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Wednesday, July 8, 2020
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Feline enteric coronavirus and feline infectious peritonitis virus – a Dr. Jekyll and Mr. Hyde story

In light of the COVID-19 pandemic, learn how research on feline infectious peritonitis virus could help fight coronavirus infections in people.

As the COVID-19 pandemic rages on, researchers and governments, as well as news organizations, are paying much more attention to coronaviruses and the diseases they cause. This increased attention COVID-19 has brought places a spotlight on feline infectious peritonitis (FIP), a disease veterinarians have been battling for decades. The benign feline coronavirus that turns into the monstrous feline infectious peritonitis virus is a true Jekyll/Hyde story. Despite decades of research, the prognosis is dismal for cats afflicted by FIP. Although the prognosis for affected cats remains grave, new research might change the course of this disease – and help people affected by coronavirus infections, as well.

Feline coronaviruses have a worldwide distribution and affect both domestic and wild cats. Most cats are exposed to feline enteric coronavirus (FECV) and infected at some time in their life. FECV is highly contagious and transmitted easily through saliva or feces. Very few cats show any symptoms and most recover uneventfully without requiring veterinary care.

After years of speculation, it is now clear that FECV can randomly mutate to feline infectious peritonitis virus. While it’s estimated that only 5% to 10% of infected cats develop feline infectious peritonitis, it is 100% fatal. Feline infectious peritonitis is most common in cats under three years of age, with more than 50% of cases in cats under one year of age. A second spike in cases has been noted in  cats over 10 years of age.

At highest risk are cats that live in close proximity to each other, such as cats that live in shelters, where FIP is five to 10 times more prevalent. Certain breeds of cats are predisposed. Although the exact mechanisms underlying genetic susceptibility to the disease are unknown, they are suspected given breed incidence and evidence that siblings of cats that succumb to FIP may be at increased risk for the same disease, even if living apart.

FIP is difficult to diagnose, and effective treatments currently are not available. However, two newly funded studies underway at Colorado State University, hope to change that paradigm.

Under the leadership of Dr. Gregg Dean, Professor and Head of the Department of Microbiology, Immunology and Pathology in CSU’s College of Veterinary Medicine and Biomedical Sciences, a research team is constructing an oral vaccine for feline enteric coronavirus. If successful, the vaccine will control pervasive FECV infection in shelters and other multi-cat environments, while also protecting individual cats against FIP.

“For years, we have tried, unsuccessfully, to vaccinate against feline infectious peritonitis, but we may have been targeting the wrong point in time,” said Dr. Dean. “Our strategy now is to eliminate FECV, the mild-mannered Dr. Jekyll form, if you will, before it can become the deadly Mr. Hyde.”

The team’s vaccine design will exploit the bacteria Lactobacillus acidophilus, familiar to most as a probiotic and inhabitant of the gastrointestinal tract. The vaccine uses specific FECV antigens to generate protective antibodies against infection by FECV.

The vaccine is designed to be given orally, rather than injected, for several reasons. Oral vaccines are preferred by cats and their owners. Oral vaccination avoids the risk of injection site sarcoma. And, since exposure occurs at the mucosal surface of the intestinal tract, an oral vaccine would hopefully stimulate a more vigorous response at the point of infection, as opposed to an injectable vaccine that might be ineffective at stimulating an adequate mucosal immune response.

Dr. Dean’s team also is tackling another elusive goal – developing an accurate diagnostic test for feline infectious peritonitis. The test would use a blood sample to look for biomarkers consistent with disease. His team has identified 18 proteins, among thousands, that appear to be common in cats with the disease. The researchers aim is to evaluate the proteins as markers for FIP and determine which ones can be detected easily and developed into a diagnostic test.

A final exciting development is that Dr. Dean’s work on a feline coronavirus vaccine has the potential to inform work on a vaccine for the current coronavirus pandemic. The research team has now focused their attention – and their expertise – on SARS-CoV-2.

“Our work on a feline coronavirus vaccine has allowed us to quickly engage in work to assess the same approach against SARS-CoV-2,” said Dr. Dean. “I strongly believe the lessons learned over years of work by many investigators to develop a vaccine for cats can be directly applied to the current pandemic.”

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Common health issues for flat-faced dogs

Pugs, shih-tzus, bulldogs, and other flat-faced dogs are more popular than ever, so there’s no time like the present to become more familiar with their unique health issues. 

A flat-faced dog’s compacted facial anatomy causes increased effort with every breath. Despite the added effort, these dogs often suffer from reduced airflow to the lungs, which can lead to Brachycephalic obstructive airway syndrome (BOAS). Symptoms include:

  • Snorting, grunting sounds
  • Wheezing on inhale
  • Gagging and coughing
  • Snoring
  • Collapsing during or after exercise

Dogs with BOAS may require surgery to shorten the soft palate, which is typically elongated in short-faced dogs. In addition, many of these dogs require surgical resection to open the larynx and nostrils. Even without BOAS, brachycephalic dogs require special anesthesia considerations . This is why most airlines have restrictions against snub-nosed breeds, as flying can bring added health risks.

Heart disease

Facial conformation is often a primary factor when flat-faced dogs present with heart disease. Because the lungs receive less than the optimal amount of air, blood oxygen levels are often chronically low, placing added strain on the heart.

Heatstroke

Brachycephalic dogs are prone to overheating and heatstroke, as their facial conformation prohibits effective cooling. Clients with short-faced dogs like French Bulldogs should be advised to keep their pets cool during hot weather, opting for exercise during early mornings and after the sun goes down rather than during the hottest part of the day. Clients can also help their pets by walking them on a harness instead of attaching the leash to the dog’s collar.

Dental problems

All dogs require regular dental cleaning, but flat-faced breeds tend to have more dental problems than their longer-nosed cousins. Check for overcrowded teeth and urge clients to practice good doggie dental hygiene at home between regular visits.

Ocular injuries and eye disease 

Most flat-faced dogs also have protruding eyes. Cherry eye, dry eye, and eye ulcers are common issues for these dogs, and so are ocular injuries, often sustained during everyday activities and play sessions.

Facial skin infections and ear infections

Where there are skin folds, there’s an increased risk of bacterial buildup and infection – and most of these dogs have pronounced facial folds. In addition, their ear canals are often narrower than average, which can lead to a higher frequency of ear infections. Teach clients to conduct routine facial fold and ear cleanings; if they’re unable to do so, advise them to have their dogs professionally groomed on a regular basis.

Obesity

Obesity is a problem for any dog, but it magnifies many of the common health issues flat-faced dogs tend to suffer from.

Being overweight makes BOAS symptoms worse since fat deposits in the chest and neck restrict breathing further. Obesity intensifies the likelihood of heat stroke in short-nosed dogs, and it greatly increases their risk of suffering heart disease and diabetes. Urge clients to keep their brachy dogs at a healthy weight, focusing on regular exercise and an appropriate diet.

While surgery can help flat-faced dogs with severe BOAS, prevention is key to better health overall.

The TCVM approach to treating geriatric patients

When treating geriatric patients, TCVM can help diagnose and alleviate pain, while also restoring the animal’s quality of life.

As a veterinarian, I find that treating geriatric patients is among my most challenging and rewarding missions. Restoring joy and mobility to a grateful animal, along with the recognition that he is now pain-free, is the underlying motivation behind my life’s work. Moreover, the animals’ owners are so thankful to have additional quality time with their babies that they are likely to remain our clients forever. I know these patients come to my clinic in order to finish their lives in a loving, supportive environment. Just as there are midwives who aid with the transition into life, I feel like a midwife to death, the one who gently guides animals toward their final portals in life. For these reasons, I have embarked on a journey to love and care for geriatric souls, using a TCVM approach.

