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An innovative approach to separation anxiety in dogs

How using a Certified Separation Anxiety Trainer (CSAT) in your practice can help you successfully alleviate this common canine behavior problem.

Statistics tell us that over 17% of dogs in the US suffer from separation anxiety. In fact, this condition is one of the primary reasons for surrender, abandonment and euthanasia — not only here, but worldwide. As a veterinarian, you most likely have clients whose dogs have separation anxiety, and know that it can be challenging to overcome. In this article, we’ll look at how a Certified Separation Anxiety Trainer (CSAT) can help your practice successfully solve this common behavior disorder.

A bit of personal background

After becoming a veterinarian and working for many years as a behavior consultant and Bach Flower therapist, I had the opportunity to specialize in canine separation anxiety. Through a Separation Anxiety Certification Program designed by Malena DeMartini, I became a CSAT (Certified Separation Anxiety Trainer), forming part of an amazing group of behavior consultants who work to help dogs and their families overcome this condition. In becoming part of a league of healers who work to mend the emotional aspect of separation anxiety, I also became a healer of their guardians’ spirits, thereby achieving my inner purpose of bringing hope to them.

Separation anxiety is a frustrating problem

When dog guardians reach out to us for help, they feel they have already tried everything. They have read all the information they can find on separation anxiety, and are almost at the point of giving up. They are confused because different specialists from different fields have given them different explanations and different advice, and in their despair they have tried it all, making the problem worse in the process. Furthermore, they have limited their social lives in order to avoid leaving their dogs alone, and many times have lost the support of their families and friends. Common in all these cases is the dog’s irrational fear of being left alone.

Steps for success: teamwork

As a veterinarian, behavior consultant, and CSAT, I have been privileged to see how truly beneficial an integrated holistic approach to healing can be. We know there are many parts to a dog (or family) that might need healing. In response, our society has created a diverse range of professions to accomplish this, including veterinary medicine, dog training, behavior consulting, and dog walking, among others. Additionally, we have created further divisions of focus within each of these categories.

A problem arises when we, as healers, who seek the best for our patients and clients, have to make the decision of asking someone else to help us. We often don’t want to share our patients, and we act as if we are afraid that something bad could happen to them if someone else touches them or adds his or her expertise.

In treating canine separation anxiety from both veterinary medical and behavioral perspectives, I have observed that veterinarians often don’t trust behavior consultants, and vice versa; and although everyone tries on their own to do their best for the dog, they fail in navigating the problem as a whole. This isn’t only an issue in the US. The country I come from, and many others I have had the opportunity to visit, suffer from this same dynamic.  Maybe we should take a step back and remember why we are here, why we are doing this, and trust in one another’s skills and fields, in order to provide dogs with the best opportunity for healing and enhanced quality of life.

We need different specialists and skills to successfully treat separation anxiety as a whole:

  • A veterinarian, who can help rule out any physical problems the dog might be suffering from, and whose field of expertise includes knowledge of behavior pharmacology, and/or holistic medicine and therapy.
  • A specialist in separation anxiety behavior modification, who puts a behavior program into practice to help the dog overcome that part of the issue.
  • Additionally, we may need another dog trainer or behavior consultant who can focus on other behavior problems the dog might be showing.

Clear communication among team members is vital

Treating canine separation anxiety is a straightforward process, but not a particularly easy or rapid one. As such, it is imperative that all team members communicate clearly with one another, and offer support and guidance from their own areas of expertise for the benefit of the dog. When we start working with a separation anxiety dog and her guardian, we offer to get in touch with their vet, dog walker, trainer, daycare, etc., so everybody knows what’s going on and what each person can do to support recovery. We emphasize that everyone’s efforts are valuable and essential pieces of the puzzle.

Addressing physical health and environmental factors

In order to maximize chances for a successful outcome, it’s important to identify and address any physical problems with the dog’s health that could be influencing his behavior. Any necessary environmental adjustments need to be explored as well. Research has shown a high correlation between general anxiety, noise sensitivity and separation anxiety, and as such, there may be a genetic predisposition to the condition. This suggests these dogs may be suffering from a chemical imbalance in which hormones and/or neurotransmitters aren’t working as they should, either due to a pathophysiological issue, a threshold alteration at the nervous system level, or over/under production. Environmental factors such as stressful changes, new noises or traumatizing events might trigger the onset of separation anxiety at any age. Once these factors are addressed, our task as CSATs is to start the behavior modification program.

The CSAT behavior modification program

The program is designed to guide and coach the guardian through daily training sessions that seek to desensitize the dog to his person’s departure and absence. They include several strategic steps that help the dog adjust to his guardian approaching the door, leaving for a few seconds, and using some of the objects she would normally bring with her when leaving (keys, purse, coat, etc.). The next session is created based on the dog’s performance during his last rehearsal. Learning to read and interpret a dog’s body language is essential. The dog’s reaction to each session’s steps will help us create the next one and strategically vary our criteria. In time the dog learns to trust and adjust to departures, giving us the chance to increase the duration of the guardian’s absences, so she can finally leave the dog alone without triggering panic.

Desensitization and respecting the threshold

Reward-based training is a very successful tool for navigating many behavior problems. Counterconditioning (or classical conditioning) and operant conditioning are great for speeding the learning process and more quickly elicit the behavior change.

However, when working with separation anxiety, we seek relaxation from the dog, not the alertness that reward-based training would trigger. Besides, having the guardian reward the dog with a treat when she returns, to reinforce the dog’s behavior for not reacting when alone, will be insufficient once the absences become longer.

Instead, by gradually increasing the intensity of the stimuli while always staying under threshold, desensitization allows us to teach the dog he has nothing to fear when left alone. In time, the dog will begin to relax and adjust to the stimuli, which will allow us to progressively increase the intensity until we accomplish our absence duration goal.

The concept of threshold is an important one, because it tells us when the dog is no longer able to adapt to change and is about to enter survival mode, from which the panic response arises. In order for the desensitization program to work, we have to find, through reading the dog’s body language, where his threshold is. In other words, we have to find how long the dog can stay alone before the situation becomes aversive. Once the threshold is identified, we must always stay under it when designing training sessions. In time, the dog’s threshold will change, and that will allow us to get closer to our goal.

Remote observation: an innovation critical to success

My mentor, Malena DeMartini, once shared this quote from Rear Admiral Grace Hopper:  “The most dangerous phrase in our language is ‘we have always done it this way’.” We can apply this wisdom to treating separation anxiety. Utilizing technology as our 21st century helper, we use remote viewing to observe dogs and their guardians so we can create customized therapy plans that allow us to daily guide and coach these families.

Yes, our whole program is done remotely! Technology optimizes our chances of success while allowing families to access help regardless of locale. I have clients who live in Chile, called the “last place in the world” by some, along with clients who live in the nearest town. Many conditions need to be addressed in person, and many fields of work require physical presence, but the opposite is true when treating separation anxiety. We need to observe the dog’s body language when the guardian leaves, or when she is rehearsing a training session, and in order to do that without becoming a disruption, we need to be “ghosts” or “spies” who can see every detail without the dog noticing. We need to teach the dog that it is okay for his guardian to leave every morning or every afternoon, and this wouldn’t be realistic if she had to practice with us in the same room; she doesn’t leave for work every morning with us by her side.

Personally, I have found the remote viewing work to be richly rewarding. I love connecting with people this way by helping them with their dogs. When I came onto this path, I was scared it wasn’t going to suit me, and that I was going to miss the dynamic of seeing my clients and their dogs in person. I was wrong. I have never connected so much with my clients, their dogs and families as I am doing now. Before treating separation anxiety this way, I never felt as if I was really bringing people hope. Now I do.

Conclusion

If we open ourselves to the amazing results that can arise from working as a team of different types of healers, we will understand the meaning and importance of synergy. Being a veterinarian, but also a dog trainer who currently works exclusively on separation anxiety cases, I feel very eager to bring vets, trainers and behavior consultants together, so dogs with separation anxiety can benefit from a holistic approach — one that includes the best of each area of expertise, and helps dogs and their families succeed.

References and resources

Crowell-Davis, Sharon L and Murray, Thomas. Veterinary Psychopharmacology, Blackwell Publishing, 2006.

DeMartini, Malena. Treating Separation Anxiety in Dogs, Dog Wise Publishing, 2014.

Overall, Karen L. Manual of Clinical Behavioral Medicine for Dogs and Cats, Elsevier Inc. Mosby, 2013.

Sherman et al. “Effects of Reconcile (Fluoxetine) Chewable Tablets Plus Behavior Management for Canine Separation Anxiety”, Veterinary Therapeutics, Vol.8, Nº1, 2007.

Tiira, Katrina et al. “Prevalence, Comorbidity, and Behavioral Variation in Canine Anxiety”, Journal of Veterinary Behavior, Elsevier Inc., 2016. 

Wilde, Nicole. Don’t leave me!, Phantom Publishing, 2010.

malenademartini.com

moirahechenleitner.com/en

This article has been peer reviewed.

Anal sac anal gland adenocarcinoma — how combination therapy impacts outcome

Surgery, drugs and nutraceuticals for anal sac anal gland adenocarcinoma, from the perspective of the surgeon and oncologist.

Tumors of the anal sac are often thought of as a local disease. But like all malignant conditions, the local development of the primary tumor, the behavior and spread of the tumor (grade and stage, respectively) and the outcome of intervention are all related to the systemic conditions that exist at any point during the disease process. The comprehension of any disease process (not just cancer) at this level, provides the veterinarian with a unique opportunity to intervene on many levels — both providing more options for the pet parent and improving outcomes for the patient. This article will define and describe ASAGASAC, and discuss traditional treatment interventions and outcomes as well as adjunct interventions from the perspective of functional food.

Tumors of the anal sac are uncommon and represent a small percentage of all skin tumors in dogs (< 2%). The most common malignant tumor of the perianal region is the anal sac (gland) carcinoma, accounting for 15% to 20% of all perianal tumors. These tumors are locally invasive and metastasize early in the course of disease. The average age of dogs diagnosed with this disease is ten or 11 years, and there does not appear to be a breed or sex predilection. These tumors are often noted as an incidental finding on a routine rectal examination. If patients present with clinical signs, the most frequently reported are perianal swelling, straining to defecate, licking at the perianal region and bleeding. It is important to measure the size of the tumor because this is prognostic. In some cases, the only presenting signs are polyuria and polydipsia secondary to hypercalcemia, which is the most common paraneoplastic syndrome seen in dogs with AGASACA, occurring in almost 30% of cases.

Diagnostics and staging

Standard pre-operative workup includes a CBC and blood chemistry, including an ionized calcium level, as well as urinalysis. Imaging studies are indicated, including three-view thorax radiographs to assess for pulmonary metastasis, and abdominal ultrasound to evaluate the regional lymph nodes, which are the most commonly affected with metastatic spread. Ultrasound is superior to abdominal radiographs for assessing the abdominal lymph nodes, but if ultrasound is not available, enlarged lymph nodes can be identified on radiographs. Computed tomography of the thoracic and abdominal cavities is a superior imaging modality and offers many advantages over radiographs and ultrasound, including cost in some cases. Aspirates/biopsy of the tumor or regional lymph nodes are necessary for clinical staging and therapeutic assessment, when possible.

The size of the anal sac tumor does not dictate the presence of metastatic disease. Abdominal ultrasound should be recommended in all anal sac tumor cases to rule out metastatic disease to regional lymph nodes. Up to 50% of patients do have metastasis to the sublumbar nodes at the time of presentation, and 10% to 20% have lung metastasis.

If ionized hypercalcemia is identified on pre-operative blood work, this needs to be corrected before anesthesia and surgery. Diuresis with 0.9% saline, furosemide and possibly prednisone will help normalize ionized calcium concentration prior to surgery.

Surgery for ASAGACA

The first stage of treatment for anal gland adenocarcinoma is surgical resection, which in many cases can be curative.

The anal sac is located between the external and internal anal sphincters. Malignant tumors commonly invade these muscles. Other regional structures of interest include the pudendal artery, vein and the caudal rectal nerve. Anal sacculectomy is considered a clean-contaminated surgery; antibiotics are given at the time of induction and, depending on the antibiotic, every 90 to 120 minutes during anesthesia. If there is no significant contamination during surgery, antibiotics are not needed in the post-operative period.

Pre-operative enemas are not recommended as they will liquefy the feces and contaminate the surgery site. Manual emptying of feces is often required prior to surgical prep of the surrounding skin. In the case of anal sac tumors, a purse string is not recommended because access to the anal sac duct opening is often required to obtain surgical margins. In some cases, part of the rectal wall will need to be resected and reconstructed. The patient is placed in the standard perineal position. A rolled towel is placed under the caudal abdomen and the cranial quadriceps muscles are padded against the table to prevent trauma to the femoral nerves.

