Mark J. Acierno, DVM, MBA, DACVIM, shares different medications available, as well as other management strategies, for appetite stimulation and nausea relief in feline patients with chronic kidney disease

Managing chronic kidney disease symptoms in cats

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What options are there for controlling nausea and stimulating the appetite of a feline patient with chronic kidney disease? In an interview with 

 discussing his lecture “Improving the Lives of Feline Patients with Chronic Kidney Disease,” presented at the Fetch dvm360 conference in Atlantic City; Mark J. Acierno, DVM, MBA, DACVIM, professor and associate dean at Midwestern University, talked about different methods for controlling these symptoms in cats, breaking these methods down into management strategies, and different medications that can be used.

There's a number of different things we can do. And so part of it, you know, I like to break it down into both… management and then medications.

And so, for the management, things like small, frequent meals, rotating the diet. You know, often what happens is we will send a cat home with a particular brand of cat food, and the owner will tell me ‘well they ate it for a while, then they stopped.’ And so what I do is I send them home with a whole smörgåsbord. I just come to rotate it, right? Just keep rotating through the different ones.

Small, frequent meals. It may mean, you know this idea of feeding a meal in the morning and a meal at night may have to be changed, because when we're sick, we don't feel like eating a big meal, right? And so, cats may nosh during the day, and that may add up to a meal, and that would be great.

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Mark J. Acierno, DVM, MBA, DACVIM, shares different available options for appetite stimulation and nausea relief in feline patients with chronic kidney disease

Colorado voters approved of the veterinary professional associate (VPA), a new midlevel practitioner (MLP) position. Proposition 129, formerly known as Proposed Initiative 145, received 52.2% yes votes, with 78% of the votes tallied as of November 7, 2024. All Pets Deserve Vet Care was behind Proposition 129 and was supported by the Dumb Friends League (DFL), the American Society for the Prevention of Cruelty to Animals (ASPCA), Animal Welfare Association of Colorado, the Humane Society of the United States, and others.

Once available, VPA’s will be master’s level trained and would be allowed to diagnose, create treatment plans, and perform surgery on patients. The American Veterinary Medical Association (AVMA) and the Colorado Veterinary Medical Association (CVMA) both came out against the proposition, stating the VPA would have inadequate training for doing complex tasks that should only be performed by a veterinarian.

 Colorado State University College of Veterinary Medicine & Biomedical Sciences is working on creating a degree program for this Master’s of Veterinary Clinical Care.

However, the program will be taught mostly online, with those against the initiative saying it would not give students sufficient laboratory and clinical exposure, putting the health and safety of pets and other animals at risk. At this time, there is no accreditation of the educational program, comprehensive test to determine the competence of program graduates, or licensing of those who would fill this role, according to the AVMA.

Multiple surveys have been conducted to determine whether or not this new position within the veterinary industry is needed. The American Association of Veterinary State Boards (AAVSB) aimed to better understand whether a hypothetical midlevel role, called advanced animal healthcare provider in the survey, was not only necessary, but wanted by veterinary professionals.

They received almost 14,000 responses from veterinarian and veterinary technicians. The results concluded that veterinary professionals in more than 60 United States and Canadian jurisdictions decided against the position stating concerns about its implementation and utilizing technicians better.

"Our extensive survey revealed that while there is some interest in exploring the concept of a midlevel veterinary practitioner, there are significant concerns regarding implementation, such as training adequacy, regulatory impacts, and timing, especially considering that credentialed veterinary technicians are not being utilized fully at this time," stated Kim Gemeinhardt, DVM, president of the AAVSB, in an organizational release.

"Our commitment remains to public protection and ensuring accessible, quality veterinary care. The survey data demonstrates that veterinary technicians can and should be utilized more extensively to address gaps in veterinary care, before a midlevel veterinary practitioner can be considered."

Want to learn more about the pros and cons of Proposition 129? Read more 

Due to their protest of the initiative, the AVMA and CVMA worked together to inform the veterinary industry and public what the impacts of voting yes to this initiative means through the Keep Our Pets Safe campaign. The campaign provided veterinarians resources to better inform clients, create social media and advertising messages sharing the dangers the proposed initiative could have, and carried out outreach to media outlets across Colorado.

