Medicine

Dr. Dottie Laflamme, a board certified veterinary nutritionist, joins the podcast to discuss a peer-reviewed article she first-authored earlier this year: Evidence does not support the controversy regarding carbohydrates in feline diets. She and Dr. Roark discuss the controversy, the role of carbohydrates in feline digestion and disease pathology and management, and finally, the pros and cons of feeding a wet vs dry commercial food.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Evidence does not support the controversy regarding carbohydrates in feline diets: https://avmajournals.avma.org/view/journals/javma/260/5/javma.21.06.0291.xml

Purina Institute: https://www.purinainstitute.com/

Tufts University Vet Nutrition: https://vetnutrition.tufts.edu/

AAVN: https://aavnutrition.org/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/training-tools/

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. Dottie Laflamme received her DVM, MS in ruminant nutrition, and PhD in nutrition and physiology, all from the University of Georgia. She completed her clinical nutrition residency as an ALPO Postdoctoral Fellow in Clinical Nutrition. Dr. Laflamme is a Diplomate and past-President of the American College of Veterinary Nutrition. She is an author on over 200 scientific and technical publications; and has been a speaker at a number of veterinary, research, and continuing education programs worldwide. She worked for Purina (first Ralston Purina, now Nestle Purina) in the Research and Development Department from 1990 until her retirement in 2015. Her research focused on therapeutic nutrition, especially obesity management, and geriatric nutrition. She currently works as an independent consultant. Dottie lives in the Blue Ridge Mountains of western Virginia.

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 :
Hey guys, if you’ve listened to this podcast for any time at all, how much I care about keeping pet care accessible to pet owners and how much I hate when people don’t have the resources they need to take care of their pets or staff included.

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Dr. Andy Roark :
To get a quick and easy quote, visit figopet.com/coneofshame. That’s F-I-G-O-P-E-T.com/coneofshame. Figo’s policies are underwritten by Independence American Insurance Company. Welcome everybody to the Cone of Shame Veterinary Podcast. I am you’re host, Dr. Andy Roark. Guys, I am here with my friend Dr. Dottie Laflamme today.

Dr. Andy Roark :
She is a boarded vet nutritionist. She’s retired. She’s only doing research and things now. She’s not affiliated with any company. As she mentions at the end, she had done some work on Purina CenterSquare, which is a public educational resource that everybody can check out.

Dr. Andy Roark :
It’s really good. But yeah, she’s fantastic and she’s just talking about carbohydrates and cats based on an article that she published earlier this year. Guys, let’s get into it.

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. Dottie Laflamme. Thank you for being here.

Dr. Dottie Laflamme:
Thank you. My pleasure.

Dr. Andy Roark :
Oh, it’s always a pleasure to talk to you. This is the second time we’ve gotten to chat and I loved the first time. And so anyway, I’m glad to have you on the podcast. You are a boarded veterinary nutritionist and you had an article earlier this year in the Journal of the AVMA called Evidence does not support the controversy regarding carbohydrates in feline diets.

Dr. Andy Roark :
And I just wanted to get on and unpack that a little bit with you because obviously we get a lot of questions in the exam room and there’s a lot of questions about cats and carbs and there’s a lot of internet discussion of that topic. So I just wanted to pick your brain a little bit and get into that. Can you start by just sort of laying down what is the controversy with cats and carbohydrates?

Dr. Dottie Laflamme:
Great, and it’s probably a multifold controversy, but I think the essence of it is that some veterinarians and a lot of cat owners perceive that carbohydrates are either inappropriate for cats or downright detrimental, and by our title, what we’re really saying is that’s not really true and nothing is quite as clear cut as A equals B, or this is not good under any circumstances.

Dr. Dottie Laflamme:
The truth is there could be if you select circumstances where carbohydrates may not be appropriate for cats, but for the most part, and hopefully we can talk about lots of the details of that. For the most part, there’s absolutely nothing wrong with cats eating carbohydrates if they’re properly processed and part of a nutritionally balanced diet.

Dr. Andy Roark :
Okay. Well, talk to me a little bit about kind of the role that carbohydrates play in feline nutrition.

Dr. Dottie Laflamme:
Okay. Well, if we think about food stuffs, whether we’re talking about cats or whether we’re talking about ourselves or any other creatures, okay, there are three what are called macronutrients because they’re in there in large quantities. There’s three macronutrients that provide 100% of the energy that our body uses.

Dr. Dottie Laflamme:
Those macronutrients are proteins, fats and carbohydrates. Our bodies, and that includes the cats, can derive energy from any of those three. In fact, they get more energy from fat on a gram per gram basis. On a weight basis, they get more than twice as much calories from fat as they do from carbohydrates or proteins.

Dr. Dottie Laflamme:
So we need to keep that in mind when we’re formulating diets or looking at what we’re feeding because how many calories do our cats need? There’s a lot of fat cats out there. That said, the benefit of carbohydrates in the diet is it is a source of calories that the cat can use.

Dr. Dottie Laflamme:
Now there’s other benefits to it as well. For example, if a cat is being fed a low carbohydrate diet, they will actually take protein and break down the proteins in order to make glucose, which is a carbohydrate. It is a sugar which can come from the carbohydrate, but it can come from protein.

Dr. Dottie Laflamme:
So if you’re not giving them enough carbohydrate in the diet, they’re going to break down protein that could otherwise be going to support lean body mass and protein synthesis and use that for energy.

Dr. Andy Roark :
Okay. Tell me a little bit about cat carbohydrates in the wild, because I think that’s where a lot of this comes from, right? Is cats obligate predator or obligate carnivore? You say, what carbohydrates are they eating out in the wild? And I think a lot of people want to replicate the traditional evolutionary diet of cats.

Dr. Andy Roark :
And so I think that’s a question that I kind of have is to say, well, what is normal for sort of cats in the wild? How do they survive in a landscape that doesn’t have-

Dr. Dottie Laflamme:
Let’s start by defining what we mean by a carbohydrate. The most common perception of that is meat eater, but that’s not quite correct. A carnivore is an animal eater, a prey eater. So they are going to eat basically all of that prey. And so that includes the stomach contents, the intestinal contents, as well as all the musculature, all the bone, all the organs, all the byproducts.

