Bitch pyos

Re: Bitch pyos

Lorna McHardy — Sun, 11 Mar 2012 13:19:18 GMT

[quote user="Mark Hedberg"]Ok, I'm in. If you guys want someone to run with this, I'm game. Anyone with me?

:) Cheers,
Mark

[/quote]

I wouldn't know where to start, or what's involved

Re: Bitch pyos

Dagmar Steele — Sun, 11 Mar 2012 06:29:18 GMT

Ice in a single malt? Nothing to do with enjoying... You might want to use a drop of still water if it's a cask strength, but that's it. Brrrrrrrrr

Re: Bitch pyos

Mark Hedberg — Sun, 11 Mar 2012 00:25:39 GMT

Ok, I'm in. If you guys want someone to run with this, I'm game. Anyone with me?

:) Cheers,
Mark

Re: Bitch pyos

John Rimmer — Sat, 10 Mar 2012 22:14:48 GMT

[quote user="James Laidlaw"]Ice? In Talisker? Why ever would you spoil such a marvellous drink Mr. Rimmer?

[/quote]

Many people enjoy ice with Whisky James. It lowers the temperature but does not dilute if you drink it soon enough. :)

Re: Bitch pyos

Malcolm Ness — Sat, 10 Mar 2012 13:55:14 GMT

[quote user="John Rimmer"]What would be a fair timescale? A year? I'll get the ice cube tray filled in anticipation if you don't mind. No offence.[/quote]

My first thoughts would be a little longer - say six months for recruiting cases, then a further six months for follow-up then six months to write up and submit for publication.

Re: Bitch pyos

James Laidlaw — Sat, 10 Mar 2012 12:09:28 GMT

Ice? In Talisker? Why ever would you spoil such a marvellous drink Mr. Rimmer?

Re: Bitch pyos

John Rimmer — Sat, 10 Mar 2012 11:14:21 GMT

[quote user="Malcolm Ness"]

re Mr Rimmer's earlier voiced scepticism - I will wager a bottle of 18 yr old Talisker that, subject to someone coming forward to lead the project (no prior experience required), we could get a paper published in JSAP.

Any takers?

[/quote]

Challenge accepted :) Remember the rules:

It would be relatively easy to conduct a robust and meaningful clinical trial comparing medical and surgical pyo treatment through the medium of vetsurgeon.

What would be a fair timescale? A year? I'll get the ice cube tray filled in anticipation if you don't mind. No offence.

Re: Bitch pyos

Anthony Todd — Sat, 10 Mar 2012 03:09:25 GMT

[quote user="Mark Hedberg"]The trouble here is that there are potentially 4 endpoints. The dog requires a spay. Dog dies of pyo. Dog dies of something else. Dog pts. How long would the dog have to be pyo-free for alizin to be considered a successful treatment? One heat free of pyo?

[/quote]

Surely the comparison should be with surgery which is [nearly] always pyo free for ever?

Or perhaps with the percentage giving birth subsequent to treatment which has got to be a good test of a normal uterus?

Re: Bitch pyos

David Mills — Sat, 10 Mar 2012 03:00:10 GMT

[/quote]

Any endpoint always has some arbitrariness about it, but I think they're clear cut in this instance. A success would be resolution of clinical signs, and a normal heat +/- pregnancy at next cycle or 2 cycles. Negative endpoint would be non-resolution of clinical signs, spaying , or recurrence at next cycle - the latter because, even if clinical signs disappeared, the recurrence at next cycle negates this. It would be most useful, though not essential, to work up the reproductive tract as including ultrasound +/- oestradiol and C/S of uterine contents so that any 'failures' can be contextualised.

I'm sure virbac could see their way to funding some of the pharmaceuticals and lab fees retrospectively. JSAP are crying out for papers like this from general practice given the paucity of first opinion published evidence.

Re: Bitch pyos

Mark Hedberg — Fri, 09 Mar 2012 23:07:51 GMT

[quote user="james herriot lied"]

[quote user="Malcolm Ness"]

Any takers?

