Anti emetics

Re: Anti emetics

Rob Loxley — Fri, 28 Sep 2012 23:55:27 GMT

[quote user="Anthony Todd"]Of course best practice now is to subject the patient to complete multimodal and comprehensive investigations for the 1 in 50ish cases [no nothing to back that figure up] which turns out to be more sinister[/quote]

I think you're record's broken

Re: Anti emetics

Michael Woodhouse — Fri, 28 Sep 2012 22:51:38 GMT

[quote user="Anthony Todd"]

Most of my colleagues used metoclopramide in the same way; as a diagnostic and or therapeutic aid. 49 out of 50 stopped vomiting and were back to normal in 24hours.

Of course best practice now is to subject the patient to complete multimodal and comprehensive investigations for the 1 in 50ish cases [no nothing to back that figure up] which turns out to be more sinister

[/quote]

Yes - that was pretty much my rule with metoclopromide. If it kept being sick then there was probably something in there.

Use Cerenia first line because very rare that vomiting in dogs is anything other than simple gastroenteritis. It works very well and the owner has brought the dog to us because they are tired of cleaning up dog sick, they want the problem stopping. Same idea giving dogs with diarrhoea kaolin.

We have Vomend and use it a bit.

Re: Anti emetics

Stephen Courtney — Fri, 28 Sep 2012 22:39:58 GMT

I also will use cerenia tablets off license in cats - a quarter of a 16mg tab daily if need be - for nausea associate with chemo and also pancreatitis, IBD if ned be also. Vomity diabetic cats often have panceatitis grumbling away under there.

Re: Anti emetics

Elisabeth Knappett — Fri, 28 Sep 2012 22:07:11 GMT

Use both at the hospital - cerenia initially in dogs, but in combination with metoclop when unremitting nausea (once investigations are underway). Cerenia tablets for travvel sickness and post-chemo nausea, client response is that they work well, and no complaints so far about the cost. Agree with the comments about keeping the injection in the fridge - doesn't work all the time but does decrease the number of reactions we've had. Started to use cerenia for cats, particularly with CKD or liver issues, seems to work well and encourages appetite in anorexic cats and stopping the same from vomiting when refeeding. Metoclop in rabbits etc for motility again in combination with ranitidine.

Wouldn't be without either if I had the option.

Re: Anti emetics

Nicola Lawlor — Fri, 28 Sep 2012 21:36:43 GMT

I use cerenia in dogs, often followed up by a day or two of tablets for a g/enteritis. I always inform owners to return if the dog continues to vomit despite being on the meds. I also use it for travel sickness cases now and again.

In cats - rarely use anti-emetics but now use cerenia when needed.

Rabbits - metoclopramide (vomend) for prokinetic effects with ranitidine.

Re: Anti emetics

Stephen Courtney — Fri, 28 Sep 2012 20:53:41 GMT

We often have hospitalised animals with severe nausea that seem to need cerenia and emeprid CRI ( ie spiked their fluids)

would not want to be without either.

but if you don't provide intensive care facilities with 24 hour monitoring of hospitalised animals on fluids then perhaps you don't need it. it is very labour intensive keeping a very ill animal on 2 or 3 lines with associated pumps, and I doubt that many people need to be able to do this. Or would want to.

I also use emeprid orally for fibrevores ( apparently the new posh word for bunnies G pigs and chins) with stasis / ileus / anorexia issues.

But my mainstay anti emetic is cerenia, and it seems to be useful for far more than just anti emesis.

I don't feel either option is that expensive and as a medicine oriented vet, i appreciate having medicines available to use. Take them away from me and you take away half the fun i get out of my job.

Re: Anti emetics

Anthony Todd — Fri, 28 Sep 2012 17:53:58 GMT

[quote user="Jo Jones"]If an animal continues to vomit despite cerenia that's a good indication we should be looking further for underlying cause.[/quote]

Most of my colleagues used metoclopramide in the same way; as a diagnostic and or therapeutic aid. 49 out of 50 stopped vomiting and were back to normal in 24hours.

Re: Anti emetics

Elizabeth Tuley — Fri, 28 Sep 2012 17:15:28 GMT

I used to use Cerenia in dogs and Emeprid in cats, now that Cerenia is licenced in cats I use that for both, it seems to be a much more effective anti-emetic in both species, which I have always assumed is because it is centrally acting.

Re: Anti emetics

Sarah Keir — Fri, 28 Sep 2012 16:57:32 GMT

[quote user="David Mills"]

Metoclopramide has a very poor action on cats because they lack the dopamine receptors centrally that mediate the anti-emetic effect.

[/quote]

I second that but only found out today, reading the notes from RVC online CPD 'Logical clinical problem solving online' with Jill Maddison.

Re: Anti emetics

Charlotte Marshall — Fri, 28 Sep 2012 16:51:21 GMT

Primarily use cerenia and I think it is a better antiemetic than metoclop. I do use metoclop for rabbits and occasionally as a motility stimulant in dogs. I only use the cerenia tablets for motion sickness and then pretty rarely as they are quite expensive.

