SOVG PATIENT Rx DRUG REFILL

AND THERAPEUTIC CARE GUIDELINES

The following information is to enable you to more easily schedule your pets recommended drug and/or lab testing in order to monitor their heath progress, as well as to remain within safety guidelines for continued Rx refills. We are providing this data to minimize your inconvenience in retesting before you are out of medication and a recheck is OVEDUE. These recommendations are partially medical common sense, as many diseases are dynamic and fluctuate in dose requirements over time AND partially legal, as the State of California requires a “hands-on doctor-patient relationship” AT LEAST ONCE A YEAR, or more often, as dictated by the nature of the condition and the prevailing standards set by the California Veterinary Community. Be aware these are the most common conditions seen and is not a complete list. The following applies to dogs unless noted otherwise for cats. If you have questions, please call us for more information.

Note: SOVG will be providing internet-based sales for both prescription and OTC supplies. Please check our website for this option. Please call ahead at least 24 hours prior to in-person pick up of

medications. Doctors may need to review your pets chart for accuracy and staff members will require time to refill and label Rx medications before the prescription can be released.

A CURRENT BODY WEIGHT is crucial for calculating a correct dose. If your pet has gained weight over time or lost weight due to severe disease, WE NEED FOR YOU TO LET US KNOW if there has been a change so that we can provide the most accurate dose.

Rx Medications and Refill Requirements۞ Condition: Bladder or Kidney Infection Drug: Antibiotic(s)

Rx Requirements: Urinalysis, Urine culture, possible kidney blood values, exam Initial Repeat Monitoring Interval: Urine culture (UMIC) 4-5 days AFTER Rx meds are completedFollow-up Monitoring Interval: 1 month additional urine culture if kidney disease 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No Appt required: Generally not if stable or unless recommended by vet. Medication to be given before testing: No - Not for 4-5 days for antibiotics

Condition: Kidney Insufficiency or Failure Drug: Rx Diet, Omega-3 oils, Epakiten, +/- enalapril (Vasotec®)

Rx Requirements: Blood panel, urinalysis, urine culture, blood pressure, exam Initial Repeat Monitoring Interval: 2-3 weeks after dismissal Follow-up Monitoring Interval: generally every 3-4 months 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No Appt required: As Recommended by Vet and patient is stable.

Medication to be given before testing: Yes Condition: Anemia due to Kidney Failure Drug: Epogen®

Rx Requirements: Blood panel, urinalysis, reticulocyte count, exam Initial Repeat Monitoring Interval: Weekly until PCV ≥ 30% Follow-up Monitoring Interval: 3-4 months 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No Appt required: As Recommended by Vet and patient is stable. Medication to be given before testing: Yes -as per schedule.

Condition: Hypertension (High blood pressure) Drug: Amlopidine (Norvasc®), Benazepril (Lotensin®), Enalapril, Captopril, Atenolol (Tenormin®), Sotolol, etc.

Rx Requirements: Blood pressure, blood panel, exam, no antihistamines Initial Repeat Monitoring Interval: 4-6 days Follow-up Monitoring Interval: 2 weeks, then every 3-4 months 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No Appt required: Yes, if stable or until BP is stable.

Medication to be given before testing: Yes

Condition: Diabetes mellitus Drug: Insulin and/or glipizide (Dogs and cats) Rx Requirements: Blood glucose (BG), glucose curve, blood panel, fructosamine, exam, urinalysis, urine culture (half of all diabetics have urinary infections), Rx diets.

Initial Repeat Monitoring Interval: 2-4 days between BG curves, 2 wks between fructosamine levels. Follow-up Monitoring Interval: every 3-4 months if stable and no excessive water intake. 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No

Appt required: Yes, if patient is stable – unless otherwise directed by vet. Medication to be given before testing: Yes -and fed on schedule –VERY IMPORTANT!

Condition: Bladder/kidney stones Drug: Rx diet, antibiotics, etc

Rx Requirements: Urinalysis, urine culture, X-rays, blood panel, diet supplements, exam. Initial Repeat Monitoring Interval: 30 days +/- antibiotic Rx period for re-culture Follow-up Monitoring Interval: 60-120 days for stone disappearance by X-ray review, Every 6 months for repeat calcium oxalate patient for cultures and/or X-rays, esp. dogs 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No

Appt required: Yes Medication to be given before testing: Yes

Condition: Seizures/Epilepsy Drug: Phenobarbital

Rx Requirements: Blood panel, urinalysis, possible bile acids test, possible MRI, exam. Initial Repeat Monitoring Interval: 2-4 weeks at 4-6 hrs after morning dose

Cats: recheck at 8 wks, then every 6 months Follow-up Monitoring Interval: 6months, then every 12 months if stable at 4-6 hrs after

morning dose. Perform asap if breakthrough seizures. 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No Appt required: No - after initial recheck, stable and if seen in past 12 months. Medication to be given before testing: Yes

Condition: Seizures/Epilepsy Drug: Bromide (cats and dogs)

Rx Requirements: Blood panel, urinalysis, possible bile acids test, possible MRI, exam.

No NaBr for hypertension or cardiac patients. No KBr for Addison’ s patients or diabetics

Initial Repeat Monitoring Interval: 1 month, then 3 months later. Follow-up Monitoring Interval: 6months, then every 12 months if stable and taken 4-6 hrs after morning dose. Perform asap if breakthrough seizures. 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): Yes No Appt required: No - after initial recheck and if seen in past 12 months and stable. Medication to be given before testing: Yes

Condition: Heart Failure Drug: Digoxin (cats and dogs)

Rx Requirements: Chest X-ray, EKG, blood panel. Blood pressure, pulse oximeter, exam, possible chest Ultrasound Initial Repeat Monitoring Interval: 5-6 days for blood levels. Follow-up Monitoring Interval: every 6 months if stable +/- heart ultrasound/EKG 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No

Appt required: No - after initial recheck and if seen in past 12 months and stable. Medication to be given before testing: Yes

Condition: Hypothyroidism Drug: L-Thyroxine (Soloxine®) (Phenobarbital lowers blood test results) Rx Requirements: Blood test (panel, UA, thyroid blood test = T4 and Free T4 levels by

ED, not RIA), blood pressure, exam. Initial Repeat Monitoring Interval: 4 weeks – 4-6 hrs after morning dose thyroid, CBC, kidney values and blood pressure. Follow-up Monitoring Interval: every 12 months with regular blood panel including post pill total T4 level, UA 4-6 hrs after morning dose. Sooner if weight gain or skin problems noted. 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No Appt required: No - if seen in past 12 months and stable. Medication to be given before testing: Yes

Condition: Arthritis/ Joint disease Drug: NSAID/Prednisolone Aka Rimadyl®, Deramaxx®, Etodolac®, Meloxicam®, Piroxicam®, Tepoxalin®, Ketoprofen, Previcox®, etc. Rx Requirements: Blood panel, urinalysis, possible X-rays, exam.

Initial Repeat Monitoring Interval: 2-4 weeks Follow-up Monitoring Interval: 12 months if stable and no gastrointestinal upset. 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No Appt required: No – if seen past 12 months and stable. Medication to be given before testing: Yes

Condition: Hyperthyroidism Drug: Tapazole® (methimazole)

(Cats) Rx Requirements: Blood panel, urinalysis, blood pressure, exam. Initial Repeat Monitoring Interval: 4 weeks, blood pressure, blood panel for kidney disease, CBC for adverse bone marrow reactions and thyroid levels. 2 months later to further evaluate blood counts and liver enzymes. Follow-up Monitoring Interval: 12 months if stable. Sooner with vomiting, kidney/liver disease, weight loss or excessive appetite. 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): No Appt required: No – if seen past 12 months and stable. Medication to be given before testing: Yes

Condition: Cushing’s Disease Drug: Trilostane (Vetoryl®),

Lysodren® (mitotane) Rx Requirements: Blood panel, urinalysis, Low Dose Dexamethasone Suppression test (8 hrs) +/- ACTH stimulation test (2 hrs) if LDDST ineffective, exam. Initial Repeat Monitoring Interval: 2 wks and 6 weeks, ACTH stimulation test (2 hrs) plus urine culture, blood panel. Follow-up Monitoring Interval: ACTH stimulation at 4 months if stable and no weight gain or excessive appetite/ water intake. 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): Yes Appt required: No – if seen past 12 months and stable. Medication to be given before testing: Yes

Condition: Addison’s disease Drug: Percorten® +/-

prednisolone Rx Requirements: Blood panel, urinalysis, ACTH stimulation test (2 hrs), exam. Initial Repeat Monitoring Interval: ACTH stimulation and electrolytes 4 weeks, Follow-up Monitoring Interval:1) Percorten® injection every 28-40 days and 2) then 8 wks, then every 4 months for ACTH stimulation if stable and no weight loss or excessive appetite. 12 Hr Fasting Required (CRITICAL FOR SOME TEST RESULTS): Yes Appt required: No – if seen past 12 months and stable. Medication to be given before testing: Yes - on schedule as per DVM instruction.

Probiotics and Prebiotics:

Diet and Health in Pets

Both of these subjects have received significant amount of attention in the past decade for medical patients of all species. The public is now been exposed to these concepts through advertising campaigns for items such as Activia® fortified yogurt and Cheerios® for their respective cultured probiotic bacteria and lipid-regulating ingredients. The benefits may be overstated by some companies, and the FDA has taken some claims to task; however, the fact is that we and our pets are well in the grip of a manmade, urbanized group of diseases unique to industrialized countries. Dietary intake and lack of exercise underlie most of them: obesity. High blood pressure, diabetes, arthritis, fatty livers and metabolic syndrome are rare afflictions in third world societies without the benefits of modern technology. Refrigeration and mass factory food production has taken us days to months away from the production site for meats, dairy, produce and pet food. Sterilization and pasteurization have wiped out probiotics from our diets (pets and owners alike), while the trend toward consumption of processed meats and starches have dropped fiber intake dramatically. A hundred plus years ago, the American diet was rich in whole grain breads, raw milk, fermented (blue) cheeses, homemade yogurt, fermented milk (buttermilk, kefir, etc), dried fruits, nuts, local butchered meat. Dogs would have been fed directly from the table while cats were forced to eat whole raw wild prey to survive.

While medical science has spent decades and trillions of dollars finding out how disease mechanisms work, much less is actually known about how the natural balance of food, nutrition and digestive systems work to our advantage. This is still a poorly defined discipline, but some very good information has come to light that may be of medical value to you and your pet’s long term health. The appearance of diseases such as Inflammatory Bowel Disease (IBD), Lymphocytic-Plasmacytic Enteritis, Nervous Colitis and Crohn’s disease are modern phenomena. The most severe forms of IBD have the least amounts of probiotics in the gut ecosystem.

New data suggests that the real answers were at hand all the time: evolution and nature knows best and violating dietary rules that evolved over millions of years can have negative consequences. Simply put, eating a more traditional diet (whole grains, fiber-rich, low fat, organic diets for dogs and people, plus grain-free organic canned diets for cats) is best suited for each species’ normal physiology.

Probiotics:

The idea that probiotics may exist and are important to everyday health came from trying to explain why patients with diarrhea and gut upsets failed to get better after treatment with antibiotics. Patients treated for long periods with drugs for diarrhea often had continued to suffer. This could be due to clinical treatment for loose stools or intentionally in preparation for intestinal surgery to reduce the risk of contamination in the belly. Either way, many patients had substantial difficulties in reestablishing normalgut health. Many patients eventually turned to alternative medicine practitioners for nutritional and herbal therapy to combat the unrelenting yeast infections that often accompany these conditions. Cultures showed only pathogenic bacteria (Small Intestinal Bowel Overgrowth Syndrome aka SIBO), or no bacteria at all on post treatment samples Eventually, this condition came to recognized as dysbiosis. Dysbiosis (aka dysbacteriosis) is defined as “an imbalance in the intestinal bacteria that precipitates changes in the normal activities of the gastrointestinal tract or vagina, possibly resulting in health problems”.

This work led to the recognition that beneficial bacteria are essential for normal intestinal and female reproductive tract function. This makes great sense in terms of evolution where certain bacteria and microorganisms would be employed to aid in digestion and stabilization of the gut micro-ecology beyond that of simple chemical action from stomach acids, bile salts and pancreatic juices of the digestive organs. This is even more critical in the cat’s gut system where there are ten time the concentration of bacteria than that of humans or dogs.

At the start of the 20th century, probiotics were simply thought to be beneficially affecting the host by improving its intestinal microbial balance, thus inhibiting pathogens and toxin producing bacteria. These pathogenic bacteria are present in the vast majority of healthy normal pet guts (approximately 75% of dogs and cats) but have substantially elevated numbers present during gut upset episodes. It has been traditionally assumed that “good bacteria” kept the ever-present introduction of pathogens (“bad bacteria e.g. E. coli, Salmonella, etc) from multiplying to cause diarrhea. Today, additional specific health effects are being documented, including alleviation of chronic intestinal inflammatory diseases, prevention and treatment of pathogen-induced diarrhea, urogenital infections, and allergic (atopic) diseases. Essentially all significant published research is in humans using cultured bacteria administered to patients. However, Drs. Deb Zoran at the Texas A&M University College of Veterinary Medicine GI labs and Mike Lappin at the Colorado School of Veterinary Medicine are leading the way in this very complicated and exciting field. Feeding of probiotics appears to reduce either the incidence or the intensity of many diseases in both cats and dogs. These are empirical observations so far, and disease mechanism studies are currently underway.

The probiotic bacteria Bifidobacteria was first isolated in 1899 from a breast-fed infant by Dr. Henry Tissier at the Pasteur Institute. Tissier found that bifidobacteria are dominant in the gut flora of breast-fed babies and he observed clinical benefits from treating diarrhea in infants orally with cultured samples of bifidobacteria. He claimed the effect was that bifidobacteria displaced the pathogenic bacteria causing the diarrhea, hence the origins of the pathogenic bacteria repression theory.

Research is emerging on the potential health benefits of multiple probiotic strains as a health supplement, as opposed to use of a single strain, such as Lactobacillus (LaB) alone. The human gut is home to at least some 400-500 types of microbes. Genomic sequencing studies at the TAMU GI laboratory suggest that dogs may have as many as 700 species of normal flora based on DNA primers optimized for the sequencing of the

16S rRNA gene fragment in the ribosome (a conserved protein factory organelle in every cell). It is thought that this diverse ecosystem may benefit from giving multiple probiotic strains at one time; different strains populate different regions of the digestive tract, and studies are beginning to link different probiotic strains to specific health benefits. The environment in the stomach, small intestines and large bowel are vastly different, and their normal gut flora bugs are respectively different, as well. For instance, different species of Lab are restricted to the jejunum, ileum or colon.

Probiotic therapy may restore or supply essential bacterial strains needed for gut maturation and homeostasis, particularly in hosts where this process has been disrupted. Additional potential mechanisms of beneficial probiotic interactions with immature intestinal epithelia include immunomodulation, upregulation of cytoprotective genes, prevention and regulation of apoptosis (noninflammatory cell death) and maintenance of intestinal barrier function to transmigration of bacteria into the blood stream. Potential mechanisms of therapeutic effect elucidated by animal models and human clinical studies implicate modulation of T-cell helper type 2 (TH2-type) actions in allergic inflammation and induction of immune tolerance.

A systematic review of nine placebo-controlled studies in children and adult humans using various probiotic products showed a 60% reduction in incidence and duration of antibiotic-associated diarrhea compared with placebo in a 2002 study. A two year follow- up showed no difference in neonatal morbidity, colic, or serious adverse effects, such as significantly fewer antibiotics prescribed to the treated (symbiotic) group and fewer respiratory infections. Animal studies are in the rudimentary stages due to the limited funding to veterinary colleges and the overwhelming volume of required testing of the approximately 700 different probiotics in different doses and in all possible combinations. On a clinical level, use of commercially available freeze dried cultured capsules and plain yogurt (cow, sheep, buffalo) will effectively control or significantly reduce the damage process for about 20% of any patient population for diarrhea, gastric reflux, dysbiosis, IBS, irritated bowel, nervous colitis. It is an excellent means of reducing or eliminating gas (flatulence) in breeds prone to this social offense (bulldogs, pitbulls, labs, retrievers, etc). A large tablespoon of plain yogurt twice daily provides a wide spread of probiotics, while a Powerdophilus® capsule (Whole Foods Market) once daily will provide 5 probiotics in the 10 billion colony forming units (CFU = live bacteria) range for each organism at a cost of less than 15¢ per day. All probiotic sources ARE NOT EQUAL. A consumer report study showed around 80% of all OTC commercial probiotic products tested in supermarkets, drugstores and nutritional outlets were not potent (less than labels content) or nonviable (dead bacteria). In contrast, plain yogurt was found to be equal in CFU content and viability from all sources.

Several new mechanisms by which probiotics exert their beneficial effects have been identified and it is now clear that significant differences exist between different probiotic bacterial species and strains; organisms will need to be selected in a more rational manner to treat different diseases. Mechanisms contributing to altered immune function in vivo induced by probiotic bacteria may include modulation of the microbiota ecology itself,

improved barrier function with consequent reduction in immune exposure to microbiota, and direct effects of bacteria on different epithelial and immune cell types. It is thought that perhaps each of the hundreds of probiotics activate or repress individual T-cell lymphocyte function via cell-to-cell referred signaling through cytokines present in the gut epithelial wall.

A note of caution is appropriate here. Despite the huge potential for probiotic, colostrum and other immunomodulating therapies; results from meta-analyses and systematic reviews that combine results of numerous studies from different types of probiotics to examine the effects in any disease state should be interpreted with caution. Specific strains alone, or in combination, are effective in treating very specific disease states. No two probiotics are exactly alike; we should not expect reproducible results from studies that employ different species or strains, variable formulations, and diverse dosing schedules.

Prebiotics:

As a functional food component, prebiotics, like probiotics, are conceptually placed intermediately between foods and drugs. Typically, prebiotics are carbohydrates (such as oligosaccharides aka small sugar molecules), but the definition may also include non- carbohydrates. The most prevalent forms of prebiotics are nutritionally classed as soluble fiber. To some extent, many forms of dietary fiber exhibit some level of prebiotic effect. The term often applied to this class of nutrition is “functional foods”. These are not the only members of this class, but have received the most attention recently. Simply put, prebiotics give probiotic bacteria something beneficial to eat and help further stabilize the micro-ecology of the intestines.

