Elevated liver values in a normal dog. Now what? New Name, Same Commitment

COMPANION
www.bluepearlvet.com
Winter
If you would like to receive an electronic version of COMPANION,
please send an email to Alicia Valle at [email protected].
2010
COMPANION is a publication for the veterinary community from
Florida Veterinary Specialists, a BluePearl Veterinary Partners hospital.
Medical Director: Erick Mears, DVM, DACVIM
Practice Manager: Stacey Wieder, CVPM, PHR
New Name,
Same Commitment
This coming January, Florida Veterinary
Specialists will change our name to BluePearl
Veterinary Partners.
IN 2008, FLORIDA VETERINARY SPECIALISTS merged with Veterinary
Specialty & Emergency Center in Kansas City, forming BluePearl
Veterinary Partners. Our goal for the merger was to take advantage
of the numerous opportunities available to larger businesses. And
that is exactly what happened: the merger has allowed us to share
veterinary community outreach projects, staff training programs, and
medical and management ideas; reduce operational expenses; take
advantage of group purchasing; and learn and consult with our
colleagues working in the now-19 BluePearl locations in 8 states.
We expect the BluePearl network of specialty and
emergency practices to continuing growing as practices with
similar philosophies and standards of care choose to join our group.
The merger has not — and will not — change how we
operate, nor will it affect our dedication to service and patient
care. BluePearl Veterinary Partners is owned by the very
veterinarians who founded our member practices. Rest assured
that we continue to be directed by onsite management that
controls our operations.
If anything, our commitment to Florida’s veterinary
community has been able to grow stronger since our merger three
years ago. As BluePearl Veterinary Partners, our mission remains to
partner with you, the veterinarians in our community, to promote
and provide optimal healthcare and service to pets and their
owners. Even as we take the name BluePearl Veterinary Partners,
Florida Veterinary Specialists will remain locally focused, locally
managed, and devoted to providing Florida’s veterinary community
with comprehensive and compassionate specialty and emergency
veterinary care.
Should you have questions or comments about BluePearl
Veterinary Partners or this issue of COMPANION, please don’t
hesitate to give me a call.
Erick Mears, DVM, ACVIM
Medical Director
BluePearl Veterinary Partners is recognized as
Florida Veterinary Specialists in these locations:
Elevated liver values in a normal dog.
Now what?
HAVE YOU EVER FOUND ALT AND/OR ALP VALUES to be elevated on routine labwork in otherwise healthy dogs?
“These cases can be very frustrating, especially in asymptomatic dogs,” says Brian Luria, DVM,
AVCIM. “I always offer an ultrasound exam in order to evaluate the liver parenchyma. That way we can rule
out an obvious tumor or serious liver disease. The next steps of doing needle aspirates or biopsies are
where decision making is a bit more difficult.”
The presence of icterus warrants an immediate diagnostic workup
Non-hepatic causes exist for elevated liver
values so increased liver enzyme activity can be secondary
to systemic or metabolic conditions such as Cushings
disease, gastrointestinal conditions, allergies, heart
disease, anemia or infections.
If liver values are elevated 2 to 3 times above
normal, a complete patient history, including
medications being administered, and physical exam
should be performed. Medications that might be
irritating to the liver should be discontinued. Concurrent
illnesses or conditions, including dental problems, should be treated. Switching to a novel meat diet might
also be considered to exclude food allergies. Finally, a course of antibiotics followed by re-evaluation of the
liver enzymes in 3 to 4 weeks is suggested.
Continued elevation of ALT and/or ALP values on re-evaluation would suggest ongoing liver
irritation. Bile acid testing and ultrasound examination of the liver are recommended. Bile acid test results
will provide information on the extent of liver involvement. Ultrasound will help assess the liver size, the
presence of unusual liver parenchymal patterns, provide information about the biliary tree, pancreas, adrenal
glands, and GI tract, and allow for the collection of hepatic aspirates for initial cytologic evaluation.
If the bilirubin value is increased or the liver values are greater than 4 times elevated over normal
values, further evaluation of the liver should not be delayed. A primary liver condition is more likely to be
present.
Tampa
3000 Busch Lake Blvd.
Tampa FL 33614
813.933.8944
The first thing to
remember is that non-
hepatic causes exist for
elevated liver values.
Brandon
607 Lumsden Professional Ct.
Brandon FL 33511
813.571.3303
Clearwater
4525 Ulmerton Rd.
Clearwater FL 33762
727. 572.0132
Sarasota
7517 South Tamiami Trail
Sarasota FL 34231
813.933.8944
The Villages
748 Village Campus Circle
The Villages FL 32162
813.933.8944
Neutraceuticals and L
The Diagnostic Dilemma of
the Coughing Canine
by Alan Spier, DVM, ACVIM (Cardiology)
A VARIETY OF NUTRITIONAL SUPPLEMENTS and purported hepato-protective
THE COUGHING DOG CAN PRESENT A DIAGNOSTIC DILEMMA. The presence of a cough can
medications have been marketed as being beneficial for treating dogs and cats
with liver ailments. But do they work? When are they indicated?