Dr. Dottie Laflamme:
So all of that is consumed by the predator, whether that’s a cat or a dog or wolf or bear or whatnot. So they’re getting more than just meat when they do that. So given that one of the, let’s look at the statistical perspective first and then the practical. Two different studies have looked at a cat in the wild eating prey and other foods that it can get to.

Dr. Dottie Laflamme:
How much carbohydrate are they actually eating? One study showed it was really low. It was about two and a half percent of the calories. A different study showed it was actually a little bit higher. It was about 15%. And let’s put that in perspective of nursing kittens and how much carbohydrate does a cat put into its milk and its about 15 to 25%.

Dr. Dottie Laflamme:
So there’s a fair bit of bit of carbohydrate that’s naturally present in the diet. So it’s not that cats don’t want carbohydrates, but it’s often said, “Well, you won’t see dogs or cats in the wild going out and grazing on a wheat plant.” Well, that’s true, but cats and wild animals in general are opportunistic in what they eat.

Dr. Dottie Laflamme:
So they eat what they can get, and if what they get is enough to keep them alive and allow them to reproduce, then the species will survive. So the feral cat diet, if there is nobody feeding them, there’s no kibble being fed generally has somewhere between five and 15% carbohydrate in and those wild cats survive.

Dr. Dottie Laflamme:
But what’s the average lifespan of feral cats? It’s something like two or three years. It’s relatively short compared to the 15, 20 plus years that we want our pet cats to live. So they could survive on that, but is it optimum nutrition? I think there’s no evidence to support that conjecture.

Dr. Andy Roark :
Right. And that fits with the conversation we have about dogs and wolves. And people say, “Well, my dog [inaudible 00:08:56] a wolf face and the average wolf die at age four.” So yeah, it’s a standard. I personally understand where people come from. They look at cats and how they’re sort made and designed and say, “Well, I want to feed something that fits with what they are and who they are.”

Dr. Andy Roark :
That all makes sense to me. When we talk about, I don’t feel like we get nearly as much pushback on this from dog owners or about dogs as we do about cats. How unique are cats and how they use carbohydrates? I mean, is cat digestion of carbohydrates fairly similar to dogs or humans, or are they pretty unique in how they break down used carbohydrates?

Dr. Dottie Laflamme:
Well, the short answer is both. Assuming we’re talking about properly processed carbohydrates. Because I have to say, if we’re talking about any kind of carbohydrate starch, think about sources of carbohydrates like rice and wheat and other grains and potatoes and things like that.

Dr. Dottie Laflamme:
We wouldn’t eat bowl of raw rice or a raw potato because that’s not digestible, but we cook it. We bake our potatoes, we boil our rice, whatever it might be. So if we’re talking about properly cooked carbohydrates, cats can digest them essentially as well as dogs.

Dr. Dottie Laflamme:
There’s one study that they made a bunch of different diets, different grains and they fed them to cats and then they made very, very similar diets and fed them to dogs. And the carbohydrate digestibility for all the different diets, dogs and cats was well over 90%. So cats really don’t have any trouble digesting carbohydrates.

Dr. Dottie Laflamme:
That said, there are some unique features about cat metabolism. They don’t have the enzyme amylase, salivary amylase that we have, so we actually start breaking down carbohydrates while it’s still in the mouth. Cats don’t have that, but neither do dogs. So it’s not absolutely unique to cats, it’s just there are some species differences.

Dr. Dottie Laflamme:
There are other digestive enzymes, pancreatic amylase, different enzymes that are produced within the digestive tract that cats have less of compared to dogs, but then there’s other enzymes that they actually have more of. They also lack the taste receptor for sweets.

Dr. Dottie Laflamme:
And there’s a number of other things, the way they actually metabolize glucose from the bloodstream, there’s an enzyme that’s required for bringing that, what shall we say, trapping that glucose into the cell. It’s a glucokinase and cats don’t have specifically glucokinase, but they have hexokinase in abundant quantities.

Dr. Dottie Laflamme:
And the hexokinase works in the same way that the glucokinase does. It just works a little slower. So cats are very similar and yet they’re different. And because of these differences, they do tend to process blood glucose a little bit slower than dogs do, for example, but that’s also consistent with the way cats normally and naturally eat.

Dr. Dottie Laflamme:
They eat a lot of small little meals, up to 20 meals a day. So they’re getting a small amount at a time compared to the way dogs in the Wildwood, which is to eat large quantities all at once. So it’s consistent with their metabolism. Bottom line, there are some differences, but a lot of similarities.

Dr. Andy Roark :
No, that’s good to know. Are there advantages and disadvantages to a low carb diet for cats?

Dr. Dottie Laflamme:
Assuming we’re talking healthy cats, not diabetic cats. But healthy cats, the advantage to a low carb diet is there, let me put it this way, there’s absolutely no evidence of a benefit to a low carb diet for a healthy cat. The potential disadvantage is, as I was mentioning earlier, if you… Okay.

Dr. Dottie Laflamme:
Cats need calories just like we all do, and they come from protein or carbohydrates or fats. By definition, when you remove one of those macronutrients, the sum of the total, you have to see the other two increase. So a low carbohydrate giant generally is higher in fat and higher in protein and higher in calories because fat has more calories than carbohydrates. Okay.

Dr. Dottie Laflamme:
So the disadvantage of a low carbohydrate diet is the resulting diets tend to be higher in calories. And because obesity is a major issue in cats, there’s actually a greater risk for obesity in cats fed high fat diets. So there’s no specific advantage.

Dr. Dottie Laflamme:
And the only real disadvantage is that calorie thing. So if you’re feeding a low carbohydrate diet because you want to, there’s no harm to the cat as long as they’re being fed the right amount of calories, but there’s no advantage either.

Dr. Andy Roark :
Hey everybody, I’m just jumping in with two lightning fast updates. Number one, if you have not gotten signed up for the Get Shit Done Shorthanded Virtual Conference in October, it’s October 6 through the 8th. You need to do that.

Dr. Andy Roark :
If you are feeling overwhelmed in your practice. If you want things to go smoother and faster. If you do not want to watch webinars, you want to actually talk about your practice. You want to do some discussion groups.

Dr. Andy Roark :
You want to do some workshops where you actually make things and work on things and ask questions as we go along and have round table discussions and things like that, that’s really going to energize you and help you figure out actionable solutions that you can immediately put into practice to make your life simpler and more relaxed.

