Lame dog with normal joints on CT

RE: Lame dog with normal joints on CT

Anthony Todd — Wed, 19 Oct 2016 14:49:53 GMT

[quote user="Lucy Fleming"]but it would still be up to them (if for example they could not afford it but could afford slightly less clinically preferable option B)[/quote]

So it's just about the money, and not a "therapeutic choice" really, as Apoquel is the preferred, advised, therapeutic option.

I'm happy with that, but the irony is that, from what you've described the diagnostic process will cost much more than the choice of treatment.

Trim that process, and you wouldn't have to defer over medication.

[sorry about the thread drift]

RE: Lame dog with normal joints on CT

Anthony Todd — Wed, 19 Oct 2016 14:00:13 GMT

[quote user="Lucy Fleming"]1) How long is an animal perceiving the sensation of pruritis before it manifests as behaviour (scratching)? [/quote]

Less than 5 seconds, I'd guess, possibly more if they're distracted if you're lucky.

They'll turn an itch. in 12-24 hours into a weeping mess, so then you can turn a "pyo-traumatic dermatitis" or "hot spot" or "moist eczema" or "linear granuloma" [cat] into a major diagnostic exercise, when a glance will tell me, and any dinovet, exactly what it is, and the owner how to get rid of the fleas, usually, whilst giving relief in 2-ish hours with a jab of dex.

Derm is usually, and solely, a visual diagnosis [er, with some embarrassing exceptions].

[quote user="Lucy Fleming"]Following on from this, I have more often than not found that when the owners re-present the animal it is self traumatised, full of secondary pyoderma and requires much more treatment.[/quote]

Oh dear, you all keep making my sole point.....

A shot of dex [don't know about Apoquel] always, always, avoids all this; totally, completely, and within 12 hours [overnight].

A good idea is to bind the opposing foot to the itchy area with sellotape, and the animal is therefore distracted in the initial vulnerable period before the dex kicks in, and chews away at the sellotape whilst the itch is relieved.

The owner is grateful for the relief, and is very likely to listen better to the diagnostic following steps.

I agree, about the "re-presentation" damage will happen over night or earlier, so an urgent jab of relief is obviously, to me anyway, the urgent, immediate, sensible thing to do.

And you usually don't get any secondary pyoderma either 'cos it's already starting to heal nicely.

They really were common before decent flea control so my n = loads.

Love to hear of a modvet doing it and the results but, fat chance...

Won't add a star but one [only]will be there soon!

RE: Lame dog with normal joints on CT

Lucy Fleming — Wed, 19 Oct 2016 13:06:13 GMT

[quote user="Anthony Todd"] at minimum effective dosage and pulse dosed as necessary[/quote]

I certainly understand your point about why this would be preferable from the point of view of avoiding side effects, there are 2 (main) reasons why I haven't found this approach useful:

1) How long is an animal perceiving the sensation of pruritis before it manifests as behaviour (scratching)? Ok, in animals without any 'I shouldn't scratch that massive mozzie bite' impulse control, probably not long, but how long until the owner notices it to the point of seeking treatment? Variable levels of not very satisfactory, IME.

2) Following on from this, I have more often than not found that when the owners re-present the animal it is self traumatised, full of secondary pyoderma and requires much more treatment.

RE: Lame dog with normal joints on CT

Lucy Fleming — Wed, 19 Oct 2016 12:56:52 GMT

[quote user="Anthony Todd"]Could I ask why you used apoquel and why the owner was involved in the therapeutic choice....???[/quote]

Replying to this because it's a bit rude to post and run, but will keep it short as the thread as a whole has veered wildly away from the OP!

In this situation, where there are (I feel) two valid medication options, where the decision making is likely to be more cost vs convenience than any dramatic clinical difference (I hope to use both medications to control pruritis) then I do feel it is a decision for the owner to make. A similar case might be use of Felimazole tablets vs the new liquid thiamazole preparation (Thyronorm) - I would be largely deciding based on how happy or not the owner would be to tablet. If I feel a particular treatment would have a clinical benefit over another I would advise the owner of this, and suggest they used that, but it would still be up to them (if for example they could not afford it but could afford slightly less clinically preferable option B)

RE: Lame dog with normal joints on CT

Aine Seavers — Tue, 18 Oct 2016 10:34:13 GMT

yep

RE: Lame dog with normal joints on CT

Anthony Dennison — Tue, 18 Oct 2016 10:19:53 GMT

[quote user="Aine Seavers"]So don't throw the baby out with the bath water, maintain a healthy skepticism about any drug claiming to be free of side effects- and individualize treatment for every case in front of you.[/quote]

I feel like this about Pexion...