Dr. M. Roberfroid, who first identified the importance of prebiotics offered a definition in the 2007 Journal of Nutrition stating: "A prebiotic is a selectively fermented ingredient that allows specific changes, both in the composition and/or activity, in the gastrointestinal microflora that confers benefits upon host well-being and health."

The United Nations Food and Agricultural Organization defined prebiotics as “a nondigestible food ingredient that promotes the growth of beneficial microorganisms in the intestines”.

Natural sources containing various prebiotics include breast milk, raw dandelion greens, leeks, onions, garlic, asparagus, whole grains, beans, banana, soybeans, inulin sources (such as Jerusalem artichoke, jicama, and chicory root), raw oats, unrefined wheat, unrefined barley and yacon (a fibrous tuber grown in the Andes mountains). Some of the oligosaccharides that naturally occur in breast milk are believed to play an important role in the development of a healthy immune system in infants. Obviously, some of these food options pose toxic risks to pets (onions, garlic and possibly leeks, cause anemia). Oatmeal is a soluble fiber source that holds great benefits for dogs. The individual ingredients can be fed to cats as food supplements.

It is becoming more common to properly distinguish between prebiotic substances and the food that contain them, as references to almonds, honey and other foods (most

commonly by growers of those foods) as "a prebiotic" are not accurate. No plant or food is a prebiotic: Wheat, honey and many other foods contain prebiotics to a greater or lesser extent, ranging from fairly large portions (chicory root, Jerusalem artichoke) to only trace quantities (thousands of other plant-based foods). Referring to a food as "a prebiotic" is no more accurate than calling a food "a vitamin."

Common purified prebiotics in use include inulin, fructo-oligosaccharides (FOS), galactooligosaccharides (GOS), soya-oligosaccharides, xylo-oligosaccharides, pyrodextrins, isomalto-oligosaccharides and lactulose. These compounds have been studied to varying degrees in animal feeding studies. They may be currently found as additives in some commercial pet foods. Be careful to limit the amounts of each prebiotic to a half teaspoon or less for pets, as too much fermentable fiber can create painful gas production. 1⁄4 tsp will be adequate for dogs 10 to 30 lbs while a half tsp daily will be effective for dogs between 50 and 80 lbs. Dogs over 80 lbs may need 3⁄4 to one tsp daily while small dogs and cats will do best on am 1/8th of a tsp in wet food.

Studies have demonstrated positive effects in human patients on calcium and other mineral absorption, immune system effectiveness, bowel pH, reduction of colorectal cancer risk, inflammatory bowel disorders (Crohn's Disease and Ulcerative Colitis), hypertension (high blood pressure) and intestinal regularity. Recent human trials have reinforced the role of prebiotics in preventing and possibly stopping early stage colon cancer. It has been argued that many of these health effects emanate from increased production of short-chain fatty acids (SCFA) by the stimulated beneficial bacteria, which are widely recognized to be beneficial to the host. Purified inulin, FOS, GOS (dogs and cats) and uncooked instant oatmeal added to the diet (dogs) has been used successfully in cases of chronic diarrhea that resist response to more traditional medications, despite a lack of statistical, evidence-based medical proof. Lactulose should be avoided at the current time due to its laxative nature.

Generally, it is assumed that a prebiotic should increase the number and/or activity of bifidobacteria and Lactobacilli where these groups of bacteria have several beneficial effects on the host, especially in terms of improving digestion (including enhancing mineral absorption) and the effectiveness and intrinsic strength of the immune system. This stipulation of selective fermentation or selective increase in growth and/or activity within the current definition has become synonymous with the observations of preferential increase in bifidobacteria and/or Lactobacilli species in the intestines treated with prebiotics. However, it is now inadequate to describe a beneficial modulation of a restricted microbiota population dominated only by a few members of the Clostridium and Bacteroides species, regarded as key species together with the bifidobacteria in dietary foodstuff sugar (simple carbohydrate) fermentation within the colon. These considerations and their implications warrant a reconsideration of the prebiotic definition and their actions on a complex ecosystem. The difficulty is how to encompass the entire field in a simple statement, since so much remains unclear.

A great source can be found on the web at http://www.jarrow.com/product/457/Inulin_FOS made by Jarrow Formulas and purchased at http://www.iherb.com/Inulin. A great option combines probiotics

and prebiotics in Jarro-Dophilus® + FOS. These are also available at Pets Naturally and Capitol Drug in Sherman Oaks, CA.

A more extensive review of these subjects plus product availability is available at:

http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/19_probiotics

_prebiotics.pdf

Obesity, Diabetes and Weight Loss

Obesity is an increasing health concern for dogs and cats in modern urban society and contributes to an increasing number of serious diseases in pets. High quality, affordable pet food is available in every neighborhood. Snacks are now available from an unlimited number of sources. 30 years ago pet superstores did not exist, cats and dogs frequently ran free all day, yards were larger and owners had more free time to walk and play with their pets. This problem is still never seen in feral populations of canines and felines. The disappearance of the extended, and, to an increasing degree, the nuclear, family structure has placed our pets in a much more prominent position in the home than in our grandparent’s generation. We dote on our pets because there are our constant companions, faithful friends and fuzzy children. Unfortunately, this devotion is often excessive and our four legged kids end up paying the price of overindulgence on our part. The obesity problem CAN be caused by metabolic disease, such as with hypothyroidism in SOME dogs or cats and contribute other medical conditions, such as arthritis in both dogs and cats and should always be considered first. However, most often obesity is a result of one simple problem: too many calories eaten compared to those burned by activity. Indoor pets are especially at risk for being overweight because of reduced activity. Small living spaces, dependence on the automobile and long work hours for owners have created the modern problem often referred colloquially to as the dreaded “condo-bod”.

When an animal (or human) consumes any type of food, it is broken down into simple sugars in the digestive tract. Unused energy (glucose) not needed by the body is converted by the liver into fat to be utilized later when food is scarce. The problem in household pets is that there is never a scarcity of food.

Evolution has designed the body to carry a certain amount of fat to provide energy between meals. Canines in the wild, like wolves and coyotes, go long stretches between meals. Therefore storing some fat is a healthy and necessary function. Feral cats on the other hand, eat small meals of protein throughout the day and do not store much fat at all. This characteristic of felines makes them highly susceptible to a specific liver problem called hepatic lipidosis if they are allowed to become obese and for some reason stop eating. This potentially life-threatening disease can occur in as little as 2-3 days. Cats were not designed to burn fat stores efficiently, and instead starvation causes the liver to become clogged with fat and subsequent liver failure. Some connections between obesity and disease are easy to understand. Overall, obesity reduces quality of life and shortens lifespan. One study by Purina showed that dogs with ideal body conditions live on average 15% longer than obese pets.

The following diseases occur at a higher rate in obese pets and owners than in lean individuals;

- - - -

Arthritis –see the document addressing this subject on the same webpage Cruciate ligament tears of the knees Vertebral disc disease and back injuries Heart and cardiovascular disease, thromboembolic strokes- High blood pressure (hypertension) - Respiratory distress - Diabetes mellitus - Cancer predisposition

- Overheating

- Anesthesia risk

Fat Tissue: Fat is stored in individual cells referred to as adipose cells or adipocytes. Everyone grows a set number (and dies) with a constant number of adipocytes upon reaching maturity. This is why liposuction works in people (note: liposuction is very damaging to dogs and cats). If fat cells multiplied, then the missing fat would be immediately be replaced for no benefit. Fat cells do not increase in number as obesity develops. Instead each adipocyte expands to hold more fat in each cell. Traditionally, fat storage (adipose tissue) has been viewed as a silent calorie repository, waiting for extra energy demands to shift it back into the blood stream. Recent research has now shown fat is dynamically and metabolically active and functions as an endocrine (hormonal) tissue. FAT IS NOT AN INERT STORAGE SUPPLY. It produces some very harmful substances when the adipocytes are stretched beyond normal size with obesity. Many of these substances are highly inflammatory. This would account for the higher levels of long term body damage associated with cardiovascular, pancreatic, joint and cellular disorders secondary to high force musculoskeletal trauma due to increased body mass and excessive cellular oxidation. Additionally, the overstretched fat cells become a highly active source of hormones released to affect numerous cell receptors and functions and include;

Leptin Resistin Adiponectin PAI-1 TNFα

IL-6 Estradiol (E2)

- hormone that stimulates hunger in the brain and is an inflammatory marker – proinflammatory factor associated with Type 2 diabetes – fat burning hormone reduced in diabetic patients – increased in obesity and promotes clot formation

- an inflammatory cytokine and promotes insulin resistance - an inflammatory cytokine and promotes insulin resistance and cancer - major estrogen molecule, increases risk of cancers, thrombosis, asthma

Diabetes and Obesity:

There are three main types of diabetes mellitus (DM) currently recognized. Diabetes insipidus is not sugar dependent and is a brain origin (pituitary) disease. However, DM patients do not always present with typical signs or treatment response and can have more than one type simultaneously. Certain breeds, such as Terriers, Cocker Spaniels, Dachshunds, and Poodles are more frequently affected. In fact, diabetes mellitus is a complex disease with numerous hereditary, physiological, lifestyle and concurrent disease factors that affect the patient. As a complex disease, most of the true types are poorly recognized and are termed “disease clusters” with overlapping common features, plus unique aspects that differentiate them in how they appear and respond clinically. Collectively, these overlapping patient groups are called “constellations” as apposed to strictly defined and separate groups called “cohorts”. These differences are the reason why some diabetics are so difficult to regulate.

- Type 1 diabetes: Results from the body's failure to produce insulin, and presently requires the patient to receive injected insulin. (aka as insulin-dependent diabetes mellitus - IDDM for short, aka juvenile diabetes.) This is not obesity dependent, may be due to a genetic mutation in the insulin gene and leads to a lack of insulin production. This is the typical form of diabetes in dogs.

- Type 2 diabetes: Results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was formerly referred to as non-insulin-dependent diabetes mellitus (NIDDM for short) and aka adult-onset diabetes. This is the typical form of diabetes in cats.

- Gestational diabetes: Occurs when pregnant females, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM. This is not generally an animal problem, but has been reported in both cats and dogs.

Also recognized minor form; Maturity onset diabetes of the young (MODY): Refers to any of several hereditary forms of diabetes caused by mutations in an autosomal dominant gene (inherited from either parent) disrupting insulin production. There are currently 11 recognized forms in humans. Research has not found these in pets yet due to financial limitations.

Diabetes mellitus (latin for “Honey-Sweet “) The signs most associated with this form of diabetes are increased water intake (polydipsia), increased urination (polyuria) – together referred to as “PU/PD”, and increased hunger (polyphagia). Clinically, the patient can gain weight, lose weight, become lethargic and often physically looks “rough” with ungroomed haircoat, flaky skin and tires easily. The medical risk to the patient is metabolic meltdown while scrambling to use fat as an energy source alternative (diabetic ketoacidosis), uncontrolled dehydration from the high blood sugar resulting when high urine sugar “sucks the water out of the patient”, bacterial infections of the urinary tract, generalized infection and a toxic affect on the nerves (diabetic neuropathy). In addition to the onset of various diseases, not limited to the list above, Type 2 diabetes mellitus is the most commonly recognized and is a rapidly expanded source of concern in pets, especially cats. It is often the result of insulin resistance, an earlier affect in obese pets and people and is known as metabolic syndrome. Insulin resistance often progresses to full Type 2 diabetes mellitus (T2DM). This is often seen when hyperglycemia develops after a meal, when pancreatic β-cells are unable to produce sufficient insulin to maintain normal blood sugar levels (euglycemia) in the face of insulin resistance. The inability of the βeta-cells to produce sufficient insulin in a condition of hyperglycemia is what characterizes the transition from insulin resistance to Type 2 diabetes mellitus. At the cellular level, excessive circulating insulin appears to be a contributor to insulin resistance via down-regulation of insulin receptors. This down- regulation occurs due to prolonged and repeated elevations of circulating insulin. As the pathological overproduction of insulin is relatively rare in individuals with normal fat

cells, it is more likely the cause of the insulin resistance associated with repetitive hypoglycemia and type 2 diabetes and sustained increases in blood glucose. T2DM patient daily Mg administration, restoring a more appropriate intracellular Mg concentration, contributes to improve insulin-mediated glucose uptake in humans. Whether this applies to cats and dogs is open for investigation and is not yet in use.

Diabetes Treatment:

The mainstay of all diabetics care is exercise, diet, weight control and insulin replacement. Without lean body mass, insulin resistance and all the other risk factors persist, even if blood sugar is controlled. Exercise acts to combat the hormonal affects of overfilled adipocytes through release of proteins from skeletal muscle that combat their negative health effects through mechanisms not well understood yet.

Diet

Feeding regimens are the first place to start when addressing obesity. Two or three small meals a day, rather than free-choice feeding (keeping a full bowl), allows the body to utilize calories more efficiently and store less fat. Table scraps tend to be high in fats and salt. They are often given in addition to the pet’s regular diet that already contains an adequate number of calories for energy. REMEMBER THAT A DIET CHANGE IS ALSO AN INSULIN ACTIVITY CHANGE.

The single greatest misconception in clients’ efforts to control weight is summed up by the unavoidable question of “Since I feed one (or two or three) cups (or cans) of food, how much should I cut it down. The problem is that all foods have different density of calories as derived from fat, sugar and carbohydrate content. Fiber type and concentration and digestibility (bioavailability), feeding schedules and snacks are also key factors in calories stored or used. Breed, age, gender and reproductive or growth stage will also influence calorie needs. Ekanuba light® is higher in fat density that Purina growth® formula. There is no truth in labels on pet food, unlike the requirements by the FDA for our food. The short answer for all is either simple – less food than you are feeding now, or more a more scientific approach.

1. Simple format first: Stop fatty (meat types for dogs) and carbohydrate snacks for cats and dogs. Dogs: Replace snack cookies and doggy snausages with green beans, squash slices, broccoli and carrot slices for dogs. They are natural omnivores and can (and will) eat all 5 of our human food groups. Feed 25% less food volume and replace the difference with pet vitamins, minerals, veggies and soluble fiber (instant oatmeal). Add instant oatmeal at 2oz for those up to 20 pounds, 4 oz for dogs up to 60 lbs and 8 oz for those heavier than this. No raisins (toxic), brown sugar (calories) or nuts (fat). Plain oats or unflavored canned pumpkin mixed with hot water or low salt broth and glopped onto the morning meal will slow down carbohydrate use and is filling. These are soluble fiber sources. A big bonus is that soluble fibers trap bile along with triglycerides and cholesterol for elimination in the feces. Insoluble fiber, like brans/fruit skin and root vegetable skins) bind up critical vitamins and minerals and are used mostly for temporary conditions like constipation.

Cats: These carnivores should be fed a lower volume of a grain free, high quality meat diet because cats have NO MECHANISM for carbohydrate processing. Cats stay hyperglycemic for 5-6 hours after a meal with grains or sugars (standard cat kibble or cookie type snacks). Most commercial foods have grain as filler. All kibbles use glutens and grain starches to hold their shape during processing and shipping. These are really CHEAP FILLERS for cats and not part of their natural diet. Innova® canned. Blue Buffalo®, Wellness® brand and Evo® (canned and kibble) are better than most all other choices (Pet’s Naturally in Sherman Oaks and Petsdirect.com can be helpful). Feed only that amount that can be eaten in two hrs twice daily. Any extra is not eaten due to hunger. It is important to not cause weight loss too quickly. Starvation is not the answer to obesity. Cats cannot metabolize fat rapidly without serious ill-effects. Check with a veterinarian to establish an ideal weight and timeline for weight loss. Cats may develop a serious condition called Fatty Liver Syndrome if forced to lose weight too quickly.

OR: Veterinary Rx diets. The problem of obesity and associated pet disease is so common that the scientific pet food companies have developed specific Rx diets for these patients. SOVG offers multiple Rx diet choices for pets including W/D, O/M, M/D, D/M for both cats and dogs (canned and kibbles). R/D (in prepackaged meal portions) is an option but has twice the carbohydrates of D/M and M/D. A prescription drug called Slentrol® is now also available to assist in pet weight loss success. Speak to our desk about these choices.

2. Scientific Option

Use a predetermined chart for your pets’ needs and then calculate from the food what is correct. Good general dog guidelines for choices are as follows (dry food basis): Protein - 16% Fat - 7-15% (fat vs thin dog wt)

Fiber - 9-10 The table shows the daily calorie requirements for dogs in a variety of situations - indoor dogs, outdoor dogs, working dogs, and very high activity dogs. It includes the calories per lb of body weight. Use the "Inside" column for your average dog (activity punctuated by rest)

2.2 64 141 130 * N/A

4.4 53 233 211 * N/A

5.0 50 250 225 * N/A

5.5 49 269 242 * N/A

Wt Kcal/ lb Inside Outside Herding Working

6.0 48

6.5 47

7.0 46

7.5 45

8.0 44

9.0 43

288 258

305 273

322 287

337 300

352 312

387 342

* N/A

* N/A

* N/A

* N/A

432 N/A

477 N/A

10.0 42 420 370 520 N/A

11.0 41

12.0 40

13.5 39

15.0 38

16.5 37

18.0 36

20.0 35

22.0 34

25.0 33

28.5 32

30.0 31

32.0 31

36.0 30

40.0 29

44.0 28

50.0 27

451 396

480 420

526 459

570 495

610 528

648 558

700 600

748 638

825 700

912 770

930 *

992 832

1080 900

1160 1000

1232 1100

1350 1250

561 N/A

600 N/A

661 N/A

702 758

775 858

828 918

900 990

968 1065

1075 1182

1197 1317

* *

1312 1443

1440 1584

1560 1740

1672 1850

1850 2075

57.0 26

66.0 25

88.0 24

118.0 24

150.0 24

1482 *

1650 *

2112 *

2832 *

3600 *

2052 2297

2310 2601

2992 3361

3894 4431

4800 5580

Cats: (these are minimum levels for can food – reduce stats by 25% for dry wt ) Protein... 30% (> 10 g/100 kcal or > 45%ME) Fat ...... 9% Calcium.... 0.6% Phosphorus... 0.5% Taurine... 0.1% Thiamine... 5 mg/kg Choline..... 2400 mg/kg Carbs.......low as possible

Feed no more than 180-200 kcal/day to the average sized cat (less if they are gaining wt, more if they are too thin or pregnant)

Remember that you are the keeper of all foods and menu selections at home. Your pet’s weight is a direct outcome of your actions and choices. Our pets will live longer and happier lives as a result of you maintaining a lean weight for them. Your pocket will not be financially as stressed and any health challenge will be more easily treated.

