1 00:00:04,899 --> 00:00:08,090 Nathalie Dowgray: Welcome to the June episode of Chattering with ISFM. 2 00:00:08,370 --> 00:00:12,059 I'm Nathalie Dowgray, Head of ISFM and host of this month's podcast. 3 00:00:12,890 --> 00:00:16,050 First up this month, we have part two of my interview with Professor 4 00:00:16,050 --> 00:00:19,969 Clare Rusbridge, and we're talking further about neuropathic pain in cats. 5 00:00:21,210 --> 00:00:24,930 And then Dr Kelly St Denis from AAFP is going to be speaking 6 00:00:24,930 --> 00:00:26,919 with Dr Julien Guillaumen 7 00:00:27,100 --> 00:00:31,319 on his clinical spotlight article, feline aortic thromboembolism, 8 00:00:31,320 --> 00:00:33,099 recent advances and future prospects. 9 00:00:38,025 --> 00:00:41,485 You gave some fantastic case studies in the paper, but with a number of 10 00:00:41,485 --> 00:00:46,315 those, I also noticed that actually, while we achieved in the first outcome 11 00:00:46,315 --> 00:00:50,695 successful management, there were often then flare ups when maybe other disease 12 00:00:50,695 --> 00:00:54,545 conditions occurred, and that may have led to the medications being difficult. 13 00:00:54,555 --> 00:00:57,795 So these aren't necessarily straightforward for the owners. 14 00:00:57,825 --> 00:01:01,375 How do you manage those initial discussions with them, but then 15 00:01:01,375 --> 00:01:05,385 also that longer term sort of role in monitoring the quality of life? 16 00:01:06,560 --> 00:01:09,590 Clare Rusbridge: Yes, I'd say that the biggest burden that caregivers 17 00:01:09,600 --> 00:01:11,080 have is giving medication. 18 00:01:11,690 --> 00:01:15,869 Some of these medications that we use for neuropathic pain are better 19 00:01:15,870 --> 00:01:21,160 to be given sometimes three times a day, and that may inform my choices. 20 00:01:21,170 --> 00:01:26,365 For example, pregabalin, one of the gabapentinoids, is about five times 21 00:01:26,365 --> 00:01:32,075 more bioactive than gabapentin, and I prefer it for cats because 22 00:01:32,165 --> 00:01:37,324 it can be given twice daily, which is much less effort for the owners. 23 00:01:37,385 --> 00:01:41,755 And there are some cases where we'll use quite unusual drugs for pain. 24 00:01:41,765 --> 00:01:44,395 You wouldn't expect phenobarbital, for example, to 25 00:01:44,405 --> 00:01:46,235 be useful for a pain condition. 26 00:01:46,955 --> 00:01:50,355 And I'm not sure that it necessarily is for dogs, but it does seem to 27 00:01:50,365 --> 00:01:55,035 be useful in some cats, especially with feline oral facial pain. 28 00:01:55,155 --> 00:02:00,225 And phenobarbital can in some circumstances be given once daily. 29 00:02:00,315 --> 00:02:05,645 So if I have a very challenging case, then I will consider that perhaps a poor 30 00:02:05,645 --> 00:02:10,695 choice you might think because of the side effects, but sometimes a low dose of a 31 00:02:10,695 --> 00:02:16,914 once daily drug of a small tablet, which the owner finds easier to hide in food is 32 00:02:16,954 --> 00:02:21,755 going to be better than them struggling to give capsules three times a day. 33 00:02:22,685 --> 00:02:26,435 There are some options for giving topical medication. 34 00:02:26,445 --> 00:02:31,345 For example, we can apply things like tramadol to formulations to the ear 35 00:02:31,485 --> 00:02:34,124 and topical amitriptyline also exists. 36 00:02:34,124 --> 00:02:37,655 But the problem with that is that they are very poorly absorbed. 