The temperature questions

As with youthful patients, we begin our work with the basic Yin and Yang questions and establish where the geriatric patient is. Ask the following temperature questions:

  • Is the animal heat- or cold-seeking?
  • In what weather conditions does he feel best?
  • Does he pant at night or is he under the covers?
  • Check the tongue for color and hydration. Red or pale? Dry or wet?
  • Has there been any change in behavior?
  • Has he exhibited aggression toward housemates and/or humans?
  • Does he seem to be in pain?

First, treat the pain

Always treat pain first. Pain is a stasis – a stagnation of the flow of Qi, blood flow or joint motion. Many geriatric patients are in pain due to a decrease in fluids (Yin) and not enough motion (Yang). These areas of stasis become stagnant, “stuck”, and they hurt. Pain can be caused by an area of Damp Cold stasis, or an area of Hot Dry stasis where too much Heat has depleted the Blood. Initiating movement in the area of stasis is a simple way to start the process of healing pain.

Bi and Wei SyndromesConsider the tongue and pulse when diagnosing stasis. The pulse often has an irregular, choppy, thin quality to it when an animal is in pain. The tongue may show redness and Heat. Establish the location, nature and extent of the pain through close observation of movement and behavior.

In geriatrics, behavior changes can be signs of pain or a loss of sensory organ function. Aggression toward a playful younger animal in the house can be the older one saying, “That hurts! Leave me alone!” Changes in urination or defecation habits may also be caused by pain. For example, I recently worked with an older poodle that had been rescued from desperate circumstances as a young animal. She had recently begun urinating in the house and on the deck. Her owners had enrolled her in an obedience class in an attempt to stifle this behavior; however, radiographic images revealed an old poorly-healed pelvic fracture her owners had been unaware of. The cold weather, coupled with the slippery stairs leading to the yard, made it difficult for the dog to urinate anywhere else. Letting her out through a different door – one without stairs – remedied the behavior in short order.

Treatment modalities for pain

The modern veterinarian has a variety of treatment approaches at hand to combat pain in geriatric patients. Once the diagnosis has been made, practitioners may select from multiple treatment modalities, including conventional medicine, acupuncture, physical rehabilitation, chiropractic treatment, prolotherapy, nutrition, homeopathic  and herbals to develop a tailor-made plan to meet the individual patient’s needs.

Conventional approaches include the use of NSAIDS, opioids and Adequan. A multimodal approach will combine the different modes and sites of action of the various agents in order to increase pain relief while reducing dosages and possible side effects. Owner education is an important aspect of the multimodal approach. Teaching owners how to recognize pain and educating them on topics such as weight control, exercise, and environmental management (e.g., flooring, bedding, etc.) is a critical part of effective treatment.

Acupuncture

The TCVM approach to geriatrics should always include the use of acupuncture. Electroacupuncture is one of the most effective methods of moving areas of stasis and quickly increasing the pain threshold. More-than-adequate research documents the efficacy of acupuncture as a method of pain relief. Acupuncture analgesia is seen more intensely along the meridian of the point being stimulated. Consideration should be given to the points used, and if they should be local or along muscle channels.

There is also evidence that acupuncture may assist in recovery from spinal cord injuries, which are common in geriatric patients. Dogs with spinal cord injuries who received a combination of conventional veterinary treatment and electroacupuncture had better recovery in urinary control, conscious proprioception and ambulation when compared with those who received conventional treatment alone.1

The main meridians that are effective from a TCVM perspective are the Yang meridians, which are responsible for gross motor muscle movements. The ability to get off the floor, squat to potty, and walk up stairs involve the following meridians:

  • Bladder meridian – controls the major superficial back muscles
  • Stomach meridian – the psoas and quadriceps
  • Gall Bladder meridian – the lateral muscles of the body, including the gluteal muscles

The most effective points are the major points in the muscles from the proximal to the distal meridian:

  • BL11
  • BL23
  • BL28
  • BL40
  • BL54
  • BL60
  • GB29
  • GB30
  • GB34
  • ST36
  • KD3

Second, establish a TCVM diagnosis

Constitutional elements

The constitutional element of the animal should be taken into consideration when making a TCVM diagnosis. A patient’s element can be a clue to the TCVM diagnosis.

  • Water — Kidney: Is the animal fearful? Does he have a history of inappropriate urination or urinary incontinence?
  • Wood – Liver and related behaviors: Does he have a short fuse? Terriers in particular have a temper and are often Wood animals.
  • Fire – Heart: Older Fire animals were previously very active and energetic, but have lost that essential nature.
  • Metal — Lung: Is the animal aloof? Has he developed respiratory symptoms, particularly as he has aged?
  • Earth – Spleen: Has the animal’s digestion been affected as he has aged? Are his stools dry and hard or too wet?

The TCVM diagnosis is always valuable. There seem to be two schools of thought on the core cause of deficiency in traditional Chinese medicine — one that focuses on the Kidney and the other the Spleen. The Spleen school sees the Spleen as the center of deficiency because it is responsible for the transportation and transformation of Gu Qi (food); this is an important consideration when evaluating the diet of a geriatric animal. In aging humans, the digestion of protein is reduced due to a decrease in hydrochloric acid. I find this to be true in aging animals as well. Simple strategies such as changing the animal’s diet to something more easily digested (from dry to wet), and feeding smaller more frequent meals can be beneficial. Also, cooking and serving the food warm can help feed the Spleen, thereby increasing Postnatal Kidney Qi and replenishing Kidney Jing.

Patterns of deficiency

Most of our geriatric patients will have deficiency patterns. First, the Qi is deficient, then the Blood becomes deficient and stagnant. The body fluids, not being nourished by the Blood, will dry up and condense to phlegm. The Jing, not having nourishment, will then become deficient. Most geriatric patients have some degree of deficiency, and zeroing in on the correct one can restore their vitality. Below are the different patterns of Kidney and Spleen deficiencies. Those that are starred are the most common:

  • Kidney Yang Deficiency*
  • Kidney Yin Deficiency*
  • Kidney Qi Not Holding Firm*
  • Kidney Failing to Receive Qi
  • Kidney Jing Deficiency*
  • Kidney Yang Deficiency Water Overflowing
  • Kidney Yin Deficiency Empty Heat Blazing*
  • Kidney and Liver Yin Deficiency*
  • Kidney and Heart Yin Deficiency*
  • Kidney and Lung Yin Deficiency*
  • Kidney and Spleen Yang Deficiency*

When determining the deficiency pattern of patients, remember that the Spleen is responsible for the Qi in the body, and for the transportation and transformation of food (without food, there would be no Qi). The Liver is like a tree, moving the Qi upward and outward through the body. When the Spleen is damaged, the Qi will be decreased due to impaired digestion. When Qi decreases, the Blood is affected and becomes deficient. The Spleen is very sensitive to Cold and Damp; it prefers Dry and Warm. Spleen deficiency patterns are therefore as follows: Qi Deficiency, Yang Deficiency, Damp Cold, and Damp Heat.

In veterinary medicine, older patients are some of the most challenging to treat. Begin by checking the tongue, feeling the pulse, and differentiating between Yin and Yang patients. When proceeding with treatment, use the points that work for you and try some of the empirical Wei points (see sidebar above). Proceed with a TCVM diagnosis, as this is always helpful when treating patients with multiple modalities. Remember, your first goal as a practitioner is to diagnose and alleviate pain. Your second goal is to restore the geriatric animal’s quality of life, using every modality available to you.

* This article has been peer reviewed

References

1Xie H,  Wedemeyer L.” The validity of acupuncture in veterinary medicine”. AJTCVM 2012;7:35-43.

Beijing College of TCM. Essentials of Chinese Acupuncture. Beijing, China: Foreign Language Press, 1980.

Dung HC.  Anatomical Acupuncture. San Antonio, TX: Antarctic Press, 1997.

Fratkin JP.  Chinese Herbal Patent Medicines. Boulder, CO: Shya Publications, 2001.

