Hello and welcome to this CPD session presented by Chanel Farmer. My name is Jonathan Moore. I'm a veterinary surgeon and the product support manager for Chanel UK.
Today, I should be talking through coniphedrine, an exciting development in the management of urinary sphincter mechanism incompetence. This product is now available to the UK market. As you know, USMI is an emotive condition which can be difficult to manage both from the perspective of vets and for owners.
Coniphedrine offers a fresh approach to managing this condition, and as we shall see, is highly efficacious and simple to administer. This presentation is part of Chanel's ongoing CPD series. We have additional content, which relates to the therapeutic areas we operate in across both companion animal and equine.
There are more details at the end of the presentation on how to access these. So what are the contents? What are we, what are we going to be talking about today?
Well, I should begin by looking at some background on urinary incontinence and bitches, anatomy, normal process of urination, etc. We'll then move on to look at USMI in more detail, thinking about diagnosis and treatment options. And then finally, we'll move on to Ciphedrine itself, more product information, how to use the product, etc.
But to begin with, we'll take it right back to the very basics and and begin with the canine neurogenital tract anatomy. I'm sure everyone listening to this presentation will be very familiar with this anatomy, but it's a great place to start in terms of expanding our story and the journey of caiphedrine. So we have our kidneys.
These are essentially filtering the blood and producing urine. The urine passes down the ureters and collects in the bladder. When the bladder is full, urine is, is passed to the outside by the urethra.
As we can see on the right-hand side here, this cross section of the bladder, the area that we're really focusing on with this product, and with this presentation is the urethral sphincter. And this sits in between positions 4 and 5 on this diagram. So what is the process of urination and how is continence maintained in the in inverted commas normal animal?
We start with a full bladder. This full bladder is detected by stretch receptors in the bladder wall. These, these receptors send sensory signals to the brain, which processes this information and responds by sending, first a motor signal to the detrusor muscle in the bladder wall, causing constriction.
It also sends suppressive signals to the via and and to the sympathetic innovation of the urethral sphincter. Under the normal process of continence, the constant steady sympathetic innovation of the urethral sphincter causes tone and constriction of this structure, and essentially maintains consonance by, by closing the urethra. So if we suppress this, we get a relaxation of the urethral sphincter, and that combined with the constriction of the trusor muscle contraction.
We get urination. So urine passes from the bladder to the outside. Once the bladder is empty, sympathetic innovation returns to the urethral sphincter, causing contraction and tone and continence is maintained.
Urine starts pooling again in the bladder and we go back round the cycle. When we're talking about cannifirine. We're talking about, we'll go into more detail further on, but we're talking about a product that is essentially mimicking the sympathetic innovation of the urethral sphincter.
So what maintains continence? We've talked about it already. The the most important structure and certainly the most important structure based in terms of this presentation, but also in terms of medical management of urinary sphincter mechanism and competence is the urethral sphincter.
This is comprised of both internal smooth muscle and external striated muscle. There are some other structures that and factors that come into play when, when we're talking about maintaining continents. First of which, is the elasticity of the urethral wall.
Second is the length and diameter of the urethra. And the third is engorgement of suburethral venous plexuses. We'll look at all of these in more detail as we move forward.
But as we said before, certainly from our point of view and from the point of view of medically managing USMI, the urethral sphincter is really our focus here. So, what causes urinary incontinence? Well, urinary incontinence is defined by an involuntary loss of urine.
And the vast majority of cases in, in female dogs are comprised of urinary sphincter mechanism incompetence or USMI as we've mentioned before. In fact, 82% of incontinence cases are USMI cases. The remaining percentage is made up by other conditions though, and these include ectopic ureters, 4%, cystitis, 2%, neoplasia, another 2%, and then 10% of others, including things like detrusa instability, fistulas, vaginal tumours, hermaphrodism, in pelvic abscesses, etc.
