Welcome to the next webinar in our COVID-19 series which has been produced by virtual veterinary specialists. So I'm Stephanie Sorrell and I'm one of the internal medicine consultants for virtual Veterinary Specialist. And during this webinar, we're going to focus on when is weight loss and emergency.
One of the important things that we need to look at is the RCVS guidance for clinical practise during this COVID-19 pandemic. And this is really important, particularly as the RCVS is our governing body. So this flow chart is really helpful.
And ideally we should have this somewhere visibly available in all of the practises so that we can look at each case individually, go through the flow chart and see whether it is actually required to do an actual consultation or not. So the first thing we look at is, is it important for maintenance of the food chain? So obviously in the small animal setting, we tend to just ignore that, that's more for large animals.
The next thing is, is it an emergency? Can we effectively support the case remotely in the first instance? Can you effectively support the case while maintaining social distance, and this is both for your team as well as the public.
And could the planned intervention have animal health and welfare or public health implications if not carried out within 2 months? I think one of the important things to realise is that we don't know how long this pandemic is going to go on for. But at the moment, the RCVS and the BVA have both put in provisional 2 month guidelines.
So when looking at this, we need to think in the next 8 weeks, are we going to have a significant deterioration or not? And always do a risk assessment for each case. The onus, as always, is still on the individual vet to decide whether to see the animal at the practise and whether to treat the animal.
BVA have also come up with some COVID-19 guidelines. So an emergency by them is defined as something which is immediate threat to life, something which has a significant impact on the health or welfare and likely to deteriorate if left unmanaged. So if we look back at normal circumstances, these are cases that we would be seen out of hours or fitted in on the same day.
We also have to look though for urgent cases, and the BVA to find urgent cases are those which have significant impact on health, welfare but are currently stable, or moderate impact but significant risk of deterioration. And I think particularly these urgent cases are ones that we need to look at because we can't keep postponing cases indefinitely while we don't know how long the lockdown and restrictions are going to be going on for. So when looking at weight loss, it's a really nonspecific sign.
So I would say that, you know, weight loss on its own is not going to be an emergency. So what we really need to look at is other concurrent signs that are going along with it. With weight loss, it can be due to so many different things, so it can be due to endocrine disease, so hyperthyroidism or diabetes.
It can be due to gastrointestinal disease, whether that's inflammatory, infectious, or neoplastic. It can be due to hepatic disease, renal disease, neurological disease, neoplastic disease, or cardiac disease. One of the things that can help to define what is causing the weight loss is also to look at the appetite.
Because the appetite can definitely try and subdivide into different groups as to what is the underlying cause. So if we have an animal which has a normal or increased appetite, our most likely differentials are gonna be hyperthyroidism if it's an older cat, diabetes mellitus, gastrointestinal disease, or protein losing enteropathy. On the other hand, if we have a patient that is losing weight but has a decreased appetite, the things that we're going to be looking at are more like gastrointestinal disease, respiratory disease, systemic disease like renal or hepatic disease, oral disease, pain, apathetic hyperthyroidism, and neurological disease.
So apathetic hyperthyroidism doesn't occur very commonly, but in these scenarios, instead of the cats being very active and eaten a lot, they actually go to being anorexic. And these cases, I would say are more of an emergency to treat, albeit they are quite rare. When looking at weight loss, a physical exam can give us a lot of information.
But what we need to realise is during the COVID-19 pandemic, we are limiting the amount that we are seeing our clients so that we can maintain social distancing. So as always, a comprehensive history is absolutely essential. And it could also be helpful to have some key questions already written down.
And we can go through those on the next slides. What we're all getting used to during this pandemic is also utilising phone and video consultations. They can be a bit tricky to get used to at the beginning, but as we get a bit better with them, we can always examine the patient together.
So we can record the respiratory rate together with the owner, we can monitor the demeanour, and we can look at the mucous membranes. Obviously, we can't do as much as we'd like. We can't aultate the heart or the chest.
We can't feel in the abdomen. We can't assess ourselves for signs of pain, so it's not always an ideal scenario. But by having kind of a history which is very comprehensive and very thorough combined with some examination with the owner, we can then decide, are we able to see the patient or not.
So we need to physically decide whether we physically see it in the practise. So when looking at weight loss, I think one of the important things that I said is to have a really, really detailed history. So this is something that can always be sent to the owners in advance, they fill it out as a questionnaire, or you can go through it with the owners as well.
So what we want to know is, what is the pet's appetite like? Is this a dog or a cat that's usually quite fussy? Or is it a dog that's a Labrador and usually eats like a Labrador and it's completely off its food and therefore we know this is definitely something that's going wrong.
Is there any vomiting or diarrhoea, cos that can definitely help narrow down our differentials. And as horrible as it may seem, it might also be helpful to actually get pictures. So actually getting pictures of the vomitous or the diarrhoea that's being produced can be helpful because owners won't really understand, for example, what Melina looks like or if there's flecks of digestive blood in the vomit.
So we can ask some specific questions like, were there coffee granules or was there black faeces and things like that, but sometimes just having an image can give us a bit more information. The other thing, looking at the diarrhoea a bit more specifically, like if there's mucus or if there's lots of water, or if there's tinesmus, or, you know, things like that, we can kind of define and see, is this more likely to be a small intestinal problem or large intestinal problem. So there's a lot that we can really garner just by getting a really good history.