Han, Hyun-Jung. “Clinical effect of additional electroacupuncture on thoracolumbar intervertebral disc herniation in 80 paraplegic dogs”. AJCM 2010;38:1015-1025.

Hayashi AM, Matera JM, Fonseca Pinto, AC. “Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs”. JAVMA 2007;231:913-8.

Johnson JA. Chinese Medical QiGong Therapy. Pacific Grove, CA: The International Institute of Medical Qigong, 2005.

Kendall D.  Dao of Chinese Medicine. New York, NY: Oxford University Press Inc, 2002.

Maciocia G. The Foundations of Chinese Medicine. London, England: Churchill Livingstone, 1989.

Maciocia G. The Foundations of Chinese Medicine. 2nd ed.  Churchill Livingston, 2011.

Schaeffer R.  IVAS Teaching Manual, Sess. 4, pp. 612-614, 2010.

Schoen A. Veterinary Acupuncture. St. Louis, MO: Mosby, Inc., 2001.

Xie H, Preast V. Traditional Chinese Veterinary Medicine. Reddick, FL: Jing Tang, 2002.

 

 

Smart.Vet: using telehealth to bridge the gap in veterinary patient care

Veterinarians rush to register for clinic-branded telehealth platform that’s up and running in as little as 24 hours. Take that, COVID-19!

In the wake of COVID-19, veterinarians are turning to telehealth technology to help bridge the gap in patient care. Smart.Vet, a telehealth platform designed by practicing veterinarian Dr. Sharon Quinn and her partners, has set up over 200 veterinary clinics all over the world in just the last few weeks alone, as veterinarians endeavour to find their way, both logistically and financially, through the pandemic. Since COVID-19 began, Smart.vet has had over 6500 consultations performed through their system.

“Veterinary care is considered an essential service, but with social distancing and quarantine measures in place, including guidelines on postponing in-person elective and wellness procedures, we are seeing mainly urgent cases in clinic” explains Dr. Quinn. “With our platform, you can have a secure, web-based telehealth option in place — serving clients and patients, and earning revenue — in as little as 24 hours. And right now, that’s more important than ever.”

The Smart.Vet team designed the platform with accessibility in mind, enhancing it over the last 2.5 years. Clients can reach out securely through messaging, phone, or the platform’s own proprietary peer-to-peer video hosting option, using a computer, tablet, or smartphone. This private one-on-one interaction is kept on record so clients can refer to it later.

The company says thousands of pet owners use the service for a variety of reasons. “The cases range from triage of acute problems, to more chronic medical concerns, to post-operative re-evaluations, behavioral and nutritional consults and much more,” says Dr. Quinn.

While the platform has a lot of bells and whistles, veterinary practitioners agree that one of the most compelling advantages is Smart.Vet’s ability to be custom-branded to each clinic rather than a third party site. Clients like Bayridge Animal Hospital in Kingston, Ontario have taken full advantage of the editable landing page that comes included with the platform, showcasing photos of their veterinary staff along with a customized statement to their clients.

“Our patients and families are very important to us,” says Bayridge veterinarian Dr. Jeff Kaufmann. “We are glad to be able to use Smart.Vet’s innovative technology to keep us closely connected to our patients, especially through challenging times.”

The entire experience is simply an extension of the clinic’s services – even client payments can be processed through Smart.Vet. So pet owners never have to leave the branding they’re familiar with.

Smart.Vet offers veterinary clinics a number of advantages, including continuity and accessibility of care, more flexible hours for better work/life balance, improved client compliance and communication, and a way to seamlessly monetize telehealth services.

“Smart.Vet allows us to interact professionally, be attentive to our clients, share information like articles, videos, and estimates, and incorporate billing all in one platform,” explains Dr. Quinn. “Pet parents see huge value in having this dedicated one-on-one communication with their veterinarian, as well as access to their pet’s medical record and consultation history. And it’s so easy to share with their family members, which helps with their decision making.”

Dr. Alan Poon, associate veterinarian at Ontario-based Allandale Veterinary Hospital, agrees. “The simplicity of Smart.Vet makes it easy to use from a computer or handheld device, and I appreciate the functionality of having a centralized platform to reply to messages, perform video consultations and invoice clients with the click of a button,” says Dr. Poon. “Feedback from our pet parents has all been positive. Smart.Vet telehealth has helped advance the high standard of care we provide at our hospital.”

The Smart.Vet telehealth platform is easy to implement because there are no upfront costs. Once it’s up and running, there is a low monthly cost, starting at $99 (which includes two consulting accounts). Additional consulting accounts (DVMs or RVTs/technicians) can be added for the low cost of $40 per month each. Consultations are unlimited and Smart.Vet does not charge transaction fees. With such reasonable prices, many clinics are realizing a Return on Investment (ROI) of 600% or better.

Smart.Vet’s technology has been reviewed by the College of Veterinarians of Ontario (Canada) and it is the only telehealth program in Canada currently operating under an accredited facility. The company serves clients in several countries, including the U.S., Canada, Australia and the U.K. The French language version of the platform is currently being used in dozens of practices as well. Other translations are sure to follow.

A complimentary demonstration of the Smart.vet platform is available by contacting Mike Parent at mike@smart.vet.

 

FOR IMMEDIATE RELEASE: May 7, 2020

CONTACT:  Michael Parent, Phone # (336) 664-8400, mike@smart.vet

Understanding canine noise phobia

Many clients report fear-based behavioral problems in their dogs, including noise phobia. Understanding underlying reasons can help you determine treatment.

Approximately 90 percent of dog owners can describe at least one behavioral problem they would like to improve in their pet.1 Behavior problems can be a result of a dog responding to different triggers while home alone, and often there’s more than one trigger for any given patient. For instance, dogs with separation-related issues have been found to have noise phobia as well. Regardless of the trigger, 15 percent of veterinary patients are euthanized due to behaviour problems.1 Understanding the underlying reasons for canine noise phobia can help you assist your clients with structuring an appropriate treatment plan.

PRN Behavior Graph
Behavioral conditions are the #1 reason for euthanasia and relinquishment

Identifying triggers for anxiety

It is key for vets to complete a thorough medical history and physical examination as physical health influences behavioral health. Inquire about troubling behavior issues including territorial responses such as barking, growling, snarling or biting, and/or excessive restlessness.  Ask your client if there have been any recent significant life changes as well as the dog’s early history and environmental exposure. For best results, it is helpful to utilize a standard history form to give to clients prior to their vet appointment. Some common questions to include in the history form are the type of behavior the dog displays and the duration of the unwanted behavior, i.e. daily, for how many months, or for how many years.

Narrowing in on noise phobia triggers

To rule out other possible reasons for behavior problems, vets need to ask several questions that can include the following:

  • Does the dog show excessive reactions to unexpected noises and thunderstorms such as urination or defecation indoor, or the destruction or rearranging of household objects? If so, was it a day where storms were predicted and occurred or were there construction noises or other loud events near the home?
  • Does the dog bark during storms or noise-related anxiety episodes?
  • Has a fearful experience occurred when you were gone like a security system alarm sounding for extended periods, attempted break-ins, or fire alarms?

All of these questions with help isolate the triggers behind your patients’ behavioral problems.

Co-morbid diagnoses

Separation anxiety and noise/storm phobia are a very common co-morbid diagnosis. Forty-three percent of dogs in Storengen’s study of 215 dogs with separation anxiety also suffered from fear of noises.7 Flannigan and Dodman indicated in a study that fear of noises or noise phobia was present in conjunction with a separation anxiety diagnosis in almost half of studied dogs.8

Some research has found that behavioral responses to one loud noise are likely to generalise to others.4 However, responses to fireworks, gunshots and thunder did not commonly co-occur with separation-related behavior. In contrast, less salient noises such as traffic or the TV co-occur with separation anxiety, indicating that fear response to louder noises may relate to specific exposure and experiences.