Dr. Andy Roark :
I got you covered, buddy, but you don’t want to miss it. Go ahead and get registered. Mark yourself off at the clinic for the time so that you can be here and be present and really take advantage of this. I don’t want to sneak up on you. I know October seems like a long way away. It’s not, but go ahead.

Dr. Andy Roark :
I’m going to put a link down below and then when registration opens, we’ll let you know it’s open and you can grab your spot, but you do not want it to sneak up on you. Check out our Get Shit Done Shorthanded Conference. It’s going to be a great one. The second thing I’m going to tell you about is Banfield.

Dr. Andy Roark :
Thank you to Banfield the Pet Hospital for making transcripts of this podcast available. You can find them at drandyroark.com. They are totally free and open to the public and Banfield supports us to increase accessibility and inclusion in our profession.

Dr. Andy Roark :
It’s a wonderful thing that they do. Guys, that’s all I got. Let’s get back into this episode. Let’s take this a little bit into a medical context and start to say, can you talk to me a little bit about clinical practice and carbohydrates?

Dr. Andy Roark :
I mean, I immediately think of cats with diabetes, things like that. Are there medical instances, cases that we commonly see where we want to pay attention to carbohydrate intake specifically where they can be detrimental or beneficial?

Dr. Dottie Laflamme:
Sure. And here’s where we’re kind of… Okay. Let’s talk specifically about diabetes first and then maybe a couple of other circumstances. So in the face of diabetes, cats are already unable to process glucose properly. And so it accumulates in the bloodstream.

Dr. Dottie Laflamme:
They’re glucose intolerant and insulin resistant, so they have a hard time clearing the glucose out of the bloodstream. And so feeding large amounts of glucose or carbohydrate to a cat that’s diabetic is going to cause an undesirable increase in glucose in the bloodstream.

Dr. Dottie Laflamme:
So two of the ways to get around that, of course, is to feed less carbohydrate, so there’s less being released into the bloodstream. And the other is to feed it in frequent small meals so that the total amount of carbohydrate going into the bloodstream, even in diabetic cats is not as much the issue, it’s the inability to clear it out.

Dr. Dottie Laflamme:
And so it’s because of the difference between the different glucose transporters, the insulin dependent and non-insulin-dependent. So the non-insulin-dependent such as glute one will still be able to process enough glucose to keep the cats cells fed, but the insulin independent and the glute four is the one that’s not working properly, so they can’t process as much.

Dr. Dottie Laflamme:
So I think the bottom line is like the consensus opinion is that limiting carbohydrate intake in the face of diabetes is a positive thing.

Dr. Dottie Laflamme:
The other conditions where carbohydrates or carbohydrate sources, in other words grains, are raised up as possible issues is in the face of GI disease and food sensitivities, the food allergies and food sensitive, whether that’s the skin related issues or GI related issues, that seems to be more of either a misperception or a rarity as opposed to a commonality.

Dr. Dottie Laflamme:
The reason I say that is if you look at the, but the published statistics, feline allergies to grains are extremely less common compared to feline allergies to various animal proteins.

Dr. Andy Roark :
That makes sense. I mean, that tracks, again, kind of with what we see with dogs as well as sort the push to the grain free foods and things like that. And a lot of people come with the idea that they’re hypoallergenic where they’re good for food allergies and things, and veterinarians have wrestled with that for a long time.

Dr. Andy Roark :
Help me understand what we can expect with carbohydrates in your average sort of commercial cat food, for example? So we talked about feral cats being at five to 15% carbohydrate in their diets. What do we see? Is there a sort of recognized standard in modern pet food or high quality pet food? Yeah. And how much variance is there?

Dr. Dottie Laflamme:
Okay. Really, really good question. There’s big differences on average between dry foods and wet foods like canned foods and pouched foods that in general, the wet foods are lower in carbohydrates compared to the dry foods. And part of that is based on the ingredients used.

Dr. Dottie Laflamme:
Part of it is the fact that normal cooking and processing of dry foods actually requires a certain amount of carbohydrate in the diet in order to form the kibble. It’d be like trying to make bread without gluten or without flour, really need to have that in there.

Dr. Dottie Laflamme:
So if we look at what’s average in the US at least, the average amount of carbohydrate in wet foods is well under 10%. Whereas in dry foods, it’s somewhere in, I don’t know, about 35% plus and minus on average.

Dr. Dottie Laflamme:
The review that we did, the paper you had referenced, one of the things we looked at was all of the published literature where they were looking for adverse effects for carbohydrates, and at what level do you start to see adverse effects?

Dr. Dottie Laflamme:
And the studies basically found no adverse effects with the possible exception of diets that were about 50% of the calories coming from carbohydrates. And at that level, first of all, at that level, the protein in the diet is really low. So the first challenge you would have is that the diet would no longer be nutritionally balanced.

Dr. Dottie Laflamme:
It would have not enough protein in the diet. In that study that used that kind of diet, they did see unusually high serum glucose levels. And in some cats, they also saw GI upset, diarrhea and so forth.

Dr. Dottie Laflamme:
So that’s the kind of risk you might be looking for. But the biggest risk, if you’re talking about that much carbohydrate in the diet, the biggest risk is there’s not going to be enough room to have enough protein in the diet.

Dr. Andy Roark :
Given the difference that we see in carbohydrate levels between dry and wet foods, just in their compositions as we sort of talked about, do you have a preference of wet versus dry food when feeding cats? Are you one of those wet food cat people or are you a mixture person? Or how does that affect your thinking? And if so, how?

Dr. Dottie Laflamme:
That’s a really great question and I really need to unpack it because the first part of that is carbohydrates and the other part of that is water, wet versus dry. So from a carbohydrate point of view, here’s really the way to look at it. Cats need nutrients, not ingredients. Okay.

Dr. Dottie Laflamme:
And they don’t require a dietary source of carbohydrates. And the reason they don’t is that carbohydrates are so important to the cat that the body has its own mechanism for creating carbohydrates, in other words, for creating glucose. Okay.

Dr. Dottie Laflamme:
So the body absolutely has a requirement for carbohydrate. Either they’re going to make their own or they’re going to get it from the diet. And so if we’re looking at carbohydrate in the diet, then the body can use that and it doesn’t have to create its own, which means it can spare protein.

Dr. Dottie Laflamme:
And I think that’s a significant benefit to the higher carbohydrate diets within a nutritionally balanced diet. Okay. So from a nutritional perspective, I think there’s no real advantage of a dry food versus a wet food or a wet food versus a dry food as long as it is nutritionally complete and balanced.

