Itchy & Twitchy Pets Part 2: What’s New in Dermatology Medications?

To bring some humor to part two of this blog discussion of skin products, I thought I would start with my December 1965 Christmas photo pfeaturing my “fake hair pony tail”. I look at it now and think it looks like one of those before pictures of extreme makeovers. What was I thinking? 

I mention this because pets hide a lot of things internally. However, when there is itching and the hair looks bad, there is no doubt things are awry. So I will "fly in" to some of the new medications. (Yes, that is me with a Piper Cherokee airplane  I flew during veterinary school in the late 1970’s.)

Is there a once a day oral antibiotic for superficial skin infections?

Yes!Cefpodoxine (Simplicef) is a 3rd generation cephalosporin administered orally once a day. The concern with this drug longterm is that overuse of antibiotics sometimes leads to things such as Methicillin-resistant Staphylococcal pseudointermedius. This  antibiotic should be saved for more advance infections, not the first line treatment. 

As mentioned last week, when possible, skin infections should be first treated with topical antiseptics. This lowers the risk associated with long term,repetitive use of antibiotics and possible drug resistance. There are other oral  antibiotic medications, such as potentiated sulfa drugs and higher doses of oral clindamycin that should be tried initially if once once a day treatments are suggested.

My pet is difficult to give oral medications to and often becomes nauseated after administration. Is there an antibiotic injection that lasts 7 to 14 days?

The injectable cefovecin (Convenia) is also a 3rd generation cephalosporin that has broad spectrum activity compared to traditional cephalexin for skin infections. Concerns with use of this product include that once the effective blood level is gone; there is a sub-therapeutic level that may persist in the tissue for up to 2 months. The potential is multi-level drug resistance with future use. Therefore, use should be limited to pets who are difficult to medicate orally, exhibiting nausea , or when first or second level tier antibiotics were tried and found ineffective. 

What's new in topical ear medications? 

Most medications are dispensed in drops, and that can be difficult to accurately administer due to inadequate volume or improper administration/application. EasOtic (Virbac) is approved for treatment of ear infections with a once-a-day treatment for five days using a pre-measured 1ml pump system. It goes deep into the ear canal. In my experience, this is easier for owners; however, many pets may need two to four weeks (or more) of topical medication. This is due to the chronicity of the infection that is secondary to the primary issue of flea, food, or environmental allergies. 

My dog is on oral prednisone to cut scratching. It leads to increased thirst and urination. Are there any alternatives to suppress the itch reflex?

Oclacitinib (Apoquel, Zoetis) is a JAX (Janus kinase) inhibitor and was recently approved to treat severe, chronic itching attributed to allergies when other treatments have failed.  It was introduced in the spring of 2014, and has none of the common side effects attributed to steroids such as prednisone. Unfortunately, it was wildly successful in its first two weeks on the market, so much so that the entire year’s drug supply was used up!  Dosing is twice-a-day for 14 days in dogs. After 14 days dosing is once-a-day. Note: This medication can mask mange, flea, bacterial, and yeast infections. It is best used as a temporary medication to alleviate incessant scratching until the primary disease is identified, such as adverse food reaction or environmental allergies.  

I conclude to pay tribute to Misty Beasley, a fabulous therapy dog that recently passed away. She was loved and will be deeply missed by all of us at Creature Comforts.

Betsy Sigmon DVM, Diplomate American Board of Veterinary Practitioners, Canine and Feline

Creature Comforts Animal Hospital

Cary, NC 27518

Itchy Twitchy Dogs and Cats, Part One, Shampoos

While recently attending a veterinary conference in Orlando, Florida, I began wondering what topics would be of interest to the blog followers. How about skin diseases and treatments? 

Being in a southern climate, itching is a chronic problem due to a variety of inciting causes:  fleas, insect bite hypersensitivity, and environmental allergens.  The most common complaint I hear from clients is incessant scratching to the point of a neurosis for pets and their owners.

What is itching?
Itching (pruritus) is a neurological sensation that provokes an intense desire to rub or scratch. Then the sensation travels through nerves to the spinal cord to the brain.  

Tell me about Benadryl (diphenhydramine, an anti-histamine) and why it often does not seem to help my dog?
The Classic Benadryl model (anti-histamine type 1) is at best very controversial as to its effectiveness in dogs. New evidence indicates many other allergy chemical mediators (neuropeptides, peptides, cytokines, and leukotrienes for example) beg for newer and different medications. Stay tuned!

What can on owner do to help in the itchy pet assessment and evaluation? 