Assisting with treatment

Research has shown that although owners are aware of their pet’s behavioral response when exposed to a loud noise, owners do not necessarily recognise this as being indicative of fear or anxiety.4 Furthermore, less than a third of owners seek professional guidance and treatment for their dog’s fear, showing that there is a need for veterinarians to increase treatment awareness among the general dog owning public. 4

Whenever owners mention noise or storm reactions in their dogs, vets should ask them to videotape the dog when it is home alone to ensure a full assessment. Once the diagnosis is verified and established, provide the owner with details of what the treatment plan would look like. Typical treatment plans include owner education, independence training, changing departure patterns, training departure exercises, and pheromones (if needed). Medication such as selective serotonin reuptake inhibitors (SSRI), have been shown to accelerate a dog’s response to behavior training, thereby reducing detrimental behaviors.

Many clients struggle with dealing with canine separation anxiety and noise phobia. Doing a thorough physical and behavioral assessment of patients will help vets determine the best form of treatment. Remember that early intervention is the best treatment option. This content came from a free, one-hour continuing education course on UniversityPRN.com entitled “Separation Anxiety: What’s New and What’s Different?” To participate in the entire CE course and learn more about separation anxiety, visit UniversityPRN.com.

References

  1. Landsberg G, Hunthausen W, Ackerman, L. Handbook of behavior problems of the dog and cat. 2003: 3.
  2. Stephen, J, Ledger, R. Relinquishing dog owners’ ability to predict behavioural problems in shelter dogs post adoption. Applied Animal Behaviour Science, 2006.
  3. Elanco Animal Health, unpublished data, 2006.
  4. Blackwell EJ, Bradshaw JWS, Casey RA. Fear responses to noises in domestic dogs: prevalence, risk factors and co-occurrence with other fear related behavior. Appl Anim Behav Sci. 2013; 145: 15-25.
  5. Overall K. The manual of Clinical Behavioral Medicine. 2013; 2.
  6. Sherman BL, Mills DS. Canine anxieties and phobias: an update on separation anxiety and noise aversions. Vet Clin North Am Small Anim Pract. 2008;38(5):1081–1106, vii.
  7. Storengen, Linn Mari, et al. “A descriptive study of 215 dogs diagnosed with separation anxiety.” Applied Animal Behaviour Science 159 (2014): 82-89
  8. Flannigan, G, Dodman, N. Risk factors and behaviors associated with separation anxiety in dogs. Journal of the American Veterinary Medical Association. 2001; 219. 460-6. 10.2460/javma.2001.219.460.
PRN Pharmacal Bottom

Phytomaxx

Profitable Practice
Phytomaxx t

INCOME POTENTIAL:
Veterinarians who started using PhytoMAXX™ for pain management and separation anxiety are now using it for more complex issues. Clients want to buy hemp extract from the veterinarian, and not an unknown company, so the income potential increases further.
TRAINING REQUIREMENTS:
When using CBD, understanding the potential available to you is of the utmost importance to you and your staff. It’s also important to understand the laws surrounding cannabis use in your area. Doctors and techs should be educated on absorption rates and proper dosing of CBD. When you purchase PhytoMAXX™, an educational brochure for future and existing clients is supplied.
TIME TO IMPLEMENT:
PhytoMAXX™ can be implemented in your clinic immediately after purchase. Clients can begin using the product at home as soon as proper instructions have been provided to them. As experts in hemp extract, Animal Nutritional Products is able to offer any information required by you or your client.
SOME POTENTIAL USES:
Veterinarians and pet parents have successfully used PhytoMAXX™ for a wide range of health concerns, including pain, separation anxiety, skin issues, sterile cystitis, lack of appetite and IBD. Compared to tramadol, galliprant and fluoxetine, this product has been reported by pet parents to have a longer half-life (three to four hours more). While this result has not been clinically studied, it has been tested in clinics and through observation.

 

PhytoMAXX™ Plus is a full spectrum hemp extract available in a liquid or chewable formula that addresses the CB1, CB2 and TRPV1 receptors. These receptors are prevalent in the body and brain of the endocannabinoid system in all animals. The formulation is designed to repair this system, which controls the CNS, immune and GI systems. This hemp extract can eliminate or reduce the need for NSAIDs and fluoxetine consumption, and can be used as part of a multimodal regime for many everyday health issues in animals.

The attention given to CBD by the internet and media is overwhelming — there is a lot of “canna-confusion” out there,and clients are struggling to find safe, effective and fairly-priced products. Veterinarians are capitalizing on the CBD boom; the key is to purchase from a reputable company that knows the laws and regulations. PhytoMAXX™ is a veterinary exclusive product, so your clients won’t find it on the internet.

Clients are much more educated about alternative medicine these days, but they still need guidance when it comes to CBD. They are seeking alternative ways to alleviate issues other medications sometimes can’t help with, and offering a safe and effective hemp extract like PhytoMAXX™ offers them peace of mind with third party lab testing.

Dogs, COVID-19, and veterinary medicine

Has COVID-19 changed the relationship clients have with their dogs? A new study explores how the pandemic has impacted human, veterinary and pet relations.

Dogs play an important role in our lives – as well as those of our clients – as valued companions that contribute to both emotional and physical well-being. Numerous studies have found that those with a dog are healthier and happier. People sharing their homes with dogs are sick less frequently, make fewer visits to the doctor, have lower blood pressure and risk of heart disease, and are less depressed and stressed than those without a dog. Dogs also help people relax and reduce feelings of loneliness and isolation by buffering the negative effects accompanying a lack of other social connections. All these benefits occur during normal times, yet, during the COVID-19 pandemic, things are far from normal. The pandemic has brought countless changes to how we live our lives, creating an uncomfortable level of uncertainty, altering our daily routines, adding financial stressors, and increasing social isolation.

How have these changes impacted the relationship clients have with their dogs? What COVID-related concerns do people have regarding the care of their canine companions? Researchers from four different US universities set out to answer these questions through an online anonymous survey for those with dogs (there was a separate survey for those with cats).

Lifestyle changes

One of the first things we want to explore is how COVID-19 and the related schedule/lifestyle changes have impacted the amount of time people spend with their dogs. The results suggest there are many happy dogs – 72% of people report spending more time overall with their dog, with most participants reporting that this increased time strengthened the bond they feel with their dog. Given the fact that 29% of respondents reported feeling they have minimal social support now (compared to only 8% who felt that way before COVID-19), this bond is more important than ever. In addition, dogs appear to help people cope with many of the negative emotions that can accompany the changes created by the pandemic. Over 50% of people report feeling that their dogs help reduce their feelings of anxiety, depression, isolation and loneliness.

Access to veterinary care

The results suggest that dogs are playing a critical role for many people during these stressful times. It is not surprising therefore, that many owners are concerned about being able to provide and care for their dogs, including the ability to afford and access veterinary care as well as dog food/supplies. For example, when asked about their concern level related to their ability to afford emergency veterinary care, 42% of respondents expressed concern surrounding meeting current needs, and 45% expressed concern for meeting future needs. Perhaps even more alarming is that 61% of respondents reported concern that their veterinarian would not be there in the case of an emergency, and 53% indicated similar concern when asked about availability for non-emergencies.
While it would appear that most people are appropriately unconcerned about giving their dogs COVID-19 or contracting it from them, 60% did report concern about their ability to care for their dog if they themselves become ill. Yet, only 60% of respondents reported that they have identified someone to care for their dog if they become ill.