37 00:02:37,655 --> 00:02:41,284 And so they're definitely not an option for many cats. 38 00:02:41,694 --> 00:02:45,755 So I think the first caregiver burden is really that they can 39 00:02:45,755 --> 00:02:48,325 struggle to give medication. 40 00:02:49,075 --> 00:02:53,025 And it can be difficult for them to find solutions for that. 41 00:02:53,065 --> 00:02:57,015 And sometimes it can be so difficult that you have to have the euthanasia 42 00:02:57,015 --> 00:03:02,804 discussion, that the quality of the life of the owner and the cat are just so poor. 43 00:03:02,834 --> 00:03:06,434 The quality of the life of the cat, because they are miserable with the 44 00:03:06,434 --> 00:03:09,635 condition and miserable having medication. 45 00:03:10,225 --> 00:03:12,655 And the owner just can't cope. 46 00:03:12,655 --> 00:03:15,725 So I think, although we focus on treatment in the article, I think we 47 00:03:15,725 --> 00:03:20,615 have to also acknowledge that euthanasia plays a role in some of these cases 48 00:03:20,625 --> 00:03:22,625 because it can be a difficult situation. 49 00:03:23,060 --> 00:03:28,220 As far as quality of life tools, I think they definitely will have a place. 50 00:03:28,240 --> 00:03:32,810 It's challenging sometimes to find one that is suitable for chronic 51 00:03:33,020 --> 00:03:35,149 pain and chronic neuropathic pain. 52 00:03:35,790 --> 00:03:40,909 And so if people are asking what I would tend to use, it would be the AWAG. 53 00:03:40,949 --> 00:03:45,910 That is a pretty useful tool for looking at quality of life and the impact of 54 00:03:45,910 --> 00:03:48,100 the disease and monitoring over time. 55 00:03:48,750 --> 00:03:51,955 Nathalie Dowgray: It's useful to know what works and we're still, I think, 56 00:03:51,955 --> 00:03:56,515 at the stage of developing good health related quality of life tools for cats. 57 00:03:56,565 --> 00:03:58,185 It's a growing area of interest. 58 00:03:59,044 --> 00:04:03,185 You also, within the article, created this really lovely treatment algorithm as well. 59 00:04:03,185 --> 00:04:05,084 And I have to say I do love an algorithm. 60 00:04:05,454 --> 00:04:08,334 In terms of a reference guide as well, I think it's really helpful. 61 00:04:08,524 --> 00:04:11,625 And I wanted to just ask a few questions about some of the drugs. 62 00:04:11,705 --> 00:04:15,580 The first one was around the anti nerve growth factor monoclonal antibodies. 63 00:04:15,600 --> 00:04:18,329 We've only had them available for the last sort of three or four years. 64 00:04:18,490 --> 00:04:21,089 And some people listening to this podcast, it only might just be 65 00:04:21,089 --> 00:04:23,080 coming available in your country. 66 00:04:23,379 --> 00:04:27,530 So I was just really interested in how you've been using them in your work 67 00:04:27,530 --> 00:04:31,599 with pain cases and which ones that you've found them the most useful for. 68 00:04:31,760 --> 00:04:34,350 Clare Rusbridge: Yes, I think this is probably the most exciting 69 00:04:34,360 --> 00:04:38,950 development in pain management that has come out in recent years. 70 00:04:39,620 --> 00:04:42,890 And obviously the big advantage of these drugs is that they're 71 00:04:42,920 --> 00:04:47,090 given by injection and they can be given once monthly, much less 72 00:04:47,109 --> 00:04:50,689 challenging than giving tablets daily. 