Re: Anti emetics

Bob Russell — Fri, 28 Sep 2012 15:47:06 GMT

Perhaps I just don't get to see gastroenteritis cases in cats! in reality most of the 'simple' vomiting and diarrhoea bouts happen where the owners cannot observe but I have very few 'sickness and diarrhoea' cats presented. Plenty of diarrhoeas that frequently show up as giardia +ve!

Vomiting and diarrhoea in dogs almost every day - most are run of the mill 'tummy bugs' - if vomiting is the primary feature I treat that (anti-emetics) and diarrhoeas get spasmolytics (if appropriate) together with one of the many preparations available.

Strange how different practices see different case types!

Re: Anti emetics

Mark Holmes — Fri, 28 Sep 2012 14:26:18 GMT

Bad mouse syndrome is a favorite diagnosis.

Assuming that a sick mouse/bird is more vulnerable than a fit one, it would seem sensible to assume cats catch a large number of small birds and mammals that are ill in one way or another. Surely eating something with something nasty would make you predisposed to getting something nasty and hence a sensitive vomiting reflex is worthwhile evolutionary speaking and gastroenteritis relatively common. Its certainly common in my clinic!

Re: Anti emetics

David Mills — Fri, 28 Sep 2012 14:17:23 GMT

[quote user="Bob Russell"]

How often do cats get gastroenteritis?

[/quote]

Who knows? There is no evidence for these things other than anecdote. Gastroenteritis don't generally make it to referral centres.

Clinical experience surely tells us that the vast majority of vomiting in either dogs or cats is self-limiting - the vast, vast majority of (especially non-aged) cats don't even get past a clinical exam. Especially outdoor ones. Unless you can put it down to 'pigging out' or 'furrball' you run further diagnostics? On what possible evidence? You don't think eating a mouse can cause vomiting? I'd be genuinely interested to know, and whether others are as bemused as I.

In fact, cats have a fantastically well developed vomiting centre. I regard it as normal for cats to be sick at least a couple of times a month.

Re: Anti emetics

james herriot lied — Fri, 28 Sep 2012 13:47:07 GMT

[quote user="Bob Russell"]

[quote user="David Mills"]

??? what about straightforward GE?

[/quote]

How often do cats get gastroenteritis?

[/quote]

. . . . . . .

Re: Anti emetics

Bob Russell — Fri, 28 Sep 2012 13:24:02 GMT

[quote user="David Mills"]

[quote user="Bob Russell"]

I rarely use any anti-emetic in cats without having a fair idea of what is causing the vomiting. Other than the 'pigging-out' or furball situations the likely causes of vomiting in cats are serious so investigation is my priority rather than masking symptoms. I have to admit I have not used Cerenia in a CRF cat and have found metoclopramide useful in the past.

Dogs often vomit for more minor reasons so a jab of metoclopramide does not seem inappropriate to make them feel better. I have not had a case where a FB was masked by either drug, yet!

[/quote]

??? what about straightforward GE?

[/quote]

How often do cats get gastroenteritis?

Re: Anti emetics

David Mills — Fri, 28 Sep 2012 13:06:23 GMT

[quote user="Jo Jones"]

I use both, for different indications.

I love Cerenia as an antiemetic, as I find they can still vomit through it if they need to. If an animal continues to vomit despite cerenia that's a good indication we should be looking further for underlying cause.

Metoclopramide is great if I want a prok-kinetic effect. In some instances that is contra-indicated (ie not 100% ruled out an obstruction), then cerenia is definitely the way to go.

I've had pretty good results with metoclopramide in cats as well as dogs. Used to us it in rabbits, but prefer ranitidine.

[/quote]

I'm really, really suspicious that metoclop doesn't do anything in a lot of cases. Saline leads to 50% not vomiting anymore:

http://www.ncbi.nlm.nih.gov/pubmed/19000277

And metoclop only really works in centrally-mediated vomiting,

http://www.ncbi.nlm.nih.gov/pubmed/19000276

and it is highly questionable in animals how significant central vomiting actually is.

Further, metoclop does increase gastric motility in dogs at higher doses but it is unsure whether this actually leads to increased gastric emptying.

Re: Anti emetics

David Mills — Fri, 28 Sep 2012 12:19:16 GMT

[quote user="Bob Russell"]

Dogs often vomit for more minor reasons so a jab of metoclopramide does not seem inappropriate to make them feel better. I have not had a case where a FB was masked by either drug, yet!

[/quote]

??? what about straightforward GE?

Re: Anti emetics

Bob Russell — Fri, 28 Sep 2012 12:06:48 GMT

Dogs often vomit for more minor reasons so a jab of metoclopramide does not seem inappropriate to make them feel better. I have not had a case where a FB was masked by either drug, yet!