The other thing that can be important is, is there any change in the demeanour? So if we have a otherwise very happy dog that's having intermittent vomiting or diarrhoea, we'd probably be happier remotely managing that than a dog that is really lethargic and really withdrawn. So any changes in demeanour are particularly important.
We also want to try and rule out that we haven't got any signs of the animal having any neurological signs. So particularly with that, we want to make sure that there's no kind of behavioural changes or anything like that at all. So when we're looking at patients with an increased appetite, we've got a few differentials that we can look at.
So we've got hyperthyroidism, diabetes, gastrointestinal disease, whether that is going to be small cell lymphoma or inflammatory bowel disease, and we can also see that with pancreatic disease such as EPI. And quite commonly, as we know, with all of these diseases, I suppose apart from diabetes, we can also get some gastrointestinal signs as well. As I said, with these cases, we always want to ask if there's any changes in the demeanour, but also if there's any information regarding any vomiting or diarrhoea and any nature of the signs present, so particularly if there's any blood present.
Whether that be fresh blood or digestive blood, and the owners may need a bit of help identifying this. So if we've got a pet that's otherwise pretty happy and is otherwise doing well, we probably don't need to see that case, but we do need to keep monitoring. And by that, what we can do is either over the phone or video consult, potentially with the owners and with a nurse, then in those scenarios, we could just have them weekly weighed, and then to get a chart to try and see where we're going and see if this is an ongoing trend or not.
And also look at this in combination with any other signs. Definitely asking the owners to drop off a urine sample can be really helpful, because one of the cases which would potentially lead into something which is more urgent or an emergency would be diabetes mellitus. So in these scenarios, we want to make sure that these patients are treated as effectively as possible, because what we know can happen is these can tip into diabetic ketoacidosis.
And that is definitely an emergency scenario which we'd like to avoid at all costs. If there's any signs of hematochezia. So like fresh blood in the poo, Melina, so where we've got digestive blood in the poo, or hemata emesis where we've got blood in the vomit, that's definitely gonna be much more urgent.
And I think for those, I would definitely recommend that we do see those cases. As we said, it's always important to assess the individual patient. So if we go back to the RCVS guidelines, we can then try and look at the two scenarios.
So we've got a 1 year old shih-tzu, which the owner rings up and says, really happy in herself, but she's had a little bit of weight loss, so unsure how much, and she's also had some intermittent vomiting and some diarrhoea. So the owners report that she's vomiting some bile, occasionally with some food, and she's got some soft faeces compared to normal. So they started weighing her.
So they've got a baseline for now, but aren't quite sure exactly what she was. So you can tell them what she was at her booster six months ago. So by that we can garner that she's lost about 500 grammes of weight.
Speaking a little bit more closely, we can garner that. The patient is fully up to date with all parasite control. There's been no change in appetite, no change in demeanour, no coughing, no PUPD and no other signs.
And the owner, as I said, has said that this patient is otherwise very happy in herself. So when we're looking at this, is this an emergency? No, it's not.
Is this something that can be managed remotely? And I think in the first instance, yes, as long as we've got a really good owner who is going to be on the ball and call us if there's any concerns, and we can follow up, I think I'd be quite happy in this scenario to suggest to the owners some things that we could do. So when a younger animal, things like a food responsive enteropathy are going to be relatively common.
So obviously in this ideal gold standard scenario, we'd want to do bloods. We'd want to rule out renal disease, liver disease, potentially even things like Addison's. But in this case, you know, this dog doesn't have any PUPD.
It's otherwise happy and it's clinical signs are quite mild. So I think it could be perfectly viable in this scenario to suggest that we go on to a diet change. So we could try on something like a hypoallergenic, like a raw cannon an allergenic or Purina HA or Hills ZD.
And we could also potentially, if the diarrhoea was getting problematic for the owner, think about a metronidazole trial which we can focus on as well. And I think with this one, what's really important is to have a follow up conversation. So we can follow up with a video consult in a week, see how the patient is doing, see if there's any improvements or anything after that, and also see what the weight is doing.
So if we're getting ones which are gonna be much, you know, if the patient has progressed and it's getting, more severely affected or getting more clinical signs, then I think at that stage it would warrant physically seeing the case. If on the other hand, an owner rings up and says that they've got an elderly staffy, so in this scenario you've got a 10 year old Stafford Gibr terrier. She's lost weight and the owners think it's up to about 2 kg.
But more importantly, they've noticed that she's been vomiting blood for the past week, and she's also got a reduced appetite. On further questioning, she's also more lethargic than normal, and she's not as interactive. And in this scenario, is this an emergency?
And I think when you've got a 2 kg weight loss, you've also got a patient that's vomiting blood. I definitely would say that this is something I would put into the urgent slash emergency scenarios. And it is going to be quite difficult just over the phone to try and get to the underlying causes.
And I think with this case, I definitely would recommend that we see the patient. We do bloods, and ideally do abdominal imaging if finances allow, and that's something that you can do. Cause what we do know is particularly in this breed and in this age, we could be more prone to getting things like gastric neoplasia.