73 00:04:51,310 --> 00:04:55,585 I think it's important to state that this is most indicated for 74 00:04:55,655 --> 00:04:57,425 peripheral neuropathic pain. 75 00:04:57,985 --> 00:05:03,945 So what it's having an effect on is affecting the way that information about 76 00:05:03,945 --> 00:05:10,164 pain is translated through the peripheral nerve and the dorsal nerve root ganglia, 77 00:05:10,174 --> 00:05:13,825 where the cell body of the nociceptor is. 78 00:05:14,165 --> 00:05:17,495 And so it affects changes in that cell nucleus. 79 00:05:18,185 --> 00:05:24,770 So I wouldn't expect these drugs to work on central neuropathic pain, only in 80 00:05:24,770 --> 00:05:29,280 peripheral neuropathic pain, and people say, Oh, isn't it for osteoarthritis. 81 00:05:29,290 --> 00:05:31,349 Actually, the mechanism is through the nerve. 82 00:05:31,349 --> 00:05:35,410 And so theoretically, it could work for any condition with 83 00:05:35,460 --> 00:05:37,249 peripheral neuropathic pain. 84 00:05:37,249 --> 00:05:43,460 So the conditions that I have used it on successfully in cats, most notably 85 00:05:43,480 --> 00:05:48,550 feline oral facial pain syndrome, which is a challenging condition to treat. 86 00:05:49,430 --> 00:05:51,600 Related to that is dental pain. 87 00:05:51,760 --> 00:05:53,810 Now, I consider those two separate. 88 00:05:53,960 --> 00:05:58,740 Yeah, feline oral facial pain is a syndrome of mutilation that cats probably 89 00:05:58,760 --> 00:06:05,310 have an inherited tendency to, having abnormal processing of information 90 00:06:05,310 --> 00:06:10,230 and it's triggered by teething and other oral lesions, which you wouldn't 91 00:06:10,250 --> 00:06:12,290 normally expect to cause pain. 92 00:06:12,830 --> 00:06:18,260 I would normally expect severe periodontal disease to cause pain, but 93 00:06:18,330 --> 00:06:22,970 sometimes those cats can be left in a lot of pain despite having dentistry. 94 00:06:22,970 --> 00:06:24,400 So they were in a lot of pain beforehand. 95 00:06:24,400 --> 00:06:25,180 They have dentistry. 96 00:06:25,209 --> 00:06:30,979 A lot of cats are discharged from dentals having had extensive dental work with 97 00:06:31,520 --> 00:06:38,205 barely any or no oral medication Just imagine if you had that work done. 98 00:06:38,925 --> 00:06:40,545 I know I'd be a complete baby. 99 00:06:40,725 --> 00:06:44,974 I have seen some cases that where the cat has had some chronic pain 100 00:06:44,985 --> 00:06:51,724 relating to tooth problems, and I've used these anti NGF monoclonal 101 00:06:51,724 --> 00:06:53,465 antibodies successfully in that. 102 00:06:53,514 --> 00:06:57,195 One of the examples I'm thinking about was a cat that had chronic 103 00:06:57,195 --> 00:06:59,625 pain related to its upper canines. 104 00:06:59,875 --> 00:07:03,865 And I was referring to a veterinary dentist to deal with that because 105 00:07:03,885 --> 00:07:07,735 that's quite a complex surgery and there was a long waiting list. 106 00:07:07,744 --> 00:07:11,675 So I had to manage that cat's pain for quite a long time. 107 00:07:11,675 --> 00:07:13,314 So that was one sort of example. 108 00:07:14,005 --> 00:07:19,605 I've also used it successfully for lumbosacral disc disease in the cat. 109 00:07:19,725 --> 00:07:25,250 So I think going forward, I would consider it for any neuropathic pain 110 00:07:25,280 --> 00:07:29,969 syndrome in a cat where the pain is peripheral as opposed to central and 111 00:07:29,969 --> 00:07:32,749 lumbosacral disc disease I regard that as peripheral because the 112 00:07:32,749 --> 00:07:34,379 nerve roots are being compressed. 113 00:07:34,870 --> 00:07:35,999 Nathalie Dowgray: No, that makes sense. 