2014 Pearls of Wisdom

American Association of Feline Practitioners Conference
September 18-21, 2014 – Indianapolis, Indiana
Feline Gastroenterology and Endocrinology

Pre-Conference Day – September 18

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Protecting Cats from the Unexpected: Feline Vector-borne Disease Agents, Dr. Susan E. Little

1. Routine use of flea, tick, and internal parasite control blocks transmission, protecting feline health. For example, using a heartworm preventive that actually blocks infection protects feline lungs from damage caused by migrating larvae and keeps cats antibody-negative.
2. Results of tests for vector-borne infections in cats, particularly when negative, should be interpreted with caution. Cats become PCR positive for Cytauxzoon felis before piroplasms are detected on blood smears, and antigen-antibody complexes may limit the utility of heartworm antigen testing in some cats, particularly early in infection.

Update on Feline Infectious Diseases: Agents Associated with Fever, Dr. Michael Lappin

1. Anaplasma phagocytophilum is a cause of fever in cats in areas endemic for Ixodes spp.  The cats will usually be PCR positive before they are antibody positive and they generally respond quickly to doxycycline.
2. Cats with bartonellosis associated with fleas generally have fever, lymphadenopathy, or myocarditis.  Bartonella spp. should be on the differential list for cats with fever and fleas.  Azithromycin administration quickly induces resistant strains and so should not be used to treat feline bartonellosis.  Imidocloprid containing products have been shown to block transmission of B. henselae amongst cats.

Update on Feline Infectious Diseases: Upper Respiratory Tract Disease, Dr. Michael Lappin

1. Pradofloxacin is a new quinolone that has action against 2 enzyme targets and so is the first to treat anaerobic infections.  This antibiotic has been effective for eliminating Mycoplasma haemofelis from the blood of some experimentally inoculated cats, is effective for the treatment of respiratory infections in cats, and is the least likely drug studied to date to induce resistant strains of Bartonella spp.
2. Polymerase chain reaction results for respiratory Mycoplasma spp. or FHV-1 do not correlate to treatment response making these tests basically useless.  Famciclovir generic can be effective for the treatment of FHV-1 infection in cats and is excreted in the tears, treating FHV-1 associated ocular disease.

Update on Feline Infectious Diseases: Lower Respiratory Tract Disease, Dr. Michael Lappin

1. Clindamycin hydrochloride is still an effective drug for the treatment of toxoplasmosis in cats.  Cats with unexplained pneumonia that could be from bacterial or protozoan infections should be administered a quinolone with clindamycin while finishing the diagnostic workup.
2. Dirofilaria immitis and Aelurostrongylus abstrusus infections of cats can mimic allergic bronchitis.

Update on Feline Infectious Causes of Diarrhea in Cats, Dr. Michael Lappin

1. Cats with diarrhea and Giardia often respond to the administration of metronidazole benzoate.  Most cats with Giardia infections are carrying feline assemblages.  Concurrent use of probiotics with anti-Giardia drugs may speed resolution of diarrhea.
2. Cats that fail Giardia treatments commonly are co-infected with other agents like Cryptosporidium felis or Tritrichomonas foetus (blagburni).

Day 1 – September 19

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New Data on Chronic Small Bowel Disease in Cats: Don’t Accept Vomiting as “Normal,” Dr. Gary Norsworthy

1. Chronic vomiting, chronic diarrhea, and/or weight loss are not normal and are usually due to chronic disease of the small bowel. They produce small bowel wall thickening which can be documented by ultrasound, and their etiology can be diagnosed with full-thickness biopsies of the small bowel.
2. The two must common diagnoses are chronic enteritis (usually due to Inflammatory Bowel Disease) and lymphoma. Both are treatable so their diagnosis has significant long-term implications to the cat and its owner.

