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Hello and welcome to
Chattering With iCatCare.

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I'm Yaiza Gomez-Mejias, iCatCare
Veterinary Community Coordinator

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and host of this month's podcast.

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This episode will include two second
parts of interviews we started to

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share with you in previous episodes.

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The topics will be skin and urinary tract.

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Dr Kelly St Denis will complete
the conversation she started

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in April with Dr Banovic about
immune-mediated skin diseases in cats.

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But first you will hear the second part
of the interview I started in February

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with Sam Taylor and Rachel Korman on
the new iCatCare consensus guidelines

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on lower urinary tract diseases in cats.

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So what are your thoughts on
supplementary or complimentary therapies?

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It's always important to evaluate
the impact on the individual cat.

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We always talk about  easy to
give and easy to administer.

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For example, plugins have the very
minimal impact on the cats sort of day

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to day lifestyle and it may be very
helpful, I think that's worthwhile trying.

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The flip side might be dietary
add-ins or capsules and might just

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be another thing that sort of causes
a change in the cat's routine.

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If it's a cat reliant on routine
and not having anything additional

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put into its food, or any additional
medications, that could result in

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further anxiety and you have to weigh
up the evidence for the benefit of what

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you might be adding into that patient.

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I agree.

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I think many blocked cats we get
referred will be on some supplement,

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glycosaminoglycans supplements, you go
on Amazon and they can buy all of these.

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I'm yet to meet a cat in that
acute phase of being blocked

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where that's been of benefit.

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I always wonder if it's a placebo
for us and the client, but I

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agree with Rachel, that's not
what that cat needs at that time.

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Change can be stressful for some of
these very susceptible individuals.

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You just don't want to
be changing anything.

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I've got one cat that has very
recurrent FIC, and he is a very hyper

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vigilant anxious cat and his latest
episode of FIC was because a large

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leaf blew off a tree and went into
his face and he developed hematuria.

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This is how sensitive some cats are.

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Giving lots of medications is not ideal.

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The other thing I would say about
a diet is that changing diet during

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that acute phase is not the time, they
like familiarity during that period.

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There is minimal evidence for the
benefit of some nutritional supplements.

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It's possible that some individuals
would benefit longer term.

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But not in that acute period.

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The number one priority, that's got
to be things like analgesics for

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what is a very painful condition.

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I was referring to the chronic or
recurrent disease where owners, we only

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see them occasionally and they look for
a way to sort out  the ongoing problem.

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Sometimes what helps me is to redirect
the conversation towards the diet, not

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for the diet to be changed immediately
in the acute phase, but in the long

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term that provides them with a tool
to do something not necessarily

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dependent on the veterinary practice.

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It makes them gain a little
bit of agency on that side.

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I feel like that's where you also have
the ability to redirect into behavioural

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and environmental modification.

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Often there are simple things
owners can change, making sure

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they're aware of the different
pillars of key resources cats need.

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Everyone wants a magic pill to fix
the problem, but a lot of times

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making sure they have all of those key
resources, that is really gonna be the

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thing that helps a lot of the cats.

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Talking about pain relief, which is
very important, and Gabapentin is very

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popular among feline practitioners.

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And in your experience, can it
provide some analgesic effect in,

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in, in feline idiopathic cystitis?

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Yeah, I think Gabapentin is one of those
drugs we over rely on for analgesia.

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I see it used a lot for many sources
of pain and having had conversations

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with brilliant anaesthetists, when we
wrote the acute pain guidelines, they

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were clear to state that there isn't
a huge amount of evidence for the

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analgesic effect of this drug, that
we need to not rely on it for that.

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Having said that, I think we all accept
it could be quite useful when you

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think of a disease that potentially
has a sort of neuropathic origin.

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I do tend to use it.

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The other reason it can be useful
is from an anxiolytic point of

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view, and cats are in the clinic.

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I know we are talking longer term
here, but for blocked cats in the

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clinic it can help with tolerance of
urinary catheters and things as well

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from that anxiolytic point of view.

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So I may be relying on it sometimes for
that as well as an analgesic effect, but I

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worry about using it as a sole analgesic.