Anal sac tumors are approached with a closed technique. The open technique will lead to contamination of the surrounding tissues with tumor cells and will not provide a clean surgical margin, often leading to local recurrence and providing an ongoing source of metastasis and hypercalcemia.

Surgery is approached with an incision directly over the palpable mass, and careful dissection is used to maintain the integrity of the tumor capsule. Maintaining the capsule is paramount to achieving local tumor control because wide resection in this area is not feasible due to the proximity of surrounding structures, including the rectal nerve, anus, rectum and sciatic nerve. If the tumor has adhered to the dermis or epidermis, it is possible and necessary to obtain a larger skin margin. If using electrosurgery, radiosurgery or carbon dioxide laser for dissection and hemostasis, care must be taken not to damage the caudal rectal nerve, external and internal anal sphincter, and the rectal wall.

Monopolar electrosurgery utilizes a grounding plate routinely placed under the patient. The energy source travels from the tip of the instrument through the local tissues, then through the body to the grounding plate, to continue the circuit. Bipolar tip attachments are preferred to minimize thermal damage as the energy only passes between the tips of the instrument.

After excision is complete, new gloves and instruments are used for local lavage and closure of the surgical wound to minimize the potential of seeding local tissues with tumor cells. If possible, external skin sutures or staples are avoided as they tend to collect fecal material along the incision in the post-operative period.

In the case of gross lymphadenopathy on ultrasound exam or CT, extirpation of the nodes is strongly recommended, especially in the hypercalcemic patient. The medial iliac and hypogastric lymph nodes are located in the region of the distal vena cava and bifurcation of the aorta. With mild levels of lymphadenopathy, removal is straightforward; but as the degree of lymphadenopathy increases, surrounding structures including the distal aorta, ureters and iliac vessels can make removal more challenging. Successful lymph node resection in this location is largely dependent on adequate exposure to the caudal peritoneal cavity and a thorough knowledge of the surrounding structures. The standard celiotomy incision will need to be extended caudally to the pelvic brim to allow for appropriate exposure to the region. Intra-operatively, it may be decided that the affected lymph nodes may not be resectable, and they are therefore biopsied prior to closure of the abdomen.

Complications include infection, fecal incontinence and recurrence of local disease. All these are minimized by appropriately prepping and positioning the patient; handling the tissue gently; providing meticulous hemostasis but minimizing the use of electrosurgery or laser; avoiding the use of external sutures or staples; and obtaining tumor-free margins (if possible). Submit all removed tissues intact; if it is worth removing, it is worth submitting.

Adjunct therapy

Adjunctive intervention with radiation and/or chemotherapy may be recommended based on the pre-surgical staging and the post-operative histopathology report.

Radiation

In cases where surgery is not complete, radiation therapy to the primary tumor site and regional lymph nodes will improve local control. Radiation therapy protocols range from 16 to 20 fractions on a Monday-through-Friday schedule. Acute side effects of radiation therapy can be moderate to severe and may result in colitis and rectal mucositis. During this period, an e-collar must be worn to prevent the dog from licking the area. One study found that dogs treated with surgery, radiation therapy (15 treatments) and chemotherapy (mitoxantrone) resulted in an overall survival of >900 days. In non-resectable tumors, hypofractionated radiation therapy has anecdotally been useful in palliation with a relatively high rate of response. Side effects such as rectal stricture may occur with this type of protocol.

Chemotherapy

The benefits of chemotherapy for this cancer are not well characterized; however, chemotherapy is often incorporated into treatment protocols. The most commonly used chemotherapy agents include doxorubicin, carboplatin, mitoxantrone, melphalan and gemcitabine. NSAIDs are often utilized for putative anti-cancer effects.

In a recent study assessing 42 dogs with AGASACA treated with surgery +/- chemotherapy, survival time was significantly associated with the presence of sublumbar LN and sublumbar LN extirpation. Median survival time was significantly shorter in dogs with sublumbar than in those without, and in dogs that underwent lymph node extirpation than in those that did not. Disease-free interval was significantly associated with the presence of sublumbar LNs, LN extirpation, and administration of platinum-containing chemotherapeutic agents. Median disease-free interval was significantly shorter in dogs with sublumbar LN than in those without; in dogs that underwent LN extirpation versus those that didn’t; and in dogs that received platinum chemotherapy versus those without.

Interestingly, survival time and disease-free interval did not differ among groups when dogs were categorized on the basis of histopathologic margins (complete versus marginal versus incomplete excision). One question raised by this study is whether chemotherapy was utilized in the “worst cases”, associating it with an unfavorable outcome to create a study bias.

In some cases, all three modalities (surgery, chemotherapy, radiation therapy) are used in the treatment of dogs with ASAGAC.

Non-resectable/metastatic tumors

No standard of care currently exists for advanced, non-resectable or metastatic tumors. However, several retrospective studies provide some data to help guide clinicians.

Hypofractionated radiation therapy (palliative radiation therapy)

One study assessed 77 dogs with measurable ASASACA; 38% experienced a partial response to RT. For dogs presenting with clinical signs related to the tumor, improvement or resolution of signs was noted in 63%. For dogs presenting with hypercalcemia of malignancy, resolution was noted in 31% with RT alone, and in an additional 46% with radiation, prednisone and/or bisphosphonates. The median overall survival was 329 days (range: 252 to 448 days) and the median progression-free survival was 289 days (range: 224 to 469 days).

A second study using a protocol of 8 × 3.8 Gy (total dose 30.4 Gy, over 2.5 weeks) was assessed in 28 dogs (15 underwent surgery, 13 underwent RT). At the time of presentation, 21% had a life-threatening obstipation and 25% were hypercalcemic. The progression-free interval and median survival time for surgery cases were 159 days and 182 days, both significantly lower than for radiation therapy cases, which were 347 days and 447 days. Surgery as well as RT led to relief of clinical signs.

Integrative and nutritional therapy

Humans with cancer commonly use physician-recommended or self-prescribed unconventional but complementary therapies in the form of herbs and nutritional supplements. An interesting insight into the widespread use of nutraceuticals to treat cancer in humans was described in a recent study in which investigators found that only 7% of human cancer patients used unconventional medical therapies when they were asked routine questions by their oncologist; however, when a questionnaire was given to patients across studies, it was revealed that 40% to 80% of cancer patients were actually using nutraceuticals to supplement their chemotherapy or radiation therapy protocols.

The high prevalence of nutraceutical use among human cancer patients further suggests that nutraceutical use in pets with cancer is likely to be as frequent, if not moreso. There is actually some good science behind the use of certain ocean-sourced natural ingredients, especially purified but not chemically-altered EPA and DHA sourced from fish and the naturally-isolated carbohydrate component of the New Zealand green-lipped mussel.

Cachexia (weight loss) in cancer patients, despite adequate nutrient intake,is a devastating consequence of malignancy in both human and veterinary patients. Alterations in resting energy expenditure and derangements in carbohydrate, protein and lipid metabolism have been documented in dogs prior to overt signs of cachexia.

EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid)

These Omega-3 fatty acids are found in high levels in fish oils. EPA is a potent anti-inflammatory mediator in the body, while DHA has its greatest impact in the brain and spinal cord. ALA, which is found in some seeds and plants and is marketed as a safe plant source of Omega-3s, requires the enzyme delta-6 desaturase to convert it into EPA and DHA in the body. Unfortunately, humans, dogs and cats have limited ability (dogs and humans) to no ability (cats) to convert ALA to EPA and DHA.

In general, the Omega-6 fatty acids, found in vegetable oils, corn oil, grapeseed oil, cottonseed oil, margarine, sesame oil, saturated fats and fast food products are pro-inflammatory. They keep the cells, tissues and body in a state of continued inflammation.  The body needs inflammation to heal wounds and fight infection and cancer cells, but too much inflammation over time leads to many systemic health conditions and diseases in dogs and cats. The body constantly strives to be in balance between inflammation and anti-inflammation, between Omega-6 and Omega-3. However, the body can’t produce or store Omega-3 or Omega-6 polyunsaturated fatty acids; therefore, it can only use what it is fed.

Studies of polyunsaturated fatty acids (PUFAs), especially the Omega-3 eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, have demonstrated prevention of carcinogen-induced tumors, the growth of solid tumors, and the occurrence of cachexia and metastatic disease in experimental tumor models. The proposed mechanisms in which these fatty acids elicit their effects may be related to the inhibition of cell proliferation and induction of apoptosis. In contrast, PUFAs of the Omega-6 series appear to enhance tumor development and metastases and are considered to be inflammatory in the tissues of the body. There is also epidemiologic evidence of an inverse relation between dietary Omega-3 fatty acid intake and the incidence of some cancers.

Some tumor cells have difficulty using lipids as a fuel source, although host tissues continue to oxidize lipids for energy. This finding led to the hypothesis that foods moderately high in certain fats may benefit animals with cancer, as compared with foods relatively high in carbohydrates. Pets in North America receive most of their nutrient intake from commercial dry pet foods. In general, these foods are usually high in soluble carbohydrate and relatively low in fat. These characteristics may make some commercial kibble-based foods less optimal for the nutritional management of animals with cancer.

High levels of EPA and DHA, as found in the triglyceride form of fish oil, are probably the most important nutraceutical to consider for animals with cancer. Several human epidemiologic studies have suggested that consumption of the correct form, source and dose of EPA and DHA is a beneficial adjunct to treating many cancers. The recommendation for feeding high levels of EPA and DHA to pets with cancer is based on in vitro cell culture studies; studies in rodent models evaluating different types of cancer; clinical trials in human patients with solitary and metastatic forms of cancer; and clinical trials in dogs treated for lymphoma and carcinoma.

Several hundred studies using laboratory models have evaluated the effects of EPA and DHA on tumorigenesis, tumor growth, metastasis and chemotherapy. EPA and DHA administration reduces the cancerous transformation of irradiated fibroblasts and inhibits proliferation and metabolism in various cancer cell lines; inhibits growth of aberrant cells; increases radiation sensitivity of cancer cells; inhibits growth of primary and metastatic tumors; demonstrates an enhanced effect of chemotherapeutic agents on cancer cells; decreases angiogenesis; reduces radiation damage to normal tissues; increases survival time when used with chemotherapy; increases disease-free interval when used with chemotherapy; and increases quality of life when used with chemotherapy.

Several well-controlled clinical trials have evaluated the use of a fish oil-supplemented food in normal dogs and those undergoing chemotherapy for lymphoma, and in a study of dogs being treated for carcinoma.

EPA and DHA supplementation were found to decrease or eliminate the metabolic alterations seen in dogs with stage IIIa and IVa lymphoma treated concurrently with doxorubicin chemotherapy, providing a significantly longer disease-free interval, longer survival times, and improved quality of life. It is extremely important to note that specifically increasing the serum DHA content was associated with longer disease-free intervals and survival times in dogs with stage III lymphoma. This is key because only the triglyceride form of fish oil provides superior absorption, bioavailability and cell membrane saturation of DHA.

Another controlled and randomized clinical trial evaluated the effect of fish oil supplementation on the acute effects of radiation injury in dogs with nasal tumors. Dogs fed the supplemented food had higher serum concentrations of EPA and DHA compared with control dogs. Higher serum levels of EPA and DHA were associated with lower plasma lactic acid concentrations, lower tissue concentrations of inflammatory mediators, improved quality of life scores, and a lower degree of histologic damage to normal tissues from radiation therapy.

Matrix metalloproteinases (MMPs)

MMPs are a family of zinc-dependent enzymes that play a key role in degrading basement membrane components and extracellular matrix. MMPs are pro-inflammatory, tissue-destructive, and thought to be involved in chronic inflammation and some neoplastic conditions. MMP activity is detectable in canine and feline neoplastic tissue and in the serum of tumor-bearing animals. MMP activity is higher in tumor tissue than in unaffected stromal tissue, indicating that MMPs may be involved in the pathogenesis of angiogenesis, tumor growth and metastasis. MMPs have been found to be significantly higher in naturally-developing malignant mammary gland tumors in dogs and most carcinomas compared with activities in normal tissues, and activities of tissue inhibitors of MMPs were lower in tumor tissue.

MMPs also play a significant role in the early and late inflammatory destruction of irradiated tissues. A study of dogs with osteosarcoma found that patients with activated levels of plasma MMPs had a significantly shorter survival time than dogs without. New Zealand green-lipped mussels (GLM) that are harvested as adults from the ocean, and immediately processed by cold live extraction methods, maintain their glycoprolex (glycogen-protein complex) component, which contains the active ingredient necessary for significant inhibition of MMP activation.

