Thoracic X Rays Wheezy JRT

Re: Thoracic X Rays Wheezy JRT

KathW — Thu, 25 Oct 2012 21:21:49 GMT

Rajat,

Thanks for taking the trouble to put all that information on. That's my bedtime reading sorted once I've taken the dog out in the dark and cold!

Edit - Fritz the Brave looks interesting too - thanks for pointing me there!

Re: Thoracic X Rays Wheezy JRT

Rajat — Thu, 25 Oct 2012 20:29:44 GMT

Hi Kath

Reviewing what I found on the topic, it appears I have misled you - I have found some conflicting info -

One source I found says it takes '7-10 days', not 30 for Flixotide to reach appropriate concentrations in the lungs. The other says '1-2 weeks, possibly longer'. However, immediate improvement can also be seen after inhaled gluco-corticoids. Sorry about saying it takes a month- that's what I had stuck in my head from a lecture a few years ago.

Having said that, I would still wean the oral preds slowly at the 10 day mark, because the dog may have severe disease which could flare up with rapid cessation or because the dog may not tolerate weaning at all i.e. may be oral pred dependent (unless other meds eg bronchodilators are added in)

Go for Seretide if I were you, one puff BID via Aerodawg inhaler, hold for 7-10 breaths, ensure pet not breath holding!

I am copying and posting the insert from Plumb's for you on Flixotide. If you want other papers or conference proceedings /lectures on it I can send you those too. PS try www.fritzthebrave.com

Fluticasone Propionate

previous | list all

(floo-ti-ca-sone)

Flovent®

Glucocorticoid, Inhaled/Topical

Prescriber Highlights

Glucocorticoid used most commonly in veterinary medicine as an inhaled aerosol

Has shown efficacy in treating feline asthma, dogs with chronic cough, & in horses for recurrent airway obstruction or inflammatory airway disease

May be useful as a nasally inhaled treatment for allergy-related rhinosinusitis

Appears to be well tolerated; suppression of HPA axis possible

Must be used with a species-appropriate delivery device

Expense may be an issue

Uses/Indications

While there are topical forms of fluticasone, most veterinary interests are in the inhaled versions of the drug. The aerosol for pulmonary inhalation appears to be effective in treating feline asthma, recurrent airway obstruction (RAO, heaves) or inflammatory airway disease (IAD) in horses, and dogs with chronic tracheobronchial disease. While the majority of small animal use has been with fluticasone, there are several other aerosol corticosteroids for inhalation (beclomethasone dipropionate, flunisolide, and triamcinolone acetonide) that theoretically could be used for the same purpose. The nasal inhalation corticosteroid products may be useful for allergy-related chronic rhinosinusitis in cats and dogs.

Pharmacology/Actions

Like other glucocorticoids, fluticasone has potent antiinflammatory activity. Fluticasone has an affinity 18X that of dexamethasone for human glucocorticoid receptors. For a more thorough discussion of glucocorticoid effects, refer to the Glucocorticoids, General Information monograph.

Pharmacokinetics

In humans, when fluticasone aerosol is administered via the lung, about 30% is absorbed into the systemic circulation. In humans, a dose of 880 micrograms (4 puffs of the 220 microgram aerosol) showed peak plasma concentrations of 0.1 to 1 ng/mL. Volume of distribution averages 4.2 L/kg and it is 91% bound to human plasma proteins. Fluticasone is metabolized via cytochrome P450 3A4 isoenzymes to a metabolite with negligible pharmacologic activity. Terminal elimination half-life is about 8 hours. Most of the drug is excreted in the feces as parent drug and metabolites.

Contraindications/Precautions/Warnings

Fluticasone is contraindicated when patients are hypersensitive to it or during acute bronchospasm (status asthmaticus).