Medical Treatment:

Insulin-

Although insulin is made by the pancreas in all higher vertebrates, they are similar protein molecules, but NOT identical. The amino acid sequence of the species-specific protein dictates which form works best for each pet species insulin cell receptors at a molecular level when injected as a supplement or replacement. Until the past year, over a dozen types of insulin were available. Dogs are identical to pig insulin and most similar to humans, while cats respond better to the beef insulin amino acid sequence. Currently, the human market is 99% of insulin sales and only two vet products are manufactured: Pro-Zinc® (90% beef + 10% pork) for cats and Vetsulin® (pork based) for dogs. Fortunately, both species can respond to human recombinant insulin forms. There are a variety of human insulins which vary in duration of activity. Most pets will require a subcutaneous injection of insulin every 12 hrs for the remainder of their lives to function normally. Dogs are often started on Humulin-NPH®, while cats never exposed to insulin prior to the current program can be given human

Glargine® with some reasonable expectation of healing the pancreas and recovering

from Type 2 diabetes mellitus. Be aware that insulins come in two concentrations- U100 and U40. The U100 is generally human form and more concentrated while the vet forms are U40 and more dilute to be able to dose smaller patients. IT IS CRITICAL that owners purchase the CORRECT U100 or U40 SYRINGES for each different type of insulin or severe dose problems will occur.

Treatment Plan:

1. Patients are initially estimated as to their insulin needs based on blood sugar levels and body weight. Food must be offered and taken within 1 hour before or after each dose of insulin for it to work correctly. Blood sugar levels are taken 3- 4 days later at the most active insulin time, aka the nadir (generally 4-8 hrs after the morning injection) as an outpatient check. It is standard to conduct urinary culture screens and general blood panels to uncover other problems associated with diabetes.

2. Patients that are stable are continued at the current dose for 2 weeks and then a day-long glucose curve is conducted to document the insulin affect on the body. A fructosamine sugar level is also taken to evaluate the two week long blood sugar average. Patients that are found to be stabilized are kept on the same dose and rechecked at one month and then every 3-4 months for blood glucose (BG) curves and fructosamine levels.

3. Cats on Glargine® that are found to be normal to below normal BG have their doses reduced and rechecked monthly for an average of 4 months until they, hopefully, no longer require insulin.

4. Dogs and cats not found to be improved will have their insulin doses moved up or down, accordingly. BG levels are taken at 72 hour intervals until stabilization. Then the two week trial is started for fructosamine level assessment. Once water consumption and urination returns to normal and agrees with control via normal fructosamine and BG curves, the patient will be able to have 3-4 month rechecks.

Note: Home Glucose Monitoring: This is very beneficial for both the patient and veterinarian. Most pets stress to some degree while either enroute or staying at the clinic for a day long glucose curve. This releases epinephrine and norepinepherine (aka “adrenaline”) which drives up glucose release. The end result is that the patient is often adjusted for conditions at the clinic, not necessarily at home. This is especially true for nervous cats. A home glucose curve with blood taken every 2 hours for the 12 hours before and after the two consecutive insulin injections is very informative. Accuracy depends on how cooperative the patient is and the quality of the home glucometer. Most specialists will recommend the One Touch Ultra® model available at drugstores. It is fairly inexpensive, but the refill strips can be a bit pricey. They are still cheaper than 4-5 glucose curves at the clinic. There are dozens of other models, but these are often not user friendly or have severe inaccuracies when the glucose is very low or very high. Since these are critical blood value readings, saving a few bucks just to get good normal readings alone does not make

sound financial or medical sense. A diabetic crisis could cost up to $1000.00 if the wrong dose of insulin is chosen with a cheap glucometer. Blood samples should be taken from a reusable site, such as an ear margin or leg, not a sensitive area, like toe pads or lips.

Insulin Problems: MOST DIABETICS GET INTO TROUBLE DUE TO INSULIN RELATED PROBLEMS, due to owner oversight, not due to shifts in the disease or insulin dose changing.

- Giving the insulin too early or too late in the day. - Giving too little or too much. Both owners may not be aware the other already

gave a dose earlier or large bubbles change actual amount of insulin given. - Vetsulin® vial not rolled to mix the insulin properly. Human recombinants do

NOT need to be mixed. - Wrong needle type for insulin. - Insulin left out of refrigerator too long. - Patient not fed OR did not eat at time of insulin. There is no new sugar in blood

for insulin to push into body cells here.

Insulin Crisis:

In the event that too much insulin is given, the patient refuses to eat, or is sick from other diseases, the BG may drop too low. Once BG is below 40 mg%, the brain is deprived of sugar and ceases to function properly. The patient will appear “dopey” or drunk, may fall over or walk with a weave from side-to-side (ataxia) or even go into convulsions.

The immediate solution is to add sugar to the blood stream asap. Oral doses of Karo® syrup (this is sterile corn syrup) under the tongue will boost sugar levels in a few minutes. Pancake syrup, agave syrup and honey are substitutes that can be used. Note: Honey is known to carry bacterial spores that are potentially harmful in infants and compromised patients. ALL HONEY USED SHOULD BE PASTEURIZED.

The next step is to get the patient to the clinic or emergency service ASAP for BG testing and/or seizure control until the crisis is passed.

Ketoacidosis crisis- Diabetic patients in prolonged and elevated BG crisis will shift their basic metabolism from a sugar-based cell energy system to a fat-based metabolism. This is very hard on the body, especially the liver. The end result is a by toxic product called ketones. These diabetic ketoacidosis (DKA) patients must be handled as intensive care hospital patients until the metabolism can be shifted back to sugar use status. This is life-threatening and may take 8 hours to a couple of days in different patients.

Glucophagic Drugs:

Type 2 DM patients (cats), especially with insulin resistance, can sometimes benefit from drugs that upregulate the expression (production) of insulin receptors on cell surfaces. Despite a number of these available to humans (over 40 types), vet patients have the option of an oral drug called glipizide (Glucotrol®). This can regulate a minority of cats without insulin, but is more often used as an adjunct therapy with insulin when doses in

insulin resistant patients get too high. In addition to tablets, this drug can be compounded into a cat friendly flavor or a paste for application to the ear. There are no tests currently available to determine if this could be beneficial.

NEW PUPPY CARE SHEET

Purchase date:_____/____/_____ Exam date required by: _____/____/_____

Age_____ Breed:___________________ Sex:___________ Neutered: Yes / No Hernia Repair: Yes / No ______________ Microchip#:_________________________ Neuter date:_____________________(6 months old)

Congratulations on adding a new puppy to your family! This handout is designed to make your life easier and your pet’s life healthier. Please take a few minutes to look over some key points. The information recommended here is based on veterinary practice standards established over the past 60 years and with our parent organization, the American Veterinary Medical Association (AVMA). These are intended to keep your pet OUT of the vet’s office as much as possible. Even though your pet was checked before and again after entering the store, it is important to get your puppy checked as soon as possible after purchase to evaluate their health. The standard time for a new puppy health exam in the pet industry is 3 days (72 hrs). This is designed to avoid having the puppies pick up new diseases after purchase that may result in additional cost and care. Getting a health exam on time will limit your medical and financial responsibilities as detailed in your purchase agreement.

Puppies are complicated individuals that have physical, psychological and health needs. These tend to change fairly rapidly during the early months of life. A puppy’s growth during the first two years (24 months) is equal to the first 22 years of your life. Approximately 12 years the first calendar year and ten the next year. The puppy will grow about one year of human development each 30 days. This means that the body and brain will undergo major changes every few months. Making sure these needs are met is the least expensive and easiest way to care for your new family member.

Routine Puppy Health Care Guidelines

1. Vaccinations: Infants and juveniles of all species, including dogs, have very little protection against infection after birth. However, this can be developed very quickly with regular vaccinations. Natural exposure to wild disease types is another option but can not be controlled and may result in serious disease. Typically, a puppy isgiven vaccines every 2-4 weeks from the age of 8 wks to 16+ wks (4 months). The frequency (every 2, 3 or 4 wks apart) is based on the degree of risk for infection in the local area. Some of the more serious viral infections have become fairly well controlled, but NOT eliminated, in the Los Angeles area and a 3 week booster schedule is recommended. BUT, this may be altered for certain home situations (travel plans, some high risk areas, show dogs, etc). Keep your puppy away from UNVACCINATED or SICK dogs and the areas they visit until all the boosters are completed!

- Distemper virus and Parvovirus (DA2PC or DHPPC) – Given every 3 weeks from 8 to 16 weeks. May be extended later if not given early enough or vaccine boosters missed. A minimum of 3 boosters is recommended for good protection. Parvovirus is everywhere in the dirt (especially dog parks, beaches and playgrounds where it survives up to 6 months) and is a painful, expensive, bloody vomit and diarrhea virus disease. Distemper virus is less common, but more easily passed to puppies and is usually fatal after a lengthy period of severe illness. Recovered distemper patients often suffer permanent brain damage and die at a young age. Vaccines are cheap, intensive care is not.

- Leptospira - Not generally recommended at the current time. While this is a potentially serious kidney and/or liver bacterial infection, it has been seen occasionally in the past 25 years in urban dogs. However, some new infection forms have just recently seen again, but are often not covered by the traditional vaccine. No new vaccines have been made available for the new strains diagnosed for cases of Leptospirosis. Also, the majority of vaccine reactions in dogs are attributed to this vaccine, and until new vaccine types are released, most vets do NOT recommend their use for almost all puppies. Hopefully, this problem will be resolved in the future by better and safer, new vaccines.

- Bordatella (“Kennel cough”) – Given every 2-3 weeks form 8 to 14 wks with at least two vaccines by 12 weeks. This is a very common upper respiratory infection in young dogs exposed to other dogs at parks, beaches, grooming parlors, kennels and other places that dogs meet. It causes a chronic cough that wears the puppy out, interrupts sleep and leads to bronchopneumonia. The vaccine is inexpensive, given by nose drop (reduces the risk of vaccine reactions) and the treatment for the infection is up to several hundred dollars.

- Rabies virus – Given at or after 16 weeks old, repeated one year later and then every 3 years after the first year booster. This protocol is set by California law and is designed to prevent the untreatable disease caused by the Rabies virus in humans and dogs. Puppies and dogs must be vacinnated, licensed and tagged. If a dog has been found to have bitten a human without these requirements in place, serious action, including quarantine for 2 weeks at the pound or examination of the brain at a lab can be required as part of the public health laws in California.

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- Other vaccines: Many other vaccines are available, but are not recommended, either because the do little to give protection, or the specific infection does not appear in our immediate area. It is important you let your vet know if the pup will be traveling, kenneled or moving out of the area, as this may be an indication for these other vaccine types, such as Lyme’s Disease, etc.

DHPP(C): 1._________wks 2.____________wks 3._________wks 4.________ wks 5. ____________wks

Bordatella: 1._________wks 2.____________wks 3._________wks Rabies: 1. ________wks

2. Fecal Tests:

The majority of puppies carry some type of intestinal parasite. This happens as Nature’s intended way of passing different types of worms and parasitic life- forms on to other dogs for their survival. Most animals and people outside of the US and Europe are infected lifelong with parasites. America is actually an exception to this rule. Since they can cause intestinal problems like vomit, bloody diarrhea and weight loss, it is important to identify which types are present and the get rid of them. Since each of the many types have size variation (microscopic to spaghetti length) and incubation periods (2 wks to 4 months), at least 2 fecal tests several weeks apart are recommended. This is because it is unknown when the incubation period was started. Treatments are generally very simple, quick and effective. Yearly tests will be done when the puppy is older, but be aware that reinfection can occur if the puppy is exposed to eggs and cysts at dog parks, beaches, etc. Eventually, most dogs with normal immune systems will develop resistance, but this may take many years to become protective.

3. Fleas and Ticks: Fleas live on blood and the bites are painful, can allow infections to be transmitted to new dogs and can promote flea allergies. Flea allergy dermatitis is a major problem in Southern California. Tapeworms can also be carried in fleas and will cause tapeworm infections if eaten by the puppy. Routine flea control every month after the age of 8 weeks is highly recommended. This should be done every month all year round at the current time due to the mild weather here. Different flea prevention topical applications are available based on the risk of tick bites, swimming/bath schedules and risk of heartworms.

4. Diet:

It is critical that your puppy stay on a growth formula until at least 1 year of age to support rapid growth and high protein + calcium needs. Many good brands are available. The breeder or store may have provided you with a high quality selection, such as Royal Canin, Iams, Science, etc. Continuing on past 1 year in some very tiny toy breeds may be needed to keep their weight up to normal levels because of their high activity and small stomach size.

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Several excellent lines are available locally, or online, and include Innova®, Blue Buffalo®, Wellness® (has probiotics and prebiotics included) and Evo® (includes a meat only kibble form also). Pets Naturally in Studio City and Petsdirect.com are good resources.

Puppies need to be fed appx. every 3 hrs to prevent low blood sugar (hypoglycemia). This means free feeding of dry kibbles and/or canned food 5-6 times per day. Puppy stomachs empty every 3 hrs at first. This will decrease over the next 6 months and can be fed 3-4 times by 8 months of age. Some foods should never be fed: - Raisins + grapes can cause kidney damage. - Onions/garlic can cause an anemia. - Chocolate can result in an “Amphetamine-Like” overdose reaction, and may include seizures or death. - Avocado can potentially result in fluid buildup in the lungs.

5. Intestinal Flora Support:

The intestinal contents are a true ecosystem. Invaders can upset the natural balance required for normal digestion. The result can be diarrhea, vomit or constipation. Keeping the gut happy is fundamental to good health in everyone. Probiotics are “good bacteria” that help stabilize the gut contents and help prevent against infectious organisms from getting established. These can be found in yogurt, buttermilk and blue cheeses (cultured dairy products). They can also be purchased as freeze-dried cultures in capsules or liquids (e.g., PowerdophilusTM, JarrodophilusTM or SpirodophilusTM at Whole foods mkt). These are generally higher in concentration for a few probiotic strains vs. a wider spread of probiotics in lower amounts in yogurt (plain is the highest source). Since puppies lick everything and often eat feces, this is a great way to try to stop or minimize diarrheas before they get started. This is not an exact science, but this practice has been shown to help reduce the number of intestinal visits to the vet. 1 to 2 large tablespoons daily at meals or as a treat is very supportive.

See the documents on Probiotics and prebiotics, Obesity, Vomiting and Diarrhea and Intestinal Parasites on this same webpage for more information.

6. Home Safety: Puppies are curious about their environment. Since they lack thumbs, everything goes in the mouth. It is how they discover new information. From there, foreign objects often end up in the stomach where toxic chemicals cause poisoning and solid objects can plug up the intestines. Both of these conditions can result in death in the right circumstances. There is no limit to what may be eaten: rubber, plastic, bones, toys, coins, etc. Therefore, every new owner should get down on the floor (the same view point as the puppy) with a flashlight and look for lost items under beds, dressers, cabinets, etc. Then vacuum every where. If you don’t find them, eventually, the puppy will. If so, they may be eaten before you can witness it.

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Rubber bands, paperclips and erasers plug up intestines and require x-rays, optic scoping and/or surgery to correct. Dimes, nickels and silver coins have zinc coatings and will cause serious bleeding in the stomach. Thumbtacks, needles and bobby pins can poke holes in the intestines resulting in peritonitis and requires hospitalization. PICK THESE ITEMS UP if you see them on the floor. It only takes 10 seconds for them to get down a throat and out of reach OR into the trash, thanks to you. Think of it as putting $1500.00 in your pocket every time instead of just a toy car or paperclip.

Cabinets should be fitted with child-proof finger locks from the hardware store. Kitchen cabinets a filled with risky items like sponges, soaps, detergents, Brillo pads, cleaning rags. Bathroom cabinets have paper (toilet paper rolls, paper towels) and cotton (cotton balls/Q-Tips, face pads, etc) products that puppies can’t seem to resist eating. These swell up inside and are hard to get out of the stomach.

Trash cans should be tall enough to prevent them being knocked over AND have a solid lid (step-type metal pails with a pedal) to prevent access to trash. Anything that touches food smells like food and is tempting for puppies. Ziplock bags, chicken bones, tin foil, etc do not pass though puppies well and may require surgery to get them out. Food poisoning is another risk when food scraps are eaten hours after being thrown away.

Clothes hampers are important, as dirty clothes piled on floors or in low baskets are too tempting for puppies to ignore. Eating dirty socks and underwear is something some puppies will do more than once. Each episode requires a trip to the vet. A tall hamper from Target or Sears will solve this problem unless it is a large breed dog. Then, one locked behind a door is required.

Cat boxes are frequently used as grazing stops. Cat stools are often consumed by puppies and dogs as “Almond Rocha nuggets” and can result in severe intestinal infections (e.g., E. coli, etc). Keep cat boxes up high and out of reach or behind closed doors.

Electrical wires coated in plastic or rubber offers a great chewing source with puppies having teething pain. Puppies get two complete sets of teeth between 2 and 7 months of age. These new teeth make for sore gums. However, electrical shock can burn tongues, stop hearts and cause seizures or brain death. Coiling cords up and using self-locking hardware strips so that they can be hung up or taped out of reach is simple and cheap. Longer, heavy cords, like those for computers and refrigerators, can be covered with hollow plastic strip covers from the hardware store until the puppy is 1 year old and no longer interested. Masking tape can be used to hold the track down.

Toxic plants are often found in potted plants and yards. The petals, leaves, fruits, bark or roots may be toxic, and some are fatal in the right amounts. Consult the

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ASPCA website at the poison control center to see pictures of toxic plants plus their names, actions and care guidelines. Website is below: http://www.aspca.org/pet-care/poison-control/

Sweaters are important during cold wet winter weather and during air conditioning use in hot weather. Floors, especially hard floors, are much colder than the air in the room. This condition results a “heat sink” phenomena. Puppy’s hearts are very close to the skin and therefore, have little insulation against heat loss when they sleep on the floor. This can lead to pneumonia. Sweaters or sweatshirts for puppies cost $10 or $15 and can be easily removed when in bed or put back on for a cold weather walk. Puppy pneumonia is very serious and fees can run in the hundreds to thousands of dollars.

