scott@vtx-cpd.com

Hello.

This is not something I have heard of. My understanding was the follows:

NAC is usually given as a 10% solution diluted 1 to 2 with saline as an IV bolus over 20 minutes through a 0.25 micron non-pyrogenic in-line filter at a dosage of 140 mg/kg initially followed by dosages of 70 mg/kg q 8-12 h.

As far as I am aware this is the same for the IV preparation.

But I stand corrected if you have other information!

Scott 🙂

Hello Austeja.

I hope you are well. Theses are really tricky cases, so don’t beat yourself up about the outcome. You did a great job.

I have popped some thoughts under your questions:

1. How long do you have to wait after discontinuing pred so you can take biopsies?

This is a great question. In an ideal world I would wait as long as possible, at least a couple of weeks. Longer if possible. Endoscopy would have maybe been a good option in this case. You could have considered endoscopic biopsies even when the albumin was lower.

2. I gave metronidazole as immunomodulatory drug, however, now I think it was unjustified. Was it wrong to prescribe it in this case?

The dog had very severe signs, so I understand your reasoning. I would probably not be rushing to use antibiotics in this case. I would have considered diet, probiotics and steroids before antibiotics.

3. Was the shaking fit similar to eclampsia, because of low calcium secondary to low albumin? I assume low glucose was secondary to long standing diarrhea and not eating?

Sounds like the shaking was due to the low calcium and I would suspect moist of this is due to the albumin. The severity of the GI disease will also contribute to issues with calcium absorption. When exactly was the low glucose documented? This could be post seizure/neurological; activity. The other possible concern for low glucose could be sepsis?

4. Could extreme liver enzymes be caused by diazepam and other drugs being more toxic with such low albumin.

I think there are lots of reasons for the liver to take a hit in this case (drugs/GI disease/hypoxia). I would suspect this was a secondary hepatopathy.

5. How would you approach hypoalbuminemic crisis like this?

These are very challenging. Treating the cause as aggressively as possible. I would also be aggressive regarding calcium supplementation (IV in a crisis) as well as considering vitamin D supplementation to help longer term. Plasma and human albumin are the only option for albumin replacement, but both options have their limitations.

6. Do you have any more comments on how would you manage this case?

I think the main thing I would have pushed for earlier on would have been endoscopic biopsies. I would also have considered vitamin D supplementation to help with calcium.

I hope that helps.

Scott 🙂

Replying to Alison Lambert 11/05/2022 - 08:13

Hello Alison.

I hope you are well. Thank you so much for your kind words.

Yes, there is no evidence to say that prophylactic use of a PPI is necessary when administering higher doses of steroids.

Hope that helps.

Scott 🙂

Hello.

Lovely to hear from you. I normally use this product:

https://www.protexinvet.com/pro-enzorb/p6243

This would normally be a capsule a day for cats. I hope that helps.

Scott 🙂

Replying to Belinda Lum 04/05/2022 - 09:51

Hey.

This is a brilliant question. Was this in dogs or cats?

Generally the worst side effect we see in dogs is hypersalivation. Capromorelin is dosed at 3 mg/kg PO q24h, which has been shown to increase food intake and weight gain in both inappetent client-owned dogs and healthy laboratory dogs. The pivotal field safety and effectiveness study evaluated 177 inappetent dogs (121 treated with capromorelin for 4 days, 56 with placebo). Treatment with capromorelin significantly improved appetite (68.6% versus 44.6%, respectively, P = 0.008) as well as mean body weight compared with placebo (1.8% versus 0.1%, respectively, P <0.001). The most commonly observed adverse clinical signs included diarrhea (7.0%), vomiting (6.4%), polydipsia (4.1%), and hypersalivation (2.3%).

There are some reports coming through with concerns with the clinical use of capromorelin in cats. The authors of the 2011 study of capromorelin in cats did note lethargy and depression, but cardiovascular parameters – such as heart rate and blood pressure – were not reported. There are unpublished reports of some cats become profoundly bradycardic and hypotensive within one hour of being given capromorelin at a dose of 3 mg/kg. It is likely there will be enough data for one or several institutions to publish data describing in more detail the incidence of adverse events in cats, and ideally identify at-risk populations. It might be enough evidence to use capromorelin in cats at a lower dose (2mg/kg).

I hope that helps.

Scott 🙂