Adverse Effects

In humans, the most likely adverse effects are pharyngitis and upper respiratory infections. While inhaled steroids generally cause significantly fewer adverse effects than injectable or oral therapy, suppression of the HPA axis can potentially occur. However, one study in cats using different concentrations of inhaled fluticasone, did not show any significant HPAA suppression at any of the doses used (Cohn et al. 2010). When transferring patients from systemic steroid therapy to inhaled steroids, wean slowly off systemic therapy to avoid acute adrenal insufficiency. Prepare to cover patients with additional steroid therapy during periods of acute stress, severe asthma attacks occurring during the withdrawal stage, or after transfer to inhaled steroids. Fluticasone is not useful for acute bronchospasm; cases of fluticasone-induced bronchospasm have been reported in humans.

Reproductive/Nursing Safety

In humans, the FDA categorizes inhaled fluticasone as a category C drug for use during pregnancy (Animal studies have shown an adverse effect on the fetus, but there are no adequate studies in humans; or there are no animal reproduction studies and no adequate studies in humans.) When given subcutaneously to laboratory animals, fluticasone caused a variety of teratogenic effects, including growth retardation, cleft palate, omphalocele and retarded cranial ossification. It should be used during pregnancy only when the benefits clearly outweigh the risks of therapy.

It is not known if the drug enters maternal milk; use with caution in nursing dams.

Overdosage/Acute Toxicity

Acute overdoses of this medication are unlikely, but there have been reported cases of dogs puncturing canisters of albuterol and developing adverse effects. A similar occurrence with fluticasone would unlikely require treatment. Chronic overdoses could result in significant HPA axis suppression and cushinoid effects.

Drug Interactions

While the manufacturer states that due to the low systemic plasma levels associated with inhalational therapy clinically significant drug interactions are unlikely, use caution when used in conjunction with other drugs (such as ketoconazole) that can inhibit CYP 3A4 isoenzymes; theoretically, fluticasone levels could be increased

Laboratory Considerations

No specific laboratory interactions or considerations were noted

Doses

Cats:

For treatment of feline "asthma":

1. Initially, try the 44 micrograms/puff MDI: one puff q12h. In the study, all three dosages (44 micrograms, 110 micrograms and 220 micrograms) significantly reduced the proportion of eosinophils in airway lavage fluid. (Cohn et al. 2010)

2. For cats with signs of bronchial disease that occur more than once per week:
Give prednisolone at 1–2 mg/kg PO twice daily for 5–7 days. Most newly diagnosed cats will have greatly diminished signs; then the dose is slowly tapered over at least 2–3 months. Some cats are effectively managed by low dose, alternate day corticosteroids, but most will continue to wheeze/cough. For those, encourage inhaled corticosteroids such as fluticasone.
Use a delivery device (e.g., AeroKat®) in combination with a spacer and 110 micrograms fluticasone metered dose inhaler (MDI) and administer one puff twice daily. Cats with more serious disease may require the 220 micrograms MDI. Author has not found the 44 microgram inhaler to provide consistent clinical results.
Attach MDI and the facemask to the spacer. Place facemask gently over cats mouth and nose and actuates the MDI to fill the spacer with medication. The cat breathes in and out for 7–10 times with the mask in place. (Padrid 2006), (Padrid 2008)

Dogs:

For adjunctive treatment of chronic tracheobronchial disease:

1. In dogs with excessive side effects associated with oral steroids therapy: Use a delivery device (e.g., AeroDawg®) in combination with either fluticasone 220 microgram or 110 microgram (1 puff) twice daily. Ensure a tightly fitting face mask and counting 7–10 respirations after actuating the MDI into the spacer is important for optimizing therapy. (Johnson 2007)

2. Using the 220 micrograms/puff MDI: 2 puffs q12h. (Hawkins 2009)

Horses:

Use a delivery device (e.g., Aeromask® or Equine-haler®) in combination with a metered dose inhaler:

