scott@vtx-cpd.com

Great post!

Absolutely agree. Malnutrition is a massive barrier to recovery, and it’s frustrating how often it gets overlooked or addressed too late. In my experience, feeding tubes are underutilized, especially NG or O tubes, likely due to concerns about aspiration, placement difficulty, or a lingering perception that they’re too invasive. But when implemented early and appropriately, they can make a huge difference, even for short-term support. I’ve seen patients recover significantly faster just from receiving consistent nutritional support. I often tell owners and O tube is actually a ticket home in many cases!

We need to normalize feeding tube use, particularly in critical or cachectic patients, and start thinking of early nutritional intervention as proactive medicine rather than a last resort. One missed opportunity I see often is failing to place an oesophageal feeding tube while a patient is already under general anesthesia for another procedure. It’s such a simple addition that can dramatically improve outcomes. And we have to remember how easily oesophageal tubes can be removed if the patient begins eating on their own. There’s very little downside to placing them preemptively.

I’m also a fan of appetite stimulants like mirtazapine and capromorelin, which can be really effective in some cases, especially when used alongside other supportive care. But I think we sometimes rely on them too heavily instead of moving forward with a feeding tube when the situation really calls for it.

Another often-overlooked use is with nasogastric tubes, not only for nutrition but also for gastric decompression in cases like parvovirus. They’re incredibly versatile and valuable tools.

That recent study by Dumont et al. (J Vet Intern Med, 2023) really stood out to me. It reviewed the tolerability of naso-oesophageal feeding tubes in dogs and cats sent home and found that 94% of owners were satisfied with the experience. Complications were mostly minor, and no major adverse events occurred. This data really challenges the hesitation many of us have about sending patients home with these tubes. I’ve routinely discharged patients with NE tubes, but not NGs, so I found this paper quite interesting and a good prompt to rethink that approach.

I am really happy sending patients home with O tubes, but not sure how I feel about the NE tubes! Would love to hear other thoughts on this!

Scott 🙂

Replying to Raquel M. 25/03/2025 - 13:18

Hi Raquel,

Thanks for the detailed follow-up, really helpful context. Given that history of chronic dysuria, confirmed staph (possibly aureus), and the recent cystotomy, I’d absolutely consider her high-risk for recurrence, so your proactive approach makes complete sense.

Great to hear she’s transitioned to Hill’s c/d wet food post-op. That’s a solid choice for long-term management.

Using a human lab on island for cultures and sensitivity can definitely be a useful cost-saving option, especially in areas where turnaround time or access is limited. You’re right to note that antibiotic panels are typically tailored toward human formularies, so that’s an important point to clarify with owners upfront, particularly if you end up with an organism that’s only susceptible to drugs we don’t routinely stock or use in veterinary medicine.

One limitation to be mindful of is that human labs may underperform when it comes to detecting some of the more veterinary-specific or fastidious urinary pathogens. For example, they might miss Corynebacterium urealyticum, Proteus mirabilis with atypical resistance patterns, or Staphylococcus pseudintermedius if they don’t routinely speciate coagulase-positive staph beyond aureus. They also might not provide MICs, which are often more helpful in veterinary practice than just “S/I/R” interpretations. That said, if you’ve had good success with this lab in past cases and results have matched clinical outcomes, it sounds like a reasonable option, especially with cost being a concern and no pet insurance available.

It’s great that you’re already using radiography routinely for urolith monitoring. It really is one of the most practical tools for early detection of recurrence and is useful even when the stones are too small to be causing clinical signs yet. It also gives some peace of mind when counselling owners long term.

I completely agree with your approach of targeting an appropriate pH based on the specific urolith type. That’s a subtle but important aspect of prevention that often gets overlooked. For struvite cases like this, keeping things slightly acidic with the right diet is usually sufficient, but it’s helpful to have a sense of her real-world pH fluctuations. If the owners are open to it and capable, having them check pH at home can provide some additional insight into daily variation, especially when we’re trying to fine-tune dietary management. As long as expectations are set that we’re watching for general trends and not single readings, it can be a very useful adjunct.

All the best,

Scott 🙂

Honestly, the biggest barrier for me is not wanting to have that slightly awkward conversation with the owners!

Just me?!

Scott 🙂

Replying to Georgia 24/03/2025 - 09:28

This is actually really interesting.