Dr. Dottie Laflamme:
Not all foods are, so that’s just an important thing to keep in mind. But assuming that they are, from a nutritional perspective, there’s really not an advantage one over the other. Now let’s talk about wet food. There are pros and cons to wet food.

Dr. Dottie Laflamme:
Some of the pro is that you’ve got a lot of water there, and that is some cats need that extra water either because they don’t naturally drink enough or because they happen to have a health condition like urolithiasis or kidney disease or something where they need that extra water, I’m going to say forced on them. They need that extra water.

Dr. Dottie Laflamme:
So that’s where wet foods are really beneficial. The other advantage of wet foods, because they come in small cans, especially if you give them the little tiny cans, there’s relatively few calories because it’s mostly water.

Dr. Dottie Laflamme:
And so feeding wet foods might make it easier for cat owners to control the calorie intake and would help them potentially in managing their cats weight. And I’m saying that potentially because it’s not an absolute for sure. That’s really the advantage of wet only in my perspective.

Dr. Dottie Laflamme:
One of the advantages of dry, since we’re doing a comparison, one of the advantages of dry is it does provide a better oral care benefit. It helps to keep the teeth cleaned longer, not that it’s a replacement for dental care, but it does reduce plaque and tarter and oral disease compared to wet food.

Dr. Dottie Laflamme:
So if you’re comparing 100% dry versus 100% wet, those are kind of the benefits. The advantage of the mix is that you get the dental benefit of the dry, and then feeding your variety of wet foods gives you a chance to feed a variety without totally changing the diet up.

Dr. Dottie Laflamme:
That said, if you’re really trying to feed wet food for the purpose of forcing the cat to consume more water, you almost have to go to a completely 100% wet food diet because if it’s 50%, the cat fully compensates and drinks water or doesn’t drink water as it needs.

Dr. Dottie Laflamme:
So one of the things we have to think about, whether we’re talking about wet food, dry food, carbohydrates, protein, whatever, cats are very adaptable. And no matter what you’re trying to do to them, they’ll adapt based on their own physiology.

Dr. Andy Roark :
Yeah. On their own willful desires often is what it seems, right?

Dr. Dottie Laflamme:
Exactly.

Dr. Andy Roark :
Dr. Laflamme, thank you so much for being here. I really appreciate you coming in and making time to talk with me.

Dr. Dottie Laflamme:
My pleasure. And if you ever happen to get more questions, let me know.

Dr. Andy Roark :
Oh, I will let you know for sure. One last question. Do you have favorite resources for people that are interested in feline nutrition? What’s at the top of your list?

Dr. Dottie Laflamme:
There’s a couple of good websites. One of them, I have to admit it, I helped with the formulation of that as a consultant for the Purina Company, and that’s Purina Institute CenterSquare.

Dr. Dottie Laflamme:
It’s a great resource for veterinarians as well as for them to share with their clientele. Tufts University has a great website also with good nutrition information. I don’t have that address for you right now, but-

Dr. Andy Roark :
I’ll pull it and I’ll put it in the show notes for people who want to find it.

Dr. Dottie Laflamme:
Okay. Those are a couple of great ones right there as well as the aavn.org website, the American Academy of Veterinary Nutrition.

Dr. Andy Roark :
That’s outstanding. Great. I’ll put all those links in the show notes. Thank you again for being here. Guys, everybody take care of yourselves. Have a wonderful week. And that is our episode. That’s what we got for you. As I said, have a wonderful week everybody.

Dr. Andy Roark :
If you love this episode, write me a review, wherever you get your podcast. Anywhere that it says, rate this podcast, you just rate this podcast. And if you don’t like the episode, then just maybe wait until next week and see what you think before you write a review. I don’t know. Just think about it for a while before you do that. Anyway, guys, take it easy. I’ll see you later on.

What role can nutrition and probiotics play in addressing behavior problems? Probably more than you think. Dr. Ragen McGowan, Ph.D. joins Dr. Andy Roark to discuss the link between the gut and the mind, how Purina’s new Calming Care supplement has been shown to help dogs and cats, and what expectations veterinarians can have (and set for clients) for working with these products.

This episode has been made possible ad-free by Purina ProPlan Veterinary Supplements!

LINKS

Purina Pet Expertise: https://www.purina.com/articles

Purina Pro Plan Vet Direct: https://www.proplanvetdirect.com/pro-plan-veterinary-diets/cat-dog-supplements

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

Ragen is the Senior Manager of the Global Pet IoT, AI and Digital Solutions Group at Nestlé Purina leading work to generate pet behavior and wellbeing insights. She has over 20 years of experience in animal behavior research, the last 13 of which have been with Nestlé Purina using a holistic approach incorporating behavior, physiology and endocrinology to quantify affective states and temperament in dogs and cats. With this knowledge she aims to create products that cater to different behavioral needs of pets and to better understand and quantify the human-animal bond from the pet’s perspective. Ragen earned B.S. in Zoology, a B.A. in Foreign Language and Literature and a PhD in Applied Ethology from Washington State University in Pullman, Washington. Her PhD research focused on Contrafreeloading behavior, a phenomenon whereby animals choose to work for food even when the same food is freely available, in grizzly bears, laying hens and laboratory mice. In addition, Ragen worked on other projects examining play behavior in piglets and children and means to reduce problem behaviors such as cannibalism in laying hens. Prior to joining Nestlé Purina Ragen held a post-doctoral research position in the Section for Ethology and Animal Welfare at the Swedish University of Agricultural Sciences in Uppsala, Sweden. Her post-doctoral research focused on the study of emotionality in dogs. Specifically, she explored new methodology to objectively evaluate positive emotions in animals. This included using Cognitive Bias and Contrast to measure emotional states and studying the ‘Eureka Effect’ (emotional reactions to learning) in dogs. She is now bringing this knowledge of animal behavior and emotions into the digital space to better connect owners with their pets. Ragen has a passion for sharing her vast knowledge of pet behavior and the human-animal bond. In addition to speaking at a variety of events for Purina, she serves as a reviewer for several scientific journals and is a contributing scientific expert for scientific congresses, roundtables and podcasts. In addition to her passion for animals, Ragen is also an avid dancer and has been an instructor of ballroom dance for many years. Ragen is based in Saint Joseph, Missouri where she lives with her husband, two children and two giant rescue dogs, Luna and Perry.

