n°14 • 2012

4 1

Editorial

With 258 million human diabetic

sufferers in 2010 and an

estimated 438 million in 2030,

it is predicted that there will be

a 54% growth in diabetes in the

coming 20 years! The number of

Type 1 diabetes remains steady;

therefore most of the increase

is due to Type 2 (the so-called

“adult form”). The causes of

such a gigantic leap are well

known: urban living, lack of

exercise, junk food and obesity.

Sadly, practitioners have noticed

the same trend in their four

legged patients. Keeping dogs

and cats slim is probably the

best preventative measure to

reverse the curve. However,

many owners do not see their

plump pet as being a major

problem until the diagnosis is

confirmed and they face having

to administer a daily insulin

injection!

Through specific nutrition, at

least in the cat, it’s possible

to alleviate the signs of the

disease. Special dietary

measures can also help

diabetic canines to maintain a

satisfactory quality of life. But

wouldn’t it be nice if we didn’t

have to run “diabetic clinics”

anymore? So let’s be proactive

and talk about DM before it’s

too late.

Dr Fabienne Dethioux, DVM, MRCVS

Sugaring the pill… of diabetes mellitus managementDefinition and pathogenesisDiabetes mellitus is defined as a metabolic disorder that is the consequence of a reduction in insulin available for the normal functioning of the cells. This leads to an increased amount of glucose in the blood. Numerous factors can induce this: degenerative changes in the β cells of the pancreas, diminished efficacy of the insulin because of the formation of anti-insulin antibodies, damage to the β cells following immune mediated cytotoxicity or inappropriate secretion of hormones induced by neoplasia in another organ. In rare cases, an increased concentration of glucagon leads to a persistent hyperglycaemia.

Recent work suggests that disturbances affecting the diabetic individual are in fact a consequence of not only insulin deficiency but also increased glucagon secretion. Elevated blood glucagon concentration further promotes the hyperglycaemia.Classically, following the human description of the disease, DM can be classified into type I and type II.

Type I is the most common form of the disease in dogs and is due to a true insulin deficiency following the loss or destruction of beta-cells (< 20% remaining). In this case, there is no or minimal insulin secretion. In people, the condition is often called “juvenile onset diabetes” but in dogs, it is seen mainly in mature animals. It is thought that like in people, diabetes in dogs is the consequence of an autoimmune process. Beta cell autoantibodies can be found in around 50% of newly diagnosed diabetic canine patients.

Type II diabetes is due to a relative insulin deficiency. In human patients, it is the result of impaired insulin secretion, peripheral insulin resistance or increased basal hepatic glucose production. The disease is called “adult onset diabetes” and mainly affects obese people. Both cats and people with type II diabetes have islet amyloidosis.

In the case of complicated diabetes (ketoacidosis), which is mainly seen in diabetic dogs, the liver produces huge amounts of ketone bodies. This will induce a major disturbance in the acid-base status as well as in the fluid-electrolyte balance and leads to prerenal azotaemia, hyponatremia, hypokalemia and acidosis.Summary: figure on slide (Ettinger, 2010)

VETS TODAY - BP 4 - 650 avenue de la Petite Camargue - 30470 Aimargues - Francewww.royal-canin.com - Telephone: + 33 4 66 73 03 00 - Fax: + 33 4 66 73 06 04 - Email: vetstoday@royal-canin.org

Editor: Dr Fabienne Dethioux, MRCVS - Deputy editors: Ms Andrea Coyle, Dr Marianne De Vries (BVSc Hons) & Dr Michelle Coles BVSc BSc (Hons)

VETS TODAY is published quarterly and sent to selected veterinary professionals. RCS: 700200983 – Nîmes - France

> DIARY

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Coming events

EVECCS – 11th Congress Barcelona - Spain15th - 17th June 2012 www.eveccs2012.org

7th World Congress of Veterinary Dermatology Vancouver - Canada24th - 28th July 2012 www.vetdermvancouver.com

ISCFR 2012 – EVSSAR 2012Whistler, British Columbia - Canada26th-29th July 2012 www.ivis.org/iscfr/2012

