New Vet Jumpstart Guide: 20 Common General Practice Cases Simplified (PDF)

 DISCLAIMER STATEMENT Please note that the information contained within this book is based on the authors' personal use and therefore can be slightly different to mainstream opinion. There are many ways to approach and apply medicine. Therefore, due to the changing nat...

 DISCLAIMER STATEMENT Please note that the information contained within this book is based on the authors' personal use and therefore can be slightly different to mainstream opinion. There are many ways to approach and apply medicine. Therefore, due to the changing nature of medical informa­ tion, the content within this book is up to date and relevant at the time of publishing. Use of the information contained is at the reader's discretion and responsibility and each dose or medication recommended should be checked with outside sources prior to use. Further information may be required from additional sources. The editors will not assume liability for injury, illness, death to persons and animals, or damage to property following the use of the information contained within this book. V  We want to give a big thanks to the following amazing veterinarians for their help and advice on our first book collaboration. We had such a great time creating this for our VOTR family and are so grateful for their support and advice. Thank you to Angela Gamboni DVM, Brent Gordon DVM, Elizabeth Franklin DVM, Jordan Jaeger DVM, DACVIM (Small Animal Internal Medicine), Nikki Johnson DVM, Katie Miller DVM, Julie Reck DVM, and Fred Wininger DVM, DACVIM (Neurology). vii --  CONTENTS Advice We Kept Referencing as New Grads......................................... 1 Case 1: Chronic Diarrhea in Older Cats............................................. 7 Case 2: Chronic Kidney Disease in Cats............................................ 17 Case 3: Chronic Vomiting in Older Cats........................................... 37 Case 4: Cushing's Disease in Dogs................................................ 51 Case 5: Cutaneous Mast Cell Tumor in Dogs................................... 63 Case 6: Dental Disease......................................................... 73 Case 7: Diabetes Mellitus in Dogs................................................. 83 Case 8: Diarrhea in Kittens...................................................... 95 Case 9: Flea Allergy Dermatitis in Cats........................................... 101 Case 10: Foreign Bodies in Dogs................................................ 107 Case 11: Heart Murmurs in Small Breed Dogs...................................... 119 Case 12: Hyperthyroidism in Cats................................................ 133 Case 13: Lick Granulomas in Dogs................................................ 141 Case 14: Osteoarthritis in Dogs..................................................149 Case 15: Otitis Externa in Dogs..................................................163 Case 16: Pruritus in Dogs........................................................ 173 Case 17: Seizures in Dogs.......................................................197 Case 18: Thunderstorm Anxiety in Dogs.......................................... 211 Case 19: Urinary Tract Infections in Dogs..........................................215 Case 20: Urolithiasis in Dogs................................................... 227 Bonus Chapters: Repeat Calcium Oxalate Formers and the 'GDSE' Method.......................... 237 When to Refer?.............................................................. 243 Interpreting ALKP............................................................ 249 ACTH Stimulation Test........................................................ 255 Conclusion................................................................... 257 About the Authors............................................................ 259 - Advice We Kept Referencing as New Grads Vaccine reaction or onophyloxis pion: ► DexSP 0.1 mg/kg IV or IM ► Diphenhydramine 2.2 mg/kg IM or SQ (NOT IV!) ► If severe, get an IV catheter in give DexSP IV (or IM if catheter taking too long) and diphenhydramine IM right away. Once the catheter is placed, begin treatment for shock. Start bolusing fluids (20-30 mL/kg is our go to shock bolus), begin flow-by oxygen, monitor vital parameters, vasopressors or hetastarch if needed, and consider epinephrine if worsening, etc. How to make 2.5% dextrose solution: ► Remove 50 ml of fluid from I l bag ►. Then, add 50 ml of 50% Dextrose to I L bag To get from % to mg/ml: Add a O to the % ► lasix 5% = 50 mg/ml ► Dextrose 50% = 500 mg/ml ► Cosyntropin I mg = 1000 mcg Shock Fluid Rotes for Hypovolemic Animals ► Shock dose crystalloid fluid rate in dogs: I0-30ml/kg. ► Shock dose crystalloid fluid rate in cats: I0-20ml/kg. ► Generally given over 15-30min. ► Careful with anyone with heart murmur/heart disease, pulmonary contusions, etc. Consider adjusting dose/rate based on heart status, cause of hypovolemia, rate of onset etc.  NEW VET JUMPSTART GUIDE Quick Dexamethasone SP Doses (IV or SQ) ► Dex SP Physiological dose 0.0Smg/kg q 12-24 hours (ex: Addison's). ► Dex SP Inflammatory dose 0.lmg/kg q 12-24 hours (ex: vaccine reaction, inflame d skin, etc.). ► Dex SP lmmunosuppressive dose 0.25mg/kg q 12-24 hours (ex: Immun e Mediated Hemolytic Anemia- IMHA). Quick Dextrose Bolus Calculation for Hypoglycemic Crisis ► 0.5-tml/kg of 50% dextrose diluted 1:4 with saline or LRS. We give over 5-15 minutes IV only. (The dilution reduces phlebitis.) ► Example: 5kg dog. Take 2.5mls of 50% dextrose and dilute with I0mls of saline. Administer IV. ► Treat based on patient, symptoms, cause, response etc. Oral dextrose on gums may be useful in some cases. ► Recheck values on glucometer and even chemistry machine if they don't seem to match patient symptoms ► Consider lower doses in insulinoma patients ► Do not use already punctured bottles of dextrose that are not refrigerated for IV use. There is debate as to how 'long' opened bottles last in the refrigerator without bacterial contamination. If there is any doubt, grab a fresh unopened bottle for IV use. CRI calculation: ► Check out http://vasg.org/ for straightforward CRI spreadsheets with com­ mon drugs for veterinary patients. We use it often for CRl's in syringe pumps for patients that need additional pain control during surgery/dentals ► If adding medication to a bag of fluid we have our patient on, we calculate like this: 1. Look up the rate of the drug you want. (ex: 2mg/kg/day of Metoclopramlde (reglan)) 2. Look up concentration of the drug (Metoclopramide Smg/ml) 3. Multiply rate x kg. Ex: 2mg/kg/day x 10kg 20mg/day 4. Find mg/hr by dividing amount/day by hours/day: _ 20mg/day + 24hrs/day 0.83mg/hr 2 ◄  ADVICE WE KEPT REFERENCING AS NEW GRADS s. Calculate the hours of fluids remaining in the current bag based on the current fluid rate: Ex: If I'm starting a lL bag+ SOml/hr 20 hrs 6. Calculate total mgs needed for that bag of fluids using the calculated mg/hr and hours remaining in current fluid bag: 0.83mg/hr x 20hr 16.6mg for current bag 7. Calculate mis of metoclopramide to add to bag using the concentration of metoclopramide and the calculated number of mgs to be added to the bag: 16.6mg + Smg/ml 3.32ml of metoclopramide to be added to lL bag of fluid that is being run@SOml/hr for a 10kg dog (make sure to remove the volume being added from the bag prior to adding the medication, this ensures proper delivery of the drug if you are adding large volumes of drug to the bag.) PU/PD: ► Polydipsia is drinking > 100 ml/kg/day ► Polyuria means urinating > 50 ml/kg/day Other random tidbits: ► Only use DexSP in cats because dexamethasone is glycol based, which is toxic to them. ► Do not forget your PO drugs that can cause esophageal strictures in cats (like doxy­ cycline, clindamycin, etc.>. We always recommend chasing pills with 3-5 mL of water after to be safe. ► You cannot ask an owner to split pills into 1/8 or 3/4. It is difficult and reduces compli­ ance. Get it compounded instead. ► Always check for any adverse drug interactions in Plumb's when you have a pet on multiple drugs. ► Mention common medication side effects to owners. 'il Example: We have each had a case where a dog became temporarily deaf from· Mometamax usage. Warning an owner of side effects allows them to monitor better, discontinue the drug, and call you right away. 3 NEW VET JUMPSTART GUIDE ► Famotidine, maropitant, and cefovecin all calculate out to the. same amount (0.045 mL/lb). ► Always explain (or utilize your tech) how to give medications clearly. You will be sur­ prised how many people do not know how to give it or do not know strategies to ensure their pet takes the medication. 