RE: Lame dog with normal joints on CT

Aine Seavers — Tue, 18 Oct 2016 08:05:59 GMT

When Bigpharma is putting its new money away from Apoquel, then the warning lights go on. With Apoquel there was such a restriction on source that one expected few side effects as you need a critical mass to really see ADRs, and yet the specialists saw them with Apoquel-now when it hits the open market-expect to see a lot more issues even when it is used correctly-whereas in fairness to preds, when those used properly- there are less issues. I am delighted we feel the same way about pre-ga blanket blood screening in non geriatrics!

RE: Lame dog with normal joints on CT

Eilidh Corr — Tue, 18 Oct 2016 07:24:27 GMT

Don't get me started on blanket pre-anaesthetic blood testing, ugh!

I think it's fair to say that Apoquel isn't risk-free, but I don't think its risks over a lifetime of atopy are really comparable to pred.

RE: Lame dog with normal joints on CT

Aine Seavers — Tue, 18 Oct 2016 02:26:28 GMT

I liked your reply so ok, I will take a nibble;-). The Poison is in the dose argument does hold true to glucocorticoids, so yes a lot of the side effects noted with 'coids' are overdosing too much per day and for too long-so we can agree on that-with some coids'' more dose-sensitive than others.

As vets, we have the individual animal variation so the dog who gets aggressive on even low doses(usually larger dogs) or ridiculous polyphagia and the cats where cardiac dysfunction early on in the piece triggered by the glucocorticoid- which is idiosyncratic and not dose related as such-there are some decent papers on that from memory-back around 2002-but I have long given up storing hard copy data so others may be able to produce those papers for you.

I agree that many of us were overtaught anxiousness about çoids at Uni(because the worst cases ended up there, a skewered population which created the angst) and when used low dose as infrequently as possible preferably of a morning, with food when any complicating co-factors addressed- then yes g/coids can be very effective safe tools in our armoury.

Apoquel is also no different, you must address cofactors, keep within a tight dose/kg regime and watch for individual variations esp in the emerging field of breed specific genomics

Does that make Apoquel a bad drug and vets who use it bad vets ? Not at all- but it is not a drug to be complacent about. My reading of it is that its blanket anti-cytokine effect is the issue, hence why all the new money and time being put by big pharma into onto monoclonal antibodies against the specific Itch cytokine – which will be less immunosuppressive and probably will be species specific as well as different itch receptors in dogs versus cats suspected etc.

So don't throw the baby out with the bath water, maintain a healthy skepticism about any drug claiming to be free of side effects- and individualize treatment for every case in front of you. What is bugging me is reading recent papers about the benefit of blood testing healthy animals, part of the Wellness drive and pre-anesthetic bloods etc- the more I read the less validity I find for doing these tests in animals under 11 years of age, seems to be a lot of money spent to given you a 4% chance of finding an aberration-and that may not be of clinical significant. It seems we have left our skeptic gene at the door for that particular aspect of modern vet medicine.

RE: Lame dog with normal joints on CT

Anthony Todd — Tue, 18 Oct 2016 01:22:48 GMT

[quote user="Aine Seavers"]Steroids have side effects[/quote]

I always think your posts are accurate and measured but this time you are just perpetuating the myth.

And as for all the evidence; there ain't none, at minimum effective dosage and pulse dosed as necessary.

Someone, somewhere [even Australia...] must have some decent evidence, but none is ever produced just recitations of obvious continuous, and usually, overdose.

Glad to hear that Apoquel is not the panacea that some claim it to be.... steroids seem to be trouble free by comparison, even when misused.