It's important to be aware of these other causes, because these other causes will require differing management and treatment options than SMI. So where and when do we see USMI? Well, as you can see on the right hand side here, there is pre predispositions.
We've got breeds such as boxers, schnauzers, old English sheepdogs, setters. Poodles, and very quickly, we can see that these are all larger breeds. And if you look down the bottom left there, in fact, the vast majority of cases of SMI are seen in dogs that have an adult body weight greater than 20 kilogrammes.
So, hence why these larger breeds tend to be overrepresented. USMI is very often seen after neutering or spaying, and indeed around 5 to 20% of dogs that undergo this procedure will go on to develop USMI later in their lives. So what is the mechanism of USMI?
Well, it's not fully understood, but there are believed to be a number of different contributing factors. Again, the most important from our point of view, involves the, the urethral sphincter. So you reduced urethral tone caused by weakened sphincter mechanism is, is a primary cause.
This often occurs post neutering due to a reduction in circulating hormones. Again, there are other factors that can come into play. So we'll just talk through those two.
These are related to the other factors that we mentioned earlier, the first of which is reduced urethral length post neutering. So, if you can imagine a shorter tube has less resistance. So if the urethra is shorter, less resistance, it's more likely to then become, you're going into a leaky situation.
The second factor is what's described as a pelvic bladder. So, in a pre-space state, the the body of the bladder and the bladder itself sits within the abdominal cavity and it experiences the same hydrostatic forces all the way around it. However, after spaying, the bladder can actually move backwards and be partially located in the pelvis.
When this happens again, essentially, you have a mismatch of pressure across the bladder and the bladder neck now. So the the part of the bladder that's still located within the abdomen is undergoing hydrostatic forces from the abdominal contents, but that piece and the bladder neck that is located in the pelvis doesn't have the same forces applying to it. And it's essentially like squeezing a balloon without having to holding onto the net and the contents leaves fairly quickly.
The third factor here is from reduced external compression from weakened urethral supporting structures. These, these plexuses we mentioned before. It's believed that in a hormonal state or a lack of hormones, then these structures become essentially less strong, and less supportive and less constrictive the urethra.
But from our point of view, really the most important factor is this, weakened sphincter, and this is what we're going to look at now. So what about the, the timing and the method of, of neutering or spaying that, that is carried out? Well, as we mentioned before, a lot of bitches that undergo a spay will be at high risk of developing USMI, moving forward.
They're around about 8 times higher risk, than, than non-spayed bitches. There doesn't appear to be any significant difference between the type of neutering or sparing operation that's carried out. So for both a variectomy, where the ovaries are removed and a very hysterectomy, where the ovaries and the uterus are removed, they carry the same risk in terms of developing USMI afterwards.
And I think what this really tells us is that the key factor is removing the ovaries and decreasing the the hormones in a post-ba state. Does it matter whether we do these operations before or after the first heat? Well, the opinions differ really on this, and I'm sure people listening to this presentation will have their own opinion.
I would refer to that or refer to the opinion of others in terms of what, what is best to do. I shall leave that to to your clinical judgement. I think it's fairly safe to say that the vast majority of clinicians in the, in the UK will choose to do a spa after the first heat has happened.
But again, I leave that to your clinical judgement. So, diving a little more detail now in terms of the, the effects of this hormones or or reduction in hormones in the post-base states and how that can impact SMI. Several mechanisms have been proposed for this, the first of which is this reduced oestrogen level.
So on removal of the ovaries, oestrogen levels decrease. And there are oestrogen receptors prominent in the urethral sphincter, and in addition, oestrogen actually increases sensitivity of alpha receptors in the urethra in the urethral sphincter to catecholamines. So if we remove this oestrogen or oestrogen levels drop, then we get a reduction in the activity of the receptors and also the oestrogen receptors can't be as activated or stimulated as a as a free space state.