1. For the prototypical young racehorse with IAD: Weeks 1 and 2: Fluticasone 2200 micrograms (10 puffs) twice daily or beclomethasone HFA 1000 mg (5 puffs) twice daily with albuterol 450 micrograms (5 puffs) prior to steroid inhaler and at approximately 30 minutes before exercise. Weeks 3 and 4: Fluticasone 2200 micrograms (10 puffs) once daily or beclomethasone HFA 1000 mg (5 puffs) twice daily. Recheck in 4 weeks to determine further treatment.
For the typical horse with moderate RAO (heaves): Begin stringent control of environment and a course of systemic prednisone therapy. (Note: Reference does not state when oral prednisone should be discontinued.) At week 3 add fluticasone 2200 micrograms (10 puffs) twice daily with salmeterol 210 micrograms (10 puffs) twice daily. Week 4: fluticasone 2200 micrograms (10 puffs) once daily with salmeterol 210 micrograms (10 puffs) once daily. If lung function shows a good response at end of 4 weeks: fluticasone 2200 micrograms (10 puffs) once every other day with salmeterol 210 micrograms (10 puffs) once daily. (Mazan 2002); (Mazan 2003)

2. Using the EquineHaler: 6 mg q12h. In the study this dose was as effective as dexamethasone (0.1 mg/kg IV) for prevention of exacerbations, but not as effective as dexamethasone for short-term treatment. It is highly likely that a lower dose of fluticasone can be used. (Robinson et al. 2009)

Monitoring

Efficacy

Client Information

Before using, shake well and, if possible, bring canister to room temperature. Do not puncture or incinerate can. Must be used with a spacer device appropriate for the species being treated.

Allow animal to breath with the mask on for 7–10 times before removing

One puff twice a day will last approximately 2 months

Chemistry/Synonyms

A trifluorinated glucocorticoid, fluticasone propionate occurs as a white to off-white powder that is practically insoluble in water and slightly soluble in ethanol.

Fluticasone may also be known as: CCI-18781, fluticasoni propionas, Advair Diskus®, Cutovate®, Flixotide®, Flixonase®, Flovent®, and Flutivate®.

Storage/Stability

Fluticasone propionate aerosol for inhalation (Flovent®) should be stored between 2–30°C (36–86°F); protect from freezing and direct sunlight. Store canister with the mouthpiece down.

Dosage Forms/Regulatory Status

Veterinary-Labeled Products: None

Human-Labeled Products:

Fluticasone Propionate aerosol for inhalation: 44 micrograms per actuation, 110 micrograms per actuation, 220 micrograms per actuation in 10.6 g & 12 g canisters with actuator. Each canister contains approximately 120-metered inhalations; Flovent® HFA & Diskus (GlaxoSmithKline); (Rx)

Fluticasone is also available commercially in combination as:

Fluticasone Propionate/Salmeterol Powder for Inhalation: 100 mcg fluticasone propionate, 50 mcg salmeterol; 250 mcg fluticasone propionate, 50 mcg salmeterol; & 500 mcg fluticasone propionate, 50 mcg salmeterol) in color-coded blisters; Advair Diskus® (GlaxoSmithKline); (Rx)

Fluticasone Propionate/Salmeterol Aerosol for Inhalation: 45 mcg fluticasone propionate/salmeterol 21 mcg per actuation; 115 mcg fluticasone propionate /salmeterol 21 mcg per actuation & 230 mcg fluticasone propionate/salmeterol 21 mcg per actuation equiv. to salmeterol xinafoate 30.45 mcg in 12 g pressurized canisters containing 120 metered inhalations.

Nasal solutions, topical creams and ointments containing fluticasone are also available.

References

1. Cohn, L.A., A.E. DeClue, et al. (2010). Effects of fluticasone propionate dosage in anexperimental model of feline asthma. Jnl Fel Med Surg 12: 91–96.

2. Hawkins, E. (2009). Treating canine chronic bronchitis: revisiting the basics. Proceedings: WVC. Accessed via: Veterinary Information Network. http://goo.gl/R2I3v

3. Johnson, L. (2007). The coughing dog. Proceedings: Univ Cal-Davis Canine Medicine Symposium. Accessed via: Veterinary Information Network. http://goo.gl/GmC6o

4. Mazan, M. (2002). Inhaled drugs: the hows, whys, and whens in prescribing. Proceedings: TUFTS 2002. Accessed via: Veterinary Information Network. http://goo.gl/2W58M

5. Mazan, M. (2003). Use of aerosolized bronchodilators and corticosteroids. Current Therapy in Equine Medicine 5. N Robinson Ed., Saunders: 440–445.