114 00:07:36,000 --> 00:07:39,880 Yeah, and it is definitely exciting and obviously with these drugs came 115 00:07:39,880 --> 00:07:43,920 out they've been licensed in cats and dogs for osteoarthritis, but it's that 116 00:07:43,930 --> 00:07:46,380 bigger piece as well that we're now starting to explore a little bit more. 117 00:07:48,485 --> 00:07:51,285 Clare Rusbridge: It should be said that all drugs used for neuropathic 118 00:07:51,355 --> 00:07:53,865 pain in cats are not licensed. 119 00:07:53,865 --> 00:07:58,645 So you need to make that, those discussions with their caregivers that 120 00:07:58,675 --> 00:08:00,615 you're not giving a licensed medication. 121 00:08:00,965 --> 00:08:03,045 Nathalie Dowgray: Yeah, no, that's important to consider. 122 00:08:04,535 --> 00:08:09,165 And now over to Dr Kelly St Denis and she's speaking with Julien Guillaumen 123 00:08:09,555 --> 00:08:12,195 on feline aortic thromboembolism. 124 00:08:12,990 --> 00:08:14,750 Kelly St Denis: When I was reading through this, one of the things I 125 00:08:14,750 --> 00:08:19,590 always forget about is this potential side effect or sequela of FATE is 126 00:08:19,590 --> 00:08:23,550 acute kidney injury, which you have a lot of really good information in here 127 00:08:23,550 --> 00:08:27,149 about, but I wondered if you would talk a little bit about that aspect of 128 00:08:27,150 --> 00:08:32,140 FATE as a sequela from the problem, how that happens, what you do to monitor. 129 00:08:33,000 --> 00:08:36,079 Julien Guillaumen: That's something that I didn't know that came out of the 130 00:08:36,099 --> 00:08:38,339 paper that we published a few years ago. 131 00:08:38,694 --> 00:08:42,744 Again, funded from Morris Animal Foundation, and I like medical 132 00:08:42,744 --> 00:08:47,645 history, and so I'm gonna start, I'm going to start all over in, in 1953, 133 00:08:47,895 --> 00:08:53,685 but the first case report in cats is actually from a French veterinarian, 134 00:08:54,014 --> 00:08:59,105 I guess the first case report that I can read, and I can only read 135 00:08:59,105 --> 00:09:04,430 in two languages, and so it was published in 1953 in, in, from France. 136 00:09:04,480 --> 00:09:07,340 Dr Collet described the syndrome. 137 00:09:07,590 --> 00:09:10,679 I think it was a necropsy, but so talked about it. 138 00:09:11,710 --> 00:09:15,819 And then, we didn't have a lot of things that was in a 139 00:09:15,830 --> 00:09:18,480 big scale until the eighties. 140 00:09:18,909 --> 00:09:25,679 And so, In 1980, Paul Pion, who was a cardio resident at QC Davis, is 141 00:09:25,679 --> 00:09:31,260 now better known for founding VIN, but before founding VIN, Paul was a, 142 00:09:31,310 --> 00:09:36,669 a cardiology resident and he treated a lot of those cats in the 80s. 143 00:09:36,709 --> 00:09:40,160 I talked to him a few times, and that's kind of what he told me. 144 00:09:40,649 --> 00:09:42,460 And he did a lot of formalising. 145 00:09:42,694 --> 00:09:49,194 At that time, when he published the case theory, there was actually no, 146 00:09:49,415 --> 00:09:56,744 no retrospective studies in the 80s on ATE cats, which I think is fascinating. 147 00:09:57,134 --> 00:10:00,944 The first kind of larger case series was in the 80s when he used 148 00:10:00,944 --> 00:10:05,124 TPA, and he said we didn't expect those cats to get complications. 149 00:10:05,795 --> 00:10:09,984 So when we gave TPA and they got complications, we thought that it 150 00:10:10,025 --> 00:10:14,744 was because of the TPA and because we had nothing to compare with. 151 00:10:15,254 --> 00:10:20,204 And so that's how TPA got its bad reputation as a thrombolytic. 