[/quote]

Hmmmm.

Any chance of switching that for a decent '94 port? I'd even take a bottle of 2007 on trust, if I must........

[/quote]

he was betting rimmer the talisker that jsap would publish it - not that he'd give the volunteer the booze. If he had, we'd be inundated with volunteers - what some vets, me included, would do for a bottle of good booze! ;)

Re: Bitch pyos

james herriot lied — Fri, 09 Mar 2012 22:49:50 GMT

[quote user="Malcolm Ness"]

Any takers?

[/quote]

Hmmmm.

Any chance of switching that for a decent '94 port? I'd even take a bottle of 2007 on trust, if I must........

Re: Bitch pyos

Mark Hedberg — Fri, 09 Mar 2012 22:47:01 GMT

The trouble here is that there are potentially 4 endpoints. The dog requires a spay. Dog dies of pyo. Dog dies of something else. Dog pts. How long would the dog have to be pyo-free for alizin to be considered a successful treatment? One heat free of pyo?

Re: Bitch pyos

Mark Hedberg — Fri, 09 Mar 2012 22:30:59 GMT

[quote user="Malcolm Ness"]

There is a very real possibility here of using vetsurgeon to generate data for publication. If Virbac were to offer a little financial assistance and somebody out there is interested in getting involved in leading some clinical research then there would be no stopping us.

Any takers?

[/quote]

i'll think about it a bit more before i throw my hat in the ring.

Re: Bitch pyos

Malcolm Ness — Fri, 09 Mar 2012 22:10:13 GMT

[quote user="Alex Allen"]Aglepristone (and other medical treatments) have been published and used succesfully in general practice for pyo management for some years and we receive a few hundred enquiries / year on this very subject.[/quote]

I am aware of that and also the literature which is dominated by reports of remarkably young patients being treated with pregnancy as the end-point. This is a very different scenario from most pyos in practice where the patient is older and retention of breeding potential is not an issue.

I am not at all comfortable in extrapolating the published work to aid clinical decision-making in more typical pyo cases. I applaud the efforts of Virbac to use the details of the licensing regs in such a way as to make a useful treatment available to us and our patients. However, I would like to see more good quality evidence than is currently available.

Any takers?

Re: Bitch pyos

Rob Davis — Fri, 09 Mar 2012 18:54:53 GMT

[quote user="John Rimmer"]Angelica something. German lady from Cambridge.[/quote]

Angelika Von Heimendahl

Re: Bitch pyos

Alex Allen — Fri, 09 Mar 2012 18:30:06 GMT

Hi Malcolm - as mentioned before surgery is always the preferred choice unless there is a reason against GA/ovariohysterectomy. Providing the case is not a critical emergency then medical management can be used as a conservative treatment - typically because breeding is desired in the future. Using Alizin in preference to surgery based on cost alone could have repercussions - as stated above costs can end up similar (antibiotics, IV fluids, bloods...) Common sense must prevail and in some cases a vet may make a clinical judgement based on their competence that goes against the owner's desire to preserve breeding potential.

Aglepristone (and other medical treatments) have been published and used succesfully in general practice for pyo management for some years and we receive a few hundred enquiries / year on this very subject.

As John and yourself point out Trasch et al looked at the follow up in 52 bitches. There are other studies by Trasch, Hagman, Jurka, Verstegen, Fontaine to name a few over the last decade looking at medical management protocols, risk factors, breeding potential etc.BUT we are a long way off finding a medical treatment suitable for all given we haven't fully understood all the risk factors yet and the disease has a permanent progressive component.

Current medical managements are aimed at interfering with a key component of pyometras - Progesterone - Drugs are either luteolytic (prostaglandins), antagonists of progesterone receptors (aglepristone) or block luteotrophins (cabergoline). They do not have any protective/ long term effects that would influence the uterine environment and hence the recurrence of pyometras next time the uterus is exposed to progestagens. They will all have limitations dependent on the extent of chronic pathology and the severity of the bitch's illness. Side effects should also be appreciated - particularly prostaglandins.

