scott@vtx-cpd.com

Replying to Claire L. 10/04/2022 - 11:06

This is a brilliant question.

I am going to chat to some ECC colleagues about this one too.

The role of gastric protection medication in acute toxicity is not clear, even in human medicine as far as I am aware. Significant gastrointestinal hemorrhage secondary to acute overdose is likely to be uncommon. It is thought that upper gastrointestinal symptoms are self-limiting; however antiemetics may be required for those with persistent or severe nausea and vomiting. No studies, to my knowledge, have investigated the role of prophylactic use of antacid or acid-suppressants such as proton pump inhibitors. I might consider a short (7-day course) of a proton pump inhibitor in patients with acute NSAID overdose who have persistent upper gastrointestinal symptoms which do not settle within a few hours of ingestion. I would not be reaching for them routinely.

I would consider misoprostol in these cases, although the evidence for this is also not great.

Hope that helps.

Scott 🙂

Replying to Raquel M. 24/03/2022 - 13:19

Hey Raquel.

I hope you are safe and well and having a lovely week. Thank you again for your brilliant questions. I have popped your questions below and my thoughts underneath. I did not want to miss anything:

Hello,

1) (a) what would you suggest for cases where an animal is reported to have a pinkish color in the vomitus or a few drops of blood as per O?

This is a great question and challenging to give a definitive answer. I would say in acute cases, when patients are well otherwise, I would not jump to use a PPI. If the presence of blood continued despite symptomatic therapy (antiemetic), or there was evidence of melena, then I would consider the use of a PPI.

(b) also if the owner reported the above was a one-off incident(or intermittent) and the other episodes of vomiting didn’t indicate any signs of blood then would you start with a PPi? Or only if the diagnostic workup confirmed GI ulceration?

Again, I would probably not. In there cases when intermittent. Endoscopy/ultrasound would be perfect to confirm ulceration or not.

Was just wondering if there’s not a substantial amount of frank blood in the vomitus and the pinkish color or specks of blood reported by owner aren’t persistent. Then is it appropriate to use PPIs or not? Especially if the owner is unable to complete a full workup to rule out ulceration.

I think for small amounts I would be rushing to use. If this was persistent and the owners were not able to carry out much work up then I would consider a PPI.

I hope that helps/makes sense.

Scott 🙂

Replying to Julie S. 24/03/2022 - 11:37

Hello.

Great question! The main data is from the human literature. There are lots of paper. A example of a recent review:

https://pubmed.ncbi.nlm.nih.gov/33560890/

The following is from that review:

Gut Dysbiosis

A growing area of concern with chronic PPI use is the development of gut dysbiosis. Gut dysbiosis results after chronic suppression of gastric acid leads to an increased pH in the small intestine, causing an imbalance in the microbiota. This affects the metabolism of foods and medications and can lead to an inflammatory state due to increased gastrin. Gastrin level elevation is directly correlated to PPI dose; this is significant because patients often have their dosage increased until symptoms are controlled. The decrease in the pH of gastric content can also result in small intestinal bacterial overgrowth (SIBO) defined as overgrowth greater than 105 bacteria per mL. Small intestinal bacterial overgrowth is characterized by malabsorption, bloating, diarrhea, and weight loss. Changes in the microbiome include increases in Streptococcus, Staphylococcus, Escherichia, Bacteroides, Lactobacillus, and Clostridium.

Overall, the effect on the microbiome is variable depending on the study. I would indeed chose the best probiotic, based on strains.

I currently tend to use Vivomixx, as it is the same composition as what used to be VSL#3, which has the most evidence attached. This is also, as Sivomixx is currently not available for shipping to the UK, they have some licensing issues. Also, Vivomixx can be at room temperature for up to 7 days, which makes posting easier, but then it should go back in the fridge. Dosing is a bit arbitrary, I popped the dosing guide for Sivomixx in another post, which I use as a guide for Vivomixx as well.

Hope that helps.

Scott 🙂

Replying to Natalie H. 06/04/2022 - 10:01

Hey.

The most evidence is actually for budesonide foam. It is used mostly in humans for ulcerative colitis:

https://pubmed.ncbi.nlm.nih.gov/32189103/

There is not data in dogs. I would consider this as an option in very refractory cases of colitis and proctitis. The biggest issue with this treatment is the tolerance of the patient!