scott@vtx-cpd.com
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Replying to Talia C. 02/12/2024 - 08:30
Dear Talia,
Thank you for your response!
I understand how strict adherence to the ISCAID guidelines can make the use of prophylactic antibiotics challenging. I don’t employ it very often myself, but in a very small number of cases, I’ve found it can help, particularly when there are no viable alternatives and recurrent infections are significantly impacting the patient’s quality of life. That said, I always try to explore other management options first, especially given the concerns around antibiotic stewardship.
Best regards,
Scott 😊
Replying to Rachel C. 12/12/2024 - 14:33
Hi Rachel,
I completely understand your concerns—this is such a common scenario in general practice, and it can be challenging to strike the right balance between monitoring and action while managing owner expectations.
For geriatric patients on long-term NSAIDs, mild increases in ALT and ALP are not uncommon. As long as the dog is clinically well and these changes are mild (e.g., less than 2-3 times the upper reference interval), monitoring is often a reasonable first step. I typically recommend rechecking bloodwork in 2-4 weeks to observe trends. If values remain stable or improve, continued monitoring every 3-6 months, aligned with routine NSAID check-ins, may suffice.
However, I would investigate further if:
Enzyme elevations become significant (e.g., >4-5 times the upper reference interval).
Other abnormalities appear, such as hypoalbuminemia or elevated bile acids.
Clinical signs like anorexia, vomiting, or lethargy develop.
In such cases, additional diagnostics like an abdominal ultrasound can help assess for underlying liver dysfunction.When owners ask about “something to give,” I often suggest liver-supportive supplements such as SAM-e, milk thistle (silymarin), or combination products like Denamarin. While evidence varies, these are generally safe and may offer hepatoprotective benefits.
Carprofen-Induced Liver Injury
It’s important to consider potential carprofen-induced hepatotoxicity, an idiosyncratic reaction seen in some dogs, typically within the first month of treatment. Clinical signs include anorexia, vomiting, and icterus, often accompanied by elevated ALT, ALP, and bilirubin levels. The condition can improve with prompt discontinuation of carprofen and supportive care. Interestingly, Labradors appear over-represented, although this might reflect breed popularity. Histopathological findings often reveal bridging hepatic necrosis, and chronic liver disease as a sequel has not been clearly established.Additionally, a study published in the J Am Vet Med Assoc (“Hepatocellular toxicosis associated with administration of carprofen in 21 dogs”) highlighted variable clinical courses among affected dogs. While most recovered after discontinuation of the drug, some cases showed associated renal abnormalities, likely secondary to tubular disease.
Let me know your thoughts or if you’d like to discuss this further!
Best,
Scott 🩺🐾
Replying to Liz Bode 29/11/2024 - 08:09
Thanks for your thoughts!
I probably think more about albumin than I should!
Scott x
Replying to Jenny G. 29/11/2024 - 12:25
Thank you again Jenny.
Scott 🙂
Hi Valeria,
Thanks so much for your question! You’re absolutely right that diazepam has been used successfully in some cases to address functional obstructions, likely caused by urethral spasms. When administered intravenously as a single dose, it can be a helpful tool, especially in resource-limited settings where catheterization might not be an option. That said, the risk of idiosyncratic hepatotoxicity in cats, although rare, is a real concern, particularly with oral or repeated dosing. The key is selecting cases carefully, discussing the risks with owners, and limiting its use to short-term scenarios.
It sounds like your experiences align with situations where diazepam has been effective in addressing spasm-related obstructions. For these cases, it’s likely not just luck, as relaxation of striated muscle in the urethra can definitely make a difference. However, when true physical obstructions like plugs or calculi are present, diazepam alone won’t solve the issue and could delay necessary intervention, like catheterization or flushing.
In cases where catheterization isn’t possible, there’s a validated alternative protocol you might find interesting. A study by Cooper et al. (2010) found success using a combination of acepromazine, buprenorphine, medetomidine, decompressive cystocentesis, and a quiet environment to manage urethral obstruction without catheterization. This protocol allowed 73% of cats to urinate spontaneously within 72 hours. While it’s not perfect, as some cases did experience complications, it’s a great option to consider, especially in low-income settings.
As an alternative to diazepam, have you considered midazolam? It offers similar muscle relaxant properties but has a shorter duration of action and may present a lower risk profile in certain cases. Its use could be worth exploring, especially in situations where you’re cautious about diazepam’s hepatic side effects.
I hope this helps! Let me know if you’d like any more info or references.