There's also believed to be an impact from increased gonadotropin levels, follicle stimulating hormone FSH and LH, luteinizing hormone. So after Spain, gonadotrophin levels rise significantly, and this is due to a lack of oestrogen suppression. So in the normal state, there's a negative feedback from the oestrogen in the body, which suppresses FSH and LH.
Oestrogen is removed, FSH and LH then increase. FSH and LH are believed to impact receptor expression in the lower urinary tract and contribute to reduced bladder capacity. So the right, the graphs on the right hand side really illustrate this change in the FSH and LH levels.
So the top graph is dealing with FSH, the middle graph LH, and the third graph looks at the pressure within the urethral sphincter in the post-pa period. So you can see the space is occurring where the green arrow is, both FSH and LH then increased significantly and continue to increase in the weeks after spaying. And this corresponds to a decrease decrease in the, the pressure within the urethral sphincter, which we can see on that lower graph.
So, how is SMI diagnosed? Well, like any condition, we start with signalment in history. What's the breed of the dog, what's the weight of the dog, what's the age of the dog?
Do we have a history of intermittent urinary incompetence? Do we have any other, any other clinical signs associated with this? And if we remember back to our pie chart from a few slides back, it's really going to be really important that we rule out those other potential causes.
So carrying out diagnostic procedures such as urinalysis, blood biochemistry, ultrasonography of bladder and abdomen can be really, really useful in these, in these cases. Urodynamic studies can be available at referral, and this is essentially pressure profiling along the length of the length of the urethra. The reality is, is that many veterinarians will diagnose, USMI based on the response to clinical treatment and medical treatment.
But I think it's important to bear those, those steps in mind when we're, when we're talking through this. So what treatment options are currently available to manage USMI? We have first line drug, medical therapies, and second line surgical options.
When thinking about the first line drug therapies, we have 3 classes of drugs that can be used to, to help manage this condition. We have the symphomimetics. Estrogens and GNRH analogues.
It should be noted that the GNRH analogues are used off licence in the UK. In terms of second line surgical options, we have such procedures as coal suspension, urethropy, transpelvic sling, trans operator sling, etc. It should be noted that we won't go into great detail in terms of the surgical treatment options in this presentation.
But we will now go on to look at the drug therapies in more detail. So many clinicians consider the alpha symphomimetics to be their first line treatment, and then a second line treatment to be the estrogens. And as we said before, those GNRH analogues are off licence in the UK.
So think about our first line drug treatment, the alpha sympathhomimetics. There are really 22 molecules we're looking at. One is ephedrine, which is our kyphedrine, and the other is phenyl propranolamine or noephedrine.
So both of these lead to increased urethral sphincter tone by indirectly acting on alpha adrenergic receptors and increasing the activity of noradrenaline in the smooth muscle. The estrogens, the second line treatments, cause an upregulation of alpha adrenergic receptors and directly act on oestrogen receptors in the urethral sphincter and urethra to increase the tone. And for completeness' sake, the GNRH analogues, the suppress FSH and LH levels, thus leading to increased receptor expression and bladder capacity.
It's worth mentioning as well that many clinicians will consider combining 1st and 2nd line treatments or combining the alpha symptomimetics with estrogens. This is often done if you're not fully successful with one or the other. The the other medical management modality can be brought into augment the first.
So this, this can be done with either of these two molecules, and as I say, it's worth considering in some cases. So looking at ephedrine and phenol propranolamine in a little more detail now, as we said previously, both lead to increased urethral sphincter smooth muscle tone by indirectly acting on alpha adrenergic receptors and increasing the activity of the no adrenaline. So they act directly on the urethral sphincter.
It's important to note and and quite interesting, I think, to note that ephedrine or kinephedrine is metabolised in the liver to nor ephedrine. So essentially, the ephedrine is converted into that phenyl propranolamine or nor ephedrine. So the active in caiphedrine, ephedrine, when it's metabolised, that metabolite is still active and and performs the same function as the ephedrine.
