Today's Veterinary Practice provides comprehensive information to keep every small animal practitioner up to date on companion animal medicine and surgery as well as practice building and management.
Issue link: http://todaysveterinarypractice.epubxp.com/i/919967
37 JANUARY/FEBRUARY 2018 ● TVPJOURNAL.COM CONTINUING EDUCATION side effects. 53 Some dogs still develop side effects of steroid administration while on budesonide, and owners should be warned about this. Sulfasalazine and related drugs are often used in dogs when IBD is limited to the large intestine. However, because side effects include keratoconjunctivitis sicca, tear production should be monitored regularly. Treatment of Patients With Severe PLE PLE is a recognized complication in a subset of chronic enteropathy cases, and hypoalbuminemia has been shown to be a poor prognostic indicator. 33,38 Patients with albumin concentrations <1.5 g/dL are at risk of developing ascites, pleural effusion, and subcutaneous edema. Many of these patients succumb to PLE within the first 1 to 2 months of starting prednisone treatment. Some studies have shown a better outcome with single-therapy cyclosporine, 55 making it a better option for many of these patients. One recent study has shown that the combination of prednisolone and chlorambucil was superior to prednisolone and azathioprine for survival. 56 Evaluation of hemostatic function in these patients is recommended to ascertain if hypercoagulability has developed as a consequence of enteric protein loss. 57 Concurrent therapy with ultra-low aspirin 0.5 mg/kg PO every 24 hours or other platelet inhibitors, such as clopidogrel, is recommended in these patients to prevent thromboembolism. In addition, elemental diets and partial parenteral nutrition may be indicated in some dogs with severe PLE. Some PLE patients can fare relatively well with dietary treatment alone, and some studies show that Yorkshire terriers with PLE may be a subgroup of solely diet-responsive dogs. In such cases, try a low-fat diet first and wait for 1 to 2 weeks before adding immunosuppressive treatment. Adequate protein content in such diets for these patients is probably even more important than fat restriction. If in any doubt, or if the patient is already anorexic, any diet will be better than no food intake. Finally, these patients may be at risk of complications associated with intestinal biopsy by laparotomy. Therefore, plasma transfusion, human or canine albumin infusion, or synthetic colloid may be indicated during anesthesia for endoscopy. Adjunctive Therapy With Probiotics The use of probiotics in people with IBD has led to some promising results, although there is still an insufficient number of large, multicenter, randomized, double-blind, placebo-controlled trials. Similarly, there has been only 1 randomized, placebo-controlled trial investigating the use of Enterococcus faecium probiotic as an adjunctive treatment in canine FRE, 58 and no additional effect was demonstrated in the group of dogs receiving probiotics. In another clinical trial, dogs with IBD were treated with the probiotic Visbiome ( visbiome.com ) in addition to standard treatment with immunosuppressives. The group that received the additional daily probiotic treatment improved more than the group treated with standard therapy alone. 59 It should be noted that consistent use of probiotics may have a greater association with their benefits. PROGNOSIS FRE is highly prevalent among dogs with chronic enteropathies (at least 60% to 70%), and a favorable response to elimination or hydrolyzed diets within 2 weeks has been associated with a very good prognosis over 1 year after diagnosis. 60 In these studies, the dogs were kept on the diet for at least 12 weeks after diagnosis before they were switched back to their original diet. In a recent large retrospective study in which all dogs with chronic enteropathy were sequentially treated, only 16% were suspected to have ARD. 60 All ARD dogs relapsed shortly after discontinuation of antibiotics, making long-term management of these patients difficult. An additional decision- making factor may be the increasing problems with antibiotic resistance in dog populations. Also, evidence is accumulating that antibiotic treatment has long-lasting effects on the intestinal microbiome, 11 which may lead to lasting dysbiosis that in itself could amplify intestinal inflammation. Many of these patients will eventually need steroids or other immunosuppressive treatments to control clinical signs. A response to prednisone has been shown in up to 50% of dogs with chronic enteropathies. 33 Other immunosuppressives can be considered if more severe disease is present or severe side effects of