Good evening everybody, it's Anthony Chadwick from the webinar vet welcoming you to one of our webinars, and it's great to be speaking to you. I'm over in the UK, but I'm really thrilled to be doing this webinar, and chairing it on behalf of ADM. We're gonna be speaking about the guts of Kabalamin, it's importance and the new evidence for oral supplementation.

And we're very fortunate today to have Doctor Amy Lamb, who's a registered specialist in small animal medicine. And, Amy graduated from Sydney University and then did her residency at the Small Animal Specialist Hospital in Sydney. She's a specialist in small animal medicine and a fellow of the Australian and New Zealand College of Veterinary Surgery, .

As, as many do, she came over to evangelise the Brits and spent a few years in Birmingham at Willows Veterinary Hospital, which is a famous veterinary hospital in the UK. And it was there that she really began to understand the importance of B12. So I'm glad that we were able to pass some information back to you, Amy.

But I'm really looking forward to the presentation, and Amy, it's over to you. Thank you so much. So, thank you to all of you for coming tonight, my time and daytime your time.

I hear that there's people from all sides of the world, which is really exciting to me. As you've heard, I'm a, internal medicine specialist at the small animal specialist hospital in Sydney, which is a really nice referral hospital. But as you've heard, a lot of my interest in gastrointestinal disease at Actually came from doing some work in the UK at Willows and at the Royal Veterinary College, and working alongside some of the best gastroenterologists in the world.

And B12's something that I think about every day with my patients as an internist. And it's something that I have really learned to love and enjoy. So, thank you to ADM for having me and thank you to all of you for chiming in tonight.

So my first question to you all is, who actually routinely measures B12 in dogs or cats with chronic gastrointestinal disease, just so we can have a bit of an understanding. You just want to click on things, that would be great. I'm not sure any of you are seeing the numbers coming up here, so I will shut up to give people another 10 seconds just to, to vote.

And it's not a trick question. No, no, no, it's fine. And we've got 26% saying that they do measure it and 74% who don't.

Great. All right. Well, let's see if this talk can, give you some, motivation to measure B12 a little bit more for those who don't routinely measure it already.

And for those that do measure it, hopefully this talk will give you some of the background information as to why it's so important. So why do we care about B12? So carbalamine, or commonly known as vitamin B12, is a water-soluble vitamin that's used by every cell in the body.

Curbalamine is required for the maintenance of normal physiological functions, including nucleic acid synthesis, amino acid metabolism, lipid metabolism, intestinal epithelial function, CNS maintenance, metopoiesis, and detoxification. So pretty much, it's a, it's got major roles throughout the body, throughout every single cell. And it's really essential, it has a really essential role in health.

So B12 deficiency is actually, I think, relatively recognised in our veterinary patients. 74% of you said that you don't routinely measure it. You may supplement it, but you may not know whether B12 is actually deficient.

And signs of B12 deficiency can actually be quite subtle, but when you start treating those patients that actually have B12 deficiency, you can notice marked improvements in those patients' quality of life. So tonight we're going to talk about the role of B12, and we're going to predominantly speak about gastrointestinal disorders and the relationship of gastrointestinal disorders with B12. We're going to talk about some breed-related inherited defects and absorption or metabolism.

We're going to talk about how and when to test for B12 deficiencies, what to do with those test results, and the therapeutic implications of what you find. So, as I said, B12 is a water-soluble B vitamin. This is what it looks like if you were to sketch up its chemistry.

The sources are from dietary, animal products, and B12 can be synthesised by various, microbes within your gastrointestinal, microbiome. Omnivores and carnivores can't actually produce it, but herbivores can. And supplementation in pet food varies.

So a keynote for this is that dogs and cats cannot produce or synthesise vitamin B12. We have to be giving it to them. This is a really nice but very busy schematic diagram that I found in nature, that shows B12 metabolism and corresponding causes deficiency in people, .

The metabolic pathway starts when dietary carbalamine is obtained through animal foods and it enters into the stomach bound to animal proteins. Pepsin and hydrochloric acid in the stomach severed the animal protein, releasing free cabalamine. Most of the free cabalamum is then bound to R protein or haptoorin, which is released from the parietal cells in the stomach and the salivary glands.

In the duodenum, the dietary carbalamine is bound to our protein is joined by curbalamine complex protein complexes that have been secreted into bile. Pancreatic enzymes then degrade both biliary and dietary carbalaminar protein complexes, releasing free carbalamine. Intrinsic factor is secreted in the stomach and dogs, but not cats, and from the exocrine pancreas in dogs and cats, but not in humans.

An intrinsic factor is one of those, is a really, really key part of this whole pathway. An intrinsic factor and carbalamine binding is actually quite weak with the presence of gastric and salivary proteins. The carbalaine intrinsic factor complex remains undisturbed until the distal ileum, where it attaches to the mucosal receptors called cubulin.

And the carbalamine is bound to transport proteins known as trans carbalamin 12 and 3, and trans carbalamine 2 is the most important one here. 1% of B12 that you ingest can also be passively absorbed through the ilium. The transcabalamine, although it only represents actually quite a small fraction of the transcobalaines, is most important because it's the one that delivers the carbalamine to all the cells in the body.

And then the carbalamine is subsequently transported, via the portal system for recirculation. So, I'm going to take you through a little bit of biochemistry and cell biology now, and I know this sounds a little bit complicated, but I think it's actually quite important, especially when we learn about deficiencies. So this slide shows you the pathway for carbalamine when it gets to the cell.

The transcabalamine 2 to balamin complex is taken up by endocytosis, and the carbalamine is then liberated into the cell. The B12 is an essential cofactor for intracellular organ enzymes. It's for both methionine synthase for the remethylation of homocysteine, which you can see in the bottom diagram of the diagram there, and methyl melanyl CoA mutase for the production of succinyl COA, which you can see in that mitochondria there.

On this diagram, you can see that methionine synthase doesn't just rely on B12, it's actually quite a complex interrelationship between folate, B12, pyridoxinee, which is vitamin B6, and riboflavin. Methionine synthase, of which B12 is required for function, regenerates methionine from homocysteine, and deficiency of cabalamine can also lead to folate deficiency. Deficiency of B12 leads to hyperhomocystinemia, which we can measure.

Methyl melannylchoA mutase is within the mitochondria and it's responsible for producing succinylchoA, which then enters into the citric acid cycle. And I'll show you another diagram on our next slide, so that you can see how important B12 is for the cofactor of this citric acid cycle. So I think this image from the consultations in feline internal medicine represents the number of pathways that are inhibited if if there's a B12 deficiency.