“We are disappointed with the outcome of Proposition 129 on the ballot in Colorado; however, rest assured that now, more than ever, we will continue our work to ensure that the health and safety of Colorado’s animals are protected,” said Sandra Faeh, DVM, AVMA president. “This includes pursuing all options to ensure that pets and other animals receive high-quality care led and delivered by comprehensively educated, proficient, and licensed veterinarians. We look forward to working collaboratively with stakeholders in pursuit of a regulatory framework that will protect Colorado’s animals, their owners, our food supply, and public health.”

Read more about the AVMA's stance and work against Proposition 129 in their recently published 

More than 200 national and local veterinary industry organizations and clinics as well as individual veterinarians, technicians, and clients opposed Proposition 129, including the American Animal Hospital Association, Student AVMA, American Board of veterinary practitioners, American Veterinary Dental College, and American Kennel Club.

Midlevel practitioner proposal secures enough votes in Colorado. News release. American Veterinary Medical Association. November 7, 2024. Accessed November 13, 2024. 

https://www.avma.org/news/midlevel-practitioner-proposal-secures-enough-votes-colorado#:~:text=Colorado%20voters%20have%20approved%20a,ballot%20measure%20called%20Proposition%20129

AAVSB Releases Conclusions of the North American Veterinary Team Delegation Survey. News release. June 26, 2024. Accessed November 13, 2024. 

Articles

Despite more than 200 veterinary industry organizations, professional associations, and veterinary professionals publicly opposing it, the veterinary professional associate position will be implemented in the next few years following a public vote

Coloradans vote yes to midlevel practitioner proposal

Ethiqa XR (buprenorphine extended-release injectable suspension) 1.3 mg/mL is now indicated for managing post-procedural pain in captive rodents and laboratory rabbits, according to Fidelis Animal Health, Inc, a commercial stage company developing, acquiring, and marketing pharmaceutical products for animals. A recent announcement by Fidelis Animal Health stated that the company had “received notification from the FDA” of the new indication.

Ethiqa XR is an FDA-indexed, pharmaceutical-grade, extended-release buprenorphine injectable suspension. This opioid analgesic is intended for use by veterinarians in mice, naked mole rats, gerbils, hamsters, rats, chinchillas, guinea pigs, prairie dogs, ferrets, laboratory rabbits, and non-human primates.

 The product, according to Fidelis Animal Health, is produced under current Good Manufacturing (cGMP) regulations.

“We are excited to bring these new indications to veterinarians in general and specialty practices, and in the research community. Ethiqa XR meets their high expectations for efficacy, safety, and quality, and makes it so much easier to comply with FDA GFI #256, which stresses the importance of using legal, FDA-indexed animal medications instead of compounded drugs for office stock and individual patient use" Michael Wells, board chair and CEO of Fidelis Animal Health, said in the announcement.

According to Steven Leary, DVM, DACLAM, chief medical officer at Fidelis Animal Health, Ethiqa XR is a new form of buprenorphine that utilizes the company’s patented lipid-based formulation to provide 72 hours of clinical analgesia with one subcutaneous injection.

“Ethiqa XR is sterilized, with no harmful excipients, endotoxins, or microbial contamination,” Leary added.

Ethiqa XR should only be administered by subcutaneous injection. The drug is not intended for intravenous, intra-arterial, intrathecal, intramuscular, or intra-peritoneal injection. It should not be used in animals with pre-existing respiratory conditions

There have been reports of death in mice when both nonsteroidal anti-inflammatory drugs (NSAIDs), like meloxicam and carprofen, and Ethiqa XR were administered together, according to Fidelis Animal Health.

Avoid using wood chip bedding for rats after giving Ethiqa XR. “Pica involving wood chip type bedding can be lethal,” read the company announcement.

Adverse effects from Ethiqa XR include sedation, low blood pressure, slower heart rate, reduced gastrointestinal movement, and respiratory depression. “Use caution with concomitant administration of Ethiqa XR with drugs that cause respiratory depression. Animals should be monitored for signs of decreased cardiovascular and respiratory function when receiving Ethiqa XR,” wrote Fidelis Animal Health in its announcement.

According to the company, the safety of Ethiqa XR in pregnant, lactating, neonatal, or immunocompromised animals has not been studied.

The product was launched to laboratory veterinarians in 2020 and is now utilized by more than 500 institutions nationwide, including some top 10 pharmaceutical companies, academic institutions, hospital networks, and government research facilities.

