1 00:00:04,890 --> 00:00:07,410 Nathalie Dowgray: Welcome to the August 2023 episode of 2 00:00:07,410 --> 00:00:11,670 Chattering with ISFM. I'm Dr. Nathalie Dowgray, Head of ISFM 3 00:00:11,700 --> 00:00:15,240 and host of this month's podcast. First up this month I'm 4 00:00:15,240 --> 00:00:18,870 going to be speaking with ISFM’s own Dr. Sam Taylor. She's the 5 00:00:18,870 --> 00:00:21,210 presenting author of the scientific committee best 6 00:00:21,210 --> 00:00:24,810 abstract award from our 2023 Congress, we're going to be 7 00:00:24,810 --> 00:00:28,830 discussing her abstract which is on the outcome of 307 cats 8 00:00:28,860 --> 00:00:32,670 treated for FIP. And that was with a combination of Remdesivir 9 00:00:32,700 --> 00:00:38,130 and or GS 441524. We're also going to be featuring our 10 00:00:38,130 --> 00:00:41,880 monthly JFMS clinical spotlight interview. And this month, this 11 00:00:41,880 --> 00:00:44,670 is with Dr. Kelly St Denis talking with Dr. Maria 12 00:00:44,670 --> 00:00:49,440 Soltero-Rivera, about feline chronic gingivostomatitis. We 13 00:00:49,440 --> 00:00:50,940 hope you enjoy this episode. 14 00:00:56,010 --> 00:00:59,490 So just to start with Sam, I was really interested to know what 15 00:00:59,490 --> 00:01:02,820 prompted you to start gathering cases for this study. 16 00:01:03,630 --> 00:01:08,520 Sam Taylor: We have been running our FIP advice email service and 17 00:01:08,520 --> 00:01:11,700 we set that up because we knew that people would have questions 18 00:01:11,700 --> 00:01:15,450 about these novel drugs. And we also ourselves wanted to learn 19 00:01:15,450 --> 00:01:17,940 and connect with people around the world who were using the 20 00:01:17,940 --> 00:01:21,870 drugs. And from that we've worked out that there were some 21 00:01:21,870 --> 00:01:25,290 of the same queries and some different queries. And we 22 00:01:25,290 --> 00:01:29,250 thought, can we bring this all together to tell more people 23 00:01:29,250 --> 00:01:32,310 about this collective experience? If we could show 24 00:01:32,580 --> 00:01:35,280 that they worked, and that they were safe, and we could educate 25 00:01:35,280 --> 00:01:39,060 people a little bit more on what to look for adverse effect wise, 26 00:01:39,120 --> 00:01:42,570 and then hopefully, as a consequence, get these quality 27 00:01:42,570 --> 00:01:45,660 kind of products where we know what's in them, to more people 28 00:01:45,660 --> 00:01:46,470 around the world. 29 00:01:46,680 --> 00:01:48,450 Nathalie Dowgray: When you were starting this process, and the 30 00:01:48,450 --> 00:01:51,930 group of you were starting the plans, how did you agree the 31 00:01:51,930 --> 00:01:55,470 inclusion criteria, especially for the diagnosis of FIP? 32 00:01:56,170 --> 00:01:58,060 Sam Taylor: Yeah, and I think that was really challenging. One 33 00:01:58,060 --> 00:02:00,490 of the particularly challenging things about a retrospective 34 00:02:00,490 --> 00:02:05,590 like this is the variable, sort of, levels of investigation that 35 00:02:05,590 --> 00:02:07,480 are done. And we had, it's another thing that I kind of 36 00:02:07,480 --> 00:02:10,390 like about the study, but it was also challenging, we had cases 37 00:02:10,390 --> 00:02:14,860 treated in referral that had MRI, CSF, PCR, you know, really 38 00:02:14,860 --> 00:02:18,760 extensive investigation. And then we had cats that were, you 39 00:02:18,760 --> 00:02:22,420 know, quite understandably and pragmatically treated based on 40 00:02:22,450 --> 00:02:26,200 the likelihood of diagnosis. And so we thought, how are we going 41 00:02:26,200 --> 00:02:29,980 to handle that. And so what I did is I reviewed all the cases, 42 00:02:30,310 --> 00:02:33,940 and we categorised them according to basically something 43 00:02:33,940 --> 00:02:36,850 that the ABCD use. And so we start off with these sort of 44 00:02:36,850 --> 00:02:40,390 categories of being confirmed, highly suspicious, and very 45 00:02:40,390 --> 00:02:43,360 likely. And we thought that might be a good way of looking 46 00:02:43,360 --> 00:02:46,900 at the cases so that we could still include those 47 00:02:46,900 --> 00:02:50,710 pragmatically treated cases that didn't have every bit of data. 48 00:02:51,040 --> 00:02:53,140 And the other reason