On the right hand side here, we can see the same picture we saw earlier, that cross section of the bladder. Here we can see the meatus, which is essentially the outside of the body and the bladder. And if you transpose that image onto the X axis of the graph, the lower axis, we can see the meatus on the left hand side and the bladder body on the right.
So essentially that X-axis becomes a line along the length of the urethra. And then the Y axis, the vertical axis there is is pressure in centimetres of water. And the solid green line, we can see what the pressure is achieved along the length of the urethra in the pre-drug state.
So we're getting to on the midpoint there, just over 40 centimetres of water pressure. Once the ephedrine is given, pressure at this point, you can see is increased dramatically to around about 65 to well, going up towards 70, but probably about 67, I think on that, that scale. And then the post drugg state, it remains significantly higher than that pre-drug state, just below 60 centimetres of water pressure there.
So caephedrine is a first line treatment for urinary sphincter mechanism incompetence in bitches. And as we've said before, the list of medical treatments is relatively short in terms of what's available to the UK market. So Ciphedrine represents a really exciting additional tool in that armoury of managing of available treatment options for managing this condition.
We'll now go on to look at a little bit more on the product information relating to to Ciphedrine. So as you can see on the picture here, Ciphedrine is available in two pack sizes, both 10, 100 tablet packs, 120 milligramme, 150 milligramme. We'll just look at the pharmacokinetics for coniphedrine just really quickly.
We've touched on some of this stuff already, but I think it's probably worth just just looking at again. Ciphedrine, ephedrine is rapidly absorbed after oral administration, and it's converted in the liver to phenol propranolamine or no ephedrine. No ephedrine is potent and it contributes to the effect of ephedrine.
Essentially the the both the molecules, as we've seen before, have the same effect. So when ephedrine is metabolised, it metabolises into an active metaboloid, which is a quite a useful product feature, I think. Both are eliminated by the kidneys and the half life of kniphedrine is around about 3 to 6 hours.
I say that conversion into no ephedrine means that we actually extend the the life of this product once it's given, and that is a part of the reason why it's a once a day dosing schedule. So how successful are we with Alpha symphomimetics in terms of treating and managing USMI? Well, the phenop propranolamine, which has been available in the UK marketplace longer than ephedrinephedrine, the efficacy is reported, reported to be between 86 and 97%.
And the good news for coniedrine is that it's very, very similar, in terms of its efficacy, 74% to 93%. So, Both of the products are, both of the molecules are very good at managing this condition. There's another factor that's worth considering when we're talking about alpha symptomimetics, and that's desensitisation.
So it's a known phenomenon in alpha symphomimetic therapy. And essentially, over a long period of time, we are stimulating the adrenoceptors, as we've talked about previously. And that stimulation again, if it's repeated and and more regular.
It initiates, a cellular regulatory process, the result of which is a reduction in the number of receptors, a reduction in the density, and also a reduction in the, receptors activity. This leads to desensitisation, which is a physiological response, of a loss of intensity. So what it boils down to is that frequent administration doesn't necessarily increase efficacy.
And there is an increased risk of ha habituation and desensitisation over long term usage and with more regular usage. When thinking about the dicing regimes for these molecules, cinephedrine is a once a day dosing, phenyl propranolamine is a 3 times a day dosing. So, again, looking at that the product overview.
As we've mentioned before, the active, incaniphedrine is ephedrine hydrochloride. We have a 20 milligramme and a 50 milligramme tablet pack size with 100 tablets in each pack. The target species is dogs, and the data sheets, specifically states it's for the treatment of urinary incontinence caused by urethral sphincter mechanism incompetence in a very hysterectomized female dogs.
What about dosing? Well, the starting days for ephedrine is 2 mes per kg, once daily for 10 days. After that time, the animal should be re-examined and assessed to see how successful the treatment has been.
If the treatment is successful, at this stage, you can actually reduce the dosage to half of that initial dose. Again, reviewing as you move forward will be very useful, looking out for any drop in efficacy or any adverse events that might occur. So a regular or semi-regular re-examination would be recommended.