Harnesses are easier on the puppy if an emergency situation requires that they be picked up quickly. Big dogs, cars and unwanted strangers may not always be in your puppy’s best interest. Collars place a high degree of pressure on the spine and neck. Harnesses are reasonably priced and can avoid potential future neck surgery because the lift around the chest.

7. Body and Social Development:

Puppies’ brain development follow children’s’ very closely. New nerves are grown every hour and respond to stimulation via brain chemical transmitters. If not, they die very quickly to make way for new nerves that may be more useful. Once they are gone, it is forever. Memory, IQ, taste, eyesight, muscle skills, etc are all dependent on this process. The more stimulation the puppy gets early in life, the better the skills and personality will be developed. This is well documented in children starting at or before 6 months of age (6 wks in the puppy) and is called Neural Pruning or Neural Darwinism. The idea is that starting at 6 weeks of age, the more you handle, speak with and teach the puppy, the higher the IQ, physical and mental abilities will become later in life. This includes both human and dog social skills (two different areas of the brain). Getting the puppy to meet with other puppies or young dogs your friends/family members will help tremendously. Puppy play dates with healthy and vaccinated puppies can also be arranged with many dog training academies (Perfect Puppy Academy in Studio City, CA).

Parent dogs teach by example and body language. Since we lack long ears and a tail, extra hand gestures, fluctuating voice tonality, facial expression and repetitive training will be helpful for your furry kid to understand what you want them to do. Also, dogs discipline, they do not punish. They stop unwanted behaviors with a “game face”, a growl and a paw to get puppy’s’ attention. THEN, they show the puppy what to do, with positive reinforcement so it is done correctly. Just saying no and yelling doesn’t give the puppy any instruction and they can not think the plan up on their own. This is punishment. Teaching and lots of praise is the key to giving your puppy a “big dog” job. Every dog needs a job to feel needed, safe and a real permanent member of the new “dog pack”.

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Since you are now the new “Alpha dog”, it is your job to give the puppy their new job(s) to feel like you are in control and keeping everything safe, including them. The true job for the puppy is to be a well-behaved family member and these skills can be included in play time and daily interactions. Puppy behavioralists are sometimes very helpful, since infants and juveniles see the world very differently than we do as human adults. An interpretation and guidance (puppy coaching) sometimes makes the job much easier and faster if they can make sense of a childhood phase that appears without warning and is complicating the bonding process.

8. Neuter Surgery:

Every puppy not destined to be a breeder dog should be neutered (castrate for males, spayed for females) at 6 months of age. This is for health purposes. Unfixed dogs are at a much higher rate for certain reproductive diseases (esp testicular/prostate or mammary gland cancers) later in life. These are often difficult to fix or fatal after surgery and/or radiation/chemotherapy. The costs are extremely high and, to date, nothing easier or better is available for these terrible diseases. A reasonable cost neuter will go along way in helping you pet stay out of the hospital many years from now. Breeder dogs should be neutered at or after 5 to 7 years old when their optimal breeding age is over. Also, owners of intact dogs are charged $250.00 more each year for the rabies license by LA County due to puppy overpopulation. In 15 years of ownership, this equals an extra $3750.00 in costs which must be paid for by dog breeders as a new business tax.

9. Microchipping:

If your puppy did not come with a microchip identification in place already, then consider getting one. It is inserted above the shoulder blades in a quick process that provides a permanent means of identification. This will be crucial in returning your puppy to you in case of theft, fires, break-ins or earthquakes. Some companies (Home AgainTM) also offer injury medical repair coverage, shipping fees back home and other benefits if your pet is lost and/or injured. It is important to register this chip number to you and your home so that you are contacted in the event that a puppy becomes lost.

10. Health Insurance:

Every owner should consider buying a health insurance policy before a puppy has been found to have a pre-existing condition. This allows for the full benefits of a policy to be used. Different companies offer various packages of coverage at different premium levels. Some have more preventive care and some less. Costs vary by breed, age and maximum coverage, just like for us. Catastrophic-only coverage is also available. This is not a third party program, as you will pay fees up front and the your vet will help you get reimbursed. While many companies offer policies, some of the better companies for honoring claims are ASPCA and Best Pets. With veterinary costs rising during the life of your dog, this may help pay for routine and/or major medical care that would otherwise be a bigger out- of-pocket expense.

Kitten Care Guidelines

Kittens should be seen between 6 and 8 weeks of age for an initial health exam and testing +/- vaccinations. The source and health of the kitten can make a difference in what care and diagnostics are recommended. Stray/feral or pound kittens are at higher risk for infection due to their unknown background.

Fecal Parasites: Approximately half of the stray kittens will carry some intestinal parasite. All kittens should be checked at least twice during the juvenile period due to the great variability in parasite incubation periods among various worms and microorganisms. An average kitten will be checked twice 4-6 weeks apart before 4 months of age. This can be extended if a parasite is found or appears thin and does not gain weight rapidly. Fecal checks are recommended annually thereafter for indoor cats to insure they are parasite free. Outdoor cats should be fecal tested at least twice each year due to their high exposure to many different parasites. For more information, see the document on this same webpage on internal parasites and fecal testing.

Toxoplasma: One major exception to routine testing is for cats where a female owner is, or may become, pregnant. An internal parasite called Toxoplasma gondii can cause a disease in humans known as toxoplasmosis. This is a serious threat to an unborn fetus. The parasite infects most warm-blooded animals, including humans, but the primary hosts are cats, especially if they roam or are found feral. Susceptible animals are infected by eating infected meat (mice, rats, etc), by contact with other cat feces, or by transmission from mother to fetus in utero. The most common means of transmission to humans is raw or undercooked meat. The illness is usually self-limiting in humans.

Between 30% and 60% of the world population is estimated to carry a Toxoplasma infection during their lifetime. During the first few weeks, the infection typically causes a mild flu-like illness or no illness. After the first few weeks of infection have passed, the parasite rarely causes any symptoms in otherwise healthy adults. However, people with a weakened immune system, such as those infected with HIV, may become seriously ill, and it can occasionally be fatal. The parasite can cause encephalitis (inflammation of the brain) or other neurologic diseases and can also affect the heart, liver, and eyes with chorioretinitis.

Pregnancy precautions:

Congenital toxoplasmosis is a special form in which an unborn child is infected via the mother’s placenta. This is the reason that both the cat in question and the pregnant woman should be checked for Toxoplasma antibodies. Cats testing negative at least one month after adoption are considered uninfected. Cats with a positive titer are retested in 30 days. A lower to negative titer is evidence of self-cure. A steady or rising titer is evidence for an active infection. A positive titer in women prior to anycurrent cat exposure indicates previous exposure and immunity and largely ensures the unborn baby's safety. If a woman receives her first exposure to Toxoplasma while pregnant, the baby is at particular risk. A woman with no previous exposure should avoid handling raw meat, exposure to cat feces, and gardening (cat feces are common in garden soil). Most cats are not actively shedding oocysts and so are not a danger, but the risk may be reduced further by having the litter box emptied daily with rubber gloves (oocysts require longer than a single day to become infective), and by having someone else empty the litterbox.

Fleas and Ticks: Fleas live on blood and the bites are painful, can allow blood cell infections to be transmitted to new kittens such as Mycoplasma bacteria and even leukemia virus, in rare cases. Flea bites can promote flea allergies and flea allergy dermatitis is a major problem in Southern California cats, including some indoor pets. Tapeworms can also be carried in fleas and will cause tapeworm infections if eaten by the cat. Routine flea control every month after the age of 8 weeks is highly recommended if outside, has contact with dogs going out or has contact with animals going outside (apartment neighbors that walk their dog and come to visit, etc). This should be done every month all year round at the current time due to the mild weather here. Different flea prevention topical applications are available based on the risk of tick bites, bath schedules as well as the risk of heartworm exposure.

See the document on this webpage for more information.

Vaccinations: All kittens should start vaccinations by 8 weeks of age and continue every 3 weeks until at least 16 weeks (4 months) of age due to the serious threat of many viruses. This generally involves 4 vaccination appointments of a single vaccine for indoor cats. Outdoor cats should receive additional protection for feline leukemia virus and rabies virus by 16 months of age.

Boosters are annually for all cats until 3 years old. Then, indoor cats are boostered at 3 year intervals with vaccine titers in between while outdoor cats are vaccinated every year due to their increased exposure to potentially lethal viral disease.

Viral Testing: Kittens may be exposed to the two retroviruses, Feline Leukemia (FELV) and Feline Immunodeficiency Virus (aka FIV) from contact with cats, their mother or in the uterus. These viruses are passed by body fluids: Felv by saliva, grooming, cat bowls and cat boxes. FIV is passed by cat bites. These viruses have increased in outdoor cats from a low of approximately 1% in the mid-1980s to 15% of all outdoor cats for both viruses, based on feral cat surveys in the US. FIV kittens will nearly always become Feline AIDS victims later in life and must be kept isolated or only with FIV positive cats. Testing should start at 8 weeks of age and be repeated in 30 days, if positive for possible recovery and escape. Negative test results warrant a repeat test in 60 days (2 months). This is important because the FELV virus can hide in the intestine and/or bone marrow. The Feline AIDS test is not definitive for infection because it is ONLY AN ANTIBODY TEST, not a virus test. Some patients may require several tests to show positive results. Most truly positive Felv AIDS kittens will die in several months to 3 years, while Feline Felv positive cats can survive 8 years plus prior to becoming

AIDS patients when kept isolated and checked frequently. Lymphocyte counts via blood tests every 6 months are helpful in predicting the health status of FIV

Respiratory Viruses: Cats, and especially kittens from outdoor or high density conditions (catteries, rescue groups or shelters) are often exposed and infected with respiratory viruses or bacteria, These infections can be very serious where the patient stops eating, has difficulty breathing, coughs, has a constant runny nose and possible fever. A recent lab test using DNA analysis by PCR (polymerase chain reaction) has allowed us to accurately differentiate the many different agents responsible and then prescribe the correct therapy. The test is a simple swab of the eye, nose and throat and results are available in 1 to 3 days. New ant-viral drugs for the feline Herpes virus and other endemic pathogens, like Chlamydia and Mycoplasmas, have made a huge difference in the recovery and survival of our patients. These cats will typically relapse yearly during the winter months and an accurate diagnosis by PCR will allow us to better control future outbreaks. This is crucial in multiple cat households. We have found about 50% of the sneezing feral, shelter or rescue group cats are Feline Herpes virus carriers, along with a variety of other pathogens.

Neutering: All cats should be neutered at 6 months of age to control fighting, urine spraying, clawing, unwanted breeding and escape attempts. These behaviors often lead to serious injury by car trauma, dog attack, cat fights and wounds inflicted by non-cat friendly people. These are very expensive medical problems ($300-5000.00 each episode) and are primarily controlled by staying indoors.

Declawing: Cats can easily be trained to not claw furniture and drapes with spray bottles. Purchase a six-pack of spray bottles from Wal-Mart or the grocery store and keep one in every room full of water. Shoot the offender with a solid stream when scratching something forbidden WITHOUIT SAYING OR YELLING ANYTHING. Let the cat think the couch is making them wet. Usually 2 weeks will break the habit. Soft paws are on option that puts soft tips on the claws. We have them available. Remember that declawing is an amputation of the end of the finger/toe that is permanent. This can always be done when all else fails, but cannot be undone.

Diet: Infant kittens need to be fed every 3-4 hrs until 8 weeks of age to prevent low blood sugar (hypoglycemia). This means free feeding of dry kibbles and/or canned food 5-6 times per day as kitty stomachs empty every 3 hrs at first. See the document on “Care of Puppies and Kittens” on this same webpage for more information.

Some foods should never be fed:

- Onions/garlic can cause an anemia. - Chocolate can result in an “Amphetamine-Like” overdose reaction, and may include seizures or death. - Caffeine will mimic chocolate toxicity and is very dangerous.

Cats are routinely fed dry kibbles for convenience and assumed tooth cleaning benefits. Contrary to standard thinking, cats do not chew food like dogs and never get the

cleaning affect from commercial kibbles. Since cats drink so little fluid compared to dogs, canned food is far better for their long term kidney and bladder health. It just makes sense to feed a cat their natural diet, which is only small animal prey, and high quality canned food provides this. REMEMBER that cats often permanently imprint on the food types fed during their first 6-12 months of life and may refuse to change later. This is important medically for several body systems, including bladders and kidneys. Feeding a variety of foods will allow for diet flexibility for an unknown future that will cover up to 20 years for some cats.

Instead of specific recommendations by brand or company, we suggest the following dietary guidelines; 1) high protein (> 10 g/100 kcal or > 45%ME) and low carbohydrates (no set point here, but the lower the better)

2) high quality protein source (meat) not generic brown wrap types. 3) feed a variety of food types starting with kittens and continuing throughout life (canned and dry, and flavors) so they learn to accept multiple foods through their life 4) feed only meals - at least 2x/day more if possible (no free choice feeding - even for single cat households - this is usually a poor husbandry choice even if the cat is thin) 5) feed no more than 180-200 kcal/day to the average sized cat (less if they are gaining wt, more if they are too thin), but prevent obesity EARLY Two available brands of no-grain diets are Innova® and Evo®. Grains contain carbohydrates which promote dental plaque and diabetes in the cat, since they have no effective means of processing carbohydrates quickly and are really used as filler to cut manufacturing costs and help shape complicated kibble styles, like fish or stars. Feeding canned food with little or no grain is THE BEST WAY OF HELPING your cat’s urinary health. Kibbles are helpful as daytime snacks. These may be needed as an Rx diet for certain medical conditions later in life. If they are not recognized as food, they will not be accepted later. Therefore, feeding a variety of foods and snacks may help avoid refusal of medically prescribed diets or supplements in 10-15 years. Several excellent grain free canned lines are available locally, or online, and include Innova®, Blue Buffalo®, Wellness® (has probiotics and prebiotics included) and Evo® (includes a meat only kibble form also). Pets Naturally in Studio City and Petsdirect.com are good resources.

See the documents on Probiotics and prebiotics, Obesity, Vomiting and Diarrhea and Intestinal Parasites on this same webpage for more information.

Also, promoting water intake by using distilled water (neutral pH aka “sweet water”) or a high quality carbon filter will generally DOUBLE water intake. SoCal ground water is slightly alkaline and tastes bitter to cats that have sensitive taste buds. Organic debris and dust will also settle in bowls and lead to a foul moldy taste over 12 hours. This can be prevented when the bowl is scrubbed twice daily and distilled water purchased at the grocery store. A dedicated cat brush will cost a dollar but save hundreds in medical costs during later life.

Cat boxes: One more cat box than the number of cats. This lets everyone be a Lion King or Queen of their very own territory. Larger cat boxes over larger numbers can help in small apartments, when space is limited. Changing cat litter to reduce odor. Clay types are cheap but often need baking soda (Arm and Hammer) on the bottom to cover up urine odor and should be changed no less than once weekly. These must be scooped of stool and stirred daily. Clumping litter types are great if they are SCOOPED ONCE OR TWICE DAILY. No cat likes a dirty box. Alfalfa, corncob or herbal pellets are on accepted by some cats and others will urinate outside the box. Yesterdays News® paper pellets need to be dumped daily. Kidney failure and diabetic cats may need to be cleaned more often and changed twice weekly due to excessive urine making for wet litter faster. Pregnant owners should not change cat boxes without consulting their obstetrician (see Toxoplasmosis above).

Cat Entertainment: Keeping kittens indoors demands planned activities to replace the explorations of the outdoors. Cat nip, toys, stuffed mice, cat trees, hiding boxes, feather- on-a-stick, laser pointers and cat tunnels are great sources of time use. A cat that never goes outside will never know what there is to miss. Be aware that some kittens will get carried away and try to eat their toys. Plastic and string hold potential serious damage for the gut system. They can bite into the walls, cut the intestines or cause a full blockage requiring reconstructive gut surgery. Don’t leave these toys unattended with kittens if they can be chewed into pieces and swallowed. If this does happen, call us at the SOVG immediately for help.

Home Safety: Kitties are extremely curious about their environment. Since they lack thumbs, everything goes in the mouth. It is how they discover new information. From there, foreign objects often end up in the stomach where toxic chemicals cause poisoning and solid objects can plug up the intestines. Both of these conditions can result in death in the right circumstances. There is no limit to what may be eaten: rubber, plastic, bones, toys, coins, etc. Therefore, every new owner should get down on the floor (the same view point as the kitten) with a flashlight and look for lost items under beds, dressers, cabinets, etc. Then vacuum every where. If you don’t find them, eventually, the kitten will. If so, they may be eaten before you can witness it. Rubber bands, paperclips and erasers plug up intestines and require x-rays, optic scoping and/or surgery to correct. Dimes, nickels and silver coins have zinc coatings and will cause serious bleeding in the stomach. Thumbtacks, needles and bobby pins can poke holes in the intestines resulting in peritonitis and requires hospitalization. PICK THESE ITEMS UP if you see them on the floor. It only takes 10 seconds for them to get down a throat and out of reach OR into the trash, thanks to you. Think of it as putting $1500.00 in your pocket every time instead of just a toy car or paperclip.

Trash cans should be tall enough to prevent them being knocked over AND have a solid lid (step-type metal pails with a pedal) to prevent access to trash. Anything that touches

food smells like food and is tempting for kitties. Plastic bags, chicken bones, tin foil, etc do not pass though kitty intestines easily and may require surgery to get them out. Food poisoning is another risk when food scraps are eaten hours after being thrown away.

Electrical wires coated in plastic or rubber offers a great chewing source with kitties having teething pain. However, electrical shock can burn tongues, stop hearts and cause seizures or brain death. Coiling cords up and using self-locking hardware strips so that they can be hung up or taped out of reach is simple and cheap. Longer, heavy cords, like those for computers and refrigerators, can be covered with hollow plastic strip covers from the hardware store until the cat is around 12 months old and no longer interested. Masking tape can be used to hold the track down.

Toxic plants are often found in potted plants and yards. The petals, leaves, fruits, bark or roots may be toxic, and some are fatal in the right amounts. Consult the ASPCA website at the poison control center to see pictures of toxic plants plus their names, actions and care guidelines. Website is below:

http://www.aspca.org/pet-care/poison-control/

Microchipping: If your kitten did not come with microchip identification in place already, then consider getting one. It is inserted above the shoulder blades in a quick process that provides a permanent means of identification. This will be crucial in returning your kitty to you in case of theft, fires, break-ins or earthquakes. Some companies (Home AgainTM) also offer injury medical repair coverage, shipping fees back home and other benefits if your pet is lost and/or injured. It is important to register this chip number to you and your home so that you are contacted in the event that a kitty becomes lost. It is typically placed at the time of neutering or spay surgery at 6 months of age while under anesthesia.