'v Give them food options to hide pills in like peanut butter, chicken, tuna, wet food (roll it into a meatball), marshmallows, cheese, Pill Pockets/Pill Wrap, etc. 'v Tell an owner if a medication is bitter (like metronidazole), so they know to hide it well. 'v Same goes for eye and ear medications. Show them exactly how to administer it by doing the first treatment. ► Never, ever give any fluids subcutaneously to pet's with dextrose in it (necrotic wounds will form). Use IV only please. When giving subcutaneous injections, we also encourage giving cerenia and famotidine in different locations than 'in the fluid bubble' (ie do not give in same location that subcutaneous fluids were administered). Though rare, there have been a few reports of necrosis noted in our area. 4.....----- ADVICI WI ICl,T lll,IUNCIN8 Al NIW GRADI NOTES: - - ------- - ------- ---- -- -- - - ------ ----- -- 5 NEW VET JUMPSTART GUIDE NOTES: ------- ----- ------- 6 Chronic Diarrhea in Older Cats When a cat presents to you with chronic diarrhea, you will often find a frustrated owner in the exam room. As you know, there are many differentials that can cause chronic diarrhea, so a work-up is needed. When working these patients up, the most important thing you can do is to progress in a methodical manner ruling conditions out in a step by step fashion. You do not want to get burned by parasites, so start simple with fecal testing and deworming, even in an indoor only cat. The basic diagnostic plan we lay out here will get you far. The second most important thing you need to do with these cases is communicate clearly with the client. Let them know upfront that these cases can be frustrating. Then, let them know the initial course of action you will take and how you will be working in a methodical step by step manner. We will try one thing first, and if this is ineffective, then we move on to the next diagnostic or treatment plan. Lastly, keep them informed on what the next step of the plan is if the current treatment does not work. This helps owners feel involved and prepared. Let's get started! Here is our basic approach: t. Differentiate between small and large intestinal diarrhea 2. Confirm acute or chronic diarrhea is present 3. Diagnostic plan 4. Treatment plan NEW VET JUMPSTART GUIDE e intestinal diarrhea. STEP 1: Differentiate between small and I arg ► Getting a good history will guide you. changes m appetite' abdomi·nal dis ► Small intestinal: large stool volume, weight losS, comfort, melena, etc.. , frequent, etc. ► Large Intestinal: small volume, tenesmus, hematochez1a STEP 2: Confirm acute or chronic diarrhea is present. ► Again, history will guide you. Chronic diarrhea typically lasts three weeks or more. STEP 3: Diagnostic plan: Common differential list ► Dietary: food allergy, food intolerance, raw diet, etc. ► Exocrine pancreatic insufficiency ► Infection: viral, bacterial, parasitic, fungal, etc. "v Examples: Salmonella, Campylobacter, Giardia, Coccidia, Cryptosporidium, Tritrichomonas, Felv, FIP, SIBO, etc. ► Infiltrative: lymphoma, other neoplasia ► Inflammatory: inflammatory bowel disease, pancreatitis, cholangitis, cholangiohep­ atitis, triaditis ► Metabolic/systemic disease: hyperthyroidism, liver disease, kidney disease, etc. 8  CHRONIC DIARRHEA IN OLDER CATS 1. Initial diagnostics to rule out systemic causes: a. CBC, Chemistry, electrolytes, T4, urinalysis, Fecal, FIV/Felv snap test (if not on file/ warranted) 2. Next steps If the above tests come back normal: a. Perform a second fecal +/- fecal culture i. Some parasites shed Intermittently, so think of this as your "second check." b. Abdominal ultrasound i. You can consider x-rays if you do not have ultrasound capabilities, but they are not as high yield in these cases. They function as a generic health screen and will not pick up on subtle changes. It would be better to have an owner save for an ultrasound if you are at this stage with financial limitations. c. Texas GI blood panel i. Make sure it includes TLI/PLI/Cobalamin/Folate. ii. The cat must be fasted for this test. It is helpful in ruling out EPI, evaluating intestinal function, and raising suspicion of lymphoma (With GI lymphoma, you often see cobalamin 10 years old. ► Test of choice is a total TT4. ► If in the gray zone with clinical signs (3.5-4, at common clinical signs: weight upper end of reference range), you can run a loss, muscle atrophy, diarrhea, free T4 as a confirmatory test. vomiting, polyuria, polydip- sia, polyphagia, hyperactive, Other abnormalities you may see: weakness, irritability, vocalizing ► Elevated liver enzymes (ALT, AST, ALP) (especially at night), poor hair ► Azotemia (BUN, creatinine), though you may coat, tachycardia, arrhythmias not see this until the cat is regulated on med­ (gallop most common), palpable ications because hyperthyroidism can mask thyroid nodule renal disease ► Hypertension NEW VET JUMPSTART GUIDE Treatment: ► Oral methimazole (2.5 mg and 5 mg tablet options) Is the drug of choice. Dosing typically starts at 2.5 mg PO twice dally. " This drug can also b·e compounded Into a liquid or transdermal to be applied on the inner ear by a compounding pharmacy. 'v Side effects are rare, but we always warn owners of blood work abnormalities and facial pruritus ► Hill's Y/D diet 'v We tend to only use this diet when other treatments are NOT an option (ex: methimazole reaction) or the "borderline cats" that have a TT4 between 3-5, as we do not find it drops the value much. 'v You cannot use it in a multi cat household or in homes where a cat has access to ANY other foods by mouth (dog food or human food). If not strict, it does NOT work! ► Surgery (thyroidectomy) 'il Curative option ► Radioactive iodine therapy 'v Curative option 'il Considered the gold standard and preferable if owners will pursue 'v Biggest con is in rare cases it can cause hypothyroidism, which would need to be treated with medication for life. Before referral, look at requirements to make sure your patient is a good fit! 1 34  HYPERTHYROIDISM IN CATS ,,. ere are a few things you should be aware of with ,h this disease. Thyroid disease can cause ea ses or be found conc urr ently w'th other dis I underlylng hyper trophlc cardlomyopathy, for m ple. Yo u may also find kidn ey dlsease (esp e......a ecially once hyp erthyroidism Is managed cu atm ent can unma sk it ) ' hear t disease, and hyperten be a se tre slon. It Is Important to be thor- h an d rul e all of these second ary di seas es out once you know a cat has hyperthyroidism. oUg you catch hyperthyroidism In the earl stage oftentimes, if Y s, you can minimize Injury to other organs. a That right there will sell many owners on bloodwork ev ery 6 - 12 months. These other mean a poorer prognosis. disease s can so, you diagnose hy perthyroidism in a cat Now, what shouId you teII theowner? Client communication points: ► Make sure to discuss ALL treatment options. with the owner when you first diagnose. their cat. The cheapest option will always be medical management, but some owners may want a more permanent solution. As we know, medicating cats can be difficult, so. we find owners can warm up to the idea of radioactive iodine over time if they struggle to medicate their cat. ► If an owner chooses medical management, do not forget to go over the side effects of methimazole. Honestly, you need to get in the habit of doing this for every drug you give a patient in order to prevent a client complaint. rgy, vomi ting, diarrhea, "v Common side effects to mention Include anorexia, letha and facial pruritus. l management, their cat will never be "v Do not forget to mention that with medica n blocks the synthesis of thyroid hormone. cured, only managed. The medicatio e iodine, contact your local facility to ► If an owner is interested in surgery or radioactiv referral. Oftentimes, you still need to start determine what you ne ed to do prior to ge me nt in ord er to ge t the cat stabilized. We know many referral facilities medical ma na u to rep ea t a TT 4 prior, as well as other tests like a urinalysis. They do also want yo th your local specialist to ensure th e referral not want concurrent infection, so talk wi process is smooth. 