scott@vtx-cpd.com
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Replying to Laura S. 20/01/2026 - 14:00
Hi Laura,
I hate having to watch myself back! 🙂 Just to reassure you (and to avoid any confusion), when I mentioned metronidazole in the context of xylitol toxicity, I was not suggesting this as a standard or routine component of xylitol management. I was specifically referring to what was reported in the published case report you’ve cited (Schmid & Hovda, J Med Toxicol 2016), and simply describing the treatment protocol that was used successfully in that individual dog.
That paper is one of the few detailed reports of survival following severe xylitol toxicity with hypoglycaemia, acute hepatic failure, and coagulopathy, and metronidazole was included as part of a broader supportive care strategy alongside dextrose, vitamin K, FFP, NAC, and SAMe. My intention on that slide was to highlight what has been reported in the literature, rather than to imply that metronidazole should be routinely added in all xylitol cases.
In practice, as we discussed, management of xylitol toxicity is centred on rapid control of hypoglycaemia, aggressive supportive care, monitoring and treatment of coagulopathy, and hepatic support with NAC and SAMe. Use of metronidazole is very much case dependent and generally only considered in dogs with severe hepatic compromise where there is concern about endotoxemia or bacterial translocation — not as a blanket recommendation.
I hope that helps!
Scott 🙂
Replying to Lesley M. 11/01/2026 - 08:40
Thanks Lesley!
I hope all is well your end!
I think that’s a great point, particularly around the fact that hospitalisation doesn’t automatically have to mean antibiotics. There’s a lot we can do for these dogs in hospital that can make a real difference, fluid support, analgesia, antiemetics, nutritional support, and time, without necessarily reaching straight for antimicrobials.
I suppose it also depends how we define “sick”. Dogs that are starting to tick boxes for sepsis, changes in heart rate, temperature, respiratory rate, or white blood cell count, are a very different group and are clearly appropriate antibiotic candidates. That’s an important distinction, and one that can sometimes get lost when we talk about stewardship in broad terms.
I completely agree that the “sick” end of the AHDS/HGE spectrum feels different, and it’s understandable that antibiotics have historically been used there. That said, your point about pain relief and antiemetics being under-recognised is really important. These dogs can clearly be uncomfortable, and addressing pain, nausea and hydration probably has a far bigger impact on how they feel (and how quickly they improve) than we sometimes acknowledge.
There’s also some interesting emerging discussion around faecal microbiota transplantation, even in more acute cases, as a way of supporting gut recovery without the collateral damage associated with antibiotics. It’s not something most of us have ready access to, but it does challenge the idea that “sicker” automatically equals “needs antibiotics”.
Your stepwise approach, supportive care first, analgesia, antiemetics, fenbendazole where appropriate, feels very pragmatic and probably does exactly what you describe: buys time while many of these cases self-resolve.
Thanks again! Your experience is so valuable and we appreciate you sharing!
Scott 🙂
Replying to Rosie Marshall 18/01/2026 - 17:28
Rosie!
Lovely to hear from you. I hope all is well. COVID… now that is a whole can of worms! How interesting you did the vaccinations! I did wonder if needle type might have an influence? That might be the next study… are there certain manufacturers that produce better needles?
Scott 🙂
Replying to Annet Krabbenborg 18/01/2026 - 20:15
I always did it and felt better for it… but it seems it makes little difference!
I think all it does it make the people giving the injection feel a little better! 🙂
I think it is interesting from an environmental perspective there is so much medical waste in the world and we should not further contribute to this if it is not necessary for patient welfare!
Scott 🙂
Replying to Annet Krabbenborg 18/01/2026 - 22:17
I just wish they would make something similar for dogs! 🙂
Replying to Annet Krabbenborg 18/01/2026 - 22:17
I agree, most do!
I was speaking to the Purina rep. about it recently and they said if the cats don’t like it, it is worth persisting. They suggest leaving fresh stuff down for 5-7 days even if they don’t take to it on day one. Some cats will go for it after a few days supposedly.
They gave us some free sample boxes, so this is relatively easy to ask owner to do, I can imagine a more challenging sell if owners are paying for it? I suppose the moral of the story is, if they have a whole box they should persist!
Scott 🙂
Replying to Laura S. 13/01/2026 - 13:34
Hi Laura,
The forum is always open for you! I hope you are well.