6. Padrid, P. (2006). Diagnosis and therapy of feline asthma. Proceedings: ACVIM 2006. http://goo.gl/ovF3z

7. Padrid, P. (2008). Inhaled steroids to treat feline lower airway disease: 300 Cases 1995–2007. Proceedings: ACVIM. Accessed via: Veterinary Information Network. http://goo.gl/zHJyO

8. Robinson, N.E., C. Berney, et al. (2009). Fluticasone propionate aerosol is more effective for prevention than treatment of recurrent airway obstruction. Journal of Veterinary Internal Medicine 23(6): 1247–1253.

Re: Thoracic X Rays Wheezy JRT

Rajat — Thu, 25 Oct 2012 09:19:01 GMT

Hi Kath

It takes a month or so for inhaled steroid concentrations to build up in the lungs. I would continue oral preds for this period of time, while the inhaler levels are building up then wean preds slowly. In some cases they are stable just on bronchodilators via inhaler and preds can be weaned earlier. But in a case like this I would probably not try that out of fear of a bad relapse. I'll see if I can find a review I may have saved on inhlaer use in dogs and cats with chronic airway disease.

PS- Not sure what happened with yr images but the second time you tried it worked beautifully !

Re: Thoracic X Rays Wheezy JRT

KathW — Wed, 24 Oct 2012 22:59:03 GMT

Thanks for the replies and help. They are digital x rays. I saved them to a cd - following the general directions on the screen (not sure if they said anything about choice in saving re compression etc. The cd saves software so at home there are 4 j pegs on the disc - size around 330 454 kB and the software to zoom in alter contrast etc. (program called minivue exe I think) I can't save anything from this programme. If I open the j pegs on the cd using windows photo viewer i can zoom in + out to some extent "properties" says 3000 pixels wide + 3000 length.

Is it to do with the way I saved them onto the cd in the first place? - So I know for next time!

Rajat I thought those ribs looked fractured as well when I was enlarging the views via Picassa!

Think I may suggest we try the inhaler for this dog. Am I correct in thinking that it can take a week or two with an inhaler to "build up" so maybe start on an inhaler and then reduce /stop prednisolone?

Does looking at the Picassa link and using their software to enlarge the pictures not help enough? (just hoping it may)

Is the bump at 1 o'clock the pulmonary artery as suggested by Rajat? Don't think I've ever seen that so clearly before.

Re: Thoracic X Rays Wheezy JRT

Anthony Dennison — Wed, 24 Oct 2012 17:54:15 GMT

Just wondering, I read somewhere (NOAH compendiumn perhaps?) that you shouldn't give over 20mg/kg Theophylline, which can be a problem with small dogs (ie Yorkies with collapsing tracheas), what do people use if the dog is too small for Corvental-D? I spoke to someone at MSD about possibly using Vivitonin and they said it could be used, anyone done this before?

Re: Thoracic X Rays Wheezy JRT

Mike Martin — Wed, 24 Oct 2012 17:38:59 GMT

I'd agree with the others I've highlighted.

R heart enlargement - cor pulmonale - pulmonary hypertension.

Secondary to lung parenchymal disease. DD - bronchitis, eosinophilic bronchitis/pneumonia, interstitial fibrosis, maybe rare things like pulm thromboembolism or paraquat. Unusually young dog for chronic bronchitis though.

The x-rays are still small for me to zoom in on the lung fields to see 'detail', which is frustrating. How are you saving the x-rays?

Good luck. Prognosis does not look good.

Re: Thoracic X Rays Wheezy JRT

Rajat — Wed, 24 Oct 2012 17:37:38 GMT

I agree with what David said

[quote user="KathW"]She also has another inhaler Seretide® (fluticasone propionate/salmeterol) a steroid + longer acting bronchodilator from what I've found on the internet. I was thinking about a steroid inhaler but would one like this be of more benefit?[/quote]

I've used Seretide as a sole inhaler in the past, either where owners have been less than reliable in monitoring their pets or where the problem is bad enough to need longterm bronchodilatory therapy. In patients diagnosed *early on* in asthma/chronic bronchitis, I often swap from Seretide to Flixotide after a month minimum and ask owners to keep Ventolin for reserve in case the pet shows any signs of respiratory distress. Seretide if I remember is significantly more expensive than Flixotide and Ventolin put together, I could be wrong though haven't checked prices in a pharmacy