135 NEW VET JUMPSTART GUIDE ► If an owner opts to change formulation, such as going from an oral tablet to transder­ mal warn them that you will need to recheck TT4 again 3-4 weeks after the chan ge, So etimes, transdermal does not absorb as well, and cats may need a higher dosage, Transdermal can take up to 4 weeks to start working. after stabilizing ► Prepare an owner that sometimes another disease can be unmasked the cat's thyroid levels. We often see normal kidney values initially with uncontrolled hyperthyroidism, then once it Is controlled, kidney disease is unmasked. This will be important because we do not always recheck kidney values, but if an owner wants to be thorough, you can do this the same time as the recheck TT4. Early intervention is always key to ensuring we are doing everything we can for their cat to keep them healthy as long as possible. ► If you have a borderline hyperthyroid cat that has a TT4 in the upper end of the reference range and normal fT4, make sure you can palpate a thyroid nodule (thyroid slip test). If so, recommend that they come back in 6 months to recheck sooner than their annual, as they are most likely still developing the disease. You have just not caught it yet. Recheck plan: Recheck TT4 in 2-4 weeks to ensure medical management is appropriate. Dose should be in the mid-normal range. ► A good approach to take with an owner when discussing a recheck of any endocrine disease is that you do not want to cause the opposite disease. Over supplementing can occur, and sometimes it can take a few dose adjustments to find the right amount for their cat. ► If an owner is "gung-ho" and not financially limited, it is always ideal to repeat a CBC and chemistry with their TT4 to see if we have unmasked kidney disease, as well as to ensure prior liver enzyme elevations have improved. Rarely, hepa topathy can develop after starting methimazole. Blood pressure can also be impo rtant to do at this stage. ► Just remember, you will have a wide variety of clientele. Always give each client the "spiel", but you will need to offer a range of care bas ed on what an owner can afford. If an owner can only do the bare minimum, focus on what ·ts most important.  IN CATS HYPERTHYROIDISM Hyperthyroid disease in cats summary 1. Diagnosis: elevated TT4 above reference range, palpable thyroid nodule, and clinical signs = hyperthyroidism. e, 2. screen for concurrent disease such as kidney disease, hypertension, cardiac diseas etc., which may not be apparent until after treatment. 3. Discuss treatment options and pick the best plan for the patient and owner. coSt 4. Recheck in 2-4 weeks with a TT4 along with a CBC, chemistr y, and blood pressure if allows. Continue rechecks until appropriate dosage is found. s. Long term recheck plan is semi-annual exams and blood work every 6-12 months (CBC, chemistry, T4, UA) based on what an owner can afford. 137 NEW VET JUMPSTART GUIDE NOTES: --  HYPERTHYROIDISM IN CATS NOTES: 1 39 NEW VET JUMPSTART GUIDE NOTES:  Lick Granulomas in Dogs not seem like a big deal....until you get a Lick granulomas may client complaint about the never ending sore on their dog's leg that you have failed to resolve. This is a disease where commu­ nicating chroniclty and expectations is VITAL to a successful outcome and forming trust with your client. Here is how we do it. First, how do you differentiate a lick granuloma from some­ thing else? Well, history will be very important here. These lesions form due to chronic licking where the pet fixates on a specific area. The most commonly affected areas are the front limbs between the elbow and toes. Underlying causes to consider: ► Allergies ► Licking due to pain/arthritis ► Psychogenic/OCD behavior ► Infectious (demodex, ringworm, etc.) ► Boredom ► Neoplasia ► Cutaneous foreign body ► And more NEW VET JUMPSTART GUIDE Client communication points: and difficult to treat: Set your 1. From the start, communicate that these are frustrating hout time, proper management owner up with this expectation. These do not resolve wit throughout their lives. at home, and often can recur if not managed appropriately 2. Underlying cause: Try to determine your underlying cause because this will guide your treatment plan along with the strategies related to prevention. Allergies are often the most common cause, but occasionally dogs can develop an OCD component or lick due to pain. You will start by gearing your treatment toward allergies, while you assess response to your treatment plan. See our chapter on pruritus for some tips on how to manage under­ lying allergies in pets. 3. Long term antibiotics: These patients often need to be on antibiotics for a minimum of 6-8 weeks, and sometimes 8-12 weeks in tough cases, as a deep infection is nearly always present. Occasionally you will need to culture the area, but most cases will not need this additional test. 4. Even if the dog licks the paw for just a minute or two, the Infection will persist, and it will never heal: CONVEYING THE IMPORTANCE OF THIS TO THE OWNER cannot be overstated. Keeping the dog from licking the paw is absolutely necessary for improve­ ment of this condition. We have healed these completely, and then the dog licks for a few days, which puts us back to square one. Just one minute of licking can set the dog back weeks. Options include use of an e-collar, dog clothing (if it will cover well), and/or www.dogleggs.com for protective wear that covers it. 5. Use a combination of the below treatment options in order to heal a lick granuloma. You can always start with an initial plan and add on over time based on response. Diagnostics to guide your treatment plan: 1. Skin scrape and cytology 2. Consider tissue culture if not improving with the following plan  LICK GRANULOMAS IN DOGS k ranuloma treatment guide Lic g Long term antibiotics: (6-8 weeks min.. ► imum)· cephaIexI n, cefpodoxime, or amoxicil- lin/clavulanic acid work ver y well. Remembe · r often deep Infectlon ls present. If it has been there a long time, a tissue culture maY be' more helpful In guiding your choice. ► Long term anti-Itch medication· See prurItus chapter for all options, but we often use Apoquel, prednlsone, or Cytop lnt. ► E-collar or other protective coverlng.. y,ou wl11 find that clients always want to try socks or at home ba dages. We find these are often Ineffective, as they just lick on top of the sock, and 1t does not do anyth ·mg. If a c1lent wants to do this, warn them that you have seen some dogs eat bandages, so they understand the risk. Try to find the best. e-collar option-there are many innovative ones out there now! ► Topical treatment: These can also be very helpful. Options include Douxo chlorhexidine mousse, Mal-a-ket wipes +/- a topical steroid like Synotic or Animax. Note: You can only use steroid ointments for 7-10 days, as they can thin the skin if used chronically. ► Flea/Tick prevention: If you are not doing a food allergy diet trial, we still like to have our patients on an isoxazoline product (Bravecto, Simparica, Nexgard, or Credelio) if possible to cover for demodex. ► Laser therapy: If you have a cold laser at your hospital, daily laser therapy has been nds. There are many shown to improve healing time with many acute or chronic wou y 2-3 days, until healed, or protocols, but a com mon one is daily for 7 days then ever the machine when you type in the nearly healed. The length of time is determined by location, size, etc. on your estimation of client compliance. ► Rechecks every 3-4 weeks: This will depend s, as it allows you to adjust therapy based We find 4 and 8 weeks are good time frame need to see it at different stages to note on response. These take time to heal, so you with treatment. pro gress and to keep the owner motivated always get a client to do this right off the bat. If ► Food allergy diet trial: we cannot sure they understand that this is our your cI.1ent 1s not ope n to the ·,dea yet, we make 143 NEW VET JUMPSTART GUIDE next step If it comes back. If you do a food allergy diet trial, here are some parasite preventative combinations you can try that will not interfere. "v Bravecto + Revolution: It comes in a chewable that is hydrolyzed pork , so it is approved for food allergies. There is also a topical. It covers demodex too! Revolution is a topical. "v Bravecto + Sentinel flavor tabs: Have your client wash off the flavoring with Sentinel. "v Topical flea/tick option (Vectra-3D, Activyl, Bravecto, etc.)