Unfortunately, the efficacy of most of these products is purely anecdotal.
Clinical studies are lacking. This is what we know:
suggest primary respiratory and/or heart disease.
Making this distinction can be very difficult, especially because the same
dogs that get heart disease can also have underlying respiratory disease as well.
Because treatment and prognosis will vary between pulmonary and cardiac disease,
it is important to differentiate the two potential sources.
Causes for a cardiac cough include compression of the left mainstem
bronchus from an enlarged left atrium, and the presence of congestive heart failure. Both
of these scenarios are typically seen in dogs with significant heart disease, usually
associated with either degenerative mitral valve disease or dilated cardiomyopathy.
There are many respiratory conditions that can cause coughing, including
pneumonia, kennel cough, pulmonary neoplasia, and heartworm disease (or other
parasitic infections). For the dog that has a chronic cough, the two most common
causes include a collapsing trachea and chronic bronchitis.
Evaluating the signalment, history and physical examination is the first
step in distinguishing between cardiac and respiratory disease. The physical exam
can provide important clues for differentiating cardiac and pulmonary causes for
coughing. The presence of a murmur is a consistent finding in patients with heart
disease, while the absence of a murmur would
favor respiratory disease as a cause of the
cough. Heart rate can also help differentiate
cardiac from respiratory disease, as an
elevated heart rate often accompanies heart
failure, and a lower heart rate is associated
with primary respiratory disease.
It is important to note, however, the
presence of a heart murmur is not enough to
conclude the cough is caused by cardiac
disease. Age is an important factor to
consider, as the vast majority of dogs with
clinically relevant heart disease tend to be
older. In addition, there are certain breed
dispositions for heart and airway disease.
However, there are limitations in using signalment to help draw distinctions, as
both chronic airway disease and degenerative valve disease tend to occur in older
small breed dogs. The history can also be helpful in differentiating heart disease
from primary respiratory disease. In general, patients who have been coughing for
many months to years are far more likely to have respiratory disease, as dogs that
have significant heart disease often (especially CHF) are unlikely to survive without
specific cardiac therapy. In addition, true dyspnea is an uncommon finding in
patients with respiratory disease, but is common in patients with CHF.
Thoracic radiographs should be performed in all coughing dogs to
determine/confirm the etiology of the cough. Patients coughing from heart disease
will almost always have an enlarged left side (either and enlarged left atrium or a
tall heart suggesting left ventricular enlargement.) The presence of pulmonary
edema supports heart failure, but only in a dog with an enlarged left side. Dogs
with primary respiratory disease will often have increased interstitial changes and
pulmonary infiltrates that are unrelated to underlying heart disease. The most
consistent finding in a dog coughing from primary respiratory disease is the
absence of an enlarged left side, clear lung fields, and/or identification of an
alternate explanation (i.e. a collapsing trachea, lobar pneumonia, etc.) Because
many dogs will have both cardiac and pulmonary changes, relying on thoracic
radiographs alone to make the distinction is not always possible.
Echocardiography is frequently necessary to differentiate cardiac from
pulmonary disease as a cause of coughing. Echocardiography provides a more
accurate assessment of cardiac changes than radiographs (especially left atrial
size), and is the only way to confirm the cause of a heart murmur. It is also the only
noninvasive method to document the presence of pulmonary hypertension, which is
often a consequence of chronic pulmonary disease.
When in doubt as to the cause of a cough, please feel free to call me to
discuss your case.
Specialists
Acupuncture
Felicity Talbot DVM, CVA
Avian & Exotic Medicine
Teresa Lightfoot DVM, DABVP
Jonathan Rubinstein DVM
Ursodiol (ursodeoxycholic acid)
Many liver diseases are characterized by bile stasis and bile acid retention. Bile
acids are organic anions synthesized in the liver from cholesterol. They facilitate
bile flow through the biliary system and promote fat absorption in the intestine.
High concentrations of bile acids, when retained in the liver, have been show to be
cytotoxic to liver cells damaging their membranes and inducing fibrosis.
Ursodiol (ursodeoxycholic acid) is a synthetic, relatively hydrophilic, nonhepatotoxic bile acid developed to help dissolve gall stones. Studies in rodent
models have shown ursodiol to improve bile flow and
reduce hepatocellular inflammation. It has subsequently
been used in humans to treat a variety of chronic
inflammatory and fibrotic liver diseases. Reports on
the use of ursodiol to treat liver disease in dogs and
cats are lacking. In a recent case report, ursodiol was
shown to help resolve ultrasonographic evidence of a
biliary mucocele in two dogs. Ursodiol’s cellular
mechanism of action is not completely understood.
