Immune mediated pancreatitis in Cockers

RE: Immune mediated pancreatitis in Cockers

Aine Seavers — Thu, 22 Sep 2016 12:50:52 GMT

Bob-you hit the nail on the head-the issue with so many drugs is the dose and the frequency as to whether its adverse or poison dose. If any animal is hypovolaemic then it should have fluids first-there are given rules-always based on good observation, full clinical exam and commonsense-it doesn't matter if its dexason or metacam you want to give a pancreatic patient- if its hypovol then you need to correct that not just dose any meds, esp i/v drugs.

Maybe that is why we didn't/don't see issues as we customise and individualise the care of each and every patient rather than follow a recipe or protocol.

Yes- one thing hanging with the aussies taught me was that pancreatitis was way up their d/d when it had hardly been mentioned in what I had been taught.

Andy Re writing findings up=I have written and published peer reviewed papers on areas of clinical passion so have been there, done that, and as you know it takes years of your life, financially punitive if in private practice, and with the new rules and ethics on what can and cannot be done-no way any ethic committee would pass such a project. You can't take a blood sample from a dog to be used in research for any reason unless the venepuncture was done for reasons other than research-ie at same time as investigative bloods in an ill animal or screening tests in a healthy pet-not just to test a theory or 30 years of personal efficacy with drug study.

That said-EBM rules and what passed for legit EBM have changed in the last 10 years so

maybe Tacit knowledge and clinical skilled observations will regain a more respected ground again that had been the case for some years.

I read 10-20hours a week minimum, and my reading suggests that steroids used early, at appropriate doses in a prepared patient are actually the way to treat many(not all) pancreatitic patients. On one hand we demand EBM, yet on the other we harangue the use of steroids based on old beliefs(often from misuse of bethamethasone extrapolated on to all g/cortiocoids(and preds are not bethameth) with no real evidence on the adverse side effect perceptions- yet the negative easily and vocally accepted but the good benefits of g/cortoicods not accepted.

Currently, a body of evidence exists that use properly these are not the demonic drugs we make them out to be for most of the 80s and 90s( a demonisation of the the drug family which I too once happily partook in pillorising as well). Now I wonder how many pseudomonas cases re otitis etc did I let suffer because of my then distaste for this family of meds -a distaste as taught to me by then specialists who really didnt have any more then than their own biased opinion their biased clinical case load which statistically and risk wise did not reflect general practice case loads nor clinical outcomes.

As you said, great to discuss these sometimes taboo subjects and hopefully the poor vet who started this thread has not run screaming for the hills as their original question led to so much not case-specific discussion.

RE: Immune mediated pancreatitis in Cockers

Bob Russell — Thu, 22 Sep 2016 11:51:59 GMT

I don't recall there being any adverse reactions but it was some years ago. This was also the era of a shot of antis and corticosteroids and investigate if that did not work. Pre pancreatic specific lipase tests!

I am getting more sceptical by the year of the idea that a shot of dex will make any infection worse (viral or otherwise). We are talking anti-inflammatory doses and not immunosuppressive ones.

Typical of so many veterinary situations. I wonder how VDS would view a vet giving steroids to every pancreatitis case!!

I seem to diagnose a lot of pancreatitis cases, to the point that an inappetant patient has pancreatitis until it is proved otherwise. Most of the time ends up being an appropriate diagnosis.

RE: Immune mediated pancreatitis in Cockers

Andrew Kent — Thu, 22 Sep 2016 11:25:15 GMT

Its a very interesting discussion but, in both human medicine and veterinary medicine, even with forms of pancreatitis that may have an immune-mediated aetiology the advice is to avoid steroids in acute disease.

The rationale for that is that these are often significantly hypovolaemic patients who may be at significantly increased risk of the adverse effects of these drugs. They are also at risk of coagulation disorders, bacterial translocation etc, all of which could be worsened by steroids. But, honestly, we don't have the evidence base to say either way whether this is an issue or whether this is useful.

If you have used it and you feel it works then it would be worth writing up - difficult to do this without a control group that doesn't have steroids - but looking at adverse effects (or lack of) would be very useful.

Andy

RE: Immune mediated pancreatitis in Cockers

Aine Seavers — Thu, 22 Sep 2016 00:08:33 GMT

It is interesting the changed approach in human medicine at the same time-in the face of severe infection esp of the lungs-steroids are now used early in the piece to stop the damage the inflammation causes-and that was some of the basis behind the dexason in the pancreatic cases-shut the inflammation down fast and address all other parameters-in the C.Spaniel you really do need to the address the immune mediated inflammation.

The potency of a drug and its effect on a target organ may not be linear-I have yet to have an ulcer with dexason-but have had dogs on hydrocort develop problems-was it a genomic adversomic in the lines and breeds I have had?-maybe.. but was a different breed each time-the specialists who had seen it that discussed it with me had problems in Wolfhounds and Brachycephalics- we now know so many French Bulldogs have ongoing gastric issues as part of their BOAD sydrome- was it a combination of that and not the stand alone drug?