Together, these studies suggest that feeding a diet supplemented with a natural triglyceride (chemically unaltered) form of EPA and DHA, and the appropriate form (isolated carbohydrate) of a GLM extract, increases survival time of dogs undergoing single-agent cancer chemotherapy; increases the survival time of a subset of dogs undergoing single-agent cancer chemotherapy by more than 30% compared with similar dogs consuming an unsupplemented food; reduces the severity of some acute phases of radiation therapy, thereby improving quality of life; suppresses the clinical signs of cancer for longer intervals; and counteracts persistent metabolic changes found in many canine cancer patients.

References

Bauer JE. “Therapeutic use of fish oils in companion animals”. JAVMA 2011;239:1441-1451.

Biondo PD, et al. “The potential for treatment with dietary long-chain polyunsaturated n-3 fatty acids during chemotherapy”. J Nutr Biochem;19:787-796, 2008.

Bougnoux P, Hajjaji N, Baucher MA, et al. “Sensitization by Dietary Docosahexaenoic Acid of Rat Mammary Carcinoma to Anthracycline: A Role for Tumor Vascularization”.

Proc Am Assoc Cancer Res 2006;47:5276.

Bougnoux P, Hajjaji N, Baucher MA, et al. “Docosahexaenoic acid (DHA) intake during first line chemotherapy improves survival in metastatic breast cancer (abstr)”. Proc Am Assoc Cancer Res 2006;47:5276.

Couch RAF, et al. “Anti-inflammatory activity in fractionated extracts of the green-lipped mussel”. NZ Med J;95: 803-806, 1982.

Fisher DJ. “Cutaneous and subcutaneous lesions”. In: Valenciano AC, Cowell RL, eds. Cowell and Tyler’s Diagnostic Cytology and Hematology of the Dog and Cat, 4th ed. St. Louis, MO: Elsevier Mosby; 2014.

Freeman VI, Meydani M, Hur K, et al. “Inverse association between prostatic polyunsaturated fatty acid and risk of locally advanced prostate cancer”. Cancer 2004;101:2744–2754.

Hansen RA, et al. “Menhaden oil administration to dogs treated with radiation for nasal tumors demonstrates lower levels of tissue eicosanoids”. Nutrition Research;31:929-936, 2011.

Hardman WWE, Barnes CJ, Knight CW, et al. “Effects of iron supplementation and ET-18-OCH3 on MDA-MB 231 breast carcinomas in nude mice consuming a fish oil diet”. Br J Cancer 1997;76:347–354.

Kawai K, Uetsuka K, Doi K, et al. “The activity of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) in mammary tumors of dogs and rats”. J Vet Med Sci 2006;68:105–111.

Larsson SC, Kumlin M, Ingelman-Sundberg M, et al. “Dietary long-chain n-3 fatty acids for the prevention of cancer: a review of potential mechanisms”. Am J Clin Nutr 2004;29:935–945.

London C, et al. “Preliminary evidence for biologic activity of toceranib phosphate (Palladia®) in solid tumors”. Vet Comp Oncol. 2012;10:194–205.

McQuown B, et al. “Treatment of advanced canine anal sac adenocarcinoma with hypofractionated radiation therapy: 77 cases (1999–2013)”. Vet Comp Oncol 2016.

Meier V, et al. “Outcome in dogs with advanced (stage 3b) anal sac gland carcinoma treated with surgery or hypofractionated radiation therapy”. Vet Comp Oncol 2016.

Moore AS, et al. “Doxorubicin and BAY 12-9566 for the Treatment of Osteosarcoma in Dogs: A Randomized, Double-Blind, Placebo-Controlled Study”. J Vet Intern Med;21:783-790, 2007.

Ogilvie GK, Fettman MJ, Mallickrodt CH, et al. “Effect of fish oil, arginine, and doxorubicin chemotherapy on remission and survival time for dogs with lymphoma”. Cancer 2000;88:1916–1928.

Potanas CP, et al. “Surgical excision of anal sac apocrine gland adenocarcinomas with and without adjunctive chemotherapy in dogs: 42 cases (2005–2011)”. JAVMA 2015;246:877-884.

Roudebush P, et al. “The use of nutraceuticals in cancer therapy”. Vet Clin Small Anim;34:249-269, 2004.

Selting KA, et al. “Evaluation of the effects of dietary n-3 fatty acid supplementation on the pharmacokinetics of doxorubicin in dogs with lymphoma”. AJVR;67:145-153, 2006.

Simopoulos AP. “Essential fatty acids in health and chronic disease”. Am J Clin Nutr 1999;70(suppl):560S–569S.

Turek M, Withrow SJ. In: Withrow and MacEwen’s Small Animal Clinical Oncology. 5th ed. 2013:503.

Uva P, Aurisicchio L, Watters J, et al. “Comparative expression pathway analysis of human and canine mammary tumors”. BMC Genomics 2009;10:135.

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Selecting supplements for your practice – 5 important questions to ask

Looking for the best animal supplements to recommend at your clinic? Asking these five questions will help you make the best choice for your patients’ health.

Animal nutritional and health supplements can play an important role in keeping your patients healthy and happy, particularly when used as an element of whole animal care.

If a client asks about adding a supplement to her pet’s regimen, it is important to help her understand the types of supplements available to her:

  • Nutritional supplements — vitamins, minerals and other ingredients intended to provide nutritional value as part of a complete and balanced diet.
  • Health supplements — products intended to support maintenance of normal biological structure and function, such as a joint supplement or a calming aid.

When researching supplements to offer at your practice or recommend to clients, we suggest you reach out to manufacturers for answers to the following questions:

1. Who formulates the product?

It is important to select products formulated by qualified professionals with knowledge and expertise in pet supplement formulation, and with a solid track record of producing animal nutritional or health products.

2. What quality standards does the company follow?

They should be following current Good Manufacturing Practices (cGMPs) modeled after the FDA’s cGMPs for human dietary supplements as defined in 21 CFR Part 111, and for animal food defined in 21 CFR Part 507 of the Federal Food, Drug and Cosmetic Act.

3. Is the product independently tested by a reputable analytical lab?

Independent testing consists of a third-party analytical lab verifying products that were purchased from the marketplace to ensure the product meets label claims.

4. Is the product labeled properly?

  • Product claims: If a product label overtly claims — or even implies — the product will treat, prevent, mitigate or cure any disease, the supplier is breaking the law and misleading consumers.
  • Lot number: Lot numbers demonstrate the manufacturer likely complies with some type of quality standards requiring product traceability and are essential in helping manufacturers notify customers if there is a problem.
  • Ingredients listing: Ingredients should be listed in descending order by amount but be aware that large numbers followed by “PPM”, meaning parts per million, actually indicate a dilute concentration of the ingredient.

5. Does the product have the NASC Quality Seal?

The NASC Quality Program provides strict guidelines for product quality assurance in production, adverse event reporting and labeling standards. To earn the National Animal Supplement Council’s Quality Seal, suppliers must pass a comprehensive facility audit every two years and maintain ongoing compliance with rigorous NASC quality requirements.

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Resolving skin inflammation in dogs and cats

The potential for diet, herbs and the microbiome to resolve skin inflammation in small animals.

Dermatological problems in dogs and cats are among the most common and frustrating cases that veterinarians see. Successfully resolving these issues involves understanding new models of skin disease, and the roles that diet, herbs and the microbiome can play in their resolution.

Current conventional treatment approaches

Apart from Omega 3 fatty acids influencing cytokine production, the current use of diet to manage skin inflammation involves the avoidance of antigenic food molecules, particularly proteins. Antigenic proteins are believed to be absorbed intact through the gut mucosa and viewed as foreign by immune cells residing in the lamina propria. Sensitized Helper T cells circulate to the skin, stimulating immune cells residing there to incite inflammation. In short, these animals are understood to be suffering a Type IV hypersensitivity mediated by T cell activation.

Typical strategies to address this problem include suppressing the immune system using pharmaceuticals, and using extruded diets in which molecular sizes are too small to incite a response. Novel protein diets are also used to avoid antigens to which the system has been previously sensitized. No conventional treatments are used to address the increased porosity of the digestive tract that allows entry of antigenic molecules; or the ability of circulating immune cells to enter the interstitium of the skin. Some of the perceived efficacy of natural therapies in dermatitis appears to be due to a targeting of these aspects of pathogenesis.

Despite conventional therapy, success is often inconsistent, even where a link between skin disease and diet appears to be present. In many cases, inflammation continues unabated when the animal is on extruded diets. New food allergies commonly develop, necessitating a parade of diets featuring ever more exotic protein sources. Immune suppression with drugs often has immediate dose-dependent side effects, as well as delayed side effects like predisposition to infections and tumors. It is for these reasons that owners seek out alternative perspectives and treatments for their pets’ skin diseases.

New models of skin disease

Ironically, one can start with current medical research when looking for a new context in which to view small animal dermatitis cases. The knowledge that gave rise to the therapeutic approaches noted above has been added to significantly to create a schema that embraces this pre-existing model; but also goes well beyond this to suggest many new potential avenues for managing dermatitis. These new directions in research provide support for, and help explain the utility of, alternative therapies such as “real food” (e.g. homemade or raw) as well as various supplements and herbs.

Two broad models are emerging of the main mechanisms by which dermatitis arises.

  1. We can call the first model inflammation dysregulation, which appears secondary to the metabolic consequences of feeding processed diets. The high insulin levels that result promote inflammation in and of themselves, but also lead to the accumulation of abdominal fat, often culminating in obesity. The fat accumulations are not inert, but secrete adipokines and cytokines involved in the generation of inflammation. This spawning of inflammation from a state of over-nutrition has long been recognized by Classical Chinese Medicine, which terms the phenomenon “Damp Heat”. Inflammation arising from insulin resistance and obesity can be countered through insulin-sensitizing herbs and the use of less processed diets. It is likely directly aggravated through the use of existing processed diets, including extruded foods.
  2. The second model we can term immune dysregulation and involves the Type IV hypersensitivity reaction veterinarians are familiar with. If a less processed diet does not materially improve the condition, then immune dysregulation is more likely to be present, but instead of managing the condition with just novel protein and extruded diets, practitioners can resolve these conditions through manipulation and deliberate support of the microbiome using various herbs, supplements and food sources. The focus of the diet probably needs to be on fiber, rather than just on novel protein sources.

We’ll now take a closer look at each of these models in turn, outlining the most effective therapies for each.

Inflammation dysregulation

The Damp Heat model

The notion that inflammation is linked to metabolism is an old one, appearing many centuries ago in an albeit more poetic guise, namely the Damp Heat model of Chinese medicine. In that model, the digestive tract (i.e. the Spleen) plays the role of converting raw materials into useful substances that can be used by the body, such as Blood, joint fluid and plasma. If the Spleen is weak due to excessive demands being placed on it, conversion is incomplete, and an unusable fluid known as Dampness accumulates.

Dampness is not used by the body, and goes wherever normal fluids are distributed, to accumulate in joint spaces, urine, and the walls of the blood vessels. Any accumulating unused tissue also qualifies as Dampness, including adipose within the abdomen. Within the vessels, Dampness is imagined to slowly encroach upon and obstruct the flow of Blood, releasing the kinetic energy of flowing Blood as a sort of heat of friction that Chinese medicine terms Damp Heat. If allowed to continue, the Blood stops moving altogether, leading to Blood Stasis and compromised circulation to the associated tissue.

Different treatment approaches are applicable at different stages of the disease’s progression. In the earlier stages, herbs that strengthen the Spleen and drain Damp are more appropriate. As problems progress, cooling and Blood-moving treatments are called for.

If this model were to have any relevance outside of Chinese medicine, there would have to be evidence that inflammation (i.e. Heat) was linked to overconsumption of food and the accumulation of body fat. We’d also want to see a link between chronic inflammation and the disruption of circulation within tissues. Modern nutritional research has confirmed both of these relationships. The disruption of circulation that attends chronic inflammation is termed “endothelial dysfunction” and is beyond the scope of this article, although it should be stated that high insulin levels are a driver of the condition, so dietary recommendations made in this article are as applicable to endothelial dysfunction as the treatment of inflammation and Damp Heat. This article will focus on the link between overconsumption and inflammation, central to which is the phenomenon of insulin resistance.