In cases where you have a relapse of the clinical signs, you can actually go back to the original dose rate, the 2 me perk and start the cycle again. On the right hand side there, we have a dose chart, which gives you some guidance in terms of how many tablets to use for different weight dogs. My recommendation would be to calculate accurately the dose in each case based on obviously the weight of the dog, and to go as close as possible to the the milligrammes required for that weight.
And as we've said before, we examine these cases on a regular semi-regular basis. It's important when we're talking about any, well, any drugs, really, but certainly when we're talking about the alpha symphomimetics, they do come with possible adverse reactions. This is because of the nature of these drugs, as the name suggests, they are mimicking the sympathetic nervous system.
So those adverse reactions that we see are essentially because of the other effects of sympathetic innovation, essentially. So, in terms of cardiovascular effects, we might see, we might well see tachycardia, atrial fibrillation, increased heart activity, vaso constriction. We can also see stimulation in the central nervous system, sleepiness, excitation, anxiety, muscle tremors.
We might see my dryosis. And from a respiratory perspective, bronchodilation, decreased mucus release in the respiratory mucosal membranes. And from a GI perspective, a reduction in motility and tone of the intestinal wall.
As a result of this, there are some contraindications for the product, which obviously relates to the factors we've just talked through. So cases that have preexisting cardiovascular disease, hyperthyroidism, diabetes mellitus, impaired renal functional glaucoma, you should really think very carefully before using the products in these cases. Connifirine also should not be used concurrently with halogenated narcotics such as halothane or methoxyfluorine.
And like all drugs, if there is any hypersensitivity reaction to the actives or the any of the excipients, they shouldn't be used. And just to finish up there, it's worth saying that if hypertension or if the hypertension that can result from giving these drugs leads to a worsening of the initial clinical signs or an unwell animal for any reason, then treatment should be reviewed and possibly altered and changed. So just to finish up, we're gonna, we're gonna look at the key points for Kniphedrine, the real take homes, I think, from, from thinking about this, this product.
So Top one there, it's a once a day dosing. So we have an alpha symphomimetic with Ciphedrine that you can give once a day. This makes it easy to manage and there's a reduced chance of desensitisation with long-term usage.
In addition, Being in tablet form, it's easy to administer, and those tablets are dividable, meaning that you can very easily get to the desired milligramme for, for the weight of the dog that you're looking at. It has a comparable efficacy to phenolropranolamine. That's really good to know if you're familiar with using phenopropranolamine at present.
It's good to know that when switching over to caiphedrine, that you would expect to see the same efficacy with the product. And finally, there are two pack sizes, the 20 milligramme and the 50 milligramme, both come in 100 tablet packs. And that makes medium to long-term management more simple, I think, from an owner's perspective.
Thank you so much for listening and for completing this coniphedrine CPD. I hope it's been useful. This is a list of references relating to the presentation for anyone who wishes to dive into these topics in a little more detail.
To view more of Chanel Farmer's product range and to access further CPD content, you can register today at vet.chanelfarmer.com.
To receive a CPD certificate for completing this coniphedrine training, please email vet [email protected]. If you have any further questions or comments, either relating to Ciphedrine or other of Chanel's products, again, you can send an email to vet updates at Chanelgroup.ie and we shall respond to you as soon as we can.
In addition, further information can be obtained by contacting your Chanel territory manager. Once again, thank you so much for your time, and we look forward to seeing you on another of Chanel Farmers CPD courses very soon. And that leads really nicely into me saying a huge big thank you to Chanel Farmer for their sponsorship of tonight's webinar.
And Jonathan, if you can pass those thanks on to the company, we really do appreciate the support that we get from companies. So thank you very much. Jonathan, now you've been a vet since 2003 and you've had 10 years in and out of practise.