We would need a pharmacologist to work out the ulcergenic potenital of both gastric and duodental tissue of each drug and then layer it against the background level of dysfunction expected in a particular breed perhaps to work out the risk-way beyond my basic Gen Pract brain. What has helped now is being able to use Cerenia, which is also anti-inflammatory to get the pain, the inflammation, the nausea and perhaps reflux all sorted and hold the dexason for the C.Spaniels and those dogs pancreatic dogs who present with suggestive previous history of having the haplotype that causes anal sacitis,KC, nephritis etc.

RE: Immune mediated pancreatitis in Cockers

Aine Seavers — Thu, 22 Sep 2016 00:00:13 GMT

I was taught exactly the same as you Bob. Then I fell into with a group of Aussies working in London, saw them give a once off dexason i/v to their pancreatic cases and their patients recover fast, whilst mine struggled on(this in the days pre PPI or Ranitidine and obviously Cerenia).So I tried it- and have done so since late 1980s-and happy with it.

In reply to an earlier question-I use raniditine at prokinetic doses for appetite assistance and uraemic gastritis -down at the 1mg/kg dose esp in older animals as you have to watch hypertension and glaucoma risk with this drug-lower doses work for my patients for the conditions I use it for. Obviously if it was being used to assist in the treatment of a drug induced ulcer then you need much higher doses than 1mg/kg.

I have replied to Jenny below

RE: Immune mediated pancreatitis in Cockers

Jenny Harris — Wed, 21 Sep 2016 21:08:32 GMT

Hi Aine

with regard to CIRCI, I believe this may still be a controversial area in human medicine as the CORTICUS study looking at pressor resistant hypotension in septic shock did show that hydrocortisone iv did improve BP but that this did not confer any survival benefit and was actually associated with a greater incidence of superinfections.

Also I guess personally I would be cautious about using dexamethasone as it has 37x the glucocorticoid activity of hydrocortisone and in a dog with acute pancreatitis that presumably has a local peritonitis and unhappy guts it could be quite ulcerogenic?

Anyway I do stand to be corrected as will happily admit don't know loads about this, have just finished endocrine module of a cert which raised some of these interesting questions

RE: Immune mediated pancreatitis in Cockers

Bob Russell — Wed, 21 Sep 2016 15:21:21 GMT

I avoid corticosteroids in acute pancreatitis because I have been told to! It was part of the standard treatment approach that was taught when I was in college.

Can anyone point me in the direction of evidence that they should not be used?

Cerenia can be a magic product but I had put that down to its anti nausea properties. You learn something new every day!

RE: Immune mediated pancreatitis in Cockers

Aine Seavers — Tue, 20 Sep 2016 23:43:21 GMT

Hi Jenny, if more vets replied like you this would be a better list as would get true debate. The reasons I use glucocorticoids are that my personal experience has been and my recent readings have suggested that Steroids up regulated specificially P.A.P(pancreatitis assoc protein:protective anti inflamm and anti cell death and protective on lungs) and have extensive protective effects. Some Cocker Spaniel pancreatic issues are immune mediated so dexason is needed- obviously don't use with an NSAID. The Spaniel issue is that the IMHA Assoc with C.Span is also Assoc with the same haplotype as the pancreatic issue AND nephritis and KCs and anal sac issues-and my experience has been that its the spaniels who go on to develop the IMHA far too often if steroids were not given. A lot of the bad press about vaccines and IMHA has come via the C.Spaniel and its high incidence of IMHA where the coincidence of a vaccine in previous months was linked as the causation of the IMHA when the 2 were not related.

CIRCI is Critical illness Response Corticocoid Insufficiency- hypotension in septic shock- they need i/v steroids..

RE: Immune mediated pancreatitis in Cockers

Jenny Harris — Tue, 20 Sep 2016 22:22:01 GMT

Also I have just seen that Aine and some other people use steroids in their pancreatitis treatment protocols- I am not sure of the evidence base for this so wasn't meaning to criticise- just passing on what I was told today on the course- I appreciate many people have different approaches

RE: Immune mediated pancreatitis in Cockers

Jenny Harris — Tue, 20 Sep 2016 22:19:12 GMT

Hello

I was at a course that Penny Watson was giving today. As Andrew has said currently no specific test for auto immune mediated chronic pancreatitis in english cocker spaniels, but they are working on a blood test (to look for IgG4 antibodies). The cockers affected have mostly been Blue Roans, middle aged to older with a higher prevalence in males. At least 50% go on to develop EPI and or DM. Often a mass like lesion is seen on ultrasound.

As Andrew also said you can look for dry eye, also dry mouth (Dental disease, tacky mucous membranes), and as it can cause glomerulonephritis also you can check a UPC. This is because the antibody attacks ductular tissue.

If you have an english cocker spaniel with chronic pancreatitis then they say there is enough circumstantial evidence to justify immunosuppression, but there have been no controlled trials. In acute pancreatitis I don't think it is recommended to use steroids in any dog.