Diagnosis & Management of Pancreatitis, Dr. Kenneth Simpson

1. The most common clinical findings in cats with acute pancreatitis are lethargy, anorexia, and weight loss. There is no single test that will accurately diagnose pancreatitis in all affected cats. Cats with pancreatitis often have inter-current disease involving the liver and small intestines
2. Medical treatment is based on maintaining or restoring adequate tissue perfusion, limiting bacterial translocation, inhibiting inflammatory mediators and pancreatic enzymes and providing enteral nutritional support.  Surgical treatment consists of restoring biliary outflow, removing infected necrotic pancreatic tissue, or coping with sequela such as pseudocysts. 
3. A recent study has identified intrapancreartic bacterial colonization, predominantly E.coli and Streptococcus spp in @1/3rd of cats with moderate to severe pancreatitis. This possibility should be considered in cats who do not respond to initial supportive care.
4. Feline EPI is typically due to end stage chronic pancreatitis. Weight loss, subnormal fTLI and low serum cobalamin are very common in feline EPI

Lunch & Learn – Feline Urethral Obstruction: New Options, New Solutions to an Old Problem, Dr. Mark Brady

1. Recurrent urethral obstruction post management after initial presentation occurs in greater than 20% of cases and, unfortunately, is a common cause of euthanasia. Future studies are needed to determine the best strategy to reduce the rate of recurrent obstruction.
2. A multimodal approach that addresses feline idiopathic cystitis would likely benefit this subset of cats. This long-term strategy should incorporate nutritional management, environmental enrichment, pain management, and stress reduction.

Are You Comfortable with Feline Constipation?, Dr. Craig Webb

1. Since dehydration is almost always a component of the presentation with a constipated cat it is one of the most important aspects of non-specific therapy to be addressed. Once the cat is well on the way to a normal hydration status, with correction of electrolytes and acid-base status, steps can be taken to remove the feces from the colon – remembering that early intervention is an important step towards avoiding significant long-term consequences.
2. Even in severe cases of feline constipation, polyethylene glycol (Miralax, PG3350), trickled through an NE tube (6-10 ml/kg/hr) may be successful. Although it may take up to 12-18 hours (Carr AP & Gaunt MC, ACVIM 2010), the success rate with this minimally invasive protocol makes it well worth the attempt and the patience. 

Is There a Direct Link Between IBD, Cholangitis, & Pancreatitis in Cats?, Dr. Kenneth Simpson

1. “Triaditis” is the term that is often used to describe concurrent inflammation of the pancreas, liver and small intestines. Triaditis has been reported in 50-56% of cats diagnosed with pancreatitis and 32-50% of those with cholangitis / inflammatory liver disease. The presence of concurrent inflammation in the pancreas, liver and intestines may be due to separate disease processes at each site or could reflect a common stimulus.
2. Bacterial infection, immune mediated and idiopathic mechanisms are considered potential causes of inflammation in each organ that may participate in the development of triaditis. Acute inflammation of the pancreas, independent of the initiating trigger, could lead to the development of triaditis through its impact on the intestines and liver. In this scenario pancreatitis induces intestinal inflammation that promotes dysbiosis and the translocation of enteric bacteria across the inflamed intestines to the liver and/or into the pancreaticobiliary duct or pancreas
3. In cats with chronic lymphocytic pancreatitis or lymphocytic cholangitis invasive bacteria are rarely visualized. In people and experimental animals autoimmune pancreatitis and cholangitis are recognized as extra-intestinal complications of IBD, with immune attack frequently directed against bile and pancreatic ducts.
4. From a therapeutic standpoint it is optimal to prioritize on the basis of the severity of each component of triaditis, and to address the potential of underlying infection prior to pursuing immunosuppression.

Diagnosis & Management of Persistent Vomiting, Dr. Kenneth Simpson

1. Try to use as few drugs as possible to control vomiting rather than combinations of as many theoretically justifiable drugs as you can think of.
2. Cats are refractory to apomorphine induced vomiting, questioning the utility of metoclopramide. Maropitant has been shown to reduce vomiting induced by xylazine in cats and has an analgesic effect in cats undergoing ovariohysterectomy. 5HT3 antagonists have been shown to reduce cisplatin and  dexmedetomidine-induced emesis in cat, but do not block the effect of xylazine
3. Uremia is infrequently associated with gastrointestinal ulceration in cats. Addressing anorexia through appetite stimulation vs. aggressive antacid therapy is likely more effective.
4. Antibiotics are usually limited to suspected infections, acute abdominal conditions or gastritis associated with Helicobacter infection.

