Veterinary Internist Dr. Andrew Woolcock joins the podcast to discuss a 6 year-old Cocker Spaniel with an acute onset of lethargy, inappetance and depression. She also had a single collapsing episode that might or might not have been a seizure. Could this actually be IMHA? Dr. Woolcock talks through his diagnostic workup of choice and a variety of treatment options.
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LINKS
ACVIM consensus statement on the treatment of immune-mediated hemolytic anemia in dogs: https://pubmed.ncbi.nlm.nih.gov/30847984/
ACVIM consensus statement on the diagnosis of immune-mediated hemolytic anemia in dogs and cats: https://pubmed.ncbi.nlm.nih.gov/30806491/
Purdue College of Veterinary Medicine: https://www.vet.purdue.edu
Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/
What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/
Dr. Andy Roark Swag: drandyroark.com/shop
All Links: linktr.ee/DrAndyRoark
ABOUT OUR GUEST
Dr. Andrew Woolcock is a veterinary internist. He’s from the Midwest and did his schooling at Michigan State University, where he graduated with his DVM. After an internship at North Carolina State University, Dr. Woolcock completed a residency in small animal internal medicine at the University of Georgia. He joined the faculty at Purdue University in 2015, and is currently an Associate Professor of Small Animal Internal Medicine.
Dr. Woolcock loves the complex puzzles that internal medicine patients present, and loves working with students as they put the pieces together. He loves all-things-medicine, because physiology is so fascinating, but he especially gravitates toward immune-mediated diseases and endocrinology. Dr. Woolcock enjoys his clinical practice, but also his research in oxidative stress, and the scholarship of teaching and learning. When he’s not at work, Dr. Woolcock is likely watching old movies with his husband and their dog, Auggie (not sure of what breed he is, so they invented one for him – a Miniature Fluftoffee).
EPISODE TRANSCRIPT
This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click Here to learn more about Equity, Inclusion & Diversity at Banfield.
Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andrew Roark. Guys, I’ve got a great one today with my friend, internal medicine specialist, Dr. Andrew Woolcock. We are talking about IMHA in the Cocker Spaniel, which is a breed that is super common to have IMHA. Guys, I love talking to Andrew. He’s awesome. This is a great episode, you’re going to get a ton of pearls in a short amount of time. Let’s get into this episode.
Kelsey Beth Carpenter:
(Singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast, Dr. Andrew Woolcock. Thanks for being here.
Dr. Andrew Woolcock:
Yes. Thank you very much. My pleasure.
Dr. Andy Roark:
All right, man. It’s my pleasure. I’m so glad to have you on here. I do love to have conversations with the internists. You guys, the number one person I refer to is the internist. And so it’s great to have somebody on and talk through these cases. You, my friend, are an internist at Purdue University College of Veterinary Medicine. You are a Midwest guy, you did your residency down at the University of Georgia, go Dawgs, which is near my neck of the woods.
Dr. Andrew Woolcock:
Yes.
Dr. Andy Roark:
And I wanted to bring you in today and share a case with you. Is that okay?
Dr. Andrew Woolcock:
That sounds great.
Dr. Andy Roark:
Great. This is a game I call how do you treat that? I’m going to lay out a case and walk me through it and make sure I don’t make a fool of myself.
Dr. Andrew Woolcock:
Okay. Okay, I’ll do my best.
Dr. Andy Roark:
Excellent. You’re like this is possibly a steep order. I get it. Okay. I have in exam room three a six-year-old female spayed Cocker Spaniel named Liza. Liza was fine until yesterday, according to the owners. And then this morning, Liza is, and here’s nonspecific for you, lethargic, doesn’t really want to eat, has to be hand fed, she seems depressed. And then what happened recently that really set them off was she collapsed. Mom thinks that this may have been a seizure, dad thinks it might be heart disease, but they are really fixated on her collapse. On a quick physical examination, she’s got elevated heart rate. Her mucus membranes are pale, maybe slightly yellow a little bit when I’m looking in her mouth especially.