So this is the mitochondria again, and you can see here that the odd chain fatty acids, the cholesterol branch chain amino acids, can't enter into the Creb cycle or the tricyclic acid cycle, for energy metabolism if there's no B12, and there's no methyl melay coase mutase. This then leads to the accumulation of organic acids immediately upstream from the obstruction. And this, these can are then excreted into the urine.

So you actually get increased methylyonic acid and increased propionic acids in the urine. And this is a form of organic aciduria. This is a representation of how the urea cycle is also inhibited when there's no B12 available.

So the increased methylamyonic acid can also inhibit the enzymes that mediate the entry of ammonia through the carbonyl phosphate system into the urea cycle, causing an increase in ammonia. And that can lead to a metabolic encephalopathy. So in summary, I know I've just shown up a lot of biochemistry.

Decreased cabalamine has effects on metabolic, multiple metabolic pathways. The methionine cycle for the remethylation of homocysteine that feeds into the citric acid cycle, that feeds into DNA synthesis, and the methylation of methamlonic acid to produce succinyl COA, which is supposed to enter into the citric acid cycle. And as you, I'm sure you all probably remember now, these are really essential cellular functions, and especially for our rapidly producing cells like our enterocytes or our or our blood cells.

So reduced B12 has problems, leads to problems with DNA synthesis, the folic acid cycle, we're unable to reduce homocysteine and we get problems in mitochondrial energy production. Excess isn't such a big problem. So the body actually has a huge ability to store B12.

It can store it in the liver, in humans it takes somewhere between 3 and 5 years to exhaust. There's hepatobiliary recirculation, there's renal tubular reabsorption using transcebalamines and the proximal renal tubular megalin receptor, and the free cabalamine is also lost through, sorry, the free curbalamine can be lost through the urine, but you've got huge abilities to store B12. Hypercbauminemia is more frequently seen in dogs than cats.

The clinical significance is unknown. So normally when I see an elevated B12 and a blood test result, I don't have a particular concern about that. Let's talk a bit about laboratory testing.

So, in Australia, we have two major laboratories that I know of that measure, vitamin B12, and they both have slightly different reference ranges, but Gnostics and Australia runs per the Texas A&M guidelines. IDEX has says that it doesn't have an accredited B12 assay, but it does run them, and the reference ranges that they've established is 190 to 740 gigamoles per litre. The, you can see on that diagram there that there's, reference ranges there for IEX, for, Labcaburn, for Sin Lab, and, Texas A&M.

And each laboratory should be, referencing its own, sorry, having its own reference ranges. Vitamin B12 is actually quite a nice stable thing to measure, so it's stable even if it's not protected from light for up to 5 days, . It's just a serum sample, so you just collect it in, in, in Australia, it's in a red tube.

You can collect it at any time. It's not particularly affected by lipemia or homolysis, but ideally you do separate the serum if it's going to be hanging around for a couple of days, but it's not absolutely vital. In people, to to identify if you have a B12 deficiency, they measure two vitamin B12 levels over, over a two-week period, or they measure one low B12, and they also look for an intracellular indicator of B12 deficiency.

So that's where they measure homocysteine or methamyonic acid. And if they're elevated in the absence of renal failure, then they'll diagnose B12 deficiency. So it goes back to those diagrams that we have there of the, with the, Methionine synthase or the methamylany COA.

So the, if you have increased levels of MMA, or if you have increased levels of homocysteine, that reflects usually a B12 deficiency. So measuring homocysteine does help us to understand what level of B12 there is in the cells. Homocysteine, you can see if that is increased.

If there's no B12 from the thinine synthase, it's measured by gas chromatography in dogs, and there's some other assays that are available. It could, but unfortunately, it could also be elevated if there's renal insufficiency or hypothyroidism. Homocysteine itself is actually toxic to neurons, endothelium and DNA, so it actually has its own effects on the body as well.

There are some pretty specific breed reference ranges, and you need to separate the serum and the red cells. So if I was looking for a B12 deficiency, although homocysteine is available, I would prefer to measure MMA. And so MMA or methamyonic acid, is more frequently performed in our patients.

It can be done on serum or in blood. It's measured in urine as it's more stable. You just need to contact your laboratory that you might be sending the test to, as some require freezing.

Routine, in people is to use a comatography tandem mass spectrometry essay. It's a marker of cobalamine deficiency, as we talked about, and it correlates with ceballumum malabsorption, transport issues, or depleted stores. When you have low B12, it does correlate with high MMA.

You can sometimes get elevated MMA if there's renal insufficiency as we're talking about before. And supplementation is recommended if the MMA is high, so supplementation of BB12. So this diagram from a recent review paper by Kaier at all shows carbalamine status and homocysteine levels and MMA concentrations.

And so normally, if you have normal cabalainemia, all of those were within them then. Reference range. But as you start to get deficient in B12, your B12 level goes, goes below the reference interval, and in deficiency, it's undetectable.

And those cellular indicators start to increase. And I guess like the homocysteine and MNNA are helpful indicators if you have B12 deficiency, but, I guess when you look at this diagram again from KO at all, if you have normal B12, you're likely to have, sorry, if you have normal B12, you're likely to have normal MMA and homocysteine. So I would never measure, homocysteine on MMA and A dog that has a normal B12.

But as that B12 levels is dropping down, if you're, if you need to get confirmation as to whether your B12 is genuinely low, running an MMA or a homocysteine can just give you added confirmation that it is, genuinely from B12 deficiency. I think, you know, routinely, this isn't something that I would measure. I would measure B12, but I wouldn't necessarily routinely measure MMA or homocysteine.

I think it's just really important to know that these levels do increase when you get deficiency or hypercebauminemia, and they also have their subsequent effects on patients. So 63% of dogs that have undetectable B12 have increased MMA, which is consistent with a cellular deficiency. I why wouldn't all patients with B12 have an increased MMA?

It's suggesting that normal MMA might, be consistent with balamin as a co-factor bound to enzymes. There is a short half-life of MMA in the blood. There may be measurement errors.

So again, like, unless I I was really concerned, that I wasn't necessarily getting a real reflection of what was happening with B12, or if someone had maybe just supplemented B12 and I wanted to, I couldn't measure it in the blood, and, but I wanted to use an MMA or homocysteine to see what was happening intracellular. That might be a time that I would measure these two things. So, just so you know, supplementation can sometimes be indicated, even if the levels are normal, as you can see again from this diagram from Kaier at all, from 2020 JBIM, .

As some patients, will have just low end normal B12s, but they'll actually be showing indications of deficiency. So there's a paper from the vet Journal in 2012 that showed that 12% of dogs with chronic enteropathy had a normal B12, but a high MMA. 22% of dogs with a low normal B12 had a high MMA.