See the document on this webpage for more information.

Health Insurance: Every owner should consider buying a health insurance policy before a kitty has been found to have a pre-existing condition. This allows for the full benefits of a policy to be used. Different companies offer various packages of coverage at different premium levels. Some have more preventive care and some less. Costs vary by breed, age and maximum coverage, just like for us. Catastrophic-only coverage is also available. This is not a third party program, as you will pay fees up front and your vet will help you get reimbursed. While many companies offer policies, some of the better companies for honoring claims are ASPCA and Best Pets. With veterinary costs rising during the life of your cat, this may help pay for routine and/or major medical care that would otherwise be a bigger out-of-pocket expense.

See the document on this webpage for more information.

Excessive Water Drinking and Urination

In general, most vets and owners are concerned that the majority of pets don’t drink enough water to support good health, urinary system flushing and prevent dehydration. It is recommended that pets be supplied with fresh water TWICE DAILY after scrubbing the bowl free of natural bacterial and fungal contamination. The water source should be from a highly filtered source or DISTILLED WATER to insure that it is free of municipal water contaminants like asbestos (most of the older cement pipes that supply city or county water are reinforced with asbestos), fuel contaminants (winter gas additives have infiltrated most of the LA County soil around buried fuel tanks), agricultural chemical run off and heavy metals NOT COVERED BY CLEAN WATER REGULATIONS ON THE DATE THAT THE WATER FILTRATION FACILITY WAS COMPLETED AND PERMITTED. Most tap filters are inexpensive and inefficient (Britta® only filters out lead and chlorine). Bottled water is, by law, just that; water in a bottle from any available legal source. Spring water comes from a natural hole in the ground, regardless of content. Distilled water is the liquid product from a heat distillation process and is the same quality, regardless of retail source, by law.

However, some pets will begin to demonstrate an increased thirst, and concurrent increased amount of urination, especially as they age. In medical terms this is referred to as polydipsia and polyuria, aka “PU/PD” for short. Sometimes this phenomenon can be presented as a lapse in discipline with indoor accidents, or as a heavier cat box weighted down by extra urine volume. These patients are a mixed group of conditions and only have an increased thirst in common. They are separated by species into the most common causes. This list is not inclusive for all patients, but does address the great majority of pets presented for diagnostics and care. Cats and dogs are addressed separately below.

CATS:

1. Diabetes mellitus- These patients are often overweight, older (greater than 8 years old), have rough haircoats due to neglected grooming, may have recent weight loss, are often lethargic or act prematurely aged and are both drinking and urinating at obviously high volumes. Appetites may have been increased, but dropped with less activity recently. This is often the presenting complaint, despite the whole process has been ongoing for months. The uncontrolled sugar in the blood spills into the urine through the kidneys and “sucks’ the water out of the cat. This leads to an excess of urine lost and a need to replace the lost water by drinking. Type 2 diabetes is the most common cause and requires a blood glucose and fructosamine test to confirm it. In cats, this most frequently results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was formerlyreferred to as non-insulin-dependent diabetes mellitus (NIDDM for short) and aka adult-onset diabetes. This is the typical form of diabetes in cats. A quick blood glucose in-house analysis will help identify these patients. Full diagnostics include a blood screen, urinalysis, urine culture (half of the affected cats will have a bacterial infection of the urinary system). A low to zero carbohydrate diet with high fiber, insulin therapy and possibly, oral glucophagic drugs will be started to control the long term toxic affects of too much sugar in the blood stream. An alternative diet program is a fairly high fat and high protein food to reduce hunger, slow digestion and promote weight loss.

A more thorough assessment of this disease is presented in the obesity and diabetes document on this same webpage.

2. Kidney Disease- Chronic kidney disease (CKD) is the number one reason that indoor cats succumb after middle age (9 years old and up). The two kidneys provide each cat with 400% more function than is needed to survive. The cells are lost during normal wear and tear as they process the excess and potentially toxic nitrogen from protein breakdown generated by food processing and normal cell death and regeneration. Acute kidney disease usually has another diagnosis, such as infection, poisoning, car trauma or viral disease. CKD cats generally are presented for PU/PD plus or minus weight loss, vomiting, poor appetite and generally are dehydrated. Creatinine levels are analyzed by blood tests taken to evaluate the kidneys ability to eliminate waste products. Tubulointerstitial diseases (versus glomerular disease in dogs) are a common cause of CKD in cats. These are the cells of the deeper portions of the kidney that select filtration or retention of metabolites and electrolytes occurs. A specific relationship between this type of CKD and urinary tract infections, stones, obstructions and toxic drugs has been reported in humans. Other risk factors that predispose cats to CKD include: Genetics; - Polycystic kidney disease (PKD) in Persians

- Amyloidosis in Abyssinians, Siamese and Orientals

Glomerular disease does occur in cats and their predisposing factors include; - Infections – chronic urinary infections,

viruses, incl. Felv, FIV and FIP - Inflammatory diseases - pancreatitis, cholangiohepatitis,

systemic lupus erythematosus, other immune-mediated

diseases, chronic progressive polyarthritis - Cancers – leukemia, lymphosarcoma - Other clinical factors: secondary of acute renal failure,

urinary stones, obstruction of lower urinary tract, diabetes,

hypercalcemia, heart failure - High blood pressure - Drugs: antibiotics, such as aminoglycosides, sulfonamides,

polymyxin B, amphotericin and various chemotherapeutic drugs.

Diagnosis:

All cats suspected to have kidney disease should be diagnosed using- - standard blood panel, this includes creatinine and phosphorous - urinalysis - urine culture (infections rise from 20% in cats 8-10 years to up to 80%

in cats 16-18 years old) - blood pressure (often elevated in renal disease cats) - Abdominal X-rays for urinary stones and calcification of kidneys - ultrasound for kidney defects and stones invisible on X-rays - biopsy –may be indicated if cancers are suspected

There are two different forms according to the International Renal Interest Society (IRIS) that span the range of progressive kidney dysfunction scale of 1-4, renal insufficiency and chronic kidney disease;

Grade 1 -the first is renal insufficiency and includes cats with a creatinine level of less than 1.6 mg/dl (nonazotemic). The do not exhibit PU/PD unless other causes are present. They have some kidney abnormality, such as poor ability to concentrate urine minerals and salts, irregular anatomy on x-rays or ultrasound or by palpation and blood pressure. These cats are considered nonazotemic and are generally active and eating well. Their water intake may still be of a normal volume. These cats qualify as being renal insufficient.

Grade 2- creatinine levels are between 1.6-2.8 mg/dl with cat now entering the range of azotemia. Many of these patients, especially at the lower end, will appear normal with some having moderate PU/PD signs and/or mild indications, such as weight loss. Blood pressure may be elevated.

Grade 3 – creatinine levels are between 2.9-5.0 mg/dl. Clinical signs are mild to obvious for weight loss, poor appetite, and/or increased vomiting incidences, kidney changes on ultrasound or by palpation, elevated blood pressure and dilute urine with excess protein losses from kidneys.

Grade 4 – creatinine levels are above 5.0 mg/dl. Clinical signs are obvious but vary in severity. Some cats will be very this, refuse to eat and vomit several times each day, while others are more stable and have entered a state of “chronic maladaption”. This is more likely the longer the degenerative process has taken. Cats that reach level 3 or 4 quickly via acute renal disease (ARD) via toxins (lilly or antifreeze ingestion, clots or traumatic injury, etc) are severely ill in a very short number of hours.

Treatment:

Cats in grade 1 and 2 can be treated with a fairly good outlook using a veterinary prescription, low phosphorous diet, preferably canned or pouch with gravy type. The goal is to get the damaged cells to regenerate wherever possible in the kidney and to return the kidneys to normal function. SOVG can provide 3 or 4 different samples at

no charge to see what type your cats will accept. These are totally nutritious for healthy cats that will be eating along with the patient. Increased water consumption is crucial for stability; use what ever method the cat prefers such as filtered fountains, bowls scrubbed TWICE DAILY, ice cubes in hot weather to cool bowls, heavy drinking glasses that can not be turned over. Distilled water will typically double water intake over tap water for nearly all cats. Do not worry about mineral deficiency; there is plenty in one mouthful of food to cover any difference in the types of water. A few will continue to prefer tap water. Supplements will also be provided as below- - Omega-3 oils from fish. This helps dilate the kidney artery to get the maximum use out of this pair of organs. - Epakitin® - this is a heat treated ground shrimp shell that traps phosphorous to prevent extra calcium losses that will lead to osteoporosis in renal disease The ideal goal of treatment for these patients is to stabilize them for up to 3 years before they begin to worsen. The real outcome is dependent on the underlying disease process. If it is age-related tubulointerstitial disease, this goal is realistic. If it is polycystic kidney disease, the duration of stability can be much shorter. Rechecks are scheduled every 3-6 months if the patient is stable.

Cats in grades 3-4 may be treated as outpatients with the program noted above, plus the addition of subcutaneous fluids (diuresis) to drive out the excessive creatinine. This is a critical component ion keeping cats stable and out of the hospital as long as possible. These patients already have a substantial amount of scar tissue (fibrosis) replacing normal cells, or the creatinine and phosphorus levels would be controlled by the kidney naturally. The frequency and amount of balanced electrolyte fluids to be given will be determined by size, other medical conditions and response to initial care. Some will be on fluids 2 or 3 times weekly, up to twice daily in advanced cases.

The goal is to increase the removal rate for the accumulated uremic toxins.

Note: A great trick is to warm up the bag of fluids in a warm water bath (sink) for 5-10 minutes before administering them to the cat. This will make them more comfortable. The rate of administration can also be helped by using an inflatable pressure cuff. We can order this for you at SOVG at our cost (around $24.00). A standard 10 pound cat dose can be finished in just over 1 minute.

Additionally, these cats may be supplemented with probiotics to control their uremia. Azodyl® is a symbiotic mix that contains a patented mixture of three beneficial bacteria; Enterococcus thermophilus, Lactobacillus acidophilus, and Bifidobacterium longum, combined with a prebiotic (psyllium husk).

Azodyl's bacteria are specifically screened and selected for their high affinity and capacity to metabolize uremic toxins. While this is not yet an evidence-based therapeutic embraced by all veterinarians, it has seemed to help our patient’s quality of life.

See the document on probiotics and prebiotics on this same webpage for more information.

High blood pressure non responsive to diuresis is treated separately with oral medication.

No treatment will cure these patients. Kidney transplants and dialysis are available, but the stress and cost of dialysis ($1000.00/day) makes this only realistic for acute renal patients with a chance for full cure in a few days. Transplant has fallen out of favor due to the high failure rate and lack of donor banks and very limited compatible candidates for kidney donation.

Stage 3-4 cats with severe clinical signs in, advanced dehydration and refuse to eat or vomit must be hospitalized to stabilize them. This process takes 3 to 6 days, on average. Progress is monitored every 48 hours to judge response to care. Some cats will continue to worsen, especially if they fall in to the category of “acute exacerbation of CKD”. These cats have had a prolonged kidney disease status that is suddenly worsened by a clot or multiple stokes, stones blocking the urine outflow (hydronephrosis), etc.

Those cats that do stabilize and become outpatients will have an initial recheck 1 to 3 weeks later, depending on the seriousness of the case. Rechecks are scheduled every 3 months once a program has been established by the initial recheck(s).

3. Hyperthyroidism –

This is the third disease of the most commonly diagnosed cats with increased thirst. These cats suffer from an overactive thyroid gland and have an accelerated physiology so that they typically eat endlessly and still lose weight. They drink more because they dehydrate at an abnormally fast rate. They do not urinate excessively because the extra water taken in is driven off as insensitive water loss. The 'classic' signs of hyperthyroidism are weight loss, usually despite an increased appetite (polyphagia), increased thirst (polydipsia), increased irritability, and restlessness or even hyperactivity. Many affected cats have a rapid heart rate (tachycardia) and develop an unkempt coat. Mild to moderate diarrhea and/or vomiting is also quite common. Some affected cats will be noticeably intolerant of heat and seek out cooler places to sit, and some (especially advanced cases) may pant when they are stressed. Most hyperthyroid cats will show some degree of polyphagia (excessive appetite) and restlessness, but in some advanced cases there will be generalized weakness, lethargy and loss of appetite and the signs will be less characteristic.

The thyroid gland in these cats most often undergoes a change to a benign tumor termed an adenoma. Only about 1-2% of the tumors are cancerous (adenocarcinoma), but these are much more serious and treated differently.

Diagnosis;

Affected patients can be diagnosed using simple blood tests to evaluate both the total and smaller amount of free (active) thyroid levels. A general blood panel is done to look for concurrent disease and to establish a kidney function baseline. This is very important as some older cats will also have chronic kidney disease (CKD) that is artificially supported by the abnormally high blood flow to the renal arteries during

hyperthyroidism. Once the thyroid levels are reduced, blood flow to the kidneys is also reduced and CKD signs may appear. Blood pressure is generally elevated (secondary hypertension) and creates an unacceptable risk for strokes and aneurysm rupture. Most cats will return to normal blood pressure once they are treated. Those that remain elevated are diagnosed as being primary hypertensive patients, unless another cause can be located. Initial treatment may also uncover hidden kidney disease and adjustments to treatment medication and/or kidney support may be indicated

Treatment:

There are three general methods of treatment, all with their strengths and weaknesses.

A. Medication. A drug named methimazole (Tapazole®) can be given orally as a tablet or liquid for resistant cats twice daily. A transdermal paste for application to the ear can also be compounded for cats that refuse oral medications. Patients are treated at a lower dose initially and then blood levels are rechecked 3-4 weeks later. Complete blood counts are also included, as some cats are intolerant and will suffer blood cell damage due to affects on the bone marrow. This will occur in the first 90 days, if the cat is sensitive to this effect (up to 3% of treated cats). Other potential side effects include lethargy, vomiting, and scratching of the face may occur in up to 10% of cats taking methimazole. These side effects usually occur within the first 3 months of therapy and can often be reduced by starting the cat on a lower dose, and gradually increasing the dose over several weeks. Tolerant cats are rechecked every 12 months to adjust their dose. Kidney failure cats are adjusted to levels slightly above normal to take advantage of the benefits of extra renal blood flow.

The advantage to this approach is that it requires no hospitalization and is monitored as an outpatient. The disadvantages are that the cat is not cured, medication is given twice daily and the cost of blood tests and medication never stops.

B. RadioiodineTherapy(I131).Thisisthepreferredmethodforcatsexpectedto be on medication for hyperthyroidism more than 3 years. This is a cost and effort-based decision as no efforts are required after the cat is stabilized and the initial recheck exam and testing performed. The cost has decreased over the past 20 years and averages about $800.00. This is an excellent option for middle aged cats, and even those up to 12 or 13 years old. Additionally, cats intolerant of methimazole are good candidates. Adenocarcinoma cats should also be screened.

Treatment initially consists of one month of oral methimazole to eliminate the accelerated physiology, blood pressure, etc and to determine if kidney disease has appeared. An initial imaging scan using a mildly radioactive substance to identify the tumor and any additional thyroid tissue is performed at a special imaging center offsite from the clinic. Most cats will have one gland affected. If both are involved, the dose can be tailored to leave functional tissue. This is crucial because the

radioactive iodine dose, which is selectively taken up by only the thyroid gland, needs to be critically calculated. If the tumor also exists in some of the extra islands of cells that are left during thyroid gland migration during development in the uterus, the dose will be too low. If the cat is overdosed, then thyroid supplements need to be started twice daily. Statistically, less than 1% of the cats become hypothyroid using this technique. Some radiologists will use a single maximum dose for all cats. This is not recommended.

For adenocarcinoma cats going to surgery, the thyroid scans are invaluable in finding all of the affected tissues. If both sides are involved and no accessory glands are available for thyroid production, these cats will necessarily need to be supplemented.

The process at the facility licensed by the Nuclear Regulatory Commission generally takes 5 days for the treated patient to urinate out the low level radioactivity for collection and disposal. A thyroid and general blood panel for bone marrow activity and kidney function is taken at SOVG in 30 days. If levels have returned to normal without complications, no more care is required.

C. Surgery.Thiswastheoriginaltreatmentpriortomethimazoleandradioiodine.It involves taking out the affected gland(s). It remains the option of choice for malignant adenocarcinomas.

4. Hyperadrenocorticocism (Cushing’s disease) - This is a condition where too much cortisol exists in the body. Cortisol is a normal hormone produced by the adrenal glands. It is produced rapidly in times of stress to prepare the body to conserve sodium and water, move fat out of the liver in to the blood as glucose and protects the body against stressful events. Cortisol triggers the metabolism of fat stores in the body as well. There are actually three forms of Cushing’s disease: Two are spontaneous; 1) pituitary-dependent, 2) adrenal-dependent and 3) is a pharmacological side-affect called iatrogenic Cushing’s from the patient being given prescription corticosteroids. Cats VERY RARELY get the first two forms, but are susceptible to the iatrogenic form after being treated with corticosteroids. This is a fairly common medication in cats for controlling allergies, inflammatory bowel disease (IBD), autoimmune diseases, flea dermatitis, unresponsive stomatitis and chronic pancreatitis. The side affects of cortisone use is rare, but recognized, in cats. Increased thirst and urination, accidents in the house, and urinary tract infections occur in almost all Cushing’s patients. A well behaved cat may begin to knock over trash cans and cry for food as they develop an insatiable appetite. Skin infections, recurring bladder infections and wounds may not heal quickly. Diabetic patients’ blood glucose will become impossible to regulate despite previously successful insulin therapy. In the case of oral medications, stopping them or tapering them off slowly can be curative. Be sure to call your pet’s doctor before changing any medication for safety purposes. Some cortisone programs are for life-threatening diseases that must be treated as is. Other drug programs will present a serious problem if suddenly stopped. If the medication has been injected, it must run its projected pharmacokinetic path first. Checking blood sugar levels is recommended.