Fidelis Animal Health, Inc. announces major label expansion for Ethiqa XR®. News release. Fidelis Animal Health, Inc. November 5, 2024. Accessed November 12, 2024. https://prnmedia.prnewswire.com/news-releases/fidelis-animal-health-inc-announces-major-label-expansion-for-ethiqa-xr-302296831.html 

Ethiqa XR. Fidelis Animal Health, Inc. Accessed November 12, 2024. https://ethiqaxr.com

Ethiqa XR now includes captive rodents and laboratory rabbits for 72-hour post-procedural pain management on its label

Buprenorphine extended-release injectable suspension now available for use in captive rodents and laboratory rabbits

Christopher Pachel, DVM, DACVB, CABC talks about essentials that should be covered with clients during their first puppy appointment

Discussing key puppy care topics in first appointments

Earlier this fall, Christopher Pachel, DVM, DACVB, CABC, sat down with 

 to talk about his lecture “Puppy Parenting: Fundamentals for Busy Practitioners” that he presented at the Fetch dvm360 conference in Atlantic City, New Jersey. In the interview, Pachel talked about some of the things that should be discussed with the puppy owner during the puppy’s first appointment.

In another video, Pachel talks about the objectives of his lecture "Behavioral Euthanasia Considerations: Bringing the Conversation Out of the Shadows." Click 

So there's a lot that we need to cover within that appointment. And of course, when we're thinking about the behavioral aspects of puppy parenting, we're talking about things like puppy socialization and exposing them to an ever-expanding world view, while we're also trying to work through potty training and dealing with the very normal mouthing and biting issues that puppies naturally do, but we're also trying to balance that with everything else that we have to cover with vaccine series and overall health issues, and all of that information has to be balanced. So, how do we do that in a way that actually is heard by our clients without being overwhelming, and making sure that we're arming them with some of the resources for them to review after the appointment, as well as what we cover within that session?

Christopher Pachel, DVM, DACVB, CABC, talks about essentials that should be covered with clients during their first puppy appointment

Jaguar Health announced that its product, cofelemer delayed-release tablets (Canalevia-CA1; Jaguar Health), received approved renewal from the FDA. This oral tablet that can be given twice a day for home treatment of chemotherapy-induced diarrhea (CID) in canine patients. 

"Canalevia-CA1 is an important prescription drug for the veterinary community and the thousands of dogs experiencing CID. This extension was granted because we were able to demonstrate that the company is making active progress toward proving ‘substantial evidence of effectiveness' of Canalevia-CA1 for treatment of CID in dogs for full approval, as required,” Michael Guy, DVM, MS, PhD, Jaguar's vice president of preclinical and nonclinical studies, said in a news release.

A new standard of care for the treatment of chemotherapy-induced diarrhea in dogs

How Sue Ettinger,  DVM, DACVIM (oncology),  treated chemotherapy-induced diarrhea in this intrapelvic sarcoma patient

Examining an innovative treatment option for chemotherapy-induced canine diarrhea

“As announced, we have reached agreement with the FDA on the design and conduct of a clinical field study of Canalevia-CA1 for full approval of the product," he continued.

 from the FDA in December 2021 for treating CID in canine patients, meaning the company could promote the drug legally, advertise and sell the animal drug for the labeled use before proving it meets the "substantial evidence" standard of effectiveness for full approval. For companies that receive the conditional approval, they can ask to renew the conditional approval annually for up to 4 years after first receiving the conditional approval, for a total of 5 years of conditional approval. However, companies must show active progress toward proving the “substantial evidence of effectiveness” for full approval. Once the company collected the remaining effectiveness data, they can then apply for the full FDA approval.

Recent studies have found that CID is 1 of the 3 most prevalent adverse effects for canine patients undergoing cancer treatments, meaning managing adverse effects such as CID can be important to help veterinary teams and clients maintain successful cancer treatment.

"Diarrhea is a highly neglected and unmet medical need in dogs and people undergoing cancer treatment," Lisa Conte, Jaguar's president and CEO, said. "Jaguar is deeply committed to supporting the quality of life of people and animals undergoing cancer treatment."

Cofelemer delayed-release tablets are restricted to use by or on the order of a licensed veterinarian and is to be used only as directed. The treatment is currently available for multiple leading veterinary distributors across the United States and the renewal for conditional approval is in effect until December 21, 2025.