RE: Lame dog with normal joints on CT

Aine Seavers — Tue, 18 Oct 2016 00:46:05 GMT

"Apoquel is a new drug that has no side effects that we know about" .I have not red starred this but I don't tend to agree. It has some really serious nasty side effects, ask any Derm centered forum and the specialist derm vets are seeing some significant ADRs with this drug. Steroids have side effects, we just know a heap about them- Apoquel in time will be the same. The trend here in Australia is to keep Apo as similar to good champagne-not something to hand around on a daily basis but reserved for fully worked up cases. It has the potential to exacerbate 2ndary infection,. will increase ap/alp/bile acids/renal parameters, it too can trigger pancreatitis, german shepherds developed linear and sut cuti masses, generalised hyperpig in Westies,can cause bone marrow depression, wt gain now being observed along with lipaemia( if on bid or split dose), Of note is Increased aggression, ataxia, causes a different lameness to the lameness induced by cyclosporin( so not a disturbed vascular perfusion) and also haematogenous borne fungal osteomyelitis and now Zoetis suggest care with neoplastic co-conditions. Some dogs reported to sleep with eyes wide open-almost like a M.gravis dog. All of these are side affects reported by veterinary dermatologists, not clients on the web- and probably if you ask your Zoetis rep they can provide you the data( as long as not like one rep of a company I won't name who replied to ph queries on ADRs that they had never seen it-when on rings a tech vet, one wants a reply based on the data reports not on personal narrow experience).

RE: Lame dog with normal joints on CT

Anthony Todd — Mon, 17 Oct 2016 19:59:13 GMT

[quote user="Beats"]I don't personally offer convenia to cat-owners[/quote]

+1 and 5 stars but you'll find a stiff shot of ordinaire PenLA works quicker and better and cheaper....

Convenia for cat bites, I have used it,but never for CBA [it's not that new], is total overkill, and bad medicine too.

RE: Lame dog with normal joints on CT

Beats — Mon, 17 Oct 2016 19:32:26 GMT

I've just started a new thread on infected cat bite treatment so can continue chat without getting in way of this clinical case thread.

Dave

RE: Lame dog with normal joints on CT

Evelyn Barbour-Hill — Mon, 17 Oct 2016 19:22:34 GMT

Why would you want to give more than 24 hours worth of antibiotic for a cat bite abscess?

RE: Lame dog with normal joints on CT

Beats — Mon, 17 Oct 2016 19:21:30 GMT

[quote user="Neil Wheadon"]

[quote user="Anthony Todd"]Any evidence that penicillin doesn't work in CBAs any more?[/quote]

Yeah that's right ,the cow Ampicillin LA injection. Unlicensed in cats and lasts maybe 3 days if that. Have you heard of Convenia, it was made in the 21st century, lasts 14 days, lovely stuff.

[/quote]

I don't personally offer convenia to cat-owners for cat bite abscesses as it is my personal opinion that it is not appropriate to use a cephalosporin in this manner. I will typically use (where I think systemic antibacterials are justified) amoxicillin injection and send home with amoxicillin drops/tablets with instructions to come back in 2-3 days for further injection if won't take the tablets/drops (rarely a problem). Occasionally I use clindamycin instead.

There are a number of amoxycillin LA injectable products licensed for cats in UK: e.g. Betamox LA, Amoxycare LA, Amoxypen LA, Clamoxyl LA, Duphamox LA

There are a number of effective and easy to adminsiter oral forms of amoxicillin licensed for cats: Amoxycare Palatable Drops, Amoxibactin tablets, Betamox Palatable drops

Additionally, there are a number of effective and easy to adminsiter clindamycin oral forms licensed for cats: Zodon, Clindaseptin, Antirobe.

From the convenia package insert:

"It is prudent to reserve third generation cephalosporins for the treatment of clinical conditions, which have responded poorly, or are expected to respond poorly, to other classes of antimicrobials or first generation cephalosporins. Use of the product should be based on susceptibility testing and take into account official and local antimicrobial policies"

If pressed by an owner for a convenia injection, for whatever reason, where I don't feel it an appropriate treatment that I would presonally recommend, I leave it vague that I think an alternative option is "better" in these circumstances.