Bring to your pet's exam a photo of your pet looking normal as well as their history including:  scratch site(s), food trials, a photo or collection of prior medications, and dynamics of the household (new baby, owner traveling, frequency of flea control of all pets exposed, and seasonality). Itching is rarely induced by a solo cause. Interestingly, allergies are not responsible in up to 25 percent of cats. There is a new app called “ITCHOLOGY’ that can help track patterns of seasonal itching. 

Why can't we just do a food trial with Pet store food e(x. venison or fish and potato) for itchy pets?

A large percentage of pet store foods have cross contamination with proteins not listed in the ingredients. Even marketed “grain free diets” can induce allergies.

Tell me about shampoo categories and why bathing pets is important?

Bathing a pet is like cleaning off a Swiffer duster: less foreign matter on the fur this it decreases the itch sensation. Topical (on the skin) therapy can cut the frequency of oral antibiotics, thus lowering risk of drug resistant bacteria in the home. There are several types of bathing products for itchy pets. (Creature Comforts regularly carries these products for your convenience.)

Class 1- moisturizing, soap free shampoos  

Example: Aloe and Oatmeal shampoo. Used to remove chemicals, irritants, and allergens. 

Itchy pets have lost a barrier outer skin function which allows moisture loss, drying skin, and an entry point for allergens into deeper layers causing itching.  

Class 2- antibacterial shampoos  

Examples: Douxo Chlorhexidine, Malaket, Seba-hex, and Pyoben shampoo.  Used to control surface bacteria & combined with other agents to control yeast. 

Recent discoveries indicate many skin bacteria produce a protective biofilm (think the sticky plaque on your teeth) hindering the efficacy of oral antibiotics, while topical therapy, such as an antibacterial shampoo, can penetrate even with just one minute of contact time.  

Class 3- anti-yeast shampoos   

Example:  Malaket shampooo. Often used in combination with antibacterial agents to control surface malassezia.

Class 4- anti-seborrheic shampoos  

Examples: Seba-Hex and DermaBenSs (Dechra). Controls irritating scaling that harbors infectious agents.

Group 5- flea shampoos. Example: NO LONGER RECOMMENDED. Contain pyrethrins. 

There is zero residual flea control left after rinsing this shampoo. Solo use is discouraged, as most flea infested pets would need one of the above therapeutic products along with systemic flea control available from your vet (avoid over-the-counter systemic flea control as it is problematic in production quality and effectiveness).  Veterinary prescription products such as Ectokyl have become obsolete and no longer recommended.

Next week I will discuss new medications for itchy pets.

In the introduction photo, note the heart on the front of the chest of my dog, Taco Belle. The Maine Coon cat is named Tabby. 

 Betsy Sigmon DVM

Creature Comforts Animal Hospital

Cary, NC

Bartonella: a Phantom Infection

Quite often I will see a patient for nebulous signs, and routine testing is unremarkable. In the current culture of instant gratification, a negative test means NEGATIVE, correct?

Well, not so fast.

I think a better term would be, “Current methodology has not detected anything”. Similar to DNA of past crime scenes, in many cases current “biomarkers” of illness may not give the full story. 

I will use my own son as an example. Back when he was 13 years old, he returned from a European Trip with the youth organization, People to People. I laugh as I reflect of his story at being hit by Italian women with Gucci hand bags because the tour guides moved his American teenage tourists group to the front of the line for a tour of the Vatican. Shortly after his return, he developed unrelenting headaches that were so debilitating he went to bed for 2 weeks. At the time, current testing could not identify the cause.MRI’s, x-rays, infectious disease tests, cultures, complete blood profiles – the list was endless. 

Through Divine intervention and a veterinary school connection, the story had a different outcome than it could have. My son had Bartonella. This was diagnosed with testing developed by Dr. Edward Breitschwerdt, a veterinarian at the NCSU college of Veterinary Medicine.  His current company, Galaxy Diagnostics www.galaxydx.com, has made huge differences in the lives of many individuals, human and animals alike. 

WHY HAS BARTONELLA BEEN SO DIFFICULT TO DIAGNOSE?

Also called “cat scratch disease,” Bartonella is a bacterium that is transmitted from cat scratches. In addition, it is speculated there is transmission from other vectors such as fleas and mosquitoes in people with no direct access to pets. One reason it is difficult to diagnose is the organism commonly lives within cells rather than in the bloodstream. Because of this, blood tests are often falsely negative. 

AS A VETERINARIAN,  IS THERE A PROFESSIONAL RISK TO CONTRACTING BARTONELLA, cat scratch disease?

Yes, there is an undercurrent of concern that the veterinary community may be at risk of this silent disease. I experienced this firsthand 20 years ago when I awoke with a fever and very swollen lymph nodes after a bad cat bite/scratch. It is believed that 75% of emerging infectious diseases may be zoonotic (passed from animals to people either directly or indirectly through vectors such as fleas, ticks, mosquitoes).