Insulin, weight gain and inflammation

Veterinarians certainly recognize insulin resistance as occurring in cats, culminating in the development of Type II diabetes. They may not, however, associate it with their canine patients at all. The reality is that both dogs and cats are prone to insulin resistance, which only requires a chronic surfeit of energy within cells to develop. In humans, this is most often due to a surplus of free fatty acids in the diet, but any excess caloric intake can produce the phenomenon, including an excess of carbohydrate intake in dogs.1

The energy surplus ramps up ATP production in the cell’s mitochondria, producing mitochondria over-activation and excesses of ATP. In response, AMPK is up-regulated, triggering pathways that inhibit further lipid and glucose uptake and oxidation by cells.1 Some of this energy glut is stored as fat instead, with circulating insulin levels correlating strongly with the tendency for future weight gains.2,3

Simply gaining some weight might not be a problem in itself, were this anabolic state not associated with inflammation. As body score increases, so do fasting plasma levels of inflammatory mediators like interleukin-6 (IL-6) and monocyte chemoattractant protein-1 (MCP-1). As feeding of energy-rich easily-digested foods continues, dogs enter a state of chronic inflammation.4 The situation only worsens as they eventually become obese.

As in humans, the incidence of obesity in small animals has achieved epidemic proportions. As reviewed by Laflamme,5 obesity in the dog or cat arises from the overconsumption of calories from any source, to the point where accumulated body fat is starting to impair health and body function.

In a human, obesity is achieved when body weight increases to 20% to 25% above the ideal for his/her frame. The same is generally presumed for dogs and cats, and even moderately overweight dogs are at greater risk than their lean-fed siblings for earlier morbidity and necessary medication for chronic health problems. Obese cats likewise face increased health risks, including arthritis, diabetes mellitus, hepatic lipidosis, and early mortality. The risk for developing diabetes increases about two-fold in overweight cats and about four-fold in obese cats.

Decades ago, extra weight was viewed simply and vaguely as producing extra physical strain on the heart and joints. Modern research has clarified that this added health risk is due to the elaboration of inflammatory cytokines and adipokines by body fat stores themselves. Leptin, resistin, tumor necrosis factor-α, IL-1β, IL-6 and C-reactive protein all increase in obese dogs and cats, resulting in a persistent, low-grade inflammatory state. This inflammatory state has been shown to play a causal role in chronic diseases such as osteoarthritis, cardiovascular disease, diabetes mellitus and many others. The oxidative stress that results from chronic inflammatory states serves as an additional aggravating factor, predisposing the animal to tissue damage and tumor formation.5

While weight gain is associated with the development of chronic inflammation in dogs and cats, weight loss produces reductions in circulating inflammatory cytokines. In one study of the effects of weight loss in 26 cases of naturally-occurring obesity in a range of breeds, body fat mass before weight loss was positively correlated with both plasma insulin concentrations and serum insulin to glucose ratios. Both these parameters decreased after weight loss, confirming the presence of insulin resistance. As weight loss progressed, notable decreases in plasma tumor necrosis factor-alpha (TNF-alpha), haptoglobin and C-reactive protein concentrations were observed.7

It’s important to note that in all respects, the link between diet, insulin, body fat and inflammation in dogs and cats is identical to that demonstrated in humans, to the point that dogs and cats have served as the animal models for researching these phenomena in humans. Since obesity with its secondary inflammatory effects in humans has been repeatedly and consistently linked with the consumption of processed foods,6 it is thus entirely reasonable to postulate the same is true for dogs and cats.

The notion of processed foods contributing to small animal disease and fostering an obesity epidemic has been understandably unpopular among veterinarians, given the reliance of the profession on these foods for the management of medical conditions, as well as routine feeding. Also denied in the past was the notion that carbohydrates could produce insulin resistance in dogs and cats, but this has been verified in clinical trials.

A case in point was the analysis offered by a study looking at the efficacy of a high-protein medium-carbohydrate diet for weight loss in dogs that had become obese on a commercial high-carbohydrate medium-protein kibble. Insulin sensitivity and body composition were evaluated before and after weight loss using a euglycaemic-hyperinsulinaemic clamp and the deuterium oxide dilution technique, respectively. Postprandial plasma glucose and insulin concentrations were substantially lower with the high-protein medium-carbohydrate diet than the commercial kibble, which the researchers felt was readily explained by the difference in carbohydrate content between the two diets. 8

Weight loss, real food and the biome

Weight loss is a primary goal in overweight animals suffering chronic inflammation. Weight loss with its attendant reduction in inflammation is achieved in association with, and even because of, shifts in the biome.16 For example, gut flora have been shown to play a crucial role in influencing metabolism, predisposition to weight gain, and blood lipid levels. Changing the microbiota by altering the diet may eliminate its role in creating a pro-inflammatory metabolism.

Raw and real food diets are being fed on an increasing basis to reduce body weight and tendencies to inflammation. Commercial high protein and high fiber diets produce weight loss with associated characteristic shifts in the microbiome that are identical to what real food diets achieve, suggesting they may work in a similar manner.9,14

The lower glycemic index of real food diets that stems from their higher protein and lower carbohydrate contents seems to promote a metabolism conducive to weight loss and an anti-inflammatory effect in many dogs and cats. A crossover study was performed to examine the effect of raw diets and their functional opposites (namely, highly processed extruded diets) on the microbiome. Raw diet effects included:

  • Reduced fatty acid synthesis
  • Increased balance and diversity of the micrbiome
  • A shift in microbiome metabolites towards those associated with a healthy gut
  • Increased lactic acid and pH of the stoll

The results of extruded diets on skin inflammation are commonly disappointing, but are perhaps explicable since in the above the study, they had a deleterious and opposite effect on the microbiome.14

Beneficial effects on the microbiome were also seen in dogs fed a minced beef diet, and these changes were reversed when the diet was replaced with commercial kibble. 15

Additional prospective research is needed to confirm whether raw and real food diets may promote weight loss and reduce systemic inflammation in overweight animals.

Herbal approaches

While real food diets are employed to induce weight loss and favorable shifts in the microbiome, Damp Heat formulas can be used to reduce excess insulin levels and counter inflammation.

San Ren Tang (Three Seeds Decoction) and Si Miao San (Four Marvels Powder) are both Damp Heat formulas used for the management of dermatitis (see Tables 1 and 2). Si Miao San, by some estimates, is the most widely used herbal formula in veterinary medicine, testifying to its utility in managing inflammation. Si Miao San is used more for acute inflammation, where a decongesting effect is needed on the body periphery; San Ren Tang is used for more chronic inflammation, where a return of blood supply is required to help actively resolve chronic lower-grade inflammation.

Si Miao San and San Ren Tang are not the only two Damp Heat formulas used in the management of skin disease, and the differences in their indications are more numerous and nuanced than is represented here. The reader is referred to professional reference texts38 for more information on how to use these two formulas safely and effectively. Both formulas exemplify, however, the strategy of combining insulin-sensitizing and anti-inflammatory herbs within the same formula. This innate synergy is likely what has driven their popularity, and provides corroboration for the role of insulin resistance in driving the development of inflammation. Since the ingredient list of both formulas reflects several centuries of refinement to achieve maximum efficacy, we can conclude that insulin as a driver of inflammation is not strictly a phenomenon of modern society but has been a problem throughout human history. It is only our awareness of the problem that is recent. To act on the knowledge requires us to overcome the inertia produced by standard industry practices.

Both Si Miao San and San Ren Tang contain Coix, an anti-inflammatory herb.39 The effects of this herb stem from its ability to inhibit nitric oxide synthesis, as well as superoxide production and release by macrophages. Coix also contributes to insulin sensitization. It has been shown to reduce adipose tissue weight, leptin and insulin levels in rat models of metabolic syndrome.40

Si Miao San is a more potent anti-inflammatory insulin-sensitizing formula, and is also antioxidant due to its Phellodendron content. Phellodendron has demonstrated antioxidant activity in numerous studies41 and also has an anti-inflammatory effect through its inhibition of the production of inflammatory cytokines and nitric oxide. It also inhibits expression of the gene for iNOS, as well as tumor necrosis factor (TNF-alpha).42

Si Miao San improves insulin sensitivity by protecting and enhancing insulin signalling.35.36 Berberine, a plant compound extracted from Phellodendron in Si Miao San, has been shown through a systematic review of clinical trials to improve multiple aspects of Type II diabetes and insulin resistance, including blood glucose markers such as HbA1c, hyperlipidemia and hypertension.34 Phellodendron as a whole has been shown to directly combat the central mechanism by which insulin resistance is generated, by reversing the inhibition by AMPK of glucose and lipid oxidation,37 facilitating the removal of adipose stored in hepatocytes.43

Si Miao San also contains Atractylodes, which has been shown to improve several metrics in diabetic patients.37

Immune dysregulation

The connection between the gut and skin

While the microbiome likely plays a key role in inflammation due to weight gain, its role in immune dysregulation is probably even more central. Gut microflora are important drivers of host immunity, help protect against invading enteropathogens, and provide nutritional benefits to the host. Their role when things go awry is still being unraveled, but so far, the discoveries for dogs and cats parallel what has been discovered for humans.

Specifically, shifts in the microbiome can:

  • Cause synthesis of metabolites that have an epigenetic role in immune dysregulation
  • Increase gut permeability, causing sensitization to antigens within the gut lumen that then propagates to the skin
  • Stimulate ongoing inflammation in the gut wall (i.e. inflammatory bowel disease or IBD) which propagates to the skin.

Cell-mediated immune reactions are important in the latter two mechanisms. Helper T cells stimulated into action at gut level through excess exposure to microflora then circulate, eventually prompting Effector T cells in the skin to secrete interleukins that prod macrophages and neutrophils to ramp up their inflammatory response to local skin irritants. In other words, inflammation from one cause in the gut ramps up the inflammatory response to antigens from other sources in the skin. Since exposure to the inciting antigen or pathogen is ongoing, inflammatory responses in the skin persist or continue to grow.18,19 Conventional treatment with anti-inflammatory and immune-suppressive therapies often provides only temporary relief but may potentiate increased permeability and dysbiosis, ironically resulting in inflammation becoming perpetuated.16 Reducing background inflammation produced by gut dysbiosis may be the primary consideration for allowing skin inflammation to subside.

Stress can amplify the role of the gut in inducing skin inflammation. Itacts through the “brain-gut-skin axis” to suppress gut immunity through increased secretion of cortisol, promoting dysbiosis. Only after enteropathogens have proliferated is the immune system once again incited into activity, producing a cell-mediated inflammatory response that damages the gut wall and leads to secondary skin inflammation.

Restoring a healthy biome

Determining all the immune mechanisms that might be involved within a given patient may be difficult, but significant improvement can be achieved by simply following the central tenet of naturopathic medicine to “restore the causes of health” by:

  • Promoting species diversification within the microflora while controlling pathogens
  • Reducing gut permeability
  • Minimizing stress to avoid immune suppression and overgrowth of pathogens.

As reviewed by Craig,16 a healthy microbiome can be supported by feeding a species-appropriate diet using real foods wherever possible.

As a highly adaptive species, dogs (like humans) can thrive on a great variety of foods, at least in the short term, allowing debate among veterinarians and consumers of just what the ideal diet is for a dog. From the perspective of gut microflora, however, the definition of the ideal diet becomes narrower. In carnivores, use of higher-protein diets promotes greater stomach acidity, reducing the predisposition to small intestinal bacterial overgrowth and deleterious shifts in the biome. Craig notes that “animal-sourced roughage” such as scales, skin, hair, teeth, tendon, bone and cartilage from real food diets may have a prebiotic effect even if not digested.

Craig also states that “low carbohydrate cereal-free diets should be considered in the investigation of any chronic skin disorder [in dogs], whether or not there is evidence of gastrointestinal disease”. His concerns extend from the presence of gluten and fermentable carbohydrates within cereal grains. Fermentable carbohydrates lead to dysbiosis and secondary impairment of the GI barrier. Gut bacteria species have been shown to create metabolites from gluten that increase gut permeability, prompting immune dysregulation.

While fermentable carbohydrates can increase gut permeability, foods containing soluble fiber can help strengthen the GI barrier by having a prebiotic effect. Short-chain fatty acids, such as butyrate, produced by gut flora from these fiber sources tighten the junctions between gut mucosal epithelial cells, thereby reducing the priming of the immune system by lumen contents. Fecal IgA is also increased, helping to bind and inhibit the activities of enteropathogens.20 Example fiber sources include those from beans and potatoes.20, 21

Note that overweight inflamed animals do not apparently experience the same boost in fatty acid synthesis from high protein high fiber diets that immune dysregulation dogs do.13 Indeed, their fatty acid synthesis may drop. Fiber supplementation thus appears a much more important consideration for the immune dysregulation animal.

Other prebiotics exist besides fiber, including inulin and oligosaccharides, which are resistant to host digestion, allowing them to be fermented in the colon, producing beneficial metabolites. They are widely used in pet foods, although their efficacy in animals has not been researched.