I appreciate there are likely to be range of acceptable viewpoints on the treatment of something as common as cat bite abscesses - this is just mine and I don't suggest it trumps others

RE: Lame dog with normal joints on CT

Anthony Todd — Mon, 17 Oct 2016 19:03:04 GMT

[quote user="Neil Wheadon"] On preds for a month [/quote]

Not a good example, sorry, but more grist for the cartel.

I have never, ever, had any animal on preds for a month and nor should anyone!

But let's not spoil another misquote.

[quote user="Neil Wheadon"]I've also seen many atopic dogs with ears that get 2 weeks of preds that helps[/quote]

Never done that either and get good results as below, again, more grist for the cartel

Pulse, intermittent dosing; I have mentioned it.....

[quote user="Neil Wheadon"]Yeah that's right ,the cow Ampicillin LA injection.[/quote]

Oh dear, ampicillin never was any good for CBA; I was talking about, you know, the original penicillin.

[quote user="Neil Wheadon"]Apoquel is a new drug that has no side effects that we know about.[/quote]

Crikey don't let these informed clients read this from the manufacturers website then:

Most common side effects are vomiting and diarrhea. APOQUEL has been used safely with many common medications including parasiticides, antibiotics and vaccines.

and make sure they don't find NOAH either, even more...

RE: Lame dog with normal joints on CT

Eilidh Corr — Mon, 17 Oct 2016 18:49:14 GMT

Steroids have their place. I don't think, however, that any vet in practice today would seriously say they're preferable to Apoquel. And if we want owners to be compliant and our treatment to be successful then a good starting point is having their agreement. Most of them are perfectly capable of making a choice when given options. Why the arrogance?

RE: Lame dog with normal joints on CT

Neil Wheadon — Mon, 17 Oct 2016 18:32:31 GMT

[quote user="Anthony Todd"]

Ah, once again, the dogmatic antisteroid cartel still with no actual evidence.

The misuse of "steroids" must be nearly worthy of a Daily Mail campaign.

[/quote]

Oh good grief Anthony, stop it

I saw a dog last week. On preds for a month and all the weight had gone south, Cushingoid, shall I take a picture?

I've also seen many atopic dogs with ears that get 2 weeks of preds that helps. It's a balance

Apoquel is a new drug that has no side effects that we know about. It doesn't cause them to drink the taps dry (AKA the Tiger that came to tea) or open their own tins of dog food. Why would you use this aside a client who can't afford a pound a day?? (Though a few vets are checking haematology every 6 months)

[quote user="Anthony Todd"]Any evidence that penicillin doesn't work in CBAs any more?[/quote]

Yeah that's right ,the cow Ampicillin LA injection. Unlicensed in cats and lasts maybe 3 days if that. Have you heard of Convenia, it was made in the 21st century, lasts 14 days, lovely stuff.

Neil (not red staring.....again)

RE: Lame dog with normal joints on CT

Anthony Todd — Mon, 17 Oct 2016 17:52:34 GMT

[quote user="Neil Wheadon"]I really wouldn't have asked that one Anthony, it shows that you are no longer in practice and might explain why you get red stars so quickly as to be honest it's pretty obvious why this was used as has minimal side effect.[/quote]

Ah, once again, the dogmatic antisteroid cartel still with no actual evidence.

The misuse of "steroids" must be nearly worthy of a Daily Mail campaign.

[quote user="Neil Wheadon"]One cat, one abscess. 'Would you prefer the injection that's twice the price of the tablets?', I always offer the choice if appropriate, half go for antirobe, half for Convenia. The client feels involved and that's good for the practice. I discuss, not lecture.[/quote]

Any evidence that penicillin doesn't work in CBAs any more?

RE: Lame dog with normal joints on CT

Neil Wheadon — Mon, 17 Oct 2016 17:38:02 GMT

[quote user="Anthony Todd"]Could I ask why you used apoquel[/quote]

I really wouldn't have asked that one Anthony, it shows that you are no longer in practice and might explain why you get red stars so quickly as to be honest it's pretty obvious why this was used as has minimal side effect.

[quote user="Anthony Todd"]why the owner was involved in the therapeutic choice....???[/quote]

again rather than red star, here goes

One cat, one abscess. 'Would you prefer the injection that's twice the price of the tablets?', I always offer the choice if appropriate, half go for antirobe, half for Convenia. The client feels involved and that's good for the practice. I discuss, not lecture.

