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Nathalie Dowgray: Hello, welcome to the
August episode of Chattering with ISFM.

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I'm Nathalie Dowgray, Head of ISFM
and host of this month's podcast.

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First up this month we have Dr
Sarah Ellis speaking with Dr Daniel

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Mills on feline pheromone use.

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And then we have AAFP's Dr Kelly St.

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Denis speaking with Dr Katie Tolbert
on her JFMS Clinical Spotlight

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Article, A Rational Approach To The
Use Of Gastroprotectants In Cats.

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Sarah Ellis: So, Daniel, it's really
lovely to get a chance to speak to

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you and on a topic that I know we're
both quite keen and interested on,

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and that is the topic of pheromones.

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There's so much terminology out there,
and I think sometimes that can be

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quite confusing for people to navigate.

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Is the word scent a better word
to use to simplify things, or

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does that make it more difficult?

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Daniel Mills: I think it is
useful to make a distinction

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between scents and pheromones.

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One of the problems for many
vets is we're not really taught

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much about that at vet school.

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They're chemicals in the air,
so aren't they all scents?

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They're chemicals that are detected, but
they are detected by a variety of organs.

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There's actually several chemo
detecting organs up your nose

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and in your mouth as well.

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We're familiar with what's on the
tongue versus on the nose, and we get

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flavour from the integration of those.

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But there's actually quite a few
organs, not just the main olfactory

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epithelium, which detects odours,
as we might like to think about,

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or scents, but there is another
structure called the vomeronasal organ.

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The important thing about the vomeronasal
organ is that it's wired to parts of

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the brain which are very much more
closely associated with emotion.

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So, it's not just a information about
what the chemical balance is in the air,

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it's actually processing information and
it says, this is emotionally important.

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And for that reason, I think it is
worth distinguishing the pheromones

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from the scents, because these are
such simple molecules, they're present

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in so many things, but in certain
combinations they have real meaning.

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So it's a bit like we've got
certain letters and we put

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them together in a certain way.

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If somebody shouts fire, then
we all react in a certain way.

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If that combination is picked
up by the vomeronasal organ, it

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gets fast tracked into the brain.

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It's not just like hearing the word fire.

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It's actually hearing the word fire and
somebody giving you a shot of adrenaline

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at the same time, because your whole
body is reacting in that situation.

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But I fully understand the skepticism that
some people have, because also as vets,

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we're often trained to think about things
in terms of disorders and pathologies.

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And this is a very different area.

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It's a natural human tendency
also to think of things in

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very black and white terms.

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But when it comes to emotional
processing, pheromones, like any other

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bit of information, they're part of
the wider picture, but they have a

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particular weight in how we see things.

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And when I started my career working
on emotions, it was driven very much

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by trying to understand what it was
these pheromones were doing that was

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different to other olfactory cues.

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And it's trying to think, how
do animals process emotion?

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What is the significance?

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And emotions are personal judgments.

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They're what give individual differences.

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Now, I'm not saying that the pheromones
are about individual identity, but

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it's about subjective judgments.

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You and I both like chocolate.

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If there's a chocolate bar there, I
might fight harder than you because

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I like chocolate more than you do.

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That's what makes me
slightly different to you.

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These individual differences
are really important.

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And as I said, at an emotional
level, we get enormous differences in

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character as a result of differences
in those emotional processes.

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Sarah Ellis: That makes complete sense.

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Something that I often get asked,
is it a pheromone or is it an odour?

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And the reality is the pheromones
will always exist where there's an

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odour as well because of the very
nature and what they're deposited in.

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Daniel Mills: Yeah, absolutely.

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In some species the vomeronasal organ only
opens up when it's triggered to open up.

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So there has to be something in the
olfactory message, usually, or you

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could say that if there's a visual
mark, then that might trigger it.

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But something has got to tell
the animal's brain to send a

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signal to open up the vomeronasal
organ and start processing this.

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They're not something
that work in isolation.

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Again, people who are used to using
drugs for managing behaviour, they

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expect it to treat the condition.

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Whereas what we're doing with
pheromones is we're nudging the

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animal to evaluate its environment
in a certain way and therefore

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hopefully respond in a more acceptable
or appropriate way for the owner.

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Sarah Ellis: So would you say
they aid that sort of emotional

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assessment of their environment?

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Daniel Mills: Absolutely.

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I think they're integral to it.

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We evaluate the world emotionally
in lots of different ways.

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What resources are there?

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What can be taken?

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But that can always be overridden
by a fear message coming in.

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Equally, are there barriers
to what I want to do?

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Because if there are, then I've
gotta do something about them.

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And that triggers the
emotions of frustration.

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But it's not that you are either
scared or you're frustrated.