Re: Anti emetics

Jo Cobbett — Fri, 28 Sep 2012 11:55:14 GMT

[quote user="Mark Holmes"]

I would caution the use of cerenia, another post has said they can vomit through it, in my experience they cannot. Or at least a number cannot. I have removed several foreign bodies from animals late due to over zealous use of cerenia.

[/quote]

We had a dog in this week that presented with V+ and D+, relaxed abdomen and Os swore no history of FB ingestion. Was treated initially with cerenia, ranitidine and sucralfate, but continued to vomit, the following day a large stone was removed from its small intestine. I would not in any way suggest that response to cerenia is used as a diagnostic (I realise my earlier post sounded a bit blase, but that was not my intention), if there is a possibility of a foreign body it should be worked up accordingly, but I'd certainly rather use cerenia than metoclopramide in these cases.

Re: Anti emetics

Mark Holmes — Fri, 28 Sep 2012 11:43:51 GMT

One had a plastic toy capsule from a kinder egg in its small inestine and 5 litres of fluid in its stomach, which needed to be pumped out. The stomach had rotated and it presented as a GDV. On a related note make sure you check your GDVs for a FB after decompressing and correcting them.... it came as a shock.

Re: Anti emetics

David Mills — Fri, 28 Sep 2012 11:20:30 GMT

[quote user="james herriot lied"]

Would that be 4mg/kg/day, or 4mg/kg BID?

[/quote]

BID-TID

Re: Anti emetics

Jo Cobbett — Fri, 28 Sep 2012 11:10:12 GMT

I use both, for different indications.

Metoclopramide is great if I want a prok-kinetic effect. In some instances that is contra-indicated (ie not 100% ruled out an obstruction), then cerenia is definitely the way to go.

I've had pretty good results with metoclopramide in cats as well as dogs. Used to us it in rabbits, but prefer ranitidine.

Re: Anti emetics

james herriot lied — Fri, 28 Sep 2012 11:08:37 GMT

[quote user="David Mills"]

Another nugget from congress was that rantidine needs to be given at around 4mg/kg to show any reduction in gastric pH - top end of quoted range is 2mg/kg.

[/quote]

Would that be 4mg/kg/day, or 4mg/kg BID?

I try to avoid use of anti-emetics full stop, and certainly in the initial stages (although I suspect like most colleagues, most of my chuckers are several days on by presentation), as we seem to be the FB capital of the world. Never use cerenia for motion sickness, partly because of cost and partly because it's failing to reduce the problem long-term; for nausea associated with vestibular events, I'll generally use betahistine and attack the motion sickness that way - seems to work well. Still use the (very) odd bit of metoclop for short term cover, although I'd agree about the extra-pyramidal effects when given at high doses/for prolonged periods.

I'm largely the same way with the diarrhoeas - support the body whilst it does its own thing.

(although I did bite the bullet with the horrible HGE this week that kept retching, just so's I could send it home. A spot of cerenia, and it was good for discharge; so what do I know).

Re: Anti emetics

David Mills — Fri, 28 Sep 2012 10:45:12 GMT

Cerenia is by far and away the most efficacious anti-emetic. Metoclopramide has a very poor action on cats because they lack the dopamine receptors centrally that mediate the anti-emetic effect. There was a very good presentation on this at BSAVA this year - a lot of the work on emesis in cats has been done in Iran funnily enought and there is plenty of evidence demostrating poor efficacy at dose rates quoted for therapy. Unfortunately, increasing the dose increase neurological side effects - as a result I never use it. The only use I see for metoclop is as CRI for really resilient vomiting dogs.

Another nugget from congress was that rantidine needs to be given at around 4mg/kg to show any reduction in gastric pH - top end of quoted range is 2mg/kg.

I don't think cerenia stings any more than an oily antibiotic and we have seen dramtic reductions in painful injections by refrigerating it. It may be expensive but it works. Like Mr Atkinson, I try to avoid supporting exploitative companies such as Eurovet (and therefore by extension, Dechra) - methadone, metoclop, prednisolone...

Re: Anti emetics

Martin Atkinson — Fri, 28 Sep 2012 09:55:09 GMT

[quote user="Mark Rowland"]

Cerenia works well in ferrets.

(runs off and hides before Martin comes crashing in with "Why the bl**dy hell would people want to keep ferrets")

[/quote] Funny you mention it but.... one of my nurses just got one and I said just that. She wants it castrated and I've tried to talk her into a Suprelorin implant but she insists, cue a smelly surgery - c'est la vie.

In reply to the OP: Cerenia most of the time for dogs and cats (even before it was licenced for cats) hardly ever use the tablets, metoclopramide for bunnies (although obviously not as an anti-emetic) and as a CRI for vomiting animals on drips. I won't say if I use Emeprid or not as I don't wan't the VMB knocking on my door but my views on companies using the cascade as a back-door means to easy profitability by licencing perfectly good generics are well known.

PS Mark, you like these questionnaires don't you - is this going to become a habit? And for the record I actually have a few ferret clients, OK I think they're on the borderline of sensible pets but they have been domesticated for a long time so I don't have a problem like I do with captive wild animal species.