Neil (not red staring)

RE: Lame dog with normal joints on CT

Anthony Todd — Mon, 17 Oct 2016 17:21:16 GMT

[quote user="Lucy Fleming"] Should we add that information in capitals whenever we post about tests we have run? [/quote]

Yep. 'cos if someone else gets a similar case they will, sensibly, treat it as you have done, or not, depending on response.

No need to use capitals though, 'cos it upsets some.

No need to shout about the tests either 'cos, even in the most obvious cases, tests are a given these days.

Could I ask why you used apoquel and why the owner was involved in the therapeutic choice....???

RE: Lame dog with normal joints on CT

Lucy Fleming — Mon, 17 Oct 2016 12:16:54 GMT

Ok I usually try not to bite when Mr Todd is doing this but:[quote user="Anthony Todd"]But usually on here nothing at all is done for the animal whilst the diagnosis is pursued [/quote]

However, if you re-read the OP, you will see that:[quote user="Anthony Dennison"]Minimal response to rest and NSAID[/quote]. Yes, you could have used dex rather than NSAID but I wouldn't really expect a different response.

Even if diagnostics are run before treatment (as is occasionally appropriate to do), it doesn't have to delay treatment. [quote user="Anthony Todd"]Derms are the worst culprit ![/quote]. I by no means consider myself a dermatologist, but did see a skin case for a work up last week. I could have posted about the case and stated that skin scrapes were negative, fungal culture negative, culture showed Staph pseudintermedius, and skin biopsy was consistent with a hypersensitivity. What I could also do, is explain that I saw the dog in evening consults one day, with a chronic history and an owner that felt she had 'tried everything' (except actually coming to the vet, but that's a different story). All the samples for the tests above were collected under sedation the next day, and the dog went home that afternoon having started apoquel (could have been steroids, but that's what his owners and I chose) and antibiotics while we waited for the results. Should we add that information in capitals whenever we post about tests we have run?

RE: Lame dog with normal joints on CT

Anthony Todd — Mon, 17 Oct 2016 00:31:41 GMT

[quote user="Aine Seavers"]agree with you, disagree with you and explain why. [/quote]

Or +1; or mine usually ['roids] so -1 and then the reason.

RE: Lame dog with normal joints on CT

Anthony Todd — Mon, 17 Oct 2016 00:24:56 GMT

[quote user="grumpyoldman"]Depends upon the client and the animal these days, some clients want a minimalist approach ,usually if they are footing their own bill , others having a glistening bulging pet plan and want everything possible done ,no stone unturned from day one . I have on many occasions been told " I would really rather you X-rayed him now" rather than having to come back again. [/quote]

[Yes, clients think that "an Xray" will cure most conditions; I've even had a client suggest I Xray a dog killed in a RTA....]

This is fine if you give relief whilst doing all these exams; no argument with tests, 'cos this just maybe the weird and unusual diagnosis [and read all the theories and suggestions already].

But usually on here nothing at all is done for the animal whilst the diagnosis is pursued and often, as there is no diagnosis, still nothing. Derms are the worst culprit !

This has the other, and vital, effect of disappointing the client who naturally, and reasonably, wants to see some improvement quickly.

How often has a client said to you "Aren't you going to give it an injection...."

The thing that really gets me is that relief for the animal, even the dreaded 'roids, won't affect any diagnosis if it ever is made, in almost all cases, and certainly in a vague lameness.

My dinoGP says the same thing; no symptom relief before a complete diagnosis is the rule with the modGPs.

Didn't give the inevitable one star this time but expect one...

RE: Lame dog with normal joints on CT

Aine Seavers — Sun, 16 Oct 2016 23:01:46 GMT

on line function still works, so pretty easy to see when only 2 others on line with you and you get 2 red stars who they are- I was most amused to see it happen before my eyes. I can just about guess with 100% certainty who the 4 amigos are that will red star me whatever I write. even with a question. I have redstarred on occassion, I tend to make a point of identifying it was me and exactly why but do feel this list would be a lot less aggressive without the stars and one just says, agree with you, disagree with you and explain why.