
Hope that helps.
Scott 🙂
Hello.
Thank you so much. Totally agree, these are challenging cases and the decision making can be difficult. Many will do well with antibiotics, hepatoprotection and supportive care. Much of the decision making will depend on imaging too. If there seems to be disease in the GI tract and pancreas too, I will often be more proactive at taking biopsies. If there is any sign of significant biliary tract obstruction, them may also be more immediate surgical candidates. There is not a definitive answer as how long to wait before GA. Sometimes they are still sick when they go for GA. I am happy to send them for GA if cardiovascular system stable and blood pressure normal.
Regarding the immunophenotyping, it is something that can be done on some FNA tissue and sometimes on blood. It depends very much on the individual lab. I would contact the lab you use and they should have a list of typing and staining they are able to do.
Hope that helps.
Scott 🙂
Regarding the cats with weight loss. The answer might be yes! I definitely will run cobalamin folate and fPL in most of my cases. TLI might depend a bit on signs, but not all cats will display classic signs of diarrhoea. Any case with more chronic signs, I would definitely run all of these.
Hello.
Thank you so much for the great questions:
1. I have never used injectable dexamethasone orally, I do not think this would be effective. What might be an option for these cases would be a liquid form of prednisolone. You can get a liquid prednisolone from BOVA:
2. There is indeed a paper about mirtazapine:
https://pubmed.ncbi.nlm.nih.gov/30307637/
Basically, I would still use it in liver cases, but will reduce dose/frequency. I would give every other day.
3. In cats we would normally dose chlorambucil 2mg every other day. So every 2 days. This dose can be reduced to the point that it can be given once every 7 days. So it would be 2mg every 7 days.
Hope that makes sense. Let me know if not.
Scott 🙂
Totally agree Sybil. More data needed… is that not the story of veterinary medicine!
I think paracetamol is a great option for many of the cases you mention. Much less of the potential negative GI effects you also touch on. Paracetamol might also be an option for pregnant and lactating bitches. As far as I am aware paracetamol is one of the only drugs pregnant humans are allowed to take?! Others in the group will have more experience of that than me!
Scott 🙂
Hello.
Maropitant is still a good first line choice for most cases. When you look at all the studies comparing ondansetron and maropitant, there are many instances when maropitant performs better:
https://pubmed.ncbi.nlm.nih.gov/32515910/
https://pubmed.ncbi.nlm.nih.gov/30272481/
https://pubmed.ncbi.nlm.nih.gov/28198032/
https://pubmed.ncbi.nlm.nih.gov/21626407/
https://pubmed.ncbi.nlm.nih.gov/19000276/I would still used maropitant first line, but keep ondansetron for cases that are not responding well to maropitant.
Hope that helps.
Scott 🙂
Thanks for this.
What is the actual product name and I will have a look at it?
It just shows how important it is to read the label!
Scott 🙂
Let me know if you have any other questions though!
I hope we see you at the next one!
Scott 🙂
This may be my favourite question yet!!! Yes, I was just discussing this over on our members discussion forum. Where did you hear this and do you know what the information was based on? I think the following study demonstrates it well:
The full thing is available for free (https://pubmed.ncbi.nlm.nih.gov/28814338/):
Anti-nausea Effects and Pharmacokinetics of Ondansetron, Maropitant and Metoclopramide in a Low-Dose Cisplatin Model of Nausea and Vomiting in the Dog: A Blinded Crossover Study
Abstract
Background: Nausea is a subjective sensation which is difficult to measure in non-verbal species. The aims of this study were to determine the efficacy of three classes of antiemetic drugs in a novel low dose cisplatin model of nausea and vomiting and measure change in potential nausea biomarkers arginine vasopressin (AVP) and cortisol. A four period cross-over blinded study was conducted in eight healthy beagle dogs of both genders. Dogs were administered 18 mg/m2 cisplatin intravenously, followed 45 min later by a 15 min infusion of either placebo (saline) or antiemetic treatment with ondansetron (0.5 mg/kg; 5-HT3 antagonist), maropitant (1 mg/kg; NK1 antagonist) or metoclopramide (0.5 mg/kg; D2 antagonist). The number of vomits and nausea associated behaviours, scored on a visual analogue scale, were recorded every 15 min for 8 h following cisplatin administration. Plasma samples were collected to measure AVP, cortisol and antiemetic drug concentrations.Conclusions: 5-HT3 receptor antagonist ondansetron demonstrates the greatest anti-emetic and anti-nausea efficacy of the three drugs. AVP and cortisol appear to be selective biomarkers of nausea rather than emesis, providing a means of objectively measuring of nausea in the dog.
The results of the study suggest that both 5-HT3 and NK1 receptors are an integral part of the emetic pathway activated by cisplatin which results in activation of the emetic reflex. The sensation of nausea is produced in cortical forebrain regions, increased activity was recorded in the left amygdala, the ventral putamen and the putative locus coeruleus. Nausiogenic signals travel from the vomiting centre via rostrally projecting pathways to the forebrain and nuclei controlling the physiological response to nausea sensation (e.g. salivating, restlessness). The ability of ondansetron to reduce cisplatin-induced nausea would suggest that 5-HT3 receptors have a role in transmitting nausea stimuli, either from the brainstem, the periphery or both, whereas NK1 receptors are limited to a central emetic triggering mechanism.
I think this demonstrates the exact point you are making!
Scott 🙂
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