Also commonly used are probiotics, which help change flora composition and activity to improve host health. Probiotic benefits include:

  • Inhibition of pathogen adherence
  • Sealing of the intestinal barrier
  • Killing pathogens through bacteriocins produced by commensal flora
  • Increasing immunity and the intestinal barrier by stimulating IgA production
  • Downregulation of cytokine secretion.

Craig states that probiotics have been effective in clinical trials of human atopy, and early exposure to probiotics reduces the intensity of symptoms in models of canine atopy. As reviewed by Miraglia del Guidice and De Luca, many clinical trials have shown that probiotics have the ability to alleviate allergic inflammation, as evidenced by both the control of clinical symptoms and a reduction of local and systemic inflammatory markers.17

When the microbiome is suspected as being operative in an animal’s inflammatory condition, certain pharmaceuticals, including antacids and antimicrobials, should be used only with great care to avoid perpetuating or worsening the problem.

At times, antimicrobials may be necessary to correct a dysbiosis, though efficacy is inconsistent. More popular among veterinarians recently has been the use of fecal microbiota transplantation (FMT) to restore normal gut flora populations.

Herbal approaches

Based on the foregoing, there are three main ways an herbal medicine can address immune dysregulation manifesting as immune-mediated dermatitis.

  1. Support a normal local immune response within the gut to correct dysbiosis
  2. Modulate the cell-mediated immune reaction being propagated to the skin
  3. Reduce stress as a cause of immune suppression and secondary enteropathogen proliferation.

Astragalus-based formulas such as Ginseng and Astragalus Combination (Bu Zhong Yi Qi Tang) are used to support or restore normal and local immunity within the gut, while Minor Bupleurum (Xiao Chai Hu Tang) derivatives work through all three pathways (see Tables 3 and 4).

Astragalus

Several studies illuminate the role of astragalus (A. membranaceus) in the correction of dysbiosis. Polysaccharide extracts from the plant have been shown to alter gut microbiota and the SCFAs they synthesize in diabetic mice.22 Another study in broiler chickens showed a reduction of pathogenic gut flora and a concomitant increase in commensal and symbiotic species.23

Indeed, astragalus (Huang Qi) is much studied for its ability to improve productivity in farm animals by correcting the microbiome. The plant was shown in pigs to reduce diarrhea secondary to dysbiosis, leading to enhanced growth rates and improved digestibility of food. Improved microbiota health was also indicated by an increase in species diversity and was likely due to an improved immune response against enteropathogens, as evidenced by increases in IL-2 and TNF-alpha.24 The same general impact was seen in a study on chicks, where the plant extract was used in tandem with probiotics to successfully combat pathogenic strains of E.coli.25

Minor Bupleurum

Minor Bupleurum consists of three key herbs: bupleurum (Chai Hu), scutellaria (Huang Qin) and panax ginseng (Ren Shen). It is an herbal powerhouse for the management of immune dysregulation caused by “leaky gut”, with all three plants showing efficacy independent of each other in all three areas of correcting dysbiosis:

  1. Reducing predisposition to, and the adverse effects from, stress on microflora
  2. Modulating the immune system to support local immunity or reducing the intensity of cell-mediated immune reactions

Dysbiosis

With respect to dysbiosis, bupleurum was shown in the context of another formula, Bupleurum Soothe the Liver Combination (Chai Hu Shu Gan San), to protect microflora from pathogenic overgrowth.26 Scutellaria (in the formula Huang Lian Jie Du Tang) has been shown to help restore normal gut flora in rats by reducing pathogens and increasing the presence of bacteria that do not incite inflammatory responses. SCFA synthesis increased accordingly.27 Many studies support the use of ginseng for the correction of dysbiosis secondary to antibiotic use.28

Brain-gut-skin axis

Ginseng is widely known as an adaptogenic herb that can normalize and optimize adrenal gland output of cortisol, lessening its secretion in times of repetitive stress, but increasing it when increased alertness is required. Normalization of cortisol secretion reduces immune suppression allowing enteropathogenic bacteria overgrowth. Scutellaria species likewise have research support for their long history of use in treating anxiety and other CNS organic and mood disorders.29 Bupleurum has likewise been shown to reduce depression and anxiety in animal models of repetitive stress.30

Immune dysregulation

Wogonin, found in scutellaria, has been analyzed for its ability to support normal immunity and reduce inflammatory bowel changes in colitis in rats. Levels of protective IgA were increased, while IgE levels associated with hypersensitivity were maintained at low levels. The ability to induce local immunity in the gut was increased in rats given wogonin, but the intensity of the inflammatory response during colitis was reduced, making scutellaria a true immune modulator.31

A decrease in bowel wall integrity can increase exposure of the immune system to endotoxins (LPS), sparking an inflammatory response that can propagate to the skin. Administration of bupleurum tempers the pro-inflammatory effects of LPS exposure, while supporting phagocytosis and removal of the offending antigens.32 Bupleurum’s tempering effect of an immune response has been widely studied and demonstrated at other mucosal surfaces as well, including for the reduction of allergic responses at respiratory epithelia.33

Conclusions

On a fundamental basis, the typical strategies in small animal dermatitis have changed very little over the last several decades and are still centered around the feeding of extruded or novel protein processed diets; and/or the use of immune suppressant medications.

Research into the role of diet in dermatitis has progressed, however, illuminating the primary role that metabolism and the microbiome play in driving skin inflammation. Use of unprocessed diets and herbs undermines the role of insulin and weight gain as drivers of inflammation; while manipulation of the microbiome using diet, herbs, prebiotics and probiotics holds significant promise for the relief of immune-mediated skin disease. These strategies are deserving of much more research attention, and appear to offer significant hope of advancing the veterinary profession in an arena that it has historically found highly frustrating.

You can view Dr Marsden’s webinar series on “Dermatological Dilemmas” by visiting civtedu.org/steve-marsden-skin-diseases-webinar-series/.

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New data on the health impacts of gonadectomy in dogs

How connections between obesity, nontraumatic orthopedic injuries and gonadectomy in large-breed dogs can impact conversations between you and your clients

For decades, gonadectomy has been promoted to both pet owners and veterinarians in North America for its various health benefits, and as a critical tool for combating pet overpopulation. It’s widely seen as an important component of responsible pet ownership.

Gonadectomy, though, is receiving increased scrutiny as veterinary medicine continues to embrace evidence-based recommendations. Over the last 10 years, researchers have attempted to find answers regarding the optimal timing of sterilization of dogs, while balancing the positive and negative health outcomes of gonadectomy with the very real problem of pet overpopulation. Study results have been inconsistent, with some studies in conflict with current recommendations and other studies in conflict with each other. While the science is far from settled, there are still takeaways that can inform the conversation veterinarians have with owners around the timing of gonadectomy for their dogs.

Obesity has become a major health issue in dogs, with estimates of up to 60% of dogs in the United States either overweight or obese. The list of diseases associated with obesity in dogs is legion and recent data suggests overweight, gonadectomized dogs have shorter life spans. Although gonadectomy has been associated with the development of overweight or obesity, the association between age at gonadectomy on overweight or obesity has produced conflicting results.

Questions surrounding gonadectomy and nontraumatic orthopedic injuries likewise have produced similarly conflicting results. Many veterinarians now recommend delaying gonadectomy in large-breed dogs, with these recommendations often based on personal experience and anecdotal evidence. While many plausible causal mechanisms exist to explain why gonadectomy may be associated with joint injury and disease, the scientific literature provides conflicting results.

The evidence surrounding cancer risk and gonadectomy is even more tangled. Although the link between early spaying and the development of mammary cancer is well known, other studies point to conflicting results when it comes to reproductive hormones and cancer.

A large Australian study published in 2018 showed that gonadectomized dogs (of both sexes) were at a higher risk for lymphoma compared to their intact counterparts. Another study looking at golden retrievers in California, also published in 2018, did not find a difference between gonadectomized and intact males in regard to cancer-related mortality, but did demonstrate a difference between intact and spayed females with more spayed females dying of cancer than males. An earlier study looking at a population of golden retrievers in California found that gonadectomy in either males or females increased the risk of several different types of cancers when compared to intact dogs. Lastly, a paper published in 2014 demonstrated that gonadectomized vizslas had increased odds of developing cancer than their intact counterparts.

Morris Animal Foundation recently published a study on the effect of gonadectomy on the incidence of obesity and overweight, and nontraumatic orthopedic injury using data from their Golden Retriever Lifetime Study. This longitudinal study is collecting data on more than 3,000 dogs as they mature from puppyhood through adulthood to better understand the risk factors for cancer and other diseases in dogs.

For the spay/neuter study, the team divided their cohort into four age groups: dogs under 6 months of age at gonadectomy; dogs 6 months to 12 months of age at gonadectomy; dogs over 1 year of age at gonadectomy; and intact dogs. Results showed that gonadectomized dogs in all categories had an increased risk of obesity and overweight compared to the intact group. For nontraumatic orthopedic injuries (in this study cranial cruciate ligament rupture and arthritis), only dogs gonadectomized under 6 months of age had an increased risk of these conditions.

“These findings emphasize that the timing of gonadectomy may impact future health outcomes, both in positive and negative ways.” said Dr. Missy Simpson, lead author of the paper and Staff Epidemiologist for the Golden Retriever Lifetime Study. “These results are especially powerful because we were able to verify that gonadectomy preceded overweight/obesity and orthopedic injury. Establishing the order of events is important because we can rule out reverse causality as an explanation for our findings. In other words, owners’ decision to spay or neuter their dogs was not a result of the outcomes we studied.”

Recommendations about the timing of gonadectomy represent one facet of a trend toward personalized medicine in both veterinary and human health care. As we learn more about the effect of reproductive hormones on health, we’ll be better able to guide our clients and improve health and longevity in our patients.

Learn more about the Golden Retriever Lifetime Study at morrisanimalfoundation.org or listen to a podcast about the spay/neuter study.

 

 

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Integrated approaches to canine cancer: augmentative treatment strategies

Three integrative treatment modalities that, when used in conjunction with chemo and radiation, can increase the longevity and life quality of canine cancer patients.

Conventional treatments for canine cancer include surgery, chemotherapy and radiation.  In recent years, however, evidence has been mounting that additional treatment modalities can increase patient longevity and life quality. Including other modalities can also increase owner acceptance of the proposed clinical plan. This article focuses on three additional functional treatment categories — immune support; apoptosis (cancer cell suicide); and extracellular matrix therapies – that can be used alongside conventional cancer treatments.

1. Immune support

“…treatment with combination chemotherapy caused a significant and persistent decrease in B cell numbers (in dogs).” — Journal of Veterinary Internal Medicine, 2006

Compromised immunity is common in cancer patients, and a strong oncological research trend is underway to deliver immune-targeted therapies.

Cancer itself is known to be immuno-suppressive. It has been shown that dogs with cancer (lymphosarcoma and osteosarcoma) experience reductions in circulating T cells. This not only promotes the development and progression of cancer itself, but also increases the risk of infection.

Neoplasia may be immune-compromising, but it is also immune-deranging. Abnormal circulating immune complexes seem to impede effective immune responses in dogs with mammary carcinomas.

Immune support can be found in several forms:

  • One existing immune therapy for canine cancer is the plasmid DNA melanoma vaccine; several other anti-cancer vaccines in development have also shown promise.
  • COX-2 inhibitors currently used in metronomic protocols, whether pharmaceutical or botanical, reduce immuno-suppressive prostaglandins.
  • The use of immune-stimulating modified bacteria has shown to be beneficial in increasing remissions and durability of stable disease in a research setting.
  • Finally, low-dose chemotherapy and local radiation can increase immune destruction of cancers without systemic immune compromise.
  • Beta glucans are another tool the clinician can use for immune support (see below).

Beta glucans for additional immune support

Beta glucans are a group of D-glucose monomers linked by a β-glycosidic bond, found in fungal and plant cell walls. Common sources are extracts derived from various mushrooms, oats and yeast. These compounds have demonstrated strong immuno-modulatory activities based on animal and human-based research.

“β-glucans are known to exhibit direct anticancer effects and can suppress cancer proliferation through immuno-modulatory pathways.” — Investigational New Drugs, 2017

Immune-supporting beta glucans have been shown to bind to pattern recognition receptors (PARRs) on a variety of immune cells. In this way, they activate an array of immune pathways.

In humans, these compounds have been shown to increase adaptive and innate immune responses, as well as decrease cancer metastasis.  As immune-stimulating molecules, they activate macrophages, granulocytes, dendritic cells — and of particular interest in cancer immunity, natural killer cells. This leads to downstream stimulation of both T and B cells.