EPISODE TRANSCRIPT

Dr. Andy Roark:
This episode is made possible ad-free by Purina Pro Plan veterinary supplements.

Dr. Andy Roark:
Hey everybody. I am Dr. Andy Roark, and welcome to The Cone of Shame veterinary podcast. Today, I am talking to my very special guest, Dr. Regan McGowan, about probiotics and their use in anxiety and behavioral problems in dogs and cats. Is it possible to use a probiotic to affect pet behavior to make pet owner lives easier? We get into it, we talk about what is out there and how it works, and what expectations are set. This guys, is a great episode. I got a lot of stuff out of this. I’m going to be changing up maybe my multimodal approach to behavior consultations. And I just found this to be super useful. I hope you will too. Let’s check it out.

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. Ragen McGowan. Thanks for being here.

Dr. Ragen McGowan:
Thank you so much for having me.

Dr. Andy Roark:
Oh, it is my pleasure. You are super cool. For those who do not know you, you are… So first of all, you’re a PhD. You have a PhD in applied ethology for those who don’t know not me, because I totally know. I completely have this nailed down. What is ethology?

Dr. Ragen McGowan:
Ethology is the study of animal behavior. It’s sort of the animal counterpart to psychology on the human side.

Dr. Andy Roark:
Love it. So you have a PhD. Actually, your postdoc work is in studying emotionality in dogs, which I thought was super awesome and cool. You also are the senior manager at the global pet Digital Solutions Group, I’m paraphrasing that, from Nestlé Purina. You do all the pet wearables, devices, data collection, artificial intelligence, you’re all up in all of that stuff. So you are a PhD behaviorist who runs the digital section at Purina. I think that’s fascinating. I love also, in your free time, you instruct ballroom dancing just as a flare.

Dr. Ragen McGowan:
Just for fun.

Dr. Andy Roark:
Exactly right. Just an accent. I love it. So thank you, thank you, thank you for being here. I want to talk to you today about behavior. I want to talk to you a little bit about anxiety. I want to talk to you about nutritional therapeutics and things like that. And this is something that I have been really excited about for a long time. The reason is because I see a lot of anxious pets, both cats and dogs. They look different when they come in. But I think anxiety and nervousness, high strung pets, I think a lot of us see that.

Dr. Andy Roark:
And I think a lot of us also see pushback from pet owners to traditional therapeutics when it comes to managing anxiety and managing neuroses and things like that in pets, especially in cats. I really think this is a tough thing in cats because people don’t want to give their cat sort of traditional medications. I think the ask is really high. But even in dogs, I still think that there’s a lot of pushback on, my dog doesn’t need to be on medications, or I don’t want to do this, or I don’t want to put him on anything.

Dr. Andy Roark:
I’m certain there is a general idea that something that is nutritional, something that is a probiotic, something like that, that doesn’t fall in people’s mental categories in the same way. And they seem much more open to trying things of that nature. And so I wanted to learn more about that. And that’s really an area of interest for you and area of study. And so I wanted to lay all of that down and say, let’s start with dogs and cats. Talk to me just generally, about anxiety presentation in dogs and catalogs. And then, how nutrition might interact with the ability to alter that behavior and that anxiety.

Dr. Ragen McGowan:
Sure. So anxiety is a big problem in dogs and cats. And often, pet owners might not realize that their pet is anxious. I’ll be talking in many different scenarios out to the general public and I’ll be mentioning behaviors that are attributed to anxiety, and people will come up to me afterwards and just say, “Oh my goodness, you’ve just blown my mind. I didn’t realize that my pet was showing me all these anxious behaviors until you described them.” So some of that is the more micro behaviors. So for dogs, the lip licking, the yawning, the avoidance of gaze, just the general presentation of uneasiness in many different situations.

Dr. Ragen McGowan:
For cats, some people think it’s just normal for a cat to be hiding under the bed all the time and never come out. People will come over and be like, I didn’t even know you had a cat except I saw a litter box, because I never met your cat. But actually, that can be a sign of anxiety in cats. So just helping people to realize this. So when they come to us with questions around this, first we say, okay, clear out any medical reasons that might be causing these kinds of behavior. If you’ve got that clean bill of health from your vet, then let’s try to think about what else you might be able to do or what the triggers might be in the environment that are causing your pet this anxiety.

Dr. Ragen McGowan:
But you’re right that people are resistant to pharmaceuticals. Behavior modification can go a long way, but that’s a lot of work. It takes dedication from the pet owner and a lot of training and consistency and routine, and it’s not a one stop save all thing. It takes a lot of work and catering specifically to the pet.

Dr. Ragen McGowan:
Nutrition is often overlooked as a contributing factor to help address behavior problems. But when you think about it, all of the nutrients that we’re taking into our bodies, those are actually the precursors for all of the hormones and the neurotransmitters that actually regulate your behavior. So altering your diet to manipulate the availability of all these precursors, the things that your body needs to make these hormones and neurotransmitters, that can actually help mitigate behavior issues. So there really is something to that old adage about having a gut feeling about something, because your gut and your brain, they’re actually directly linked and connected through what’s called the gut-brain axis.

Dr. Andy Roark:
So gut-brain axis is really interesting. I’ve actually been reading a lot about that in human nutrition recently. There’s a couple different books that have come out fairly recently on treating things like anxiety, depression, things like that in people. There’s more and more research about the gut-brain relations. I wanted to mention real quick, one of the things that really turned me on to the idea of working with therapeutics to lower stress and anxiety in dogs is, when we talk about training… When you have an anxious dog, people will jump up and say, “Oh, you need to train them, you need to train them.” Training a pet that is dealing with anxiety who is anxious, it’s not easy, because they’ve already got so much tension and now you’re working with them. And even if you’re low stress, everything gets easier if you can reduce the stress and anxiety that pet is having. And then do the training. And I say that because that’s a mistake I’ve made early in my career.