You've worked for other drug companies, and now you're with Chanel Farmer with what is looking like a really exciting product. I How does it compare to, to, the, the sort of efficacies, as you mentioned earlier, of things like phenyl propanollamine, longer term, with excretions as one of our questions is asked. Thanks, Bruce.
Yeah, no, it's great to be here and thanks for the questions that have come in already. So, as we talked about in the presentation there in terms of efficacy, the efficacy is very similar in the clinical papers to phenyl propranolamine. And I think it's worth remembering, obviously, that the ephedrine is metabolised to phenol phenyl propranolamine, essentially in the body, which, which is probably the reason why we get this very similar efficacy.
In terms of long term usage, both products are and can be used long term, as, as I'm sure everyone knows out there. One of the nice things, I think, because we've got a once a day dosing, there is this talk around the desensitisation piece, and it is mentioned in the clinical papers that the more often that you dose these type of products, the more likely to get, to get that desensitisation. So with the once a day.
SID products, hopefully that, that's less likely to happen in the long term. Yeah, that's, that's really good to know. And when you were talking about dosing, you were talking about starting at 2 milligrammes and then reducing it in time.
Is there any evidence to show that, you know, you may need to go back up again for a short period of time, intermittently and then drop it down to maintenance? Yeah, absolutely, that can happen. So if you do get a decrease in the efficacy, once you've dropped the dosage to that, that lower dose one or less, you can actually return to the initial dosing and start again, essentially.
If you're getting a failure at that point, it's time to, you know, rethink the treatment options, essentially. But, but yes, if you do have a drop in efficacy, you can essentially hit the reset button and go back to the start again. Yeah.
It's exciting to have a product on the market that's, as you said, convenient in a tablet form and and obviously is effective from all the studies and everything else that you've done. Yeah, we're, we're really excited about it. And I think, you know, talking to people out there, there, there seems to be a lot of interest in, in this, and, and a lot of that comes down to management from an owner's perspective and, and making things as kind of easy and user friendly as possible, I think.
Yeah, yeah. Great question just popped in from Sam, who says, is there any concern at using that loading dose long term if needed? Well, it would be off licence usage.
So, obviously, it comes down to the responsibility of the attending veterinary surgeon at that point to go beyond that, that, loading dose time frame. And so it might be one of those things to again, think about your treatment options if you feel that you need to stay at that high dose. Is it time to Maybe bring in an oestrogen alongside, so you can lower the dose to a maintenance level or even think about other options.
So I would say stick with the SBC and data sheet recommendations at this time. And if you need to change it, or you feel that you need to stay there, it might be time to just just have a rethink on, on the treatment protocol. Yeah, I'm, I'm feeling Sam's frustrations.
We've all had those cases where you just think, what now, you know, so, yeah, great question, Sam. Well, like, like some of the other questions have come in, you know, a lot of this, these questions relate to kind of off-license usage and And certainly there are indications that that can be, can be worthwhile to look at from this perspective. It's always worth remembering under the cascade that off licence usage, usage remains the responsibility of the attending veterinary surgeons.
So there's one question I think there around the use in in male dogs. Yeah, it has been used in male dogs. The efficacy is reported to be lower, around about 50% success rate there.
And obviously again based on that, that data sheet and SPC isn't off licence usage there, I think that's good to know that you know that it has been used and and . As I say, you know, sometimes you get those, those frustrating cases and, you know, it's not, it's not as good in males as is in females, but it's still there. 50% is, is still better than nothing.
It, it's, it's an option, maybe for, for those cases. I think the other, interesting area that, that has been mentioned again in the literature is, is for those, trauma cases, that have had sustained, like a physical trauma that's damaged the neural pathways. And it has been used in those cases as well, again, off licence usage.
Yeah, absolutely. And I'm, I'm pretty sure that your answer's gonna be similar again and the next question popped in from Julia. What about cats?
There is no data that I, I have on cats, I'm afraid. So I would, I would have to like refer you to, to dive into a literature search on that, that one. Yeah.