HOW IS IT DIAGNOSED?

There are a variety of methods, such as specialized testing of tissues, a series of collected blood samples using DNA analysis, and a special culture media such as that mentioned at the GALAXY DIAGNOSTIC TEST SITE, among others. Even so, false negative results of these in antibody laboratory testing can be frustrating. 

WHAT ARE THE SIGNS IN PEOPLE? 

The presenting complaints are almost anything from chronic fatigue, enlarged lymph nodes, fever, neurological signs, weight loss, joint pain, and a series of negative tests on most conventional lab tests for traditional, infectious diseases.  Many are concurrently infected with other diseases, and in those cases it becomes more complicated to develop an accurate diagnosis. As a result many are placed on antidepressants, sleeping pills, anxiolytics, anti-convulsants, and this list goes on and on as psychological disorders become overwhelming when no one can find a physical reason for the illness.  Many with concurrent Lyme disease experience similar frustration. 

WHAT ARE THE SIGNS IN DOGS AND CATS? 

Pets experience many of the similar signs of people with the exception that their headaches may be manifested as depression and hiding. Others may develop severe oral, heart, eye, liver, and other chronic illnesses. 

HOW IS IT TREATED?

Traditionally, a variety of antibiotic protocols have been implemented. Research is continuing as to non-traditional treatments including amino acid infusions and agents to treat concurrent infections. Unfortunately, by the time it is diagnosed there are chronic changes in many tissues that may be challenging to reverse. 

Betsy Sigmon DVM, Diplomate American Board of Veterinary Practitioners, Canine & Feline

Creature Comforts Animal Hospital 

Cary, NC.

COBALAMIN DEFICIENCY (VITAMIN B12) IN PETS

As a new year begins, I am once again reflecting on medical problems of the last week to share information that may be helpful to others.

Each week I watch a father and his special needs child walk their dog in the neighborhood and the interdependence of each of them. The role that I serve for this family is to educate the owners and treat the pet, and it is rewarding knowing that this beloved family pet is healthy and the owners are equipped to care for him for hopefully a long, long life. 

But sometimes, pets do get sick. Today I will share one common cause of intestinal issues, Vitamin B12 or cobalamin deficiency.

WHAT IS VITAMIN B12 AND ITS FUNCTION?

Vitamin B12 is a water-soluble vitamin. Vitamin B12, like the other B vitamins, is important for cell metabolism. It helps in the formation of red blood cells and in the maintenance of the central nervous system.

WHY WOULD A CLIENT SUSPECT VITAMIN B12 DEFICIENCY IN A DOG OR CAT?

Pets may exhibit weight loss, a variety of GI signs (vomiting/diarrhea/constipation), depression, weakness, and anemia. 

ARE THERE ANY PETS THAT HAVE INHERITED MALABSORPTION DEFECTS IN VITAMIN B12 METABOLISM/ABSORPTION?

Yes, Border Collies and Giant Schnauzers.

WHAT ARE THE SUSPECTED REASONS FOR ACQUIRED VITAMIN B12 DEFIENCY IN DOGS AND CATS?

This is most commonly due to inappropriate cleaving off the vitamin from dietary meats in the stomach, lack of intrinsic factor (produced in the  pancreas) to carry the vitamin to the distal small intestine, or inability to absorb it through the ileum (last part of the small intestine).

CAN INTESTINAL DISEASES CAUSE A LACK OF ABSORPTION OF VITAMIN B12?

Yes, intestinal lymphoma, bacterial overgrowth, irritable bowel disease, and inflammatory bowel disease (Crohn’s disease of people) are some of the more commonly suspected concurrent illnesses.

HOW IS IT DIAGNOSED?

Blood levels of vitamin B12, folate, pancreatic lipase, and trypsin levels are concurrently run. 

WHAT IS THE TREATMENT?

Injections of vitamin B12, weekly for 6 weeks, then every other week for 3 weeks, then once every 3 weeks for life. A recheck blood test is recommended after 2 to 3 months. Oral supplementation is not effective.

ARE THERE ANY MEDICATIONS THAT PLACE PEOPLE AND ANIMALS AT RISK OF VITAMIN B12 DEFIENCY?

Yes, omeprazole (Prilosec OTC), Nexium, Prevacid, and Pepcid AC can interfere with the acid conditions needed in the stomach to make the B vitamin available. Thus, long term use is discouraged. 

IN A RECENT SURVEY, HOW MANY SENIOR CITIZENS (HUMAN) MAY HAVE COBALAMIN DEFIENCY?