Side effects from the use of ursodiol are
uncommon but may include diarrhea when given at higher doses. Ursodiol should
be administered with a meal to aid its absorption from the GI tract.
SAMe (S-adenosylmethionine)
S-Adenosylmethionine (SAMe) is an indirect precursor of the amino acid glutathione.
Glutathione is produced in the liver where it serves the primary function of
neutralizing free radicals and oxidants responsible for damaging cell membranes.
Free radicals and oxidants contribute to the liver damage associated with
inflammatory, infectious, and toxic insults to the body. SAMe also reduces the toxicity
of bile acids by promoting their conjugation with taurine and sulfur molecules.
The liver is an important source of SAMe production in the body. In the
presence of liver disease or damage, the production of SAMe is reduced. Glutathione
production and the conjugation of toxic bile acids are impaired allowing for
progressive free radical damage to the liver and enhanced bile acid toxicity.
The supplementation of SAMe has been recommended in human patients
for treatment of osteoarthritis, depression and some forms of liver disease.
However clinical studies evaluating the efficacy of SAMe for treating liver disease
in humans are lacking. A few studies have suggested it could be beneficial for
treating alcohol-induced cirrhosis.
Do Compounded Medications Work?
MEDICATIONS FORMULATED FOR HUMAN USE are commonly used in our veterinary
patients. Unfortunately, it doesn’t make financial sense for pharmaceutical
companies to take the steps required to achieve FDA approval of their medications
for use in the veterinary market. That’s where compounding pharmacies come in.
There is little doubt that many human medications are efficacious for
treating diseases in our pets. One such compounding pharmacy has been active in
supporting research on some of the products they produce. That would be Premier
Pharmacy Labs (www.rxnations.com), a BluePearl Veterinary Partners’ continuing
education sponsor. Medications compounded by Premier Pharmacy Labs recently
shown in controlled published studies to be efficacious include an omeprazole
injectable solution for treatment of GI ulcers and an isoproterenol elixer for
treatment of coughing and respiratory disease.
Kudos to Premier Pharmacy Labs for studying efficacy. We strongly
encourage the study of compounded products to determine their efficacy in our
patients, because too little information is known whether the formulations being
offered are truly effective.
Cardiology
Alan Spier DVM, PhD, DACVIM
Nicole Piscitelli DVM
Sarah Silverman DVM
Critical Care
John Gicking DVM, DACVECC
Miryam Reems DVM, DACVECC
Terry Corona DVM
Juliet Gladden DVM
Jacqueline Nobles DVM
Dermatology
Michael Canfield DVM
Heather Willis-Goulet DVM, DACVD
Nadine Znajda DVM
Emergency Medicine
Kate Brammer DVM
Dee Ann Dugger DVM
Colleen Elligott DVM
Sonja Olson DVM
Allison Shreve DVM
Steve Tutela DVM
Marie Yakubik VMD
iver Disease
beneficial effect to the supplementation of vitamin E on the progression of liver
disease in humans and small animals are also lacking.
Being a fat soluble vitamin, the absorption of vitamin E may be reduced
in patients with hepatic disease as a result of the reduced production of bile acids.
Excessively high doses of vitamin E have been associated with coagulation
abnormalities.
What’s our opinion?
How about dogs and cats? Studies have shown supplementation with
SAMe to increase glutathione levels in the liver of cats and dogs. However, there
are no controlled clinical trials demonstrating the efficacy of SAMe for treating
naturally occurring liver diseases in cats and dogs.
SAMe appears to be a very safe medication for use in pets. Oral
administration of SAMe on an empty stomach optimizes its bioavailability.
Milk Thistle (silymarin)
Extracts from the milk thistle plant have been used
for centuries as a natural remedy for diseases of the
liver and biliary tract. Silymarin the active constituent
of milk thistle has been reported to work as an
antioxidant, scavenging free radicals and inhibiting
lipid peroxidation.
There are no well-controlled human studies
evaluating the efficacy of silymarin for the treatment
of liver disease and, to date, there is only one
Extracts from the milk thistle
published clinical study in dogs. In a placeboplant are believed to have
controlled study, silymarin was shown to have a
antioxidant properties.
beneficial effect on the degree of histological liver
damage and the survival outcome of dogs with experimental mushroom poisoning.
Clinical trials in small animals with naturally occurring liver disease, however, are
lacking and reports of silymarin’s efficacy are merely anecdotal.
Vitamin E (d-alpha tocopherol)
Vitamin E (d-alpha tocopherol) is believed to function as a membrane bound
intracellular antioxidant, protecting membrane phospholipids from free radical damage.