Dr. Andy Roark:
Just because she was pale, I did just a quick PCV total solids. PCV’s low, it’s under 18. So I’m definitely worried about some bleeding disorder. Total solids seem normal. But the serum itself is red and the texts were like, “Hey, you better look at this.” So when they spin it down, I’m still just getting red, yellow sort serum in my PCV, which hey, maybe that’s nothing, maybe it’s something. I want to bring Liza to you and just say, “Andrew, how do you treat that?” Where’s your head when I lay this case out? Where do I need to go from here?
Dr. Andrew Woolcock:
Yeah, thanks very much. First of all, yeah, let’s do our best for Liza, I’m guessing Liza with a Z here.
Dr. Andy Roark:
Yeah, totally.
Dr. Andrew Woolcock:
And so I think one of the best things that happened already is that on intake when it is discovered that Liza had this collapse episode, it was triaged to the point where she’s already in the back and you’re doing some triage diagnostics, which I think is great because the owners, when they see a collapse episode, of course that’s very dramatic, very scary. And so for them to already be bringing you differentials like seizure or heart disease is wonderful. And so then you’re in the back going, “Okay, is it one of those two things or should I be concerned for something else?” And the pale mucus membranes to me always makes me think, “Okay, we’re dealing with some poor perfusion issue. We’re not getting oxygen to the tissues that we’re hoping.”
Dr. Andrew Woolcock:
And that’s either because of a blood pressure issue, a state of shock, maybe heart disease, or as we now know with the PCV total solids, some very severe anemia. And likely in a dog who’s very ill, it’s some combination of those things, poor perfusion and anemia, or anemia with hypotension, or something like that. So already with this case, the anemia is a big concern and is a high yield problem that if you pursue, we’re likely to get to the bottom of.
Dr. Andy Roark:
Okay. Go ahead and start to lay down what does your initial diagnostic workup of this dog look like? So I told you PCV total solids, you just lay down a couple of things. You mentioned blood pressure. Where do you go? So mom and dad, they’re obviously very concerned. I just did a very quick test. What is your initial battery of tests on this dog and why?
Dr. Andrew Woolcock:
Yeah. Great. So because of the collapse episode, I think in addition to doing the PCV total solids which you’ve already done, the blood pressure to evaluate for hypotension, if you’ve got an ECG nearby, just to make sure that we don’t have an obvious cardiac arrhythmia or something like that then that’s a quick thing to do given that the collapse episode is being reported. But already with the anemia, you can at least suspect that there’s a chance that there is a cardiac arrhythmia without that being the primary cause. But at least good to evaluate for. But now that you know that you’ve got such a severe anemia, you can probably link that to the lethargy, poor appetite and likely the collapse episode that they’re seeing.
Dr. Andy Roark:
Right.
Dr. Andrew Woolcock:
So completing the remaining parts of your physical exam may reveal some of the other things we expect to see with anemia, like probably a heart murmur, likely to be quite tachycardic and tachypneic as compensation for that anemia. And then you’re going to evaluate on your physical exam for any other things that can help you move toward one of the three main causes for anemia, whether that be blood loss somewhere, a hemolytic process, or bone marrow disease or decreased production, although that can be difficult for you to detect anything on your exam. So in reality, you’re looking for markers of loss or hemolysis. So do you see bruising? Do you see obvious hemorrhage somewhere like in the mouth, coming from the nose, on your rectal exam, things like that? Are you detecting pain, distended abdomen, decrease or dull sounds when you’re trying to auscult the chest? Anything that would indicate to you that you’re looking for evidence of blood loss.
Dr. Andy Roark:
Yeah.
Dr. Andrew Woolcock:
Especially to explain the acute decline of this patient. So that would be the very initial thing before you’re really reaching for true diagnostic tests that just aren’t in your own hands.