ECVIM CongressMaastricht - The Netherlands6th - 8th September 2012 www.ecvimcongress.org

International Society for Companion Animal Infectious DiseasesSan Francisco - USA14th - 17th November 2012 www.iscaid.org

AFVACParis - France30th November - 2nd December 2012 www.afvac.com

BSAVA / WSAVA CongressBirmingham - UK4th - 7th April 2013 www.bsava.com

26th Congress of ESVD-ECVD Valencia - Spain19th - 2th September 2013 www.esvd-ecvd2013.com

The unspoken rule about feline heart disease is: do nothing! Hopefully things are going to change with the publication of

a textbook on feline cardiology. Written by top cardiologists, this innovative work is

likely to become THE reference for every practitioner having to deal with heart murmurs, gallop sounds, cough, dyspnea and hyperthyroidism. Each chapter is backed up with lots of references. Feline cardiology is definitely moving fast. This book clearly explains the usefulness and limitations of some tests and most of all, it provides the latest therapeutic options

(yes, heart diseases in cats can be treated!) with the doses and the potential side effects. Screening programs are also described in a very practical way. This book should be in your bookshelf if you are serious about the cat’s heart! FD

www.wiley.com/wiley-blackwell

Feline cardiology Côté E, MacDonald KA, Montgomery Meurs K, Sleeper MM ISBN: 978-0-8138-1242-7 Wiley-Blackwell 2011

O b e s i t y h a s reached epidemic propor t ions in both human and pet populations, at least in West-ern countries. As

such there is a considerable amount of time, energy and money spent by govern-ments, medical and veter inary associations to try to eradicate or at

least slow down this phenomenon. This book explains the reasons for the problem (even if we all know them), pro-vides diagnostic tools (I’m not sure if we really need these as the disease is right in front of us) and tries to provide guide-lines for implementing successful and hopefully long lasting weight loss pro-grammes. Most practitioners are well aware of the obesity problem but some-how it tends to be overlooked. Will buying

239 pages of “common sense” be a big enough incentive to do something about it? The past decades have shown the limi-tations of communication campaigns: more and more people, dogs and cats are getting fat! In the last part of the book, several prac-tical examples are provided to help practitioners implement a weight man-agement programme. Each practice should design its own plan and the book

describes specific examples such as the “Go fetch fitness™”. In this campaign, pairs of (fat) dogs and owners get together and meet three times a week for six weeks to exercise and lose weight. Of course, this is combined with adequate dietary changes and is an excellent way to bond the clients to the practice. Just make sure the walkers avoid passing in front of a fast food restaurant! FD

www.wiley.com/wiley-blackwell

The fifth version of the 5 Min is orange! More than 1500 pages written by a crowd o f spec ia l i s ts

(more than 300), provides readily availa-

ble advice to the practitioner. The paper version is complimented by client educa-tion handouts available for download and customization as well as images and videos. Each condition is classified in alphabetical order and the format has not changed

much (however the vet’s way of function-ing has not changed much either): definition, symptoms, diagnosis and treat-ment. Focus has been included in the follow-up section and a “miscellaneous” section provides interesting links to asso-ciated conditions or internet resources.

If your green book is a bit “worn-out” by intensive use in your practice, get the latest version. And if your practice is a

“no paper” one, you’ll be glad to know that it exists in digital format. FD

www.wiley.com/wiley-blackwell

Practical Weight Management in Dogs and Cats Towell TL Editor ISBN: 978-0-8138-0956-4 Wiley-Blackwell 2011

The new veteri-nary pharmacy reference book is out! No doubt your previous one is beginning to look a bit worn.

This version has of course been updated and completed with 22 new products. There is an interesting section on topical dermatological products and where appli-cable, the principles of compounding are clearly explained. This comes in handy when talking to your local chemist!

