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Tuesday, December 6, 2016

Fatty Liver Syndrome, Feeding Tubes, And Guilt

A few days ago I received the following email....
My sister lives in Italy and has just had to put her beloved female cat down of 12 years due to a bad case of hepatic lipidosis.  They were moving house, the cat was stressed and feeling out of sorts, and had lost weight. The problem was they have two cats and my sister in all the stress of moving wasn’t aware that she had stopped eating as the other cat was obviously eating for both.  I live in Australia and when I first heard that her cat was sick and a trip to her vet with blood tests came back normal, except for an elevated liver result, I immediately started to research this exact thing. ‘Excessive weight loss, no interest in eating, blood tests normal except for high liver result, ultrasound normal showing no mass, but slight inflammation of liver’… It told me a number of things but kept flagging lipidosis as primary or secondary outcome. In any case, I sent my sister this information and she discussed with her vet.

The vet kept the cat in for a few days and immediately rehydrated her via a drip and gave her AB’s, a shot of Vitamin K but at no point did she suggest an entero tube for feeding, instead she allowed my sister to take the cat home (understandably my sister felt that the cat would respond better with people she knows around her) and for my sister to force feed her via syringe a special supplemental food to get her back on track. Of course, my sister did that but noticed not much of an improvement in her cat. She was walking albeit wobbly, rapid, at times laboured breathing and was very emaciated. However, with the force feeding she had started to gain weight. My sister took her back after a week for a check up and they vet gave her a shot of anti-inflammatory medication and then a course of anti-inflammatory pills if she wasn’t vomiting. My sister noticed the next day the cat had really come alive (wanting to go outside for a walk, drinking water and using litter box as normal) but still no interest in eating on her own. Still, there was no mention of putting the cat on a gastro feeding tube via the stomach (which I read is less invasive to the cat and can be administered at home by the owner) which I know my sister would have happily done. In direct contraction now I read that giving an anti-inflammatory medication can make a cat with a liver issue much worse, so I have no idea why this was given when the blood test and ultrasound originally showed pointers to the liver being affected.

To cut a long story short nearly 2 weeks passed of my sister force feeding her cat, the continued laboured breathing got worse, she started vomiting a bit and wetting herself, then her ears became tinged yellow, a clear sign of jaundice related only to the lipidosis. She had to take her back to the vet when it was clear that she was suffering. Two days ago they had to put her down and my sister is blaming herself for a( not noticing her initial lack of appetite amidst all the stress of moving, and not knowing that a cat not eating for a certain period can affect the liver so seriously. What I cannot understand is the vet not immediately putting the cat on a gastro feeding tube, instead allowing her to go home to be force fed and ultimately allow the lipidosis to take a hold where it got beyond manageable. I feel she could have been saved 2 weeks ago and I’m so upset at what has happened.

I guess what I’m asking is do you think there’s a reason it wouldn’t have been offered? Perhaps a cat that is under so much stress from moving house, even with the feeding tube and recovery (and from what I’ve read 80% of cats can recover after a bout of lipidosis) perhaps if the initial stressor remains i.e moving house the cat will still refuse to eat on her own and continue to go down hill?

Maybe I’m clutching at straws, but both of us are feeling incredibly upset, guilty and frustrated that we didn’t do all we could to save Kity.

I would appreciate and be very grateful for any input/insight you have regarding a situation like this.


I definitely don't want to second-guess the vet in charge of this case, or say that they were wrong.  I wasn't there and don't have access to the medical notes, so I'm not going to assume that I know better.  That's not ethical for me to do as a veterinarian, and it would be the height of hubris for me to assume that I know better than the doctor who is directly involved with the case.  So I'm going to take this from a perspective of what I would do, as well as explain a few things about some of the points.

