scott@vtx-cpd.com
Forum Replies Created
-
AuthorPosts
-
Replying to Mónica P. 22/04/2024 - 14:58
Hello!
Thank you for sharing all of this information.
It sounds like Sofia’s case has been quite challenging, but you’ve been thorough in your approach to her care. Given the complexity of her presentation and the fluctuations in her thyroid hormone levels despite treatment, it may be beneficial to consider a few additional steps:
Confirm Medication Compliance: Ensure that the owner is administering the medication as prescribed, ideally without food, as food can interfere with levothyroxine absorption. It might also be helpful to ask about any changes in the medication brand or formulation.
Review Diagnosis: Revisit the initial diagnosis of hypothyroidism. Given Sofia’s breed and the presence of other conditions, such as severe skin infection and ovarian cyst/tumour, it’s possible that these factors are affecting her thyroid function tests. It may be worth consulting with an internal medicine specialist for a second opinion.
Further Testing: Considering Sofia’s weight gain and persistent otitis and facial dermatitis, additional tests such as a complete blood count (CBC) and a more comprehensive blood chemistry panel could provide valuable insights into her overall health and potential underlying conditions contributing to her symptoms.
Discuss Histopathology: While the owner chose not to pursue histopathology on the ovarian mass, it may be worth discussing the benefits of obtaining a definitive diagnosis, especially if there are concerns about the mass potentially affecting Sofia’s health or hormone levels.
Lab Results Clarification: Follow up with the lab to confirm the type of TSH (cTSH) and the method used for fT4 measurement (ED). This will help ensure the accuracy of the thyroid function tests.
Long-Term Management: Consider a long-term management plan for Sofia’s hypothyroidism, which may include regular monitoring of thyroid hormone levels, adjusting medication dosage as needed, and addressing any concurrent conditions that may be influencing her health.
If Sofia is doing well now, I would consider weaning her off all thyroid medication and monitoring her clinical signs closely. If clinical signs of hypothyroidism persist, then testing could be undertaken again. It’s worth noting that thyroid hormones can have a general effect on metabolism, so even if a patient is not hypothyroid, thyroid supplementation can lead to an improvement in mood and overall well-being. Owners often report a lift in mood and energy levels in their pets after starting thyroid supplementation, highlighting the broad impact of thyroid hormones on the body, including effects on energy levels, appetite, and skin and coat condition.
In Sofia’s case, total T4 is generally fine for monitoring, but free T4 might be helpful in future assessments about the possibility of hypothyroidism, especially if there are concerns about the accuracy of the total T4 measurements. However, TSH and free T4 would not be used for monitoring.
If you are experiencing any issues uploading images, please feel free to email them to me at scott@vtx-cpd.com. I’ll be happy to assist you further.
Hope that helps.
Scott 🙂
Replying to Nikki McLeod 24/04/2024 - 10:07
HAHAHAHAHAHAHA!
Scott 🙂
Replying to Talia C. 23/04/2024 - 09:53
Hi Talia,
We are on the same page!
Thank you for sharing your experience with OFT tubes. It’s great to hear that you find them effective for managing patients, especially for administering medications. It’s interesting to hear about the use of NFT tubes in Sweden and the differences in tolerance and potential issues compared to OFT tubes.
Your preference for OFT tubes seems well-founded, especially considering the ease of administration of medications and the lower likelihood of blockage compared to NFT tubes. I was speaking to the Royal Canin reps. this week about their liquid diets for feeding tubes. Have you used them?
Best regards,
Scott 🙂
Replying to Talia C. 23/04/2024 - 09:41
Hi Talia,
10 – 30 μg/kg (0.01 – 0.03 mg/kg) standard buprenorphine IM, IV, or buccal/OTM every 4 to 8 hours. Dosages at the high end of the dosing range may be required for more severe pain. NOTE: If using buccal/OTM, suggest using upper end of dosing range or higher (up to 0.05 mg/kg). Use of high-concentration buprenorphine (Simbadol®) 0.12 – 0.24 mg/kg buccal/OTM provided analgesia under experimental conditions with a duration of 8 to 12 hours (not 24 hours as provided by SC administration).