On antibiotics, we are certainly moving toward more judicious use, but in the context of suspected biliary or acute hepatobiliary disease, amoxicillin–clavulanic acid is usually the more appropriate first-line choice. It provides broader coverage for common biliary pathogens, including beta-lactamase–producing organisms, which are not uncommon in these cases. Plain amoxicillin may be reasonable in selected, lower-risk situations, but in acute liver or biliary presentations, particularly where ascending infection or neutrophilic cholangitis is suspected, I would generally favour amoxicillin–clavulanate. Practical considerations such as IV availability can influence initial drug selection, but where possible, amoxicillin–clavulanate remains the empiric antibiotic of choice pending culture and sensitivity results.
In the specific context of neutrophilic cholangitis and cholangiohepatitis, acute disease in both dogs and cats is characterised by neutrophilic periportal and intrahepatic bile duct inflammation, with neutrophils present within bile duct walls and lumina. The distribution and severity of inflammation can vary considerably both within and between cases, and in some patients the inflammatory infiltrate extends into the hepatic parenchyma, resulting in cholangiohepatitis. Broad-spectrum antimicrobial therapy remains the cornerstone of treatment, particularly when bactibilia is confirmed. Amoxicillin–clavulanate is a sensible initial empirical choice in these cases. Because antimicrobial resistance is relatively common in biliary isolates, aerobic and anaerobic culture and sensitivity testing is strongly recommended whenever possible. Current recommendations suggest treatment courses of six to eight weeks, but in practice this should be guided by response to therapy, using serial ultrasound, serum liver enzyme activities, and bilirubin concentrations. If biochemical abnormalities or gall bladder changes persist or worsen despite appropriate antibiotics, prompt repeat cholecystocentesis should be considered to rule out antimicrobial resistance.
Regarding the gall bladder case and Denamarin, this is a really common point of debate. Your referral centre colleagues are technically correct in that there is no strong evidence that Denamarin directly treats primary gall bladder disease or alters outcomes in conditions such as biliary sludge or mucoceles. Where I think Denamarin still has a role is in supporting the liver around the gall bladder. Gall bladder disease almost never exists in isolation, there is usually secondary hepatocellular stress from inflammation, cholestasis, endotoxin exposure, or impaired bile flow. In that context, antioxidant and hepatoprotective support with SAMe and silybin is biologically plausible and, in my view, reasonable. I would not frame it as treating the gall bladder itself, but rather as supportive therapy for secondary hepatic injury.
Where did I make the metronidazole and xylitol comments? Just so I can check the context before I answer.
I hope that makes sense.
Scott 🙂
Replying to Laura S. 28/12/2025 - 15:39
Hi Laura,
The pressure to get patients home quickly, balance costs, and still make safe decisions absolutely influences real-time judgement, whether we like it or not. In your case, the concern about pyrexia suppressing appetite versus an early surgical complication is entirely reasonable, and I can completely see why a single NSAID dose felt like a pragmatic way to help clarify the picture.
The fact that he went straight to the food bowl once home does suggest that stress, hospitalisation, or mild post-op discomfort may well have been bigger contributors than anything more sinister. Hindsight is always generous, but I agree with your conclusion that in a similar case, holding off and reassessing may be just as reasonable, particularly if demeanour remains good.
Thanks for sharing the outcome!
Scott 🙂
Replying to Annet Krabbenborg 27/12/2025 - 15:25
Hi Annet,
That’s a great question, and I’m glad you’re finding the discussions useful.
In terms of duration, I’ve so far used capromorelin continuously for several months in a small number of cats, particularly those with CKD and progressive sarcopenia, without running into obvious tolerance or safety issues. In the published study it was used for 55 days, so we’re obviously extrapolating beyond the evidence base when we go longer term, but clinically I’ve found it can be helpful to think of it less as a short “kick-start” and more as ongoing supportive therapy in carefully selected patients.
That said, I don’t automatically plan it as lifelong treatment for every case. I usually reassess at 4–8 weeks, looking at weight trajectory, muscle condition, appetite, quality of life, and owner perception. If there’s a clear benefit, I’m comfortable continuing, sometimes with short breaks or dose adjustments, and if there’s no meaningful improvement, I stop it. Cost and owner expectations also factor into that decision.