Let's start with the question of elevated liver enzymes.  Typically we look at two main values:  alanine transferase (ALT) and alkaline phosphatase (ALKP).  ALT is more specific to the liver as it is found exclusively in liver cells, while ALKP can be found in a few other tissues.  There are also several non-liver conditions that can cause ALKP to become elevated, including steroid use and laboratory artifact.  The is always a baseline level of these chemicals in the body, which is why we have a normal range for them.  When we see elevations in these values, especially when ALT increases, we generally assume that there is a problem with the liver.  However, these values don't give us the specific disorder, and only indicate liver damage with increased destruction of liver cells.  The cause for this damage can be from dozens of reasons, including toxins, infection, cancer, trauma, abnormal blood circulation, and many, many other things.  Elevation does not necessarily mean liver "failure", as the liver can still be functioning completely normally even while there is damage.  So when we see abnormalities in these values, we need to try and do further testing to determine the cause so we can focus treatment on the appropriate disease process.

Hepatic lipidosis, more commonly called fatty liver syndrome, is a condition that in veterinary medicine we see almost exclusively in cats.  This happens when abnormal fat metabolism results in infiltration of fat into the liver, causing abnormal liver function and possible liver failure.  Overweight or obese cats are far more likely to develop this condition than normal weight cats, and in my personal clinical experience I've never seen a normal weight cat develop fatty liver syndrome.  A key thing to keep in mind is that rarely is this a primary condition.  In almost every case lipidosis is secondary to another disorder.  That primary disease causes the cat to stop eating, and when that goes on for long enough the liver becomes infiltrated with fat.  So really it is a cessation of eating that leads to hepatic lipidosis.

Remembering this underlying cause is important for two reasons.  First, we need to find out why the cat is no longer eating.  We can possibly treat the fatty liver, but that doesn't tell us why the cat stopped eating in the first place.  The reason for the anorexia could have nothing whatsoever to do with the liver, and sometimes can be difficult to determine. Second, the primary way to treat fatty liver syndrome is to get food in the cat.  And that's not easy.

If a cat won't eat on their own, you have to force food into them.  This is rarely done intravenously because the IV feeding solutions carry a significant risk of systemic infection if not handled properly, so they are not done outside of critical care hospital situations.  That leaves having to somehow get food into the stomach.

The least complicated but often most difficult method of force-feeding is simply to use a critical care food and give it with a syringe by mouth.  Cats hate having anything forced into their mouth, and a cat that is nauseous or sick will typically resist having this done.  You also end up wasting some food as it dribbles out of the mouth, you miss with the syringe as the cat pushes away, or they push it back out with their tongue.

Another option is a nasoesophageal tube.  This is a small, soft rubber tube that is passed through the nasal passage into the esophagus.  It's relatively easy to perform and usually doesn't require any form of sedation.  The external part of the tube is taped or sutured to the top of the cat's head.  A syringe can be attached to the end of the tube and liquified food be fed through the tube directly into the esophagus.  This is a relatively short-term option and is usually used for only a few days.  A longer-term option is to perform minor surgery, making a small incision through the skin and esophagus to place a tube directly into the esophagus through the side of the neck.  While this second procedure allows longer feeding through the tube it also requires anesthesia and a higher level of skill to perform.

There is a downside and a risk to either nasoesophageal or esophageal tubes.  If the cat vomits, the end of the tube can turn back on itself, and the vet or pet owner can't always tell that this happens.  The end of the tube can advance back up towards the mouth, and when food is placed into it there is a risk that it can be forced up towards the trachea, resulting in aspiration of the food into the lungs.  This is a very bad situation and will result in a form of pneumonia.  While the risk of this happening to the tube is low, it is definitely a risk and something to watch for.

A more permanent option is a full stomach tube, often called a PEG tube.  This is performed under general anesthesia and usually with an endoscope.  A probe is placed into the stomach and pushed up against the stomach wall.  A small incision is made through the stomach and abdominal wall, enabling the placement of a small device that goes through the skin and into the stomach.  This device has a cap on the outside to allow closure between feedings.  The wound quickly seals around the PEG device, giving a long-term way to place food and liquid directly into the stomach, bypassing the esophagus and mouth.  These devices can be used long-term, and I've known cats to have them for up to a year.  Because of the equipment and expertise needed, PEG tubes are usually placed by a specialist.