Whether you opt for the “pocket” version or the “desk” format, this exhaustive medication encyclopaedia is a must have for every practitioner. So make sure you order your copy! FD

www.wiley.com/wiley-blackwell

Veterinary Drug Handbook 7th Edition Plumb DC ISBN: 978-0-4709-5965-7 Wiley Blackwell 2011

Fifth Edition Blackwell’s Five-Minute Veterinary Consult: Canine and Feline Tilley LP, Smith FWK ISBN: 978-0-8138-0763-8 Wiley Blackwell 2011

Insulindeficiency

Glucose uptake ↓Gluconeogenesis ↑

• Hyperglycemia• Glucosuria• Electrolyte loss due to

osmotic diuresis• Polyphagia

• Excess amino acids used for gluconeogenesis

• Weight loss, weakness• Poor wound healing

• Increased NEFA*• Production of ketones• Hepatic lipidosis• Weight loss

Protein catabolism ↑

Lipid catabolism ↑

Effects of insulin deficiency (from Ettinger et al, 2010)

*NEFA = Non-Essential Fatty Acids

> Book REVIEW

Last Autumn, Bangkok suffered from severe floods. Thousands of residents were evacuated and many lost everything. This terrible situation dramatically affected the dogs and cats of the Thai capital. The Royal Canin team reacted promptly and built shelters for the stranded pets. Together with volunteers, they set up the Animal Rescue Centre at Gymnasium 2 Thammasart University Rangsit.

On the 12th of October, the RC Marketing team brought Royal Canin Dog & Cat food to all rescued dogs, cats and pets whose owners were affected by the flood. These people had to leave their homes in a rush, leaving everything underwater. The operation was maintained for the whole duration of the floods (several weeks).

SolIDARItY

2

Pets are not people and dogs are not cats!The link between obesity and reduced insulin sensitivity has been clearly established in people and cats (Appleton, 2001) and it is also highly suspected in dogs. Indeed, there is an association between canine diabetes and excess bodyweight (Lund, 2000). In dogs, there seems to be a relationship between pancreatitis and the development of diabetes. Obesity is a recognised risk factor for pancreatitis. A careful history must be compiled not only to understand the cause of the disease (for example administration of glucocorticoids or progestogens which will interfere with the action of insulin) but to also start building the therapeutic plan.

Clinical signsPU/PD is a frequent clinical sign. When the disease is advanced, weight loss may be noticeable; however polyphagia (less prominent in cats) is a common feature. The physical examination of the diabetic patient is usually not specific. Up to 70% of cats will exhibit neurological signs (sometimes very subtle and subsequently not always picked up by the owner) such as lethargy (but cats sleep a lot!), weakness, inability to jump or mild ataxia. Other vague clinical signs such as dehydration, dull coat (cat), cataract (dog) or systemic hypertension (dog) are also observed.

DiagnosisBased on clinical signs, diabetes mellitus is rather easy to diagnose. The combination of polyuria and polydipsia, weight loss despite a preserved appetite and a persistent hyperglycaemia combined with a glycosuria is usually sufficient to point the practitioner in the right direction. Nevertheless, some other conditions will have to be ruled out such as: primary renal glycosuria, kidney insufficiency, stress (especially in cats), hyperadrenocor-ticism, pancreatitis, pancreas neoplasia, acromegaly, dioestrus, postprandial hyper-glycaemia (get a good history) or pheochromocytoma.

Treatment and long term managementOral hypoglycaemic agents such as glipizide, glimepiride and glyburide have been used to try to alleviate the signs of DM in cats. Their adverse side effects (anorexia, vomiting and liver toxicity to name a few) combined with the difficulty of administering oral medication to the feline limit their usage. They can be an option when the owner is reluctant or unable to inject insulin, however they have no benefit in the treatment of type I diabetes (dog).The current trend in the treatment of DM is to combine insulin injections with dietary changes. Insulin injections are the cornerstone of the treatment of DM in both dogs and cats. The choice of which insulin should be used depends on the availability and legal constraints in each country as well as the practitioner’s preference. A porcine lente insulin is often used in veterinary medicine. Often, the initial treatment will be implemented by hospitalising the patient. The goal of the treatment is to have a normoglycemic patient with no PUPD. Dogs usually require the lifelong administration of insulin while cats can be lead to remission. Usually remission appears within a month but it can take up to 8 months after the beginning of the