And so we do actually start to recommend supplementation in the lower end of their dose ranges to reduce MMA production or homocysteine that can still lead to toxicity and damage. So B12 isn't alone, isn't always sufficient enough just to diagnose or exclude B12 deficiency, but I really do think it's a good starting point. And I feel like MMA is particularly important if you're trying to work out how severe the deficiency is.

So this is a question out there for the audience, what are the potential clinical signs of hypocabalainemia? We've got failure to thrive, diarrhoea, anaemia, neutropenia, encephalopathy. Just letting people vote again, Amy, would you say that Dave is a, a world authority on on Locabalamin as well, cos he seemed to be very interested in your talk there before your cat.

Oh yeah. Did you see him? Yes, he looked very interested.

Yeah, Dave likes to come and talk with me sometimes. Dave's a talk. So let's have a look, we've got .

36% saying failure to thrive, 34% saying diarrhoea, 13% saying anaemia, neutropenia is 0%, and encephalopathy is 17%. We've just got a very big thunderstorm over us, so if I disappear, that's what's happened. But, so the, the main one seems to be failure to thrive and diarrhoea as what the, the, attendees have said.

Fantastic. Great work, guys. So now we'll, answer the question.

It's actually all of the above. So everyone got it right. So, presentation of of hypogbauminemia, can manifest in a wide range of clinical presentations.

So most patients will come in with, some form of gastrointestinal signs. Young dogs, especially dogs with congenital deficiencies, do present with failure to thrive. I actually saw a patient today at Border Collie with, some with what we think is B12 deficiency.

So the common gastrointestinal signs would include anorexia or dyspraxia, vomiting, diarrhoea, weight loss, oral laceration, dysphargia or glossitis. So that's actually more common in the congenital group than the chronic enteropathy group. And these clinical signs might not just be due to the primary gastrointestinal disease.

CBC abnormalities, would be consistent with blood disclosures, including non-regenerative anemias. Megaloblastic anaemia is something that's seen in people, but in dogs, they're typically normocidic and normochromic, unless they have chronic gastrointestinal signs that might lead to microcytosis. This is an image that I took from, MSD, and, this is from the Atlas of Clinical haematology, that shows a beautiful hyper-segmented neutrophil.

So basically, the nucleus is as full of blobs. And that's quite consistent with B12 deficiency. But a lot of patients that have, B12 deficiency actually also are immunodeficient.

Obviously you don't see that necessarily on a CBC, but they might present with some form of immunodeficiency, which is what I think was going on here with Bob. So Bob was a 9 month old border collie that presented to me for a referral for PUO or pyrexia of unknown origin, and diarrhoea. And he surprised me by actually having hypercobauminemia.

I wasn't necessarily expecting this. He presented with profound neutropenia, so his neutrophil count was 1 times 10 to the power of 9, and he had hyper-segmented neutrophils. He had a very mild thrombocytopenia, his platelet count was 150 to 10 of 9, our reference range was 200 to 500.

He was pyrexic, his temperature was 40.4, and it had been for days, despite having some in refloxacin given by his referring vet. He had blood cultures and urine cultures for, and both bacterial and fungal cultures were negative.

His urine faecal analysis was unremarkable, his abdominal ultrasound was unremarkable, his basal cortisol was robust. His bone marrow actually showed that he had dysmyelopoiesis. And you can see here, he's just a bit sad for himself, and his coach just doesn't quite have any lustre to it.

And when I compared his body size to some of the other dogs in the litter that I'd seen, he fit that failure to thrive sort of category. And, when we measured his B12, it was actually completely undetectable. I didn't measure his MMA, What I did do was I initially did give him some glucocorticoids, and I started B12 supplementation, and then I subsequently rapidly decreased my steroids and, continued him on B12 supplementation.

And he's currently doing well. He's, it's about 6 months down the track now. He's on daily oral B12 supplementation.

He's starting to eat better, he's brighter, his pyrexia is resolved, and he's living a happy life. And so hopefully he'll stay that way. This is another little kitty cat that surprised me.

So, presentation of hyperbalainemia can also lead to organic asidedemiass, which we talked briefly about before. And, you know, like, when I first heard the term organic asidedemia, I really didn't know what I was, going to be learning about, and I found it a bit scary. But these patients present with neurological signs, including encephalopathy and potentially seizures.

And so we, when we run our biochemistry or electrolytes, what you might notice is they might be a little bit ketotic. But, they can be normoglycaemic or even hypoglycaemic. And obviously that excludes diabetes mellitus, and it, you start to think, well, why would you, why would a cat have ketones?

Or even why would a dog have ketones? So obviously, dogs can get ketones if they're not eating. But they don't typically become hypoglycemic at that point unless there's, they're really unwell.

And so, this is such an opportunity to again measure the measure B12 and ammonia levels. And then, but if you have B12 deficiency and you measure the ammonia, which obviously needs to be done carefully, their ammonia levels are quite high. And that goes back to that diagram I showed you earlier of how carbonyl phosphate and the urea cycle inhibited when you get B12 deficiency.

So, this is Billy, who was a 6 month old male neutered British, British blue, sorry, and he presented with failure to thrive, diarrhoea and encephalopathy. He had mild hypoglycemia on his blood work, and initially my major differentials were portosystemic shunt, excessive insulin production, malnutrition. And then I thought, oh, he's young, I'll put inherited disorders of metabolism on my differential list, or severe gastrointestinal disease.

So I did a bile acid stim, and that returned normal. And in Australia, we quite routinely measure ammonia in-house at our hospital, and so I measured an ammonia, and that surprised me. It was above 100.

Which is, the reference range is 10 to 100. We excluded shunting on the basis of the abdominal imaging with a specialist, but he had a really small pancreas. And I subsequently measured his B12, and it was actually undetectable again, and I measured his MMA and that was high.

So then I measured his TLI, the trypsin, like immunoactivity, and that was undetectable. And he was subsequently diagnosed with an exocrine pancreatic insufficiency, reduced intrinsic factor, and subsequently hypocabainemia. So he's been on B12 injections weekly, dietary modification, and pancreatic supplementation, and as you can see on the picture on the right there, he's now doing incredibly well.

He's now 3 years old and living the best life. And has no longer got encephalopathic signs, which obviously delights his owners and delights me when I get to give him cuddles too. So let's talk about problems with B12 metabolism.