As you can see, putting a tube in a cat isn't always simple, and each method carries various degrees of risk and cost.  Some vets don't do it because they don't feel comfortable with the procedure or worry about the secondary risks.  But if you're trying to treat fatty liver syndrome you absolutely HAVE to get food in the cat.  With proper feeding the fat will eventually come out of the liver and the liver has a great ability to regenerate.

Now let's get to some specifics of this particular case.

I've seen a lot of cats get stressed from a move, but I've never seen one completely stop eating.  Yes, it's possible, but not common.  Most of the time when a cat is stressed from a move it will have other behavioral changes, such as inappropriate urinating and defecating, marking behavior, hiding, and so on.  So in this case I would look for other causes of the sudden decrease in appetite, and come back to stress only if other problems have been eliminated.

The vet in this case did what I would have done as the next step after blood tests and performed an ultrasound.  It sounds like there was no evidence of a tumor, and apparently the imaging showed "inflammation".  Unfortunately this is a very non-specific term, and doesn't indicate lipidosis or any other specific disease.  I would also want to know if the inflammation was diffuse throughout the liver or if it was in focal areas.  Fatty liver tends to be more diffuse.

A yellowing, or jaundice, is specific to diseases of the liver or gall bladder, but is not specific to fatty liver syndrome.  Any advanced liver disorder can lead to this discoloration of tissues

If this had been my case, I would have likely done a trial of antibiotics, low-dose prednisolone, and a liver supplement to improve function.  At the same time I would have used an anti-nausea medicaiton and an appetite stimulant to help the cat eat better.  If it still wasn't eating I'd recommend at-home syringe feeding of a critical care diet.  A recheck would have been scheduled for one week when I would have repeated the blood tests to see if there was any improvement in the lab values, as well as looked for improvement in clinical symptoms.  Steroids can be indicated in many cases of liver disease as they do decrease inflammation.  However, I feel that oral medication should be used instead of injections because the pill or liquid can be more precisely dosed up or down and gets out fo the system faster.

If the cat wasn't improved I would next recommend a liver biopsy.  If someone has the right skills this can be done with a special needle guided by ultrasound, and doesn't always require surgery.  The biopsy should be able to tell us more specifically what is happening with the liver.  In fact, you can't accurately diagnosis lipidosis without a biopsy.

Yes, that's correct.  We can strongly suspect hepatic lipidosis based on clinical signs and the cat's weight but you can only truly diagnosis it by documenting excessive fat within the liver tissue on a biopsy.  So "inflammation" on an ultrasound may or may not indicate a fatty liver.

All of these steps and tests are to get down to the bottom of what is causing the lipidosis.  Remember that this is typically a secondary condition and we always need to find out why the cat stopped eating.  If we don't address that primary problem we'll never get the cat better.
Your sister shouldn't feel guilt.  I've moved many times and it's always stressful.  You have so many things going on that it's really hard to keep track of it all.  Also, the vast majority of cats go through a move with minimal stress, and if there is stress it rarely causes them to stop eating.  If her cat became so stressed that it wouldn't eat and that led to a fatty liver, this is an extremely rare situation that she couldn't have predicted.

Since fatty liver syndrome can only be properly diagnosed with a biopsy the vet probably had no reason to immediately suspect this as the main problem.  I probably wouldn't have.  Most vets probably would have proceeded similarly, with the potential exception of recommending a liver biopsy earlier in the process.  Again, I'm not going to completely second-guess that vet since I wasn't involved with the case.  But there are many reasons I can see for why they made those decisions.  Honestly, the best thing to do is ask that vet these questions, and see why they proceeded as they did.