Dr. Andy Roark:
Yeah. That totally makes sense. So yeah, we’ve got anemia, start looking for blood loss, yeah, with palpation, auscultation, all the things. Okay, that totally makes sense. If I go through this process, I’m not finding fluid in the abdomen. I stuck an ultrasound probe on there, just looked around looking for free fluid in the abdomen. I don’t see anything. The lungs generally auscult normally other than rapid heart rate that I can hear. So at this point, I’m getting interested in hemolytic disease. Let’s talk root cause analysis. So if I have a hemolytic disease in this dog, right, there’s idiopathic hemolytic disease, there’s also cancer related hemolysis, where do you go from there? Does it matter to you in the moment what you’re looking for? Are you trying to differentiate underlying pathology right now? Or are you just trying to stabilize the patient? How do you balance those things?
Dr. Andrew Woolcock:
I think that right now, stabilizing the patient is going to be key. But some of the root causes or the causes for hemolysis are going to be really important in determining the steps immediately following stabilization because they’re really going to guide the long-term therapy. So I think at this point, we turn our attention to the color changes that you’ve already described. The mucus memory maybe had a slight yellow tinge to them, the serum on the PCV total solids tube, which is a really helpful piece of information, was red to maybe orange in color. So it had a change that didn’t clear when you [inaudible 00:08:33] again. And to me, those are some real clear clues that there’s a hemolytic process going on. And so from there, you can pursue further diagnostics.
Dr. Andy Roark:
I want you to unpack that for me a little bit. So PCV total solids, you’re a big fan of this initial step. And I’ve heard you explain this before, but just real quick, run me through all the information that we get out of this simple PCV total solids test. Write that down for me.
Dr. Andrew Woolcock:
Yeah. It’s an incredible test. It’s a small micro hematocrit tube that gives you a huge amount of information because not only in Liza were we able to identify that her PCV is less than 18%, so quite a severe anemia, but you can also identify things like the total solids, which we already have learned is normal, and that can help us to deprioritize things like blood loss where you’d expect to be losing all that protein as well. And then the serum color is something that we don’t often think about but can be incredibly helpful because we’ve all spun a bunch of PCVs, hundreds of them. And so often, the serum color is clear and so we think nothing of it.
Dr. Andy Roark:
Right.
Dr. Andrew Woolcock:
But those times where the color is abnormal, it can really start to guide us towards an underlying disease process. The red discoloration can be really helpful for hemolysis. The yellow discoloration also helpful for hemolysis or for liver disease or something like that. So the serum color can be really helpful. And then even some smaller things like looking at the buffy coat, if it’s a huge buffy coat, then you know this patient is highly inflammatory, lots of white blood cells and circulation. So it’s a lot of information from a small tube.
Dr. Andy Roark:
Okay. So we’ve brought this patient in and we done our diagnostic batteries. We have a general idea acutely of what’s going on. The owners are going to ask me prognosis, how do you have that conversation especially if you’re not exactly sure what has caused this? What guidance do you give to them? Because they’re going, “Doc, how severe is it?” And they’re looking for some guidance for me. I still feel largely in the dark at this point. As far as what the long-term prognosis is going to be. I don’t expect you to have a crystal ball and have the answers, but how do you handle those conversations?
Dr. Andrew Woolcock:
Yeah. It is a challenging conversation because at this point, you have enough information to say to them that you are suspicious of a hemolytic process. But from there, your responsibility as a veterinarian is to try and determine is there a secondary or underlying cause for this hemolysis? And if there is, some of those are very fixable, very treatable, even curable, whereas other ones pose other challenges. But if ultimately you settle on an idiopathic cause, which is the most common in terms of canine hemolytic anemias, then prognosis is really and unfortunately dependent on the ability of the client to move forward with treatment.
Dr. Andy Roark:
Yeah.
Dr. Andrew Woolcock:
A dog like this, who’s already decompensating for an anemia is very likely to need blood product. And that’s only in the initial phase.
Dr. Andy Roark:
Right.