The 1st 3, the diet, digestion and absorption of B12 are the major problems that we see in our veterinary patients. As far as I'm aware, transport and intracellular mechanisms aren't necessarily things that we've identified as being abnormal in dogs or cats at this point in time. So as talking about before, B12 comes in through animal proteins through the diet, and we have very strict guidelines from ISCO in 2018, this is their recommendations.

For B12 supplementation that needs to be in diets for growth and reproduction and for adult maintenance. And then, these diets need to be formulated to be complete and balanced according to AFCO guidelines, and then, and B12 is often, needed, needing to be supplemented. If it's not stated on the label or maybe it's a boutique brand or a homemade diet that's not formulated by a nutritional specialist, you cannot guarantee that any ingredients meet the minimum requirement for B12.

B12 is an essential ingredient, as we talked about before. And it Even if it is supplemented in animals that get maldigestional absorption issues, they can still become deficient. These standards have been calculated with a margin of error due to processing loss that can be seen in some pet foods.

In the EU there are some slightly different guidelines, the FED IEF guidelines that pet food companies need to comply with. At this stage, I don't know of any brands that are deficient in B12, but if you wanted to confirm that you had a B12 deficiency from dietary intake, you just need to send the sample to the lab or call the company that produces the diet for analytics. So digestion of B12 is a little bit complicated.

You need gastric acid and Pepin, and intrinsic factor, and bile acid and pancreatic function to be, to work. And causes of hypercabalainemia and chronic enteropathies include B12 digestion issues, massive gastrectomy, not commonly performed in our patients, but something to be aware of. Chronic proton pump inhibitor use is something which I think we saw quite a lot, 5 years ago, and I, I think what people are being a little bit more aware of the effects that drugs like omeprazole, pantoprazole on a long-term basis can have on the microbiome.

So they really change your microbiome. It's not something that I'd recommend for long-term administration, unless you really had, like, a reflux syndrome. Exocrine pancreatic insufficiency, as we briefly mentioned before, but I'll talk about more in a minute, dysbiosis and gut bacterial imbalances and chronic enteropathies, which we'll talk about in a minute as well.

Oral antibacterial administration, including Tylain, was reported as a cause of digestion issues of B12 at ACBIM in 2019. And bile acid disorders can also lead to maabsorption of B12 potentially or maldigestion, sorry, of B12. So this is a dog that that I saw with EPI 82% of dogs with EPI have hypocabauminemia.

There's breed predispositions for EPI, German Shepherds, rough collies. It doesn't necessarily, like, the dogs can produce intrinsic factor from both the stomach and the pancreas, so it doesn't, it's not just the fact that they aren't producing enough intrinsic factor from the pancreas that results in. Not being able to digest and absorb their B12.

We think there might be a problem with digestive enzymes, reducing the release of curbalamine from Patoorin, or dysbiosis leading to changes in B12 production and utilisation by those bacteria, or compromise in the lymhosa due to the toxic metabolites, due to dysbiosis. So, It You really need to think about supplementing all dogs with EPI with B12. Low B12 is actually a negative prognostic indicator for dogs with EPI as was studied by Dan Batchelor in 202007.

So absorption, happens down predominantly at the ileum, using the intrinsic factor and the cublin receptor. Chronic ileal disease like inflammatory bowel disease or chronic inflammatory enteropathy, and alimentary lymphoma and chronic infectious diseases can potentially affect absorption, so can dysbiosis or gut bacterial imbalances and inherited diseases. Curbelaum malabsorption is predominantly seen in young dogs, with a failure to thrive, diarrhoea, they might have a mucosa ulcerations and glossitis as we were talking about before, and these are the dogs and the cats that often will have some form of ketoacidosis or hyperinominemia, plus or minus the hyperglycemia.

And on their CBCs, they might have, the segmented neutrophils and, and non-regenerative anaemia as well. When you see a young patient which has got these symptoms, we think about whether it could be a congenital disease process, and we start to think about whether there's a potential for B12 deficiency here. It was first acknowledged as a congenital disease process, as far as I'm aware, in, in the giants Schnauzer.

So a selective intestinal malabsorption of B12 was observed in a, colony of giant schnauzer dogs back in 1991. And they did the family studies and breeding experiments to show that it was autosomal recessive. Affected dogs had inappetence and failure to thrive, starting from 6 to 8 weeks of age.

The CBCs had the segmented neutrophils, anaemia, with some megaloplastic changes. They showed that they had methamyloic aciduria and homocystinemia. They're, B12, so obviously very low, undetectable.

And parenteral B12 actually eliminated all of the clinical signs of curbalamum deficiency. They looked into how this was, how, why was this happening in these dogs. So to determine what was going on, they gave some radioactive cyanocabalamine, with or without simultaneous oral administration of intrinsic factor or normal gastric juice and intrinsic factor.

They looked at transcabalaine assays, they looked at the ilealmorphology. And then they identified that there was a selective defect of carbalaine absorption at the level of the ileal enterocyte. An electron microscopy of ileal biopsies showed that there wasn't any intrinsic factor of cubalamine complex.

And this is when they identified the cublin receptor, abnormality, and they identified that this is actually a really, similar problem to what they see in people called Imalin-Glazebach syndrome. I hope I've said that right, which is seen in young children. And subsequent to that, multiple other breeds have been shown to have B12 deficiency from young ages, but as with any type of congenital disease process, the age of presentation can vary.

So in the Border Collie, the first paper describing B12 deficiency and hyper hyperonemic encephalopathy due to the B12 deficiency was written by Ian Battersby back in 2006. And it was subsequently further described by Lutz in 2012. This is something that I saw in the UK a few times, and I've seen in Australia a few times, .

And usually they're young, juvenile, border collies about 11 months of age, between 7 to 24 months of age. Sometimes they have increases in ALT and a bit of protein urea. If you measure homocysteine or MMA, they tend to be elevated, and you can obviously identify the B12 being severely deficient.

You do need to just make sure you've excluded EPI as well in these dogs, because that can sometimes occur in young ages as well. The dogs described in these papers, they do have full recovery, you know, all dogs that get parental B12 supplementation, and the laboratory abnormalities resolve as well. The one thing that doesn't, so there's two things that don't resolve, that's the proteinuria and the elevated AST.

And yes, there is a, a genetic test that you can do to look for this disease process in Border collies. Beagles also can develop this disease process, they can have undetectable carbalamine levels. Two dogs were described in JBIM in 2015.

Those dogs had elevated ALT. Interestingly, these are young dogs, 12 months of age, and they actually had ascites and indications of liver failure, and one dog ended up being euthanized from its liver failure fairly, fairly, quickly. The other dog, sorry, had a liver biopsy performed and then had some steroids because it had fibrosis of its liver and inflammation.