Friday, December 2, 2016

A Client Apologized

A few weeks ago I had a client do something that has never happened to me in almost 20 years of practice.  She apologized for her behavior.
 
Vets are often faced with rude, thick-headed, or just difficult clients.  Most of us realize that this is part of working with people and most of those clients aren't intentionally causing problems.  We don't enjoy those kinds of people as it makes communication and treatment much more difficult.  But we learn how to handle it and how to continue caring for that client's pets.  Sometimes a client becomes very belligerent, unreasonable, or a general pain in the tush.  If the person is beyond the norm in their behaviors many vets will politely but firmly let that client know that they should seek veterinary care elsewhere.  While we can be used to tricky interpersonal situations, we're not psychologists and don't get paid enough to put up with anything that the worst client can throw at us.
 
Let's call my client Ms. A.  She is a long-term client of mine and I've cared for her pets for several years, being the preferred doctor when she comes in.  In October I saw her dog for some skin issues, and not serious ones.  I vaguely remember her being worried and asking some very pointed questions, even repeating them and saying "are you sure?"  But overall I didn't think much of it.  She can be a slightly difficult person, but well within reasonable limits and I've learned to have patience with her because she really does care about her animals. 
 
She came in for a follow-up visit and I was happy to see that her dog was much better and the problem had completely resolved.  As we were finishing up she asked my tech if she could speak to me alone.  That sent up some red flags!  I have never had a client do that, and I immediately started worrying and trying to figure out why she needed just me in the room.  I considered that there were problems with my staff, that she was angry at me, and a whole list of bad situations.  I was completely unprepared for what happened next.
 
"Dr. Bern, I need to apologize to you for my behavior last visit.  I was a real jerk."
 
I swear I think my jaw dropped open.  That was definitely not what I was expecting to hear!  And I started going through my memories to try and figure out what in the world she was talking about.  As I thought back to the previous visit I honestly couldn't remember her being a problem, and definitely not something that needed an apology.
 
I told her that and she thought I was just being nice.  I had to really firmly let her know that I couldn't remember anything bad that she had said or did, and emphasize that if I couldn't remember it then the incident must not have been a real problem.  She appreciated that but continued to explain and say how sorry she was for her attitude, as I've always done such a great job of caring for her pets and listening to her.
 
We talked for a bit, I assured her that there were no problems at my end, and we hugged it out.  I walked out of the room and explained it to my tech, who had also been wondering why she was asked to leave.
 
Over my career I've had numerous clients who really did owe me an apology.  I've been yelled at, cursed at, called names, blamed for every problem under the sun, and generally been treated by dirt.  Thankfully these bad clients are few and far between, otherwise I probably wouldn't be able to keep working in this field.  Most of my clients are wonderful and appreciative of our care.  But many of those difficult clients really did act impolitely and unreasonably, completely out of the realm of normal reactions.  Yet with all of those people I have never had a single one apologize.
 
Now I've had a client apologize for an attitude that I can't even remember! 
 
I told her how much I appreciated her and her apology, even if I couldn't recall any of the specifics and it didn't stand out in my mind.  Too many people don't take personal responsibility for their actions, and always try to blame someone else.  Ms. A absolutely sucked it up and put herself in a vulnerable position because she felt it was the right thing to do.  That amazed me and restored some of my faith in humanity.  And I'll be happy to put up with her in the future if she continues to have this attitude about herself.  A great client and one of the most positive experiences I've ever had.

Tuesday, November 29, 2016

Are "Prescription" Diets Really By Prescription?

As a follow-up to the last two posts I've made on "prescription" foods, I wanted to add this topic.  It's actually something that is currently being debated by the profession for various reasons and there is misinformation out there.  In fact, astute readers may have noticed that I've frequently put the word prescription in quotation marks over the last week of posts.  My discussion is going to focus on the US, even though I have an international readership, because I know US laws and not ones in other countries.
 