we wanted to include all those cases, 49 00:02:53,140 --> 00:02:56,350 because I wanted it to be real. And if we just include those 50 00:02:56,350 --> 00:02:59,380 cases that have had 1000s of pounds of referral workup, 51 00:02:59,380 --> 00:03:02,470 that's not real, that's not relevant to the person who is 52 00:03:02,470 --> 00:03:05,530 working in primary care. And so we really wanted to have those 53 00:03:05,530 --> 00:03:08,260 cats included. And I hope we've managed to do it in that way. 54 00:03:08,500 --> 00:03:10,060 Nathalie Dowgray: Brilliant. Now, that's a really clever way 55 00:03:10,060 --> 00:03:14,290 of doing it. And you managed to include 307 cases, that's a 56 00:03:14,290 --> 00:03:17,860 fantastic number. How many did you have to exclude? 57 00:03:18,070 --> 00:03:21,130 Sam Taylor: Well, not too many is the answer. So things that we 58 00:03:21,130 --> 00:03:24,220 excluded, we were very clear, we wanted to exclude cats that have 59 00:03:24,220 --> 00:03:28,240 been treated with black market products for part of their 60 00:03:28,240 --> 00:03:31,030 treatment, which in some countries, and particularly in 61 00:03:31,030 --> 00:03:33,850 the early treated cases, very understandable that some of them 62 00:03:33,850 --> 00:03:37,450 had some treatments in that way. But that would mean we couldn't 63 00:03:37,480 --> 00:03:40,780 interpret the results and the effects of the treatments that 64 00:03:40,780 --> 00:03:43,630 we wanted to study. So we excluded those cats and then we 65 00:03:43,630 --> 00:03:47,710 also excluded cats where, when I followed their history or when 66 00:03:47,710 --> 00:03:49,660 the vet submitted their history, we didn't have enough 67 00:03:49,660 --> 00:03:52,630 information on how they'd responded and we couldn't 68 00:03:52,660 --> 00:03:57,070 provide that level of detail. We actually only excluded about 11 69 00:03:57,070 --> 00:03:58,180 cases in the end. 70 00:03:58,780 --> 00:03:59,590 Nathalie Dowgray: Brilliant. 71 00:03:59,750 --> 00:04:03,500 Sam Taylor: In general, higher doses give you better responses. 72 00:04:03,980 --> 00:04:06,050 But the other thing I really learnt from the study, which 73 00:04:06,080 --> 00:04:08,870 probably is true of all cats is this huge amount of variation. 74 00:04:09,140 --> 00:04:12,140 So what really surprised me was that some cats that were treated 75 00:04:12,140 --> 00:04:16,040 with lower doses, that were very sick, actually responded very 76 00:04:16,040 --> 00:04:18,740 well. And then you've got other cats that were treated with 77 00:04:18,740 --> 00:04:22,100 higher doses that didn't do as well. Although we will give 78 00:04:22,100 --> 00:04:25,790 dosage advice, that should be adapted to the individual, 79 00:04:25,820 --> 00:04:29,660 depending on their response. We weren't seeing adverse effects 80 00:04:29,660 --> 00:04:33,110 with those high doses. So the drugs do seem to be very well 81 00:04:33,110 --> 00:04:37,490 tolerated. But lots of individual variation. I never 82 00:04:37,490 --> 00:04:41,360 thought we'd be here where we're talking about 84% response to a 83 00:04:41,360 --> 00:04:44,870 treatment when you have FIP in the same sentence. So I'm hoping 84 00:04:44,870 --> 00:04:46,850 you know that in another five years, we'll have really 85 00:04:46,850 --> 00:04:50,300 individualised treatment, we'll have other drugs, we'll do 86 00:04:50,300 --> 00:04:53,120 combination. I think it's, you know, super exciting, where 87 00:04:53,120 --> 00:04:54,290 we're gonna go with this. 88 00:04:55,580 --> 00:04:57,620 Nathalie Dowgray: The full paper from this abstract has now been 89 00:04:57,620 --> 00:05:02,000 accepted for publication, so do watch out for that in JFMS. Now 90 00:05:02,000 --> 00:05:05,030 I'm going to be handing over to Dr. Kelly St Denis talking with 91 00:05:05,030 --> 00:05:15,410 Dr Maria Soltero-Rivera on her JFMS clinical spotlight article 92 00:05:15,470 --> 00:05:18,050 ‘Feline Chronic Gingivostomatitis: Current 93 00:05:18,260 --> 00:05:22,790 concepts in the clinical management’. Don't forget JFMS 94 00:05:24,050 --> 00:05:27,440 is an open access journal now. So the link to read that full 95 00:05:27,470 --> 00:05:29,000 article is in the show notes. 96 00:05:29,000 --> 00:05:29,330 Kelly St Denis: Welcome Dr. Soltero-Rivera. 