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So for example, if you are a cat
and you can't get to safety, then

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you're gonna be scared and then
you're gonna be frustrated and

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it's sometimes useful to
anthropomorphise, and I would say that

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might be more like a terror state,
if you want to put a word on it.

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It's more than just fear, because
it's fear followed by frustration,

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and I can't escape from it.

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So I feel that much worse about it.

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And this is how the emotions blend
into our conscious experience.

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Whereas if you are frustrated,
and then scared, whilst you've got

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frustration and fear again, they're
in a different sequence and so it

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will feel like something different.

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Sarah Ellis: I'm thinking about
the example in the vet clinic

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where the vet offers food.

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So you have that, they want the food,
they want to approach, but also there's

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that avoidance piece because they're
not comfortable in those surroundings.

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So you get those two
emotions, one after the other.

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Daniel Mills: Yeah, so you'll
get a state of conflict there and

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often, yes, a conflict will involve
quite often different emotions.

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We often think about it in terms of
approach avoidance from a behavioural

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point of view, but actually from
an emotional point of view as well.

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And it's this that really guides
us what we do as individuals.

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Sarah Ellis: Absolutely.

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Nathalie Dowgray: And now over to Dr
Kelly St Denis and she's speaking with

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Dr Katie Tolbert on her JFMS Clinical
Spotlight Article, A Rational Approach

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To The Use Of Gastroprotectants In Cats.

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Kelly St Denis: Why don't we just start
talking about some of the things that I

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noticed in the article that probably will
affect other people in clinical practice.

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I just do feline medicine, but I
noticed years ago when I was practicing

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with dogs that oftentimes if we
were prescribing non steroidals,

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we would often do medication to try
and protect them from GI ulceration.

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And that's not recommended for cats.

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And I wondered if we could talk
a little bit about why that is.

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Katie Tolbert: Cats are not small
dogs, even though sometimes we like to

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treat them as such, but the way that
they metabolise drugs is different.

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We know that their nutrient
requirements is very different.

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We know that cats are not as at
risk for GI ulceration as dogs.

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In fact, when we do see GI ulceration
in the cat, more commonly, it's

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related to a neoplastic disease
or something like lymphoma or

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carcinoma or rarely gastronoma.

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And if it's non neoplastic, it's usually
something like inflammatory bowel disease.

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Although they can get GI
ulceration, it's just not very

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common as compared to the dog.

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We know that, actually, when you
use gastroprotectants in combination

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with NSAIDs, just based on some
early work that we did in dogs and

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then some work that's been done
in rats and humans, that it might

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actually increase risk of ulceration.

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Kelly St Denis: There's some
discussion around dietary fibre.

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There were studies that looked
at the cat's stomachs in terms of

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when they were on medications and
whether or not they had ulceration.

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And it was noted that there were
changes in how they were going to

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respond to different types of fibre.

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We always think about fibre and diarrhoea,
or fibre and constipation, but not really

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about what's happening in the stomach.

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Katie Tolbert: Absolutely.

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There are obviously a few different
characteristics of fibre that can

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be beneficial for the GI tract.

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And one of them is the fact that
soluble fibres can form gels.

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So if they're viscous fibres, they
can form a protective layer in the

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stomach and the intestinal tract.

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And so there have been a couple of
studies actually, ironically enough

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with NSAIDs and whether or not they
caught some GI bleeding in cats.

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And in this case, they
used extremely high doses.

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So doses that wouldn't be
necessarily therapeutic.

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And what they found was that cats
that received soluble fibres actually

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did have a benefit of those and in
preventing some of that ulceration.

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Kelly St Denis: One of the things
in here, like you guys have

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nicely divided up gastric acid
suppressants and your protectants.

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And I just wondered if you
could talk about the difference?

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Katie Tolbert: Yeah.

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So we, yeah, divide them for
gastric acid suppressants.

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So we have our histamine 2 receptor
antagonists being promoted in our PEPCID.

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And then we have our
proton pump inhibitors.

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Those are going to work directly
on the acid producing cell of the

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stomach, which is the parietal cell.

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So they're going to inhibit acid
secretion by two different mechanisms.

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And then we have cytoprotectins.

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So that would be things that are
like traditionally thought of as

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coding agents, although they can
have some other benefits as well.

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So something like sucralfate or
barium, for example, and then we

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have our prostaglandin analog, so
that would be like misoprostol,

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which is not used as commonly in
feline medicine, but that would be

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the other one that we think about.

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Kelly St Denis: And again, if we're
talking about quality of life and

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how pain and emotion are so connected
that pain is a sensory and an

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emotional experience, again, keeping
a patient comfortable is so important.

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And I wondered if you could just elaborate
a little bit on the use of sucralfate.

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Katie Tolbert: Sucralfate has this
interesting benefit in that it has

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been shown to have some ability to
treat pain in the case of oesophagitis.