Dr. Andrew Woolcock:
Then you’re starting immune suppressive therapy, which can sometimes be months of therapy and a lot of doctor visits. But if the client is able to support their pet through that and comply with what can be a really challenging treatment course, then the prognosis can be fair to good in these patients. I think over the last 25 years when you look at the literature, survival rates used to be abysmal. And now more and more new literature, because of the greater availability of blood product and the greater knowledge and access to different medications, I think has helped us to really improve our success with this disease. But it’s still a long road.
Dr. Andy Roark:
Okay. No, that absolutely makes sense. I think that I can have that conversation in a reasonable way. Hey, guys. I just want to jump in with a couple of quick announcements. I have got to thank Banfield the pet hospital for making transcripts of this podcast possible. Guys, in an effort to increase inclusivity and accessibility in our profession to get people the information and to make sure everyone is included, Banfield has stepped up and made transcripts possible. You can find them at drandyroark.com. Thank you to them, this is something I wouldn’t be able to do without their help. God, it makes me feel so good to be able to offer this. Hey, gang, let me ask you a question. If you could make clients easier to handle for your veterinary team, would you do it? Would you make the client experience better for yourself and the people that you work with? Well if your answer is yes, I just want you to know that I have worked really hard to help make this happen. I have two online on demand courses in the Dr. Andy Roark store.
Dr. Andy Roark:
One of them is all about charming angry clients and the other one is all about building trust and relationships with pet owners. Guys, I worked really hard on these. This is the culmination of over a decade of lecture that I have done around the world and working on these topics. It is my best stuff broken up into five to 10 minute modules that you can just drop into staff meetings. You can put them wherever you want, it doesn’t have to be a big deal. You can use them in morning huddles, but it is a way that you can keep giving your people tools just to make their lives easier because that’s what they’re all about. If you’re interested, head over to drandyroark.com and just click on the store button and you can see what’s there. I’ve also got What’s On My Scrubs card game, which is just something fun, little team building educational activity that might make your people laugh. Anyway, I want you guys to know that’s there. I hope that you will check it out.
Dr. Andy Roark:
In the Uncharted Veterinary community, guys, we’re doing a workshop that I’m super proud of. It is my friend, the one and only Dr. Amanda Doran, and she’s doing a workshop called Navigating Neurodiversity, your clients, coworkers and self. This is all about navigating interactions with different people and creating a culture that is supportive of neurodiversity in the workplace. Guys, this is not a workshop that I have seen before. I am super excited to have it, I think these are conversations we need to be having. I’m really proud to be a part of the Uncharted Veterinary community and being able to help bring out workshops like this. As always, this workshop is free to our Uncharted members. It is $99 to the public. I will put a link down in the show notes. And now, let’s get back into this episode. Let’s talk about beyond a blood transfusion, right, especially if we’re having what seems to be a rapid drop in the PCV since no concerns last night. And then today, we’re having these things.
Dr. Andy Roark:
I know it’s more art than science probably, would you hear of those types of drops? Do you anticipate a continued drop? If you see this, are you a wait and see person? If this presents to me, if a PCV of 18 and they say she was fine last night, in my mind, I’m picturing the trajectory, the downward slope of what’s been going on and I’m concerned it’s going to continue on, I’m going to go ahead and push hard for blood product at this point. Do you agree with that? Do I have a little bit more leeway than I think? In your experience from the time that they come in, what is the risk that they continue to decline rapidly versus by the time they come in, they’ve generally stabilized?
Dr. Andrew Woolcock:
Yeah. With the acute presentation that lies ahead, I think that your instinct to be more aggressive in the way that you’re recommending stabilization in blood product is appropriate because I think that these are patients who will continue to hemolyse their red blood cells and continue to decline in their clinical state. And because of the fact that we know the bone marrow is going to take three to five days before it’s really able to respond to this drop, we’re not going to have that time to let them start to resolve this on their own.
Dr. Andy Roark:
Yeah. Okay, that makes sense. Let’s go ahead and start talking about immunotherapy if you don’t mind. Can you go ahead and walk me through the thought process there and the most up to date treatment approach for trying to get this back under control?