Dogs:

1. Diabetes mellitus- These patients may or may not be overweight, any age, have rough haircoats due to neglected grooming, may have recent weight loss, are often lethargic or act prematurely aged and are both drinking and urinating at visibly high volumes. Appetites may have been increased, but dropped with less activity recently. This is often the presenting complaint, despite the whole process has been ongoing for months. The uncontrolled sugar in the blood spills into the urine through the kidneys and “sucks’ the water out of the dog. This leads to an excess of urine lost and a need to replace the lost water by drinking. Type 1 diabetes is the most common cause and requires a blood glucose and fructosamine test to confirm it. In dogs, this results from insulin deficiency, a condition in which cells fail to produce insulin properly. This form is aka as insulin- dependent diabetes mellitus - IDDM for short, aka juvenile diabetes. This is not obesity dependent, may be due to a genetic mutation in the insulin gene and leads to a lack of insulin production. A quick blood glucose in-house analysis will help initially identify these patients. Full diagnostics include a blood screen, urinalysis, urine culture (half of the affected dogs will have a bacterial infection of the urinary system). A low carbohydrate, high fiber with high quality protein diet with, insulin therapy will be started to control the long term toxic affects of too much sugar in the blood stream. A more thorough assessment of this disease is presented in the obesity and diabetes document on this same webpage.

2. Kidney disease- The two kidneys provide each dog with 400% more function than is needed to survive. The cells are lost during normal wear and tear as they process the excess and potentially toxic nitrogen from protein breakdown generated by food processing and normal cell death and regeneration. This is called chronic kidney disease (CKD). Acute kidney disease usually has another diagnosis, such as infection, poisoning, car trauma or viral disease. However, chronic infection can be associated with CKD and urine cultures are always recommended. Renal disease dogs are generally presented for PU/PD plus or minus weight loss, vomiting and/or poor appetite and generally are dehydrated. Some are discovered through the annual blood and urine screening tests recommended at SOVG for all patients over 6 years of age. Creatinine levels are analyzed by blood tests taken to evaluate the kidneys ability to eliminate waste products.

Glomerular diseases are a leading cause of renal disease in dogs. These cells are located in the outer regions of the kidney and are responsible for filtering blood in order to create urine. They can be primary, or secondarily disorders associated with other diseases such as infectious diseases, neoplasia, and inflammatory causes and other miscellaneous conditions. Any elevation of creatinine in blood analysis is

highly significant as the kidneys have been compromised to a level of 25% or less functional tissue. In general, dogs with elevated creatinine are considered to be more at risk than cats with the same grade, at least in the first 3 levels.

Diseases associated with glomerular disease in dogs: - Infectious causes- Canine adenovirus 1, bacterial endocarditis, brucellosis, borreliosis, dirofilariasis, erhlichiosis, leishmaniasis, hepatozoonosis, Rocky mountain spotted fever, bartonellosis, babesiosis, blastomycosis, coccidiomycosis, trypanosomiasis, chronic bacterial infections (periodontal diseases, pyoderma, pyometra, septicemia, prostatitis) - Cancers- Leukemia, lymphosarcoma, mastocytosis, primary erythrocytosis, systemic hisitiocytosis, others - Inflammatory diseases - Pancreatitis, prostatitis, systemic lupus erythematosus, other immune-mediated diseases - Other causes- hyperadrenocorticism (Addison’s disease), excessive corticosteroid administration, familial, diabetes mellitus, cyclic hematopoiesis (grey collies), trimethoprim-sulfa therapy, hyperlipidemia, sequelae of acute renal failure, urinary tract infections, urinary stones, obstruction of lower urinary tract, diabetes, hypercalcemia, heart failure, high blood pressure, high level of proteinuria, poor glycemic control in diabetes mellitus - Genetics – breeds predisposed to glomerular disease; Renal dysplasia: Lhasa Apso, Shih Tzu, Standard Poodle, Soft-Coated Wheaten Terrier, Chow-Chow, Alaskan Malamute, Miniature Schnauzer, Dutch Kooiker hound, Golden Retriever

Primary glomerulopathies: Samoyed (X linked), English Cocker Spaniel (autosomal recessive), Bull Terrier (autosomal dominant), Dalmatian (autosomal dominant), Doberman, Bull Mastiff, Newfoundland, Rottweiler, Pembroke Welsh Corgi, Beagle

Polycystic kidney diseases: Bull Terrier (autosomal dominant), Cairn terrier and West Highland White terrier (autosomal recessive) Amyloidosis: Shar-Pei, English foxhound, Beagle

Immune-mediated glomerulonephritis: Soft-Coated Wheaten Terrier, Bernese Mountain dog (autosomal recessive suspected), Brittany Spaniel (autosomal recessive) Miscellaneous: Basenji - Fanconi Syndrome; German shepherd - multifocal cystoadenocarcinoma (autosomal dominant); Pembroke Welsh Corgi- telangiectasia

Diagnosis:

All dogs suspected to have kidney disease should be diagnosed using- - Standard blood panel, this includes creatinine and phosphorous - Urinalysis - Urine culture (infections rise from 20% in cats 8-10 years to up to 80% in cats

16-18 years old) - Blood pressure (often elevated in renal disease cats)

- Abdominal X-rays for urinary stones and calcification of kidneys - Ultrasound for kidney defects and stones invisible on X-rays - Biopsy –may be indicated if cancers are suspected

The International Renal Interest Society (IRIS) grades the range of progressive kidney dysfunction scale of 1-4 for chronic kidney disease in dogs;

Grade 1 -the first is renal insufficiency and includes cats with a creatinine level of less than 1.4 mg/dl (nonazotemic). The do not exhibit PU/PD unless other causes are present. They have some kidney abnormality, such as poor ability to concentrate urine minerals and salts, irregular anatomy on x-rays or ultrasound or by palpation and blood pressure. These dogs are considered nonazotemic and are generally active and eating well. Their water intake may still be of a normal volume.

Grade 2- creatinine levels are between 1.4-2.0 mg/dl with dog now entering the lower range of azotemia. Many of these patients, especially at the lower end, will appear normal with some having moderate PU/PD signs and/or mild indications, such as weight loss. Blood pressure may or may not be elevated.

Grade 3 – creatinine levels are between 2.1-5.0 mg/dl. Clinical signs are mild to obvious for weight loss, poor appetite, and/or increased vomiting incidences, kidney changes on ultrasound or by palpation, elevated blood pressure and dilute urine with excess protein losses from kidneys.

Grade 4 – creatinine levels are above 5.0 mg/dl. Clinical signs are obvious but vary in severity. Some dogs will be very this, refuse to eat and vomit several times each day, while others are more stable and have entered a state of “chronic maladaption”. This is more likely the longer the degenerative process has taken. Dogs that reach level 3 or 4 quickly via acute renal disease (ARD) via toxins (raisin or antifreeze ingestion, clots or Leptospirosis infection, etc) are severely ill in a very short number of hours.

Treatment: Dogs in grade 1 can be treated with a fairly good short term prognosis using a veterinary prescription, low phosphorous diet. The goal is to get the damaged cells to regenerate wherever possible in the kidney and to return the kidneys to normal function. Lowering the work load on the kidneys is critical to success here. SOVG can provide 3 or 4 different samples at no charge to see what type your dog will accept. These are totally nutritious for other healthy dogs that will be eating along with the patient. Increased water consumption is crucial for stability; use what ever method the dog prefers such as filtered fountains, bowls scrubbed TWICE DAILY, ice cubes in hot weather and automated water fountains attached to a hose. A kiddies’ wading pool in hot weather will do much to reduce water requirements, help prevent heat stroke and provides an extra source of drinking water. Be certain the plastic is thick enough that nails can’t punch a hole in the bottom. Shaded areas for sleeping are also important if the dog will be outside all day.

Supplements will also be provided as below- - Omega-3 oils from fish. This helps dilate the kidney artery to get the maximum use out of this pair of organs. - Epakitin® - this is a heat treated ground shrimp shell that traps phosphorous to prevent extra calcium losses that will lead to osteoporosis in renal disease The ideal goal of treatment for these patients is to stabilize them before they begin to worsen. The real outcome is dependent on the underlying disease process. If it is age- related glomerular disease, this goal is realistic. If it is polycystic kidney disease, the duration of stability can be much shorter. Rechecks are scheduled every 3-6 months if the patient is stable.

Dogs in grades 2-4 may be treated as outpatients with the program noted above, plus the addition of subcutaneous fluids (diuresis) to drive out the excessive creatinine. This is a critical component ion keeping your dog stable and out of the hospital as long as possible. These patients already have a substantial amount of scar tissue (fibrosis) replacing normal cells, or the creatinine and phosphorus levels would be controlled by the kidney naturally. The frequency and amount of balanced electrolyte fluids to be given will be determined by size, other medical conditions and response to initial care. Some will be on fluids 2 or 3 times weekly, up to twice daily in advanced cases.

Note: A great trick is to warm up the bag of fluids in a warm water bath (sink) for 5-10 minutes before administering them to the dog. This will make them more comfortable. The rate of administration can also be helped by using an inflatable pressure cuff. We can order this for you at SOVG at our cost (around $24.00). A standard 30 pound dog dose can be finished in just over 3 minutes.

Additionally, these dogs may be supplemented with probiotics to control their uremia. Azodyl® is a symbiotic mix that contains a patented mixture of three beneficial bacteria; Enterococcus thermophilus, Lactobacillus acidophilus, and Bifidobacterium longum, combined with a prebiotic (psyllium husk).

Azodyl's bacteria are specifically screened and selected for their high affinity and capacity to metabolize uremic toxins. While this is not yet an evidence-based therapeutic embraced by all veterinarians, it has seemed to help our patient’s quality of life.

No treatment will cure these patients. Kidney transplants and dialysis are available, but the stress and cost of dialysis ($1000.00/day) makes this only realistic for acute renal patients with a chance for full cure in a few days. Transplant has fallen out of favor due to the high failure rate and lack of donor banks and very limited compatible candidates for kidney donation.

Stage 3-4 dogs with severe clinical signs, advanced dehydration and refuse to eat or vomit must be hospitalized to stabilize them. This process takes 3 to 6 days, on average. Progress is monitored every 48 hours to judge response to care. Some dogs will continue to worsen, especially if they fall in to the category of “acute exacerbation of chronic kidney disease – aka CKD”. These dogs have had a

prolonged kidney disease status that is suddenly worsened by a clot or multiple stokes, stones blocking the urine outflow (hydronephrosis), etc.

Those patients that do stabilize and become outpatients will have an initial recheck 1 to 3 weeks later, depending on the seriousness of the case. Rechecks are scheduled every 3 months once a program has been established by the initial recheck(s).

3. Hyperadrenocorticocism (Cushing’s disease) - This is a condition where too much cortisol exists in the body. Long term exposure to increased levels of cortisol leads to many deteriorative effects on all parts of the body, especially the liver. Cortisol is a normal hormone produced by the adrenal glands. It is produced rapidly in times of stress to prepare the body to conserve sodium and water, move fat out of the liver in to the blood as glucose and protects the body against stressful events. Cortisol triggers the metabolism of fat stores in the body as well. There are actually three forms of Cushing’s disease: Two are spontaneous; 1) pituitary-dependent, 2) adrenal-dependent and 3) is a pharmacological side-affect called iatrogenic Cushing’s from the patient being given prescription corticosteroids.

Signs of Cushing’s disease may be vague, mild, and/or multi-systemic at first, progressing into a classical appearance as the patient’s disease becomes more advanced. Symptoms may be inappropriately attributed to old-age or senility by owners. Increased thirst and urination, accidents in the house, and urinary tract infections occur in almost all Cushing’s patients. A well behaved indoor dog may begin to knock over trash cans and beg for food as they develop an insatiable appetite. Skin infections, recurring bladder infections and hair-loss (alopecia) become more frequent or severe, and wounds may not heal quickly. A bizarre condition called calcinosis cutis causes calcium to deposit in the skin leaving raised, rock-like formations anywhere on the body can be seen in more advanced cases. Also, muscle mass will atrophy (shrink) and fat will accumulate in the abdomen giving the dog a “pot-bellied” appearance. Diabetic patients’ blood glucose will become impossible to regulate despite previously successful insulin therapy.

Dog owners are directed to the document on adrenal diseases on this same webpage for a more detailed discussion of this important and not uncommon condition in pet dogs.

Ear Care and Disease

Otitis externa is one of the most frequent reasons for owners to seek veterinarians help. The prevalence of otitis externa in dogs has been reported to be between 10-20 percent, although in more tropical climates it is probably closer to 30-40 percent. Unfortunately, the term otitis does not refer to a specific disease but to an inflammation of the external ear canal. It is a symptom of many diseases and not a specific diagnosis. The actual underlying causes of otitis are numerous. The purpose of this lecture is to review the general principles of ear care and the most important causes of otitis externa. Physiology of the Ear Canal

The ear canal in the dog and cat can be divided into a vertical segment (which is continuous with the pinnae) and a horizontal segment that abuts the tympanic membrane. The canal is almost entirely surrounded by cartilage that offers stability to the structure. Besides the obvious auditory function of the external meatus, the canal also offers protection of the tympanic membrane and the middle ear from direct injury. Preventative Ear Care and Ear Cleaning Preventative ear care begins with a complete history and thorough physical examination. Historical information and physical findings are necessary to identify patients at risk. Specific information about previous and concurrent medical disorders is essential, because ear disease may co-exist with other disease or be secondary to systemic diseases.

Routine cleaning of the ear canal is not necessary and may be contraindicated in the healthy dog and cat. Most dogs do not require cleaning of the ears. Mild to moderate amount of wax is normal. Cerumen has antibacterial properties that help to reduce the over population of bacteria and yeast.

Cleaning, when necessary, should be complete and non-irritating. A mixture of vinegar/water (1/10) is a good degreasing solution to remove wax and dry the excessive moisture in the ear canal. The liquid should be gently applied in the canal, the ear massaged to allow breakage of the cerumen and cotton balls used to remove the cerumen and wipe out the excess of liquid. Extreme care should be used when mechanically cleaning the ears. The use of cotton applicators should be avoided or limited as they may cause rupture of the tympanic membrane. Also powders should not be applied in the canal as they build up predisposing to the development of secondary infections.

Accumulations of cellular debris and exudates indicate the presence of ear disease. Swabs of this material should be collected and the canal should be cleaned. The color, texture and odor of the exudates from a diseased ear can provide clues regarding the underlying primary cause of the otitis and the perpetuating factors that may be involved. Dark brown

Robert Clipsham, DVM, PhDor black, granular, dry (like coffee grounds) exudates characterizes infestations due to ear mites. A moist brown discharge tends to be associated with bacteria (cocci) and yeast infections. Purulent creamy to yellow exudates are most often seen with bacteria such as Pseudomonas. Waxy, greasy, yellow to tan debris is typical of a ceruminous otitis. Thorough cleaning of the ear canals is vitally important for successful management of otitis for several reasons. Examination of the external ear canal and the tympanum cannot be complete until the canal is cleaned. Wax, oil and cellular debris may be irritating, prevent medication from contacting the canal epithelium, and produce a favorable environment for microorganisms to proliferate and inactivate certain antibiotics. Several products are available on the market and they should be used as directed by a veterinarian as some of them may interfere with the efficacy of the topical medications. Also some of them may be irritating if not completely removed thus appropriate flushing by a veterinarian might be required. These products are usually classified as either ceruminolytic or drying agents.

1. Ceruminolytic agents (e.g. Cerumene) emulsify the waxes and lipids to help flush them more readily from the ear canal. They contain surfactants and detergents (e.g. diotyl sodium sulfosuccinate or DSS, squalene, carbamide). In general such products should be applied 5-15 minutes prior to cleaning. General massage improves their effect. Most of these products are contraindicated with ruptured tympanum. However, frequently the condition of the tympanum cannot be determined until after the canal has been cleaned. In those cases the probability of ototoxicity may be decreased by flushing with water after the application of such agents. In a recent study several cerumuminolytic agents were applied in the middle ear and squalene was the only one that did not cause any damage.1 However, it should be realized that there is no completely safe solution for cleaning the middle ear. Even water can cause ototoxicity.

Some disinfectant cleansers, such as chlorhexidine, are contraindicated with ruptured tympanums.

2. Drying agents (e.g. Epi-Otic) are applied after the ear has been cleaned and is relatively dry. Most contain alcohol and one or more of the following: boric acid, benzoic acid and acetic acid. Some products are a combination and they tend to have less drying agents and mildly ceruminolytic than the standard desiccants (e.g. Epiotic, Oticlens). When flushing an ear with a ruptured tympanum the use of saline of 1:1 or 1:3 dilutions of five percent acetic acid (white vinegar) are recommended. The fluid is discarded with every flush and suck cycle and the canal is filled again with clean saline. This is repeated multiple times using a fair amount of saline. The best results for deep ear cleaning or flushing are obtained with the patient under general anesthesia. Cleaning cannot be done on very swollen, stenotic, ulcerated or painful ears. Such cases need to be treated symptomatically initially and cleaned at a later date when the inflammation has been reduced and the canals have opened.

Causes of Otitis Externa

Otitis may have numerous causes and a common classification is to break them down into predisposing, primary and perpetuating. Predisposing factors are those that place a patient

at risk but by themselves are not able to cause otitis externa. Primary causes are usually the actual inciting agent that directly causes otitis externa. Perpetuating factors are those that prevent the resolution of otitis externa once the problem has been established. Predisposition Factors and Risk Assessment

The most successful management requires that these factors are recognized and, whenever possible, controlled. Early detection may prevent unnecessary pain/hearing loss and reduce the prevalence of chronic and refractory disorders. 1. Breed Predisposition and Anatomic Conformation Otitis occurs more frequently in breeds of dogs that have pendulous ears (e.g. Cocker Spaniel) and those with hair growth in the ear canal. Originally this difference was thought to be secondary to variations in the temperature and/or humidity of the ear’s microenvironment in dogs with different ear types, however no difference in temperature was found between ear types. It is becoming more and more evident that variations in the anatomy and the number of glands may predispose certain breeds to otitis externa. Dogs with longhair coats and pendulous ears should have the hair clipped frequently around the auricular orifice and the concave surface of the pinnae. Hair in the ear canal should be removed with a forceps and twisting (rather than plucking, which is more painful) the hairs out by twirling the forceps to improve ventilation in the canal. Great care should be used when removing these hairs as excessive trauma to the area may predispose to an infection. Stenosis of the ear canal (e.g. Shar-Pei) is another variation in the anatomy that can predispose dogs to otitis externa. In Shar-Peis the stenotic canal and the conformation of the pinna that is tightly folded over the external orifice increases the risk of otitis externa. Stenosis of the canal can also be acquired (e.g. abscess, neoplasm). 2. Climatic variations In a recent study monthly variation in ambient temperature, rainfall, and relative humidity correlate positively with increases in the number of first-time otitis externa cases seen. 3. Life Style Dogs used for activities that involve exposure to field are at increased risk of ear disease. Foreign bodies, especially plant material, often become trapped in the canal. These animals should be examined frequently. 4. Maceration of the Ear Canal Any increase in the moisture of the ear canal can lead to maceration. Moisture in the canal, whether introduced by swimming, bathing, or inappropriate treatment may cause otitis externa of inflammation of the external part of the ear canal. A combination of water retention, epidermal maceration, increased ceruminous gland activity and secondary infections may be responsible for disease. Dogs that swim may benefit from prophylactic treatment with a drying agent (e.g. acetic acid). 5. Excessive Ear Cleaning Mechanical trauma of the ear canal through vigorous hair plucking and the use of cotton swabs or other objects to remove wax, as well as the use of irritant topical solutions and excessive cleaning that alters the normal micro-flora, are all factors that predispose to the development of infections.