I would go high end when giving orally. What formulation are you using?
Regarding the case of cortisone and chronic pancreatitis in your 13-year-old DSH, it’s a complex situation. Given the chronic nature of the pancreatitis and the presence of steatitis and dilatation of the pancreatic duct on ultrasound, chronic pancreatitis is a strong possibility. The intermittent vomiting and reluctance to eat can be consistent with this diagnosis. The bloods certainly are!
I would always be worried about the GI tract and liver in these cases. What are the liver parameters doing? Is there an option for cholecystocentesis, cobalamin, folate and TLI bloods? Would hydrolysed be a diet consideration option?
Considering the response to maropitant and the presence of abdominal discomfort, it may be beneficial to consider adding prednisolone to the treatment plan. Prednisolone can help reduce inflammation in the pancreas and may improve clinical signs. However, as you mentioned, the potential for weight gain and development of diabetes mellitus should be considered. It might also help if there is GI disease. I think it sounds like the next step to me.
Regarding the difficulty with tabletting, you could consider using a compounding pharmacy to prepare a liquid formulation of prednisolone, which may be easier to administer.
Ondansetron might be another helpful option.
It’s also important to continue monitoring the cat’s weight, appetite, and overall condition closely, and to address any new or worsening clinical signs promptly. Regular rechecks and monitoring of bloodwork, including renal function, are important in managing this case. What is the USG in this case?
Best regards and thanks for sharing such an interesting case!
Scott 🙂
Replying to Talia C. 23/04/2024 - 09:41
Hey!
Really interesting case. Would you be able to share the fully bloods for this case?
What are the liver parameters doing?
Scott 🙂
Replying to Þórunn J. 22/04/2024 - 23:30
Also…
What did the liver values do after you started treatment?
Scott
Replying to Þórunn J. 22/04/2024 - 23:30
Hi Thorunn,
Thank you for sharing this interesting case.
This is a tricky case! Given the improvement in your patient’s clinical signs and the initial laboratory findings, I can understand why you might want to continue the medications. What are the owners feelings? Would they be OK with stopping medication? What was the cholesterol at the point of diagnosis?
Th good thing is that hypothyroidism is not life threatening. I would stop medication and only re-test if you had concerning clinical signs develop again. Worst case scenario would be having to start the medication again.
I would not run any more tests when the patient is on medication. If the patient comes off medication and you are testing again, I would consider T4, TSH, TGAA and possibly free T4.
Given the mitral valve disease, regular monitoring of cardiac status is important. Ensure that the thyroid medication does not exacerbate any cardiac issues. I will get Liz to comment on the heart side of things.
Honestly, I would not perform routine testing in this dog after coming off meds. I would test again if clinical signs creep in!
Hope that makes sense.
Scott 🙂
Replying to Neus E. 20/04/2024 - 15:11
Hey pal.
I’m glad to hear that you’ve had a positive experience using HFO2! It’s indeed a valuable option for patients who may not be adequately supported by nasopharyngeal oxygenation alone. The ability to provide high flows can be crucial in preventing flow starvation, especially in patients with high respiratory rates or panting. It’s great to hear that it has helped you avoid transitioning to full mechanical ventilation in some cases.
Thanks again for your insight.
Best regards,
Scott x
Replying to Neus E. 20/04/2024 - 15:09
Hi Neus,
It’s been a pleasure having you involved in the VTX course once again! Thank you for your active participation, engaging questions, and insightful thoughts. Your contributions have enhanced our discussions and learning experience.
All the best to you too!