I don’t normally consider changing to an alternative renal diet. That is definitely something I would consider in future.

Scott

Hi Raquel,

The Minnesota Urolith Center recommendation to perform routine urine cultures every one to three months in dogs with a history of struvite stones is based on the fact that infection-induced struvites are caused by urease-producing bacteria, most commonly Staphylococcus pseudintermedius. These organisms raise urinary pH and promote precipitation of magnesium ammonium phosphate, making early detection and treatment of even asymptomatic infections theoretically beneficial for preventing recurrence.

When it comes to evidence, the picture is a bit nuanced. The 2019 ISCAID Guidelines recommend against treating subclinical bacteriuria in most dogs, unless they are at increased risk due to immunosuppression, pending urinary tract surgery, or recurrent urolithiasis. For dogs with previous infection-induced struvite uroliths, the guidelines acknowledge that monitoring and possibly treating subclinical bacteriuria may be warranted, particularly in the first six to twelve months following stone dissolution or surgical removal. That said, there is currently no strong evidence showing that routine prophylactic urine cultures or treating asymptomatic infections leads to better long-term outcomes or reduces recurrence if the dog is clinically stable.

A reasonable approach might be to perform urine cultures every three months during the early post-treatment period, especially in dogs that are high-risk or have a history of multiple stone episodes. If subclinical bacteriuria is detected and the organism is urease-producing, treatment could be justified, particularly if there are signs of rising urinary pH or if the sediment suggests crystal formation. Over time, if the dog remains stable, is on a preventive diet, and has consistently acidic urine with no signs of active crystalluria or urinary discomfort, it may be reasonable to stop routine cultures and simply monitor with urinalysis. If the pH starts to trend upward or if the sediment changes, that would be a good point to consider a culture again.

When discussing this with clients, I usually explain that some bacteria in the bladder are benign bystanders, while others are more disruptive and can promote stone formation. It’s important to strike a balance between preventing future stones and avoiding unnecessary antibiotic use. I might say something like, “Some bacteria are just visitors, others rearrange the furniture; we only treat the latter if they’re likely to cause trouble.”

So, in summary, while routine cultures may have a place early in the monitoring period or in high-risk individuals, long-term prophylactic culturing and treatment of subclinical bacteriuria is probably not necessary for most dogs. The decision should be tailored based on individual risk factors, urinary trends, and the bacterial species involved.

Happy to discuss further if needed.

Scott 🙂

Hi Rosanna,

You’re absolutely right, Elura (capromorelin) is technically available in the UK only via a Special Import Certificate (SIC) at the moment, and the cost is definitely on the high side. I spoke to Elanco and they confirmed it’s not officially available in the UK yet, despite being listed on the VMD database. It hasn’t been launched or marketed here, so it has to be imported under an SIC if you want to use it.

We used to get capromorelin (for dogs, Entyce) through Ramapharma in the UK. That might still be an option worth exploring: https://www.ramanpharma.com/. Are you currently getting the dog version through anyone? Honestly, I would just use that in cats if needed, especially for off-license appetite stimulation in palliative or CKD cases where cost and access are limiting factors.

If you do want to go the Elura route, you’d need to apply for a Special Import Certificate through the VMD. Supply is usually arranged through a wholesaler that handles imports.

As far as I’m aware, there is no data directly comparing capromorelin and mirtazapine in cats, so we can’t say it’s better or worse based on evidence. That said, I’ve found it effective in practice. Cats often respond well, though many do salivate quite a lot after administration.

Also worth noting, there’s a good safety study on capromorelin in cats:

Randomized Controlled Trial

J Vet Pharmacol Ther. 2018 Apr;41(2):324–333. doi: 10.1111/jvp.12459
Evaluation of the safety of daily administration of capromorelin in cats
Wofford JA, Zollers B, Rhodes L, Bell M, Heinen E
PMID: 29057482 https://pubmed.ncbi.nlm.nih.gov/29057482

Two studies looked at daily oral administration in cats over 14 and 91 days. Doses up to 60 mg/kg were tested. Adverse effects were mostly mild and included vomiting, hypersalivation, lethargy, head shaking, and lip smacking. No significant differences in clinical pathology values were seen between treated and placebo groups.

Hope that helps.

Scott