/// QUARTERLY BEAT / OCTOBER 2022
QUARTERLY BEAT / OCTOBER 2022 ///
OPTION 3: A DIET TRIAL Given the likelihood that Toby has a diet-responsive chronic enteropathy, I would strongly recommend a diet trial as the first option to try. And if the first diet I try doesn’t get results, trying a second or third diet may be advisable before prescribing other therapeutic options. Here’s why: • Efficacy . Finding the right diet can sometimes take time, but most dogs with CE will ultimately improve on a diet. 4 If you are successful in getting his owner on board, Toby is likely to have a positive outcome that is lasting. • Compliance . Provided the patient has a good appetite, dietary therapy is easy to administer. However, you must take the time to explain to Toby’s owners what compliance looks like (e.g., strict adherence to the prescribed diet with no unapproved treats, table-scraps, etc.) and make sure they understand the anticipated timetable for evaluating—and revaluating—success. • Safety . While the convenience of a “quick fix” is always appealing to clients, owners ultimately want what is best for their pets. Here again, take the time to explain why alternatives such as antibiotic and immunosuppressive therapies are best reserved for patients that truly need them. Making the dietary recommendation Now that Toby’s owner is on board to try dietary therapy, which diet should you recommend? Three nutrients to consider when selecting a therapeutic diet for CE dogs are fat, fiber and protein . • Protein . Protein can be the culprit for many dogs suffering from food intolerance and/or food allergy . A trial with a hydrolyzed protein or amino acid-based therapeutic diet can lead to improvement of clinical signs in chronic enteropathy dogs in as little as 10 to 14 days. 5,6 Truly food-allergic dogs often suffer from concurrent nonseasonal pruritis and otitis as well as GI signs and may require up to eight weeks to show improvement in their extraintestinal (i.e., dermatological) clinical signs. • Fat . Clinical signs such as burping, regurgitating, vomiting and/or discomfort after eating are indications that a patient may be experiencing delayed gastric emptying. These dogs may benefit from a lower-fat diet so that food can exit the
stomach more quickly. Meanwhile, dogs with protein- losing enteropathy and/0r lymphangiectasia are candidates for ultra-low fat therapeutic diets. They do not always require immunosuppression. 6 • Fiber . Dogs with large-bowel diarrhea may benefit from diets with increased fiber to add bulk to their stool. Diets formulated with prebiotic soluble fibers, such as psyllium, can provide further healing for the colon due to the fiber fermentation and conversion to short-chain fatty acids that feed colonocytes. An answer for Toby Based on his clinical signs, you recommend a hydrolyzed protein diet for Toby, giving detailed instructions as to the transition from the current diet, the amount to feed, and what to expect. Two weeks later, his owners reported that his stools are more formed and less frequent. This rapid response suggests that Toby has a diet-responsive chronic enteropathy . In such cases, it isn’t always necessary to determine the offending protein—nor do all dogs need to stay on hydrolyzed diets for the rest of their lives. For some, a food intolerance may have been triggered by an inflammatory episode that may resolve with time, allowing them to tolerate components of or even their entire previous diet. In other cases, reintroduction of intact proteins or the previous diet triggers a flare-up of CE signs. Realistically, I find that many owners who have endured months of GI upset with their dogs prior to a successful diet trial will opt to stay on the trial diet rather than rock the boat and risk a relapse. Successful management of Toby’s condition required taking time to educate his owners and enlist their partnership in finding a solution that was both safe and effective. Making diet trial the first choice—versus the second or third choice—is a paradigm shift to consider when managing patients with CE. Sidebar: Elemental diet offers a new diet trial option I recently conducted a prospective, uncontrolled study 7 to evaluate the effectiveness of feeding Purina® Pro Plan® Veterinary Diets EL Elemental Canine Formula—an amino acid-based diet—to client-owned dogs with CE. I recruited 23 dogs experiencing signs such as diarrhea, vomiting, reduced appetite and/or unexplained weight loss. The gastrointestinal (GI) mucosa of the dogs was evaluated via upper and lower GI endoscopies, with all showing evidence of intestinal inflammation. After a gradual food transition, the dogs were exclusively fed EL Elemental for two weeks and monitored closely at home. Of the 23 dogs, only one refused to eat the diet. The remainder were fed the diet for a total of eight weeks, with
Please note the opinions of this article are the expressed opinion of the author and not directly endorsed by VETgirl.
SPONSORED ARTICLE
ALISON MANCHESTER , DVM, DACVIM (SAIM) Veterinary Specialist and One Health Fellow Colorado State University College of Veterinary Medicine and Biomedical Sciences A Case of Chronic Canine Enteropathy: Should Diet Change Be Your First Option?
In this VETgirl featured article sponsored by Purina Pro Plan Veterinary Diets, Dr. Alison Manchester, DACVIM discuss how to manage chronic enteropathy.
Is this scenario familiar? A client comes in with a 1-year- old Labrador retriever—let’s call him Toby—who has been suffering from intermittent diarrhea for several months. Toby’s body condition and appetite are both good. His blood work and albumin levels are normal. Given the length of time he’s been experiencing clinical signs, you’ve ruled out stress diarrhea and dietary indiscretion. Knowing that Toby’s owner is eager for a solution, what do you recommend? OPTION 1: AN ANTIBIOTIC Understandably, Toby’s owner would love you to prescribe a pill that would resolve his dog’s diarrhea quickly and inexpensively. And many of us might respond
Antibiotics—especially those that target anaerobic bacteria— can have long-lasting effects on a patient’s GI microbiome. I’m especially hesitant to give antimicrobials to young animals because their microbiomes are still developing. While we don’t yet have animal studies on this, there are compelling human data showing that antibiotic exposure early in life can set people up for serious problems such as Crohn’s disease, asthma and allergic rhinitis later on. 1,2,3 Antimicrobial resistance is another potential consequence. For example, if Toby were to develop a urinary tract or other infection in the future, it is possible the repeated antimicrobial courses he was given for diarrhea will have selected for antimicrobial-resistant bacteria, thus complicating his treatment. OPTION 2: A COURSE OF STEROIDS Another tool many of us consider in managing CE is an immunosuppressive medication such as prednisone, budesonide or cyclosporine. The rationale is that steroids can be effective in managing patients with conditions such as inflammatory bowel disease and protein-losing enteropathy. Once again, sending Toby home with a bottle of prednisone may temporarily meet the owner’s desire for a quick and inexpensive solution. But he or she will probably not be happy with the side effects (e.g., polydipsia, polyuria and polyphagia) that accompany steroid use—especially if it becomes necessary to keep Toby on long-term therapy. While specific immunomodulatory drugs have their place in the management of serious enteropathies, reserving this option for situations where you are certain the patient will not respond to other treatment modalities may be best.
in that spirit by sending him home with a course of metronidazole or another broad-spectrum antibiotic. After all, we know from experience that these antimicrobials will likely suppress clinical signs, at least for a time. The problem is that
the antibiotic probably won’t resolve his chronic
enteropathy (CE) long-term. Why? Because Toby probably isn’t suffering from a primary bacterial enteritis. Once he’s finished his course of antibiotics, you will likely see him in your office again when his clinical signs return. And while another course of metronidazole might, again, suppress these signs temporarily, you will not have addressed the underlying cause of his diarrhea.
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