scott@vtx-cpd.com
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Replying to Liz Bode 17/04/2023 - 10:41
Thanks Liz!
Very helpful!
Scott x
Hey Ornella.
Thanks for the questions.
I will pass these on to Hilary and let you know.
Scott 🙂
Replying to Tessa Verkade 20/04/2023 - 12:16
Hello Tessa.
Great points and great questions!
Honestly, I must admit I am not finding hypoadrenocorticism that often in chronic GI patients. These papers are probably most helpful:
https://pubmed.ncbi.nlm.nih.gov/35118742/
https://pubmed.ncbi.nlm.nih.gov/32573832/Although maybe not that common, I still think it is an important thing to rule out.
Hope that helps.
Scott 🙂
Replying to Magda Upton 19/04/2023 - 13:52
Thanks Magda.
I agree. I think that if there was any doubt about the diagnosis from the ACTH stim… the rest of the haematology and biochemistry is indeed supportive.
The administration of glucocorticoids before an ACTH stimulation test can interfere with and/or cause decreased response to the test. Most synthetic glucocorticoids, including prednisone and methylprednisolone, cross-react with the cortisol assay, which can cause falsely increased results. Dexamethasone and triamcinolone do not.
So, if a steroid is given just before the test, dexamethasone is slightly less of a concern. Other short-acting glucocorticoids (such as prednisone) should be withheld for 12–24 hours before the test. Longer-acting glucocorticoids, such as methylprednisolone acetate, should be withheld for at least 4 weeks before the test to avoid cross-reactivity.
The administration of glucocorticoids decreases endogenous ACTH concentrations, which causes atrophy of the adrenal cortex. A blunted response to the ACTH stimulation test is expected in patients that have received glucocorticoids (oral, parenteral, or topical) within about a month of the test or longer in case of longer-acting glucocorticoids.
In short – If a suspect Addisonian patient is given a one-off dexamethasone, the ACTH stimulation can be performed, because dexamethasone does not cross-react on the cortisol assay and one dose would not cause complete suppression of the cortisol levels. One dose of dexamethasone may slightly decrease adrenal cortex response to ACTH stimulation.
However, this suppression is likely small and will not affect the ability of the test to diagnose or rule out hypoadrenocorticism.Thanks again. Hope you are having a great week.
Scott 🙂
Replying to Ornella R. 15/04/2023 - 18:36
Hey Ornella.
I agree! I would be suspicious of Addison’s based on these results. You bring up a really good point regarding basal cortisol. It is a good test to rule Addison’s out in a patient with more chronic signs (particularly the GI patient). If you have a patient in an adrenal crisis, it is not that helpful. You need to do an ACTH stimulation test in a crisis. Basal cortisol can also be surprisingly low in normal patients! I see many basal cortisol results that are <10 nmol/l, which go on to stimulate completely normally.
Have a great week!
Scott 🙂
Hello everyone!
Just wanted to say another massive thank you to Felipe for a brilliant session.
Let me know if you have any questions.
Scott 🙂
Replying to Kathryn B. 15/04/2023 - 08:02
Hey Kathryn.
I hope you are well. I agree, basal cortisol is only really useful in well patients. In sick patients with a higher index of suspicion of Addison’s, I would do the ACTH stim! Many of the Addison’s dogs that we see have very low cortisol results pre and post-ACTH… like <10/<10... I thought this one was interesting as there was a wee bit of stimulation.
In a dog with normal adrenal function, injection of ACTH should result in a surge of cortisol secretion from the adrenal glands. Therefore, serum cortisol concentration before ACTH administration is expected to be between 14-165 nmol/l and after ACTHst it is expected to be >55 nmol/l. In a dog with HA, the adrenals have been destroyed and are unable to mount an appropriate response to ACTH. In most dogs with HA, serum cortisol concentrations before and after ACTHst are 27 nmol/l (undetectable). A small number of dogs with HA can have serum cortisol concentrations between 27-55 mcg/dL after ACTHst. In this case, the adrenal axis may have been suppressed a little by the dexamethasone, so if there was any doubt, I would repeat the ACR+TH stim in 48-72 hours.
The administration of glucocorticoids before an ACTH stimulation test can interfere with and/or cause decreased response to the test. Most synthetic glucocorticoids, including prednisone and methylprednisolone, cross-react with the cortisol assay, which can cause falsely increased results. Dexamethasone and triamcinolone do not.
So, if a steroid is given just before the test, dexamethasone is slightly less of a concern. Other short-acting glucocorticoids (such as prednisone) should be withheld for 12–24 hours before the test. Longer-acting glucocorticoids, such as methylprednisolone acetate, should be withheld for at least 4 weeks before the test to avoid cross-reactivity.
The administration of glucocorticoids decreases endogenous ACTH concentrations, which causes atrophy of the adrenal cortex. A blunted response to the ACTH stimulation test is expected in patients that have received glucocorticoids (oral, parenteral, or topical) within about a month of the test or longer in case of longer-acting glucocorticoids.
In short – If a suspect Addisonian patient is given a one-off dexamethasone, the ACTH stimulation can be performed, because dexamethasone does not cross-react on the cortisol assay and one dose would not cause complete suppression of the cortisol levels. One dose of dexamethasone may slightly decrease adrenal cortex response to ACTH stimulation.
However, this suppression is likely small and will not affect the ability of the test to diagnose or rule out hypoadrenocorticism.Hope that helps!