It is estimated to be 20%.

Many thanks to Sue Wiza for the photo of her dog, Nitschke.

Betsy Sigmon DVM, Diplomate ABVP, canine and feline

Creature Comforts Animal Hospital

Cary, NC

Appetite Stimulants in Cats

After finishing a week of holiday celebrations, the lack of appetite has hardly been a problem. Food has been freely available at every holiday festivity, and I am not looking forward to the weekly weight date. Perhaps I need to bring the stretchy pants out of hibernation.  Unfortunately, with change of routine, travel, and illness many cats experience a significant decrease in appetite. While a dog could theoretically go weeks without eating, a cat can into liver failure, called hepatic lipidosis (fatty liver) with less than a week of inappetence. Thus, the blog today is about ways to stimulate the appetite. I would like to say in most cases it is very important to find the reason for the lack of appetite. These are options to implement while investigating the cause(s). 

WHAT IS THE MOST COMMON APPETITE STIMULANT USED IN CATS?

 The one most commonly used, mirtazapine, was developed for human use as an antidepressant for moderate to severe depression. Mirtazapine acts to increase norepinephrine and serotonin in the brain. These are neurotransmitters associated with relaxation and comfort. It has strong anti-nausea properties by acting on the neuroreceptors in the intestine and stomach that communicate with the vomit center of the brain. It also acts as a strong appetite stimulant that was FIRST NOTED AS A BENEFICIAL SIDE EFFECT FOR CANCER PATIENTS. Obviously, a medication that addresses both nausea and appetite loss is an asset to treating many medical conditions. Administered orally every 2 to 3 days, mild sedation maybe noted. 

I HAVE HEARD OF A CONDITION CALLED SEROTONIN SYNDROME THAT IS OCCASIONALLY SEEN WITH THE USE OF MEDICATIONS SUCH AS MIRTAZAPINE. WHAT IS IT? 

Serotonin syndrome is a potential side effect should brain levels of serotonin get too high. The signs can occur 10 minutes to 4 hours after ingestion. Symptoms of serotonin syndrome in pets can include agitation, depression, aggression, vocalization, seizures, lack of coordination, muscle rigidity, muscle twitching, muscle spasms, tremors, change in heart rate, elevated blood pressure, changes in skin color, hyperthermia, and diarrhea.

 This syndrome generally requires a combination of serotonin-increasing medications. A partial list of these medications include the following: anti-anxiety meds (Prozac, clomipramine, Elavil), herbal supplement (St. John’s Wart), tryptophan, pain medications (tramadol, amantadine), anti-histamine (chlorpheniramine), and liver supplement (S-adenosylmethionine (SAMe).

WHAT OTHER DRUGS ARE UTILIZED TO STIMULATE APPETITES IN CATS?

1.     Periactin (cyproheptadine). In some cases it is rotated every 48 hours with mirtazapine. Sometimes, particularly with cyproheptadine, you may have some aggressive behavior tendencies. May also be worth a try to have compounded as a transdermal medication to apply to the ear flap.

2.        Midazolam, a sister drug of diazepam (Valium), will make a cat eat most anything. Sedation is a potential concern.  Oxazepam is a similar medication. These are not for long term usage.

3.       Prednisolone is often used to stimulate appetite. The side effects of eating, drinking, and urinating more often curtail use long term.

WHAT ABOUT VITAMIN B12 (COBALAMIN) INJECTIONS?

They may be used safely in many cases. I will discuss a deficiency of this vitamin with intestinal problems in both people and animals in next week’s blog. 

I AM INTERESTED IN MANY NATURAL APPROACHES AND I HAVE HEARD ABOUT AN ACUPUNCTURE SITES IN CATS THAT STIMULATES THE APPETITE. WHERE IS IT?

There is an acupuncture point that you can use (dry needling or acupressure). It is located on the dorsum of the nose, midline, where the haired and unhaired areas meet. 

DOES ELEMENTAL ZINC WORK AS AN APPETITE STIMULANT?

Yes, in an older paper out of Tennessee 1mg/kg of elemental zinc once a day may increase appetite by replacing if zinc deficiencies present leading to lack of appetite. Another theory, unsubstantiated suggests it increases a neuropeptide Y. 

CAN CATNIP BE UTILIZED FOR PICKY EATERS? 

 While catnip can work to stimulate the appetite in some cats, the result is mixed. 

I want to thank all of the blog followers for your kind words of support. The picture above is of my son, Jason, home for the holidays. The beach picture is from this weekend at Myrtle Beach. 

Betsy Sigmon DVM, Diplomate ABVP, canine & feline

Creature Comforts Animal Hospital

Cary, N