152 00:10:20,854 --> 00:10:26,114 And then in the 90s, there have been a couple of more retrospective studies, 153 00:10:26,134 --> 00:10:32,209 usually from the East Coast, looking at ATE cats, and they do basically say the 154 00:10:32,209 --> 00:10:36,579 same thing in terms of 30 or 40 percent survival rate, all those type of things. 155 00:10:37,199 --> 00:10:39,680 And, but they don't really, they didn't really go into the 156 00:10:39,680 --> 00:10:41,959 details about why those cats died. 157 00:10:43,139 --> 00:10:47,799 And to the point that when I designed my study with the cardiology team at 158 00:10:47,869 --> 00:10:51,759 Ohio State University, while I was there at that time and then other 159 00:10:51,759 --> 00:10:57,099 people, we also did not expect those cats to die very quickly in a way. 160 00:10:57,599 --> 00:11:03,099 And so I think our study was the first one that reported why they died and, and the 161 00:11:03,099 --> 00:11:05,349 complications associated with treatment. 162 00:11:05,779 --> 00:11:08,059 Which again was acute kidney injury 163 00:11:08,409 --> 00:11:12,879 and probably more acute kidney injury than reperfusion injury to be very honest. 164 00:11:13,129 --> 00:11:17,809 And so that's something that I was not expecting and treating those 165 00:11:17,839 --> 00:11:21,269 cats, having those grants, being able to treat a lot of those cats. 166 00:11:21,869 --> 00:11:23,639 That's something that we saw. 167 00:11:24,279 --> 00:11:29,029 Kelly St Denis: Yeah, and so it seems like based on what I read in your articles that 168 00:11:29,039 --> 00:11:33,920 there's the, maybe there's a concern that cats that have pre existing kidney disease 169 00:11:33,920 --> 00:11:38,569 may be at increased risk of that acute kidney injury if they have a FATE episode. 170 00:11:38,569 --> 00:11:40,769 Is that what I'm reading correctly? 171 00:11:41,175 --> 00:11:41,935 Julien Guillaumen: Yes, I know. 172 00:11:41,944 --> 00:11:45,185 Again, that's for me a little bit more of a clinical experience. 173 00:11:45,344 --> 00:11:48,495 So most of the cats are old, right? 174 00:11:48,495 --> 00:11:51,215 I think the average is about 8 to 10 years old. 175 00:11:51,345 --> 00:11:57,375 They have chronic kidney parts in necropsy or ultrasound if you do those things. 176 00:11:58,000 --> 00:12:02,310 And when I have a cat that has an ATE, the first thing I'm going 177 00:12:02,310 --> 00:12:05,990 to look at, it's going to be its admission creatinine value. 178 00:12:06,569 --> 00:12:06,879 Kelly St Denis: Right. 179 00:12:07,299 --> 00:12:13,540 Julien Guillaumen: If it is 3, or if it is 0.8, I think my suspicion is that the 180 00:12:13,540 --> 00:12:18,300 ones that are coming with a creatinine of 3 are going to be more likely to get 181 00:12:18,339 --> 00:12:23,300 into a more rapid acute kidney injury compared to the one that is coming 182 00:12:23,300 --> 00:12:25,699 in with a creatinine of 0.8, right. 183 00:12:25,699 --> 00:12:30,229 I looked at that spreadsheet for a very, very long time and I've treated 184 00:12:30,229 --> 00:12:33,899 a decent amount of those cats and this is my clinical impression. 185 00:12:34,869 --> 00:12:37,329 I'm going to be very careful with those cats. 186 00:12:37,419 --> 00:12:40,289 A lot of those cats are dehydrated as well. 187 00:12:40,879 --> 00:12:44,270 In our study, we had cats that came in with a PCV of 188 00:12:44,270 --> 00:12:47,599 55 and a total protein of 10. 