Beta glucans (β-1,3/1,6) extracted from yeast and administered orally to dogs elicited an immune response (and competency) similar to that of a kennel cough vaccination. Beta glucans from oat were shown to balance canine vaccination immune response by maintaining cellular immunity alongside humoral immunity. (Cellular immunity is in general the main effector branch of anti-cancer immune responses.)

It was previously assumed that oral delivery of these compounds did not yield appreciable results. However, it is now known that pinocyte microfold (M) cells, located in the small intestine, actively transport beta glucans to the Peyer’s patches.

“Glucan effects on cancer inhibition are well established.” — Anti Cancer Research, 2018

In clinical practice, the author uses both K-9 Immunity® as well as Im-Yunity® as beta glucan sources. K-9 Immunity contains a spectrum of beta glucans from a variety of medicinal fungal sources. The encapsulated formulation is preferred. Im-Yunity® contains various glucans along with a protein component, which together comprise the active ingredient, PSP.

Cases of canine hemangiosarcoma deserve special mention. At 100 mg/kg PO daily, Im-Yunity® was shown to increase median survival times to 199 days in a small cohort of dogs with splenic hemangiosarcoma. To the author’s knowledge, this is the highest median survival time reported for splenic hemangiosarcoma treatment.

Transfer factors found in low molecular weight lymphocyte extracts are thought to enhance the binding of beta glucans to immune system cells, particularly T cells, which are active in cell-mediated immunity. Transfer Factor is available commercially and the author uses it concurrently with beta glucans.

The beta glucans as a group have a high safety margin, with only rare cases of digestive upset that can be minimized by administration with food. The same can be said for Transfer Factor. However, the author avoids these immune therapies in cases of historical or active immune-mediated disease.

 2. Apoptosis: cancer cell suicide induction

“One of the few areas in the cell death field that everyone does agree upon is that having cancer cells undergo apoptosis would be a good thing.” — Carcinogenesis, 2005

Cancers uniformly lack the normal cell suicide response (apoptosis) seen in damaged, aged, infected or otherwise deranged cells. Triggering normal apoptosis in these deficient cells is a targeted approach to decreasing cancer cell burden. In fact, traditional oncologic therapies for canine cancer, such as chemotherapy and radiation, trigger apoptosis or programmed cell death of neoplastic cells.

“Owing to the fact that apoptosis causes minimal inflammation and damage to the tissue, apoptotic cell death-based therapy has been the centre of attraction for the development of anticancer drugs.” — Cell Death and Disease, 2016

However, both chemotherapy and radiation have additional effects that are not specific to neoplastic cells. The resulting toxicity leads to dose limitations.

Other compounds, called apoptogens, are capable of inducing apoptosis. An array of naturally-occurring, low-toxicity, phytochemical apoptogens selectively induce cancer cell suicide. In general, they are limited by oral bioavailability, which should be enhanced to obtain a therapeutic effect.

Common phytochemical apoptogens include curcumin, silymarin, EGCG, luteolin, lycopene, capsaicin, resveratrol and many others. Interestingly, these and other apoptogens can be extracted from dietary sources. These naturally-occurring dietary apoptogens act at multiple sites in the intracellular cascades involved in activating normal apoptosis.

“A long list of such dietary constituents is known to induce apoptosis of cancer cells without affecting normal cells.” — Biochemical Pharmacology, 2008

Additionally, several dietary apoptogens are chemo- and radio-sensitizers, enhancing the effects of chemotherapy and radiation when used concurrently. These include curcumin, silymarin and luteolin, among others.

The author uses Apocaps® as a combination source of bioavailability-enhanced dietary apoptogens. This formula may also be used alongside conventional therapies such as surgery and chemotherapy.

The author typically discontinues most therapeutic supplements, including Apocaps®, at least four days prior to surgery until ten to 14 days post-operatively. When anti-inflammatory treatments such as corticosteroids or NSAIDS are used, the author will reduce the labeled Apocaps® dose by approximately half, since Apocaps® constituents have mild to moderate COX-2 inhibiting effects.

Apocaps® has a high safety margin in clinical practice, with rare cases of digestive upset, usually loose stool. This can often be minimized by administration with food.

3. Extracellular matrix therapies

Reducing cancer spread is central to mitigating mortality and morbidity. Cancer spread occurs through a complex series of events, including mutation, loss of cancer stem cell anchoring points, migration, vascular invasion, immune dysfunction, alterations in the extracellular matrix (ECM), adhesion, and proliferation of distant tumor cells.

One possible reason for loss of remission after chemotherapy or radiation is an altered microenvironment that results from these conventional treatments. This altered matrix actually favors metastasis. In particular, the injury of cancerous tissues seems to favor conditions for regenerative responses, including aberrant neoplastic cell migration.

“Several studies demonstrated that ionizing radiation might promote migration and invasion of tumor cells” — Critical Reviews in Oncology/Hematology, 2016

“Chemotherapy by itself can instigate metastatic spread while simultaneously restraining growth of the primary tumor.” — Cancer Research, 2015

It is the author’s opinion that substantially increased attention should be placed on this subject in veterinary cancer patients.

Modified citrus pectin

The use of modified citrus pectin is one way to address this problem. Modified citrus pectin (MCP) is a complex water-soluble indigestible polysaccharide obtained from the peel and pulp of citrus fruits. To increase oral bioavailability, the citrus pectin has been modified by means of high pH and temperature treatments.

“Modified citrus pectin (MCP), a complex water-soluble indigestible polysaccharide…has emerged as one of the most promising anti-metastatic drugs.” — Carbohydrate Research, 2009

MCP has anti-adhesive properties relative to metastatic mobile cancer cell attachment. After neoplastic cell detachment and vascular invasion, endothelial attachment and neoplastic accumulation is mediated by galectin-3. MCP appears to antagonize galectin-3 adhesion. Galectin-3 also mediates mobile neoplastic cell extravasation from blood vessel to adjacent tissue extracellular matrix, where MCP appears to be active as well. Finally, MCP has the potential for increasing apoptotic responses of tumor cells to various events such as loss of anchoring, chemotherapy and radiation. Inducing normal apoptosis of cancer cells by MCP is also mediated, at least in part, by inhibiting galectin-3 anti-apoptotic function.

It has been shown in humans that high doses of MCP over one to three weeks, or modest doses long-term, increase urinary excretion of the toxic heavy metals lead, arsenic and cadmium, without increased excretion of normal dietary mineral elements.

MCP is exceptionally safe, with few to no clinical side effects. Digestive upset or allergic response is possible, but the author has not seen adverse effects clinically. The author uses approximately two to three times the human adult labeled doses pound for pound, mixed in food. Bear in mind that MCP is a pectin, so it can form a clear gelatinous substance in the presence of moisture, including dog rations.

Summary

When it comes to cancer, relative to other disease states, dog owners are often concerned about adverse survival metrics and life quality concerns. This can lead to dissatisfaction with canine cancer management, and treatment refusal. By practicing cancer care that includes immune support, cancer cell suicide induction, and extracellular matrix therapies, the clinician may experience increased opportunity for more favorable treatments.

References

Immune support

Walter CU, Biller BJ, Lana SE, Bachand AM, Dow SW. “Effects of chemotherapy on

immune responses in dogs with cancer”. J Vet Intern Med. 2006 Mar-Apr;20(2):342-7.

Rutten VP, Misdorp W, Gauthier A, Estrada M, Mialot JP, Parodi AL, Rutteman

GR, Weyer K. “Immunological aspects of mammary tumors in dogs and cats: a survey. including own studies and pertinent literature”. Vet Immunol Immunopathol. 1990. Nov;26(3):211-25. Review.

Klingemann H. “Immunotherapy for Dogs: Running Behind Humans”. Front Immunol. 2018;9:133. Published 2018 Feb 5.

Stuyven E, Verdonck F, Van Hoek I, et al. “Oral administration of beta-1,3/1,6-glucan to dogs temporally changes total and antigen-specific IgA and IgM”. Clin Vaccine Immunol. 2009;17(2):281-5.

Ferreira LG, Endrighi M, Lisenko KG, et al. “Oat beta-glucan as a dietary supplement for dogs”. PLoS One. 2018;13(7):e0201133. Published 2018 Jul 31

Bashir KMI, Choi JS. “Clinical and Physiological Perspectives of β-Glucans: The Past, Present, and Future”. Int J Mol Sci. 2017;18(9):1906.

Brown DC, Reetz J. “Single agent polysaccharopeptide delays metastases and improves survival in naturally occurring hemangiosarcoma”. Evid Based Complement Alternat Med. 2012;2012:384301.

Yoon TJ, Koppula S, Lee KH. “The effects of β-glucans on cancer metastasis”. Anticancer Agents Med Chem. 2013 Jun;13(5):699-708. Review.

Stier H, Ebbeskotte V, Gruenwald J. “Immune-modulatory effects of dietary Yeast Beta-1,3/1,6-D-glucan”. Nutr J. 2014;13:38. Published 2014 Apr 28.

Vetvicka V, Vetvickova J. “Glucans and Cancer: Comparison of Commercially Available β-glucans — Part IV”. Anticancer Res. 2018 Mar;38(3):1327-1333.

Berrón-Pérez R, et al. “Indications, usage, and dosage of the transfer factor”. Rev Alerg Mex. 2007. Jul-Aug;54(4):134-9. Review.

Apoptosis

Kaufmann SH, Earnshaw WC. “Induction of apoptosis by cancer chemotherapy”. Exp Cell Res. 2000 Apr 10;256(1):42-9. Review.

Eriksson D, Stigbrand T. “Radiation-induced cell death mechanisms”. Tumour Biol. 2010 Aug;31(4):363-72.

Baig S, Seevasant I, Mohamad J, Mukheem A, Huri HZ, Kamarul T. “Potential of apoptotic pathway-targeted cancer therapeutic research: Where do we stand?” Cell Death Dis. 2016;7(1):e2058.

Khan N, Afaq F, Mukhtar H. “Apoptosis by dietary factors: the suicide solution for delaying cancer growth”. Carcinogenesis. 2007 Feb;28(2):233-9.

Khan N, Adhami VM, Mukhtar H. “Apoptosis by dietary agents for prevention and treatment of cancer”. Biochem Pharmacol. 2008;76(11):1333-9.

Limtrakul P. “Curcumin as chemosensitizer”. Adv Exp Med Biol. 2007;595:269-300. Review.

Garg AK, Buchholz TA, Aggarwal BB. “Chemosensitization and radiosensitization of tumors by plant polyphenols”. Antioxid Redox Signal. 2005 Nov-Dec;7(11-12):1630-47. Review.

Prasad NR, Muthusamy G, Shanmugam M, Ambudkar SV. “South Asian Medicinal Compounds as Modulators of Resistance to Chemotherapy and Radiotherapy”. Cancers (Basel). 2016;8(3):32. Published 2016 Mar 5.

Fantini M, Benvenuto M, Masuelli L, et al. “In vitro and in vivo antitumoral effects of combinations of polyphenols, or polyphenols and anticancer drugs: perspectives on cancer treatment”. Int J Mol Sci. 2015;16(5):9236-82. Published 2015 Apr 24.

Extracellular matrix therapies

Moncharmont C, et al. “Radiation-enhanced cell migration/invasion process: a review”. Crit Rev Oncol Hematol. 2014 Nov;92(2):133-42.

Vilalta M, Rafat M, Graves EE. “Effects of radiation on metastasis and tumor cell migration”. Cell Mol Life Sci. 2016;73(16):2999-3007.

Karagiannis GS, Condeelis JS, Oktay MH. “Chemotherapy-induced metastasis: mechanisms and translational opportunities”. Clin Exp Metastasis. 2018. Apr;35(4):269-284.

Ran S. “The Role of TLR4 in Chemotherapy-Driven Metastasis”. Cancer Res. 2015;75(12):2405-10.

Glinsky VV, Raz A. “Modified citrus pectin anti-metastatic properties: one bullet, multiple targets”. Carbohydr Res. 2009 Sep 28;344(14):1788-91.

Tehranian N, et al. “Combination effect of PectaSol and Doxorubicin on viability, cell cycle arrest and apoptosis in DU-145 and LNCaP prostate cancer cell lines”. Cell Biol Int. 2012 Jul;36(7):601-10.

Eliaz I, Hotchkiss AT, Fishman ML, Rode D. “The effect of modified citrus pectin on urinary excretion of toxic elements”. Phytother Res. 2006 Oct;20(10):859-64.

Zhao ZY, et al. “The role of modified citrus pectin as an effective chelator of lead in children hospitalized with toxic lead levels”. Altern Ther Health Med. 2008 Jul-Aug;14(4):34-8.