To me the bigger size images have normal looking pulm vasculature..there are signs of bronchial disease, but it doesn't radio graphically look like hell..(rads not following clinical course of disease or me under-interpreting!) - I also believe I see 2 rib fractures, ribs 9 and 10 on the R side on your DV from October. Maybe even 11. 10 looks like its older. Rib fx: can happen with chronic asthma type/bronchial diseases. But I have a habit for forgetting costo-chondral junctions and what have you so prob worth having that confirmed by someone else..!

Re: Thoracic X Rays Wheezy JRT

David Mills — Wed, 24 Oct 2012 16:03:38 GMT

From these images, and history, it looks bang on chronic bronchitis.

You may have 2y pulmonary HT but you need an echo to confirm this- I wouldn't treat without because its hellish expensive (sildenafil) or slightly less expensive (pimo). There are once daily options of PDE5s (tadalafil, vardenafil) which may reduce costs. There is limited, but convincing, evidence base for sildenafil and pimo (pimo may be more effective if the PHT is due to L-sided heart issues) improving qulaity of life scores and clinical appearance. Neither have been repeatedly shown to reduce pulmonary artery pressure though.

If you have access, this is a great review (you can get them open access sometimes if you google the article):

http://www.sciencedirect.com/science/article/pii/S0195561610000392

Re chronic bronchitis, inhaled c/st appear to be a great tx in those that will accept them, partly because they don't cause weight gain which exacerbates the issue. Some authors recc methylxanthines (theophylline) which are hellish expensive, aren't bronchodilators but appear to make them less likely to collapse, and are of questionable clinical benefit; alpha 1 agonists (e.g. terbutaline) which are very cheap and have some evidence of success of preventing bronchospasm; pulses of abx such as doxycycline which appear to exert an anti-inflammatory effect on the respirtaory mucosa as well as treating recurrent infections. We have a lot of these on our books, and haven't found a winning formula; I doubt there is one, but inhalants appear to be the most reliable at improving life

Re: Thoracic X Rays Wheezy JRT

KathW — Wed, 24 Oct 2012 15:31:46 GMT

The above two were the Oct 2012 one's I'll post the June ones here - they seen to enlarge (enough?). I was thinking respiratory - small dog no murmur. heart rate = pulse rate= 120 ish from what I remember. marked expiratory effort. Not as wheezy /crackly when came in for the x rays as had been a few weeks prev (in meantine had had antibiotic course). Owner later volunteered that he had markedly declined after the antibiotics eneded -came back then for another check and booked for re x rays. Unfortunately no BAL done :(

On viewing the x rays I saw the heart enlargement on the RHS + bronchial and started to think is this pulmonary hypertension - but I've never actually diagnosed it (not looked hard enough in other cases maybe).

O also volunteered the info that they have a yorkie diagnosed with "asthma" about 4 yrs ago and they usea paediatric inhaler (with spacer) and ventolin for that one! We haven't seen it for ages - she gets ventolin from doctor for "herself"

She also has another inhaler Seretide® (fluticasone propionate/salmeterol) a steroid + longer acting bronchodilator from what I've found on the internet. I was thinking about a steroid inhaler but would one like this be of more benefit?

Re: Thoracic X Rays Wheezy JRT

KathW — Wed, 24 Oct 2012 15:19:40 GMT

I'll see if this os any better otherwise look at linking them from somewhere else on the net.

Link to Picasa https://picasaweb.google.com/110171768049071152635/October24201202?authkey=Gv1sRgCO3y49bmxdKnFQ#

Re: Thoracic X Rays Wheezy JRT

Martin Atkinson — Wed, 24 Oct 2012 11:39:30 GMT

NT pro-BNP to differentiate respiratory and cardiac causes of the cough and stage heart disease. BAL to see if its asthmatic/chronic bronchitic (these are frustratingly difficult to diagnose on X-ray) - if so Aerodawg with fluticasone inhaler. +/- Ventolin. Pimobendan at double doses works as well as Viagra at a fraction of the cost in pulmonary hypertension.