Hopefully I have summarised accurately what was said today, hope it helps- I'm not a specialist. If you do become suspicious this may be what you are dealing with in this dog then Penny is asking people to contact her to help with the research into the condition.

Jenny

RE: Immune mediated pancreatitis in Cockers

Aine Seavers — Tue, 20 Sep 2016 04:41:29 GMT

Could the person who scored this a 1-ie strongly disagree- please explain how you can strongly disagree with published facts and with someone else personal experience and background knowledge of what is happening with this drug with the vets researching it ??? - otherwise this star marking thing is a farce and should be altered so it no longer appeals to the lowest demoninator

RE: Immune mediated pancreatitis in Cockers

Aine Seavers — Tue, 13 Sep 2016 04:34:07 GMT

Yes, there is published data going back a few years now, Twedt did the early work showing it was as effective as morphine for abd pain op analgesia. And never underestimate the effect of good clinical observation skills noted to support or decry any data-in this case Watch a pancreatic case within 20mins-1/2 hr of a Cerenia-the pain relief is almost palpable and is better than an opiod as you dont get sedation or nausea-just a relaxed animal no longer in agony. The anti Sub P effect(Gabapentin as similar anti Sub P action) is also effect in bladder pain/cystitis where the wall inflammation is the cause of the pain- so I use it in my bladder cats- data on that not yet published but a few vets working in background looking at this. Other researchers have used it in lung inflammation/infection- I would not instinctively think it would work here -and it would appear from early feed back that those using it have not found the same efficacy as in gut and bladder. The family of this drug is fascinating with lots of actions so worth reading up on it as Cerenia has become a handy helper in my clinic for more than just anti-emesis. Some Feline idiopathic ulcerative lesions or intense pruritis cases respond as a short term rescue - again quite a bit on that from the derm world.

RE: Immune mediated pancreatitis in Cockers

Julian Earl — Mon, 12 Sep 2016 22:10:17 GMT

Pancreatitis is an interesting condition I think and a few years ago 29/3/12 to be precise Penny Watson gave an illuminating presentation to Lincs. BVA. She happened to mention Cockers can have a genetic defect in carbonic anhydrase functionality and this enzyme is important in several body-systems viz including : anal glands/lachrymal glands/pancreas and it struck me that what are three common doiseases or syndromes in Cockers?Dry-eye/pancreatitis/anal cac disease all linked by one genetic defect perhaps. I'm not sure that it helps yur treatment of a case but understanding usually helps sooner or later? So yes, HTH?

RE: Immune mediated pancreatitis in Cockers

Anthony Dennison — Mon, 12 Sep 2016 13:54:38 GMT

[quote user="robloxley"]

[quote user="Aine Seavers"]Cerenia these days is so powerfully gut analgesic[/quote]

Is there any data for this??

[/quote]

There was a study performed in cats that showed maropitant does have a visceral analgesia effect.

RE: Immune mediated pancreatitis in Cockers

Rob Loxley — Mon, 12 Sep 2016 13:48:27 GMT

[quote user="Aine Seavers"]Cerenia these days is so powerfully gut analgesic[/quote]

Is there any data for this??

RE: Immune mediated pancreatitis in Cockers

Kathryn Burton — Mon, 12 Sep 2016 12:30:59 GMT

Sorry there are new replies since I last logged in - so adjusting above comment to 'thanks everyone'!

RE: Immune mediated pancreatitis in Cockers

Kathryn Burton — Mon, 12 Sep 2016 12:30:00 GMT

Thanks Andy.

RE: Immune mediated pancreatitis in Cockers

Aine Seavers — Mon, 12 Sep 2016 00:15:23 GMT

I have lost count of the number of pancreatic cases we pulled back with glucocorticoids-and given the work on C.Spaniels esp and that g/c are in fact back in vogue for pancreatitis -then this dog needs i/v dexason, s/c cerenia so that in 24hrs it will be dramatically better and less painful. The concern often with this CS pancreatic cases is they develope AIHA as a sequel, hence why the g/c early a good option(unless you are already used Metacam....). I used to use ranitidine at 1/2mg/kg does give some palliative relief from nausea but Cerenia these days is so powerfully gut analgesic and anti-nausea that not using Zantax as commonly as once did.

RE: Immune mediated pancreatitis in Cockers

Martin Atkinson — Wed, 07 Sep 2016 09:21:01 GMT

In the oldern days before the asteroid struck we dynovets used to give corticosteroids as part of a treatment protocol for acute pancreatitis and they seemed to help whether this was because or despite I'm not sure. Their use has been frowned upon more recently and I don't use them having learned from the asteroid strike but maybe this is a situation where they could be considered.

RE: Immune mediated pancreatitis in Cockers

Andrew Kent — Wed, 07 Sep 2016 08:24:12 GMT

Hi,

there isn't a specific test for that disease at present (it's being worked on) other than potentially biopsy findings but I doubt that would change your treatment at present.

it does, in some dogs, occur with other immune mediated diseases (dry eye, glomerulonephritis).

I would still manage this conventionally at present unless more chronic or recurrent.

Andy