I think the key is being clear that this is aimed at supporting body condition and quality of life, rather than reversing the underlying disease process. Used with that mindset, longer-term use can make sense in cachectic or sarcopenic patients where options are otherwise limited.
Really pleased you’re enjoying being a member, and thanks for joining in the discussion!
I hope life in practice is treating you well.
Scott 🙂
Replying to Liz Bode 07/01/2026 - 20:19
Thanks Liz.
I had never heard of it until the cardiologist here suggested it. I will keep you posted. I will also find out how much it ended up costing!
Scott 🙂
Replying to Laura S. 06/01/2026 - 13:48
Laura!
Thank you so much for this! Brilliant suggestions. I really appreciate you taking the time to reply.
Scott 🙂
Replying to Emma Johnstone 23/12/2025 - 15:20
Hi Emma,
You’re very welcome, I’m glad it was helpful.
With respect to darbepoetin, when it does work the response can be quite variable. In non neoplastic or renal cases you may see a meaningful rise in PCV over two to four weeks, sometimes in the order of a five to ten percent increase, but in dogs with lymphoma the response is far less predictable and often modest at best. If there is bone marrow infiltration or significant inflammatory cytokine driven suppression, the effect is frequently blunted or absent. Even when a response is seen, it is usually short lived unless the underlying disease is being controlled, so we are generally talking weeks rather than months. There is also the ongoing concern about antibody formation, thromboembolic risk, and the monitoring burden, which is why I tend to reserve darbepoetin for very select scenarios and would not routinely pursue it in a purely palliative lymphoma setting.
For omega three supplementation, I usually dose based on the combined EPA and DHA content rather than total fish oil volume. A commonly used target is around fifty to one hundred milligrams per kilogram per day of combined EPA and DHA. In practice, for a medium to large dog this often equates to a few standard fish oil capsules daily, depending on the specific product. I do not have a single must use brand, but I tend to favour veterinary labelled products where the EPA and DHA content is clearly stated, as this makes dosing much easier and more consistent. Products such as EicosaCaps are a reasonable example of this approach.
You are absolutely right about capromorelin in the UK. Access has become very limited, and many wholesalers no longer stock it. We used to obtain it from places like Raman Pharma at https://www.ramanpharma.com/
, but it no longer seems to be available through UK supply chains or listed on pharmacy websites. As a result, mirtazapine has become the more practical and familiar appetite and nausea support option in most of our patients. I also tend to be a bit cautious with capromorelin in cancer patients anyway, as increasing appetite does not always translate into meaningful weight gain when cancer associated cachexia is driving the process.Chlorambucil is definitely easy to forget about in dogs, particularly as many of us associate it more strongly with feline IBD and lymphoma. In dogs with multicentric lymphoma where owners are open to something beyond steroids but are not pursuing full chemotherapy, chlorambucil in combination with prednisolone can be a useful and relatively gentle next step.
Keep me posted!
Scott 🙂
Hi Emma,
Thanks for sharing the case. Framed purely around comfort and quality of life rather than disease modification, I think much of what you are already doing is very appropriate. Increasing prednisolone closer to a true palliative lymphoma dose in the region of 1.5 to 2 mg/kg/day is entirely reasonable at this stage, particularly given the fairly rapid progression of peripheral lymphadenopathy. This may provide some short-term cytoreduction with improvement in comfort, appetite, and general wellbeing, although I would be clear with the owners that any benefit is likely to be transient and measured in weeks rather than months. Despite the existing PU/PD, proteinuria, and mild azotaemia, I would not withhold escalation of pred purely on that basis if she remains bright and engaged, although increasing the dose cautiously and reassessing clinically is sensible.
The progressive, non-regenerative anaemia is very consistent with anaemia of chronic disease, possible bone marrow involvement, or cytokine-mediated suppression associated with lymphoma. Unfortunately, there is very little that reliably improves this in the absence of chemotherapy. Cobalamin supplementation is reasonable but is unlikely to meaningfully affect the PCV, and I would generally avoid iron supplementation unless there is clear evidence of deficiency, as it is rarely helpful in this context. While anaemia of chronic disease is the most likely explanation, I do think it is reasonable to keep an open mind about other contributing factors, particularly marrow infiltration or less commonly immune-mediated mechanisms, even though identifying these does not substantially change management in a palliative setting. I have occasionally considered darbepoetin in neoplastic cases, but in lymphoma the evidence for benefit is very limited, and the risks, costs, and logistical burden usually outweigh any potential short-term gain, so I would not routinely pursue this as part of palliation.