97 00:05:29,330 --> 00:05:30,110 Maria Soltero-Rivera: Thank you, Kelly. Thank you for having me. 98 00:05:30,110 --> 00:05:31,310 Kelly St Denis: So some of your focus on your research obviously 99 00:05:31,310 --> 00:05:32,630 has been within the feline dentistry aspect and obviously 100 00:05:32,630 --> 00:05:34,850 FCGS. So in addition to just diagnosing dental disease in 101 00:05:34,850 --> 00:05:38,240 general, like Feline Chronic Gingivostomatitis is something 102 00:05:38,270 --> 00:05:42,800 that some clinicians struggle with, because as we've learned 103 00:05:42,800 --> 00:05:45,230 through the review article, one of the main treatments is 104 00:05:45,230 --> 00:05:49,130 surgical extraction. There's always some hesitancy there. So 105 00:05:49,190 --> 00:05:52,220 are there any tips that you could give to clinicians that 106 00:05:52,220 --> 00:05:55,940 would say help them to feel more confident in that diagnosis on 107 00:05:55,940 --> 00:05:59,420 observation and moving forward with dental that you could 108 00:05:59,420 --> 00:05:59,840 share? 109 00:06:00,380 --> 00:06:02,510 Maria Soltero-Rivera: Yeah, absolutely. It's a disease that 110 00:06:02,510 --> 00:06:07,160 has been for some time recognised grossly, and it 111 00:06:07,160 --> 00:06:11,630 hasn't been recognised in more objective ways. What I mean by 112 00:06:11,630 --> 00:06:14,930 that is we've relied on people looking at the oral cavity and 113 00:06:14,930 --> 00:06:17,960 saying, yay or nay, it has stomatitis. But I think we have 114 00:06:17,960 --> 00:06:21,950 to remember that there are some objective ways to characterise 115 00:06:21,950 --> 00:06:25,370 the disease that we haven't been as reliant on in the past that I 116 00:06:25,370 --> 00:06:29,390 hope that we can bring into light with this review. This is 117 00:06:29,390 --> 00:06:33,710 a disease that affects different areas of the oral mucosa, the 118 00:06:33,710 --> 00:06:37,130 buccal mucosa is affected, the alveolar mucosa is affected, and 119 00:06:37,130 --> 00:06:40,160 you need to have all of those affected, not just one or the 120 00:06:40,160 --> 00:06:43,310 other. I think all of those need to be affected. Where is the 121 00:06:43,400 --> 00:06:46,790 inflammation centred, usually in the back of the oral cavity 122 00:06:46,820 --> 00:06:50,360 lateral to the palatoglossal arches. And then you dive in and 123 00:06:50,360 --> 00:06:54,560 you say, All right, what is here microscopically. You want to 124 00:06:54,560 --> 00:06:58,040 find lymphoplasmacytic inflammation. We're currently 125 00:06:58,040 --> 00:07:01,760 working on this theory that if you see other cell types in 126 00:07:01,760 --> 00:07:05,210 there, like eosinophils, things can be a little bit different. 127 00:07:05,240 --> 00:07:07,520 And we could be dealing with a different subtype of this 128 00:07:07,520 --> 00:07:09,290 disease. So I think characterising the 129 00:07:09,290 --> 00:07:14,060 histopathology is important to confirm your suspicion, and to 130 00:07:14,090 --> 00:07:18,650 see if there's anything that could modify the disease or the 131 00:07:18,650 --> 00:07:23,090 prognosis for these cats, and then figuring out, Hey, how are 132 00:07:23,090 --> 00:07:26,660 we doing in terms of viral status, right? So is FeLV FIV 133 00:07:26,660 --> 00:07:29,780 involved and FCV involved and whenever possible, once there 134 00:07:29,780 --> 00:07:32,600 becomes a commercial test, is foamy virus involved? Because 135 00:07:32,600 --> 00:07:35,930 all of these have been known to modify the disease, if you will, 136 00:07:35,930 --> 00:07:38,690 and certainly the response to treatment can be affected by 137 00:07:38,690 --> 00:07:42,650 these factors. It's not only the oral cavity that's affected, 138 00:07:42,650 --> 00:07:45,380 there are multiple systems affected and that's what we're 139 00:07:45,380 --> 00:07:49,640 trying to pull apart as we continue to study this disease. 140 00:07:49,710 --> 00:07:51,750 Kelly St Denis: Did you want to tell us a little bit about how 141 00:07:51,750 --> 00:07:55,440 someone decides between partial versus full mouth extraction? 