treatment. It is essential to spend time with the owner to make sure that he/she understands the condition and its management. Whenever possible, a nurse should be dedicated to the follow up of these patients, especially at the beginning. There are dedicated tools available to help the owner with the daily treatment of their pet.Diet plays a key role in the treatment of DM. In dogs, it is recommended to provide a food with an increased content of dietary fibre, a limited quantity of starch of low glycaemic index, a high protein level and a moderate energy density. For cats, the dietary therapy is extremely important since it is the key element leading to diabetic remission (meaning no more insulin injections, something the owner is always happy to hear). A diet containing a high amount of protein and a low quantity of carbohydrate is the most effective approach.Obesity is a promoting and aggravating factor for degenerative joint disease. Glucosamine-chondroitin sulphate is one of the therapeutic agents used to alleviate pain and slow the progression of the disease. It doesn’t seem that it causes diabetes mellitus or interferes with the treatment of the condition (Lenox, 2010).Summary of dietary approach:

Diabetic dogs and cats must be closely monitored. Portable glucometers can be used by the owner at home and they often replace the regular urinary checks. These are easily done with reactive strips and remain useful when the owner is unable to use the glucometer. In order to avoid misleading interpretation of the glycosuria (urine accumulates in the bladder, which means it does not necessarily reflect the blood glucose level and it depends on the hydration status and urine concentration ability), it is advised to perform a test on all the urine samples voided over a 24h period.

It is also recommended to provide the owner with a readymade dietary/insulin diary that they can complete in order to keep track of the potential variation in administration of the treatment. Ideally, the blood glucose concentration should be maintained between 5 and 15 mmol/L (or 90 to 270 mg/dL).Serum fructosamine concentration provides information on the glycaemic control in the long term. It reflects the mean blood glucose concentration of the preceding 2 weeks.

Consequences of the diseaseThey are numerous.Diabetic patients are more prone to bacterial and fungal infections. An allergic skin disease, corticosteroid administration prior to the diagnosis of DM or a concurrent endocrine disease will increase the risk of developing a dermatologic disorder (Peikes, 2001). About 70% of diabetic dogs (not cats) will develop bilateral cataract which is thought to be related to the accumulation of sorbitol in the lens leading to an osmolar accumulation

of water. This causes swelling and even rupture of the lens. Oxidative stress is also incriminated, which means that diabetic dogs should be receiving a diet enriched in antioxidants.Iatrogenic:Excessive amounts of insulin can lead to hypoglycaemia affecting all organs including the brain. The ensuing neurohormonal response is responsible for the clinical signs often observed: tremors, twitching, tachycardia and hypertension. Recent research suggests that hypoglycaemia causes oxidative stress leading to neuronal death (Loose, 2008).

ConclusionThe most common endocrine disease encountered in dogs and cats carries a good prognosis provided that the owner is committed to following the practitioner’s recommendations. Nutrition plays a key role in the management of the disease and is a precious ally which should not be overlooked. Of course, the best approach remains prevention. Since obesity is clearly involved in the pathogenesis of the disease, the threat of having to inject insulin on a daily basis is an excellent incentive to keeping dogs and cats at their ideal body condition score. FD

Urinary strips remain a useful tool when the owner is not able to monitor the blood

glucose. © F. Dethioux

insulin injections can usually be performed by the owner © F. Dethioux

CoMMon CAuSES oF InSulIn RESIStAnCE (from Hackett, 2005)

Infections: Bacterial pyoderma, Pneumonia, Pyelonephritis/lower urinary tract infection

Concurrent endocrine diseases: Hyperadrenocorticism, Hypothyroidism (Canine), Hyperthyroidism (Feline), Acromegaly, Glucagonoma (Canine), Pheochromocytoma

Renal insufficiency

Pancreatitis

Obesity

Dioestrus (intact bitch)

RECoMMEnDED DIEtARY APPRoACH In DIABEtES MEllItuS

3

> IntERnAtIonAl PRESS REVIEW

Sorry Sir, he is not just “big boned”.