Editor’s noteIf you are interested in learning more about Dr. Dressler’s approach to managing canine cancer, he has created a private video training series, sponsored by Functional Nutriments, that is free to veterinarians. You can find it at FunctionalNutriments.com/IVC.

Disclosure Statement

The author of this publication developed the Apocaps® formula and is a paid consultant for Functional Nutriments, LLC. He has no equity interest in either Functional Nutriments, LLC or Apocaps®.

Homeopathic approach to cancer in companion animals

A case study involving a senior cat with cancer demonstrates how a homeopathic approach treats cancer and extends longevity.

At our veterinary surgery on the Sunshine Coast in Queensland, Australia, chronic skin disease and cancers represent the majority of our daily caseload. On average, we have about 50 cancer cases ongoing at any one time. We treat most of them with alternative medicines, predominantly homeopathic ones. In this article, I will provide an overview of our therapeutic approach to cancer, and illustrate this approach through a case study involving a feline patient named Miss Kitty.

Beginning a cancer case

When cancer cases are presented at our surgery, they have commonly just finished an intensive diagnostic or surgical regime. Often, they are still in the process of receiving chemotherapy. For each animal that presents to our surgery with a cancer diagnosis, we begin by addressing the following general aims:

  1. To slow tumor growth
  2. To address pain and discomfort
  3. To strengthen the body so it can begin to heal
  4. To improve the patient’s overall mental and physical well-being
  5. To gently lead the body to cure, if it is able.

As we work towards each of these goals, while the patient is on homeopathic treatment, we observe several different outcomes. Some will hold a cancer in a steady state, unchanged, for many years. Some will experience a slowdown in the growth of their cancer. And still others will be led to cure, with a complete shrinking of their cancers.

Miss Kitty – case study

August 2012

Miss Kitty first presented at our surgery at ten years of age. She had recently become quite breathless with any exertion. Her usual vet recommended euthanasia because thoracic radiographs revealed large growths on her lungs. Miss Kitty’s heart had been pushed sideways and could only be auscultated on the right side of her chest dorsally. An exact histopathological diagnosis was not pursued by the owners; however, homeopathic treatment was begun using her history, presenting symptoms, physical exam, and preliminary diagnostics.

 

Treatment began with two homeopathic medicines, Lycopodium Clavatum 200c and Carcinosin 200c. These two medicines were used in alternation, one for three days, then the other, using the methods devised for human cancer treatment by A.U. Ramakrishnan and Catherine Coulter and outlined in their book A Homeopathic Approach to Cancer,  a distillation of Dr. Ramakrishnan’s  treatment of over 10,000 people.1 The Ramakrishnan approach uses an organ-specific remedy that has an affinity for cancer in that area, alternating with a more general cancer homeopathic medicine like Carcinosin or Scirrhinum. Dr. Ramakrishnan uses the remedies in 200c potency as he has found it matches the energy of the cancer in most cases. The potency is then increased as the being heals.

Several other homeopathic medicines were used with Miss Kitty over the following year. They were prescribed depending on the presenting symptoms at her monthly visits. During one visit, she became quite cyanotic during handling and was treated with a homeopathic medicine called Carbo vegetabilis in a 1M potency; this helped with her general breathing for many months.

April 2014

After almost two years of homeopathic treatment, a new growth the size of a lemon was palpated in Miss Kitty’s abdomen behind the liver. It was not causing any symptoms but had grown rapidly over the past month. Her owners declined further diagnostic work. Her breathing was now quite stable, but there was no great change in chest auscultation, with the heart only audible on the right dorsal side.

Based on the location of the new mass, Miss Kitty’s homeopathic protocol was changed to homeopathic Phosphorus 200c and Tuberculin 200c, to be given in three-day alternation. Often, a change of remedy in a chronic case will stimulate the healing mechanisms again, as opposed to using the same medicine at the same strength. Miss Kitty’s case was re-analyzed with the new symptom of the liver tumor, allowing determination of a new homeopathic prescription.

June 2014

Almost four years post initial presentation, a new lump appeared in Miss Kitty’s mammary area; it had some firm nodules inside it. This mammary tissue was managed over the next two years with homeopathic Sepia officinalis, alternating with Carcinosin, both in 200c potencies.

Mammary growth in June of 2014.

March 2016

Miss Kitty’s breathing remained stable. The lump in her abdomen had shrunk somewhat, but was still palpable at around 6cm in diameter. Behaviorally, her owners reported a return to her original nature, similar to how she was when she first came to live with them. She had become more affectionate, and was now wanting to lie on the bed with them again. She even worked out a manageable relationship with the other cat in the household. However, at the March 2016 recheck, it was evident that her mammary lumps were enlarging. In addition, she had new symptoms — changes in her appetite, and some weight loss.

Mammary growths in November of 2016.

 

Her owners reported that all she wanted to eat or drink was cream. An older childless couple, her owners informed me at this visit that when they got her as a rehomed cat at two years of age, she was like their baby. They held and cuddled her like an infant for many years, until they got their second cat. They told me she would even put her front feet around their necks like a real baby.

Unusual information like this is important in a homeopathic consultation. It assists the prescriber in individualizing the case so s/he can select the most similar homeopathic medicine to that particular patient. Miss Kitty’s owners had previously mentioned her desire for cream, but an assumption was made that this was not an individualizing symptom, as many cats like cream. However, her almost exclusive craving for cream at this point in her therapy demanded further investigation. The emphasis placed on this symptom led to a closer analysis using a computer repertory search tool called MacRepertory.2 This database offers an easy method of searching symptoms unique to a case, and identifying homeopathic medicines that exhibit those same symptoms.

These repertory databases hold all the information that has been obtained from either provings (data obtained from the intentional taking of a substance by healthy persons to observe the symptoms), accidental poisonings, or the clinical use of potentised medicines, collected over the past 200 years. In this case, it was observed that, at least in humans, a huge desire for cream is a symptom experienced many times in patients who have benefited from a homeopathic medicine called Lac humanum, derived from human breast milk.

For Miss Kitty, the remedy Sepia was now changed to Lac humanum in a 200c potency, to be given every three days in alternation with Carcinosin 200c.

June 2016

The growth in Miss Kitty’s abdomen was no longer palpable at this visit. Her breathing had continued to improve. Her energy was good, and her appetite had also improved. While she continued to enjoy cream, she was less focused on that food alone.

February 2017

Almost five years after treatment was begun for large lung tumors, followed by an abdominal tumor and then mammary tumors, Miss Kitty succumbed to general age-related weakness and debility, with further ulceration of her skin tumors. She was euthanized at 16 years of age.

Conclusion

In Miss Kitty’s case, homeopathic treatment followed Hering’s Law of cure (see sidebar above), gradually shifting her disease from deep within vital organs to more external locations. As aspects of her illness resolved, other symptoms surfaced, allowing us to individualize her homeopathic prescriptions further, improving her vitality and physical and mental well-being. A homeopathic approach to Miss Kitty’s care allowed her to live a long and full life with her family.

1Ramakrishnan AU, Coulter, Catherine R. A Homeopathic Approach to Cancer. Berkeley Springs, West Virginia: Ninth House Publishing, 2001.

2MacRepertory (Computer Software), 2017.

This article has been peer reviewed.

CBD case studies: anxiety and epilepsy

The following case studies demonstrate how CBD can be used in the treatment of anxiety and epilepsy in dogs and cats.

In this author’s clinical experience, full spectrum CBD products have been most effective in cases of anxiety, osteoarthritis and seizure disorders in both dogs and cats. For the purposes of these case studies, HempRx Forte was used.

Anxiety

CBD-rich cannabis is the most effective natural method for treating anxiety in both dogs and cats, in this author’s practice. Start at a dose of 0.5 mg/kg by mouth every 12 hours with food, and increase every three days to the desired effect. Most guardians notice improvement within 12 to 24 hours. In refractory cases, this author has administered CBD with SSRIs. However, there are no studies proving their combined safety.

Pugsley’s anxiety and dog aggression improved dramatically with the use of CBD. Photo courtesy of Angie Krause.

Anxiety case study

Pugsley is a nine-year-old MN Pug weighing 14 pounds. He has a history of anxiety and dog aggression that began at the age of two. He was reactive when seeing other dogs, both in the home and on a leash. Pugsley was started on 5 drops (5 mg of CBD) of HempRx Forte, twice daily with food. After three doses, Pugsley’s leash reactivity improved by approximately 50%. Pugsley has continued to show significant improvement with continued use of CBD.

Epilepsy

CBD-rich hemp extracts have gained popularity for treating children’s seizure disorders. Due to the lack of THC, these children can enjoy life without the sedative effects of traditional anticonvulsants. Many pet guardians are hesitant to use drugs like potassium bromide and phenobarbital long-term due to their undesirable side effects. Other drugs like levetiracetam have questionable efficacy and dosing schedules that make compliance difficult. CBD may provide a safe and efficacious alternative for some animals. It may also help reduce dosage in conventional pharmaceuticals.

In this author’s experience, many animals with refractory seizures may require doses of up to 2 mg/kg to 4 mg/kg of CBD every 12 hours. CBD is metabolized by the icytochrome P450 system and may therefore alter metabolism of anticonvulsants such as phenobarbital.7

Oliver’s seizures decreased from one to two seizures a month to less than one every 6 months on CBD. Photo courtesy of Angie Krause.

Epilepsy case study

Oliver is an eight-year-old MN DSH cat weighing 11 lbs. He presented after having one or two seizures a month for five months. His guardian was reluctant to start anticonvulsants due to the possible side effects. Bloodwork and physical examination were within normal limits and imaging was not performed. Oliver was started on 0.2 mls of HempRx containing 3 mg of CBD, twice daily with food.

After starting CBD, Oliver stayed seizure-free for six months. At that time he had one seizure. His current seizure frequency is approximately twice yearly.

Click here to read more about incorporating medical cannabis into your practice.

TCVM: An integrative approach to treating cancer

TCVM may be a stand-alone or adjunctive treatment for animal cancer patients. It not only treats cancer, but can potentially prevent recurrence and metastasis. 

Cancer is one of the most despised and feared words in the medical vocabulary. It’s also one of the biggest health concerns facing not only humans, but also our canine and feline patients. Cancer afflicts one in every three1 to one in every four dogs2, with incidence increasing to almost 50% in dogs over the age of ten years2. In fact, it is the leading cause of death in dogs and cats in the United States; as many as 50% of our companion canines and felines die from cancer.

Conventional medicine seeks to kill cancer cells by utilizing surgery, chemotherapy, radiation therapy and immunotherapy. Treatment is based on the particular type of cancer a patient has, and focuses more on the disease itself than on the overall health of the individual patient. Conventional treatments often cause collateral damage to the body, with impacts ranging from mild to severe.

In contrast, Traditional Chinese Veterinary Medicine (TCVM) treats the disease pattern identified in an individual patient (irrespective of the conventional biomedical diagnosis), taking into consideration the overall condition of the patient at that time. TCVM treatments work with the body rather than against it, and the side effects, if any, are typically mild. TCVM may be used as a stand-alone treatment or an adjunctive treatment for cancer patients. It provides the veterinary practitioner the ability to not only treat active cancer, but to potentially prevent recurrence and metastasis.

Traditional Chinese Medicine etiology of cancer

According to Traditional Chinese Medicine (TCM), cancer develops from three primary sources: exogenous factors, endogenous factors, and emotional factors. If Zheng Qi (Upright Qi, Antipathogenic Qi) is strong, these pathogenic factors will be defeated and the body remains unharmed. However, if Zheng Qi is weak, the pathogenic factors invade the body, creating a disharmony that develops into cancer. Cancer is therefore a pattern of both excess and deficiency with an underlying Zheng Qi deficiency.

1. Exogenous or external factors include toxins such as heat toxin, food toxin, radiation, chemicals, heavy metals, and the six pathogenic factors (Wind, Heat, Summer Heat, Cold, Dryness, Dampness).

2. Endogenous factors include internal organ (Zang-fu) disharmony(ies), an imbalance of Yin/Yang and Qi, and Blood deficiency (weak constitution).