To begin, "by prescription" really does have a definition.  Each state has their own laws so there are essentially around 50 different variations on the theme, but there are a lot of similarities.  The basic idea is that there are certain medications that have been established by the Food and Drug Administration (FDA) as requiring a prescription from a licensed doctor.  Without that prescription you cannot purchase the medication or product.  States typically require a prescription to be written by a licensed doctor that has a valid client-patient-doctor relationship with that person or pet.  The specifics may vary, but essentially the doctor must have personally seen the patient within at least the last 6-12 months and be familiar with their medical conditions and history.  Over time some prescription-only medications can be approved for over-the-counter use, such as many antihistamines and stomach acid reducers.  Whether or not a drug is by prescription is determined by the FDA, and what is required to issue a prescription is determined by the state.
 
What about "prescription" foods as produced by Hill's, Royal Canin, Eukanuba, and Purina?  Here's a shocker for you....they technically do not fall under prescription laws. 
 
Yes, that's right.  These "prescription diets" do not legally require a prescription.  They fall into a gray area of foods and supplements that the FDA does not regulate.  It's similar to taking Echinacea for colds or St. Johns wort for depression.  The manufacturers do not specifically claim that these products treat any specific condition, and they often even say so on the label.  By not making a claim of treatment they can bypass the FDA regulations and do not have to prove their efficacy.  Any claims come by word-of-mouth between people or through books and internet sites, but not directly from the product label.
 
So-called prescription foods in veterinary medicine occupy the same category as vitamins and supplements for humans.  They do not go through any FDA trials or tests, and therefore do not fall under that agency's jurisdiction.  Since it's the FDA that determines whether something is dispensed by prescription, these foods technically don't need one because the FDA hasn't ruled on it.  And because they don't legally require a prescription, a valid client-patient-doctor isn't necessary.
 
So why do vets require a visit?  Why do vets talk about these foods as "by prescription".
 
Some of these diets are fine no matter the health status of the pet that eats it.  Others, however, could cause problems.  For example, diets for kidney failure have significantly low protein levels.  This is necessary to help progression of kidney disease, but it's low enough that we wouldn't want a health pet eating it.  We don't want a client picking up a food for urinary issues because their dog is peeing a lot, when in reality that dog has diabetes and should be on a much different diet.  Clients also aren't sure exactly which food they need or even have purchased in the past, so we don't want them to be able to just pick up any food and make their own judgment.
 
Using the wrong therapeutic diets can indeed lead to health consequences because of how highly specialized they are.  By requiring authorization from a vet both the doctor and the food manufacturer take steps to ensure that the correct food is being given to the right patient and we're not doing any harm to pets.  If someone wants to buy a therapeutic diet from my clinic we don't require that we have seen them, but we do require a written or oral confirmation from their vet as to which food is being used.
 
Recently the FDA has been paying more attention to these foods, since they actually are recommended and used for the treatment of diseases.  Anything with that definition must be regulated by the government, and foods currently aren't.  This is leading to discussions as to whether or not the FDA may actually start doing tests and requiring that foods follow the same laws and rules as antibiotics, antidepressants, and other medications.  If so, expect the cost of food to go up because compliance on these issues is very expensive for the manufacturer.
 
This increased government scrutiny has already resulted in some changes by the food companies.  For example, Royal Canin makes a diet for food allergies that breaks down the proteins into single amino acids, putting their size below the threshold that would trigger an allergy.  It used to be named Hypoallergenic, but that name implies a specific claim about the function of the food in relation to a disease.  Because that treatment claim would classify it as a medication and the Royal Canin wanted to avoid trouble with the FDA, they changed the name to Ultamino.  Same product and no change in the ingredients, but an important change to comply with prescription laws and regulations.  Several other foods have had name changes for similar reasons.
 