+ Sentinel flavor Tabs "v Revolution: You can use it on its own if tick coverage is not needed. "v Simparica Trio: It comes in a chewable that is hydrolyzed pork. ► Reduce boredom: Have clients try to increase activity to reduce boredom, which can promote licking. This can look like 2-4 walks per day. Short, frequent walks may be best if they are not a highly active breed. An owner can also offer daily Kongs with canned food or peanut butter to lick instead of their arm, 15 minute training sessions daily, puzzle toys, etc. Extra tips for lick granulomas ► Take pictures and attach to your patient file. This will help you remember exactly how it looked so that you can objectively compare it at each recheck. This can also be helpful if an owner does not feel it is healing, as you can show them the picture. ► Send home with a handout. We ALWAYS give owners a handout eliciting the points we make so that the plan is clearly stated for best compliance. It is easy for them to miss a point or forget one, as there are several things that they have to understand. You can also state next steps at the end of the handout if it does not improve such as a food allergy diet trial, relaxant medications like trazodone, pain medications like gabapentin, or a dermatology consult for allergy testing. ► Culture when Indicated. Let the client know that if an infection persists, a tissue cul­ ture is the next step. Prep them with the price and an estimate. The most ideal way 144  ooGS LICK GRANULOMAS IN ue to to co\lect your culture sample is to sedate your patient and get a sample of tiss send off because the infection is typica\\y deep. ► Give them the option of a dermatology referral if the \ick granu\oma is not responding as you exp ect. We always mention that if they ever get frustrated and want to go to a dermatologist to just \et our office know. \t is important to show that you are a\ways open to collaboration and a second opinion. It builds trust. 145 NEW VET JUMPSTART GUIDE NOTES: ---- - -- ---- - -----  LICK GRANULOMAS IN DOGS MOTES: ------ ---- -------- ---- --- - - --- - -·--------------- ---------- -- 1 47 NEW VET JUMPSTART GUIDE NOTES: -··----------------- ----- -- ----- --  Osteoarthritis in Dogs Arthritis can (and does) occur at any age. We have both seen two year old dogs present with chronic lameness due to arthritis that developed at an early age. We have both euthanized dogs due to mobility issues. We have both seen pets in chronic pain where the owner is resistant to medical management. These cases can be difficult for both the owner and you as the veter­ inarian because expectations can vary. Some owners will be on board with trying anything, while others will be resistant to any therapy options you offer. so, what is the best approach for your young and old patients? How will you communicate the importance of arthritis management in your middle aged to senior pets? We are here to share our approach with you, as we dish our random tips, drug protocols, alternative therapies, favorite management strategies, and more! Classic phras es you will hear from owners about pets with arthritis ► "My dog is not able to jump up on his favorite couch as gracefully as he once could." ► "My dog seems a little stiff in the morning but warms up after a while." ► "My dog still plays but not as much as she used too." ► "My dog sleeps all the time and used to be active." ► "My dog struggles to get up from laying down." ► "My dog is sitting weird." NEW VET JUMPSTART GUIDE Client communication basics Here are some points you want to ensure you get across to owners. occur over their life. ► Arthritis Is a degenerative Joint process that will continue to ► Arthritis leads to Inflammation In the joints, which Is the main source of acute or chr onic pain. It helps to relate these symptoms to human medicine, s many owners have arthritis or chronic pain as well. ► Lameness will be a common presenting complaint that you will see in general prac­ tice. Outside of lameness, dogs cannot easily tell us about their chronic pain, so it is important to analyze any behavior changes closely. We also stress to owners to bring them in for clinical signs that seem off from their normal routine. ► Recommend to the owner that they consider starting therapy sooner rather than later. The goal is to manage arthritis early in order to slow down the process of cartilage degeneration. Your treatment is aimed at slowing and decreasing the inflammatory cascade and stress on the joints as much as possible. By being proactive, the owner can slow down the progression of arthritis. ► Recommend x-rays for lamenesses that are recurrent or not improving with exercise restriction and NSAID therapy. Random tips: ► T p 1: When taking an x-ray of a limb, always take the opposite limb for com parison. Tip 2: Do not forget to check for neck and back ► pain, as forelimb lameness can often be due to neck pain. ► Tip 3: Do not fight with your patient. Sedation is your best.. fr·,end , espec1a · II y 'fI surgery may be md1cated so that you can get the appropriate views.  OSTEOARTHRITIS IN DOGS for every pet with suspected arthritis or mob·i· 1 1 ty issu. es, recommen d: 1. Keep your p t lean. We like a Bes of 4/9. Explain to ow ners that this Is the single most important thing they can do for the 1r pet. Help the ir goal be attainable by giving them a calorie count and diet suggestion for weight loss.. We recommend monthiy weIgh-ms · w1·th nurse appointments to help them remain accoun table and keep track of their goals. This approach allows you to adjust the plan If ft is not wo rking. a. Some great die t options are Purina JM and Hill's Metabolic Mobility. We love these two because they function as both weight loss diets AND are formulated with joint supplements. If the dog will not eat them, you can try traditional weight loss foods like Purina Pro Plan Weight Management, Puri na OM, Hill's Metabolic, or Royal Canin Satiety. 2. Transition to low impact exercise as a way of life. Exercise must be consistent and daily. Arthritic joints need movem ent but not stress. Explain to the owner with the dog that likes to chase balls to instead go on long walks with his ball or do short tosses in the yard. If their dog likes to swim, this is another great option for their dog. Decrease use of stairs and have them limit pets from jumping on and off furniture. a. If the owner is able to take it a step further, physical therapy is a great modality to assist orthopedic conditions in dogs. They can go to a facility that specializes in this, ensuring the dog gets a mix of underwater treadmill exercise, balance therapy, obstacle courses, etc. You can also incorporate exercise plans for your patients where owners take their dogs up and down hills, do short but frequent walks to build over time, and more. The goal here is to improve muscle mass. 3. Supplements and medications: a. Omega 3 fatty acids: Suggested Dose: the optimal dose has not been determined but we use 4? i. 1 mg/kg/day eicosapentaenolc acid (EPA) and 25 mg/kg/ a d cosahexaeno c. but this 1s Just one we use. acid (DH A) · There are many doses you can use,.. a · · · · st do g f oo ds ·11 wt not have this much unles s 1t 1s prescription Joint d'1et. Mo in, be mindful of the amount of 1 Note: W hen you add this supplement ts. It is also important to warn wners. calories it adds with some produc. ' diarrhea in some dogs. We will often that its sudden addition can cause NEW VET JUMPSTART GUIDE. administration for a few weeks' tell owners to start with every other day normal stoo1 s. then increase to daily when they note mend it come from a company ii. It should be deep sea fish baSed , so we recom... vita 1 also hel pfu l if it con tain s min E as an anti· with good quaIlty controI. It ·s oxidant too. iii. Avoid cod liver and plant based fish oils... oil bec aus e it has high con cen t at1on of _ :1t amin 1. Why? Avoid cod liver A and D, which can result in toxicity. P lant based are inefficient in dogs due to minimal elongation of a-linolenic acid to EPA and DHA. iv. over-the-counter products we recommend: Weiact in, Nordic Naturals, and Freeform Omega Fatty Acid b. UC 11 (Flexadin Advanced): i. There is more research behind the efficacy of this supplement than glu· cosamine. It is in Flexadin Advanced (not Flexadin plus). It can be used with omega3's. ii. It is not recommended to use with glucosamine, as it decreases efficacy ( Gupta paper). c. Glucosamine: i. There is little evidence that glucosamine works. However, we do have some patients that seem to respond to it based on the owner's interpretation. ii. There is more evidence supporting avocado oils, so if you do recommend glucosamine, Dasuquin is a reasonable option because it has extra ingredi­ ents in it. iii. If the owner is insistent on an over-the-counter version, you can recommend Cosequin, which is just plain glucosamine and chondroitin. Most glucosamine products take about 4-6 weeks to work, due to needing a loading dose, where an owner notices a difference. d. Adequan (polysulfated glycosaminoglycan): i. This injection is one of our favorites! It is the only FDA approved disease-modi­ fying osteoarthritis drug. It inhibits cartilage loss in the dog joint which maY 's s, help to restore joint lubrication, relieve inflammation, and renew the buil ding blocks of healthy cartilage. (information taken from adequancanine.com). ii. It works best to start it at the first signs of arthritis and then to stick with it in management long term.  