Day 2 – September 20

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Chronic Diarrhea: What’s the Cause?, Dr. Kenneth Simpson

1. Parasite associated diarrhea is common. Giardia or tritrichomas (coinfection is uncommon) colonized approximately 48% of cats at US cat shows.
2. How you test for infectious agents impacts your ability to detect them. Fecal PCR for tritrichmonas, IFA for giardia and cryptosporidium are more accurate than other methods.
3. Subnormal cobalamin is common and typically reflects small intestinal disease (typically IBD or LSA) or less commonly EPI. It should be treated with parenteral cobalamin. Ultrasonographic detection of muscularis hypertrophy of the intestines is consistent with IBD or lymphoma.
4. The pathologist should be able to give an indication of villus height and morpholgy, ratio of crypt to villus and the type and degree of cellular infiltrate and intraepithelial lymphocyte count. Recent studies in cats with chronic enteropathies show that changes in mucosal architecture (atrophy, fusion) are more important than subjective alterations in mucosal lymphocytes and plasma cells.

ICU Booth Camp: What You Should Know on Day One!, Paula Plummer

1. Important topics to understand when starting a career as an ICU technician are; how to properly calculate drug dosages, calculation of constant rate of infusions, infectious patient handling, patient assessment, basic nursing care and performing CPR.  A basic knowledge of what to expect with common critical care patients will make each ICU technician better prepared for their shift.
2. Working long shifts and not having time for personal time and sleep deprivation can cause burnout. Learning how to balance a personal life and career is the key to success with any ICU technician.

Managing Cats with Chronic Gastrointestinal Disease, Dr. Kenneth Simpson

1. The two major chronic enteropathies of cats are inflammatory bowel disease and alimentary lymphoma. Distinguishing IBD from alimentary lymphoma (particularly low grade small cell) typically requires intestinal biopsy. Treatment of IBD, predominantly ”lymphocytic- plasmacytic” is usually a “best guess least harm“ approach employing a step wise approach with dietary modification and vitamin supplementation, followed by antimicrobial agents then immunosuppression. Treatment is to some extent based on the severity of the disease.
2. In cats with neutrophilic or granulomatous inflammation it is essential to consider infectious agents vs. “idiopathic immune” and Vitamin P (prednisolone).
3. Alimentary lymphoma is now the most common anatomic form and predominantly affects middle age to older cats.
4. Small cell (T-cell) low grade lymphoma is the most common form of alimentary lymphoma and can respond very well to chlorambucil and prednisolone + parenteral cobalamin where indicated. Large cell (lymphoblastic lymphoma, B or T cell) has a poor prognosis. Since recent studies have revealed bacterial invasion and translocation in the intestines of these patients it is important to consider antimicrobial therapy in concert with chemotherapy.

Feline Friendly Handling & Restraint, Paula Plummer

1. Friendly handling includes restraint with towels and rigid e-collars along with reducing the stress level of the patient.
2. When handling feline patients be slow and calm, handle the patients with a trustworthy teammate ask for sedation and know your limits.  Be cognizant of common stressors in the patient and reduce those stressors as much as possible when the feline patient is hospitalized.

Stem Cell Therapy in Feline Chronic Enteropathy: In Theory – Bench Top Research, Dr. Craig Webb

1. The field of stem cell biology covers a diverse group of cells with both regenerative and immunomodulatory activities.  Much remains unknown about stem cells and their potential ability to be used to elucidate disease processes as well as treat clinical diseases. 
2. Importantly, regulation on stem cell use is not yet standardized and potential clinical use of the cells should be associated with significant and thorough research and understanding.

The Winn Feline Foundation interviewed Dr. Craig Webb on research of stem cells for the treatment of chronic intestinal disease in cats. Click here to listen to the podcast.

Diagnosis & Management of Feline Diabetes Mellitus, Dr. Catharine Scott-Moncrieff

1. In cats diagnosis of diabetes mellitus may be complicated by stress hyperglycemia so it is important to document clinical signs of hyperglycemia in cast with suspected DM.
2. Cats being treated for diabetes mellitus should be carefully monitored for occurrence of hypoglycemia, because of the possibility of remission of diabetes mellitus.