With respect to the kidneys and proteinuria, starting benazepril with a persistently elevated UPC above 5 is entirely appropriate. I would keep expectations modest regarding any improvement in the UPC, but ACE inhibition may help slow further renal decline and can indirectly support comfort. Monitoring blood pressure if feasible is worthwhile, as hypertension can accompany both proteinuric renal disease and neoplasia. I would avoid aggressive dietary protein restriction unless there are clear clinical signs of uraemia, as maintaining appetite, caloric intake, and body condition is usually the higher priority in a palliative context.
Weight loss and muscle wasting are unfortunately very common in multicentric lymphoma and often progress despite a reasonable appetite. I would prioritise calorie-dense, highly palatable foods over any attempt to adhere to idealised renal or oncology diets. Low-dose mirtazapine can be helpful not only for appetite but also for nausea and overall demeanour, even when intake seems subjectively acceptable. Omega-3 supplementation may offer mild anti-inflammatory and cachexia-modulating benefits, although expectations should remain realistic.
In terms of additional supportive care, I do not routinely use omeprazole simply because a dog is on steroids, but if the prednisolone dose is increased, or if there are concerns about gastrointestinal comfort, nausea, or appetite consistency, then acid suppression can certainly be considered on a case-by-case basis. Analgesia is worth considering proactively even in the absence of obvious pain, as marked lymphadenopathy and visceral involvement can be uncomfortable. Low-dose gabapentin is often well tolerated, including in dogs with mild renal compromise, and can improve overall comfort and demeanour. Anti-nausea medication can also be helpful if there is any suggestion of nausea or food aversion developing. Appetite stimulants can play a role as the disease progresses and cachexia becomes more prominent. Mirtazapine is generally my first choice in this context. I am more cautious with capromorelin, as stimulating appetite does not necessarily counteract cancer-associated cachexia and can sometimes lead to frustration if increased intake does not translate into weight gain, but it can still be considered if appetite itself becomes a limiting factor for quality of life.
Overall, I think your current plan is entirely appropriate. Increasing prednisolone, continuing ACE inhibition, and layering supportive and comfort-focused care is realistically as much as we can offer without chemotherapy, and while further improvement in blood parameters is unlikely, maintaining her current brightness and enjoyment for as long as possible is a very reasonable and compassionate goal. From a practical standpoint, if the owners wish to pursue something beyond steroids alone but still avoid full chemotherapy, chlorambucil in combination with prednisolone is the most practical and commonly used metronomic option for multicentric lymphoma, offering the best balance of tolerability and potential benefit. Cyclophosphamide-based metronomic therapy is an alternative but requires more caution, particularly in a dog with proteinuria and renal involvement.
Hope that helps!
Scott 🙂
Replying to Laura S. 07/12/2025 - 11:50
Hi Laura,
Really interesting case, and only in vet medicine do we get to say “nerf gun bullet enterotomy” with a straight face!
I completely understand your thought process. Cats add another layer of complexity because we have fewer comfortable multimodal options, and they can be trickier to keep adequately analgesed without stacking side effects.
A transient pyrexia post enterotomy is not unusual, and I agree that if the cat is bright, eating and clinically well, we often end up making a judgment call in the moment. A single NSAID dose in an otherwise stable cat with good perfusion is unlikely to cause harm, but the theoretical concerns around GI healing are the same as in dogs, reduced mucosal perfusion and possible impact on anastomotic strength are the reasons manufacturers advise caution.
I think the key is exactly what you have done, good pain control with buprenorphine, careful monitoring,
and a case by case decision when temperature, comfort and demeanour all point towards needing a bit more support.Do let us know how she does!
Scott 🙂
Replying to Georgina F. 08/12/2025 - 16:00
Hi Georgie,
Thanks so much for sharing your experiences, really interesting cases and very helpful to hear. The overlap with ipsilateral KCS and worsening drooling during excitement does sound similar to what we’re seeing with Randall, and your experience reinforces my caution about any surgical duct procedures.
Good to know MRI was unrewarding in your case too. We’ve started Randall on a very low dose of glycopyrrolate, so I’ll update the thread once we see how he responds.
Really appreciate your input,
Scott
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