DOGS OSTEOARTHRITIS IN iii. You can teach some owners how to give it at home to decrease stress on your patient. Off label, most vets will teach owners to give it subcutaneousiy, instead of intramuscularly. e. CBD (cannabidiol): i. At the time of our publishing, there ls promising data that CB D's can be help­ ful in management of arthritis. It is still not accepted by the AVMA that we recommend it for our patients, so it is a "fine line" right now where we can mention its use. Let owners know that it is important to find a good source if purchasing for their pet and that they can use it "off label at their own risk." Many companies are doing research on it, as we speak, which is great. ii. Many of the current CBD products for pets have poor quality control, uncertain ingredients, and are poorly regulated as a whole. iii. Encourage the choice of products with independent laboratory testing and certificate of analysis on their products (Example: Ellevets and Chroniquin, which is made by a Nutramax subsidiary). There are also local compounding pharmacies making their own treats for owners. f. Gabapentin: i. This is a drug in the anticonvulsant class that helps treat neuropathic pain. It works by decreasing the release of excitatory neurotransmitters. ii. Most of the specialists in our area prefer for owners to try this prior to daily NSAIDs due to the potential long term effects with chronic NSAID therapy. However, it is a great complement to an NSAID because it works through a different pathway. iii. This drug is helpful for many dogs, however, some owners do not like it. The main complaints are that it causes their dog to be sleepy or that owners do not think it is working well. If it causes drowsiness, try to adjust the dose lower or try an NSAID instead. g. NSAIDs: i. This will be one of your most effective drugs for decreasing joint inflamma- tion. Though there are some chronic side effects with its usage, it does tend to work very well. ii. Examples of products in this category that we like are Rimadyl, Deramaxx, and Galliprant. Choice is often based on availability, cost, and presence of NEW VET JUMPSTART GUIDE ce for any dogs with liver other systemic diseases. Galliprant ls a good choi or kidney enzyme elevations. iii. For owners resistant to its use, here is an example conversation on how we recommend its usage: 1. "Based on how you describe Fluffy's mobility at home, paired with my exam findings today, I do feel this is all due to arthritis. I can tell by feeling her knees and elbows that she has degenerative changes with muscle loss and thickened joints. There comes a time where we need to weigh comfort with side effects. Though these medications can cause side effects like GI upset and kidney/liver changes, they also have great benefits to where Fluffy feels better and is able to do the things she loves again. If you are open to it, why don't we try a 2 week trial with Rimadyl, and see how Fluffy does on it. If you can tell she feels better, I would continue it long term. We recommend blood work every 6-12 months in order to stay on top of her health while on this medication. n h. Amantadine: i. This is a drug with many mechanisms of action. In human medicine, it has been used as an antiviral. How it works to treat chronic pain is through antagoniz­ ing NMDA receptors in the central nervous system, which is similar to how ketamine works. It also helps neuropathic pain. ii. You should consider its use as a second or third medication added to the dog's regimen because gabapentin and N SAi Ds will always be your best first choices. It is a great add on when your patient has worsening chronic pain, and it has been shown to complement NSAIDs well when you find an NSAID alone is not helping a patient's comfort. iii. There are no known side effects with this drug. 154  OSTEOARTHRITIS IN DOGS Quick doses of our favorit e drugs: ► Adequan: " It comes in a 5 ml 000 mg/ml) vial, and you often sell It by the vial. " Dose 0.02 ml/lb (1 ml per so lbs). " With either protocol mentioned below, Adequan can be discontinued after 6+ months if the owner does not feel it is helping anymore. It can always be restarted at a later date again with the protocols mentioned below if symp­ toms flare.. " Dosing schedule varies, we use one of the two protocols: 4.4 mg/kg IM or SQ twice weekly for 4 weeks, then once weekly for 2 weeks, then once every 3-4 weeks long term. 4.4 mg/kg IM or SQ twice weekly for 4 weeks, then once monthly long term. ► Amantadine: 3-5 mg/kg PO SID " Always use with other medications. ► Gabapentin: 5-20 mg/kg PO BID " Start with a lower dosage at SID to BID, then build. You can increase to TID over time. Building will help to decrease sedative side effects. ► Galliprant (grapiprant): 2 mg/kg PO SID " Best given on an empty stomach an hour before feeding. ► Rimadyl (carprofen): 4.4 mg/kg PO SID (or 2.2 mg/kg PO BID) " Give with food to prevent GI upset. 155 NEW VET JUMPSTART GUIDE Basic plans based on age no clinical signs or minimal historical sig n s. Pre-arthritis (middle age to early senior): Dogs with l as an appropriate exercise routine. ► Ensure they are maintaining lean body weight as wel ► Recommend a daily joint supplement, by prepping owners for the idea that even at this age, there are already degenerative changes starting to occur. Our favorite to begin with is an omega 3 fatty acid. See above for options. ► Go over some of the signs an owner may see develop over time so that they can start actively monitoring their pet. Dogs with mild to moderate signs of arthritis: These dogs can be any age, though typically they are seniors. ► Consider a prescription joint diet. "v This is the easiest way to get their dog the needed amount of omega 3's, so there is no need for additional supplementation. ► Continue daily joint supplements, and you may want to add additional options. "v If your owner started an omega 3, then you can ask them to add in glucos amine +/-Adequan. ► Gabapentin trial. "v Initially, we will start a pet on gabapentin ever y 12-24 h ours. you can start a 10 -14 day trial, and then follow up with the owner to see if they noti ced any effect. "v The EV is le ting the owner know the effect will be mild. They may notice thei r dog 1s following them around more or seems to.. get up the stairs more easily. The goal 1s to find a dose that w·11. 1 contro 1 pain but also not make them extremely lethargi.c. Have the owner caII I'f their. dog th e.r i. seem s too seda te and o ut of normal routine.  OSTEOARTHRITIS IN DOGS ► NSAID as needed. " Next, you can add In an NSAID of your cho ice. You can start a 10-14 day trial, and then follow up with the owner to see If they noticed any effect. " If so, tell them to use It as needed when their pet seems "slower than normal." However, the owner should tell you If they feel their pet may benefit from daily use over time. There may become a point where an NSAID is beneficial on a routine basis. ► Alternative modalities. " Physical therapy can be very helpful here in helping dogs to maintain lean muscle mass through a combination of an underwater treadmill, balance exercises, etc. ► Environmental support needs to be started here, if not already implemented. " Mention tips that make the home mobility friendly with non-slip rugs, orthopedic beds, preventing their dog from climbing stairs unnecessarily, moving food/ water to easily accessible spots, toe grips, etc. Dogs with moderate to severe mobility issues: Do the above recommendations, in addition to... ► Daily use of NSAIDs. " This drug is an important part of comfort for an arthritic pet, but you MUST ensure your client understands the risks, monitoring parameters (i.e. give with /d ea is noted, etc.), food, discontinue if any inappetance/lethargy/vomiting iarrh in for bloodwork every 6 m nths and that they are willing to be diligent and come · ·mum requirement for those owners who are cost conscious). (annua I.1s the mm1 owner. Quality of life is a very " Just ensure you are on the same page as your important factor with these patients. 