Scott 🙂
Hi Rachel,
I am sorry gluten is infiltrating your everyday life! Gluten allergies are rare – both in humans and dogs. A small percentage of people have celiac disease (an immune reaction/allergy to eating gluten, a protein found in wheat, barley, and rye) and require a gluten-free diet since the gluten proteins found in some cereal grains cause damage to the villi in the small intestine and impair their ability to effectively absorb nutrients. However, less than 1% of dogs have a true sensitivity to grain. In dogs, this sensitivity is called gluten-sensitive enteropathy. It is a rare inherited disease reported only in a small number of Irish Setters in the UK. It is not the same disease process as celiac disease in humans:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1576718/
Paroxysmal dyskinesia (Border Terriers) would be the other reason to think about gluten:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10020495/
Thank you so much for your kind words regarding the course, I am so glad you are enjoying it.
Thanks so much.
Scott 🙂
Replying to Magda Upton 10/04/2023 - 12:42
Hello Magda!
Lovely to hear from you! I am glad you are enjoying the course. Thank you for the brilliant questions!
1. It does seem that febantel is effective in these cases. Drontal-Plus® (Bayer Corp, Shawnee, Kan). [Dose: 5.4-7mg/kg praziquantel, 26.8-35.2mg/kg pyrantel, 26.8-35.2mg/kg febantel in combination (label dose for Drontal-Plus®), q24h, for 3 consecutive doses]:
https://pubmed.ncbi.nlm.nih.gov/11829263/
https://pubmed.ncbi.nlm.nih.gov/19575233/2. This is a great question. Most of the Protexin products are a single strain Enterococcus formulation. I think there is some evidence that these types of products will be beneficial in improving fecal scores and outcomes particularly in acute/uncomplicated gastroenteritis. The studies that have looked at infectious or chronic enteropathies did not show much benefit. So I think in acute uncomplicated cases, you are fine with the products you mention. I think in more chronic enteropathies, I would be considering the Vivomixx as there is quite good evidence for this:
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0094699
3. I have shared a great paper that reviews the process. I would normally sedate/GA the patient if possible… much easier, although I have done it once in a conscious dog! I would use a Foley to help with the retention and keep them sedated for at least 1/2 an hour. It is surprising how well they keep it in when awake!!! Honestly, I have only ever done it once, but I know of cases where it has been repeated. I laughed out loud… the thought of you getting your hair done and discussing a fecal transplant!!!
Hope that helps.
Scott 🙂
Hello.!
Great questions. The next lesson is all about feline pancreatitis! I should cover all of this, but if I don’t answer all of these questions let me know!
Hope you are having a great week.
Scott 🙂
Replying to Sybil Dryburgh 19/04/2023 - 15:17
Really interesting!
Thank you for brining it up!
Scott 🙂
Replying to Sybil Dryburgh 19/04/2023 - 17:03
Very helpful!
Will share tonight.
Scott 🙂
Replying to Magda Upton 10/04/2023 - 12:14
Thanks for this.
These are tricky cases! I have not see a case in a little while! Touch wood!
Hope you are well.
Scott 🙂
Replying to Victoria B. 04/04/2023 - 17:06
Hello Victoria.
Thank you so much for your question. I am sorry about the delay in getting back to you!
I am really pleased you enjoyed the webinar. I am pleased to hear that you have acess to capromorelin… I would love to hear your experiences with using this drug. Generally, I would use capromorelin as a first line in dogs. I might be a bit cautious in patients with diabetes mellitus as there is the possibility of insulin antagonism. I would generally not use more than one appetite stimulant at a time, I am not aware of any evidence that the combination is beneficial. I would often allow supportive care to work, but would not delay jumping in with an appetite stimulant too long. The main concern with too much of a delay is that we know that early enteral nutrition is always going to benefit patients.
I think if there was microcytic, hypochromic anemia and increased urea, I would feel confident in starting omeprazole. These are cases that might benefit from fecal occult blood to confirm/suggest bleeding.
I hope that helps. Let me know if you have any other questions.
Scott 🙂
Replying to Ornella R. 04/04/2023 - 13:41
Hello Ornella.
1- If you were going for biopsies, I must admit I would try and biopsy as much of the GI tract as possible for completeness. FMT has not been demonstrated specifically in cases of T. foetus but I would think about using it in very refractory cases. FMT would be interesting, does this work in cats with T.foetus? I am sure VN in Manchester would be able to facilitate it. I would also consider Chestergates or NW Referrals. Where do you normally refer? I will pop on a separate post about the fecal transplant protocol.
2-I think the honest answer is… we don’t know. Some studies support Fortiflora, but only in very specific conditions. Fortiflora is generally a good option in cats, but in more refractory chronic enteropathies I would always try Vivomixx. I will share the dosing chart for Vivomixx again. How long depends on the patient, I have used long-term in some patients if they respond well and relapse when the probiotic is stopped. I would do a minimum of 4 weeks in chronic cases. Regarding endoscopy, I always do diet, wormer, and probiotics before discussing endoscopy. I like to do endoscopy before steroids, but if you have done as much as you can and owners are not up for steroids, it would not be unreasonable to try them.
3- Great question! I must admit, I only tend to use clopidogrel in PLE cases when the albumin is below 20 g/l. Having said that… most of the ones I see are below 15 g/l! We probably should be using it more! Could you share the paper you mentioned?
Hope that helps.
Scott 🙂
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