When your vet talks about a "prescription" food, realize that they are using the word loosely and probably incorrectly.  Heck, I've been doing it for 30 years, so I still fall into that habit even though I know better.  If you walk into a store or vet clinic and they don't know you, understand that they may not sell you the food, but not because of the law.  In fact, if they say that it is illegal for them to sell it to you they are absolutely wrong since it doesn't fall under prescription drug laws.  But there are darn good reasons for them not to sell it to you if they don't know the specifics of your pet's case.
 
Hopefully this makes sense, as it's a somewhat complex issue.

Saturday, November 26, 2016

Are There Differences Between "Prescription" And Over-The-Counter Foods? (Part 2)

My post earlier in the week was specific for one situation but opens a wider discussion.  Are there really differences between OTC foods and "prescription" foods?

The short answer is "Yes, absolutely!"
 
When I prescribe a specific food for a patient it is common for clients to say "Wow, that's expensive.  Isn't there anything over the counter that can do the same thing?"  And I certainly understand their concern.  Being worried about money and affording food is legitimate, as few of us are wealthy.  We do have to watch the cost of feeding our pets, and some of these therapeutic diets are two to three times as much as a "regular" bag of dog food.  So I don't take offense when a client brings up to me their financial concerns.
 
It's hard to make a blanket statement about how all prescription diets are different, and it would take more than a simple blog post to go into the "why" behind each and every one on the market.  But I can take a few examples as illustrations.
 
Foods for kidney disease are specially designed to lower the protein and improve the protein:phosphorous ratio.  There are no OTC diets with the right ratio and a low enough protein.
 
Dogs with recurrent pancreatitis need to be on an extremely low fat diet to help lower the risk of future episodes.  OTC diets aren't low enough in fat.  In fact, the labels only give maximum and minimum percentages for things like fat, so you can't even tell the exact amount in a food without contacting the manufacturer.
 
Dogs and cats who have had bladder or kidney stones need to be on a urinary diet that will properly regulate the pH of the urine, lower certain minerals, and promote drinking to ensure dilute urine production.  There are no OTC foods that will do all of these things.
 
Animals with severe food allergies need to be on extremely restricted diets which avoid certain ingredients.  Currently most OTC foods don't have significant enough restriction and could cause trace ingredients.  Severely allergic animals may need to be on a food that not only limits ingredients but also breaks down the proteins into smaller chains (hydrolyzed) or single amino acids in order to prevent a reaction.  There are no OTC foods that process the proteins in those ways.
 
Like diabetic humans, dogs and cats with diabetes need dietary regulation, especially with a high protein to carbohydrate ratio.  OTC diets don't achieve the same ratio and are worse at regulating blood glucose levels.
 
As you can see from just a few examples there really are significant differences between these prescription diets and what people typically feed their pets.  When comparing virtually every therapeutic food there simply are no cheaper foods that achieve the same results.  So that cat with kidney failure, the schnauzer with pancreatitis, or the bulldog with food allergies really do need to be eating a food that a client can't get other than through a vet.  There are decades of research to show the importance of these foods compared to "normal" pet foods. 
 
The ancient Greek, Hippocrates, is famously quoted as saying "Let food be thy medicine and medicine be thy food."  He was referring to using the right kinds of foods as a central part of treating diseases, and no modern doctor would disagree.  The same principle applies with pet foods.  I have successfully treated many disorders by placing the pet on very specific diets and did not have to give medicine to some of them.  Think about that for a moment...what do you think would be better?  To give the dog pills twice daily every day for its life, or to feed it a specialized food for the rest of its life?  Which is healthier?  Which will have fewer side effects?  Which will be easier for you and the dog?
 
Yes, prescription diets are much more expensive than other foods.  But pet owners have to stop thinking about them as merely food.  They are an essential part of medical treatment and are usually not recommended lightly.  Sometimes it comes down to spending $90 per month for a bag of food, or $40 for food plus $60 for medications.  Suddenly that expensive food doesn't seem so unreasonable, right?
 