It had B12 supplementation as well, and it actually is doing well, at the time of they wrote it up 3 years afterwards. So some of these disease processes can be resolved if you identify them early and can manage them. And the fibrosis resolved and subsequent biopsies as well.

So cubulin receptor complex abnormalities have also been detected in Australian shepherds, and the Commodore dog, which is some sort of Hungarian, shepherd dog, I think, I've never seen one. Chinese Sharpei says it also, they also have this disease process. In the Chinese Shar Pei, the B12 deficiency isn't just due to a chronic enteropathy or mucinosis.

It's, it actually has a, genetic abnormality as well. They're just still trying to get a commercially viable assay from what I understand. They do tend to be autosomal recessive disease processes, and in the dogs that do have B12 deficiency, a juvenile form, they do tend to have persistent proteinuria.

So, chronic inflammatory enteropathy or CIE is actually the most common cause of hypercabauminemia that I tend to see. And in the Journal of Small Animal practise in 2013, a paper showed that there was very similar dogs that have low B12 levels and chronic enteropathies, with the staffy, the Sharpei, and the German Shepherds, all being the dogs, which are more frequently seen with B12 deficiency. They're also the ones that tend to have the chronic inflammatory enteropathy.

So, I think there's a, a paper there, in the writing. So let's talk about chronic inflammatory enteropathies. This is kind of like IBD.

Maybe IBD is getting a new term. I like the word, I like the term chronic inflammatory enteropathies, because I think it explains quite a lot of disease processes all in one. Chronic inflammatory entopathies is typically a patient that has had chronic diarrhoea or gastrointestinal signs for more than 3 weeks, where hypoadrenal corticism, EPI, and hepatic hepatobiliary disorders have been excluded.

They're typically associated with an interplay of genetics, dysbiosis, inflammatory dysregulation, and antigenic stimulation abnormalities. They can be food responsive, antibiotic responsive, immunosuppressant responsive, or non-responsive, and they can, they're all diagnosed retrospectively on their response to treatment. If you were to biopsy these dogs, they may not look particularly different.

There's no studies to demonstrate reduced cubulin receptors in the ilium in any any dog that's got chronic inflammatory enteropathy. The presence of hypocabauminemia in chronic enteropathy is between 19 and 38%. I think that's a pretty high number, so it's something that I measure routinely in my dogs with chronic inflammatory enteropathies or chronic enteropathies in general.

Given that B12, half life is 6 to 6 to 16 weeks, sometimes you do need to retest B12 in, some dogs that have got persistent gastrointestinal signs, or if they're non-responders to, the treatments that you've been prescribing. And these dogs may not actually respond to the treatment for that you're prescribing, like the diet or the, the steroids, or the cyclosporin, unless you actually do supplement the B12, because the B12 is so important for the regeneration of those enterocytes and the cell function. It's suspected that B12 deficiency contributes to mucosal inflammatory infiltration on its own right, and villous atrophy.

So, If there's one takeaway message from my talk today, it's, please measure a B12 in a dog that's got chronic gastrointestinal signs. So, the standard sort of workup for me for a dog with, chronic enteropathy is, to exclude Addison's, EPI, neoplasia, infectious agents. I check a B12, and I think about whether I'll eventually biopsy the ileum.

The ileal biopsies really should be collected routinely in dogs that have chronic gastrointestinal disease. Biopsies are helpful to differentiate the cause of the enteropathy, whether it be infectious or neoplastic. Hypercobouminemia correlates with the increased intraepithelial lymphocytes in the in the ileal mucosa, which is a key feature of inflammatory bowel disease.

Flow and par are sometimes used to differentiate from lymphoma, in particular in cats. In dogs, the frequency of hypocballuminemia in low grade alimentary lymphoma is actually 40 to 71%, so huge numbers. Obviously, low grade alimentary lymphoma isn't as common in dogs as in cats, but it, that's, that's a pretty startling statistic for me.

And in multicentric lymphoma, 16% of dogs actually had low B12 in a study from Cook in 2009, so, and it's associated with a poor outcome. So, again, B12 is important for the prognosis for these patients. In dogs with chronic inflammatory enteropathy, hypercurbauminemia is correlated with a negative outcome.

And sometimes that is the first paper by Es back in 2007 said that it was a negative outcome despite whether they were supplemented. But subsequently, another paper did suggest that actually they do succeed with treatment and they do very well if they have B12 supplementation. So it's, so it's all good, we're allowed to do it.

Hypergbalinemia also correlates with hypoalbuminemia in chronic inflammatory enteropathy, which is also a negative prognostic indicator. This is a cute little girl, Amy, who presented me with a protein losing enteropathy. Protein losing enteropathies are a severe manifestation, of in sometimes chronic chronic inflammatory enteropathies, but also potentially Addison's or pancreatitis, or neoplasia.

Dogs with PLE present with hypoprotemia, pan hypoprotemia, so both album and the globulins are low, low cholesterol, and you just need to check a urine protein or urine protein creatinine ratio to exclude, concurrent proteinuria, significant proteinuria. But you shouldn't get low globulins or low cholesterol in, dogs with PLN. You do need to think about biopsying, if sorry, if you need to think about biopsying the bowel, endoscopy is quite helpful in these cases because it can help to determine if there's altered lymphatic drainage and, changes in mucosal permeability, and you can help to diagnose what the underlying disease process is.

And then treat that at the same time. The prevalence of low B12 in dogs with non-infectious, non, cancerous PLE is 43 to 75%. So it's really important to check a B12 in these dogs.

And then obviously treat it. Dysbiosis is often a part of a chronic enteropathy. Competitions of cells and bacteria for carbalamin can lead to decreased B12 absorption.

Actoroides loves to compete for B12, which is why metronidazole sometimes helps in some dogs in with inflammatory bowel disease, or one of the many reasons. It also loves to increase the production of folate, so sometimes what you'll notice on a blood panel if you measure a B12 and a folate is a low B12 and a high folate. In my opinion, that's not a rationale for using antibacterials for chronic diarrhoea.

If we considered actually prescribing anti, so probiotics, I think that would be a better situation, because we might be able to actually establish a nice healthy microbiome. And I think we're going to hear a little bit later about a product which is quite exciting from my side of things, that can help with dysbiosis. Some of these patients, well, these patients do need to have B12 supplement supplemented if it's decreased.

And they, I think that it's a good opportunity to think about using probiotics, which, which, compete with the bad bacteria for, For the B12 potentially, and also to help create a more healthy gut bacterial balance. What about cats? So, cats with lymphoma, up to 78% have a low B12.