Some more studies:

Fontaine et al looked at 24 bitches treated with Aglepristone +/- cloprostenol with age ranging from 1 to 7yrs, mean 3.6yrs. 23 out of 24 were successfully treated, all were bred at the next ovulation - 19 became pregnant, 5 didn't and had recurrence of pyometra.

Jurka et al - 24 bitches, split into two groups based on age. 14 <5yrs and 10 >5yrs. In this study none of the bitches >5yrs became pregnant on the subsequent oestrus and 3 had recurrence of pyometra - CEH, ovarian cysts and high oestradiol levels were noted. In <5yrs group 8/14 had successful pregnancies and none had a recurrance of pyometra.

Quoting blanket recurrence rates for all breeds and all ages can be misleading given the complexity of the disease and the amount of research still required. What is known is that some breeds may be at higher risk independent of the breeding history and age. Others the risk will depend on the previous breeding history - for example two 6 year old dogs (same breed) will have different risk factors if one is nulliparous and the other has had 3 litters - this theory is based on the cumulative hormone exposure over the lifetime of the bitch.

The older the animal the more likely that endometrial and ovarian cysts may be present and both will affect both medical management and recurrence rates.

Owners must always be advised the use of aglepristone is 'off label' and second to surgery and that success is not 100%. Ideally if a breeder wants more assurance about future breeding prospects and recurrence then a more extensive work up should be performed - ultrasound, bloods, oestradiol levels etc.

The reason we advise vets to contact us in person (please don't ask your non-medically trained part time receptionist to phone us!) is so that all the case details can be discussed to provide a balanced and suitable protocol. We may advise a possible protocol or advise against its use. Detailed forum discussions for off label uses could be viewed as "promoting" the use of off label drugs so we have to very careful and minimise what contributions we make otherwise we risk contravening the VMR.

Re: Bitch pyos

John Rimmer — Fri, 09 Mar 2012 16:45:09 GMT

By the way, for the record, to answer the OP's question - in a stable animal that the owner does not wish to breed from in the future, I also recommend surgery.

BUT - if it's not stable, I use Alizin/fluids/antibiotics and operate when stable.

If they want to breed and animal as healthy enough, decent age etc, I will give medical management if owner guarantees to breed from at the next season and then spay.

Oh, and in a poor client who can't afford surgery, I will strongly advise Alizin/Ab. If they can't afford that and I think there is a chance of survival, i will give antibiotics alone. In the past I have given grave grave prognosis in these circumstances and been shocked at the positive outcome. Bit red-faced actually.

Re: Bitch pyos

John Rimmer — Fri, 09 Mar 2012 16:35:35 GMT

[quote user="Malcolm Ness"]

It would be relatively easy to conduct a robust and meaningful clinical trial comparing medical and surgical pyo treatment through the medium of vetsurgeon.

[/quote]

Really? Seriously? Good luck getting that one published.

Re: Bitch pyos

John Rimmer — Fri, 09 Mar 2012 16:33:57 GMT

[quote user="Malcolm Ness"]

I believe that the drug companies have a duty of care to provide reliable safety and efficacy data in relation to the products and indications that they are selling us.

[/quote]

Well you can sleep safe at night then, because they are legally bound to. But Alizin is not licensed for pyometra so presumably isn't SOLD for the indication of managing pyometra. Certainly never has been to me. If it was I would report the rep.

Re: Bitch pyos

Malcolm Ness — Fri, 09 Mar 2012 16:23:25 GMT

I am familiar with that work and it was the reason I posted here. The 98% success id oft quoted but, I think that it is a very misleading statistic. Closer inspection of the data shows that of 52 bitches treated, 1 died and 3 were operated within three months and 7 were lost to follow up. After 3 months it seems that a further 11 recurred and 3 more were operated and more were lost to follow up. The rendition of 98% success to me while not overtly untrue is a bit like describing double cream as 85% fat free.