So things like a gastric adenocarcinoma would be high up on the list. And that's something that is definitely wanting to be aware of because although treatment unfortunately is quite limited, this is gonna have severe implications on the quality of life of this pet. So it's important that we can get a diagnosis and try and institute treatment as quickly as possible.
And I think leaving this case just on, you know, a week's trial of, for example, omeprazole probably isn't in the patient's best interests. If we do need to see a patient, we do need to take some things into consideration. So, as I said, ideally we're going to get a really full history prior to seeing the case.
We want to check if any one in the household is symptomatic and make sure, particularly if they are, they do not visit you in the practise. We ideally want all owners not to physically come into the practise in itself. So we want the owners to stay in the car with a patient taken into the hospital via a nurse or via a vet.
We can then do a thorough physical examination of the patient. We can come up with a plan and decide what we think needs to be done, and we can email the consent form to the owner. We can have a phone and video consult with the owner to discuss possible investigations in the plan and make sure they're happy.
And in some scenarios, you might want to consider keeping the patient in for monitoring. And particularly in this, it could mean that in this scenario, then the we aren't having to and fro. So in these cases, we could then have the patient being with us, make sure it's improving before we send it back to its home environment.
So if you've got a patient with weight loss, with normal to increased appetite, and no mild signs of vomiting and diarrhoea, I said in the first instance, you could probably manage this remotely. So we could do a video consultation with the owner. And I think it's always important to be honest and say in a gold standard scenario, yes, we'd probably want to do bloods, we'd want to do a physical exam, but as long as the patient is otherwise happy, the signs are mild, and we will monitor it closely, we could do a treatment trial.
So in this scenario, there are some medications that we could consider doing. So we could consider having a mropotin trial to see whether that resolves the vomiting. We could also have omeprazole, as well as a trial, which could be considered, and we could also have metronidazole.
As well as a diet trial. So I think in these scenarios, a diet trial is something that I would definitely consider in these cases. So, particularly because they've got that normal to increased appetite, hopefully introducing a new diet, so a hypoallergenic diet like Pria HA Hill ZD or Royal Canon allergenic would be absolutely ideal.
The Meropotent and the metronizole and omeprazole, I think will depend on each case. So particularly if the diarrhoea, it might be mild but it's more bothersome for the owner, then trying metronidazole would definitely be considered, whereas if vomiting is more of an issue or nausea than mropotent. And omeprazole could also be considered as well if there's any concerns about GI erosions or ulceration or anything like that.
But one thing we do need to realise with omeprazole is that that in itself can cause diarrhoea. What we want to do is then have a phone consultation or a video consultation with the owner, ideally a few days later or potentially a week later, and that can make sure that the owners are feeling supported, but also you as a vet can check that you're happy with the progress. So if we're looking at a scenario where we've got weight loss, the patient still has a normal but increased or increased appetite.
But in this scenario we have moderate to severe vomiting or diarrhoea with hematocheziamata emesis. I definitely would consider that to be urgent. And I think in this scenario I would want to see the patient.
I'd want to check the hydration status, do a really good physical exam, and see whether I could potentially feel any abnormalities within the abdomen. I definitely think in this scenario, it would be worthwhile doing further investigations. So in most practises we can do haematology and serum biochemistry in-house, and we probably need to send off for other things like folate, balamine or TLI.
The other thing that I probably would recommend if finances allow, and if you're happy in your practise to do that, would be to have an abdominal ultrasound. So when looking at cases with weight loss and increased appetite, after investigations we can help to narrow down differentials. So if your abdominal ultrasound is unremarkable, then IBD is gonna be the most likely.
Biopsies are required of a definitive diagnosis, but we need to consider whether that's really appropriate during the current restrictions. With abdominal ultrasound, we want to try and rule out foreign bodies and neoplasia. We also want to look at the wall thickness, and we also want to look at the wall layering as well.
So on this one, we can actually help you quite significantly with this. So with member practises, specialists can live guide vets whilst they scan the abdomen, and we can see the scan with you at the same time. We can also see you as the vet, holding the probe and therefore can advise on positioning the probe to get better pictures.
We can also assist with taking measurements and interpreting whether these are normal or abnormal. So in this scenario, things like gastrointestinal tract or layering or thickness. Nor member practises can still send still images of ultrasound scans for help with interpretation.
We also provide multidisciplinary help for cases. So in a lot of these scenarios, our diagnostic imaging specialist will be helping to live guide vets through the scan. She can then advise on the abdominal ultrasound findings and together with a medicine specialist we can advise on the overall case management and treatment options.
And in some cases, specialist input can be required several times over the course of investigation and management. So I said in an ideal scenario to try and get a definitive diagnosis for inflammatory bowel disease and to rule out other things like lymphaectasia or neoplasia, we'd need to do endoscopy or potentially surgery. So endoscopy is gonna be really useful if there's something in the stomach or in the duodenum or in the colon.
And it should be considered in cases which are refractory to medical management. So by that I mean where they don't have response to diet trial and don't have response to metronides or trial. Cases where we feel that there could be neoplasia.
So in the locations where we can actually get the scope, so to the stomach, duodenum or colon. By having an endoscope and taking biopsies, it can give us a definitive answer in these cases. In addition, in cases with severe hyperalbinemia, so for that I would class it as an album in less than 15, endoscopy can also be really helpful because in these cases often we want to start them on immunosuppressive therapy.