Warm regards,
Scott x
Replying to Christina Frigast 20/04/2024 - 10:27
Hi Christina,
You’re welcome! I’m glad to help. Here are some answers to your questions:
Erythromycin can be used as a prokinetic agent in cats and dogs, typically at a dose of 0.5-1 mg/kg q8hrs. The onset of action can vary, but you may start to see effects within the first few hours after administration. However, the full effect may take longer, up to 12-24 hours, to be apparent. I must admit I normally see a quick effect!
For sedation to facilitate NG tube placement, many colleagues use a combination of drugs to achieve the desired level of sedation without causing excessive drowsiness. Common choices include acepromazine, butorphanol, and midazolam, given at appropriate doses based on the patient’s size and condition. It’s important to monitor the patient closely during and after sedation to prevent complications such as aspiration pneumonia. Adjusting the sedative dose based on the patient’s response can help minimize these risks. I must admit that I often don’t use any sedation and just make sure to have instilled some local up the nasal cavity. I have also found it useful to strap some Intubeaze on the end of the nose too! I think the benefit of the procedure is that you can get away without sedation.
I hope this helps! Let me know if you have any more questions.
Best regards,
Scott
Replying to Mónica P. 20/04/2024 - 09:51
Hi Mónica,
I’m glad to hear you’ve been learning a lot! Let’s address your questions:
It would be very uncommon to measure T3 in a practical stetting. I have never measured it in a clinical case. If there is a cat with a high clinical suspicion of hyperthyroidism with a normal TT4, I would consider free T4 by ED helpful in this stetting.
When a cat presents with symptoms of hyperthyroidism but has a normal TT4 result, it can still be beneficial to repeat the TT4 test on another day to confirm the result. Additionally, adding a measurement of free T4 (fT4) can help provide a more comprehensive assessment of thyroid function, as fT4 is the biologically active form of thyroid hormone.
Repeating total T4 or running free T4 would both be options. Overall, if I have a normal total T4 with a high index of suspicion my next step would be to run a free T4.
Hill’s y/d is specifically formulated to manage hyperthyroidism in cats by restricting iodine intake, which is necessary for thyroid hormone production. While it can be beneficial for managing hyperthyroidism, it may not be the ideal choice for managing concurrent chronic kidney disease (CKD). Hill’s k/d and Royal Canin Renal are formulated to support kidney function in cats with CKD and may be more appropriate for cats with both conditions. I would not use y/d with renal cats and would prioritise the renal diet as we know this can have a more specific and important impact on survival. Do you have access to the transdermal methimazole? This article is an interesting read:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9543258/
When assessing thyroid function in a cat on prednisolone or other corticosteroids, it’s generally recommended to wait at least 2-4 weeks after discontinuing the medication before testing thyroid hormones. This allows time for the corticosteroid to clear from the system and for thyroid hormone levels to stabilize. However, the exact duration may vary depending on the individual cat and the specific corticosteroid used. If this was not possible, free T4 might be a good option here.
I hope this helps clarify things for you! If you have any more questions, feel free to ask.
Kind regards,
Scott 🙂
Replying to Jenny C. 22/04/2024 - 21:49
Jenny!
So lovely to have you here! My very first job was the PDSA in Gateshead. To this day I can say without hesitation that it is still the best job I have ever had.
Say hello to the crew from me!
I hope we can help get your clinical brain engaged again.
Scott 🙂
Replying to Janette B. 19/04/2024 - 19:59
Hello Janette!
What an honour to have you here. Thank you so much for working with us and providing such a brilliant course!
Hope you are having a great weekend.
Scott 🙂
Hi Christina,
Dealing with regurgitation in hospitalized dogs, especially those with conditions like haemorrhagic gastroenteritis (HGE), can be quite challenging. Here’s a general approach to consider:
1. Ensure there are no underlying anatomical issues (e.g., megaoesophagus, oesophageal stricture) contributing to the regurgitation.
2. Maintain hydration with IV fluids.
3. Start with a single antiemetic, such as maropitant or ondansetron, and assess response before adding others. I have no issue using these in combination with each other and with metoclopramide. Maropitant is often the go-to, but ondansetron often works better. Some patients need all three for use. I normally add them in an escalating pattern depending on response.