  No concern Minimal concern Some concern Great concern NA/not an issue
Ability to afford emergency veterinary care now 1183 (29.6) 931 (23.3) 1153 (28.9) 521 (13.0) 208 (5.2)
Ability to afford emergency veterinary care in the future 1051 (26.3) 975 (24.4) 1231 (30.8) 569 (14.2) 170 (4.3)
Ability to afford non-emergency veterinary care now 1629 (40.8) 1117 (28.0) 807 (20.2) 245 (6.1) 198 (5.0)
Ability to afford non-emergency veterinary care in the future 1516 (37.9) 1094 (27.4) 939 (23.5) 279 (7.0) 168 (4.2)
Concern that my vet will not be open/available if I need them for emergencies 598 (15.0) 860 (21.5) 1544 (38.9) 898 (22.5) 96 (2.4)
Concern that my vet will not be open/available if I need them for non-emergencies

 

683 (17.1) 1103 (27.6) 1434 (35.9) 672 (16.8) 104 (2.6)
Concern about having to leave the house if my dog gets injured or sick 1078 (27.0) 1140 (28.5) 1076 (26.9) 552 (13.8) 150 (3.8)

How these findings can assist veterinarians

Capitalizing on these results, veterinarians have the opportunity to better address their clients’ concerns. Helping your clients understand that your veterinary hospital will work with them to meet their pets’ needs, and proactively reach out to your clients and explain your new (and changing) protocols. Perhaps you might want to offer guidance to your clients in determining an appropriate designated caretaker. And most importantly, as we all transition into this new reality, reassure your clients that your medical team will continue to be there for them in their times of need. To learn more, you can access the full report at https://fidofortcollins.org/

Does the coronavirus mean your patients need masks?

Is COVID-19 transmittable between humans and animals? Are masks necessary? We explore precautions  your clinic should be taking

We’ve heard multiple reports that companion animals cannot carry or transmit the novel coronavirus COVID-19. This has now been refuted with domestic cats, dogs, and big cats having contracted COVID-19.

A 17-year old Pomeranian belonging to a coronavirus patient in Hong Kong tested “weak positive” for COVID-19, and veterinarians assumed that the dog had picked up the virus from its caretaker.

The recent case of a tiger at the Bronx Zoo testing positive for COVID-19 leads to even more questions about whether previous assumptions about whether pets can carry and transmit this virus are true. Even before two dogs in Hong Kong tested positive for COVID-19, some pet parents were already opting to err on the side of caution, having their dogs wear masks during walks through heavily populated city centers.

CDC and AVMA representatives weigh in

After news of the first COVID-19 positive tiger broke, we learned that three lions and three more tigers at the Bronx Zoo tested positive after developing symptoms. The big cats were under the care of an asymptomatic keeper, again suggesting that humans may transmit the disease to animals even without showing any signs of COVID-19.

MarketWatch asked American Veterinary Medical Association President Dr. John Howe whether it’s possible for humans to get COVID-19 from pets. Howe replied that “the answer at this point is no. At this time, there is no evidence that companion animals, including pets, can spread COVID-19 to people or that they might be a source of infection in the United States.” But not having diagnosed a case yet doesn’t mean that animals can’t spread COVID-19 to humans. In the future there may be cases of this occurring.

The reason for this is COVID-19 requires special ‘cell surface proteins’ which act like doors to enter a body and cause infection. Without these ‘doors’, viruses can’t attach to human or animal cells and this explains why some species catch certain viruses but can’t spread it to other species. ‘ACE2’ is the ‘door’ COVID-19 uses to infect humans. The concerning part is that this specific cell surface protein called ‘ACE-2’ is present in both humans and our canine friends, making COVID-19 theoretically possible to be passed from humans to dogs and potentially vice-versa.

On its Coronavirus and Animals page, The CDC repeats Dr. Howe’s statement and maintains that “CDC has not received any reports of pets becoming sick with COVID-19 in the United States. Furthermore, they recommend that people who have COVID-19 should restrict contact with pets and other animals, at least until more information is known.

Neither CDC nor AVMA recommend masks for pets. Instead, they recommend that those who are sick with COVID-19, or who suspect that they may have the virus but haven’t tested positive should:

  • Limit contact with their pets and other animals
  • Have another member of the household care for pets
  • Avoid contact such as petting, snuggling, being kissed or licked
  • Avoid sharing food or bedding with their pets. If you have a young pet who usually sleeps in your bed or likes to wander, consider a spacious puppy pen

In the event that someone who has or suspects they have COVID-19 must take care of their own pet, CDC recommends handwashing before and after contact with pets. Furthermore, they recommend that the patient wear a cloth face covering.

Given that there is evidence that all the animals who have caught COVID-19 did so from the virus crossing from human to animal, it is very reasonable to suggest that all caregivers and those who interact with animals wear masks to prevent droplet transmission. The troubling part is that pet parents and animal care workers can transmit the virus to the animals they are in close contact with, without even knowing they are infected with the viruses themselves.

What about cats? 

There have been cases of cats getting COVID-19 in Hong Kong and Belgium to name a few countries. So the question must be asked: if a cat is in contact with a COVID-19 positive human, what steps should caregivers take?

  • Triage the case – if the case is not critical or an emergency, please reschedule until after the caretaker has cleared quarantine
  • Wear PPE when examining the cat – a mask, eye protection, gloves and a disposable or washable gown
  • Minimal handling of the cat
  • Practice good hand and environmental hygiene
  • If you need to hospitalise a cat who has had exposure to a COVID-19 positive human patient, it should be isolated from other animals and staff should wear PPE when cleaning cages or handling the cat
  • Only perform essential procedures to any cat in contact with a COVID-19 positive human. A P2 mask is required for all in-contact staff if doing a procedure where aerosol may be generated. This includes intubation. Ensure you do a fit check on your mask

Protect your practice 

Even though animal patients don’t need to wear masks, there are ways that you can protect your practice during the COVID-19 pandemic. Consider:

  • Implementing telemedicine
  • Transferring patients to your clinic in the parking lot
  • Postponing elective procedures
  • Wearing a mask and practicing safe social distancing when meeting with pet parents
  • Accepting online payments when possible
  • When clients enter the office, ask them to wear a cloth mask, practice social distancing, and sanitize common areas afterward. Also make it mandatory that they hand sanitize before entering the premises
  • Temperature test your staff twice a day (at shift sign-on and around 2pm). Any staff with temperatures 99.5F or above should be sent home.

There are many unknowns and the situation continues to evolve. For in-depth information, read AVMA’s COVID-19 FAQs for Veterinarians.

The ‘other’ cannabinoid. Does THC have a role in veterinary medicine?

Exploring questions surrounding THC (trans-Δ9-tetrahydrocannabinol), the “other” cannabinoid, its safety, legality and place in the veterinary field.

In the last issue, we looked at veterinary indications for CBD and the complex regulatory picture affecting its use. While CBD products for both humans and animals have already taken over your local farmer’s market, coffee shop and feed store, the “other” cannabinoid, THC (trans-Δ9-tetrahydrocannabinol), is another can of worms altogether. Many federal, state and local cannabis regulations conflict with each other and are in flux, so if you are confused, join the club! Here are the big questions most vets are wondering about:

  1. Does THC have useful indications in veterinary medicine?
  2. Is it safe for pets?
  3. Is it legal for veterinarians to recommend or dispense THC-containing products?

This article will help provide answers to these questions.

1. Is this THC a useful medicine for pets?

There is considerable overlap in the effects of THC and CBD, the principle compounds found in the Cannabis sativa plant (see chart below). THC-rich compounds can be an important clinical adjunct to treating severe pain and neurologic disorders,2-4 in the treatment of cancer,5-10 and in complex gastrointestinal imbalances.11-13 Because of the decades-old prohibition of cannabis research, we are only just learning the many roles of the endocannabinoid system (ECS), which includes CB1 and CB2 receptors as well as their endocannabinoid ligands and the ligands’ synthesizing/degrading enzymes. Broadly speaking, the ECS is the mechanism through which the nervous system and immune system (inflammatory reactions) communicate and balance each other.