But what we want to make sure is that we haven't missed anything, for example, Neoplasia. And in this scenario, having an endoscopy would be ideal. But I think it's always important with owners to say this is a gold standard, but is this appropriate for your case and is it appropriate in these current restrictions?
So the problem with doing endoscopy is we need to see is it essential. So if you've had an ultrasound scan which you were happy with, where there are no abnormalities seen on the scan, it's much less likely to have neoplasia than it is to have inflammatory bowel disease. So will endoscopy actually change the management for that case?
No, it won't. The other problem is during the restrictions, is that we need at least 3 people for the endoscopy. And it is gonna be virtually impossible to maintain the 2 metre social distancing rule within your team.
So if we think even just about intubating the patient for the anaesthetic, you're gonna have people that are quite close to each other where one holds the animal's mouth open so that you can intubate it. You then need to have someone monitoring the anaesthetic, someone doing the actual endo endoscopy, and someone also taking the biopsies. And the person taking the biopsies is gonna be standing very close to the person doing the endoscopy.
So in these scenarios, particularly now, we do need to consider whether endoscopy is actually vital. The other thing to consider is that it does utilise oxygen and this may be required by the NHS. So we do need to think very carefully about the cases that we are anaesthetizing.
So I have put a link here about oxygen conservation, which is a really helpful guide. So I would recommend anybody that's still doing surgery and things at this time to have a look at how we can try and conserve oxygen in the best possible way. The other thing that we always need to think about is that with endoscopy, even in cases where it is deemed ideal and gold standard, it's not always the option.
So, for example, your practise may not offer endoscopy, and that's quite common in a lot of first opinion practises. Owners might not want to make a longer journey to referral, centres, and there might also be financial constraints. So particularly in these scenarios, it can be quite expensive to do endoscopy and owners may prefer to spend that money on treatment.
So in these cases, in particular, by consulting with a medicine specialist, we can help advise you. And in this scenario, there may be nothing to lose by trialling medical therapies, including immunosuppressants, if we feel those are going to be required. But what's always important is that the client is fully aware that it's not the gold standard, but it's something that is a valid option to try.
One of the important things to always make owners aware of is once we start immunosuppressive therapies, it's gonna be very difficult for us to get a definitive answer if the patient doesn't improve. So when we're looking at cases with suspected inflammatory bowel disease, I said the first line is gonna be diet trial. So in dogs, the hypoallergenic diets that I always consider are Purina HA Hill ZD, or raw canning and allergenic.
In cats, we can consider purina HA, Hill ZD or Dequapecific feline allergen Management plus. The other thing that we consider is a metronidazole trial. And really in this scenario, we're not using metronidazole so much as an antibiotic, but we're using it for its immunomodulatory effects.
So we use it as a lower dose than we would if we were using it as an antibiotic. So, we use it at 10 mg per gig, twice a day orally. I have to say that I do find with cats, I often miss the step of metronidazole trial.
It's not very palatable, and the cats can find it really distasteful. And I think with this, it can often just affect their quality of life if the owners are trying to medicate them twice a day, and there's a lot of resistance against it. So in cats, I tend to try a diet trial and if that fails, I'd go to a steroid trial.
We always need to consider as well carbalamine supplementation. So the enterocytes definitely need B12 for normal health and normal growth. So if our patients are hypocabalamic, they do need to have carbalamine supplementation.
And there's two ways we can supplement that. So historically, we only really had the subcutaneous route where we injected carbalamine. Over a 6 week period, so once a week for 6 weeks, then usually 1 month after that, and then we tested the B12 in the serum again to see if we needed to have further management.
Fortunately nowadays we now have Kabbalaplex, so this is an oral cabalamine that's given for 12 weeks, and I think definitely given the current restrictions that would be my go to. Cause we don't want the patients and the owners travelling unnecessarily and coming in every week for an injection when we do have an oral alternative. The other thing that we can consider is if we've got a patient where the diet isn't working, metronide isn't working, or one which is more severely affected and we think that steroids are going to be required, then we can consider having a steroid trial.
As discussed, we would want to ideally have a definitive diagnosis, but there's many reasons, whether they be financial or you know, not having the availability in-house and owners not wanting to refer. And also given the current restrictions that this may be less appropriate. So as long as the owners are fully informed, there is there can be no problem in most cases of starting steroids.
And generally for dogs, I'd start at 2 migs per kg, orally once a day or in divided doses. For cats, you can go much higher, so looking at 2 to 4 migs per kg, once a day or in divided doses. So for suspected feline small cell lymphoma, the survival is comparable to severe IBD with a median survival of about 2 years.
So just like with inflammatory bowel disease, dietary management is really important, and any of the previous hydrolysed diets will be absolutely fine. Carbalamine supplementation as well is also essential if they're hypercabalinemic. So again, I'd consider cabalaplex particularly given the restrictions.
But in this scenario, as well as steroids, we'd also want to give chloramacil. So the steroids are gonna be at a slightly higher dose for cats, so 2 to 4 mg per kg, once a day or in divided doses. And for chloramacil we give 2 mgs, which is the total dose, every 48 hours if the ped is more than 4 kg, or every 72 hours if it's less than 4 kg.