Fortunately, it's not as big a clinical syndrome in cats as we see it in dogs. No, and I think that's, yeah, that's very much the case. .
Yes, there was another question I think, a little further up, . On environmental effects of excretion. Yeah, excretion of the drug into the environment.
Yeah. And that's, that's a really interesting question. I don't have any data on that.
I think the only thing I would say is that that based on the fact that that essentially the the ephedrine is being metabolised to phenyl propranolamine, which is a product that is used widely in the UK. Then I think we wouldn't change the level that's probably in the environment based on the number of dogs that are requiring this kind of medication already, if that makes sense. So I don't have any data on it, but it, but using this.
It's probably not going to increase the environmental level, I would say, if you're swapping from one to the other. Yeah. Well, that's good to know.
That's just my guess. That's that's purely off the top of my head. I like I said, I don't have any data on that specifically.
It makes sense when when it's metabolised across the you know, it's yeah, it, it, I would, I would hazard to say that that would be a logical assumption. I, I think so, like I said, that would be, yeah, my assumption, I think. Yeah, fantastic.
I know Jonathan, when you put these sorts of presentations together and do pre-recordings and that, there's often things that pop up when when you're thinking about it and sitting listening to yourself. Anything else you want to add to this? I suppose in terms of questions that that we've heard already about this is, is, you know, really along the lines of what people are using already and and why they should switch across.
I think there was a question earlier about another ephedrine product that that has been used in the past. That's an unlicensed human product that has been used under the Cascade. So there will be people out there that have experience of of ephedrine.
That's great. At least it's good to know now that there is a product that is licenced for those people who have been using it in the past. So, yeah, take some of the, the worry about, about usage, I think, and also, obviously there's more support around the products.
As we said before, anything used off licence, there's no support from the pharma companies, whereas if you have a licence products, then it can be a much more integrated process, which is good to know, I think. I think that's really important, you know, the, the, the VMD and the Cascade and everything else is there for a reason. And the fact that they've granted you guys a licence for this, basically endorses your product.
You know, so, and, we know that Chanel Farmer is there to back us up. As you put up on the, the details on the screen there, you know, if people have got questions, they can get in contact and and ask, whereas if anybody's ever tried to find details about a human product, it's, it's an interesting time. Yeah, it's, it's, it can be very tricky, and it's something that I've looked into with a variety of different products and molecules in the past.
And I think it's always good to know from a, from a clinician's point of view that what they're using is licenced, because like we said before, it just takes some of the, the pressure out of those, those, treatment decisions, I suppose. Yeah, absolutely. Another question just popped in from Maria is how long is it safe to keep using this product?
This can be used indefinitely, and that that lower dosage. As we said in the presentation, it's really good to review cases on a, on a regular, semi-regular basis to make sure that A, the product is still working as you'd expect it to work, and B, to make sure you haven't got any of those side effects creeping in that we talked about or any adverse reactions, etc. So apart from that, you can keep on, if the dog is, is stable on it, keep going at that dosage.
Yeah, fantastic. That's fantastic. Folks, that's the end of our questions.
Once again, a big thank you to Chanel Farmer, for sponsoring this evening, and bringing us this exciting new product. Jonathan, thank you for your time tonight in coming in to talk to us about it. And, thanks for jogging the memory on the, the anatomy.
Like you, it was quite a while ago since we did it. It was great to see it again. I thought it was a good place to start.
Always, always. Sorry, carry on. Oh, I was just gonna say thank you so much for, for everyone's great questions there.
And, and if there is anything else that that you think of afterwards, or you want to get in contact and and talk it through further, then the contact details are there or direct questions through the webinar there, and I'm sure we can get back to you as soon as possible. Fantastic. To everybody, thank you for your time tonight.
Thank you for attending and look forward to seeing you on another webinar. From myself, Bruce Stevenson, it's goodnight.