The Feline Diabetic: Understanding the Disease, Heather Lynch

1. The development of diabetes in feline patients is multifactorial.  While the primary underlying cause is debatable and likely varies from patient to patient, it is known that beta cells become toxic when the cat’s blood glucose is high and stop secreting insulin.  Therefore early detection and prompt institution of insulin therapy is integral to successful case outcome.
2. Recent recognition of a “pre-diabetic” status in cats may enable the clinician to intervene and prevent clinical diabetes from developing.

Stem Cell Therapy in Feline Chronic Enteropathy: In Practice – Clinical Application, Dr. Craig Webb

1. A search of PubMed for studies on MSC therapy in clinical cases of feline diseases produces a single pilot study looking at their use in cats with Chronic Kidney Disease. Stem cells have become the latest in a long line of therapies in veterinary medicine where our use is fast and far out-pacing our understanding.
2. If considering the use of stem cell therapy in feline patients, proceed with optimism and hope, but significant contemplation and caution.

The Winn Feline Foundation interviewed Dr. Craig Webb on research of stem cells for the treatment of chronic intestinal disease in cats. Click here to listen to the podcast.

Diabetic Ketoacidosis: Understanding Pathophysiology is Critical to Treatment, Dr. Catharine Scott-Moncrieff

1. There is a high incidence of concurrent illness in cats with diabetic ketoacidosis so it is important to investigate for underlying disease as part of the diagnostic approach.
2. Cats undergoing treatment for diabetic ketoacidosis are very likely to become hypokalemic so monitoring the potassium concentration is vital.

The Feline Diabetic: Successful Management, Heather Lynch

1. The goal of therapy in all newly diagnosed diabetic cats should be remission.  84% of cats diagnosed with diabetes will go into remission and no longer require daily insulin therapy.
2. In all of the studies where remission rates were reported at over 84%, cats were treated with protocols that included a diet change to a low carbohydrate diet, insulin therapy and home blood glucose monitoring.

Lunch & Learn – Diagnosis & Management of Feline Chronic Kidney Disease, Dr. Jane Robertson

1. Early diagnosis of CKD can be challenging: Measuring creatinine in healthy cats, for example during routine wellness visits, can help establish a normal baseline for an individual cat and an upward trend can be helpful to identify CKD while creatinine is still within the reference interval. A new serum renal biomarker, SDMA, allows for identification of CKD on average 14.6 months and as early as 4 years earlier than creatinine in cats and is unaffected by lean body mass. When SDMA becomes available, it will allow practicing veterinarians to diagnose CKD earlier and with more confidence.  
2. IRIS Staging System for CKD can help to guide appropriate therapy: The international renal interest society staging system stages cats diagnosed with CKD based on their serum/plasma creatinine and then cats are substaged based on the presence or absence and degree of both hypertension and proteinuria. One of the key benefits for using the IRIS staging system for a cat with CKD is that IRIS also provides treatment recommendations by stage for managing hydration, systemic hypertension, proteinura, hypokalemia, anemia, vomiting/decreased appetite/nausea, metabolic acidosis and for reducing phosphorus intake.

Diagnostic Testing for Hyperthyroidism in Cats: More Than Just T4, Dr. Mark Peterson

1. False positive results (ie, a high T4 in a cat without hyperthyroidism) are rare but are being seen with increasing frequency. Up to 30% of cats presenting with high free T4 concentrations will turn out not to be hyperthyroid.
2. Hyperthyroidism is a clinical diagnosis and should never be based on a serum T4, free T4, or TSH concentration alone. One must combine these lab results with the cat’s clinical features and the presence of a palpable thyroid nodule to make the diagnosis.

Managing the Feline Diabetic: Picking a Protocol, Dr. Audrey Cook

1. Establish a clear picture of the owner’s expectations and abilities: finding a program to match these is key to success with the patient
2. Identify suitable candidates for remission early and tailor the treatment to optimize this outcome

The Unstable Feline Diabetic Patient, Paul Plummer

1. The feline diabetic patient can quickly become unstable throwing them into an emergency situation.  Common causes include; hypoglycemia, insulin resistance, concurrent medical conditions or infections as well as treatment protocols for those medical conditions. 
2. Rehydration and starting appropriate insulin therapy after diagnosis of the unstable diabetic patient is the key to success.