157 NEW VET JUMPSTART GUIDE that struggles to get up easily and go on ,. Example: 10 year oId Fs Labrador. Rima dy l. She shou ld have 1t every day because her regular walks w1'thout her 1 of l'ife, so long as the owners are ok with the risks it improves her qual·ty ► Add in Adequan injections. " Anecdotally, we have many pets that do really well with this medication. Some owners will not start it initially due to cost, so it is always good to recommend one last time at this stage. " cost can be an issue for larger dogs, but we always let owners know that if they can push through the first 6 weeks, it will become a lot more affordable (See above box for dose and schedule options.). ► Alternative modalities. " Consider acupuncture, laser therapy, stem cell therapy, etc. ► Harness or sling support. " These are both useful in helping dogs get up from lying down. The Help 'em up harness is one of our favorite brands because it can be left on the patient and has a few handles to help support both the front and hind end. Guiding the dog up and supporting them as they start to walk will help their mobility by loosening up their joints as they walk. It can also be used to support them on stairs to outside. Dogs with arthritis and kidney disease or other systemic disease: ► For these patients, we try to come up with a multimodal plan that steers away from NSAIDs and leans more into the other drugs, supplements, and alternati ve therapies like omega 3's, gabapentin, Adequan, acupuncture, etc. ► Galliprant is acceptable for some dogs with bad arthritis and mild/mod erate ki dney disease or liver value elevations. Use on a case by case basis. we have both used this drug in these patients and not seen significant changes over time. Performi ng blood  OSTEOARTHRITIS IN DOGS work on these pati en ts ever y 6 mo icant changes, warranting nths will be help a medication ch ful in ensuring there are no signif ange. ­ References: ► cachexia and Sarcopenla: Emerg ing Syndromes of L.M. Freeman: J Vet Intern Med 2 Importance In Dogs and Cats. 012;26:3-l ► comparative therapeutic efficacy and safe ty of type-II amlne and chondroi tin in arthritic do collagen (uc-11), glucos­ gs: pain evaluation by g Gupta 1, TD Canerdy, J Lindl ey, M Ko round force plate. R C nemann, J Minniear, BA Goad, K Rohde, R Doss, M Bagchi, D Carroll, C Hendrick, J T Bagch. JAnim PhysiolAnim 2012;96(5):770-7. Nutr (Berl). October 159 NEW V T JU PSTA T GUID OTE -- 160  OSTEOARTHRITIS IN DOGS NOTES: ------------- NEW VET JUMPSTART GUIDE NOTES: --- 162  Otitis Externa in Dogs Four types of ear infections in dogs (often a combo) ► Yeast (malassezia, candida) ► Bacteria (rods-pseudomonas, ► Bacteria (cocci-staph, strep, proteus, e. coli) enterococcus) ► Parasitic (ear mites-less common) Common underlying causes of otitis externa 1. Allergies. Allergies. Allergies.. '..;··.. ; -. , ,,·,_;..... ',. ' ";.., 2. Swimming or frequent bathing. ,,.., 3. Excessive hair in ear canal. Pluck hairy ears! I".... '........ - 4. Masses, polyps or foreign bodies.... 5. Otitis media or interna (we explain these to clients as a "deeper ear infection behind the eardrum") 6. Drug Reactions 7. Hypothyroid disease, etc.. NEW VET JUMPSTART GUIDE ent summary Creating a smooth otic appointm y + /- ear smear. t. Diagnose type of Infection present through ear cytolog are moSt painful. 2 Examine your patient and check ears last because they...c nifi ant are una ble to see due to Sig 3: Clean/pluck the ear If the patient allows and If you debris. You want to visualize the tympanic membrane. 4. Determine if there are any underlying causes to address today. 5. Discuss your treatment plan. Creating smooth otic appointments-Our approach Understanding this basic approach to ear infections will help you succeed in the majority of your otitis appointments. Be sure to master the communication points, which will help you avoid frustrated owners. For 'frustrating cases' (because they do happen), see our last section. t. Diagnose the infection: If the patient allows, have your tech get ear swabs right away and start running the cytologies for you before you enter the room. This saves you time and can allow you to start mentally preparing treatment options based on the type of infection and the exam findings (i.e. is the eardrum intact?, etc.). 2. Examine the pet: Next, we enter the room to perform the exam on our patient. We recom­ mend examining the patient's ears last due to the discomfort associated with the infection, as this decreases the patient's stress level. During our exam, we will not be discussing everything we see unless something surprises us, as we are really here today to focus on the ears. While performing the exam, we will tell the owner this... a. "Let mejust look him over real quick, and then I'll get to his ears last because those look painful. I like to make sure there isn't anything else going on with Louis because sometimes I can see changes that may relate to the ear infection, such as allergies with paw irritation, etc." When we perform our otic exam, we are assessing the eardrum to ensure it is intact. It is also important to look for other abnormalities that may cause an Infection such as a tumor,  OTITIS EXTERNA IN DOGS polyp, or clumps of wa xy ear hair. sometimes ' you eed to cle n the ear out in order to look tor these things if there is sig nificant ear debr is. Start thinking about the various underlying causes. 3. cl ean and pluck the pet's ears , as allowed·. ThIs tip removes debris to set the pet up for succe ssful treatment as well as allows you time outsIde of the exam room to start thinking about causes and your plan. As a new vet, you can also use this time to consult with another doctor before discussing your plan with the owner. a. "Oh no! That ear looks very painful. Ok, let me start by cleaning the ear to see if he will allow me to look in there a little better. I am going to take Louis to the treatment area where we have all of our supplies to give him a thorough cleaning. We will be right back." 4. Determine if there are any underlying causes to address today: a. First time offenders: With your first time or infrequent offenders, keep it simple. i. "There are a variety of causes for an ear infection. Since it is his first infection, I will treat it with "x", then we will see how he responds. Many infections resolve with this therapy and do not recur. If Louis starts having multiple ear infections in a year or one that we cannot easily resolve, then we may need to dig deeper. In general with dogs, allergies tend to be the most common underlying cause." b. Recurrent otitis externa patients: With patients that have recurrent ear infections within a year, we start having a more serious conversation around causes and start setting up expectations for owners as to next recommended steps. Always make sure these pets are on their monthly flea and tick prevention. Our client commu­ nication on recurrent otltis externa patients may go like this: i. Discuss the cause: "Well, the most common cause of ear infections is allergies, but I will sometimes find other causes in dogs like ear conformation (Cocker ing or swimming, deeper spaniels or dogs with heavy ears), water from bath n tumors (older dogs)." infections (otitis media/interna), or eve ii. Focus the owner on the immediate hurd le of getting rid of the infection: "But painful that I cannot get a great look in the right now, the ear is so swollen and is getting rid of his ear infection." ear. so, what I'd like to focus on for this visit iii. Set expectation of needing a rechec k: "He will definitely need to come back can assess improvement and hopefully at that and see me in two weeks, so we  NEW VET JUMPSTART GUIDE time I can get a better look when he is less painful. 1 want you to come back even if you think the ear infection has resolved because they often look bet ter, but the ears can still have bacteria present that we need to continue treating." iv. Set expectations of reassessing ear Infection and creating a long term plan at recheck: "Based on response to therapy, we will discuss how to prevent ear infections at the next visit. This may mean he needs to be on allergy medications seasonally or long term, consider a hypoallergenic diet to rule out a food allergy, get routine ear cleanings, or additional grooming procedures like ear plucking, etc. Patients with recurrent ear infections may still get infections on and off, but the goal is to give you tips at home that will help reduce their frequency in the future. Some pet's that have recurrent ear infections like Louis, ultimately need to see a dermatologist which we can discuss further at our recheck." v. Discuss your treatment plan. We always ask owners if they think they can get ear medications into their pet at home to help guide us on what type of plan (leave in or not) will help set the pet and owner up for compliance and success. Client communication summary for recurrent otitis externa patients ► Discuss the suspected cause. ► Focus the owner on the immediate goal of getting rid of the infection. ► Set expectations of needing a recheck. ► Set expectations of reassessing ear infection and creating a long term plan at the recheck (i.e. food allergy diet trial, etc.). Otitis externa treatment options Most ear infections are treated for 7-14 days based on severity. Mild to moderate infections can be treated for 7-10 days with more severe infections for 14+ d. ays b ased on your recheck The key 1s to treat past resolution of the infection · Hence , the ·m i port ance of rech eck s so that.. you can confirm this! We have included some ear medicati'ons b I. e ow th at we commonIy us e1·n practice. Many are commercial products ' and others are compo you can. unded med1c at1ons make m-house or at a local compounding pharmacy· Though topical therapies listed below 166  OTITIS EXTERNA IN DOGS are th e mainstay of otitis extema treatmen t do not for et abo t oral m. g u edica tions such as Apoquel or pred one. e use these m ca,s nis W es where pets show some discomfort or are inc essant head shaki exhibiting ng or scratch'mg. They can · make your patients · considerably m fortab le, especially until.. the ear med1cat1on starts kic rnore co king in. ► Yeast infection alone: Treatment opt 1 ons for a straightforward infect n include io M ometamax , Claro, Osurnia, Miconazole with DexSP Tresaderm ' ► Bacterial infection (cocci) with or wI thout yeast: Treatment options for a straight-.... 