CONNECTED. Feline Pancreatitis. Canine Hyperadrenocorticism Clinical Trials Update IN THIS ISSUE:

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1 CONNECTED Yo u r L i n k to V e t e r i n a r y S P E C I A LT Y H O S P I TA L A P R J U N 0 9 Feline Pancreatitis IN THIS ISSUE: Canine Hyperadrenocorticism Clinical Trials Update FACE Foundation in the News Veterinary Specialty Hospital Sorrento Valley Rd. San Diego, CA

2 richter scale We are all sad to report that Frank LaBonté has left VSH. We are all grateful for Frank s contributions, and we wish him well. I will be temporarily taking over Frank s duties as hospital administrator while we search for a long-term replacement. I am both nervous and excited. I have several ideas to improve VSH, things that I could never do while actively having a full clinical load as an internist. I welcome any feedback and look forward to this new challenge. Recently we received the results and feedback from the Pfizer Satisfaction Survey that was conducted this past winter. After reviewing the data I am developing action plans to address areas that were identified within the survey as opportunities for improvement. One of the major focuses for us this year will be the development of a more personalized approach for the Client Experience. We are designing and will be implementing a comprehensive approach that will ultimately enhance the overall experience for your clients when they come to VSH. As an extension of your practice in these difficult economic times, we want to ensure that the clients experience is one that is value driven and meets their expectations. In this issue of Connected we have included articles written by Dr. John Hart: Tips on Diagnosis and Treatment of Hyperadrenocorticism ; and Dr. Steve Hill: Feline Pancreatitis. I hope that you will find these articles informative. As always, I appreciate your collaboration and look forward to continuing to work with all of you, our Partners, as we continue the journey together to deliver the best and highest level of quality patient care available. Keith Richter, DVM Diplomate ACVIM

3 Feline Pancreatitis by Steve hill, DVM, MS, DACVIM Overview Feline exocrine pancreatic disorders have traditionally been considered uncommon. The incidence of pancreatitis in cats has been underestimated and pancreatitis is now recognized as an important gastrointestinal disorder. Premature activation of digestive enzymes initiates pancreatitis while the inflammation leads to the progression of disease and systemic complications. Feline pancreatitis can be acute or chronic and most cases are idiopathic. Acute pancreatitis can be mild and subclinical to severe necrotizing with high mortality. Chronic pancreatitis may be associated with signs that wax and wane over months to years. Histopathology is required to reliably distinguish acute from chronic pancreatitis. Cats with pancreatitis commonly have concurrent disease conditions. Most cats with pancreatitis are presented for anorexia, lethargy, and dehydration while vomiting and abdominal pain occur less commonly compared to dogs. Abdominal pain is likely underestimated in cats with pancreatitis. Pancreatitis should be considered in any cat with anorexia, lethargy, weight loss, vomiting or abdominal pain of unknown cause. Diagnosis Diagnosing pancreatitis in cats can be challenging. It s essential to integrate patient history, physical findings, laboratory data, and diagnostic imaging. The development of a pancreatic lipase specific immunoassay (fpli, Texas A&M GI Laboratory and Spec fpl, IDEXX) combined with advances in ultrasound have improved the clinicians ability to diagnose pancreatitis. Results of a CBC, chemistry profile, urinalysis, and abdominal radiographs are not specific for pancreatitis but are important for the diagnosis of other disorders with a similar presentation. Anemia, leukocytosis, elevated hepatic enzymes, and hyperbilirubinemia are variable findings. Serum amylase and lipase are not useful for diagnosing feline pancreatitis. Ultrasound combined with the fpli are the most useful clinical tests for diagnosing pancreatitis in cats. The fpli is specific for pancreatic lipase which is elevated in most cats with pancreatitis. Recent data showed a