What’s the Best Treatment for Hyperthyroidism? Antithyroid Drugs, Surgery, Diet, or Radioiodine?, Dr. Mark Peterson

1. When dealing with hyperthyroid cats, treatment is aimed at either removing or destroying the hyperfunctioning thyroid tumor (surgery, 131I) or inhibiting thyroid hormone synthesis and release (methimazole, low-iodine diet). Neither antithyroid drugs or a low-iodine diet can cure this disorder, allowing the thyroid tumor to grow and sometimes undergo malignant transformation over time.
2. In younger cats without concurrent disease, definitive treatment with either surgery or radioactive iodine to cure the disease is recommended whenever possible. In contrast, long-term medical or nutritional management is best reserved for cats of advanced age or for those with concurrent diseases, and for when owners refuse either surgery or radioactive iodine.

Diabetes: Home Monitoring, Dr. Audrey Cook

1. Introduce home monitoring at the time of diagnosis: be positive and encouraging
2. This is a team effort: educate your staff to improve compliance and provide support for cat owners.

What Every Technician Should Know about Feline Hyperthyroidism, Paula Plummer

1. Feline Hyperthyroidism is one of the most common endocrinopathies diagnosed in older feline patients.  The gold standard for diagnosing this disease is palpation of an enlarged thyroid lobe with matching clinical signs and history reported from the owner with an elevated thyroid hormone level. 
2. Treatment of this disease can include oral medications, iodine restricted food, thyroidectomy or radioactive I-131 treatment. Treatment protocols will be determined by multiple factors based on the needs of the patient, owner compliance, availability of treatment methods and owner wishes.

Day 3 – September 21

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Hyperthyroidism & the Kidney: A Strategy to Slow Progression of CKD in Treated Cats, Dr. Mark Peterson

1. Hyperthyroidism and CKD are both very common problems in the senior and geriatric cat, and may occur concurrently in the same cat. However, hyperthyroidism may be actually damaging the feline kidney, leading to a higher-than-expected prevalence of CKD in these cats.  Therefore, withholding treatment or undertreatment of hyperthyroidism may contribute to worsening of their CKD.
2. In most cats that first develop azotemia following treatment for hyperthyroidism, the azotemia is mild (IRIS stage 2) and associated with few, if any, clinical signs. The survival time of these euthyroid cats that first develop azotemia after treatment of hyperthyroidism is not significantly different from the survival time of cats that remain non-azotemic. However, if these azotemic cats are overtreated and become hypothyroid, the prognosis becomes significantly worse. Thus, our aim is to lower T4 concentrations into the lower half of the reference range to ensure that hyperthyroidism is being effectively treated.

Feline Hypothyroidism: Much More Common Than You Think!, Dr. Mark Peterson

1. Although early reports suggested that clinical signs associated with severe iatrogenic hypothyroidism in cats were uncommon and that most cats did not require treatment, it is now realized that milder degrees of iatrogenic hypothyroidism are relatively common and that these cats may benefit from thyroid replacement therapy.  Diagnosis of hypothyroidism in cats may require evaluation of more than a single thyroid function test. Use of complete thyroid panels, which include serum total T4, free T4, total T3, and cTSH, can be very helpful in improving diagnostic sensitivity for hypothyroidism. 
2. In many older cats, L-T4 is poorly absorbed, making it difficult to achieve adequate post-treatment serum T4 values. Because of the poor apparent absorption of L-T4, coupled with the short plasma half-life of T4 in cats, we recommend that one administer the L-T4 twice daily and give the supplement on an empty stomach, if possible.