4. I would maximize metoclopramide at 2 mg/kg/day by CRI. If these patients are still regurgitating and you are concerned about ileus, I would consider using cisapride and even erythromycin. I would reserve erythromycin for more refractory cases. The benefit of erythromycin is that it is injectable and cisapride is not.
5. Use of opioids for pain management should be balanced with the risk of gastrointestinal side effects. Paracetamol is a brilliant option for these cases. Opioids can contribute to gastrointestinal motility issues, including delayed gastric emptying and potentially exacerbating regurgitation. If opioids are necessary for pain control, consider lower doses or alternative analgesics, especially if regurgitation is a concern.
6. I think some of these cases will benefit from NG tube placement to remove/siphon some gastric contents if this is just sitting in the stomach. I would then replace with some trickle feeding. This really helps some GI patients.
Hope that helps!
Scott 🙂
Replying to Mónica P. 14/04/2024 - 08:27
Hello Mónica,
I hope you are well. I have popped some thoughts below:
1. Thyroglobulin autoantibodies (TgAA) are specific for dogs are used to diagnose autoimmune thyroiditis, which can lead to hypothyroidism. The test should be specific for veterinary use and not cross-react with human antibodies. I would double check with the lab you are using, but the veterinary labs I checked with are canine specific.
2. Fasting for Thyroid Hormone Testing: No, thyroid hormone levels do not need to be tested after fasting. Unlike some other tests, such as cholesterol, fasting does not significantly affect thyroid hormone levels. This is the protocol I have always used. I am often testing thyroid values along with other parameters, so my patients might be fasted for other reasons. I also found some evidence in human medicine that there may be an effect:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4171896/
I will chat to Yvonne regarding this question as she will have the most up to date lab based information.
3. Here are the conversions for TSH:
1 ng/ml = 1 µg/L
0.5 µg/L = 0.5 ng/mlI do not have a table, I am afraid.
4. Since phenobarbital can affect thyroid hormone levels, it’s best to test thyroid function before starting phenobarbital therapy if possible. If a patient is already on phenobarbital, testing can still be done, but the results should be interpreted with caution, knowing that phenobarbital could potentially affect the results. Ultimately, it often will come down to clinical suspicion. I would have to be VERY clinically suspicious that these patients had hypothyroidism before starting treatment.
5. The frequency of levothyroxine (T4) administration depends on the individual patient. While some guidelines recommend once daily dosing for T4 levels above 7.5 µg/dL, others may suggest adjusting the dosage. In practice, once daily dosing is often practical and effective, especially for owner compliance. However, I find that the majority of dogs do better on twice daily dosing overall.
6. The maximum recommended dosage of levothyroxine is usually around 0.8 mg twice daily. In giant breed dogs, dosages should be individualized based on the patient’s response to treatment and monitoring of thyroid hormone levels. I am comfortable increasing this dose further as long as I am confident that we have an accurate diagnosis and the patient requires the higher dose. I would be monitoring carefully.
7. Successful response in dogs treated once daily is associated with a median peak TT4 concentration (6 hours after administration) of approximately 4 mcg/dL (50 nmol/L). Values below 2.7 mcg/dL (35 nmol/L) are usually associated with an inadequate clinical response, and an increase in dosage is indicated. Markedly increased peak TT4 concentrations >7 mcg/dL (>90 nmol/L) occasionally occur. Although dogs are usually resistant to severe clinical thyrotoxicosis, such values should prompt a decreased dosage.
Regarding the Dogue de Bordeaux case, it’s true that some breeds, including the Dogue de Bordeaux, can have lower thyroid hormone concentrations compared to other breeds, so interpreting the results should take this into consideration.
Feel free to ask if you have any more questions or need further clarification!
Scott 🙂
-
AuthorPosts