scott@vtx-cpd.com

Hi Josep,

Thank you for your contribution to the neurology course! Neurology is always such a challenge, and I truly appreciate the effort you’ve put into making it approachable. Along with ophthalmology, it’s one of those topics I’ve always found particularly tricky—but I’m excited to dive in and learn from the cases and insights you’ve prepared. I’m sure your guidance will make all the difference.

Looking forward to this journey!

Scott 🙂

Replying to Raquel M. 17/01/2025 - 12:37

Hi Raquel,

That’s fantastic news about Lloyd’s progress! It’s great to hear his stool is normal now. Since he’s currently on a grain-free diet, transitioning him to a more nutritionally balanced option, such as Purina HA, is an excellent next step. This will help him regain weight, improve his body condition score (BCS), and avoid potential long-term effects associated with grain-free diets. For the transition, given his GI history, I’d recommend a 10- to 14-day gradual change to minimize the risk of GI upset. Start by replacing 25% of his current diet with the new food for 3–4 days, then increase to 50% for another 3–4 days, followed by 75%, and finally 100% of the new diet. During the transition, monitor his stool consistency and adjust the timeline if needed.

I also wanted to address your concern about introducing the idea of reducing metronidazole as the first-line treatment for acute uncomplicated diarrhoea, which I completely understand is a sensitive topic as you’ve recently joined the clinic. Evidence increasingly suggests that metronidazole may not be the best option for such cases. Studies show it does not significantly decrease the duration of diarrhoea compared to probiotics or placebo, and it has been associated with disruptions to the gastrointestinal microbiome that can persist for weeks, particularly affecting bile acid metabolism. These microbiome changes can have longer-term implications for canine gut health.

Probiotics or synbiotics, on the other hand, appear to offer comparable or slightly better reductions in diarrhoea duration without the adverse effects on the microbiome. Studies like those by Shmalberg et al. (2019) and Kelley et al. (2009) suggest probiotics can reduce diarrhoea duration by up to 2.5 days in some cases. Moreover, probiotics are generally safe and provide a tangible treatment option for owners who expect medication. Products like Visbiome Vet or FortiFlora could be used to meet these expectations while aligning with evidence-based medicine.

To encourage a shift in clinic practice, you might consider a few strategies. First, sharing educational materials or presenting a brief overview of the evidence could help highlight the risks of overusing metronidazole and the benefits of probiotics as a first-line treatment. Proposing a standard clinic protocol for managing acute uncomplicated diarrhoea could provide a clear and structured alternative. This could include dietary management with GI support diets, probiotics like Visbiome Vet, and deworming with fenbendazole if indicated, reserving metronidazole or other antimicrobials for cases with clear evidence of bacterial overgrowth or systemic involvement.

The available evidence supports probiotics as a safe, effective alternative to metronidazole for uncomplicated diarrhoea and shows that dietary changes and supportive care are sufficient for most cases. If you’d like, I’d be happy to help draft a specific protocol or provide materials to assist in discussions with your colleagues. Let me know how I can support you further with this or Lloyd’s ongoing care!

Kind regards,

Scott

Hi Rachel,

Thank you for the great questions!

For your PUO patient on 5mg prednisolone daily for chronic bronchitis, this dose (approximately 0.3mg/kg for a 16kg dog) is a low anti-inflammatory level. While it may partially mask pyrexia, it’s unlikely to fully suppress a febrile response. Chronic steroid use can, however, blunt the immune system and complicate diagnostic clarity. If the bronchitis is stable, consider tapering the steroid dose gradually, especially if empirical treatments fail and no underlying cause is identified. Alternatively, you can maintain the current dose and pursue further diagnostics (e.g., bone marrow aspirate, infectious disease panels).

If you suspect an immune-mediated disease, I recommend starting 2mg/kg/day of prednisolone for at least 7 days. Most immune-mediated diseases tend to respond quite quickly to this therapy. For your 16kg patient, this would equate to 32mg/day, ideally split into two doses for better stability. If there’s no response after 7 days, reassess the diagnosis and consider adding adjunctive immunosuppressants such as cyclosporine or azathioprine rather than further increasing the steroid dose. In older patients, immune-mediated disease remains a strong possibility, but I would also actively investigate for underlying causes such as neoplasia, infectious diseases, or paraneoplastic syndromes. When financial constraints limit diagnostics, a short course of antibiotics to rule out a treatable infectious process is not unreasonable, especially when infection cannot be entirely excluded.

In an ideal world, I would allow for a 3-day washout period between NSAIDs and steroids to minimize risks like gastrointestinal ulceration. However, in cases of severe immune-mediated disease, waiting may not be feasible. In these situations, I would start steroids sooner if necessary, while clearly warning owners about the potential risks. While a washout is a good practice, it’s not a hard-and-fast rule in emergencies or severely affected cases.