Chart

It is probable that many chronic neurologic syndromes, such as multiple sclerosis, refractory epilepsy, brain tumors, Parkinson’s disease, Alzheimer’s disease, traumatic brain injury/chronic traumatic encephalopathy,2 amyotrophic lateral sclerosis (ALS) and its canine analogue, degenerative myelopathy,3 have their origins in ECS dysfunction. THC is a partial agonist of both CB1 and CB2 receptors in the CNS, and is a phyto-mimetic for the neurotransmitter AEA (anandamide, also known as N-arachidonoylethanolamine).

While the psychoactive properties of THC are legendary, its analgesic properties are in large part mediated outside the endocannabinoid system: THC is a positive allosteric modulator of mu and delta opioid receptors, so it enhances the endogenous enkephalin response and potentiates any exogenous opioid medications.4 Because of this phenomenon, compassionate “medical marijuana” use has long been approved for severe chronic pain conditions.

In human medicine, THC has been used to alleviate the side effects of oncology treatments in addition to pain management, and as an anti-emetic and appetite stimulant to address cancer cachexia. However, growing research indicates that phytocannabinoids, both CBD and THC, also have direct anti-tumor effects. The National Cancer Institute states as follows:

“Cannabinoids may cause antitumor effects by various mechanisms, including induction of cell death, inhibition of cell growth, and inhibition of tumor angiogenesis invasion and metastasis.5-8 Two reviews summarize the molecular mechanisms of action of cannabinoids as antitumor agents.9,10 Cannabinoids appear to kill tumor cells but do not affect their non-transformed counterparts and may even protect them from cell death.”

Some of the more exciting recent research trends concern the role of the ECS in the gastrointestinal tract,11-13 leading to applications for phytocannabinoids in managing chronic disorders like inflammatory bowel disease. Cannabinoid receptors are fundamentally involved in all aspects of intestinal physiology, such as motility, secretion, and epithelial barrier function. The ECS has a strong impact on the pathophysiology of the gastrointestinal tract, and is believed to maintain homeostasis in the gut by controlling hypercontractility and promoting regeneration after injury.

2. Is THC safe?

THC is not toxic to dogs — researchers were unable to establish an LD50 with doses higher than 3,000 mg/kg.14 THC exhibits a surprising lack of respiratory depression for a substance with such profound psychoactive properties. However, the effects of accidental high dose THC ingestion in canines can be alarming and include ataxia, obtundation, urinary incontinence, hyperesthesia and tremors.15 These incidents most commonly happen when dogs steal and ingest their humans’ recreational high dose THC edibles, whether commercial or homemade, such as baked goods made with THC “butter”. “Static ataxia” has long been recognized as a characteristic of canine THC ingestion, and is due to the unusually high concentration of CB1 receptors in the canine cerebellum.16 Despite many medical reports on canine cannabis toxicosis, fatalities are very rare and arise from indirect causes.
Veterinarians in states with early adoption of legal cannabis have found that with careful habituation, dogs can access the medical benefits of THC. It is usually recommended to build tolerance slowly over the course of several weeks, after which the psychoactive effects are no longer present. At professional CE events given by cannabinoid experts, dosage has been suggested as equal parts THC:CBD, ranging from 1 mg/kg to 5 mg/kg, or even products with a higher THC to CBD ratio. At this point, the evidence is primarily anecdotal. This veterinarian’s anecdotal experience includes a cat with an advanced facial tumor that completely resolved within six weeks of the owner feeding him homemade “bud butter” from a recipe found online. Cats do not seem to share the canine sensitivity to THC’s psychoactive effects.

3. Is it legal for you to prescribe or even discuss cannabis for pets?

In my previous article, I wrote: “If you don’t like the cannabis regulations in your state, wait ten minutes,” thereby reflecting the rapidly changing regulatory picture. This is an oversimplification, of course. The regulatory picture is confusing because it is conflicting at every level. We have the US federal government, whose Farm Bill of 2018 declared (industrial) hemp to be treated as any other agricultural product (USDA regulation); but down the street at the FDA, they claim that CBD is a drug, citing the recent approval of Epidiolex to treat pediatric refractory epilepsy. The FDA, on paper, still considers all cannabis products to be Schedule 1 drugs under the Controlled Substance Act. Meanwhile, the state governments of AK, CA, CO, ME, MA, MI, NV, OR and WA have made all forms of cannabis legal for both medical and recreational use. Other states’ regulations range from medical and decriminalized, to medical only, decriminalized only, and fully illegal. But this is just the beginning — once a state (or a nation, such as Canada) legalizes cannabis, there are endless decisions required on how to regulate cannabis products for safety, accountability, taxation and distribution.
THC sidebarThis has resulted in some awkward transitional situations for veterinary use in the US. For instance, in California, any adult can buy hemp CBD products at any grocery story, and THC products at both medical and recreational dispensaries; but veterinarians are forbidden to talk about either cannabis product with their clients. So Californian pet guardians who think (rightly or wrongly) that cannabis can help their animals have full access to the substance, but zero access to professional veterinary medical guidance. Legislation to address this problem has been held up in the state capital by lobbying from a manufacturer of OTC pet cannabinoids who wants to sell in recreational dispensaries, while vets advise that veterinary therapeutic cannabinoids should be restricted to medical dispensaries, like their human equivalents. The bill calls for vets to be able to “discuss” cannabinoid use, but has yet to define what that term means.
Big monied interests have moved aggressively into the cannabis industry world wide, so this confusion and struggle is universal. On the recreational side, Big Tobacco and Big Alcohol argue that they are best prepared to comply with a complex regulatory structure. On the medical side, the FDA is playing both sides of the coin: while keeping cannabis as a Schedule 1 drug, they reserve the right to regulate it as a pharmaceutical, which is in the interests of the large pharmaceutical corporations who are heavily invested in cannabis drug development and tightly linked to the FDA.
Dr. Gary Richter, a nationally recognized veterinary cannabis expert and educator, comments: “For years, herbalists and health care practitioners have been making the case that cannabis is powerful and effective medicine. When we lobby to have the medical benefits of cannabis recognized, we have to accept some degree of FDA regulation. We can’t have it both ways.”17 However, unlike most drugs, hemp or marijuana can be grown in one’s backyard and easily converted to medicinal form — so how closely can any agency truly regulate its use?
The most recent AVMA guidelines rely heavily upon the FDA interpretation. However, state by state, veterinary medical boards will be influenced by local political forces, lobbyists, or even by the ages and personal experiences of their members. In my home state of New York (which has a strong agricultural hemp program), the official state veterinary board guidelines speak of our obligation to educate our clients on cannabis use. Yet, at the most recent New York State Veterinary Conference, I spoke to many colleagues who firmly believed they could lose their NY veterinary licenses if they did so. There is a serious disconnect between the consumer drive for pet cannabis products, their veterinarians’ ability to knowledgeably counsel them, and the ever-changing legal and regulatory landscape.
There is a sense of profound frustration among veterinarians who have studied the potential medical benefits of CBD and THC for their most vulnerable patients. Most vets do not join the profession to become paper-pushers or business magnates. We put up with the educational investment and hard (often thankless) work because we are dedicated to the well-being of animals and the power of the human-animal bond. Phytocannabinoid therapies offer enormous potential to ameliorate the pain and ravages of serious chronic disease in animals. How can we justify not using them when we have taken an oath to help prevent avoidable suffering? Many veterinarians are carefully walking this line, risking their licenses and livelihoods to do so. It’s about time that veterinary medical professionals, researchers and regulators — both state and federal — put their heads together and figure out how to quickly and safely navigate this profound cultural transition to therapeutic cannabis use.
Editor’s Note: IVC Journal is closely following advancements in this rapidly-changing industry, and will continue to update readers on the latest research and applications regarding cannabinoid use in animal patients.

References

1Silver R. Veterinary Medical Cannabis: Part One. NYS Veterinary Conference, Cornell University, October 2018.

2Russo EB (2018). “Cannabis Therapeutics and the Future of Neurology”. Front Integr Neurosci. 12: 51.