Re: Thoracic X Rays Wheezy JRT

Hannah Wynne Richards — Wed, 24 Oct 2012 10:03:02 GMT

What about a flixotide inhaler bid?

Wynne

Re: Thoracic X Rays Wheezy JRT

Mike Martin — Wed, 24 Oct 2012 09:11:03 GMT

These are too small an image size for me to read. If I try to magnify the image at all, they pixelate. Can you upload higher resolution images? I'd suggest approximately 1000 pixels wide would suffice? If these are digital x-rays - when saving as a Jpeg, opt for maximum quality (ie. minimum compression) they will still be small files compared to DICOM files.

Re: Thoracic X Rays Wheezy JRT

Rajat — Wed, 24 Oct 2012 00:38:10 GMT

[quote user="james herriot lied"]TBH, I think Rajat must have a large-screen monitor, because I can only just make out that it's a dog.... [/quote]

No, just a regular laptop -I blew the images up - but obv lost some/a lot of resolution. And hence what I posted included a fair bit of guesswork!

Re: Thoracic X Rays Wheezy JRT

tess — Tue, 23 Oct 2012 23:59:28 GMT

Owners need to stop smoking! Any therapy is likely to be limited in a house full of smoke...

Re: Thoracic X Rays Wheezy JRT

james herriot lied — Tue, 23 Oct 2012 22:39:46 GMT

TBH, I think Rajat must have a large-screen monitor, because I can only just make out that it's a dog....

These cases are certainly interesting from a clinical viewpoint, as I think chronic respiratory issues are some of the least-protocol'd and most difficult to get on top of. We all have our own approaches, and the only inevitability is that we all end in more or less the same place.

For me, as a long-time asthmatic, I find these patients easy to empathise with. I like inhalers, because of my own experience, but after 2-3 years of chronic symptoms - and an asymptomatic lead-in which was probably double that - the compliance of small airways is likely to be much reduced, particularly if you're at the stage of pulmonary hypertension. Are costs an issue here? Viagra is great for the right-sided hypertensions, but cripplingly expensive.

But as luck would have it, smoking can cause impotence - so the male owner might just have his own supply

Re: Thoracic X Rays Wheezy JRT

Rajat — Tue, 23 Oct 2012 21:56:37 GMT

Oh, and also there is hyperinflation on both lateral and DV on the first set of radiographs where the dog is not anaesthetised...

Re: Thoracic X Rays Wheezy JRT

Rajat — Tue, 23 Oct 2012 21:53:42 GMT

Hi KathyW

On a wing and a prayer I could be way off the mark here but..

I'd say you have evidence of chronic bronchitis, a moderate broncho-interstitial pattern and what looks like bronchial wall calcification..

There is cardiomegaly, and suggestive of R sided cardiomegaly (incrsd sternal contact and widening on lateral, and suggestion of reverse D shape on DV)

I think the bump you're seeing at the 1 o clock position is the Pulmonary artery. The dog may be suffering from pulmonary hypertension (cor pulmonale) secondary to respiratory disease (or R sided heart dzs/Pulmonary hypertension due to another cause). Is there by chance soft murmur on the R side?

I'd guess that the radiolucent wedge is air trapped between a skin fold..

Any signs of collapse or exercise intolerance? Can they use an inhaler? As I'm sure you know, oral bronchodilators like Terbutaline or Theophylline can help fair bit in increasing resp signs and helping to reduce steroid dose..Shame they won't stop smoking!!

Bigger pictures would be more helpful btw -if the size limit is too small you could try posting them on another site or google docs/drive and putting the links here.Just a thought.

Re: Thoracic X Rays Wheezy JRT

KathW — Tue, 23 Oct 2012 20:12:04 GMT

Think I may have cracked it now

June

Then October

and October again

Re: Thoracic X Rays Wheezy JRT

KathW — Tue, 23 Oct 2012 20:07:16 GMT

That didn't work sorry! I've looked for some info on how to post pictures but can't find it. Here's the June x ray.