Lecture 9 2/7/25 Flashcards
What are the components of chronic enteropathy treatment?
-diet
-microbiome
-vitamin status
-immunosuppression
What can lead to treatment failure when treating chronic enteropathy?
-failure to approach all aspects of treatment
-failure to recognize mild improvement
What are the general steps to chronic enteropathy treatment?
step 1: empirical deworming and diet trials
step 2: microbiome-directed trials
step 3: GI biopsies
step 4: immunosuppression: corticosteroids +/- second agents
How does food intolerance differ from food hypersensitivity?
-food intolerance is non-immunologic
-food hypersensitivity is immunologic
What are the characteristics of patient response to diet trials?
-50 to 60% of patients with chronic enteropathy respond to a diet trial
-response typically takes 2 weeks; dermatologic signs and cyclical signs can take longer to see improvement
When are patients more likely to respond to a diet trial?
-concurrent atopic dermatitis
-younger age
-normal, hypoechoic bowel mucosa in dogs with chronic diarrhea when assessed via ultrasound
Which factors are NOT reliable predictors of diet trial response?
-severity of histologic changes
-degree of bloodwork changes
-serum IgE screens for dietary allergens
How does the treatment for food allergies differ from the treatment for lymphangiectasia?
-food allergies require a hypoallergenic elimination diet with either hydrolyzed or novel protein; nothing else should be fed during trial
-lymphangiectasia requires a low-fat diet in addition to hypoallergenic
Which type of diet is preferred for small intestinal dz?
highly digestible, low-residue diet or elimination diet
Which type of diet is preferred for large intestinal dz?
fiber-enriched diet or elimination diet
Which type of diet is preferred for fat malabsorption?
low fat diet
Which type of diet is preferred for dermatological signs?
elimination diet that removes pet’s specific allergy
Which aspect of diet is important when a pet shows signs of delayed GI motility?
ensuring the diet is low fat
What are the indications for an elimination/hypoallergenic diet trial?
-most chronic enteropathies
-chronic large intestinal dz that fails fiber-enriched diet
-concurrent dermatological signs
What is a novel protein diet?
diet that introduces a new protein source that the pet has never eaten before
What is a hydrolyzed diet?
diet in which the proteins are hydrolyzed to small peptides; intends to “hide” the peptides from the immune system
Which carbohydrate sources are commonly used in novel protein diets?
-potatoes/sweet potatoes (dogs)
-green peas (cats)
Why is it important to know whether a pet completing a diet trial has eaten a grain free diet?
grain free diets often use potatoes and peas as carbohydrate sources; it is possible for the patient to have an allergy to these, which would persist through the diet trial
Why is it ideal to use a prescription novel protein diet?
over the counter diets are more likely to be contaminated; risk exposing pet to food allergen
What are the hydrolyzed/elemental diets available?
-purina HA; soy based, low fat
-hill’s z/d ULTRA; chicken and soy forms
-rc HP; soy based
-rc Ultamino; chicken based
-purina Elemental; individual amino acids from the start
What are the indications for low fat diet trials in dogs?
-suspicion of lymphangiectasia
-evidence of fat malabsorption; esp. hypocholesterolemia
-concurrent pancreatitis
-delayed gastric emptying
What are the important notes regarding diet trials?
-new diet should be transitioned to over 1-2 weeks; abrupt change could worsen or cause clinical signs
-nothing else should be fed during trial, including treats, flavored vitamins, flavored medications, flavored toothpaste, and chew toys
Why should a low fat diet NOT be fed to a patient with exocrine pancreatic insufficiency?
it can lead to fat soluble vitamin deficiencies
What are the characteristics of capromorelin?
-ghrelin-agonist
-appetite stimulant
-flavored
-side effects include vomiting, diarrhea, and hypersalivation
What are the characteristics of mirtazapine?
-alpha-2 antagonist
-appetite stimulant
-available as an oral pill or a transdermal ointment
-side effects include vocalization, agitation, vomiting, restlessness, trembling, and hypersalivation
What are the characteristics of cyproheptadine?