Best regards,
Scott
Replying to Valeria Bergomi 27/11/2024 - 15:20
No problem!
I am looking at you post about diazepam in cats now!
Let me know if you have any other questions.
Scott 🙂
Thank you so much for sharing!
Scott 🙂
Replying to Talia C. 24/11/2024 - 20:40
Dear Talia,
Thank you for your reply! It sounds like you have a very systematic and thorough plan in place, which is great for these tricky cases. You’re absolutely correct in your understanding of the response to desmopressin (synthetic ADH). The diagnostic utility of a DDAVP trial lies in its ability to differentiate between central diabetes insipidus (CDI), nephrogenic diabetes insipidus (NDI), and psychogenic polydipsia (PD), as you outlined. A marked increase in urine concentration, with a urine specific gravity (USG) above 1.025 or a rise of over 50% from baseline, strongly supports CDI. In contrast, only minimal improvement in USG is expected with NDI because the kidneys are unresponsive to ADH. Dogs with psychogenic polydipsia may show a mild reduction in urine output and water intake as plasma osmolality normalizes, but this response is often subtle.
The morning USG of 1.028 does introduce some complexity. While it suggests some ability to concentrate urine, it doesn’t entirely rule out CDI, as partial CDI cases may show intermittent concentrating ability. Similarly, primary polydipsia can also present with variable USG patterns, making it challenging to differentiate between the two based on USG alone.
If there is still concern about being “stuck” between NDI and primary PD, adding SDMA testing and advanced imaging are excellent next steps to rule out subtle renal disease or structural abnormalities. Iohexol clearance testing could also be considered, as it provides a precise measure of glomerular filtration rate (GFR) and might uncover early renal dysfunction not evident on routine tests. Monitoring USG at different intervals, particularly during periods of water restriction if feasible, may also help establish a clearer pattern of water handling and concentration ability.
The planned full abdominal ultrasound is an important step and will help exclude other systemic causes, particularly structural or functional abnormalities that could impact water balance. Chronic conditions, such as low-grade inflammation or mild endocrine issues, could also contribute to her clinical signs and would benefit from this thorough evaluation.
If you proceed with a DDAVP trial, I recommend carefully monitoring water intake and USG over several days before and after administration. While this won’t definitively distinguish between all potential causes, it often provides enough diagnostic clarity to inform further management or investigations. Please let me know how she progresses following the ultrasound and any additional testing.
Best regards,
Scott
This is so helpful!
Thank you for sharing. I hope everyone is having a wonderful (ulcer free) weekend!
Scott 🙂
Replying to Lesley M. 22/11/2024 - 22:36
Thank you so much and thank you again for sharing via email.
I will make sure to post here!
Scott 🙂
Replying to Lara Brunori 18/11/2024 - 13:36
Hi Lara,
Thank you again for your response. I wanted to provide an update with additional details. We checked ionized calcium, and it was marginally increased at 1.40 mmol/L (reference: 1.13–1.38 mmol/L). This might be age-related as Siichba is still a growing kitten, but we’re keeping it in mind. To help manage this and potentially reduce calcium excretion into the urine, we’ve recommended adding 1 gram of bloomed chia seeds daily to Siichba’s diet.
Based on the findings and concerns for stone formation, we suspect struvite stones as the most likely culprit given Siichba’s age (<6 months). We’ve initiated a therapeutic diet starting with feline c/d for two weeks, transitioning to feline i/d, which is nutritionally complete for kittens and designed to manage urinary health while preventing recurrence. We’re monitoring closely for any signs of worsening hydronephrosis or ureteral obstruction, as these could progress to renal insufficiency or failure. Currently, the blood work does not suggest renal dysfunction, but we are being proactive in case this changes.
Pending the repeat urine culture results via cystocentesis, we’ll decide on whether to continue antibiotics or adjust based on sensitivity findings. Regular rechecks, including imaging and urinalysis, will help us track changes in the stones’ size, position, and composition.
Your point about considering minimally invasive techniques like lithotripsy is well-taken—it would certainly be ideal if dissolution fails or calcium oxalate stones are confirmed. I’d love to hear your thoughts on this plan and any further suggestions you might have!
All the best,
ScottReplying to Talia C. 18/11/2024 - 07:46
Dear Talia,
Thank you for sharing your experience and for providing such a detailed breakdown of cystinuria genetics! The case of your miniature Bull Terrier is a great example of how combining chemical and surgical castration with dietary management can lead to excellent outcomes. It’s encouraging to hear that voiding hasn’t been needed for over a year—a testament to the success of the combined approach!