142 00:07:55,780 --> 00:07:58,180 Maria Soltero-Rivera: Yeah, in general, when you do your oral 143 00:07:58,180 --> 00:08:01,480 evaluation, again, going back to where is the inflammation 144 00:08:01,480 --> 00:08:04,810 localised and extending to. In our practice when the 145 00:08:04,810 --> 00:08:08,590 inflammation extends all the way rostrally to affect the incisors 146 00:08:08,590 --> 00:08:12,220 and the canines, we recommend full mouth extractions. It's 147 00:08:12,220 --> 00:08:16,270 when those incisors and canine teeth look a little bit less 148 00:08:16,270 --> 00:08:18,460 effective or less effective altogether. Sometimes you have 149 00:08:18,460 --> 00:08:20,890 those that have the inflammation just confined to the back of the 150 00:08:20,890 --> 00:08:25,210 mouth, then you start thinking, should I try to preserve teeth 151 00:08:25,210 --> 00:08:29,800 and it's not wrong to take a staged approach, but the 152 00:08:29,800 --> 00:08:32,920 conversation with the client should be very clear in that 153 00:08:33,160 --> 00:08:37,630 this may not be curative. When we look at those studies that we 154 00:08:37,630 --> 00:08:40,630 did, comparing partial versus full mouth extractions, we 155 00:08:40,630 --> 00:08:43,000 didn't necessarily see a significant difference in 156 00:08:43,000 --> 00:08:47,590 response between the two treatments. That said, we were 157 00:08:47,590 --> 00:08:50,980 treating with partial mouth extractions. So the patients 158 00:08:50,980 --> 00:08:54,460 that didn't have that rosteral involvement, right? So whether 159 00:08:54,460 --> 00:08:58,390 we're treating the different degree of severity, a different 160 00:08:58,390 --> 00:09:03,040 manifestation or subtype of the disease or treating other 161 00:09:03,040 --> 00:09:07,510 diseases that were confusing with FCGS? That's a good 162 00:09:07,510 --> 00:09:11,110 question. I think that, again, it's not wrong to start with 163 00:09:11,110 --> 00:09:14,140 partial mouth extractions, if the inflammation is only 164 00:09:14,140 --> 00:09:16,360 confined to the caudal oral cavity, it's just the way that 165 00:09:16,360 --> 00:09:19,150 we present it to the clients saying, this is, you and I are 166 00:09:19,150 --> 00:09:22,540 going steady here. Now that we're treating this patient. 167 00:09:22,570 --> 00:09:23,830 Kelly St Denis: it's not a one and done. 168 00:09:23,920 --> 00:09:26,560 Maria Soltero-Rivera: This is not a one and done. And we're 169 00:09:26,560 --> 00:09:29,140 going to have to monitor them closely. And if we have to come 170 00:09:29,140 --> 00:09:33,160 back to extract the rest of the teeth, we will, we will do that. 171 00:09:34,360 --> 00:09:37,450 Kelly St Denis: Excellent. Thank you so much. I've really enjoyed 172 00:09:37,450 --> 00:09:40,090 chatting with you. And I hope everyone has the opportunity to 173 00:09:40,090 --> 00:09:42,910 check out the current concepts in the clinical management of 174 00:09:42,910 --> 00:09:45,280 Feline Chronic Gingivostomatitis. Thank you, 175 00:09:45,280 --> 00:09:48,430 Dr. Maria Soltero-Rivera, and thank you to your colleagues as 176 00:09:48,430 --> 00:09:51,970 well for this great review article. And as I've said, 177 00:09:51,970 --> 00:09:54,340 there's a lot of really practical information in that 178 00:09:54,340 --> 00:09:57,460 review article that you can use in practice and some charts and 179 00:09:57,670 --> 00:10:00,940 guidance that I think we all could use on a day to day basis. 180 00:10:00,940 --> 00:10:03,880 So definitely check it out, and it is open access. So have a 181 00:10:03,880 --> 00:10:05,200 look. Thanks again. 182 00:10:05,640 --> 00:10:06,300 Maria Soltero-Rivera: Thank you 183 00:10:11,550 --> 00:10:13,680 Nathalie Dowgray: Thank you for listening. If you are an ISFM 184 00:10:13,680 --> 00:10:16,440 veterinary member don’t forget you can access the full version 185 00:10:16,440 --> 00:10:19,800 of this podcast and all the other ISFM veterinary membership 186 00:10:19,800 --> 00:10:23,160 benefits including congress recordings, monthly webinars, 187 00:10:23,190 --> 00:10:26,700 our clinical club, the discussion forum and much more 188 00:10:26,700 --> 00:10:31,590 at portal.icatcare.org. We will be back next month, If you don’t 189 00:10:31,590 --> 00:10:34,080 want to miss out, do make sure you sign up to Chattering with 190 00:10:34,110 --> 00:10:36,660 ISFM on you preferred podcast platform.