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So it does seem to have some
antinociceptive properties.

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And in fact, if you have really severe
oesophagitis and you have the option

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of taking a protein pump inhibitor
or something like sucralfate, you'll

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choose sucralfate every time because
it immediately ameliorates some of

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that painful stimulus versus the PPI.

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It takes a long time to take care
of the acid and decrease the acid.

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So sucralfate is a really nice
drug to use in conjunction

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with a protein pump inhibitor.

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If you're feeling like whatever
disease that you're treating is

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erosive, it's ulcerative and the
cat has pain associated with it.

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Kelly St Denis: And the challenge
always being getting it into the cats.

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Katie Tolbert: That challenge is real.

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You want to make sure you have really
clear instructions for how to make

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sucralfate slurries so they're doing
it appropriately, that you're giving

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it in the way that it needs to be given
and that there's a real conversation

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with the client about, it's okay if
you can't do that, then we think of

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something else that we can try to help.

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Obviously in cats that are very painful
sucralfate alone is not going to cut it.

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It just has that added benefit.

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Like maropitant, for example, we know
that in those studies that sometimes

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animals needed less inhaling gas when
they were undergoing spay because

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of the properties of maropitant on
helping with visceral induced pain.

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And nobody would withhold an opioid
from a dog or cat undergoing a spay just

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because they're getting maropitant..

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So same with sucralfate.

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You're just happy that it also
helps with some of the pain.

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Kelly St Denis: Lately, a lot of my
lectures have been focusing on pain.

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It's the fourth vital
assessment after TPR.

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I think that's a big gap that a lot
of us experience when we're seeing

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patients on a day to day basis.

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We forget how that really
impacts the patient.

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One of the things that we do
a lot with painful cats that

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are older is dental surgeries.

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And one of the things that comes up
in here is a reflex under anaesthesia.

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And I know over the years, I have
heard people recommend to use

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gastroprotectants in those cases.

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And I know in this article you guys
suggest maybe that's not a good idea.

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So I wanted to talk about why that
might be a consideration and why you

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wouldn't recommend it as a routine thing
for an old cat undergoing a dental.

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Katie Tolbert: This is the
section that I really went back

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and forth on how to write it.

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I want to be really careful
about the misuse of these drugs.

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They come, obviously, also with the costs
to the clients so we want to be careful.

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I think there are situations
in which I would recommend it.

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For example, a patient, for whatever
reason, couldn't be fasted for

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the length of period that you
want, I think it makes sense.

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Because this is more of an evidence
based article, we don't have evidence to

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suggest that giving them perioperative or
preoperative acid suppressants actually

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decreases their risk of oesophagitis.

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And so for that reason, we haven't
made a recommendation about it.

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However, it would be
great to have a study.

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In this case, I would give from famotidine
perioperatively and see if there's

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a benefit to reducing oesophagitis
and oesophageal strictures in cats.

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Kelly St Denis: So you wouldn't use
something like a proton pump inhibitor if

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you were going to do it, like Omeprazole,
you would reach for famotidine.

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And so why would that be?

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Katie Tolbert: So famotidine works
very quickly when given injectably.

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The PPI will be more effective.

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But it has to be over time.

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For example, if you had a client who
was very worried about it and you want

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it to be doing everything possible,
then you would really want to,

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especially in cats, you'd really want
to start the proton pump inhibitor,

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like four days before the procedure.

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Kelly St Denis: Wow.

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Katie Tolbert: Yeah.

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Based on our studies that, in cats, they
start to see max effect around day four.

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And so just giving one dose, you're
missing the maximal efficacy.

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So I would give famotidine
because it works within 30

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minutes to an hour of injection.

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Kelly St Denis: Right.

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So if we do have those higher risk
patients, like brachycephalic,

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you have, I think, hiatal hernia.

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Katie Tolbert: Yeah, exactly.

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Kelly St Denis: Yeah, instead of maybe
like diabetics, I'll have them give half

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their meal in the morning with their
insulin because their stomach transit

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time seems to be so quick in cats
anyways, but we don't fast them as long.

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So those would be patients that
you might consider doing that with.

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Katie Tolbert: Exactly.

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And then I would just
wouldn't let your guard down.

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You should do all those care
things that you would do otherwise

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in a high risk patient or a
patient that you're worried about.

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We know the consequences of a
ooesophageal stricture can be fatal.

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You're suctioning out the oesophagus,
for example, or if you notice there's

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a large volume of fluid pooled
into the oesophagus, suction it out

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really well and maybe give a little
bit of a barium or a bicarb like

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solution to help neutralise that.

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Kelly St Denis: Great.

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Those are great tips.

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Nathalie Dowgray: Thank you for listening.

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