The information you found on the genetic aspects of cystinuria is fascinating and adds depth to our understanding of the condition. The distinctions between different types of cystinuria (e.g., Type I, II, III) and their inheritance patterns really highlight how diverse and complex this condition can be, particularly when androgen dependency comes into play.
Thanks again for sharing this!
Best regards,
Scott 😊
Replying to Talia C. 18/11/2024 - 07:25
Dear Talia,
Thank you for your thoughtful message and for sharing your experiences! It’s always fascinating to hear perspectives from different regions, and it seems cystoliths are a universally challenging topic! I’ll do my best to address your points below:
Mixed Cystoliths
Your example of the pug with a history of PSS and mixed struvite-urate stones highlights just how unpredictable these cases can be. Mixed stones are particularly frustrating because they defy straightforward dissolution protocols and often require multifaceted management. In these cases, I try to focus on minimizing recurrence through individualized dietary and urinary pH strategies, though success can be limited by the complex interplay of factors.Retrograde Hydropropulsion
I completely agree—retrograde hydropropulsion is a fantastic tool, especially for managing small stones and avoiding repeated cystotomies. I’ve found it to be particularly useful for recurrent cases, provided the stones are small and accessible. Your point about timing the procedure when stones are very small is critical to its success, and it’s great to hear it’s working well in your practice.Calcium Oxalate (CaOx) Stones
CaOx stones are indeed a challenge, especially in dogs, as there’s no effective dissolution strategy. I sympathize with the frustration of recurrent cases, particularly in compliant owners doing everything right. For these patients, I emphasize regular monitoring with imaging (as you already do), ensuring a low urine specific gravity (USG <1.020 ideally), potassium citrate is often helpful if tolerated, though I understand the dilemma with diarrhea in some cases. In such instances, exploring alternative alkalinizers might be worth a try. Hydrochlorothiazide as a diuretic may help in reducing urinary calcium excretion, though it requires careful monitoring for side effects. It’s always a balancing act, but I find client education about the likelihood of recurrence helps manage expectations.Cystoscopy and Antibiotic Use
Cystoscopy can be invaluable in chronic or refractory UTI cases, as your example demonstrates. The narrowed urethra you found is a great illustration of how underlying anatomical issues can perpetuate UTIs. Whether to repeat cystoscopies is a really interesting question. I think a lot of the time we don't get to repeat these procedures because of financial constraints for the owners. It also depends on what we’re looking for. If we’re just visualizing generalized inflammation, I’m not sure a repeat cystoscopy is always warranted. On the other hand, if we’re biopsying inflammatory areas and the problem isn’t resolving with our treatment, that might justify repeating the cystoscopy. In many cases, I think we’re addressing the inflammation we see and ruling it out as the cause of the problem.UTI and Prednisolone
Chronic immunosuppression is always a tightrope walk in these cases. For patients like your Frenchie with recurrent UTIs due to incomplete bladder emptying, I often consider the following: bladder management, encouraging manual expression or intermittent catheterization if incomplete emptying is severe; antibiotic stewardship, regular cultures to guide targeted therapy, and I sometimes use prophylactic low-dose antibiotics if the recurrences are frequent and clinically significant; corticosteroid dose, if possible, I aim to taper to the lowest effective dose. In combination with leflunomide, it might be worth evaluating whether the steroid dose could be reduced further; adjunctive measures, cranberry extract, D-mannose, or other supportive therapies. Regarding urinary tract infections and steroid use, I think it really depends on the case. With the French bulldog you’re describing, could you consider interventions to help the dog empty the bladder better? Residual bladder volume is definitely an issue in cases like this. Could you consider a drug such as bethanechol to improve detrusor muscle contractility or other medications to help with bladder emptying? Addressing incomplete bladder emptying may significantly reduce the risk of recurrent infections.Thank you again for your kind words and for taking the time to share your cases and thoughts.
Warm regards,
Scott
Replying to Laura Jones 18/11/2024 - 11:29
Thank you again pal!
We appreciate you!!!
Scott 🙂
Replying to Talia C. 18/11/2024 - 16:53
Thing is…
This case is doing really well! I suppose it is challenging as it is very expensive and there is not a huge amount of evidence out there.
The owners are very dedicated and happy to continue with the treatment. It is not a treatment I would have started, but if the patient is doing well, it is hard not to justify continuing for now.
Scott 🙂
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