Dr. Andrew Woolcock:
Yeah. I think if we can fulfill the diagnostic criteria for IMHA, which I’m happy to talk about, then treatment wise, gold standard is immune suppression and still we reach for old reliable of corticosteroids of prednisone because that is a medication that at immune suppressive doses has some of the broadest immune suppressive effects of any drug out there in terms of suppressing every type of leukocyte and complement and antibody responses, it suppresses it all, and it has the added benefit of doing it pretty rapidly. So you’re able to start seeing immune suppressive effects within 48 to 72 hours of starting that drug. And we don’t have anything else out there that can do it that quickly.
Dr. Andrew Woolcock:
So in this disease, it is absolutely the mainstay. There is of course lots of information out there about other drugs that can be added to steroids to help with this disease. And as of now, we don’t have a lot of consensus about if there is one that is superior to the others. But we at least have some criteria that we try to use to guide when we would add a second drug. And so for me, that is often a patient who isn’t responding to steroids in the first few days.
Dr. Andy Roark:
Okay.
Dr. Andrew Woolcock:
A patient who needs more than one blood transfusion within a 24 hour period, that’s something that we’ve chosen as a marker of severity of the disease process. A patient who’s suffering really quite severe side effects of their steroids. And we want to use this second medication as a means to taper that steroid more quickly to try to relieve those steroid related side effects. And then probably the fourth criteria that I often use when I’m thinking about choosing a second agent is if I’m dealing with a very large breed dog. Now Liza being a Cocker Spaniel is not a large dog so she may not be a dog that I’m immediately thinking about needing more than just steroids.
Dr. Andrew Woolcock:
But large breed dogs, as we all know, are so susceptible to high dose steroid side effects, especially things like muscle loss, atrophy, ligament, laxity, weakness, et cetera. And so we just can’t get away with high dose steroids and large breed dogs like we can in some of our smaller breed dogs. And so if it is a Labrador, something bigger than that, then I’m often using more than just steroids to try and get them off of the steroids sooner.
Dr. Andy Roark:
Talk to me a little bit, I’ve got a couple questions here, but I want to stay on this large breed dog thing for a second because I totally understand what you’re saying and that resonates and makes sense with everything that I’ve seen. What is your go to right now in the Labrador, in the Rhodesian Ridgeback, in the big dog that’s 90 pounds that presents for this? If you’re wary of steroids, what are you reaching for right now, Andrew?
Dr. Andrew Woolcock:
Yeah. So I still reach for steroids, but I think when you look at the formularies that cite an immune suppressive dose of steroids as being between two and four milligrams per kilogram per day.
Dr. Andy Roark:
Yeah.
Dr. Andrew Woolcock:
And then you have your Labrador patient who’s, I don’t know, 40 kilograms.
Dr. Andy Roark:
Yeah.
Dr. Andrew Woolcock:
And so now you’re looking at starting at something like 80 or 100 milligrams of pred per day, that’s a lot of steroid and can really do a lot more harm than good. So I still do start steroids, but I try and dose them more based on body surface areas. And so oftentimes, they may end up with about 50 to 60 milligrams of pred. And that’s often the cap that I use almost regardless of the size of dog. But then I think it’s natural to be fearful that you’re not accomplishing what you’re hoping to in terms of immune suppression. So on top of that, I add an adjunctive agent and I would say the two that I use most commonly are cyclosporine or mycophenolate are the probably two immune suppressive medications that I use in addition to steroids.
Dr. Andy Roark:
Okay, that’s super helpful. That definitely makes sense. I think it fits anecdotally with what I see. Anytime I have a dog over about 40 milligrams of pred, they pant, they drink, they pee, they drive the owner’s nuts, it seems to be a miserable experience for them. So that makes complete sense. I have 100% done those calculations, just been like, “This doesn’t seem right.” It seems like this is going to be miserable for everybody.