Dr. Andy Roark:
Terry Curtis, who’s a vet behaviorist, talked me out of it a couple years ago. Because what would happen, I’ll just be honest about what I did, is I would talk to people and they would have an anxious dog or cat, and I would sort of present pharmaceuticals and they would say, “Oh no, no, I don’t do that,” and I’d say, “Okay, well let’s try some training then.” And what would happen is they would go away and they would do some training and it wouldn’t get better and it would get worse. And then they would come back and they were tired and they’re frustrated. And now we’re throwing drugs at the problem, but they’re already kind of tired of trying to train. And she really convinced me that working together with nutrition or with therapeutics and the training together. Lower the stress, do the training, and then you can even, like if you’re using pharmaceuticals, you may be able to lay off of those later on, because you’ve done the training now and it was effective. Anyway, I just always like to point that out.

Dr. Ragen McGowan:
For sure. We call that the multimodal approach. Not one thing is really going to solve everything. It’s about getting the pet in the right frame of mind. With appropriate socialization, we can give pets the skills that they need to cope with stressors that come their way, but if they have an underlying anxious temperament, they’re always going to have that underlying anxious temperament, just like people. You can learn how to deal with a situation and not be overstressed by it, but you’ll still have that underlying level of anxiety. So if we can treat that to get pets in a better frame of mind, then they’re more responsive to that behavior modification, it’ll stick with them, and they’ll actually start to improve in their behavior. But until you can get them over that hump, it’s really, really difficult. Whether that’s a nutritional intervention or pharmaceutical intervention together with the behavior modification, that’s where you’re really going to make those big steps, and really be able to celebrate even the little baby steps that you get your pet through so that they can cope more with the stressors around them.

Dr. Andy Roark:
Give me a basic 101 level understanding of nutritional therapeutics in behavior and pets. We talked a little bit about the relation of the gut and the mind. There’s a number of different products out there that are nutritional or nutriceutical or things like that. Help me understand a little bit about how this works. What is important in using these products effectively, and are they all effective? What should I be looking for in products like this?

Dr. Ragen McGowan:
Yeah. This is sort of a tricky question, because you really need to find products where there’s good data behind it, and that’s hard to assess. And we know that there’re many studies out there that show there’s a large placebo effect. People are so emotionally drained with dealing with their anxious pet, that they’re really looking for any solution that will give them even a tiny bit of relief. They’re very quick to say, “Oh, this must be helping,” because they notice some subtle change, so we know there’s a huge placebo effect. So look for products where there’s really good data that shows not only behavioral effects, but even a step further, physiological effects, that show that you’re actually reducing the stress response. And this is the approach that we take to get over that placebo effect or only relying on behavior changes or indicators that are visible on the outside, we’re also looking for invisible changes on the inside.

Dr. Ragen McGowan:
We take that holistic approach, where we’re taking both behavioral and physiological measures. And by physiological measures, this could be something like hormones like cortisol, it could be physiological responses like changes in heart rate or respiration rate or body temperature. Pairing those together with behavioral changes, then you really get a good picture of the impact or the efficacy of some of these nutritional solutions. Now, there’s a handful of things out there where there is published data, but for the most part, there’s very little. So when you’re researching a product, make sure it’s coming with some data behind it, some solid claims that are on the product there. And I can give you an example of a probiotic that we’ve developed at Purina, if you’d like that.

Dr. Andy Roark:
Mm-hmm. Sure, yeah. Of course.

Dr. Ragen McGowan:
It’s the Calming Care probiotic. This is a specific strain of bifidobacterium longum. It’s important to remember, probiotic, by its name, means that it has a positive biological impact on the animal or human, whoever it might be that is consuming it. But not every probiotic is the same. They’re very, very strain specific. So when you’re researching probiotics, you want to make sure that you’re identifying one where there’s good data behind that specific probiotic for whatever the claims are. So we assessed this strain of bifidobacterium longum in a population of anxious Labrador Retrievers, and later in cats.

Dr. Ragen McGowan:
For the dog study, we took a population of 24 Labradors that had been previously assessed and characterized as being anxious. And because every dog, every pet, we all know is an individual, just like every person is an individual, we use every pet as their own control, knowing that their baseline physiology and their baseline behavior will be different. So every dog served as their own control, participating in two phases where they had both this probiotic treatment and a placebo treatment. All the caretakers were blind to the study, so they didn’t know what the dogs were eating. They just knew these are dogs that have been having anxious issues, they show anxious behavior, but they didn’t know what the treatments were. It looks the same to them. It was just sprinkled upon their complete and balanced diet that they get every day from a little sachet.

Dr. Ragen McGowan:
For six weeks, we fed the dogs with the supplements, and then we had a three-week washout phase, and then they switched treatments. So every dog got both treatments again. This way, everything was controlled for. Then we looked across the six-week feeding time and their day-to-day normal responses to any type of anxiety inducing stimuli that they came across. So this could be, we live in the Midwest, so maybe it was a thunderstorm. Maybe they’re going for their vet exam. Maybe they’re going to get groomed or have a bath, or maybe they’re out for a walk and something surprising is happening to them. We looked at their just normal day-to-day change in behavior across the whole feeding period. Then at the end of each feeding period, we actually subjected them to a formal anxiety test, where we looked for non-social, social, and separation anxiety. This was things like bringing them to a novel room, which we know can be stressful for some anxious pets.

Dr. Ragen McGowan:
In that novel room, we had music playing, and then we would suddenly turn off the music. That’s what we call the sudden silence effect, similar to if you were in a grocery store or a mall or something, usually there’s background music playing. You don’t really notice it until it turns off, and then you become vigilant and you’re like, “Wait a minute, something changed. What happened? Oh, the music stopped.” So we look for that vigilance in our pets as well. And then surprising objects. So it could be a novel object, like a motorized car that drives out from a corner, or a panel opens up from the ceiling and a balloon falls out, novel noises, something they’ve never heard, like an elephant call or a chimpanzee, just to simulate strange noises that pets might hear out in their environment. Then we had a stranger come in, always with a mask on, their eyes covered, so the dogs couldn’t read their intentions. This could be similar to like a contractor coming to your house, wearing their hard hat or equipment, or trick-or-treaters. And then we left the dog alone for a short period of separation in this novel environment, so we could see their response to separation.

Dr. Ragen McGowan:
Throughout, we were measuring their physiology. We had little cardiac monitors on them so we could measure their heart rate and heart rate variability. We also took saliva samples before and after the test, to be able to look for their cortisol or stress response. And then we also tracked their behavior throughout. And what we found, is that during that six-week period, the dogs that were supplemented with the probiotic, the bifidobacterium longum, BL999, they showed much more calm behavior. They showed reductions in anxious behavior like excessive barking or jumping or spinning or pacing. They were less reactive going out and about at the grooming stations or for their veterinary exams or meeting strangers out on walks, compared to themselves, remember when they were on the placebos. We’re always comparing the dog to themselves. And we also found a physiological response. They showed improvement in their cardiac response, with reduction in their heart rate, increases in heart rate variability, and reductions in circulating cortisol. So overall, they were in a more calm, less reactive state.