If your vet recommends an expensive prescription food, it is usually for a very good reason and I recommend following their advice.  It is fine to ask if there are other options, but the likelihood is that there are no other comparable OTC foods and you could be delaying or preventing adequate treatment by using a cheaper diet.

Thursday, November 24, 2016

Happy Thanksgiving

Today here in the US we celebrate Thanksgiving Day, which is supposed to be a time to reflect and give thanks for what we have.  In reality it ends up being an opportunity to spend time with family and eat lots of food!  And as it does every few years today coincides with my daughter's birthday (she is 14 today).

I hope that everyone does pause to count their blessings and give thanks for what they have.  I hope all of my readers have an enjoyable day and truly can give thanks for many things.




P.S.:  Indulge in food for yourself, but please don't share Thanksgiving goodies with your pet or you may end up at the vet soon.

Monday, November 21, 2016

Are There Differences Between "Prescription" And Over-The-Counter Foods? (Part 1)

Recently I received a great question from a reader:
 
One of our cats was recently put on a novel-protein diet for IBD, in addition to prednisolone.  He's been responding well to the steroids, and we just put him on the new diet today.
The diet prescribed was Royal Canin PV, which is Venison and Pea, and goes for the lovely sum of $67/8lb bag.
I see that Natural Balance also has a Limited Ingredient Diet Venison and Pea dry formula, and the ingredient list is awful similar.  Is there any significant difference between the two, other than the Natural Balance being $40 cheaper?
 
Many food companies have realized that the "prescription" veterinary diets are a huge revenue opportunity.  Therefore some of them are trying to develop OTC foods that are supposedly comparable to the veterinary ones as a way to capture a share of that market.  While I understand this from a business perspective and don't fault them for wanting to increase their corporate revenues, it does cause confusion among pet owners and difficulty for vets.  But the OTC foods are not always comparable to the veterinary ones. 
 
Royal Canin, Hills, Purina, and Eukanuba all make veterinary-specific diets for use in treating various medical conditions.  Inflammatory bowel disease (IBD) is a common one that needs a change in food, as it is often related to a sensitivity to ingredients (typically proteins, but secondarily carbohydrates).  Because these ingredients are not brand-specific we look at changing to "novel" foods, which means foods containing ingredients to which the pet has not previously been exposed.  In the above case the protein comes from venison and the carbohydrates from peas.  For a truly novel food you want to avoid other major ingredients, especially the protein.  In order for a diet to qualify as "limited ingredient" you want single sources of proteins and also ideally carbohydrates.
 
I compared the ingredients of both the Royal Canin PV and the Natural Balance LID Venison and Pea.  Both of them pass the "limited ingredient" test, as both rely only on venison for protein and pea as the major carbohydrate.  But there are some slight differences in minor ingredients, though none that I can see will make a huge difference in the nutrition of the diet.  One thing that Royal Canin has is some added fish oil.  The omega fatty acids in fish oils are a natural anti-inflammatory so they can be a great additive to cases like this.
 
On the surface it looks like these two foods are nearly identical.  However, there is another consideration that is not obvious, and there is no way tell from the packaging.....quality control.

With veterinary-specific diets the manufacturers spend a lot of time and money to ensure that other trace ingredients don't get into the mixture.  OTC diets may not have those same quality controls.  Ingredients must be listed by pre-cooked weight, but when you get to trace ingredients you may not have them listed because they are below a certain threshold.  What this means is that if there are minute amount of ingredients not listed on the label, that is allowable.  The more expensive diets are very careful to keep these trace ingredients out of the diet, while OTC diets typically don't care about them and may include them.
 
Why is this an important distinction?  Think about someone with a severe peanut allergy.  These people can't eat anything that has even touched nuts, whether or not it is an ingredient.  A food prepared on a counter that had previously had nuts on it could trigger an allergy.  Some people are so sensitive that even the nut dust being in the air is enough to cause a reaction.  While not common, some pets are similarly sensitive to even trace ingredients that wouldn't be on the label.