Dr. Andrew Woolcock:
Yeah. And I think if it was just going to be for a short course of steroids, something for a severe inflammatory response, allergic reaction, of course we know these large breed dogs can tolerate that. But when you’re talking about immune mediated hemolytic anemia for which they’re going to be on steroids, maybe four to six months, something like that, then you really start to worry about the long-term side effects of high dose steroids.
Dr. Andy Roark:
Well let’s talk about that because that’s another emotional part of this for me, because I do not want to be too soft and not get the job done. And so I feel this pressure to go heavy. And at the same time, I go, “Man, this is not a week. This is a long-term experience.” Walk me through your rationale on monitoring this condition. So let’s say that we get some 72 hour response and we feel like the patient’s doing better, we’re seeing an uptick in the cell volume. I’m starting to feel good about this. The owners are ready to go home, they’ve spent a good amount of money. They would like to try to nurse at home.
Dr. Andy Roark:
Talk to me about where we go from here. And again, they’re going to want to know how long are we in this for? And I want to set realistic expectations because I do not want them to get in their head they’re done with this in three weeks or six weeks, and then I’m fighting with them and saying, “Look, if you move too fast, this is going to be a problem.” And so it’s much easier if I can just set some good expectations at the beginning. Help me do that.
Dr. Andrew Woolcock:
Yeah. So one of the things that I think is a relief to clients is that it is not our goal that we normalize their PCV before they can go home, right? We just want to see that they’re stable. And so usually, my first celebration is when they plateau. If I gave them their blood product, they’re getting on their treatment and they’ve been sitting at 22% for 24 hours, that’s huge. That’s amazing that they’re holding steady. So once they’re home, then a few of the milestones we’re looking for to help us feel comfortable adjusting their medications are evidence of a regenerative response. So you want to see that their bone marrow does start to catch up and start to replace their deficit. And then you want to see some of those markers of hemolysis start to go away. So things like the serum discoloration that we already talked about, the icterus, the red discoloration, let’s hope that that has gone away. Some of the cell changes that you can see on a blood smear, like agglutination or spherocytes, you want to see that those have normalized.
Dr. Andrew Woolcock:
And then once a patient has been at home about two to three weeks and they are either in a clinical remission or approaching that, meaning their PCV is getting close to the normal range, that’s a very reasonable time to start a conservative taper of their steroids. And then often what I talk with clients about is I say, “Let’s get your calendar out and let’s start choosing a very regular time that we see you, somewhere between two and four weeks,” depending on your preference as a clinician, depending on how severe their disease process was, depending on how risk averse your client may be. If they are extremely risk averse, then maybe you don’t taper quite as quickly. And then just have them coming in regularly to have something at least like a PCV total solids checked in a physical exam. If not, occasionally evaluating a full CBC and use each of those time points to help give you the stamp of approval to reduce their steroid dose by usually about 20 to 25% at a time.
Dr. Andy Roark:
That makes sense. Any pitfalls I should look out for in this process? Where do people go wrong? Where do they move too fast? Where do they get faults that ends up coming back and biting them in the rear? What do I need to look out for, Andrew?
Dr. Andrew Woolcock:
I think the biggest thing that we worry about with IMHA is that it can be really easy to focus in on the red blood cells, because of course that is what is so dangerously low and we need to replace. But what we know about this disease is that one of the leading causes of death is that these are patients who are at a very high risk performing blood clots and having embolic disease. So whether that be most commonly a pulmonary thromboembolism or something maybe like an ATE in cats or to the brain or something like that.
Dr. Andrew Woolcock:
So blood clots are a real risk. And so making sure as a clinician that in addition to addressing the immune mediated aspect of this, that you’re also having them on some good prophylaxis to reduce their risk of clot formation is really important for these guys, because it’s shocking that they don’t really die of their anemia as long as you’ve got a client that can afford blood product and things like that, because we can always give them more red blood cells. But it’s the onset of a pulmonary thromboembolism that can make these guys really decline.