We do want to have haematology as a baseline, then every month for 3 months and then every 2 months thereafter due to the risk of bone marrow suppression. So in this scenario, we can see anaemia and neutropenia which can be severe, but they are reversible. Given the current restrictions, I still think that the blood sampling is gonna be crucial, but what we could try and do is wean out the extended periods.
So instead of doing it every month, consider every 6 to 7 weeks and hopefully then we will be out of the restrictions. If, for example, though, we do see on the 6 week blood check that we are developing a mild anaemia or anything like that, you do need to recheck the bloods at the 4 week point rather than eking it out every 6 to 7 weeks. Because it's really important in these scenarios that we pick up if there is any significant bone marrow suppression, because this will be reversible.
So in some cases, we are going to be considering treatment for a protein losing enteropathy. And this can be due to inflammatory bowel disease, lymphaectasia, or neoplasia. So in these cases, they can have very similar clinical signs, so potentially with the vomiting and diarrhoea and everything, but they will also be having a low albumin.
And in these scenarios, we do need to treat them a bit more aggressively. So while diet and metronidazole and carbalamine is really important, we usually do need to add in steroids and potentially even a second immunosuppressive agent to get good control. So when looking at the 2nd immunosuppressive agents, there aren't a lot of information about which ones are better.
Generally though, my go to would be cyclosporin or chlorambucil. Azathioprine can also be used, but we do need to be aware of its potential side effects with hepatopathies as well as bone marrow suppression. The other thing that we also need to think about is, in these patients with the protein losing enteropathy, one of the proteins that they lose is antithrombin 3.
So they are at an increased risk of getting thrombinbolic disease. So aspirin is absolutely essential for these cases and is dosed at 0.5 mg per kg twice a day.
So EPI is a relatively rare diagnosis, and I have to say in most cases they'll have quite a chronic history. So a lot of these cases won't be deemed absolutely essential, but if we do have cases which have severe weight loss and severe diarrhoea, then obviously we would need to consider investigating and treating. So carbalamine supplementation will be required as well as pancreatic enzyme supplementation.
And it's really important that it's given with each meal for it to be fully effective. So hyperthyroidism is something that we may diagnose in our patients during the COVID-19 restrictions. So in most cases, cats with hyperthyroidism are going to be relatively mildly effective.
So in most cases, I think we aren't going to be seeing anything significant until after the restrictions. But in some cases, cats can lose quite a lot of weight, and they may have quite severe gastrointestinal diseases. So in these cases where we deemed it appropriate to have a physical consultation with the owners and then subsequent blood work and diagnosed hyperthyroidism, I do think in those scenarios it would be worthwhile treating.
It's always important to get a baseline haematology and biochemistry prior to starting. And that's really important because treatment can cause abnormalities, but they are rare. So the things that we can see are things like neutropenia, thrombocytopenia, hemolytic anaemia and agranulocytosis.
But all of them are documented in very few cases. One thing that we do know is that they usually occur within the 1st 3 months of treatment, and that's why we do relatively robust monitoring at the early stages. The other thing that we know is that we can unmask renal disease once u thyroidism is achieved.
So that's why it's important to have a baseline biochemistry and then repeat blood work after. What we need to try and consider is are we going to be monitoring them as effectively during the COVID-19 restrictions? So definitely having remote consultations are gonna be really helpful.
So with a remote consultation, we can try and gauge from the owner, has there been weight gain and hopefully they can physically weigh the patient as well. Has the appetite normalised? Have we got normal demeanour?
Is there reduced vomiting or diarrhoea? Is there normalisation, thirst and urination for any cases that a PUPD? So just having the over telephone and video consultation will give us a lot of information.
Some of the more severe things that we can see like hepatopathies, facial prurituss, severe vomiting, or anorexia. Again, we can also garner a lot of information by video consult. So we can always ask the owners to look at the mucous membranes with you and make sure that they're not icic.
We can obviously ask if there's any worsening of vomiting or any change in the appetite. And we, the owners will also inform us if there's any facial pruritus. A couple of the things though that we can't really assess remotely is, have we got iatrogenic hypothyroidism?
And that's only really problematic if the patient is concurrently aotemic, because we know in that scenario, the survival is worse. So really in those cases you would want to reduce the amount of thyroid medication you've been given. In addition, with remote consultation, we aren't going to be able to fully assess any haematological abnormalities.
So really we need to decide on a risk assessment basis, whether it is worth us actually monitoring these cases. And I think with these ones, we do need to always discuss with the owners that doing remote monitoring, we can actually manage quite a lot of the cases this way, but we won't be able to pick up every single abnormality, for example, the haematological abnormalities. So in these scenarios, it may be that we just have to have as much information as we can garner from the video consult and providing the patient is still happy and well, we might wait to do bloods until the restrictions are lifted.
Another scenario could be that instead of following the strict guidelines as per the data sheet, we could just consider a blood test in like 6 or 7 weeks. If we diagnose a new diabetic case, then we definitely need to consider urgent management, because in this scenario, we want to prevent DKA. So I do think in these cases that you see, ideally we'd always want to get a urine sample as well because occult UTIs can be common.
For dogs, I generally always start on peninsulin. For cats, in an ideal scenario, I would start on PZI, but it should be noted that there's a temporary manufacturing issue and shortage of PZI. So if you have a newly diabetic, cat, it is worthwhile ringing Boringer to see whether the, supply issue is still a problem, because if there is, we'll need to consider another insulin such as caneninsulin.