DISEASES OF THE EAR FLAP aka the “Pinna”

Infections of the Pinna

Bacterial or fungal infections of the pinna (earflap) commonly occur. Scrapes and scratches to the pinna can allow bacteria to invade the skin. Often damage is done when the dog scratches at the ear as ear canal problems are present. This allows natural, resident bacteria (often staphylococcus species) to invade and start an infection. These bacterial infections of the earflap present signs such as local areas of hair loss, small bumps where infection is present (called pustules) and crusts or scabs in areas where the infection is trying to heal itself. Sometimes similar patches of infection are present on other areas of the body. (aka pyoderma).

Fungi can also invade the earflap. Although not very common, superficial fungal dermatitis (ringworm infections) will cause local areas of hair loss, sometimes in a ring or circular pattern and occasionally as crusts on the pinna. As with bacterial infections, lesions on other parts of the body may also be present. Diagnosis of these infections is based on examination, woods light screening, and microscopic examination of plucked hair root samples and/or special cultures. Hair and skin sample preparations should reveal either internal (endothrix) or external (ectothrix) fungal bodies (spores or hyphae) affecting the shafts and root. Ectothrix fungi fluoresce while endothrix do not due to the UV light of the Wood’s lamp not reaching them. Some fungi are only in the skin and must be prepared with a 10-20% potassium hydroxide solution (KOH).

Young pups with poorly developed immunity can have severe, sterile inflammatory disease of the face and ears known as puppy strangles, properly called Juvenile Cellulitis. In these cases, the face, eyes and/or ears are very red, swollen and often discharge oozing pus. The pup may also have a fever and nodes in the neck will swell and sometimes rupture. The cause of this condition is unknown.

TREATMENT OF INFECTIONS OF THE PINNA

Bacterial and fungal infections of the pinna are treated using topical and/or oral antibiotics or antifungal medications, medicated creams and shampoos to disinfect and cleanse the ear. If ear canal disease is present, that too must be treated for any level of success to occur. With severe infections, clipping and scrubbing the area with antiseptic preparations often helps quicken the recovery. Puppies that have Juvenile Cellulitis are frequently treated with prednisolone, antibiotics and astringent topically.

PARASITE INFECTIONS OF THE PINNA

Demodicosis due to demodectic mange will generally show lesions of reddened, localized, circular areas of hair loss, itching (prorates) and crusting of the skin. Lesions on the face and legs are usually present. Sarcoptic Mange will produce a very pruritic (itchy) and (often) crusting dermatitis along the edges of the earflap as well as other areas of the body. This parasite causes such an intense itching that simply rubbing the edge of the pinna will cause the dog to try to scratch with the hind leg. Diagnosis of these parasites is based on physical exam and positive skin scrapings. Demodex mites are easy to diagnose and will be present in large to huge populations. Srcoptes mites are very hard to find and will require dozens of scrapings in some pets and/or surgical biopsy to diagnose them definitively.

Dogs left outside in areas where flies are present, particularly around horses, often suffer from Fly Bite Dermatitis aka “flystrike” when they attack the edge of the pinna. The bites ulcerate the skin, which bleeds, then black crusts will form in the area. The pet may scratch the ears or shake the head to relieve the local irritation. Myiasis is the result of blowfly larvae feeding on living tissue. Repellents may help prevent this problem. Fly control is accomplished by picking up dog wastes and fly traps are crucial for any degree of control. Ear hematomas often result and require expensive surgery when fly control is not practiced. Fly Bite Dermatitis is treated by cleaning the earflap and applying medicated ointments to prevent further damage.

TREATMENT OF PARASITES OF THE PINNA

Treatment for Sarcoptes or Demodex is the same as per these problems generally. Clipping hair from the ears and scrubbing scabs and crusts away with medicated shampoos is very helpful. Antibiotic treatment is also needed if secondary infections have occurred. Local creams are used for small skin spots while whole body baths and dips for several weeks are used for extensive infections. Fortunately, specific spot on medication formulas sold as flea control can be used for both types of mange at two week intervals for most cases. It is not uncommon to treat sarcoptic mange suspects rather than biopsy them to expedite recovery without anesthesia and surgery.

ALOPECIA OF THE PINNA (HAIR LOSS)

Loss of hair from the pinna without inflammation, crusting, or other symptoms is known as Idiopathic Pinnal Alopecia. This most often occurs in male Dachshunds and is considered to be a hereditary disorder similar to human male pattern baldness. Sometimes an endocrine (hormonal) disease may be involved. Miniature Poodles may suffer from a related form of this problem but the hair will usually regrow several months later while the Dachshund may never regrow the hair. Treatment is usually not needed or effectual.

EAR MARGIN SEBORRHEA

Seborrhea is a disorder of keratinization that most often occurs in breeds with pendulous ears such as the Dachshund or the Cocker Spaniel. Seborrhea will usually also affect other parts of the body, as well. However, when the ears are involved, signs including scales, crusts and loss of hair will occur along the margins of the ear, especially near the tip. Itching is uncommon, but the problem may become quite unsightly. Diagnosis is based on clinical signs, skin scrapings and skin biopsy and lack of other causes.

TREATMENT OF EAR MARGIN SEBORRHEA

Rarely is there a cure for Seborrheic diseases, so treatment often centers on controlling the symptoms which includes the buildup of scales, crusts, plugs and excess oil on the ears and other body areas. Medicated shampoos such as Allerseb®, T-lux® or benzoyl- peroxide (Pyoben®) based products among others are very good at cleansing the skin. Antibiotics and cortisone are used in cases where infection and inflammation has become apparent. Retin-A, vitamin A, zinc, essential fatty acid (EFAs) supplements extracted from fish oils and several other drugs may have applications in various forms and secondary problems of the disease that occur.

AURAL HEMATOMA

An aural hematoma is a blood and fluid filled swelling of the pinna. It most often occurs secondary to traumatic head shaking and scratching of the ear from any problem which causes the ear to itch. Some studies indicate that immune-mediated disease may be present causing a spontaneous bleeding between ear layers. The swelling may be localized or encompass the entire area of the flap; diagnosis should include a search for the initiating cause.

SEE THE DOCUMENT OF THIS SUBJECT ON OUR WEBSITE.

TREATMENT FOR AURAL HEMATOMA

First, an attempt to determine and treat the initiating cause of a hematoma is very important. If a hematoma was secondary to a foxtail in the ear for instance, and that was left untreated, the problem would not be solved. Rarely will a hematoma resolve by itself and if so, the ear is often left grossly deformed. Drainage with a syringe or test tube may produce results if repeated frequently or left in place for long periods of time, but most often, the ear will refill with blood after such treatment. The best recognized therapy is to surgically open the skin of the ear on the inside surface, remove a small flap of tissue, place numerous regular sutures along the line of the incision in some fashion for 3-4 weeks to help encourage smooth healing. The goal is that the layers of skin and cartilage will "weld" together to form a permanent bonding of the pinna tissues. Surgery is usually successful and permanent.

ENVIRONMENTAL DISEASE OF THE PINNA

Sunburn of the earflap is uncommon but can occur in areas of high sun exposure on dogs with white or light colored ears. The earflap will show signs of localized hair loss and redness, followed by crusting and possibly ulceration. Frostbite can occur when the dog is exposed to subzero temperatures for prolonged periods of time. Damaged areas may be whitish or blue and will later slough. This predisposes the patient to skin cancers later. Pale pigmented cats and dogs (esp. boxers and pit bulls) should NOT BE ALLOWED to sun outside for more than a few minutes! Diagnosis is based on the history of exposure and physical examination.

SYSTEMIC ILLNESS AND THE PINNA

Immune-mediated diseases (autoimmune induced), endocrine diseases and allergies can all affect the pinna. Signs may range from redness and itching of the flap, to hair loss, ulceration, severe infection and crusting of the area. Most often other signs of illness are present and treatment of the primary problem will return the pinna to normal. Diagnosis is based on history, physical examination, blood counts, serum chemistry and hormonal analysis as indicated.

DISEASES OF THE EAR CANAL

INFECTIONS OF THE EAR CANAL (OTITIS EXTERNA)

It is important to understand that most infections of the ear canal have some initiating cause; rarely do these infections simply erupt on their own. Bacteria, yeast's and fungi reside in and around the ear canal and under normal circumstances do little more. Parasites, moisture, diseases of the pinna and allergies can all initiate ear canal disease.

The usual signs of ear canal disease are head shaking, scratching the ear, rubbing the face and/or ear, soreness when touched, a sharp fetid odor and possibly some type of exudate or discharge coming from the ear canal. Many people quickly and erroneously conclude that most dogs with these symptoms have ear mites, which is not the usual case. The type, color or consistency of the discharge does not always reveal the cause of the problem. Again, as ear canal problems are often secondary to other disease processes, the dog may be showing signs of skin disease or other problems that must to be taken into account.

Your veterinarian will make a diagnosis by examining the ear, including a deep otoscopic exam and perform cytology or possibly a culture to determine the cause of the problem and the best course of therapy. Often cleaning the ear under sedation may be needed to

reveal the initial cause if deeper ear problems are present. In cases where the ear disease has kept returning after treatment, or fails to respond to therapy, middle or inner ear problems may be present.

Signs of Middle Ear and/or Inner Ear Disease include head shaking, rubbing the face and ear, scratching, discharge and pain. Poor appetite, fever, dry eye, drooling, a head tilt, facial nerve paralysis, trouble walking or balancing and circling to one side or direction may additionally occur. Diagnosis is made by otoscopic exam, which may reveal a ruptured eardrum in many cases. Cultures and X-rays are also important to establish a diagnosis and prepare a treatment plan.

Dogs that have heavy, pendulous ears, such as the Cocker Spaniel, seem to be more prone to ear problems, although the German Shepherd is a notable exception, being a dog with upright ears but also an increased risk for infections. Dogs that swim or live and play in a moist environment are also at increased risk. Dogs that have keratinization disorders or produce excess wax in the ears for any reason will have more trouble with ear canal disease. Breeds such as the Poodle or Schnauzer, which tend to have heavy hair growth in the ears, are also prone to frequent ear infections.

Another problem commonly seen in dogs which have had repeated and/or uncontrolled ear infections is that of sclerosis of the ear canal; a thickening and narrowing of the canal itself. Given enough time, an infection can cause scar tissue to build up. This may become a permanent change and require surgery to reopen the ear so that air may dry the canal and medication to be administered regularly. Dogs like the Shar Pei are often born with a small, twisted ear canal, predisposing even the youngest of puppies to infections.

TREATMENT OF DISEASE OF THE EAR CANAL

While the causes and exacerbating causes of ear canal disease may vary, basic principles of treatment are consistent:

1. Cleanse the ear of any debris and exudates. Wash solutions may be used daily at home in minor cases, while more advanced cases require sedation and flushing of the ear with medicated solutions. Ceruminous otitis is also treated this way as to cleanse the ear of the waxy buildups.

2. Physically remove any foreign objects; again, sedation will most likely be needed. Excess hair should also be removed from the ear.

3. Bacterial infections will be treated with antibiotic drops (or ointments) and oral medication; Yeast infections with antifungal drops and oral medications. Mites will be treated with topical drops and possibly injections of ivermectin. It is also advisable to treat dogs that have ear mites with a flea powder around the ear, neck and rump areas.

PREVENTION AND CONTROL OF EAR CANAL DISEASE

Not only is treatment for ear canal disease important, but as many dogs are prone to recurrent attacks of ear infections, preventative measures are very important. Dog owners can take a few simple steps to control this problem. Three basic principles can be employed:

1. Keep excess hair pulled and clipped from the ear canal to aid air circulation.

2. If your dog gets wet, swims or after a bath apply a few drops of rubbing alcohol to the ears to speed drying and follow a few hours later with a preventative wash.

3. Use a preventative wash solution weekly (or more often) and as advised above to clean debris from the ear and disinfect the internal environment. Avoid the concoctions sold in pet supply stores as these often contain ingredients that can promote or exacerbate ear canal disease.

TREATMENT FOR MIDDLE, INNER AND CHRONIC EAR PROBLEMS

As many chronic infections result in damage and narrowing of the ear canal, treatment and preventative care can become difficult if not impossible. For this reason a Zepp procedure is often performed, which in short, is removal of part of the vertical portion of the ear canal to open the ear for ventilation. It is not always a perfect cure, especially if grossly scared tissue is present. Some ear canals may become so badly damaged and infected as to necessitate complete removal (Alblation) of the ear canal. While such a procedure may sound radical, the alternative to it is often chronic suffering.

Middle and inner ear infections are treated with antibiotic medications, like other ear canal infections and by establishing drainage for exudates produced during the infection. This may necessitate the performance of a Bulla Osteotomy that involves opening part of a bone in the skull where fluids from these types of infections can collect and flushing out the material therein. A drainage tube may be installed. Sometimes, simply rupturing the eardrum and flushing and aspirating the material from this area may be effective. Cultures are very important to determine the type of infection and help insure the best possible chance for cure.

EAR MITES (Otodectes species)

Ear mites are probably the most over diagnosed problem of the ear. Mites cause signs including a buildup of black crusty debris in the ear and intense itching; every time a dog owner notes these symptoms the diagnosis seems automatic. Most commonly, ear canal infections that produce similar exudates are present.

Ear mites are caused by the mite Otodectes cynotis that is common to both the dog and cat, but does not attack humans. The mites burrow and feed within the ear canal, which in itself can cause intense itching, but as time goes on and the mites multiply, infection of

the ear canal and allergic reactions to the mites can occur, compounding the problem all the more so. ((Ear Mite))

The mites can easily move between animals with even minimal contact but cannot live for long without a host. They also lay eggs in the ear canal, which hatch and molt into adult mites about every 19 days. Diagnosis is based on clinical signs and visualization of the mites under the microscope; a procedure called ear cytology.

TREATMENT OF EAR MITES

Mites are easily killed with good quality mite drops, but these will need to be used for about 21 consecutive days. Ivermectin injections have been used with good success with and without the drops. If the ears are full of secondary debris, cleaning or flushing of the ear canals should be performed first. The use of flea powders on the neck and rump of the dog will also hasten the death of these mites.

FOREIGN OBJECTS OF THE EAR CANAL

Foreign body otitis is quite common. Ticks and grass awns, called "foxtails" can easily and quickly make their way deep into the canal. At first, they may simply cause head shaking and itching of the ear, but as these invaders rupture the ear drum and damage the lining to the ear canal, infections generally occur and exudates may hide the object as they accumulate. Pain may also occur, often in proportion to the damage being done by the foreign object. Damage to the pinna and surrounding skin may occur as the dog tries to scratch the ear.

Tumors and polyps that often occur in the ear canal are mentioned here as they most commonly manifest as a foreign object will. Masses in the ear can plug the canal and set up an infection therein. Surgery to open the ear canal and remove the mass may be the only option to stop the infections that then occur.

TREATMENT OF EAR CANAL FOREIGN OBJECTS

Most times, with the help of sedation, the veterinarian will be able to capture and remove foreign objects and then medication will be useful to heal the ear. Plugs and other masses may require some degree of surgery to remove them.

CERUMINOUS OTITIS

Ceruminous Otitis is an increased production and accumulation of waxy debris in the ear canal and can become quite irritating for the dog. Owners often mistake it as a primary ear infection. Yellow oily or waxy material is often seen coming from the ear canal.

Bacteria and yeast in some cases may cause a secondary infection. Many of these dogs have generalized Seborrhea, a disorder of keratinization that most often occurs in breeds with pendulous ears such as the Dachshund or Cocker Spaniel.

Seborrhea will usually affect other parts of the body, but when the ears are involved symptoms include scales, crusts and loss of hair will occur along the margins of the ear, especially near the tip, often with the buildup of the waxy secretions in the ear canal. Itching is common as increased accumulation or secondary infection begins and the problem may become quite unsightly. Diagnosis is based on clinical signs, skin scrapings and skin biopsy. ((Ceruminous Otitis))

TREATMENT OF CERUMINOUS OTITIS

While there is currently no cure for this condition, your veterinarian will have several products available that when used on a regular basis will help dissolve and keep the ear clean of these exudates.

IMMUNE MEDIATED DISEASES

Allergies to airborne irritants, foods or contact with certain objects can lead to inflammation of the ear, as well as other areas of the skin. The earliest clinical signs include redness and itching to the ear canal and the pinna. Sometimes the ear may appear normal, yet be very itchy. Fleas, mites and drugs can also cause these allergic reactions and need to be considered by your veterinarian. Autoimmune disease can also cause eruptions of the earflap and canal and should not be overlooked. Diagnosis is based on history, physical examination, blood tests, skin scraping and skin biopsy in some cases.

DEAFNESS

By definition, deafness is a partial or complete inability to hear. Deafness may occur in one or both ears. Some animals may be born deaf, most times due to genetic defects. These defects are often hereditary so affected dogs and their parents should not be bred.

Other causes of deafness include middle and inner ear disease, foreign objects of the ear canal, ear infections, excessive wax buildup, neoplasia of the ear, trauma to the head or ear(s), poisons and toxins and hypothyroidism. Many older dogs, like many older people, suffer from simple degeneration of the organs of the inner ear which perceive sound. This too produces an often gradual but noticeable loss of hearing in the geriatric dog.