We intuitively know it; owners often have a mistaken perception of their dogs body condition score. In other words, it’s very difficult for them to admit that their beloved pet is fat! In a 680 dog study, owners were asked to fill in a questionnaire in the waiting room about the body shape of their pet. The results show that 77% of owners underestimated their dog’s body shape (and 23 % overestimated it). The authors conclude that it is paramount to tackle the misconception of body shape before even hoping to convince them to put their dog on a weight reduction programme. FD

Source: Courcier EA, Mellor DJ, Thomson RM et al - A cross sectional study of the prevalence and risk factors for owner misperception of canine body shape in first opinion practice in Glasgow. Preventive Veterinary Medicine 2011; 102 (1): 66-74.

Treatment of Malassezia dermatitis

The treatment of Malassezia overgrowth, a frequent complication

of numerous skin conditions such as allergies, endocrine diseases or keratinisation disorders, is always a challenge. Most practitioners recommend topical treatment. Two shampoos were compared: a first one containing 3% of chlorhexidine and a second one based on the combination of 2% chlorhexidine and 2% miconazole. They were used according to the manufacturer’s recommendations in a double blind study. Out of the 67 dogs recruited, 54 completed the trial with good compliance. Both shampoos were effective in controlling the yeast overgrowth. The authors conclude that topical therapy with 3% chlorhexidine alone is as effective as the combination of miconazole and chlorhexidine. FD

Source: Maynard L, Rème CA, Viaud S – Comparison of two shampoos for the treatment of canine Malassezia dermatitis: a randomised controlled trial. Journal of Small Practice 2001; 52: 566-572.

Predicting feline hyperthyroidism?

The onset of hyperthyroidism is usually progressive in elderly cats, and many of them actually have

subclinical disease for months or even years. The condition is usually related to other diseases such as kidney insufficiency or hypertension. An early diagnosis will allow the practitioner to implement the adapted treatment as well as preventative measures to limit the clinical signs. A study performed on 104 cats over 9 years of age, showed that those with a high level of alkaline phosphatases (but still within the normal range) usually developed hyperthyroidism within the next 14 months. However, it’s the TSH which has the best predictive value. The authors conclude that geriatric cats with undetectable levels of TSH bear an increased risk of developing hyperthyroidism, whilst those having a concentration of 0.03 ng/mL are less likely to become hyperthyroidic. TSH should be systematically measured when performing old age screening on geriatric felines. FD

Source: Wakeling J, Elliott J, Syme H – Evaluation of predictors for the diagnosis of hyperthyroidism in cats. Journal of Veterinary Internal Medicine 2011; 25: 1057-1065.

Feline injection-site sarcomas: cut it XXL

Most injection site tumours are fibrosarcomas. They are often diagnosed at an advanced stage and the prognosis is usually bad since most of them reoccur (26-59%). Practitioners are much more aware of the risks, and recommendations have been issued to try to limit the incidence or at least offer a therapeutic perspective (such as avoiding injections between the scapulas). In a recent study, 91 affected cats underwent extra wide margin resection: 5 cm minimum. The mean survival time was 901 days and in 97% of the cases, the tumour was completely removed. The surgical procedure can be rather complicated and the authors recommend referral of these patients to specialists. FD

Source: Phelps HA – Radical excision with five centimetre margins for the treatment of feline injection-site sarcomas: 91 cases (1998-2002). Journal of the American Veterinary Medical Association 2011; 239(1): 97-106

DoGS

Hight protein level

Low starch level

Higher fibre level

Moderate energy

CATS

Hight protein level

Low starch level

Moderate fibre level

Moderate energy

Low energy in case of obesity

REFEREnCES AnD FuRThER READIng:

1. Appleton DJ, Rand JS, Sunvold GD – Insulin sensitivity decreases with obesity and lean cats with low sensitivity are at greatest risk of glucose intolerance with weight gain. Journal of Feline Medicine and Surgery 2001; 3(4): 211-228.

2. Zachary JF, McGavin MD – Pathologic Basis of Veterinary Disease Fifth edition. Elsevier 2012.

3. Loose NL, Rudloff E, Kirby R – Hypoglycaemia and its effect on the brain. Journal of Veterinary Emergency and Critical Care 2008; 18(3): 223-234.