When these questions come up with my own clients I typically recommend feeding only the veterinary diet until the pet is stable for several months.  Once we have achieved effective control we may discuss trying a comparable OTC diet and watching for a reaction.  If there is no reaction we can use the less expensive diet.  If there is a return of symptoms we have to go back to the veterinary one. 
 
Remember that when using these very specialized foods you are not just providing nutrition.  These are being used as medical therapy.  You need to look at these foods in the same way that you would consider pills, capsules, and other medications.
 
Before making any food switches be sure to consult with your veterinarian first.  If you make the switch and the dog or cat isn't any better, the vet may assume that the prescription diet is failing when it's really the OTC one.  Since the diet recommendation is a vital part of the treatment, you need to keep your vet in the loop on any decisions.
 
This is a great topic and brings up some other issues that I'll discuss in some upcoming blogs.

Friday, November 18, 2016

Joyful Parts Of Being A Vet.....An Update On The "No-Eye" Dog

My last post was rather sad and depressing, so let's talk about some happy things!

Back in 2013 I wrote about a Siberian husky named Diesel.  Due to worsening glaucoma I surgically removed both of his eyes, and it turned out well.  You can read about that experience here.  He has continued to be a regular patient and has been doing exceptionally well since then.

A couple of weeks ago I saw him for a routine wellness exam and checkup, and was talking to one of our new staff members about his case.  It really made me think about some of the positive things about being a vet, and I thought that would be great to include in a blog.

One of the things I love most about being a vet is the bond that will often develop between me as a doctor and the clients and patients.  There is something magical about being able to continue to see patients year after year and continue to get to know them.  Diesel is a great example of this!  His surgery in 2013 is very memorable because it was the first time I removed both eyes at the same time.  I've used him as an example many, many times since then when discussing similar issues with other clients.  I love when he comes in because he is still such a friendly, happy dog, and being completely blind hasn't affected his quality of life at all.  In fact, the quality is much better than when he was dealing with glaucoma.  It is a true joy for me to see him a few times a year since that surgery, and to see how well he has been doing.  In fact, the clients recently moved to a new home and were worried about how he would adjust to the new environment.  We were concerned that he might become anxious because he didn't know the layout of the home and furniture.  But it didn't affect him in the least!  He didn't seem to care about the new place and hasn't had any problems making adjustments.  Over the last three years he's learned how to move around a place he doesn't know without hurting himself.

Here is a photo of Diesel from his most recent visit.  

 
Besides just being able to continue to follow up on him I also have the bond with his owners.  They are great people who love their dogs, and always try to do the best for them.  Since he did so well they have never regretted the decision to have the surgery done, and we always enjoy talking to each other when they come in.  I love clients like that!

I also recently saw another long-term client for a semi-annual checkup on her puppy.  As we were talking she happened to mention that her oldest child was now eight years old and I had seen her when she was pregnant with him.  I didn't realize it had been that long!  During those eight years I helped her with one epileptic dog, another who developed cancer, and the unfortunate euthanasia of both of them (at different times).  When she got a new puppy I was happy to see her family able to move on and welcome a new love in their home.  There is something so rewarding about knowing that family for so long, and having go through so many things with their pets.

The human-animal bond is something incredibly special.  As a life-long pet owner I couldn't imagine my life without my pets.  As a vet I love seeing that bond in my clients, and love getting to know them over many years.  When things like what I described in my last post happen, it's cases like Diesel that remind us of why we went into this profession.  It's great clients like his owners and many others I have that make the job worthwhile, and give us those emotional boosts that allow us to make it through the hard cases.

Veterinary medicine is hard and often emotional.  We deal with real tragedies and life-or-death situations.  But thankfully it's not always like that, and we can look at all of the patients we've helped and the clients we've gotten to know.  Those bright spots are what get us through the darkness, and why so many people want to become a vet.