Dr. Ragen McGowan:
So from both a behavior perspective and a physiological perspective, we could see that the dogs were in a more positive emotional state when they were supplemented with the probiotic versus a placebo. And again, always using themselves as their own control because you can’t really compare dog A to dog B because they’re going to have different responses, so within themselves, we could see this significant difference. And that was just from feeding this probiotic that really brought to life the power of nutrition and that gut-brain communication, how we can actually manipulate behavior by modifying what we’re feeding our pets.

Dr. Andy Roark:
That’s amazing. I will tell you, my dog has watched lots of Stephen King, and so a balloon through the ceiling and a man in a mask coming in, you’d have to [inaudible 00:16:02] him off the wall. He would be pretty stressed. So, all right. Tell me a bit about cats, because I think selling pet owners on traditional pharmaceuticals in cat anxiety, one, I think they’re less likely to believe it when I tell them, “Hey, this sounds a lot like anxiety.” I think cats show less and owners are less believing that their pet has a problem. And then two, I think that the reticence to intervene with a therapeutic is much higher in pet owners. They are much less likely to take steps traditionally in cats. When you talk about, well, there’s a medication and their eyes just kind of glaze over, and they immediately think about how awful it’s going to be. Talk to me about the study in cats, please.

Dr. Ragen McGowan:
Sure. You’ve just said it all with cats there. So one, it’s hard to get people to admit their cat is even showing anxiety, or to teach them what to look out for, that their cat might be anxious. So again, looking at those behaviors in their day-to-day routine, and what the cats are doing, and kind of tracking how they’re responding. So if you have strangers coming to your house and your cat disappears, and they never know you have a cat, that could be a sign that they’re anxious. Or if your cat’s eliminating outside of the box, if all health reasons have been cleared and it’s not a urinary or kidney issue going on and your cat’s still eliminating out of the box, it could be a sign of anxiety.

Dr. Ragen McGowan:
The thing with cats is, they’re so highly sensitive to changes in their environment, just based on their natural history of being territorial and being predators, they’re really keen on even subtle changes in their environment. So for your cat, just changing something like the litter box that you’re using, or rearranging your furniture, these could be stressors and actually lead to anxiety for them. We actually use that as the model to test whether the same probiotic, this BL999, could show efficacy for helping cats with anxiety.

Dr. Ragen McGowan:
We used a model of switching housing environments for cats. We took groups of cats and moved them between different housing types, and again, assessed both their behavior and their physiology. And we found, again here, that cats that were supplemented with the probiotic, that bifidobacterium longum that’s in Calming Care, they were able to much better cope with the stress of moving between housing environments, shown by lower cortisol, reductions in anxious behavior like pacing back and forth, and really increase social ability. So seeking out more contact from the observers that were involved in the study. And also, even being more willing to do vulnerable things in front of people, like eliminate. Like urinate and defecate in front of people. Whereas usually, that’s something that would be hidden away for an anxious cat. So even with the cats, looking at slightly different behaviors than we would for the dogs, using a little bit of a different model, we were able to really show that this probiotic can have a positive impact for them as well.

Dr. Andy Roark:
Very nice. I think that’s awesome. Let me ask you about communicating expectations. This is always a big thing for me, especially when I’m talking about behavior, because behavior with clients is challenging. It’s a lot of handholding, there’s a lot of communication. Oftentimes I’m trying to set realistic expectations with pet owners, because that’s where I get blown up all the time in the exam room. They’ll come in and they’re expecting a magic switch and this to be fixed, and I’m trying to get them to understand what progress looks like and things like that.

Dr. Andy Roark:
So let me start by giving you two questions. One, if I’m talking to a pet owner and I’m like, hey, I want to try this calming probiotic. And this is as I’m talking through what the expectations are and why I want to recommend it and say, I want to try it. And they say to me, “How long will it be before I start to see signs?” I’m pretty impressed, honestly, that your study length was six weeks. That seems like a minimum to me. If you’d said, how long is it before you start seeing benefits? I would’ve said six weeks, just as a gut reaction, if you will. Talk to me about speed with which we start to see changes in behavior, and then the magnitude of those changes. Because people are going to say, “How much of a difference am I going to see?” So help me set those expectations.

Dr. Ragen McGowan:
Yeah. These are great questions. It’s important to remember that every pet is an individual. This is why we’re using pets as their own control. But out in the real world, just the same with pharmaceutical interventions, you’ll have some pets that might show response slightly ahead of others. But in general, at that six-week mark, that’s where we saw a statistical significance. So that’s where the group effect, we had enough pets that were showing such a response that we would get statistical significance. That means for some pets, earlier than that, you’ll start to see signs. For other pets, it might be slightly longer. But in that six-week range, that’s right on par with something like fluoxetine or some of these other pharmaceutical interventions where you’re expecting at least four to six weeks of that loading period before the physiology is changing enough that it’s starting to manifest in actual behavioral changes.

Dr. Ragen McGowan:
Here, again we were looking not only at those behavioral changes, but the physiological changes. So we can say that, yeah, at that six-week mark, we are seeing statistical differences with the pets between when they’re on the placebo and they’re on the supplement. Telling pet owners that though, they want an immediate solution. They also want something that, they know something stressful is going to happen and they want to give it to their pet and it works instantly. And here we’re telling them, “No, this is a nutritional solution, so it takes time for your body to change, the physiology to change enough that actually that ladders up to a change in behavior.” So just giving them that perspective that it’s not an instant change, and there’re few things that are instant changes. And as far as magnitude, again, there’s going to be a lot of individual variation there, but really looking out for subtle differences and also asking the people around you. So anecdotally, we’ve heard from multiple people that said, “You know, I didn’t really think it was helping my dog. The dog’s behavior wasn’t changing dramatically in my mind until I had a neighbor come over, and my neighbor said to me, what is going on with your dog? Your dog never lets me pet them. Your dog always barks at me. And now your dog is right here by my side and I’m petting them, what happened?”