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I wouldn't in a blocked cat or a
cat that had an extremely inflamed

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bladder, I think then we need to
think about multimodal analgesia,

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but I dunno what Rachels thoughts
are on Gabapentin in urinary cases.

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I would agree.

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We use it quite a lot in our
blocked cats, but not as an

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analgesic, often as an anxiolytic.

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We'll also use it preemptively in cats
coming to the clinic for assessments

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for potentially other disease processes,
but where they've had a history of

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anxiety related urinary tract disease.

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We may use it after their visit
for a couple of days to help and

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take the edge off their anxiety.

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But in that acute phase when cats
are presenting with an obstruction,

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we are using opioids traditionally.

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Catheters have always been a big topic.

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How long to leave and what do you do
with the bladder distention in cats

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who present with inability to urinate?

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Would you like to talk about catheters
on the most controversial aspects?

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Well, it was interesting doing
the guidelines with international

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differences because some countries
they routinely use red rubber

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catheters and find them cost effective.

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I haven't used one in
the UK for a long time.

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We tried to illustrate different
types of catheter in our guidelines.

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I just wanted to mention that because
I found it really interesting and I

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learned something from how the red
rubber catheters are attached to the cat,

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we've detailed that in the guidelines,
which is a slightly alternative

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approach from what I'm familiar with.

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Hopefully people will pick
up some tips and information.

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The cat that that sort of recurrent blocks
or doesn't urinate after catheterisation

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is a really interesting one.

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There are a few aspects to it.

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Sometimes we have cats that
have anxiety and there may be

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cats stressed in the clinic.

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They may be cats that are
used to urinating outside.

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When we remove their urinary catheter, we
expect them to produce a perfect urination

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in a litter tray so that we all feel
better that they're no longer obstructed.

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But it's not entirely realistic.

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If you have a cat that is not
familiar with using a litter tray in

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a stressful environment of the clinic,
they're not gonna use litter tray.

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So sometimes you have to be brave and
discharge these cats to see if they will

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urinate within their normal environment.

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I would say that's like using your own
toilet versus a toilet in public for them,

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they're not going to want to do that.

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So that doesn't apply if they're straining
or anything like that and that's where

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a retrograde, again, I keep advertising
retrogrades, but it's reassuring because

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if you know you haven't got a physical
obstruction, you might feel bolder

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in giving them more time to urinate.

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There are other reasons for cats not being
able to urinate after an obstruction.

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In your clinic, Rachel, do you keep
them in or do you try and get them home?

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No, we actively try and get them home
and I would say that it's more common

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to remove a urinary catheter and
discharge them almost straight away.

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But we're hyper vigilant about making sure
the owners understand the risk factors

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and what they need to be monitoring for.

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If those owners are picking their cat
up at 7:30 in the morning, dropping

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him off and then going to work for
the whole day, that's not a cat we'll

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discharge into that environment.

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They need to be going home and being
closely monitored for signs of straining

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and dysuria, but certainly my own cat,
perfectly normal, never had an episode of

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lower urinary tract disease, but if she
goes into the clinic, she's scared of her

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own shadow, won't urinate for a long time.

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For these cats where we know they're
anxious and stressed, expecting them to do

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a large, normal stream urination in front
of an audience is really not gonna happen.

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And now Dr Kelly St Dennis will speak
with Dr Banovic about the two articles

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he co-authored and published in the
Journal of Feline  Medicine and Surgery

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on Immune-Mediated Skin Diseases in Cats:
Presentation, Diagnosis and Management.

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I know we talked a little bit about
plasma cell pododermatitis in the last

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episode, but I also wanted to talk
about PNOE, which is proliferative

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necrotising otitis externa, which
has been interesting problem that

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we don't see very often in cats.

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I've had a couple cases in my own career.

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That can look like ear mites, a food
allergy response or, at least that's, I've

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seen a few cases respond to food changes.

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What sets them apart in terms of
the things that we see with PNOE

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that we wouldn't see with ear mites?

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We're gonna do cytology to diagnose
ear mites, but what are the other

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things that we see in PNOE in cats?

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Depends where you practice.

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Population-wise, majority of patients are
getting some kind of isoxazolines in cats.