189 00:12:47,930 --> 00:12:50,349 And when they are in congested heart failure. 190 00:12:50,500 --> 00:12:56,269 So, you know, they are coming in with a PCV of 55, a total protien of 10, 191 00:12:56,284 --> 00:13:01,544 a creatinine of 3, and in congestive heart failure, at some point I'm going 192 00:13:01,544 --> 00:13:05,424 to have to switch from Lasix to IV fluid. 193 00:13:06,154 --> 00:13:12,574 And we are all very scared by giving IV fluids to a cat who is in severe HCM. 194 00:13:12,594 --> 00:13:14,734 So, that's why I say it's tricky. 195 00:13:14,774 --> 00:13:18,194 That's why I say it's not an easy clinical management. 196 00:13:18,569 --> 00:13:20,560 Kelly St Denis: Sounds like a crazy balance to do when you do 197 00:13:21,339 --> 00:13:24,549 start being what's going to roll out for that individual patient. 198 00:13:25,059 --> 00:13:28,029 Julien Guillaumen: One of the things I wanted to mention, Dr St Denis as 199 00:13:28,029 --> 00:13:33,259 well, is that even if they develop acute kidney injury, it's not a death 200 00:13:33,469 --> 00:13:38,449 sentence because in our study, we found that around 40 percent of them 201 00:13:38,449 --> 00:13:40,349 will survive their complications. 202 00:13:40,579 --> 00:13:46,634 And so, you know, I have a cat that, you know, did develop a KI, creatinine 203 00:13:46,634 --> 00:13:54,089 goes up 5, 6, 7, but with time, judicious fluids, then they kind 204 00:13:54,089 --> 00:13:56,504 of go back to, to their baseline. 205 00:13:57,084 --> 00:13:57,564 Kelly St Denis: Brilliant. 206 00:13:57,994 --> 00:13:58,414 Okay. 207 00:13:58,904 --> 00:13:59,594 That's good to know. 208 00:13:59,594 --> 00:14:02,034 Again, like, like I said, that wasn't something I was really aware of, and 209 00:14:02,034 --> 00:14:05,294 I think it's partly because I've been in general practice for so long, and 210 00:14:05,294 --> 00:14:09,304 most of these patients don't make it very far in general practice, as we 211 00:14:09,304 --> 00:14:10,694 discussed, for a variety of reasons. 212 00:14:10,694 --> 00:14:12,814 So hopefully we can start seeing that change. 213 00:14:19,383 --> 00:14:20,353 Nathalie Dowgray: Thank you for listening. 214 00:14:20,423 --> 00:14:24,113 If you're an ISFM member, don't forget you can access the full version of this 215 00:14:24,123 --> 00:14:28,913 podcast and all the other ISFM member benefits including congress recordings, 216 00:14:28,953 --> 00:14:33,303 monthly webinars, the monthly clinical club, the discussion forum, and much 217 00:14:33,323 --> 00:14:36,863 much more at portal.icatcare.org. 218 00:14:36,983 --> 00:14:40,763 Later on this month we will be dropping the recordings from our annual congress 219 00:14:40,763 --> 00:14:41,413 in Malta so do look out for those. 220 00:14:42,863 --> 00:14:46,733 If you're looking for more free CPD from ISFM, we do also have an open access 221 00:14:46,733 --> 00:14:49,183 webinar this month from Paulo Steagall. 222 00:14:49,373 --> 00:14:51,993 That's going to be going live on the 24th of July. 223 00:14:52,283 --> 00:14:56,143 And following on from our updated non steroidal guidelines, Paulo's going to be 224 00:14:56,143 --> 00:14:58,443 talking about non steroidals, what's new. 225 00:14:59,473 --> 00:15:02,603 We'll be back again next month with another episode so if you don't want 226 00:15:02,603 --> 00:15:05,733 to miss out, do make sure you're signed up to Chattering with ISFM 227 00:15:06,033 --> 00:15:07,833 on your preferred podcast platform.