1i forward mfect1on include Mometamax , Claro, Osurrna, resaderm ► Bacterial infection (rods +/- cocci) w1 th or without yeast: Treatment options for · · a straightforward or complicated ·mf ect1on me I ude Posatex (more specific to rods than cocci_>, Mometamax (can get some rods), Keto-Triz ear cleaner+ large ani­ mal Baytril + DexSP (safest, see formula we use below), EKT ointment (enrofloxacin-ketoconazole-triamcinolone) ► Resistant ear infection: Often, you will see minimal response at your recheck. Consider a culture and sensitivity of the ear if finances allow, though it may grow contaminants. Consider adjustment to a "stronger medication" like Keto-Triz ear cleaner+ large ani­ mal Baytril + DexSP and/or Triz EDTA+ SSD cream. These are very difficult cases, and it is often best to involve a dermatologist at this point. ► R uptured tympanic memb rane: In general, it is not recommended to use topical medications due to the risk of side effects. Instead, treat with oral antibiotics/antifun­ gals (good choices include cephalexin, cefpodoxime, cefovecin, and ketoconazole), prednisone taper starting at tmg/kg/day if appropriate, pain medications (gabapentin +/- NSAID if not doing steroids), and possible antiemetics if vestibular signs are noted (meclizine+/- cerenia). Treat for 3-4 weeks and recheck, as some dogs require treat­ ment for up to 6-8 weeks for it to heal completely. These ears can be gently cleaned with Triz EDTA, which is safe in a ruptured eardrum. If you are unsure if an eardrum is ruptured and feel the need for treatment, discuss the risks with the owner. In these cases, consider medications that tend to be 'safe' for the middle ears of most dogs which include miconazole, enrofloxacin, topical steroids, Keto-Triz and Triz-EDTA. binations outside of this. You'll want to stay away from medications or medication com no rantee that these A frank discussion with owners is important here as there is gua. Some pet's eardrums may not are safe so they have to understand there is some risk  NEW VET JUMPSTART GUIDE heal or may continue to have recurrent ear Infections that are nonresponsive to your treatment plan. In these cases the patients need to be referred to a dermatologist to have the middle/Inner ear flushed under general anesthesia. Notes about the above medications ► Mometamax: We have seen a few dogs (with intact eardrums) lose hearing on this medication (Including Monica's dog, a Westie named Frodo). All of them were small breed dogs. In all cases, the hearing came back over time. So when we prescribe this medication, we warn owners that in really rare cases we have seen hearing loss. So, if they notice deafness, they should stop the drops right away and call the hospital. Again, this is one of our go-to medications, and this phenomenon is super rare, but just some­ thing to be aware of. ►..Mlconazole 1% with DexSP: This is a mixture you can make in-house. You create it by removing 6 ml from Miconazole and adding in 6 mL of injectable DexSP (4mg/ml). ► Keto-Triz ear cleaner+ large animal Baytril + DexSP: Remove 19 ml of Keto-Triz cleaner from bottle. Add 20 mL of large animal Baytril (100 mg/mL), and then add 6 ml of DexSP. Have the owner instill 0.5 ml into the ear canal once daily for 10-14 days. ► EKT Ointment: This is a medication you can get from a compounding pharmacy. Do not use it if you suspect a ruptured eardrum. It is not that the meds are toxic, but that it is more the lanolin in the product. Derm hates this. ► Triz EDTA + SSD cream: Add 50 grams of 1% SSD cream to a 12 ounce bottle of Triz EDTA. Have the owner instill I ml into the ear canal once daily for 10-14 days. Tips to know when managing otitis externa: ► Always get ear swab samples before cleaning. If possible, have your assistant get samples when they are checking the pet in (only if they can do so safely alone). They can start this while you finish up your last appointment. Often our cytologies are done before we have even seen the dog, which helps you to save time and stay efficient! ► Clean the yucky ears out, as this usually helps you get a better view. Triz EDTA is a great first choice ear cleaner because It is safe in a ruptured eardrum and does not 168  OTITIS EXTERNA IN DOGS cause pain in a sensitive ear (as compared to other alcohol based cleaners). Always pluck the hairy ones if the dog aIIows you (usually those with curly poodle or shih tzu hair) ' as the added ha"tr traps m oisture and may d ecrease penetration of your med- ications. There is an ear plucking powder that makes plucking. easy and the owner can ask the1r groomer to do it in the future. ► With some painful patients , you may onIY get ,one shot' to look In the ear. So If appro-. priate, have the ears cleaned out first. If the dog 1s too painful for you to perform your. ot1c exam, you have three optio ns. 'v First option is to offer to se date thetr pet. Sedation. because you. can be nice are able to clean the ear thoroughly and remove any unwanted hair with mini­ mal stress or pain to your patient. You can then easily examine the ear prior to reversing sedation. 'v Second option is to consider sending the dog home with medications and then have them come back in a few days once the inflammation has subsided. This is a great option if you are concerned there may be a more serious infection present or a ruptured eardrum. + Start your patient on a short prednisone course (5-7 days)+/- KetoTriz ear cleaner and recheck in 5-7 days. Consider gabapentin +/- trazodone combi­ nation to give prior to the recheck if you think the dog will benefit from it to allow you to finish your exam. This combination allows you to get a second exam in, so you can finalize your treatment plan of topical medications, etc. 'v Third option is to consider treating the ear ONLY if you feel comfortable doing so, but warn owners of possible adverse side effects if there were to be a damaged eardrum (ototoxicity, vestibular signs, etc.>. If these adverse side effects occur, owners get very upset if they are not warned about them. ► Have your tech show the owner how to clean the ear and go over how to medicate the ear if you are not doing a leave-in treatment. You will be surprised how many owners have no idea how to clean their dog's ears or are performing it wrong at home. ear cleaner. Cleaning the ears is ► You should always send each owner home with an n when they are dirty or after any water one of the best ways to prevent an infectio exposure (bathing, swimming). 