For your patient diagnosed with polyarthritis and azotaemia, I would recommend starting 2mg/kg/day of prednisolone while investigating potential infectious causes like Leishmania. Polyarthritis and azotaemia may be linked through an immune-mediated mechanism, such as concurrent immune-mediated glomerulonephritis. However, they could also represent separate conditions, particularly given the patient’s geographic history (e.g., Trinidad). Azotaemia warrants close monitoring of renal function, hydration, and blood pressure while managing the polyarthritis with immunosuppressive therapy. Infectious causes must be ruled out or treated appropriately, as some mimic immune-mediated disease presentations.

Ultimately, even if there is an infectious trigger, the immune system still needs modulated.

I hope that helps.

Best regards,

Scott 🙂

Replying to Raquel M. 14/01/2025 - 11:04

You’re very welcome! I’m so glad to hear that Purina HA is available on the island—that should be a great option for Lloyd. Repeating the Panacur is an excellent plan, and hopefully, it helps resolve any potential parasitic contributors. It’s also great that the owner has been using the Purina fecal scoring chart; it’s such a helpful tool for tracking progress. Following up on compliance after your holiday will be key to ensuring we’re getting the full picture.

Let me know how things go with the owner and Lloyd.

Speak soon.

Scott

Hi Raquel,

Based on the information provided, I’d recommend considering Purina Pro Plan Veterinary Diets HA Hydrolyzed as an alternative diet option. This diet is formulated to support growth in puppies and is a great choice for managing GI issues like Lloyd’s chronic large intestinal diarrhoea. It’s often well-tolerated by puppies and can provide the nutritional support he needs for proper growth while addressing his GI concerns. If Purina HA is accessible on the island, I’d suggest transitioning him to it for at least 6–8 weeks while monitoring his stool consistency and overall development.

In terms of deworming, given Lloyd’s persistent symptoms and environmental exposure, I’d recommend repeating fenbendazole (Panacur) for a further 5 days at 50 mg/kg SID. This extended treatment will ensure that any occult parasite burdens, particularly Giardia or whipworms that might have been missed or shed intermittently, are effectively addressed. While faecal testing has been negative, parasite infections can sometimes be tricky to detect, and a full treatment course is warranted given the history.

1. Dietary Management
Switch Lloyd to Purina HA as a primary diet, feeding him small, frequent meals (3–4 times daily). Avoid treats, table scraps, or other additions to minimize dietary variability. Consider adding psyllium fibre to his diet. Start with a small dose (e.g., 0.5–1 tsp of unflavoured psyllium husk mixed into meals twice daily) and adjust based on stool consistency. Psyllium can help regulate bowel movements by increasing stool bulk and binding excess water. Pumpkin can also be incorporated into his meals in small amounts (1–2 tsp per meal). It’s a good source of soluble fibre and may help with mild diarrhoea. If pumpkin doesn’t seem effective or causes any adverse effects, it can be discontinued.

2. Deworming Protocol
Administer an additional 5-day course of fenbendazole (50 mg/kg SID) to address any potential residual or undiagnosed parasitic infections. Confirm that no environmental reinfections are occurring by advising the owner to maintain strict hygiene, including cleaning up stools promptly and disinfecting areas where Lloyd has defecated.

3. Probiotics and Gut Support
Continue using Proviable DC if it has been well-tolerated, but I’d also recommend considering a switch to Visbiome Vet. This high-potency probiotic is specifically formulated for GI support in dogs and may provide better outcomes for chronic large intestinal diarrhoea. Ensure consistent dosing for at least 4–6 weeks. If possible, introduce a prebiotic supplement to further support gut health (e.g., FOS or MOS-based prebiotics, available in some veterinary GI supplements).

4. Other Diagnostics and Preventatives
Given the chronicity of Lloyd’s symptoms, consider repeating faecal diagnostics. it might also be worth considering TLI, folate, cobalamin and basal cortisol.

5. Monitoring and Long-Term Approach
Track Lloyd’s response to the diet, psyllium, pumpkin, and deworming over the next 2–4 weeks. Evaluate stool quality using a faecal scoring chart and document weight gain and BCS regularly. If diarrhoea persists despite these measures, consider referral or advanced diagnostics such as abdominal imaging or endoscopy to assess for inflammatory bowel disease (IBD), food-responsive enteropathy, or other chronic GI diseases.

Summary of Recommendations
Transition Lloyd to Purina HA, as it is a diet labelled for growth and suitable for managing GI disorders. Supplement his meals with psyllium fibre and small amounts of pumpkin as tolerated to help regulate stool consistency. Use Visbiome Vet as a high-potency probiotic for improved GI support. Administer an extended 5-day fenbendazole treatment and ensure strict environmental hygiene.

A faecal transplant might also be a consideration. Please let me know how Lloyd progresses or if you have any additional questions.

Kind regards,

Scott 🙂

Rosanna!

Thank you for all of your brilliant contribution to the forum!

Happy new year when it comes.

Scott