4. Lenox CE, Lunn KF – Effects of glucosamine-chondroitin sulphate supplementation on serum fructosamine concentration in healthy dogs. JAVMA 2010; 236(2): 183-186..

5. Fascetti AJ, Delaney SJ – Nutritional management of Endocrine Diseases in Fascetti AJ, Delaney SJ Editors Applied Clinical Nutrition. Wiley Blackwell 2012: 289-293.

6. Lund EM, Armstrong PJ, Kirk CA et al – Prevalence and risk factors for obesity in adult dogs from private veterinary US practices. Int J Applied Res Vet Med 2000; 4: 177-186.

7. German AJ, Hervera M, Hunter L et al – Improvement in insulin resistance and reduction in plasma inflammatory adipokines after weight loss in obese dogs. Domestic Animal Endocrinology 2009.

8. Peikes H, Morris DO, Hess RS – Dermatological disorders in dogs with diabetes mellitus: 45 cases (1986-2000). JAVMA 2001; 219(15): 203-208..

9. Hackett T – Endocrine and metabolic emergencies in BSAVA Manual of Canine and feline Emergency and Critical Care, 2005: 177-189.

10. Graves TK (Editor) – Obesity, diabetes and adrenal disorders. Veterinary Clinics of North America SA Practice. Elsevier Mars 2010

FRuCtoSAMInE ConCEntRAtIonS

< 375 μmol/l Normal

< 400 μmol/l Excellent control

400 - 500 μmol/l Good control

500 - 600 μmol/l Moderate control

> 600 μmol/l Poor control

> nEWS

MRSA and MRSP guidelinesMRSA and MRSP are on the rise. In addition to the health issues related to the “superbugs”, practitioners must not overlook the liability side of the problem. The BSAVA (British Small Animal Veterinary Association) has recently updated their practice guidelines on reducing the risk of MRSA and MRSP. The information can be found on their website, together with very practical videos on hand washing techniques. FD

http://www.bsava.com/Advice/MRSA/tabid/171/Default.aspx

Small animal practitioners at risk MRSP (Methicillin Resistant Staphylococcus Pseudintermedius) are more and more often isolated in dogs, and human carriers are on the rise. Small animal practitioners attending a dermatology meeting in Italy were screened for MRSP carriage. Amongst the 128 veterinarians, 3.9% were hosting MRSP. The authors recommend the implementation of preventative measures in order to prevent contamination.

Paul NC et al - Carriage of Methicillin-Resistant Staphylococcus pseudintermedius in Small Animal Veterinarians: Indirect Evidence of Zoonotic Transmission. Zoonoses and Public Health

2011; 58(8): 533-539.

Thoracic X-ray: take an extra one!Classically, for chest radiography, dogs are placed in lateral and ventrodorsal position – with the forelimbs pulled upwards. In order to better visualise the cranial lung lobes, it is worth taking an extra shot, placing the animal in “humanoid” position (pulling the limbs along the rib cage). This provides a better view of the cranial lung field and cranial mediastinum without superimpression of the scapula and the associated musculature FD

Chang J – Clinical usefulness of thoracic humanoid radiographs of dogs. Poster WSAVA congress 2011.

Activated charcoal: with or without food?Activated charcoal is often used in the management of some poisonings in order to prevent or reduce the absorption of the toxic substance. It is unpalatable and can be a challenge to administer to a non-cooperative patient. A study presented at the last Veterinary Emergency and Critical Care Society congress showed that there was no statistical difference in the in vitro absorption of acetaminophen whether the activated charcoal was mixed with food or not. FD

Wilson H – The effect of dog food on the adsorptive capacity of activated charcoal: an in vitro study. Journal of Veterinary Emergency and Critical Care 2011; 21 S1: 59.

Interested in working dogs?The 7th International Working Dog Breeding Conference was held in South Africa in October 2011. Over 185 delegates from 20 countries from around the world attended this event. The bids are open for hosting the 2013 edition FD

More on: www.iwdba.org.