Chronic inflammatory enteropathy, 28 to 72% of dogs, cats have low B12. The circulating half-life of, of parental cyanocebalamine can be shorter in IBD in comparison to healthy cats. So another reason why we need, when we think about supplementing them, we need to supplement it fairly frequently early on, and we need to make sure we supplement it well.

Curbalamine deficiency correlates with elevated serum MMA, but there can also be a discordance in those assays. But, it surprisingly high numbers of cats with chronic inflammatory opathies have low B12s. Hyperthyroidism is another situation where we might also see low B12 in cats.

So in a study from Cook in 2011 of 76 hyperthyroid cats, sorry, it demonstrated the high prevalence of hyperbauminemia in moderate to severe hyperthyroidism in 76 cats, compared to the 100 geriatric e thyroid cats. Curbalamine concentrations in the hyperthyroid cats was lower than the control group. In addition, 41% of hyperthyroid cats had subnormal B12 concentrations compared compared to 25% of the controls.

So there was a correlation between the serum cabalamine and the T4 concentrations in the hyperthyroid cats, suggesting that hyperthyroidism directly or indirectly affects curbalamine uptake, excretion, or utilisation. So this has made me start to think about more, about measuring B12 in my hyperthyroid caps as well. So as I said before, at this stage, I'm not sure if there's any problems with, transcobalamine in dogs or cats.

And the same with the intracellular intracellular mechanisms. Obviously, there's intracellular abnormalities, but I don't know about intracellular mechanisms being abnormal. So, we've done our testing, we've identified a patient with low B12.

The good news is that treatment can be pretty easy. And restoration of normal carbalamine in hypercabalaine, dogs and cats, when treating the underlying disease, can be really effective and improve their quality of life. So, the supplementation protocols have have been discussed.

In 2012, RA produced a study of over, suggesting that dogs and cats needed to have over 4 weeks of, subcutaneous treatment in order for restoration of B12 levels. A more recent study from Kemp in 2017 showed that it takes 6 weeks to restore the numbers, but the effect is transient. So initial treatment protocols could be subcutaneous or now oral.

And let's think about a clinical scenario. So you've identified a dog which is chronic enteropathy, for example, and you've identified that the dog has a low B12 level. We've recommended injectable treatments.

And client one goes for it. Dog really likes coming into the veterinary clinic. Dog tolerates it really well.

And this is the protocol that we use at Sash. We use a 50, per kilo subcutaneously for 6 weeks, and then we give an additional dose one month later, and then we measure the B12 1 month after the last dose. I also don't mind if the client just says to me, I don't care what the B12 level is, I just want to keep on supplementing it, and then they can continue on.

But let's face it, like, if you don't need to continue to have injections, it's also a good thing to just do a measurement and see if you need to. Let's go to scenario 2 though, and client number 2 doesn't want to come in every single, every week for 6 weeks for subcutaneous injections. The dog might be really anxious, or the owner doesn't want to come into the clinic, or you might have COVID restrictions that suggest that your clients shouldn't be coming in as frequently as they are.

Is there an oral alternative? So when I was preparing for this talk, I actually found a really great RCBS knowledge review from 2019. There is little published evidence comparing oral and parenteral administration of curbalamine in dogs with chronic enteropathy, and protocols for the parental doses of carbalamine are based on expert opinion and clinical experience.

But Torresson in 2016, produced a really nice retrospective study based on medical review of some clinical records of dogs that they've been treating with oral cabalam, demonstrating that oral supplementation. Oral supplementation led to normocabainemia. The next study that they did showed that oral and parental supplementation of curbalamin resulted in decreased MMA concentrations.

And there wasn't a significant difference between the groups. So that was great. That was Taurus and in 2019.

Then oral and parental carbalamine supplementation now provides effective cellular carbalamine concentrations, and oral supplementation in dogs is an effective treatment option for hypercabauminemia in chronic enteropathies. We also know that giving cabalamine even at high dose dosages, doesn't lead to toxicity. So, after supplementing a dog with B12 deficiency, their appetite and well-being can improve to normal within 12 to 2012 to 48 hours.

You'll be the the best vet on the block. Haematological abnormalities can improve over 14 days. We can see weight gain within a few weeks.

We see improvement of urinary MMA within one week, but unfortunately, our patients may continue to have protein urea. So this is the protocol that we use at SAS. We use oral supplementation once daily for 12 weeks, and then we recheck 1 to 4 weeks after the last supplementation.

It's suspected that this sort of super saturation of the ilium with B12, it leads to a non-receptor mediated transport. It's also been documented that quite effective in beagles with inherited defects of metabolism, with ongoing supplementation. But you do need to just check the B12 after you finish your 12 weeks of supplementation, because some of the dogs with congenital deficiencies might actually need to have, ongoing supplementation or injectable supplementation, for example, if you haven't quite hit the mark.

But in the dogs with chronic inflammatory enteropathies or gastrointestinal disorders, we are treating the concurrent disease process, you should get control of the B12. So this is cabalazorb. In each capsule, it contains cyanocabalamine, some folic acid, some preflex probiotics, sorry, pre prebiotics, and an artificial chicken flavouring, which made me really happy when I found out that, so I can use it with my hypoallergenic diets, which I often use for managing my chronic inflammatory entropathies.

The dosing, is half a capsule per day or 1 capsule every other day for a small dog, medium size is 1 capsule daily or a large dog, one capsule twice daily, or 2 capsules per day. You do obviously need to treat the concurrent disease process and monitor that. And we do see that B12 supplementation restores the body stores within about 6 weeks, and at that point, B12 should be getting to above the reference ranges.

If you have a congenital disease process and the levels are still low, in particular, you may think about using hydroxycabalamine 1 milligramme intramuscularly, monthly or bi-monthly and have ongoing monitoring potentially of MMAs. So hypocabauminemia has been associated with a shorter survival time in dogs with diseases such as EPI, chronic chronic enteropathies, and multicentric lymphoma. The prognosis does largely depend on the management of the underlying disease resulting in the hypercballuminemia.

But treating dogs and cats with hypercabauminemia improves clinical condition and quality of life. In diseases with the potential for remission, the outcome's really favourable. So I'd really strongly encourage you to think about B12 in these patients.

So our final question for the night is, who plans on measuring a B12 in dogs or cats with chronic gastrointestinal diseases? You've convinced us, Amy. 99%.

There's a doubter in the room, but otherwise I'd love to know why the doubter doesn't want to do it. Maybe it's my colleague Joe White. Somebody's trying to wind you up, Amy.

Well, I want to know why. Well, that's great. Well done, everyone.