TREATMENT OF DEAFNESS

Dogs with congenital or genetic deafness most often cannot be treated. Dogs with deafness secondary to some other ear disease will often regain most if not all of their hearing once the primary condition is resolved. Age-related hearing loss is usually permanent although adapting human hearing aids to them has helped some patients. In general, most dogs can survive and live happy normal lives with partial or complete hearing loss as long as they are kept away from busy roads and other dangers.

Primary Causes of Otitis Externa

When discussing the primary causes of otitis externa, it is important to remember that the epithelium of the external ear canal is simply an extension of the rest of the skin. Most causes of otitis externa are associated with generalized dermatologic conditions. A complete dermatologic history and work up may therefore be necessary in the diagnosis of many primary otitis externa cases. The most common causes seen in dermatology are atopy (inhalant allergies), food allergy, diseases of keratinization (e.g. primary seborrhea of Cocker Spaniels), and ear mites. It is critical to long-term management of otitis externa that a primary cause can be found.

1. Parasites

The ear mite (e.g. Otodectes) is the most common mite, being responsible for up to 50 percent of the cases of otitis externa in cats; in dogs the incidence is controversial but most authors agree that it is responsible for 5-10 percent of cases. They are most commonly found in the external ear canal, but can survive for some time on the surface of the skin, typically of the head and neck. In the ear the mites are protected by desiccation by a typical dark brown crust. In recurrent cases, it is possible that other in contact animals can act as asymptomatic carriers.

Other mites that can be responsible for otitis include Sarcoptes (mite that causes scabies), Demodex (mite that causes the so-called red mange), Eutrombicula (chiggers) and Otobius (the spinous ear tick of dogs). 2. Micro-organisms

Dermatophytes (which cause “ringwormâ€␣ ) are a relatively common cause of disease of the pinna and in rare occasions may cause otitis externa. Bacteria are most commonly perpetuating factors. 3. Allergies

Allergies are the most common underlying cause for otitis externa in dogs. They include inhalant allergy (also called atopy), food allergy and contact allergy. Inhalant allergy is extremely common in dogs and cats and is the most common underlying cause for recurrent otitis externa in dogs. At least 50 percent of atopic dogs have bilateral otitis externa. In up to five percent of cases, otitis may be the only

complaint. Atopic dogs tend to have itchy feet (e.g. they lick and chew their feet), itchy face (e.g. they rub their face against the carpet or pieces of furniture) and itchy ears. They are predisposed to secondary skin and ear infections that tend to recur after treatment unless the underlying allergy is well controlled. A familial history is present in most cases and strong breed predilection has been reported (e.g.Dalmatians, Terriers, Golden Retrievers). Clinical signs are initially seasonal. Progressive worsening with time is also typical. Diagnosis is based on history, clinical signs, exclusion of other diseases and intradermal skin test.

Food allergy is not as common as the inhalant allergy, but over 20 percent of these cases start with just otitis externa, and ear disease is present in 80 percent of the cases. Food allergy should be considered as a top differential for otitis externa in any young dog (less than one year of age). Food allergy is diagnosed by appropriate food trial (a novel source of protein is selected based on the individual history and used for a minimum of two months).

Contact allergy can result from medications used to treat otitis externa. Whenever a case of otitis externa fails to improve with therapy or worsens after therapy, a contact dermatitis should be suspected. 4. Foreign bodies

Plant material (fox tails), dirt, sand, impacted wax, loose hair and dried medications are frequently responsible for otitis externa. In most cases this is a unilateral otitis. 5. Diseases of keratinization (e.g. primary seborrhea of Cocker Spaniels) Excessive and abnormal composition of cerumen in these cases is responsible for the development of otitis externa and secondary infections of skin and ears. It is usually seen in young animals.

6. Endocrine disorders

Hypothyroidism (decreased production of thyroid hormone) and Cushing’s disease (disease associated with excessive production of steroid hormones) are the most common endocrine diseases that can cause otitis externa. If a middle-aged dog keeps relapsing with otitis externa and is not itchy, then endocrine diseases should be considered as possible underlying causes. 7. Autoimmune disorders Pemphigus (disease in which the organism produces antibodies against component of its own skin) affects the pinna and may extend to the ear canal causing otitis. Lupus (other autoimmune disease in which the organism produces antibodies against various components of the body) can also cause ear disease.

Perpetuating Factors

They include anything that prevents the resolution of an already present otitis externa. Perpetuating factors are a major reason for poor response to therapy regardless of the predisposing factors and the primary cause. In early cases treating the primary cause might be sufficient to resolve the otitis, while in more chronic cases perpetuating factors have to be addressed to resolve the case.

1. Bacteria

In most normal ear canals a variety of bacteria can be cultured. Once predisposing and primary factors cause alterations in the ear canal environment, these bacteria may proliferate and perpetuate an inflammatory reaction. In most cases of chronic otitis

externa bacteria such as Staphylococcus and Pseudomonas are present. Aggressive treatment is warranted as resistance to antibiotic may easily occur, especially in cases when Pseudomonas is cultured. Although bacteria are not a primary cause of otitis, once the infection is established, they can cause significant inflammation and damage. These dogs often present with purulent discharge in the ears. Pain on palpation of the ears is quite common and a strong odor is usually present.

Diagnosis is based on cytology and culture. Initial topical therapy for a case of otitis externa is based on the results obtained from the cytology of the exudates, while in chronic cases is best based on results of culture and sensitivity. Pseudomonas-related infections are extremely frustrating and difficult to treat. Most effective treatments include topical Polimixin B and systemic enrofloxacin or ciprofloxacin. Doses that are used are higher than the ones suggested on the label as resistance occurs rapidly. A commonly used dose for these drugs is eleven mg/kg twice daily. Dogs with OM frequently require two months of systemic antibiotic. As Polimixin B is rapidly inactivated by the exudates, aggressive cleaning is an essential part of therapy. Other topical treatments used for Pseudomonas include acetic acid (vinegar/water 1:1) and silver sulfadiazine (one gram of silver sulfadiazine is mixed with 100 ml of sterile water and 0.5 ml of the mixture is applied twice daily). Also pre-soaking the ear with edetate trisodium (tris-EDTA) 15 minutes prior to application of the antibiotic increases the efficacy. Finally, topical enrofloxcin (Baytril otic) can be used in Pseudomonas infections. In cases where Staphylococcus is the cause of otitis, other antibiotics are usually used including cephalexin (22 mg/kg twice daily) and trimethoprim-sulfa (25 mg/mk twice daily).

2. Yeast

Malassezia is the most common perpetuating yeast that contributes to otitis externa. It is a budding organism with the shape of a peanut and is part of the normal flora (both skin and ears) of dogs and cats. It is a common complication with allergic otitis (80 percent of cases) and may result as a super-infection following antibiotic therapy. Grossly the discharge is thick, dark, and sweet smelling. Diagnosis is usually based on the physical findings and microscopic examination of the exudates (cytology). Topical therapy is usually sufficient and miconazole and clortrimazole (e.g. Conofite, Lotrimin) are the most commonly used ingredients. In rare cases of otitis media due to Malassezia, systemic treatment is necessary and ketoconazole (Nizoral tablets) is used at five mg/kg twice daily for three to four weeks. Side effects include anorexia, vomiting and diarrhea. 3. Progressive pathological changes

Chronic inflammation stimulates the proliferation of the skin lining the ear canal. As a consequence, thickening of the canal occurs leading to stenosis of the canal. More importantly the skin is thrown into numerous folds, which inhibits effective cleaning and the application of medications. These folds act as a site for the perpetuation and protection of secondary microorganisms (e.g. bacteria). Laser surgery has been used successfully to correct excessive stenosis and thickening of the canal.

4. Otitis media

Otitis media (inflammation of the middle ear) results from chronic inflammation of the external part of the ear canal, rupture of the tympanic membrane, and establishment of infection in the middle part of the ear. Exudate in the tympanic cavity is difficult to treat with topical therapy and often remains as a source for infection. Otitis media is usually

bacterial in origin. Clinical signs suggestive of otitis externa include head shyness and pain on palpation of the ears. Some cases of otitis media might present with head tilt, circling and dry eyes, but the vast majority does not have neurological abnormalities. As the tympanic membrane quickly grows back after rupture, otitis media may also be present even if an intact membrane is seen on otoscopic examination. Radiography cannot be used to completely rule out the presence of otitis media since 25 percent of confirmed cases had no radiographic evidence of the disease. In a study otitis media was present in 80 percent of cases of chronic, relapsing otitis externa therefore it must be considered as a possible cause of any refractory or relapsing otitis externa. Treatment of otitis media is based on bacterial culture/sensitivity results. Most cases require long-term antibiotic therapy (minimum of two months) and aggressive topical therapy. Conclusions

Otitis externa is a very common clinical presentation in small animals. A good history is very important in every case of otitis externa to identify predisposing and primary factors. Aggressive treatment is needed in most cases of relapsing otitis externa as an infection of the middle ear might be present.

1 Mansfield PD, et al. The effects of four commercial ceruminolytic agents on the middle ear. JAAHA 97; 33: 479-86.

1Griffin CE, Kwochka KW, MacDonald JM. Current Veterinary Dermatology: the art and science of therapy.Mosby Year Book, St. Louis, 1993

Considerations in Choosing A New

Cat For Your Home

Caring for a cat brings many years of unconditional companionship, joy and enrichment to our lives. Choosing the right cat for your home is essential to avoid behavioral problems that can make for a rocky relationship with your pet. Whether to adopt a kitten or an adult cat, take in a stray, select a male or a female, or have more than one cat are just a couple of the important questions that need to be asked by each owner before making a decision that will last 15 to 20 years with good luck and calculated care.

Many behavioral problems (not health related) with adult cats stem from improper socialization at a very young age. This should be realized when taking in an abandoned kitten that may not be fully weaned. If possible, a kitten this young should be introduced to adult cats as soon as possible in order to receive socialization skills and discipline that a human can not communicate. Bottle raised kittens have reputations for being aggressive or “scardy cats” toward people and other pets.

All healthy kittens are playful and silly. Their antics are necessary practice for learning hunting skills. Being crepuscular (multiple daily naps) animals, kittens may practice a lot of these future skills at night while you are trying to sleep. This especially true for the first 8-10 months of like when the “Midnight Express” may run through the house 7 nights a week. A cat’s true personality is not well revealed to an owner until full adulthood. While having a kitten can be a lot of fun, some owners may choose to adopt an adult cat with an easy going, calm demeanor and forego the rambunctious kitten stage. Whether to choose a male or female cat is a purely personal preference. Some people’s personalities better mesh with one or the other. Spend time with numerous cats of both sexes to see if you prefer one over another. Males may tend to be a little more social with people and other pets, but this stereotype does not always hold true in old age.

Cats adopted from shelters are usually mixed breeds. If you want to purchase a specific cat breed, be sure to do some research about any health problems and behaviors to which the cat breed may be predisposed. You will also want to get references for a breeder or a breed specific rescue group to be sure they are reputable. Consider the hundreds of thousands of homeless kitties in shelters each year before purchasing a cat just because you like the markings or body shape. HOWEVER, get these cats checked out asap for diseases that come with crowded populations undergoing high stress levels. Feline herpes virus, mycoplasma, Chlamydia, Bordatella bacteria and even H1N1/H1N3 viruses can be found in shelters and rescue center cats. These are picked up on the street and passed around quickly in crowded catteries. A viral screening panel can be performed in cases of chronic sneezing with very little effort by your vet at the SOVG.Two cats can give each other company, but sometimes three or more unrelated cats can lead to conflicts when not raised together as kittens. Cats have strict hierarchies and territories. Introducing a new cat into a multiple cat household can upset the established territorial boundaries. A trial adoption may want to be considered, if possible, to test the cats’ interactions.

Of course, it is most important to be sure that a new cat is healthy. It should have a thorough veterinary examination before taking it home and exposing other pets. The cat’s eyes will be bright and clear, and its coat will be shiny and well groomed. There should be no discharge from the nose, eyes, or ears. Stools should be formed. The doctor will check the cat for intestinal parasites, viral diseases like leukemia, and external parasites like ear mites and ringworm. All vaccinations should be brought up to date. If the medical history is unknown, then vaccinations will be recommended as a safety margin. Shelter cats are generally vaccinated only once and a booster 2-4 weeks later is critical for full immune protection.

Diet:

Some foods should never be fed:

- Onions/garlic can cause an anemia. - Chocolate can result in an “Amphetamine-Like” overdose reaction, and may seizures or death. - More information is available at the National Animal Poison Control Center

@ http://www.aspca.org/

include

Cats are routinely fed dry kibbles for convenience and assumed tooth cleaning benefits. Contrary to standard thinking, cats do not chew food like dogs and never get the cleaning affect from commercial kibbles. Since cats drink so little fluid compared to dogs, canned food is far better for their long term kidney and bladder health. It just makes sense to feed a cat their natural diet, which is only small animal prey, and high quality canned food provides this. Raw diets are generally not recommended due to high levels (70%) of samples being found positive for pathogenic bacteria (E. coli, Campylobacter, Salmonella, etc). Mass food production has increased the amount of handling and people involved in raw food production. This is a direct risk to young pets. Kittens have very limited resistance to infections due to incomplete immune system development.

REMEMBER that cats often permanently imprint on the food types fed during their first 6-12 months of life and may refuse to change later. This is important medically for several body systems, including bladders and kidneys. Feeding a variety of foods will allow for diet flexibility for an unknown future that will cover up to 20 years for some cats.

Instead of specific recommendations by brand or company, we suggest the following guidelines: 1) high protein (> 10 g/100 kcal or > 45%ME) and low carb (no set point here, but the lower the better)

2) high quality protein source (meat) not generic brown wrap types. 3) feed a variety of food types starting with kittens and continuing throughout life

(canned and dry, and flavors) so they learn to accept multiple foods through their life 4) feed only meals - at least 2x/day more if possible (no free choice feeding - even for single cat households - this is a poor husbandry choice even if the cat is thin) 5) feed no more than 180-200 kcal/day to the average sized cat (less if they are gaining wt, more if they are too thin), but prevent obesity EARLY

Several available brands of no-grain diets are Innova®. Blue Buffalo®, Wellness® and Evo®. Grains contain carbohydrates which promote dental plaque and diabetes in the cat, since they have no effective means of processing carbohydrates quickly and are really used as filler to cut manufacturing costs and help shape complicated kibble styles, like fish or stars. Feeding canned food with little or no grain is THE BEST WAY OF HELPING your cat’s urinary, pancreatic, heart and musculoskeletal health. Kibbles are helpful as daytime snacks. These may be needed as an Rx diet for certain medical conditions later in life. If they are not recognized as food, they will not be accepted later. Two resources helpful to owners are Pets Naturally in Studio City and Petsdirect.com

Also, promoting water intake by using distilled water (neutral pH aka “sweet water”) or a high quality carbon filter will generally DOUBLE water intake. SoCal ground water is slightly alkaline and tastes bitter to cats that have sensitive taste buds. Organic debris and dust will also settle in bowls and lead to a foul moldy taste over 12 hours. This can be prevented when the bowl is scrubbed twice daily and distilled water purchased at the grocery store. A dedicated cat brush will cost a dollar but save hundreds in medical costs during later life.

Anal Glands and the "Scooting" Problem 

Many domestic dogs, and on rare occasions, cats, will experience irritation and discomfort within their anal sacs found under the tail. Here, we will explain what anal glands are and how they can cause problems for your pet. We will also look at the symptoms of full anal glands and also how your veterinarian can help with various solutions to this annoying problem.

Dogs and cats both have anal glands anatomically positioned on either side of the anus, just below the skin and wedged inside the anal sphincter muscle that surrounds the anal opening. These glands, sometimes called anal sacs, produce a thick brown liquid, with a very foul odor. These sacs express their contents onto the feces onto each bowel movement when functioning properly. This secretion on the feces is believed to serve as a means of marking territory in wild canines and felines, such as wolves, jackals, coyotes fox, tigers, etc. Domesticated dogs and cats will commonly use urine and feces to scent mark territory, instead. This is why a pet dog or cat will often sniff another dog's feces, and then urinate or defecate on top of it.

Occasionally, the small ducts that drain the anal sacs become clogged with this thick secretion. When this occurs, the anal gland becomes swollen with trapped liquid and painful. Dogs and cats will attempt to relieve the discomfort by scooting their rear quarters across the ground or by biting and chewing at that area. The intent is to release the trapped liquid. Scooting has often been misinterpreted to mean a dog has worms. Though this may be true in some rare cases of tapeworms or pinworms, it is most usually due to full anal glands. In Southern California, one major alternative diagnosis is skin allergies because dogs and cats alike release large amounts of histamines from the tender skin under the tail and anus. If these symptoms occur, especially if they have persisted for several days, it is important to seek medical assistance for your pet at SOVG.

Your veterinarian or the trained veterinary staff will be able to assist your pet in releasing the accumulated pressure in these glands. This is a learned technique, takes time to perfect and should not be attempted by pet owners without experience. Especially in cats. They do not appreciate rough and clumsy squeezing of a tender behind. The technique most often performed through a quick procedure of gently squeezing the gland while performing an internal rectal digital exam. Your groomer may also be trained to perform an anal gland expression and may do this routinely during your pet's grooming. However, doing this when no problem exists is potentially harmful due to recurrent bruising and scar tissue formation that can eventually interfere with anal gland anatomy.

Your veterinarian will assess your pet's condition to determine if any other treatment is necessary, such as antibiotics for an infection or biopsy for analysis of any irregular lumps and bumps. Occasionally, anal glands become infected and will need much moreaggressive treatment which sometimes includes a surgical procedure to clear up any infections. Even less often, but of critical importance, anal gland tumors can occur in dogs, unlike cats. Blood tests can be used to help confirm suspicions in most dog cases.

Though no one understands why some dogs are more effected than others, early attention to symptoms will certainly eliminate some of the more serious complications, such as infection. Those pets that suffer from chronic problems (more than 3-4 times per year) with their anal glands may benefit from an elective surgery that removes both anal glands. This delicate operation is not for every dog, but your veterinarian can help you decide if your dog may be a good candidate for this procedure. Adding Quaker Instant® oatmeal can bulk up a pet’s stool and correct around 90% of the chronic cases by adding more squeeze power to each stool and forcing the liquid out under increased pressure during defecation. Using 1-2 ounces for 10-20 pound dogs/cats and 3-8 ounces for 30- 100 pound dogs once daily is effective. Mixing the oatmeal with hot water, or even better yet, soup broth, makes it meaty and super appealing for your pet at breakfast each day.