Saturday, December 11, 2010

270. Immunosuppressive drugs, oxalate urinary stones, cheek tumour dog cases

3 reports are written by the vet intern. They are:
immunosuppressive drugs, oxalate urinary stone management and 24-hour follow up on a surgery to excise the recurred right cheek tumour in a dog for the 4th time.

Atopica® (Cyclosporine-systemic) 50mg soft caps
INDICATIONS: Normally indicated for perianal fistula, atopic dermatitis, feline necrotizing gingivitis, renal transplantation and other immune-suppressive purposes.

Dose rate (CANINE): 2-5mg/kg PO q12h OR 2-5mg/kg PO q24h if concurrent ketoconazole administration*
PRECAUTIONS: Ensure to adjust dose to attain good clinical response. Overdose or excessive use may cause nephrotoxicity (protein-losing nephropathy), gingival hyperplasia, anaphylaxis (type 1 hypersensitivity reaction) possibility with IV administration.
DO NOT use in dogs aged less than 6 months or weighing less than 2kg as efficacy and safety has NOT been assessed for the above-mentioned parameters.
Occasionally, Atopica may cause gastrointestinal disburbances such as vomiting, mucoid or soft stool and diarrhoea as well.

Imuran® (Azathioprine) 50mg tablets
INDICATIONS: This is an immunosuppressive agent, normally indicated for use in autoimmune diseases such as Rheumatoid Arthritis, immune mediated hepatopathies, pemphigus, polymyositis, myasthenia gravis, atopic dermatitis, Idiopathic thrombocytopenic purpura (ITP) etc.
PRECAUTIONS: DO NOT USE IN CATS as it is TOXIC. Ensure to monitor CBC, bone marrow suppression and biochemistry (to ensure that leukopenia and thrombocytopenia does not occur). Although incidence rate is rare, use of Imuran may occasionally result in hepatotoxicity.
NOTE recommended dose rates for Diazepam + Ketamine drug combinations for anaesthetic induction is 0.25mg/kg IV for Diazepam and 5.0mg/kg IV for ketamine

UROLITHIASIS: This is essentially aggregates of crystalline and occasionally non-crystalline solid substances that form in one or more locations within the urinary tract
CLINICAL SIGNS: Signs normally vary according to the locations of the uroliths and normally include cystitis, stranguria, dysuria, haematuria and Urinary Tract Infection (UTI). Acute urethral obstruction may also occur. Hydronephrosis and sometimes renal failure also occur with nephroliths. Ureteroliths are normally accompanied by intense pain.
DIAGNOSIS: Based on clinical signs, palpation and diagnostic imaging.
UROLITH TYPES: There are generally 6 types of uroliths, which is basically made up of a central Nidus, coated with stone, followed by a shell and surface crystals


The types include:
Calcium Oxalate
Ammonium Urate (Urates)
Only Calcium Oxalate uroliths shall be discussed
RISK FACTORS: Increased urinary calcium excretion DUE TO
- Increased GI calcium absorption (absorptive hypercalciuria)
- Renal-leak hypercalciuria (a tubular defect)
- Hypercalcaemia (of any cause, usually chronic)
- Hyperadrenocorticism (Cushings)
TREATMENT: Medical dissolution of calcium calculi is NOT possible so the only treatment is surgical removal, lithotripsy or hydropropulsion.
- Correction of hypercalcaemia if present
- A reduced protein, calcium and oxylate diet for absorptive hypercalciuria
- Urinary alkalisation with potassium citrate
- Consider thiazide diuretics in dogs with highly recurrent disease (eg. Hydropchlorothiazide at 2mg/kg q12h PO)
- Recurrence is common.

POST OPERATIVE Subjective, Objective, Assessment and Plan (SOAP) for XXX, 11 Y/O mixed breed male dog
Subjective: XXX was eating and drinking normally. No observed signs of anorexia, dysphagia or dysuria. His attitude was BAR (Bright alert and responsive).
Objective: On physical examination, XXX’s heart rate and respiratory rate were within normal limits at 72bpm and 30bpm respectively. Weight remained relatively constant at 9.5kg. Rectal temperature was at 38.8 degrees Celsius, mucous membranes were pink and moist with CRT <2s, displaying no abnormalities in peripheral perfusion.
Assessment: XXX was given 1 tablet Imuran (Azathioprine) 50mg PO and antibiotic and antifungal coverage with metronidazole* 10mg/kg IV slowly via fluid bag.
*Side effects of metronidazole may include vomiting, hepatotoxicity and skin hypersensitivity so use with caution and keep under close observation.
Roy was also given 500ml of 5% Dextrose, 0.45% NaCl fluid therapy overnight at maintenance flow rates to maintain electrolyte balance, prevent hypovolaemia and dehydration.
Plan: To assess again in the morning and to administer another dose of metronidazole given at 10mg/kg IV q8h. Ensure vitals, temperature and peripheral perfusion are within normal limits.

Done by
Name of student

4th year vet student, Murdoch Univ
Seeing vet internship practice at Toa Payoh Vets
Dec 6-10, 2010. One of the few interns who was hardworking to write up case studies seen. Most observe and do not write. University professors do require report writing from students seeing practice in some instances but this is not a consistent policy.

4th year exam results are out for Murdoch Vet students. I hope this intern has good news.
XXX went home on Day 2. Imuran tablets will be given 1/4 tab/day. Antibiotics Baytril and multivitamins are given. Need to follow up. Prognosis very poor as this is the 4th recurrence of tumour. Tumour has spread to bones and gums.

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