The importance of the antioxidant properties of vitamin E, at the
concentrations normally present in the body, have not been determined. The function of
vitamin E in the body is not really understood. Clinical trials demonstrating a
The efficacy of ursodiol, SAMe, silymarin, and vitamin E to treat hepatic
disease in dogs and cats has not been well studied. It is unknown whether
the co-administration of these medications will have additive beneficial
effects. Because of their theoretical benefit and the paucity of reported
side effects, their use as an adjunctive treatment to complement more
specific treatments for the patient’s particular liver disease certainly
should be considered. Looking at their mechanisms of action, ursodiol and
SAMe are most likely to be beneficial. Optimum doses for these
medications based on controlled studies have not been determined. The
bioavailability and potency of over-the-counter medications may vary with
the manufacturer.
What about diet in liver patients?
Studies indicate that nutrition can play a significant role in the management
of advanced liver conditions. The ideal diet would have lower copper contents,
an increased ratio of branched-chain aminio acid to aromatic amino acids,
lower sodium concentrations, and higher concentrations of vitamin k and
antioxidants. Hill’s L/D diet was formulated with these goals in mind. In
theory, diets meeting these criteria should be beneficial for those patients
with active inflammatory conditions of the liver and those with diminished
liver function. When using Hill’s L/D or similar prescription diets formulated for
the management of advanced liver conditions, identification and treatment
of the specific underlying disease remains important.
A Feline Anemia-Causing Tongue-Twister
TEN (MONOPOLY) DOLLARS TO WHOMEVER can pronounce the newest name for
Hemobartonella felis-associated anemia! How about, feline hemotropic
mycoplasmosis (FHM)?
Many of you are aware that studies now suggest Hemobartonella felis
belongs in the Mycoplasma genus, rather than with the Rickettsias genus with
which it was formerly grouped. Based on gene sequencing, the genus formerly
classified as Hemobartonella felis has been subdivided into two groups —
the larger Mycloplasma haemofelis and the smaller Candidatus
Mycoplasma haemonitinutum. (That’s a mouthful!) Mycoplasma
haemofelis is more likely to cause clinical anemia than Candidatus
Mycoplasma haemonitinutum, however, the latter is suspected to
promote the ability of feline leukemia virus to induce cancer in coinfected cats. Fleas — and possibly other blood-sucking insects
such as ticks, lice and mosquitoes — are responsible for transmission
of the infection.
Internal Medicine
Anthony Ishak DVM, DACVIM
Brian Luria DVM, DACVIM
Erick Mears DVM, DACVIM
Melanie Otte DVM, DACVIM
Cathy Meeks DVM
Neurology
Michael Kimura DVM, DACVIM
Oncology
Virginia Coyle DVM
Curtis Kane DVM
Ophthalmology
Tammy Miller Michau DVM, DACVO
Michele Stengard DVM, DACVO
Radiology & Diagnostic Imaging
Wendy Gwin DVM, DACVR
Val Sadler DVM, DACVR
The good news is that diagnosis of the formerly named Hemobartonella
felis has not significantly changed. Identification of the organism on the periphery
of red blood cells utilizing fresh blood smears, rather than smears done from EDTA
or heparinized blood, remains the preferred diagnostic test. PCR testing is more
sensitive than microscopic detection of the organism, however, it is more likely to
detect asymptomatic carriers.
A three-week course of doxycycline is recommended to treat FHM.
Enrofloxacin may also be effective and can be tried in those cats
intolerant of doxycycline. Aazithromycin has not been shown to work.
Despite resolution of the anemia with treatment, many cats remain
carriers of the disease. Newer medications are being evaluated with
the goal of eliminating the carrier state.
Mycoplasma haemofelis organisms can
be seen adhered to the cell membranes
of affected red blood cells.
Rehabilitation
Felicity Talbot DVM, CVA
Surgery
Helga Bleyaert VMD, DACVS
Michael Reems DVM, DACVS
Cory Pinel DVM
Nicole Salas DVM
Natasha Stanke DVM
CE by the Sea a Balmy Success!
FVS AND TBVSECC WOULD LIKE TO THANK all the speakers of CE by the Sea for
making our annual event such a huge success. We would especially like to
thank platinum sponsor Antech Sound-Eklin and silver sponsors BioMedtrix,
Novartis, Nutramax and Webster for their support. It was a gorgeous night on
the beach. We hope to see all of you there next year!
WOULD YOU LIKE TO HELP OUT THE ENVIRONMENT and save some trees? You can sign up to receive future issues of COMPANION electronically by emailing Alicia Valle at
[email protected]. We use email addresses solely for professional notifications and do not share our lists with vendors or others. The Planet Earth thanks you, as do we!
3000 Busch Lake Blvd.
Tampa, FL 33614
www.bluepearlvet.com
If you would like to receive an electronic version of Companion, please send an email to Georgia Flood at [email protected].