scott@vtx-cpd.com

Replying to Svetlana D. 22/01/2026 - 13:36

Haha!

Love all of these! Great suggestions! There are some words that I just give up trying to pronounce and just make a joke about not being able to say them during presentations!

I hope you are well.

Scott 🙂

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 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 - 22:17

I just wish they would make something similar for dogs! 🙂

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 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 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 🙂