sensitivity of 79% with a specificity of 82% for the Spec fpl in cats with pancreatitis. Technological advances and improved clinician skill level have resulted in ultrasound becoming very important for diagnosing pancreatitis. Pancreatic enlargement, hypoechoic (necrosis) and hyperechoic (fibrosis) appearance, pancreatic mass effect, peripancreatic hyperechoic mesentery and fluid, and dilated pancreatic duct are common ultrasound findings. Sensitivity for ultrasound is reported from 24-80% and specificity of 88%. Treatment and Prognosis Treatment is primarily supportive and symptomatic. Most cases respond when treated with intravenous fluids, analgesics, antiemetics, appetite stimulants, and nutritional support. Fasting should only be ordered for patients that are vomiting. Standard fasting periods are not necessary and early enteral nutrition is recommended to prevent hepatic lipidosis, protein/calorie malnutrition, gut atrophy, and bacterial translocation. Vomiting can be controlled in most patients with antix x Ultrasound of an enlarged hypoechoic left limb of the pancreas with dilation of the pancreatic duct and hyperechoic peripancreatic mesentery emetics such as maropitant citrate (Cerenia ) 1 mg/kg SQ q24h. If persistently anorexic, esophagostomy or nasogastric tube feeding is recommended. Jejunostomy tube feeding or parenteral nutrition are not commonly required. A highly digestible low fat diet is optimal. It is important to be proactive with analgesics. Buprenorphine (Buprenex ) mg/kg IV, SQ, or buccal q6-8h or fentanyl transdermal (Duragesic ) 25 mcg/hr are good choices. There is no evidence that other therapeutic strategies are effective in cats with pancreatitis. Antibiotics are controversial and are not needed for most cases. Chronic pancreatitis in cats may be similar to human immune-mediated pancreatitis. Concurrent inflammatory bowel disease and cholangiohepatitis are common resulting in a condition referred to as triaditis. These patients often respond to corticosteroid therapy. The prognosis is directly related to disease severity. Mild disease without pancreatic and systemic complications has a good prognosis whereas severe disease with complications carries a poor to grave prognosis. Take Home Points Pancreatitis is an important gastrointestinal condition in cats that is diagnosed with increasing frequency. Feline pancreatitis is a unique disease compared to its canine counterpart. Combining ultrasound and fpli gives the highest diagnostic yield. Treatment is supportive and symptomatic; cats with chronic pancreatitis or triaditis may benefit from corticosteroid therapy. Prognosis depends on the severity of disease.

4 Tips on Diagnosis and Treatment of Canine Hyperadrenocorticism by john hart, DVM, DACVIM Urine Cortisol to Creatinine Ratio Pros: Excellent screening test. A negative result makes the presence of hyperadrenocorticism highly unlikely (98% specificity). Cons: A positive result is suspicious for HAC but frequent false positive results occur due to stress and further testing to substantiate HAC. Tip: This test should be obtained by the owner at home, ideally from the first morning urination by free catch. This reduces the likelihood of stress causing a false positive result. Low Dose Dexamethasone Suppression Testing Pros: The most sensitive test for HAC (97% sensitivity). Cons: In 2 studies in dogs with non-adrenal illness that were tested with a LDDST, false positive results were found in 38% and 56%. Tip: Up to 65% of the time will also differentiate pituitary dependent HAC from an adrenal tumor. A drop of 50% from the baseline level or a 4 hour level under 1.5 ug/dl where the 8 hour level in both instances is above 1.5 ug/dl is diagnostic for pituitary dependent HAC. Atypical Hyperadrenocorticism Tip: In patients where clinical signs, physical exam findings and biochemical testing are strongly suspicious for HAC and standard diagnostic testing is negative, consider obtaining pre and post ACTH stimulation testing levels of sex steroid hormones including androstenedione, estradiol, 17-hydroxyprogesterone, and progesterone. Trilostane Therapy (Vetoryl ) Trilostane is an orally active steroid analogue that is a competitive inhibitor of the 3-ß hydroxysteroid dehydrogenase