So generally, I would start at 0.25 of a unit per kg twice a day if the blood glucose is less than 20 or 1/2 a unit per kg twice a day if the blood glucose is more than 20. So I think with having a newly diabetic patient, it's really important that we give the owners as much support as possible.
So having a diabetic patient can definitely be quite intimidating for owners. So giving them quite a lot of online videos and things to have a look at can assist with instructing owners on how to inject the insulin. So this is a link to a YouTube video which has been published by International Society of Feline Medicine, so ISFM which looks at how to actually give your patient insulin effectively.
We can also consider using video conferencing to monitor the owners given in the injections, so that they feel supported and we're happy that they are effectively given the medication. The peninsulin website also has some really useful owner advice that can be really helpful. We don't want to scare owners about the diagnosis, but we do want to warn them.
So we want to warn them about hypoglycemia and give them guidelines to, for example, put honey on the mucous membranes if they notice any signs, and also warn them of signs about DKA, so particularly in appetences, lethargy, vomiting, and diarrhoea. So as we know with diabetes, monitoring is absolutely essential. But I do think that it's worthwhile considering during these COVID-19 restrictions, we're not gonna be able to monitor our patients as effectively as we would have liked.
So having a diabetic patient, what we do know is that blood glucose curves are gonna be the most informative. So if owners are able to do the monitoring at home, which hopefully they will be, particularly with most owners working from home now, once they purchase a glucometer, it's something that can be quite easily done. We can go through it with them on video conferencing to help with any troubleshooting.
And again, there are videos produced by ISFM about how to do ear pricks and take samples. So we can provide the owners with all the necessary equipment, and they can start doing the blood glucose curves for us. And that, in combination with the history, can provide us with all the information that we do need to have.
Owners can then email you the blood glucose curves. I think what's really important with blood glucose curves is we don't want to perform them more than every 1 to 2 weeks. It's always essential to interpret the information with what's happening clinically.
So we want to know, has your pet gained weight? Has the PUPD reduced? Has the appetite normalised, and what is their demeanour like.
We also want to know exactly when the glucose was given so that we can see exactly what time the nadir's happening, what time the peak's happening, and we can see how long the insulin is lasting. Based on a blood glucose curve and our history, we can adjust the doses required and reassess 10 to 14 days later. If we are getting uncontrolled diabetes, we always need to consider concurrent diseases.
So in cats, we need to consider things like acromegaly, so we'd measure things like IGF one, and in dogs, things like Cushing's. But I have to say that during the current restrictions, I don't think that measuring and testing for these is essential. We aren't going to be treating a cushionoid patient ideally during any of these restrictions, and an acromegalic cat for, treatment needs to be thinking about radiotherapy or surgery, which we're not going to be doing again during these restrictions.
So it's something to have in the back of your mind that we may need to consider once the restrictions are lifted, but during this time, what we want to do is manage it as effectively and try and make sure that we're not tipping into a DKA state. So now we come on to weight loss with a reduced appetite. So if we've got a severe weight loss in combination with a poor appetite, I would consider that to be urgent.
So in these scenarios, we would definitely want to ask about any concurrent clinical signs to help us determine the underlying aetiology. So I think in these cases, we are going to want to see the patient. So we know, particularly in cats, if they're anorexic for 57 days, they can go into a lipidotic state.
And again in dogs as well with anorexia, we don't want that to be prolonged. So we do want to consider haematology and serum biochemistry. Obviously, by taking bloods, we are going to be in very close contact to another member of our team.
So particularly in fractious patients, we might need to consider sedation earlier than we would have usually just to try and limit close contact of staff. Urinalysis can definitely be considered if there's PEPD and this may indicate underlying diseases such as renal disease. If we diagnose renal disease, which is significant, then we want to rule out a few things.
We want to rule out any toxicities, stop any nephrotoxic drugs, and for dogs, we also want to consider about Addisons cause we know with Addisons we can get a pre-renal lasotemia. And we can also get inappropriately dilute urine. So in these scenarios, it's really important that we don't misdiagnose an Addisonian case for having renal disease.
Obviously, the treatment is very different. Ideally we would have an abdominal ultrasound. So in younger animals which are presented with severe azotemia, we want to try and look, does it, are there congenital changes, for example, a renal dysplasia, cos this will definitely affect the prognosis and the outcome.
If there are ureteric obstructions, so that are causing significant pelvic and ureteric dilation, then ideally this patient should be referred for surgery to relieve the obstruction. Obviously that's not always going to be possible. These are cases which are financially very expensive, and the outcome isn't necessarily always favourable.
We also want to look at if there's evidence of a pyelonephritis or if there's evidence of neoplasia. And here at Virtual Veterinary Specialists, we can remotely help with these cases. So we can definitely help you by live guiding you through an abdominal ultrasound, as well as non-members can still send in images and loops for assessments.
So this kidney is like, it's got a bit of decreased corticoma dullery distinction. I don't see the difference between the two very well, and we can see if we can go into a bit more longitudinal. Oh there we go, there we go, that's a nice image.
There we go. So we can just see the decreased corticoma dullery distinction, but the kidney is normal in size. I think this is pancreas here that we're actually seeing.