Dr. Andy Roark:
Okay. Talk to me a little bit about the anti-clot medications. What are your top choices for that? And are these medications cost prohibitive?
Dr. Andrew Woolcock:
Yeah. Well so thankfully, the answer to your second question is no longer the case. There are some really cost effective options. But in terms of what are the options out there, there’s two ways to look at this. You can either inhibit the clotting factors with something in the heparin family.
Dr. Andy Roark:
Mm-hmm (affirmative).
Dr. Andrew Woolcock:
Those are accessible, but can be a bit cost prohibitive and certainly can be challenging from the standpoint of administration and monitoring, right? So there are people that would advocate strongly to use a heparin and I don’t think that’s wrong. But case selection’s really important, that you’ve got a client that is able to give that medication because if you’re going to be sending it home, it’s a subcutaneous injection and you’ve got to have the ability to be regularly monitoring things like their clotting time. So I don’t use those all that frequently, but I think that there is a place for it and certainly the IMHA experts out there are somewhat split on what would be the best approach. But the other approach that is certainly more convenient and accessible would be an antiplatelet drug. So something that’s going to inhibit the platelets. And for a long time, low dose aspirin was used and that is still appropriate, but is somewhat falling out of favor just because we have some good research that suggests that about half of the dogs we use that in might have some degree of aspirin resistance.
Dr. Andrew Woolcock:
So we might not be achieving what we were hoping. And so the antiplatelet drug, clopidogrel, which is brand name Plavix, used to be somewhat cost prohibitive but now is available as a generic and is a mainstay for platelet inhibition. It’s a, irreversible platelet inhibitor, it does a really nice job of reducing that platelet function so that you don’t form clots and things like that. So that tends to be a lot of people’s go to for antiplatelet. And then there’s a newer drug, anti-Xa inhibitor called rivaroxaban that is getting a lot of attention and people are really excited about. And I think it’s going to be wonderful and there are already groups using it for things like saddle thrombus in cats. But that is quite cost prohibitive at this point. So I think there’s a lot of people just watching the market to see when that goes generic because I have a feeling it’s going to come in real handy for diseases like this in the future.
Dr. Andy Roark:
That’s fantastic. That’s great. I always love to hear, it’s like there’s something new and it’s looking real good and it’s in the pipeline, that makes me super happy. Andrew, thank you for being here. Do you have any resources that you really like in this subject matter, any place that you would say, “Hey, this is a good place just to pick up some more tips and pearls?” Anything that pops to your mind.
Dr. Andrew Woolcock:
Yeah. To me, something really exciting that happened, I want to say it was in 2016 or 2017, is that the Journal of Veterinary Internal Medicine published a consensus statement and they usually published two to three consensus statements a year, but that year they published a consensus statement about IMHA. It’s two full articles, one dedicated to a consensus on the diagnostics to be performed for IMHA and another article dedicated to treatment for IMHA. And they’re a fantastic resource and a great read. And I think what is interesting about them is that they actually reveal in so many ways the parts of IMHA for which we don’t have consensus yet because it’s still a work in progress and we’re still learning so much about this disease. But I think for people that maybe don’t see IMHA that often and are wondering what’s out there and what do I need to know, that’s a really great resource.
Dr. Andy Roark:
Outstanding. I’ll put a link in the show notes so that people can check it out for sure. Andrew, thanks for being here, man. I really appreciate it.
Dr. Andrew Woolcock:
Sure thing.
Dr. Andy Roark:
And that’s it. That’s what I got for you guys. I hope you enjoyed it. I hope you liked the episode. If you did, if you’re watching on YouTube, hit that subscribe button. If you’re not, wherever you get your podcast, if you’d love to leave us a little review, that means the world to me. Yeah, if you like learning, check out the drandyrourk.com website and take a look at our store. We’ve got some training tools, I have a charming the angry client course and an exam room communication toolkit course. Both of them are on demand, both of them are very, very good, they’re both very flexible and they are a great way to learn with your team. Guys, until next time, take care of yourselves. I’ll talk to you later on.