So, on my next slide here, I've got just some nice references. These were my favourite references when I was looking into B12. If you want to have a look at those, they're the key references.

I've got heaps more references. If you do want to have a look at them. And thank you so much for joining me for a talk about the guts of Kabbalaun, and thank you to ADM for having me tonight.

Amy, that was really splendid. I know Liam from ADM wants to talk to us a little bit about a couple of other things as well, so let's pass over to Liam. Before we do that, if, if people want to tell us where they're listening in from, I know a lot of people listening in from Australia and New Zealand, so tell us where about you're listening in from, and if you're listening in from other countries.

Then let us know where you're listening in from, but Liam, over to you and we'll just, we'll show that data afterwards. Yeah, hi, everybody. Good evening.

Thanks, Anthony, and, and firstly, thanks, Amy for a fantastic presentation. I'm not going to take a very long of your time at all, just 2 to 3 minutes to introduce you to ADM, have a very quick look at the products we've got on the market in Australia, and introduce you to our team as well. So ADM is the parent company of protecting Veterinary who are based in the UK.

In fact, you can see our, Manufacturing and warehouse facility there on a typically warm and sunny day in the southwest of the United Kingdom in Somerset. Our range of products has been on the market in the UK in one geyser another for about 2025 years. But we've only recently made it to Australia back in 2019, where the products are under the ADM brand rather than the protected veterinary brand, but they are the same products.

So you've heard about Kabalazor, but I'm not gonna go over that ground again. Again, thank you to Amy for introducing that product, to you. One thing I should mention is that if you've been to the UK or worked in Europe, or Hong Kong or Singapore, you might be familiar with Kabbalaplex, which is one of our products.

This is exactly the same product we had to tweak the name for the Australian market, but it's exactly the same. It was interesting to see the first poll there seeing, you know, relatively few of you routinely testing your chronic enteropathy cases for, for B12, and some of the feedback we've had is that one of the reasons for that is that the test is quite expensive right now in Australia. And I, I wanted to make you aware that we're working with Gribble's veterinary pathology, an Australian lab to try and bring the cost of this test down.

So Gribbles are working hard right now to validate the test in-house and offer a cost effective solution, which should be available in the coming weeks. So you can contact us or you can contact Gribbles directly for more information on that. The price of the test is much lower in the UK and Europe.

It's very routinely done. It's part of, GI panels that most of these labs offered, so. Yeah, it's pretty ubiquitous and I think that the vets and their their patients benefit from that, so that's hopefully something we can help with in Australia as well.

Another bit of news about Kabbalazor is that we have a study that's just finished. It's just being written up now, so I can't say too much, but I can share these visualisations with you. So it mirrors some of the work that Torresson did, looking at, oral or parenteral supplementation of B12 in dogs with chronic enteropathies, and you can see from these visualisations that supplementation with Kabbalahor daily as, as Amy described, was at least as effective as as injectable.

And that's in both increasing serum carbalamine concentration and reducing the clinical disease activity score. We also looked at palatability and how well each treatment was tolerated, and I, I don't have a visual visualisation for that but as you can imagine oral came out pretty well. We have another product that Amy alluded to there, which is Procholine Eerogenic.

So this is a powder in a sachet which is formulated to support the long-term gastrointestinal health of your patients. Oh sorry. And so that contains probiotics.

It contains a mixture of prebiotics, you know, to help rebalance any dysbiosis. We've got a mucoprotective, MPS Protects, which is a mucopolysaccharide that reinforces the intestinal mucin layer, so helping to build up that mucus layer in the gut and reduce any inflammation. We've got alpha glucan butyrogenic in there, which increases luminal butyrates.

We know that butyrate is a key energy source for the enterocytes. It's known to reduce inflammation, help, increase the mucus layer and promote mucosal regeneration as well. And we've got beta glucan, which enhances the phagocytosis of pathogens in the gut.

So support for the immune system and of course, the cyanocabalamine. So it's a great product for these patients which require long term gastrointestinal support. It's given once daily, we recommend you treat for at least 30 days because that's when you'll see the biggest increase in luminal butyrate concentration.

Completing our GI range, we've got procholine, which is our probiotic prebiotic kalin and pectin paste for acute GI disturbances. And we've got symbiotic DC which is a high concentration prone prebiotic capsule, which is supported by a large, in fact, we think it's the largest study ever done using probiotics in dogs, which was published in the Journal of Veterinary Internal Medicine. And our team who are present across Australia would, would love to introduce each of those products into that study as well.

And then finally, very quickly, the urinary products, we've got ayan, which is specifically targeted for feline urinary tract support. So we've got two, glycos amino glycan building blocks in there to help support the bladder lining and L tryptophan, to reduce anxiety, promote the production of serotonin, in the brain. And we've got Sister Pro, which is again, targeted, but this time for cats and dogs, but containing ingredients such as type Aparthocyanidin, so a high concentration cranberry extract, which is gonna have an anti-adhesion effect, in the urinary tract, as well as the glucosamine for bladder lining support and some probiotics and prebiotics in there as well.

So hopefully you've met one of our friendly, passionate and knowledgeable team members already, but be sure to contact them about the products, about lunch and learns on any of the range, or with any questions you've got after today as well. And with that, I'll leave you and pass back to Amy, I'm sure will be happy to take any questions. Thanks Liam, that was fantastic, er, great to see people listening in from all over er Australia and further afield, .

Vivian's in Melbourne. Arthur's in Albury Wodonga, I hope I'm saying these names OK. Sunshine Beach.

We've got somebody listening in from New Zealand, Noosa in Australia, Brisbane. Oh well that's nice. Southport, that's just up the road from us, but I think it's the, I think it's the Gold Coast one in in .

In Australia we've got one a couple of miles up the road from me in in Liverpool, and then Brisbane as well, Western Victoria, Orange, Australia, Bina. Sydney so people listening in Southern Highlands listening in from all over, from, from all over Australia, so that's great to see. And I think we do have a couple of questions, so I'll, I'll ask those, .

I think talking about the cat that we saw that was having the, the neurological problems, and Beth is asking, did this cat need B12 injections weekly, longer term. Yeah, good question. I, we did, we, we used monthly B12 injections for this cat.

We've continued it on injections at this point because, it was 3 years ago that we diagnosed this cat, with the EPI. So this cat's still on weekly, sorry, monthly injections, and the owner actually does those at home. That's fantastic.

A question from Xiao He saying can dogs with EPI be supplemented with oral vitamin B12, or does it need to be parental? I don't know of any studies that show, about oral B12 and EPI. Liam, do you know of any studies?