3. Emotional factors result in emotional stress or heightened emotions (e.g. lack of exercise or social interaction, changes in household schedule or members, etc.). Any of these factors, singly or in combination, may cause stagnation of Qi/Blood, Phlegm, Dampness or Toxicity, which may then develop into cancer. Often, a root deficiency of Qi, Qi/Yang, Blood or Yin have enabled the external factors to have a strong impact, or are the actual cause of Zang-fu

In veterinary medicine, some of the most common TCM etiologies of neoplasia include:

  • Trauma and/or Cold-Damp, leading to Blood Stasis
  • Inappropriate diet, which may result in Food Stagnation, leading to Accumulation of Phlegm and/or Heat Toxin
  • Environmental changes (household changes, boarding, travel, etc.), leading to Qi Stagnation
  • Invasion of the six Pathogenic Factors, leading to Stagnation of Blood/Qi, accumulation of Phlegm, Heat, Heat Toxin, and/or Damp
  • Disharmony of Zang-fu (internal) organs, leading to Zheng Qi deficiency, which then leads to Stagnation of Blood/Qi, accumulation of Phlegm, Heat, Heat Toxin, and/or Damp
  • Note: Vaccines and chemicals are Toxins/Heat Toxins. Their administration may bypass the normal route of TCM pathogenic invasion; thus, the body is unable to “fight” these pathogens, and they can have a strong negative impact on the body . Additionally, as these exogenous toxins may be introduced to the body at the deepest (Xue) level, they may remain latent as a pathogenic factor, only to emerge in the future when the body’s Zheng Qi is weakened.

Strategies for treating cancer with TCM

1. Tonify Zheng Qi

If Zheng Qi is deficient, the body’s resistance to pathogenic factors is weak. Zheng Qi deficiency is ultimately the root cause of cancer.

  • Tonify Qi
  • Tonify Spleen
  • Nourish Blood
  • Nourish Yin

 2. Move Qi and Blood

Stagnation of Qi and Blood is the basic pathologic change seen in the development of cancer.

3. Clear internal Heat and toxins

Infection and chronic inflammation are predisposing factors in the development of cancer.  In TCM, Heat-toxin is a major cause of cancer.

4. Dispel Phlegm and Dampness

Damp obstructs the smooth flow of Spleen Qi. This means the Spleen’s ability to transform food into Food Qi (Gu Qi) and transport Gu Qi to the Upper jiao (Lungs for distribution to the rest of the body, and Heart where the transformation into Blood occurs) is impaired.  The Spleen hates Damp; when there is Damp, the Spleen must work extra hard to eliminate the pathogen. Damp is the origin of Phlegm, and when Phlegm accumulates, masses develop.

  • Support Spleen to drain Damp
  • Drain Damp
  • Transform Phlegm

5. Bring the body back to balance

The fundamental basis of TCM is balance and harmony.  When the body is out of balance, disharmony occurs and disease is manifested. Treatment therefore seeks to help the body come back into balance, eliminating excesses and supplementing deficiencies.

 The five main branches of TCM

The strategies discussed above are accomplished through the five main branches of TCM: acupuncture, herbal medicine, dietary or food therapy, Tui-na, and Tai-chi/Qi-gong.In this author’s opinion, the best results are achieved when at least two branches are utilized concurrently, and a kibble diet is eliminated.

1. Acupuncture

To date, the full effects of acupuncture are not completely understood. Its physiological effects cannot be explained by a single mechanism; however, there is evidence that acupuncture stimulates a series of interactions among the nervous system, endocrine system and immune system, resulting in somato-somatic, somato-visceral and somato-autonomic reflexes. Acupoints and needling technique should address the TCM pattern of disharmony as well as the side effects from current treatment protocols, such as chemotherapy-associated nausea and diarrhea, or pain secondary to the cancer or subsequent to the treatment modality. Insertion of a needle at or very close to a known malignant mass is contraindicated, as is electro-acupuncture across a neoplastic mass.

 2. Chinese herbal medicine

Herbal formulas may be used separately or in tandem with conventional therapies. Strategies to employ prior to and after conventional therapies should focus on supplementing Qi, nourishing Blood, and tonifying the Spleen, Liver and Kidneys. During conventional therapies, herbal formulas may be utilized to mitigate negative side effects. When used as the primary therapy, formulas to dispel pathogenic factors to directly address the tumor should be used in tandem with formulas that supplement Qi, nourish Blood and tonify Spleen, Liver, Kidneys and other affected Zang-fu. In this author’s experience, as the TCM patterns change with the disease state, formulas are typically modified or changed altogether.

3. Dietary or food therapy

From a TCM perspective, the poor ingredient quality and processing of commercially-prepared dry and canned pet foods are at the root cause of many cancers. Kibble has an astringent effect on the Stomach and engenders Food Stagnation and Damp Heat in the body. Damp Heat congeals with time and forms Phlegm. Additionally, the Spleen gets overtaxed dealing with the extra Dampness and becomes weakened. The high pressure and temperature used in processing canned foods releases more heat energy and alters Qi, creating a food that is warmer than its original contents and damages/decreases Qi and Blood. There are also concerns that bisphenol A (BPA) or bisphenol F (BPF), contained in the lining of most canned foods, may be carcinogenic. Freeze-dried foods tend to be Qi deficient and drying, leading to Blood deficiency and Body Fluid deficiency when used long-term. Considering that the patient with cancer is already in a state of deficiency with excess, the optimum diet is one that will help tonify the Spleen/Stomach to create good Qi and Blood, as well as address the other disharmonies specific to the patient.

In this author’s opinion, fresh foods, either home-cooked or from a gently-cooked, commercially-prepared, frozen raw diet, are critical to the treatment of cancer in our companion animals. Historically, we have designed TCM diets utilizing 60% to 70% high quality protein, 10% to 20% primarily low-glycemic index carbohydrates, and 20% to 30% lightly-cooked vegetables in tandem with nutraceuticals such as digestive enzymes, pre- and probiotics, fish oil or algae-based EPA/DHA, microalgae, medicinal mushrooms, and whole food vitamin-mineral supplements. Current research utilizing a ketogenic diet is promising, and when combined with the tenets of TCM may yield the best results yet.3

4. Tui-na

Other veterinary substitutions for Tui-na include body work such as massage, chiropractic, and craniosacral therapy.

5. Tai-chi/Qi-gong

Daily exercise, ideally in environments with minimal chemicals and electromagnetic fields, is recommended as a “substitute” for Tai-chi/Qi-gong.

Cancer case studies illustrating the principles of TCVM

Amynta

Amynta, a 4½-year-old spayed female Rhodesian ridgeback, was presented for TCM treatment following exploratory surgery with resection and anastomosis for an ileal intussusception. Histopathology of the resected small intestine and cytology of an abdominal lymph node were consistent with high grade lymphoma.

One month post-surgery, the patient was started on CHOP-based chemotherapy with a board-certified oncologist, as well as Chinese herbal medicine, nutraceuticals, and a home-cooked diet for support during chemotherapy. Amynta’s owner also started her on alkalinized water. The patient received dry needle and aqua-acupuncture with vitamin B12 and lyophilized thymus extract on a regular basis, but after four months, her owner discontinued chemotherapy due to the negative side effects.

Since then, Amynta has been maintained on regular dry needle and aqua-acupuncture, Chinese herbal medicines, nutraceuticals, daily oral thymus extract with colostrum, DLLV (lily extract), and a primarily home-cooked diet to address her TCM patterns of disharmony. After the owner moved out of town, she and her local veterinarian added rectal ozone therapy with microbiome restorative therapy to address Amynta’s chronic intermittent diarrhea (often secondary to dietary indiscretion). Chinese herbal medicines and nutraceuticals have been changed over time to address her changing TCM patterns of disharmony.

To date, two years and two months since initial presentation, Amynta is doing extremely well, and is lively and active, with no evidence of recurring disease.

Treatment strategies utilized: Tonify Spleen Qi and drain Damp, nourish Blood and Yin, move Qi and Blood, and support Kidney Jing.

Camille

Camille, a ten-year-old spayed female domestic shorthair cat, was presented for TCM treatment following duodenal resection for a mast cell tumor one month prior. She was also in the early stage of chronic renal disease at the time of diagnosis.

Camille has been maintained for four years and four months on prednisolone, Chinese herbal medications, nutraceuticals, a commercially-prepared raw meat diet (slightly and gently cooked) and monthly aqua-acupuncture with vitamin B12, bioregulatory medicine, and lyophilized thymus extract. Her renal values have remained stable, and no signs of MCT recurrence or metastasis have been identified on repeat abdominal ultrasounds. Chinese herbal formulas and nutraceuticals have been changed over the years to address Camille’s changing TCM patterns of disharmony.

Treatment strategies utilized: Tonify Spleen Qi, nourish Blood, move Qi and Blood, tonify Kidney Qi.

Magnus

Magnus, a 4½-year-old neutered male boxer, was presented to the emergency service for hemoabdomen. The day before, an approximately 8cm complex mass was seen on abdominal ultrasound. No metastasis was appreciated on thoracic radiographs, and biopsy of the spleen and liver revealed splenic hemangiosarcoma but no apparent hepatic involvement.

The owner opted for follow-up TCM treatment only and presented with Magnus one month after surgery.  The patient was prescribed two Chinese herbal medications, coriolus mushroom extract, and a home-cooked diet to address his TCM diagnosis. He was also treated twice with aqua-acupuncture using vitamin B12, bioregulatory medicine, and lyophilized thymus extract.

The patient moved out of state one month after presentation, but was continued on herbal medication for one year.

Three years and five months after initial presentation, the owner informed us that Magnus was still alive and thriving. She ran out of herbs but continued the TCM diet and added colloidal silver and several drops of food grade hydrogen peroxide to his drinking water.

Treatment strategies utilized: Tonify Qi, tonify Spleen, nourish Blood, move Qi and Blood, support Kidney Jing.

Conclusion

The use of TCM, either independently or in an integrative approach with conventional medicine and other holistic modalities, enables the practitioner to address the changing landscape of health and disease our cancer patients exhibit as they progress through treatment. By identifying and addressing disharmonies, the body is provided an enhanced and supported chance of survival.

1wearethecure.org/

2vetcancersociety.org/pet-owners/faqs/

3ketopetsanctuary.com/

This article has been peer reviewed.

Non-surgical treatment for feline resorptive lesions and chronic periodontal disease in a cat with chronic kidney disease

This layperson’s case study demonstrates how a patented blend of natural oils helped a high-risk feline overcome chronic periodontal disease.

Synopsis

Patient: Yochabel (feline)

Weight: 11.0 pounds
Age: 18 years old
Diet: Not kibble. Homemade species specific diet and wet food.

Diagnosis:

  1. Periodontal disease: Dental calculus and gingivitis. COHAT and frm to stage and treat. Possible underlying TR
  2. Tooth resorption: COHAT and frm, probing to rule out TR. 409 has retained root(s), rule out other lesions. Extraction is indicated
  3. Renal insufficiency-elevated BUN, Creatinine.
  4. Periodontal disease stage 2
  5. Retained root fragment

Ramifications of Diagnosis: Inability to eat food
Other Medical Issues: Chronic kidney disease
Treatment: 1/4 of a capsule of DentaPet rubbed on Yochabel’s gums/ twice daily
Outcome: Improved gum health and return to regular diet

____________________________________

My 18 year old cat, Yochabel, was a “foodie”, her passion in life was eating. When the day came that she didn’t knock over her food bowl trying to devour the last morsel, I knew something was wrong. After a consultation with her veterinarian followed by a referral to a veterinarian dental specialist, Yochabel was diagnosed with chronic periodontal disease and feline resorptive lesions. During her oral exam, it was found that Yochabel had several broken teeth and exposed nerve roots, making eating painful. After Yochabel was diagnosed with resorptive lesions, I pureed and warmed all of her food to make eating more comfortable. The specialist stated that the solution was surgical teeth extractions, which required anesthesia. However, we were faced with a dilemma: Yochabel had chronic kidney disease, which, combined with her age, made surgery high risk.

I was reluctant to proceed with surgery, and set upon researching more innovative, non-surgical treatment options. This is when I discovered Hope Science Vet DentaPet: a patented blend of natural food oils targeting periodontal disease and gum inflammation, created to naturally support oral health. The directions recommended rubbing Yochabel’s gums with the ointment and/or placing it on her paws so she would lick the ointment onto her own gums. As I slowly introduced her to the ointment, first through smell, then taste, she seemed receptive. Gradually I approached her from behind her head and stroked her as I gently introduced the ointment into her mouth. In no time at all, she let me rub her gums. This became part of our daily routine and the results were astonishing. After three months of consistent Dentapet application twice daily, Yochabel’s gum health markedly improved. Within four months she no longer required pureed food and was able to resume her regular diet with ease. Her normal diet wasn’t kibble because I know that she would not have been able to crunch down on hard food. She could however chew chicken and turkey breast, ground beef, etc. comfortably after healing took place. I continued to apply Dentalpet once per day for maintenance.

This non-surgical, alternative treatment improved Yochabel’s quality of life, a decision that was in the best interest of her care. After her diagnosis, Yochabel continued to have a great life until she passed away at the age of 20.