There's this weird hypoechoic structure there that looks like pancreas. See there's a little stone, and this hypoechoic structure here is pancreas there sitting around it. So I think that's in the duct.
I think that might be the duct right there. There's hypoechoic anechoic little tube there, and we've got a stone and there's a second stone. I think that's the that is the adrenal gland that you had there a second ago.
That, that little structure there, yeah, yeah, it's a cat's adrenal gland is very hypoechoic. OK, yeah, and it's very round. Compared to the dog.
So for a patient that is aotemic, so particularly for the ones that we're seeing as an emergency, we'd expect them to have weight loss, they might have gastrointestinal signs, they're probably, they will be, PEPD as well, and they might be anorexic or auric as well. So if the patient is anuric, then it's really important to discuss either referral or euthanasia. So we can trial treatment, for example, with rosamide or cautious doses of Manitol, but if they remain anuric, the prognosis is very poor.
We want to continue fluids in these cases and then slowly taper them until the aoemia resolves, and that would be the absolute ideal. However, that's not possible in all cases, and in a lot of cases you'll find that the aotemia improves but doesn't resolve, and we are left with residual renal disease. We'd want to repeat the biochemistry after about 3 to 5 days to assess what our new baseline is.
And again at BBS we're always here to support you with these cases. So as well as IVFT supportive therapy is gonna be required. So in these cases, I definitely would consider omeprazole or famotidine because gastric hyperiddity can be a problem.
In cases with nausea, vomiting, or inappetent, definitely consider mropotent as well. And where we want to maintain an appetite, or where the appetite's been poor, then we want to consider mirtazapine. What we do know for renal disease is that renal diet is really important.
However, this is not something we'd want to introduce in a hospital environment, and we would never introduce this once the appetite is reduced. So until the appetite is normalised, we wouldn't introduce a renal diet. Ideally, we'd want to do weekly blood work to monitor progression until they're stable.
However, in the current climate, we do need to consider whether this is going to be appropriate. So if we've got a patient with renal disease, which we've stabilised with fluids, started on antiemetics, and we've got its appetite back after a few doses of mirtazapine, and the patient's now eating well, with no vomiting or diarrhoea, and right, we could try and wait as long as possible to repeat bloods. If it maintains being very bright, we might be able to wait until restrictions are lifted.
Once it's stable, we want to repeat our blood work every 2 to 3 months. So a patient with hepatobiliary disease, we always want to look at both the bile acids and the bilirubin, so we can try and see liver function a bit more closely. What we do need to remember is that our hepatic parameters, particularly ALT and ALP can be normal or only mildly increased in end stage hepatic disease.
Ituri is gonna be indicative of more severe disease, but what we do need to remember is that it can be due to prehepatic diseases, for example, IMHA, so hemolysis of red blood cells, so we always want to do a concurrent haematology. Abdominal ultrasound is gonna be essential to try and distinguish between hepatic and post-hepatic disease, and particularly post-opathic biliary disease that may be surgical. In some cases, we may need to consider a pateed biopsy to determine the underlying cause.
So we can virtually assist you with this, and we can do live guided abdominal scans and also help you take an aspirates. On the right side of the gallbladder on the right side of the screen, there was that little vessel that duct that you could follow and let's see if you can slowly follow that to see where it's going. Let me just get the gallbladder again.
Yeah, that's definitely it there. There are these little tubular structures here. And then the one goes off to the left again.
So the question is, is this all So I think if I do if I do that you can kind of see that it's going that way and then there's a little connection just here. I think actually sitting, let's see if that if those two structures are connected to each other. They're very, very close to each other, so just above where the colour is, yeah, yes, because I'm wondering, is one of them the pancreatic duct that's just really close to the biliary duct or if if this is just one structure that we're seeing the pancreatic duct is so dilated, and I mean they're associated with each other in the cat.
So if one is dilated and obstructed, the other one could potentially be as well. Hypercalcemic animals, particularly dogs, may present with significant weight loss, lethargy, anorexia, and potentially GI signs as well. It's often associated with PEPD.
And in dogs in particular, malignancy is gonna be the most common cause. Whereas in cats, idiopathic hypercalcemia will be more common. So routine blood work is essential to rule out renal disease and Addison's because both of these can cause a hypercalcemia.
We'd want to question the owners to try and rule out toxicities, so the main two we're looking at are adenticides and psoriasis cream. And we want to do a full physical exam, assessing all lymph nodes carefully and doing a rectal to assess for anal sat neoplasia, as that can be associated with hypercalcemia. So if the patient was stable and eating well, we could consider less invasive steps with measuring PTH or PTHRP.
So if PTH was high, that would be indicative of the patient having primary hyperparathyroidism. If the PTHRP is high, that can indicate an underlying neoplasia. It's always important to check with your lab before sending, as the EDTA sample needs to be spun and frozen immediately.
If there's a lymphadenopathy, then I would FNA as a matter of urgency, because particularly in dogs, neoplasia is common with lymphoma being one of the main causes. So in dogs, hypercalcemia of malignancy is the most common cause, and of this lymphoma will be the most common neoplasm which is diagnosed. If there's no peripheral lymphadenopathy, then advanced imaging and potential bone marrow biopsy could be considered, or we can consider a steroid trial if the owner doesn't want this.