There was one study presented by Torres, and I'm not entirely sure if it was published or just presented as a poster, but she had a, a small number of dogs with EPI that all responded to oral supplementation, and we've used the products, in the UK for coming up to 4 years now, I think, and there's plenty of cases over here that have that have responded to oral. I was going to say, like, I do use oral, for these patients, and I'm more than happy with it. I just don't, didn't know that there was a paper, so that's great.

Somebody else has said, is Cabalazo readily available and can clients use other oral supplements, so that's one for you, Liam. Slightly depending on where you are, but yeah, Kabbalazorb is readily available in Australia and Kabbalaplex is readily available in in a number of other countries worldwide, so no need to use any other, any other supplements. Because it's all, was I right there, Liam, in saying that it has some of the supplementation within it.

It's not just B12, was it folic as well in there as well? Folic acid in there as well, yeah, because we, as Amy said, we know a lot of the hypercarbalaminemia are are low in folate as well, and, and the two vitamins are, you know, are linked in how they're metabolised. So we've, we've got folic acid in there and some prebiotic, again, because a lot of these.

A lot of the product, the products used a lot in in dogs with enteropathy, so. That's fantastic. Alison is saying are the changes in our red blood cells and white blood cell morphology in cats with low B12 the same as seen in dogs?

So that was a lovely photograph of that multi-segmented neutrophil, so. It was so pretty, wasn't it? I had to take this.

Yes, they are the same. You can get the same non-regenerative anemias, and you can get the same, segmented neutrophils and cats. I have to say, on a clinical standpoint, I think it's less frequently seen than the dogs with, with the segmented neutrophils, but you're definitely seen, it's very pretty when you do see them down the microscope.

They do look lovely. Somebody else has said, will you use long-term probiotic pre prebiotic for chronic enteropathy cases with or without hypochobinemia. Yes, good question.

So, would I use long-term prebiotics, probiotics? Yes, I would, in a dog with a chronic enteropathy, especially if they were responding to them. So, most of my interns and residents know that for me, probiotics and prebiotics should be used for more than 7 days, more than 2, more than 1 month.

I like using them for 3 months. I like seeing a response to them within a month. I don't expect to see instant changes with them in in a chronic disease process.

I want to see a slow improvement, and I also want my patient to like them as well. And I think that's one area where, the products from ADM, they're actually really palatable in my experience. So thanks to these guys for making a good product for us to actually use.

Brilliant, thanks Amy. Do you do a lot of testing of the bacteria, you know, in the gut, looking for things like Helicobacter as well and you know, do probiotics and prebiotics work in in those sort of situations alongside or or with or without antibiotics, what are your thoughts on that? Again, I might be a bit of a stickler on the Helicobacter side of things.

I'm not convinced of the role of Helicobacter as a pro-inflammatory organism in cats or dogs with, inflammatory enteropathies or gastroenteropathies. From my reading, I was just wasn't convinced that it was a primary agent. I do see that if I was to repeat the biopsy, sometimes that Helicobacter has gone away when I've actually treated the disease process, but it's so rare for us to rebiopsy or reassess a gastrointestinal tract when we've actually got good results, from the treatment.

So, we don't do a lot of other measurement of gastrointestinal bacterial loads in Australia, . Yeah, it's just not something that we can do. Liam mentioned how expensive B12 testing is, so, for us to measure those things, it would be challenging.

Yeah, great. Thanks, Amy. Steven has got a good question.

He's saying, if an animal has CIE or a disease process that doesn't improve in your 6 to 12 weeks of supplementation, but you measure serum B12 and it's normal, would you still need to continue to supplement B12? Yeah, I guess, Steven, if the dog has a norm or the cat has a normal B12 with your treatment, but the treatment wasn't, resulting in improvement in the dog, I don't see any harm in continuing with the B12, because if the inflammatory disease process continues, the B12 levels may actually start to drop again. And then the dog may become unwell, as a result of obviously the primary disease process and the fact that you have taken away the B12 supplementation.

So, I guess, I think my answer would be yes. OK, that's great. It's very interesting, the way I, I know Mike Willard has lectured for us on a number of occasions, and he often says, you know, what I told you 10 years ago was a lie.

And I think before we started this, I was talking about how vets when I was in college used to mix a bit of, the red stuff with a bit of white stuff, and I, you were, you were talking about your own dad, who's a vet as well. I don't know if he's on the webinar today, but . That.

It, well, I'm hoping he is. It's always interesting the way things go in cycles, isn't it? So it's fantastic to, to hear, I'm, I've really loved the the webinar today.

I know a lot of other people have done as well. I think even Tom, is it Dave? Dave the cat I think has enjoyed it as well, although I'm, I'm not sure if he's still in the room.

Has he slinked off now or is he still listening? I think he's off having cuddles, with bored with the questions perhaps. So, it, it's great to see that he was entertained.

The problem with webinars is that, of course you don't hear the tumultuous applause, but there's lots of people saying nice things about how much they've enjoyed the webinar. We've also got . An Australian that I know quite well, has, has gone back to, to Australia.

I think Lee Danks is there, so he's saying, Amy, apologies for missing the start of your talk. Terrible, Lee. But can you give advice on preventative supplementation, would set the populations of dogs or cats not showing clinical signs, benefit or is it contraindicated for any reason to give B12?

I, I think. We've answered that question. B12 is, it's always good, a little shot of B12, isn't it?

Yeah, look, I think, you're not going to cause harm by giving B12 supplements, but I think if you've got the patient on a diet that's, that's appropriate, that's like AFO guide, that meets the B12 guidelines through AFO. Guidelines, then, if the dog or cat doesn't have any reason to be getting B12 deficiency, I probably wouldn't add in B12 supplements. But at the same point in time, I swear I have some clients that come in and they're just like, I just want my cat to have a B12 injection, because it always gives it a zing.

And I've measured B12, and it's normal, and I, there's no reason for the cat or dog to have B12 deficiency, and they still think the cats get a great zing out of B12. So it's like, OK, it's not going to cause you any harm. Fantastic, and I'm sure your dad would agree with that as well, wouldn't he, Amy?

He certainly would. Well, listen again, Amy, thank you so much. We've got Elizabeth here saying thank you so much, really great information.

Loads of people have enjoyed it. Of course this wouldn't have been possible without the sponsorship of ADM, so thank you, Liam, and ADM for for making it possible and hopefully Amy, looking forward to seeing you on another webinar very soon. That was really splendid.

I enjoyed it and as I say, a lot of other people did as well, so thanks again and good evening. Thank you for having me. Take care, thanks Amy, thanks, Liam, take care.

Bye now, bye bye.