FDA Approves Renewal of Canalevia-CA1, Jaguar Health's Drug for Chemotherapy-Induced Diarrhea in Dogs. News release. Jaguar Health. November 6, 2024. Accessed November 12, 2024. https://jaguarhealth.gcs-web.com/news-releases/news-release-details/fda-approves-renewal-canalevia-ca1-jaguar-healths-drug-0

Mason SL, Grant IA, Elliott J, Cripps P, Blackwood L. Gastrointestinal toxicity after vincristine or cyclophosphamide administered with or without maropitant in dogs: a prospective randomized controlled study. 

. 2014;55(8):391-398. doi:10.1111/jsap.12237

Canalevia-CA1 is currently the only treatment on the market for treating CID in canine patients. 

FDA approves renewal for canine chemotherapy-induced diarrhea treatment

Wolfie, A shepherd-lab mix, was treated at the Washington State University veterinary surgeons for chylothorax (Image courtesy of Washington State University) 

In the spring of 2022, a stray canine walked into the yard of Curt and Caroline Putter of Hayden, Idaho and since they are dog lovers, they welcomed the stray into their home with their other 2 dogs and has called the Potter’s house his home ever since. Fast forward to July 2024 and the couple began to realize Wolfie was having difficult breathing and soon after began refusing food, even his favorite, confirming that something was not right with Wolfie. They brought him to veterinary clinics across north Idaho and eastern Washington, had a brief scare with a potential terminal cancer diagnosis, but later discovered Wolfie was suffering from chylothorax.

Despite the relief the Potters felt when they learned he did not have cancer, chylothorax can still be fatal, with most veterinary clinics not having the resources needed to handle the complex condition. Chylothorax is caused by an abnormal tangle of lymph vessels and leakage of lymphatic fluid in the patient’s chest cavity. According to a release from Washington State University,

 the leakage can make it extremely difficult to breathe and posed a risk of damage to his heart and lungs that is irreversible.

“Dogs that have this disease, they have what looks like a worm’s nest of lymph vessels, which is not normal. There should just be one or two ducts,” explained Boel A. Fransson, DVM, PhD, DACVS, in the release.

After being told that their best option for Wolfie to get treatment is at Washington State University Teaching Hospital, they brought him into Fransson and the team at the hospital. Fransson reviewed Wolfie on the monitor screen and was able to see real-time images detailing the intricacies of his thoracic system. She then injected a special dye into Wolfie and watched as traces of his thoracic duct began to turn green as the dye spread.

Chylothorax can be treated successfully with a procedure known as thoracic duct ligation, which is usually performed as an open surgery. In Wolfie’s case, the team was able to perform the surgery minimally invasive using a thoracoscopy for a higher rate of success and quicker recovery times. Although its rates of success are higher and recover is quicker, this procedure is not available everywhere due to the high level of experience and skill required from the surgeon as well as technology not being available at most facilities. 

A week after his symptoms began, Woflie’s surgery was scheduled, and the team began prepping him by injecting fluorescent dye that moved rapidly through lymphatics into his chest to highlight the thoracic duct. Wolfie’s surgery team, consisting of Fransson, Peter Welsh, DVM, a surgery resident, and Thomas LeClair, a 4th year veterinary student, was also able to utilize a recently acquired near-infrared imaging system that was used to highlight the dye, This provided assistance to Fransson to precisely locate the leaking ducts, this were then closed with metal clips guided through the incisions made in the chest. During the 3-hour surgery, the team completed the procedure by removing Wolfie’s pericardium because in some cases, the leaking lymphatic fluid can cause the pericardium to thicken and constrict the heart.

Success rates for the alleviation of the diseases in both canine and feline patients is 40-60%. If surgical methods failed to fix chylothorax, alternative techniques can be discussed to attempt to prevent the accumulation of chyle, which are small molecules of fat that appear milky, in the thorax.

The surgery was successful and after a few days in the intensive care unit, Wolfie was given the okay to go home to his family, who shared that he was recovered well and is back to his normal self.

Rokyta D. WSU surgeons save dog battling rare condition. WSU Insider. Published November 7, 2024. Accessed November 12, 2024. 

https://news.wsu.edu/news/2024/11/07/wsu-surgeons-save-dog-battling-rare-condition/

American College of Veterinary Surgeons. Chylothorax. American College of Veterinary Surgeons. Accessed November 12, 2024. 

https://www.acvs.org/small-animal/chylothorax/

Wolfie, a shepherd -lab mix, was diagnosed with the rare and life-threatening condition after presenting to veterinary clinics for trouble breathing and lack of appetite 