169 NEW VET JUMPSTART GUIDE lf you have a pet th at I s INC ESS ANT LY shaking their head, be warned that an aurai ► hematoma can occur. We WI..11 do one of two things depend.mg on how concerned we will send these dogs home on we are about this compIIcat 10n · Most of the time,.. su. c.. I I th their ear medi cations, and th is 1s ffi ient m preven ti ng a prednlsone to go a ong w where the pet was SO inces hematoma. However, there have been certain instances e sant with their ear flapping In the clinic (especially after it was clean d) that we went ahead and gave them an injection of DexSP before sending home with prednison e to start the next day. Always ask the owner before doing this, but this method allows us to ensure the flapping stops quickly. The few times we have done this were situations where the dog came in with a very painful, inflamed ear due to shaking their head for a long time. After the cleaning in the hospital, the dog continued audibly flapping incessantly. Giving DexSP helps the dog feel better quicker, and many owners are thankful. For a dog that has a less inflamed ear, we will prescribe Apoquel instead. The frustrating otitis cases Sometimes we get here, and that's ok. What will help you succeed is clear communication of expectations and a plan. With recurrent or difficult to treat ear infections, you must keep the list of possible causes in mind. It can be very frustrating to an owner when they feel that we cannot keep their pet free of infections. One of the main reasons a client sees a new vet is when they feel their pet's condition is not resolving or being managed appropriately. Setting client expectations is key here. Be open and up front with them from the start. Explain that ear infe ctions can be frustrat­ ing and require multiple therapies to prevent in the future. We tell clients that our goal is to decrease the frequency of ear infections, so they underst and their pet may still get them intermittently. By utilizing all of our tips above and trea ting for any of these additional causes, you will get better client satisfaction and patient hap piness. If we have an ear infection that is difficult to get under control despite taking all the priate precautions, we will consider cultur appro· e, a sedated deep flush, and/or referral to a ermatologist. Start having this conversa tion early, once you notice the patient is becorn· mg re ractory to treatment or having recurr ent infections. Owners can warm up to the idea over time.  OTITIS EXTERNA IN DOGS NOTES: ------- -- - ------------- NEW VET JUMPSTART GUIDE NOTES: -----·--- --- - ----------- ----------- ----------------- ------ ------- ----- ------------·------ ·-· -- --·--------------------- ----- ------·----- ----- ____ _____ _____,_ ------ ------ ---- ----- --- -------- ------------.. _____-- - ------ 172  Pruritus in Dogs pruritic dogs are one of THE most common cases you will see in general practice. Allergies make up a large percenta ge of these cases and tha t will be what we focus on in this chapter. Th ese cases will be really frustrating to owners wh o do not understand quick fixes are not always possible. Many clients will also struggle to unders tand the value of rechecks when their dog looks better, yet rechecks are the key to ensuring appropriate treatment and reduction of chronic skin issues. Setting expectations with the owner and providing thorough commu­ nication will be of the utm ost importance in reducing owner conf usion and frustration. Let's start with a quick revie w of the basic clinical signs of allergies in dogs befor e we dig into our approach and client communication tips. Common presentations for allergies ► Paw licking: This will be the most common clinical sign noticed by owners at these · appointments. 8e sure to check each paw's dorsal and palmar/plantar interdigital space,. each natl, paw pad , etc. t o be thorough · Be sure to notate which paws are affected,. so you can rev1s1t these spect fie-areas at your recheck to assess for improvement. v The most common cause 0f Paw licking is allergies, though other causes such. as anxiety, bored om' pain' foreign bodies, ectoparasites (demodex), cutane- ous d rug reaction' trauma, an d more can cause it too. If you are.not seeing.any improvement with your treatment pIan' these are other differentials to consider at the recheck.. ► Ear flapping/shaking with or without an ear infection: see our chapter on otitis externa for thorough notes on this clinical sign. NEW VET JUMPSTART GUIDE t skin lesi on y,ou may see a healthy coat or notice changes s. ► s Pruritu wit h or wit hou consistent with dermatitis (see below). ► Salivary staining on paws or focal areas ination such as erythema, pap- ► Dermatitis: You may on I Y have one symptom or a comb... ' l , hY perpigmentatio n, seborr hea, excoria tions, and more. ules, pustules, hchernf cation ► Moth eaten or diffuse alopecia ► Llcheniflcation: You may see a cobblestone appearance or 'elephant skin,' which is often indicative of a yeast infection (check axilla and neck closely!). When it is not allergies Not every skin condition is due to allergies. Differentials like pemphigus, other autoimmune diseases, hepatocutaneous syndrome, MRSA, and more have tricked us. So, here are a few clues that it may NOT be allergies... ► The dog is not responding to your basic treatment plan. Make sure drug doses are correct, check owner compliance, and that rechecks are occurring, etc. If the dog worsens despite treatment, consider culture, biopsy, referral, etc. ► The dog is not feeling well. Examples include a fever, severe lethargy, or limping because their paw pads are sore. We have seen dogs limp because of a severe infection secondar y to allergies, but we have also seen odd paw pad deformities due to allergic reactions to medications, hepatocutaneous syndrome, etc. ► People in the home also have lesions. Think zoonotic diseases like ringworm, scabies, staph infections (like MRSA, though rare), etc. 174  PRURITUS IN DOGS oW to sy5fematically approach an H appointment with allergy sympt ms o rhe a pproach mentio ed be low will work for the majority of your prurltic dogs and will help you a void frustrated clients. Be sure to be thorough, systematic, and document appropriately to make your rechecks run smoothly. Throughout each step, we will discuss Important client communication points to bring up to owners to ensure you cover all of your bases. The end of the chapter will give you specific communication points for certain situations. Be sure to clearly explain underlying causes, what you are treating, set expectations, and stress the importance of rechecks in order to tailor therapy appropriately. owners need to under­ stand their dog will now need routine visits In order to make them comfortable and that therapies that o nce worked may not work later In life. Recheck exams allow you to work together as a team to keep their dog comfortable. Lastly, it is important owners understand that unfortunately it can be rare to get a dog's symptoms completely resolved. The goal is to improve symptoms to a manageable state through a combination of the steps mentioned below. General approach for a straightforward case 1. Rule out a flea allergy: If not on reliable flea prevention, send the owner home with it and multiple doses for future months. 2. Diagnostics: Skin cytology+/- other diagnostics to guide treatment plan. tY of our cases go home with both topical and oral medications. 3. Treatment plan: M aJori. Commumca 4. Chent.. o·1scuss underlying causes, set expectatio. t1on. ns, and stress the h ere you ill ensure complete resolution and discuss prevention and need for a recheck w W management strategies. 175 NEW VET JUMPSTART GUIDE le): s TEP 1: Rule out a flea allergy (and demodex if possib SING E. TIME. Classic i tribution Your first step Is to ALWAYS rule out a flea allergy. EVERY. _ the tail bas e/hi nd hmb reg ion, excoriations, and continues to be a moth eaten appearance at too. Many clients will swear intense sudden pruritus. You will also see dogs without hair loss a wall here. they do not see a flea on their dog, so here are some tips if you hit ► Explain to your client that adult fleas make up less than 5% of the flea population, so this can make it very difficult to find a flea on a pet. All it takes is one flea, and a flea allergy is something very easy to fix and treat. A flea comb can be your best friend in finding a flea! It Is Important owners understand that this step Is just part of the pro­ cess because we have to rule causes out in order to be systematic in our approach. Insist each animal in their home gets on reliable, vet recommended flea prevention. ► If the dog Is not on flea prevention, send the client home with a product THAT DAY. Fortunately, due to the isoxazoline class of drugs (Bravecto, Nexgard, Simparica, and Credelio), we can rule out both flea allergies and demodex by simply putting them on this medication. Make sure to stress this product must be continued year-round for l best results. We often tell owners that even though it may not be a flea allergy, f eas can complicate clinical signs, so it is important to prevent them at all times to be thorough. v1 Caution: If you have a patient with a history of seizures, you will want to use a different product because there is evidence the isoxazoline class of medications can make seizures worse. A safe and effective product dermatologists often use is topical Activyl. We also avoid isoxazoline products in very ill patients. TEP 2: Diagnos ics: Skin cytology (EVERY TIME)+/- skin scrape+/­ rmgworm culture 1f applicable. We always start with skin cytology in order to determine what we need to treat (bacteria, yeast, etc.). You may want to do a skin scrape too, if the owner wants to be thorough and/or s you have a suspicion of mites. Perform cytology on the areas that the dog is itching uch a l the f ank, paws, etc.