3Fernández-Trapero M, Espejo-Porras F, Rodríguez-Cueto C, Coates JR, Pérez-Díaz C, de Lago E, Fernández-Ruiz J (2017). “Upregulation of CB2 receptors in reactive astrocytes in canine degenerative myelopathy, a disease model of amyotrophic lateral sclerosis”. Dis Model Mech. 10 (5):551-558.

4Kathmann M, Flau K, Redmer A, Tränkle C, Schlicker E (February 2006). “Cannabidiol is an allosteric modulator at mu- and delta-opioid receptors”. Naunyn-Schmiedeberg’s Archives of Pharmacology. 372 (5): 354–61.

5Guzmán M (2003). “Cannabinoids: potential anticancer agents”. Nat Rev Cancer. 3 (10): 745-55.

6Blázquez C, Casanova ML, Planas A, et al (2003). “Inhibition of tumor angiogenesis by cannabinoids”. FASEB J 17 (3): 529-31. 

7Vaccani A, Massi P, Colombo A, et al (2005). “Cannabidiol inhibits human glioma cell migration through a cannabinoid receptor-independent mechanism”. Br J Pharmacol 144 (8): 1032-6.

8Ramer R, Bublitz K, Freimuth N, et al (2012). “Cannabidiol inhibits lung cancer cell invasion and metastasis via intercellular adhesion molecule-1”. FASEB J 26 (4): 1535-48.

9Velasco G, Sánchez C, Guzmán M (2012). “Towards the use of cannabinoids as antitumour agents”. Nat Rev Cancer 12 (6): 436-44.

10Cridge BJ, Rosengren RJ (2013). “Critical appraisal of the potential use of cannabinoids in cancer management”. Cancer Manag Res 5: 301-13.

11Taschler U, Hasenoehrl C, Storr M, Schicho R (2016). “Cannabinoid Receptors in Regulating the GI Tract: Experimental Evidence and Therapeutic Relevance”. In: Greenwood-Van Meerveld B. (eds) Gastrointestinal Pharmacology. Handbook of Experimental Pharmacology, vol 239. Springer, Cham.

12Hasenoehrl C, Taschler U, Storr M, Schicho R (2016). “The gastrointestinal tract – a central organ of cannabinoid signaling in health and disease”. Neurogastroenterol Motil Dec; 28(12): 1765–1780.

13Uranga JA, Vera G, Abalo R (2018). “Cannabinoid pharmacology and therapy in gut disorders”. Biochem Pharmaco  Nov;157:134-147.

14Thompson GR, Rosenkrantz H, Schaeppi UH, Braude MC (1973). “Comparison of acute oral toxicity of cannabinoids in rats, dogs and monkeys”. Toxicology and Applied Pharmacology 25(3), 363-372.

15Meola SD, Tearney CC, Haas SA, Hackett TB, Mazzaferro EM (2012). “Evaluation of trends in marijuana toxicosis in dogs living in a state with legalized medical marijuana: 125 dogs (2005-2010)”. J Vet Emerg Crit Care (San Antonio) Dec;22(6):690-6.

16Freundt-Revilla J, Kegler K, Baumgärtner W, Tipold A (2017). “Spatial distribution of cannabinoid receptor type 1 (CB1) in normal canine central and peripheral nervous system”. PLoS One Jul 10;12(7):e0181064.

17Richter G, DVM. Personal communication.

Fear Free ™ approach to pain management in companion animals

The veterinarian developed Fear Free ™ approach for pain management is a way to improve outcomes and create a rewarding therapeutic experience.

Fear, pain, anxiety and stress may coexist in animal patients, challenging even the most experienced diagnostician and care provider. A painful animal may be fearful of examination, which could lead to a masking of symptoms due to elevated adrenaline or cortisol. The animal may also be overreactive in anticipation of painful handling, or may exhibit fear-based aggression. The body language signals of the fearful and painful animal are similar, and they can be difficult to differentiate. Approaching the case management of the painful (or potentially painful) patient in a way that minimizes confounding emotional and behavioral triggers leads to improved outcomes and a rewarding therapeutic experience. Enter the Fear Free ™ approach.

What is the Fear Free ™ approach?

The Fear Free ™ initiative was created by Dr. Marty Becker to benefit animals, their people and all veterinary professionals by reducing patient fear, anxiety and stress (FAS). Fear Free implements a range of specific behavioral and handling techniques, incorporates environmental modifications at home and in the clinic, and employs multi-modal alternative and conventional pharmaceuticals as indicated.

In a Fear Free practice, every patient has an emotional record and owners are counselled about how to make the trip to the veterinarian a calmer event. Once in the clinic, thoughtful traffic flow and scheduling reduce the situational escalation of stress, and the environment is managed so every sensory experience is as low-stress as possible. Frequent food rewards and distraction with toys and other pleasant experiences build successful interactions. Communication, gentle handling, frequent patient assessment and adaptable therapeutic plans involve the entire veterinary team.

Implementing Fear Free in your practice may be as simple or extensive as resources allow. The training builds naturally on the foundation of compassionate care, articulating specifically integrated steps and procedures. Fear Free certification is available to veterinarians, the veterinary support team, students and facilities. Commitment to the mindset and the holistic approach is a key step, and many improvements may be made even with existing equipment and infrastructure. The versatility and flexibility of the approach are showcased in the context of pain management by two Fear Free certified practices (Aspetuck Animal Hospital and The Cat Clinic); a Fear Free designed educational space (Norwalk Community College Veterinary Technology Program Live Animal Lab); and the author’s holistic consulting practice.

Fear Free Scale

In full-service hospitalsFear Free factors

Aspetuck Animal Hospital has been AAHA certified since 2011, and Fear Free certified since 2016. Dr. Michael Gorra, a 1997 graduate of the Cornell College of Veterinary Medicine, recently spoke about how Fear Free and Low-Stress Handling® have changed his practice, staff, patient care and approach to the painful patient.“It’s made a big difference in our flow and how we do things, and how we look at challenges,” he says. “Even if we don’t get to the point where [our patients] are happy, wagging their tails with their ears up — at least we can do things safely and not make things worse…. What I have found is that my lay staff dive right into it…. They really feel empowered that they’re truly making a difference.”

The hospital implemented multi-modal proactive pain management even before its Fear Free training. Nonsteroidal anti-inflammatories, gabapentin, tramadol and trazadone are frequently prescribed in combination. Sometimes medications are given prior to a procedure that is expected to be painful, in order to decrease sensitization and wind-up. Multi-modal therapy including anxiolytics has decreased the practice’s need to prescribe opiates for painful patients.

In addition to conventional pain management, Dr. Trish Grinnell, a 1997 graduate of the Cornell College of Veterinary Medicine, is certified in Veterinary Acupuncture and incorporates this modality: “I do acupuncture as general pain management. I had a friend who would do acupoints on all emergency patients to help calm them, but most of my acupuncture patients are pretty fear-free in the first place. Or if they start out nervous, they relax over time.”

examples of this approach
Right: NCC’s Live Animal Lab with rolling Tristar privacy screens, Snyder quiet-latch cages, walk-on scale (with mannequin) and FAS posters
Left: In the Live Animal Lab with veterinary technology students, Opal is enjoying peanut butter, a favorite treat.