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Isoxazolines are good medications
that deal with ear mites efficiently.

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Suspecting ear mites with isoxazolines
is rare unless the owner is not applying

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it and just keeping cubes at home.

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The ear mite itself versus this
disease, this disease based on the

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images causes unique plaques, generally
erythematous plaques, raised, bumpy,

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proliferative lesions, they can
have hyper pigmented crusting on

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top, probably scaling with crusting.

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The mites tend to be preauricular,
so before the entrance to the ear

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canal, although sometimes we see
them in the ear canal as well.

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The mites itself, they don't like
to usually cause any proliferative

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epidermal lesions, like this entity.

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So just looking clinically, you
probably would figure out, but just to

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be safe, you can always run cytology.

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If you suspect you don't mites and you
don't find them on cytology, doesn't mean

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they may not be there, still run your
treatment to be certain it's this disease.

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We do not know a lot about
proliferative necrotising otitis.

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It's called proliferative because like
I said, they tend to be like raised

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elevated lesions and it's necrotising
because there is a lot of cell death of

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keratinocytes in these lesions likely
associated with a lymphocytic attack.

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The most common reason lymphocytes
would kill epithelial cells, you

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would think infectious, so like the
herpes virus, because to kill viruses

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you send these cytotoxic T cells.

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But all the times that we have ever
seen, we never find any virus, so we

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really don't understand the aetiology.

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It does happen usually in younger
cats, but can happen in older as well.

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But.

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Usually tends to respond
to immunomodulation.

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I would say it's 50 50 with sometimes
cats going in remission fully, and you can

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stop your immunosuppressors, but sometimes
you may still need to do something

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that the lesions don't come back.

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Again, really unique, unknown to us why
this would happen, but once you see it,

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I think it's very unique clinically.

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Sure.

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Specifically, if you look at the
images we show there, those are the

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classic examples of the disease.

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Yeah, tacrolimus is the preferred
treatment then for, as a topical?

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As a topical, yes.

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People will use topical glucocorticoids
depending what access you have.

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Tacrolimus is a calcineurin inhibitor,
like cyclosporine, except it's more

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potent and it's topical in why we
use it in veterinary dermatology.

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What probably usually happens
is that people will use oral,

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like oral glucocorticoid.

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It's in a topical.

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You have to be careful that you apply it
in areas that a cat cannot lick it off.

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So preauricular would be a good
area because they cannot do that.

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So yeah, we will try to do
tacrolimus, but it's not wrong

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to do topical steroids either.

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They're just not ideal long-term
for the skin because they can cause

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atrophy, commodos, and fragility.

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Tacrolimus would be a better
long-term option if you can get that.

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Thank you.

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That's much appreciated.

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I really appreciated the conversations
we've been able to have, like,

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Just really highlighting how
practical these articles are.

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I love how they're laid out in terms
of each disease, how you have the

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pathophysiology signalmeant, how to
diagnose and what are the clinical

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features that are  hallmark to those
specific diseases, and where to

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take your biopsies depending on the
condition that might be suspected.

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And so I just wanted to thank you again
for agreeing to write the articles

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for us and doing such a great job
and for joining us today as well.

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Again, we are talking about the
clinical spotlight articles in

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the Journal of Feline Medicine
and Surgery Feline Immune-Mediated

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Skin Disorders part two today.

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But we also have a part one that
we discussed in our last podcast.

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So Dr Banovich, again,
thank you for joining us.

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Thank you, Kelly, and
thank your team as well.

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We hope these articles contribute a
lot to public knowledge of the diseases

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and hopefully people will have a
better understanding of these entities

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and how to treat them in the future.

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Thank you for listening.

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If you are an iCatCare Veterinary Society
member don’t forget you can access the

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full version of the podcast and all
the other member benefits including

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congress recordings, monthly webinars
and clinical clubs, the discussion forum

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and much more at portal.icatcare.org

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If you are looking for more Free CPD
from International Cat Care on the

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15th of July Prof. Dr Nadine Passlack
will host an open access webinar

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on Nutritional strategies in Feline
Urolithiasis, sponsored by Purina

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We’ll be back again next month with more
from the world of feline medicine and JFMS