I agree that there is a place for a medical pyo treatment and ultimately, it would be nice to see something that is simple, safe and predictably effective. To the best of my understanding, we are yet a very long way from that goal. I believe that the drug companies have a duty of care to provide reliable safety and efficacy data in relation to the products and indications that they are selling us.

It would be relatively easy to conduct a robust and meaningful clinical trial comparing medical and surgical pyo treatment through the medium of vetsurgeon.

Re: Bitch pyos

John Rimmer — Fri, 09 Mar 2012 16:03:21 GMT

Oh, another indication - where they want to breed at the next season.

As Angelica mentioned in her talk, neutering is not the answer to all reproductive problems, as many vets seen to think.

Re: Bitch pyos

John Rimmer — Fri, 09 Mar 2012 16:01:50 GMT

Regarding which cases suitable Malcolm. certainly those cases not stable enough for surgery. Also owners who refuse surgery. Would have thought that was obvious.

Re: Bitch pyos

John Rimmer — Fri, 09 Mar 2012 15:59:26 GMT

J Vet Med A Physiol Pathol Clin Med. 2003 Sep;50(7):375-9.

Follow-up examinations of bitches after conservative treatment of pyometra with the antigestagen aglepristone.

Trasch K, Wehrend A, Bostedt H.

Source

Clinic for Obstetrics, Gynaecology and Andrology of Large and Small Animals, Justus-Liebig University, Giessen, Germany. katjatrasch@yahoo.de

Abstract

The aim of this study was to determine the therapeutic success of the medical treatment of canine pyometra with the antigestagen aglepristone and to document the recurrence rate in relation to the time interval after treatment with antigestagens. In 48 (92.8%) of the 52 treated bitches, healing could be achieved within the first 3 weeks after the treatment had been started. One bitch died as a result of renal insufficiency; in three bitches there was no emptying of the uterus, so ovariohysterectomy became necessary. In these three patients, ovarian and endometrial cysts were present. Forty-one bitches could be followed up for 3 months. Four animals developed a recurrence (9.8%). In three bitches ovarian cysts and cystic endometrial hyperlasia could be found intra operationem. The development of 37 bitches could be followed for at least 1 year. Seven animals developed a pyometra again (18.9%). Two received a repeated treatment with aglepristone and have been free from recurrence for over 12 months. In 37 animals data on the subsequent sex cycles are available. In 22 bitches next heat started at the expected time, in seven animals heat started too early. In eight bitches the period of anoestrus was prolonged. Five of the six bred bitches delivered at least one litter. The presented data show that treatment of pyometra by aglepristone results in a high healing rate. The recurrence rate can be minimized by the selection of bitches without ovarian cysts and cystic endometrial hyperplasia.

Re: Bitch pyos

John Rimmer — Fri, 09 Mar 2012 15:58:34 GMT

I have numbers I can share Malcolm. 92.8% success rate in a study I read - citation below.

Expert opinion important as well of course. I heard a reproduction expert speak recently on the subject, and she recommended medical management. Angelica something. German lady from Cambridge. She also said that recurrence rate was far below what people thought. I honestly can't recall whether she quoted a paper or not, it may have been her experience - but either way, she said recurrence rate was low.

Re: Bitch pyos

Clive Ansell — Fri, 09 Mar 2012 15:58:30 GMT

I only ever offer surgery for pyometra, being the treatment of choice. If a client requests an attempt at medical management I will try, but it is against my best advise.

I had case last week; a 10 year old Chow, has been treated several times over 2 years with Alizin and antibiotics for a low grade grumbling pyometra, but treatment was less effective and clinical signs more pronounced each time. Finally spayed, and the dog is already (10 days post op)so much brighter and happier. From a cost viewpoint, we actually added up what had been spent on Alizin and countless courses of Synulox and Baytril, and it amounts to almost as much as the surgery. The owners, who are sh-eye-te dodgy back street breeders, claimed we had failed the dog and should do the surgery at half price as they had spent so much money! (surgery was advised at the onset, but declined)