Dr. Gorra adds how Fear Free Touch Gradient and Considerate Approach techniques have improved his ability to identify when an animal might be in non-procedure-based pain. “[They have] allowed me to evaluate what is really going on with the animal,” he says. “If the dog is freaked out, I’m not going to get an accurate reading on where the back pain, joint pain, abdominal pain is. Is the heart rate elevated due to a medical issue, because they hurt, or because they’re hyped up? We de-escalate when we can, and that begins at home with the owner.” For example, owners are encouraged to bring their animals to the hospital hungry so they will be enthusiastic about food rewards. Owners may wait in the car with their pets rather than the waiting room if the animal’s FAS score is 3 or above, and enter through a back entrance directly into an exam room to avoid other animals.

examples of this approach
Left:Veterinary Assistant Cailie has prepared cages for inpatients, including a privacy towel sprayed with Feliway.Right: Dr. Gorra with a homemade hiding space for caged cats. Felines also often feel secure in low-sided exam baskets. Above:Soft colors, shelves and terraces, vertical stratification, and hiding areas. Right: NCC’s Live Animal Lab Cat Zone, for felines only, complete with raised Snyder quiet-latch cages, Feliway diffuser, towel warmer and plug-in aquarium

In the feline-only practice

Using the Fear Free approach, feline-only practices have the opportunity to manage the medical, surgical and behavioral needs of feline patients without interspecies stress. Although cats are obligate carnivores and consummate hunters, they are an emotionally and metabolically sensitive prey species with a highly developed flight instinct and ability to mask pain. Owners are frequently unaware that their cats may be in pain or stressed, and may believe that stress-induced behaviors like trembling, vocalizations or open-mouth breathing are normal. Good client education, preparation at home, considerate transportation, minimization of antagonistic environmental cues (auditory, olfactory and visual), providing stratified hiding spaces, and accurate reading of behavioral cues may all help contribute to a calm and productive feline examination experience.

The Cat Clinic of Danbury has been Fear Free certified since 2017. Dr. Barbara Fanning, a 2006 graduate of the University of Tennessee College of Veterinary Medicine and The Cat Clinic’s owner, estimates that the Fear Free approach has improved the clinic’s ability to help 90% or more of its patients, including cats that could barely be handled before. An understanding of how quickly cats can turn fear and stress into undesirable behavior means there are no “bad cats” at the clinic. Before their visit, a Calm Kitty Kit that includes gabapentin, Zylkene® and a Feliway wipe is dispensed for most cats. In many cases, owners report an improvement in their cat on Zylkene alone, and are able to continue these benefits since hydrolyzed milk proteins are safe for long-term use.

Dr. Fanning and her veterinary team work closely with cat owners to determine the least stressful handling situation for their felines. Many cats are “afraid of everything…if we don’t know there’s pain, and we touch something that hurts, are they painful or are they acting out because they’re terrified?”

She describes her examination of a cat whose chief complaint was lameness and whose hind leg was trembling. Dr. Fanning, her helper and the owner worked together gently and easily with the cat, maintaining continuous gentle touch, proceeding slowly and cautiously, supporting his body in a secure position, trying to find step-by-step what didn’t hurt and saving the painful leg for last. Although the presentation was acute, which meant the patient hadn’t been given the benefit of the Calm Kitty Kit, he was examined in a warmly-lit room with a Feliway-sprayed towel on the exam table and iCalmCat music playing.

“Applying Fear Free methods really makes a huge difference,” says Dr. Fanning. “Instead of fighting and man-handling them, we keep that wind-up from happening. They can tolerate things a lot longer and not be so afraid.” If the patient described above became too painful to work with comfortably, or too frightened, he would have been sedated with an injectable sedative like butorphanol or Dexdomitor®. Without the wind-up to a terrified state, lower doses of sedatives and anesthetics can be used.

Dr. Fanning and Dr. Gorra’s teams embrace the Fear Free approach, keeping vets and staff safe, implementing all aspects of compassionate patient care, and educating clients about the approach. Veterinary support staff may be primarily involved with many potentially stressful therapeutic interactions: restraint, sample collection, diagnostic procedures, medication, treatments and therapeutic grooming. When veterinary assistants and technicians know how to read when an animal is fearful, stressed or anxious; when they appreciate the many ways in which painful animals can act; and when they have acquired a body of relevant techniques and communication skills, they are empowered and integral members of an effective veterinary team.

In the veterinary technology curriculum

Educating knowledgeable and compassionate caregivers is the mission of Norwalk Community College’s AVMA-CVTEA accredited Veterinary Technology program, for which this author is the Program Coordinator. The Program has incorporated Fear Free into its curriculum and clinical instructional space, the Live Animal Lab. Both the Program Coordinator and its Clinical Coordinator, Valerie Ramos CVT, LVT, MBA, are Fear Free certified, as are a number of other program instructors. Many of the Program’s veterinary technology students take advantage of the Fear Free complimentary student training. The veterinary technician’s multi-faceted role is a well-supported area of Fear Free education.

The Program’s Community partners welcome its Fear Free approach and its Fear Free oriented students. For example, one of NCC’s clinical partners, the Pet Animal Welfare Society (PAWS) located in Norwalk, uses Fear Free techniques. When PAWS brings kittens to the Live Animal Lab for Intake examinations, the students complete a standard Feline Medical Record and an Emotional Record, under supervision. The Intake form was developed in collaboration with PAWS’ head technician, Matthew Berg, and records information such as specific behaviors on Intake, behavior during handling and procedures, food preferences, what worked and what didn’t, and FAS scores before, during and after handling and procedures. PAWS is delighted to have behavioral information to assist in homing their new kittens successfully. The students gain valuable experience in a holistic approach to patient care, and accept the responsibility of building positive patient experiences early on.

holistic consulting practice
Left: Their holistic consulting practice exams concluded, Maddie and Zoe eagerly await more treats.
Below:Dr. Gorra in Fear Free exam room, ready with treats and a soft non-slip exam surface.

In a holistic consulting practice

Fear Free techniques extend naturally to a variety of clinical and practice settings. The author’s holistic practice serves patients whose owners are seeking therapeutic alternatives, or whose primary care veterinarians have referred them for integrative care. Many patients have had previous traumatic clinical experiences and managing their FAS is essential to therapeutic success.

The author’s practice footprint is a single-room consulting office in a quiet location, designed to be as non-threatening as possible; patients generally regard an office call as a social visit. There is abundant natural light, soft cushions and mats, and no harsh odors or metal surfaces. Examinations are conducted to the extent that is safe and comfortable for the owner and the animal, as there are no cage facilities or support staff.

Appointments begin with the client interview, which allows the patient to acclimate to the surroundings without forced contact, and allows observation of patient behavior including curiosity, mobility, interactivity and potential guarding of painful areas. Fear Free techniques align with the patient-centered practice philosophy and have increased the scope and range of examination and diagnostics that are possible with minimal assistance.

In summary

Veterinary medicine is a caring profession for people who love animals; if we can help them without hurting or scaring them, everybody benefits. With the understanding that even non-painful routine procedures may be perceived as threatening and/or stressful, veterinary care may be delivered in a way that does not erode trust and confidence. Animals suffering acute or chronic pain, which may be exacerbated by the fear of pain or unrelated fear and anxiety, can be diagnosed and treated in a respectful, compassionate way that leads to better experiences and outcomes.

References

Chapel D. (2016). “How Your Hospital Design Can Be Fear Free”. Paper presented at the North American Veterinary Conference, Practice Management, 375-376.

Dalla Costa E, Bracci D, Dai F, Lebelt D, Minero M (2017). “Do different emotional states affect the Horse Grimace Scale Score? A pilot study”. Journal of Equine Veterinary Science, 5 4, 114 -117.

Fanning B. Personal communication. May 14, 2019.

Fear Free, LLC. FearFreePets.com. Retrieved May 31, 2019. Gorra M. Personal communication. May 28, 2019.

Grandin T, Deesing M. (May 2002). “Distress in animals: is it fear, pain or physical stress”. Manhattan Beach (CA): American Board of Veterinary Practitioners Symposium.

Grinnell P. Electronic communication. June 1, 2019.

Griffenhagen G, Jamie Kadrlik CVT, Petty M, MAV C, CVPP, D, Sheilah Robertson, BVMS, DECVAA WS. “2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats”. aaha.org/public_documents/professional/guidelines/2015_aaha_aafp_pain_management_guidelines_for_dogs_and_cats.pdf. Accessed April 1, 2019.

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