-phenothiazine with anti-serotonin and antihistamine properties
-appetite stimulant for cats
-not commonly used
-side effects include paradoxical activity in cats
-not recommended for use in cats with hepatic lipidosis
What are options besides appetite stimulants for patients with decreased appetite?
-glucocorticoids; must rule out infectious dz and contraindications first
-nasogastric tube
-esophagostomy tube
What are the characteristics of idiopathic dysbiosis?
-around 10% of dogs with chronic diarrhea respond to antibiotics
-common in young, large-breed dogs, esp. german shepherds
What are the potential etiologies of idiopathic dysbiosis?
-enteropathic bacterial infections (uncommon)
-secondary small intestinal bacterial overgrowth
What are the characteristics of a probiotic trial for idiopathic dysbiosis?
-14 day trial
-ideally want 10-20 billion CFU/kg/day
-probiotics are not created equal; choose best product for patient, goals, budget, etc.
What are the characteristics of an antibiotic trial for idiopathic dysbiosis?
-only consider after failed response to diet and probiotic trials
-avoid antibiotics in young boxers and french bulldogs
-consider if evidence of dysbiosis on GI trial
-involves a 14-21 day trial of tylosin; may become a lifelong medication
Why is metronidazole not used for antibiotic trials in idiopathic dysbiosis?
causes shifts in natural microbiome that can take upwards of 4 weeks to return to normal
What are the indications for immunosuppressive therapy?
-diagnosis of idiopathic inflammatory bowel diseases
-no response to diet trials, deworming, or probiotics/antibiotics and infectious disease should rule out
What is important regarding immunosuppressive therapy as a treatment for chronic enteropathy?
it should be added to other therapies, not used as sole therapy
What are the criteria for diagnosing idiopathic IBD?
-documentation of lymphoplasmacytic and/or eosinophilic enteritis
-no response to elimination diet trial, deworming, probiotics, or antibiotics
-responsive to immunosuppressive therapy
What are the characteristics of immunosuppressive therapy for IBD?
-diet +/- probiotics should be continued
-start with corticosteroid (pred)
-add second agent if response is incomplete
-end goal is to wean corticosteroid down to lowest possible dose or discontinue if possible
Why is prednisolone used in cats instead of the prednisone used in dogs?
cats have poor conversion of prednisone into prednisolone
What should be done prior to starting an animal on prednisone?
-rule out large cell lymphoma
-rule out infectious disease
ensure no concurrent bacterial hepatobiliary infections; evaluate liver enzymes
What are the characteristics of prednisone dosing?
-should use an anti-inflammatory to immunosuppressive dose
-should not exceed 40-50 mg total per dog per day
What aer the side effects of corticosteroid use?
-PU/PD
-panting
-polyphagia
-muscle wasting
-behavior changes
-possible induction of cALP
What are the characteristics of remission with immunosuppressive therapy?
-want to see resolution of clinical signs and normalization of blood proteins if PLE
-taper to lowest effective dose over 3 to 4 weeks
-continue diet +/- probiotics long term
What are the characteristics of budeonide?
-glucocorticoid with high hepatic clearance
-no difference in remission rates or adverse effects compared to prednisone
-used in patients unable to be weaned off steroids; lessens unacceptable corticosteroid side effects
What are the indications for second tier immunosuppression?
-refractory to glucocorticoids alone
-response seen but with intolerable side effects
What are the characteristics of chlorambucil?
-alkylating chemotherapy agent
-effective against small cell lymphoma
-main side effect is bone marrow suppression; CBC should be monitored
-can cause Fanconi’s like syndrome in cats; glucosuria, proteinuria
What are the characteristics of cyclosporine?
-T cell inhibitor
-want to monitor blood conc.
-side effects include vomiting, inappetance, gingival hyperplasia, alopecia, and secondary fungal infections
What are the characteristics of azathioprine?
-purine analog that inhibits RNA and DNA synthesis
-contraindicated in cats due to impaired detoxification
-side effects include neutropenia, thrombocytopenia, hepatopathy, and pancreatitis