enzyme system. This enzyme mediates the conversion of pregnenelone to progesterone, a precursor of cortisol as well as aldosterone and androstenodione, effectively inhibiting their production. The drug has recently been approved by the FDA and is now easily obtainable. Pros: Reversible inhibition of steroid synthesis which allows finer control of steroid synthesis with a lower frequency of side effects compared to Lysodren. Side effects are usually minimal, typically with no abnormalities are noted, or there is occasionally a slight reduction in activity or lethargy noted during the first week of therapy. Tips: Some dogs will be controlled based on ACTH stimulation test results (exactly the same control level targeted with Lysodren), yet still have persistent clinical signs. In these dogs consider increasing the dosage interval to BID. Very occasionally TID dosing may be required. Remember to repeat the ACTH stimulation test days after every increase or decrease in dose. Timing is important, with the ACTH stimulation test performed, ideally 4-6 hours post pill. The medication should be given with food to enhance absorption. Lysodren Therapy (Mitotane ) Mainstay of therapy for PDH, a toxin selectively targeting the adrenal cortical layer producing sex steroids and corticosteroids and to a lesser extent mineralocorticoids. Pros: Less expensive than Trilostane over time. Typically only requires once or twice weekly dosing after the initial loading phase. Cons: High frequency of major and minor complications, 25% in one large study of 200 cases, with 5% having iatrogenic Addison s requiring long term steroid and mineralocorticoid supplementation. The loading dose is different for each patient and loading can take as little as 3 days or as long as 21 days. Tips: The most accurate indicator of adequate control during Lysodren loading is the point where water intake normalizes in those patients that are PU/PD. Consider having the owner quantitate water intake before and follow that intake daily during loading. The point where intake normalizes (< 60 ml/kg per day) stop the Lysodren and repeat the ACTH stimulation test. Polyphagia, if present, with normalization of appetite is the second most accurate indicator of control. Good control is the point where the gland has minimal stimulation. The target cortisol is 1-5 ug/dl of both the pre and post ACTH stimulation test. Even when good control is attained, repeat ACTH stimulation testing is required as the drug induces it s own metabolism over time and dose adjustment is often required over time. Cons: Requires daily lifelong therapy. Costly, $1.62 for a 60 mg capsule. The major side effect of iatrogenic hyperadrenocorticism are possible and in a small number of cases has been irreversible.

5 In Our Community FACE Foundation Featured in Ranch & Coast Magazine The FACE Foundation, a not-for-profit 501(c)3 public charity, was featured in the February 2009 issue of Ranch & Coast Magazine. The article featured the Giblin family who was assisted by the FACE Foundation for the care of their dog Coconut who had suffered a serious leg injury just over a year ago. When they learned how much Coconut s procedure was going to cost, they were devastated. That s when Veterinary Specialty Hospital told them about FACE Foundation, which was able to provide financial assistance, relieving the family of the heartbreaking decision they were being faced with during such a difficult time. To read the heartwarming article in its entirety, please visit Larry and Louise Giblin with Morgen, Coconut, and Elyse. Photography by Bob Stefanko Take Note Announcements Newest Member Dr. Laura Stokking is now a member of the Veterinary Dermatology Journal Editorial Board. She will be on the board for the next three years. Speaking Engagements Dr. Steve Hill spoke at the Comparative Gastroenterology Society Meeting (CGS GutSea) in March. This international meeting was held in Playa del Carmen, Mexico. current CLINICAL TRIALS Dermatology Medication to Control Pruritus Dr. Laura Stokking is enrolling dogs for a new medication to control pruritus. Contact Christie Yamazaki, RVT, CW2 at (858) x640. Dermatology Treatment of Cutaneous Lesions Dr. Laura Stokking has a phase 1 clinical trial to test