However, we also need to think that we have, potential implications on these kind of decisions. Because of the current restrictions on nonessential travel and potential shielding of vulnerable members of society, so particularly if we have an older owner, they may not want to travel to get advanced imaging and bone marrow biopsies and things like that done. Here at VVS we can always discuss the pros and cons of various options.
If, for example, we have a scenario where we've done advanced imaging. We've done PTH and PTHRP which are unremarkable. And we've gone down the route of doing bone marrow biopsy and we've diagnosed a leukaemia, then we need to think about chemotherapy or euthanasia at that point.
If advanced imaging isn't possible or it's not appropriate in this scenario, then we could trial with steroids. What we do need to realise is that steroids probably will reduce the calcium in the short term, but if there is an underlying malignancy, this is going to be a very short term response. So the owner should be expecting, unfortunately for the patient to deteriorate.
And when deterioration occurs again, then we will need to consider euthanasia. In cats, idiopathic hypercalcemia will be more common. The first line treatment is to consider dietary management.
So we have a high fibre diet to reduce intestinal calcium absorption. Royal Cannon fibre response is gonna be a really good choice for this. The next thing we need to think about is steroid therapy.
So with steroids, then what we can consider with these ones is prednisolone. And the dose that we use is going to vary. So with this, we generally start at about a mg per gig, increase if there's poor response.
And then again, we decrease the lowest possible dose. In some patients, we are gonna need to have bisphosphonates. The first choice for this would be edrenate.
It's always important to give it on an empty stomach, but to follow with water to avoid any esophageal damage. In some cases we are going to have a reduced appetite with weight loss and normal blood work, and in this scenario, it's gonna be really important to consider in this one other concurrent signs such as coughing or reduced exercise tolerance. In these scenarios, the physical exam will be really important.
We want to assess if there's any abdominal masses or any reduced lung sounds and consider advanced imaging of the thorax in the abdomen. So chronic pleural effusions can lead to weight loss. On the physical exam, will often have reduced lung sounds and may also have a muffled heart sounds, and coughing may also be noted by the owner.
It's essential to perform thoracocentesis and remove as much fluid as possible, and we want to submit the fluid for full analysis, including cytology. We want to try and define is this a transitate, a modified transitate, or an exedate. So one of the more common pleural effusions that we may see in association with a weight loss is a pyothorax.
So when cats were more likely to be able to manage this medically. Dogs, however, may need surgery, but there are successful reports of medical management in the literature. We want to remove as much fluid as possible and then perform thoracic imaging.
Ideally, if finances allow, then we would consider referral for a thoracic CT because that is going to be more sensitive than radiographs. Cytology will give you the diagnosis in these cases, as can be seen here within the white blood cells, we have numerous rods, and always consider seeking advice from us at VVS or from your referral centres. So with the Pythorax, we often need to place bilateral chest drains.
We want to remove the fluid every 4 hours so that we can try and minimise the quantity. We want to submit the fluid for full culture and sensitivity, but pending culture would start the patient on potentiated amoxicillin. Analgesia is essential as it is painful, and if the patient's an appetent, then we also need to consider placement of an esophageal feeding tube at the time of chest strain placement.
So thoracic neoplasia could also be associated with weight loss. And in these scenarios, you want to have thoracic radiographs or CT. If we diagnose widespread thoracic mets, then it is academic to search for a primary lesion.
And for the cases that are going to be presented during the COVID-19 restrictions, these are cases that you'd expect to have significant weight loss, being off their food, coughing, or having dysneic episodes. And in most cases, treatment is really not going to be beneficial for the cases, so euthanasia should be considered. If the owners are very keen for treatment and the animal is not too severely affected, you could consider referral to an oncologist or to speak to our oncologist at BBS to consider things like metronomic chemotherapy.
But in this scenario we'd want to have an FNA of the lesion if it's accessible so that we can guide you appropriately. So to summarise, we definitely want to make sure that we get the full history as much as possible over a phone or video platform. If we've just got weight loss and the patient's otherwise fine, then we want to get the owners to weigh the patient weekly and monitor.
If the patient's inappetent or has a poor appetite that is urgent, if there are signs of hematochezia, hemato emesis, or severe vomiting or diarrhoea, then it's also urgent. Screening blood work can be really informative, and advanced imaging may be required. So at this time here at VVS we can help by providing specialist consultations.
So decision making for complicated medical cases can be tricky even during normal times. But at the moment with all the extra things we need to be taken into account in terms of restricted movement, social distancing, shielding vulnerable members of society, decision making can be extremely challenging. It's very hard to know what's to do best, and VVS can help reduce this burden.
Having a practical discussion with a specialist can help you work out your most appropriate next step for each individual case. There'll be further free webinars available. So there's a webinar available on Is cancer an emergency?
And common neurological presentations, what is an emergency and what can wait. As well as equine respiratory distress, should I go and see it, or can I manage remotely, which may interest those of you who do equine work as well as small animal work? We've also developed some essential clinical guides which contain all the essential information in one place for managing the cases in-house.
So the different guides that are available are those on block hats, IMHA, seizures, lily toxicity. DKA, gastrointestinal disease, and diabetes. These are all available from our website.
If you have any questions, then please do not hesitate to contact us. Thank you for listening and I hope you found it helpful. If you have any questions, then please contact us via email at the link below.