Nutritional Management of Endocrine Disease in Cats, Dr. Mark Peterson

1. Hyperthyroidism is a hypermetabolic state that has profound effects on multiple organ systems (body condition, muscle, endocrine pancreas, parathyroid, and kidney). To best accomplish our nutritional goals, hyperthyroid cats should be fed a diet containing high amounts of dietary protein with low amounts of both carbohydrates and phosphate.
2. Dietary management plays a key role in the successful management of diabetic cats and should be used in conjunction with long-acting insulin treatment both to improve diabetic control and help induce diabetic remission. Because cats are obligate carnivores, diabetic cats are relatively carbohydrate intolerant and respond best to a low carbohydrate diet. Because diabetes is a catabolic state, weight loss, muscle wasting, and poor muscle condition scores are also common in diabetic cats. Therefore, feeding high-protein diets is essential to ensure replacement of any lost muscle mass.

Management of Problem Diabetic Patients, Dr. Catharine Scott-Moncrieff

1. Common causes of a poor response to insulin therapy in diabetic cats include problems with owner administration, inappropriate insulin dose or formulation, rapid metabolism, insulin induced hypoglycemia and insulin resistance.
2. A blood glucose curve is necessary to identify the cause of a poor response to treatment.

Managing Cats with Idopathic Hypercalcemia, Dr. Mark Peterson

1. Idiopathic hypercalcemia is difficult to manage, but a diet change should always be considered as first-line treatment. Feeding a more “natural” low carbohydrate, higher protein/fat canned or raw diet may help normalize serum calcium concentrations in some cats, particularly those with milder forms of idiopathic hypercalcemia. When such a diet is chosen, it is best to select one that contains lower amounts of both calcium and vitamin D.
2. When diet fails to control hypercalcemia, use of prednisone or alendronate, alone or together, can be added to the treatment regimen.

Role of Concurrent Illness in Insulin Resistant Cats, Dr. Catharine Scott-Moncrieff

1. Common causes of insulin resistance in cats include administration of exogenous glucocorticoids, bacterial infection, and pancreatitis.
2. Acromegaly and hyperadrenocorticism are less common but important causes of insulin resistance which can be distinguished by physical examination and endocrine test such as the low dose dexamethasone suppression test and measurement of serum IGF-1 concentrations.

Lunch & Learn – What’s New in Acute Feline Pain Management: Before, During, and After Surgery, Dr. Robin Downing

1. Our feline patients are at GREAT risk to become cold during anaesthesia and surgery.  Being cold interferes with their ability to metabolize their drugs properly and can make their pain experience WORSE!
2. We need to build our acute pain management plan for felines based on how much pain a particular procedure will induce.  Multi-modal – – reaching for medications that complement one another – – creates a far more effective strategy than single drug therapy and allows for smaller doses of each agent. 
3. Simbadol® is the first pain management tool of its kind – – feline specific, once per day dosing (up to three days), subcutaneous delivery (making less painful to deliver than IM) – – this is an important addition to our pharmamentarium!

Feline Adrenal Disease, Dr. Audrey Cook

1. The clinical signs of hyperadrenocorticism in cats are subtle; look for thinning of the skin and poor musculature.
2. Hypoadrenocorticism is uncommon in cats, but should be considered in any cat with unexplained hyperkalemia.

Feline Hypertension Secondary to Endocrinopathies, Dr. Catharine Scott-Moncrieff

1. Hypertension is a common problem in geriatric cats. Causes of hypertension in cats include chronic renal failure (CKD), hyperthyroidism, and adrenal disorders (hyperadrenocorticism and hyperaldosteronism).
2. Amlodipine is the initial treatment of choice in most cats with hypertension, however spironolactone and potassium supplementation are recommended in cats with primary hyperaldosteronism.

Hyperaldosteronism, Dr. Audrey Cook

1. Primary hyperaldosteronism should be considered in any cat with hypertension or hypokalemia
2. Establishing a diagnosis can be challenging, but effective management can be life-saving

Diagnosis & Treatment of Feline Acromegaly, Dr. Catharine Scott-Moncrieff

1. Clinical signs of acromegaly include polyuria, polydipsia, polyphagia (due to insulin resistant diabetes mellitus), large body size, weight gain despite poor glycemic control, and enlargement of the head and extremities.
2. Diagnosis of acromegaly relies on measurement of IGF-1 in cats with appropriate clinical signs but it is important to remember that not all acromegalic cats have obvious enlargement of the head and extremities. 

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