the use of an emulsified oxygen cream to treat cutaneous lesions in horses and dogs. The first phase of this study is now closed; the second phase should begin in April or May. Contact Karina Benish, RVT, CW2 at (858) x640. Internal Medicine - Testing a new ACTH product for evaluating adrenal function in dogs. To evaluate a new ACTH product to assess effectiveness in diagnosing dogs with suspected Cushing s syndrome and suspected Addison s disease. Monetary support is provided to clients, including complete diagnostic work-up and lab costs. Contact Dr. Richter or any of the internal medicine specialists at (858) Neurology- Feline Diabetic Neuropathy In conjunction with the University of California San Diego, VSH is enrolling cats in a study to evaluate the use of Prosaptide, a neurotrophic peptide. Cats with diabetes mellitus or pelvic limb weakness are eligible. Contact Dr. Lipsitz at (858) x2707. Medical Oncology Canine Mast Cell Tumor Trial To evaluate a novel chemotherapeutic agent. Dogs diagnosed with measurable (non-resected) subcutaneous, or multiple cutaneous MCT. Dogs with regional nodal metastasis are eligible. Contact Dr. Phillips at (858) x2713 Radiation Oncology- Treatment of Oral Squamous Cell Carcinoma and Acanthomatous Epulides in Dogs To evaluate a novel radiation therapy technique for the reduction of side effects in normal tissue. Any dog with a measurable SCC of the oral cavity or acanthomatous epulis is a potential candidate. Contact Dr. Burke at (858) x2706. Surgery Sliding Humeral Osteotomy To evaluate the sliding humeral osteotomy (SHO) as a treatment of advanced medial compartment elbow disease. Patients are considered candidates if the response to conventional surgical therapy (fragment removal or OCD lesion curettage) has been less than ideal. Sponsored by VSH and New Generation Devices. Contact Dr. Pike at (858) Surgery- Micro Total Hip Replacement VSH is enrolling 25 small dogs in a clinical study to compare the results of micro THR to those of femoral head and neck excision. If you know of a candidate for this procedure or would like to learn more about the benefits of participating, contact any VSH surgeon at (858) Surgery Bone Induction Product for Diaphyseal Fractures in Dogs To investigate a Bone Induction Product for use in Diaphyseal Fractures in dogs. Patients considered are skeletally mature, client owned dogs (not pregnant or lactating), that have sustained a diaphyseal fracture requiring internal fixation. Patient must be presented to a veterinarian within 24 hours of injury and the fracture must be repaired within 7 days. Patient must be medically stable without head trauma and without chronic use of steroids. Sponsored by a major Global Animal Health Company. Owners will receive free radiographs, bloodwork, recheck exams, and $500 upon completion of the study. Contact Dr. Aiken at (858) x315, , or sean.aiken@vshsd.com.

6 10435 Sorrento Valley Rd Suite 100 San Diego, CA We re Listening In 2008 Veterinary Specialty Hospital participated in client and referring veterinarian satisfaction surveys conducted by Pfizer Animal Health. Pfizer randomly surveyed 400 VSH clients and 200 referring veterinarians in the areas of client and veterinarian satisfaction. Based on survey results, Veterinary Specialty Hospital has actively updated it s strategic plan to include areas identified in the survey and has created a Client Experience Committee to address and implement improvements. We very much appreciate the input received by the participants in the survey as this allows us the opportunity to enhance our operations. If you have a comment or concern about an aspect of VSH, please get in touch. Contact Keith Richter, DVM, DACVIM at (858) save the date April Roundtable Discussion: Osteosarcoma April 30, 7:00 pm Dermatology Rounds May 28, 8:00 am June Roundtable Discussion: Orthopedic Radiography Review June 10, 7:00 pm Spring CE Dinner and Lecture May 21, 6:00 pm Dr. Steve Hill, Feline Pancreatitis Dr. Sean Aiken, Patella Luxation Dr. John Hart, Tips on Diagnosis and Treatment of Hyperadrenocorticism Dr. Tony Basher, Ocular Melanosis in Cairn Terriers For more information on Continuing Education events, please visit or contact Megan Sage at (858) or megan.sage@vshsd.com.