Dr. Ragen McGowan:
So sometimes you’re with your pet every day and you’re not noticing those changes until you get in a context and someone else alerts you like, “Wait a minute, your pet’s acting differently, what’s going on?” And that’s when you start to realize, hey, there’s something here, this is helping. But again, it’s part of that multimodal approach. Just by feeding the probiotic, doesn’t mean you shouldn’t also be doing the behavior modification, encouraging your pet, providing your pet that confidence to get through those more stressful encounters, working hand in hand with your veterinarian. Because perhaps you’re also layering on pharmaceutical interventions together as part of this plan, to really cater to what is needed for that individual pet, because every pet is individual.

Dr. Andy Roark:
Talk to me a little bit more about acute stressors. To be honest, I was kind of surprised when you tossed out thunderstorms and things like that, as areas where you found this to be particularly beneficial. I guess in my mind, when I’d thought about nutritional intervention, I was thinking of low-level anxiety, just general neuroticism, things like that. I think back to the 4th of July and the fireworks and things like that. To me, I’m kind of surprised. I tend to think more along the lines of, again, pharmaceutical things like that, for that level of acute fear coming on. What’s the research like on nutritional therapies in those cases?

Dr. Ragen McGowan:
Again, it’s not going to be that light switch goes off, now your dog’s not reacting to thunder or fireworks anymore, but again, part of our discussion before getting them in that better state of mind to be able to handle the stressors coming their way. So if you have your anxious pet that in the past, they’ve been reactive to these things. You’re starting them on a nutritional intervention. Now it’s been weeks that they’ve been on this. You’re also still preparing them. So if it’s 4th of July and you know they react to fireworks, you’re not out there outside while fireworks are going on. You’ve created a calm space in your house, you’ve provided them things to distract them, you’ve set all that up, you will likely see that your dog is responding better than they have in years past. Where those other, the behavior modification, the preparing them, wasn’t working as well, now you’re saying, “Oh, it is taking the edge off.”

Dr. Ragen McGowan:
You’re right. If you’re looking for that acute response of really bringing the dog down from that panic or stress, then that’s more of a sedative situation, a pharmaceutical intervention. Here, we’re lessening overall the reactivity. You have pets that have extreme fear responses, all the way to pets just being hypervigilant or hyper reactive. In both cases, we’re bringing them in a better frame of mind to cope with that. But it’s still part of the approach that you’re building into your routine. So it’s not the one solve everything silver bullet, it’s just part of everything else that you’re already doing with your pet.

Dr. Andy Roark:
And that totally makes sense. It goes back to what we talked about before, about being multimodal. I would much rather use less sedative. You know what I mean? And not completely have to gork the dog or cat out, because they’re in a better place. That totally makes sense. Again, I was just a hundred percent thinking back to, I want to have clear expectations here so that I can speak about this and get clients on board. And I can also gauge my therapeutic plan, so that… You want to get as close to ideal as you can, just because the trust of the client is in you. And if you try things and they don’t feel like they see any sort of a benefit, it can be much harder to keep them on board and keep them trying. So I really like that idea of, this is part of a multimodal approach and I go, great, that helps me make my plan and figure out where I need to put these things.

Dr. Andy Roark:
Are there any final pearls that you have in using, whether it’s probiotics or other nutritional approaches to behavior, are there best practices? Are there words of advice that you would give? Time of day for feeding, time of starting treatments, anything like that?

Dr. Ragen McGowan:
Again, just building it into the routine that you already have for your pet. So not stressing them out by making this one extra thing. The beauty of the probiotic, for instance, we’re not asking you to switch their diet. We’re not asking you to have to pill them or anything. It’s literally sprinkling on top of the food, it’s actually in the digest carrier that pets love, so they’re eager to eat it up. Just making it as seamlessly a transition into your routine as possible, and then taking the time to let it work. So really waiting at least that six weeks before you’re giving up, because a lot of people, they’ll try it for three days and they want to see something happening and if nothing’s happening, then they give up. So just encouraging them to continue to build it into their routine, keep it going, and then make that judgment. And just as part of that multimodal approach. So you can’t give up doing the behavior modification that you’ve been trying, or maybe wean them completely off the pharmaceuticals they’re on, but it’s that balance. And I think in working in partnership with their veterinarian, they should be able to strike that balance.

Dr. Ragen McGowan:
And for some pets, it does make a dramatic difference relatively quickly. We’ve seen pets that become much more easy going and less dramatic about their responses. For other pets, it’ll be very subtle changes that you’re seeing. But it all is important because at least we can see, even if it doesn’t manifest fully in the behavior you’re seeing, internally, physiologically, it’s helping with their stress response. You don’t want your pets in that chronic stress, because it can lead to all sorts of other immune issues and things going on. It might even be that their stress before was manifesting in something visceral like digestive upset or obsessive licking or self-injurious behavior. So look out for things like that too, like if their coat is improving because they’re no longer licking so much, or the redness between their paws is going away. There’s all these other indicators that could show, actually you’ve taken that mental load off and they’re much less stressed, even if it’s not hugely apparent in their reactions to big events happening in their life.

Dr. Andy Roark:
That makes tons of sense. We always want to celebrate pet owners. When something is working, I want to be able to say, “Look at this, look how much better this is.” And that totally makes sense. So yeah, the licking and chewing, and just those types of behaviors, yeah, that absolutely makes sense. Where can people get more information online? Where can they learn about the studies that have been done? Yeah, where can they read up?

Dr. Ragen McGowan:
Yeah. If you go to purina.com/expertise, there’s information there. And also, if you go to the Pro Plan Vet Direct website, you can learn a lot more about Calming Care.

Dr. Andy Roark:
That sounds awesome. Guys, I’ll put links to that down in the show notes. Dr. Ragen McGowan, thank you for being here. I really appreciate your time and energy. Thanks for sharing your knowledge.

Dr. Ragen McGowan:
My pleasure. Thanks for having me.

Dr. Andy Roark:
And that is our episode. Guys, I hope you enjoyed it. I hope you got something out of it. I know I certainly did. Thanks again to Purina Pro Plan veterinary supplements for making this episode possible. Gain, be well, and I’ll see you next week.

Veterinary cardiologist Dr. Anna Mac joins us to discuss the case of Baguette, a 2 year-old english bulldog with brachycephalic airway disease and pulmonic stenosis. Dr. Mac covers the diagnostic workup, treatment options and likely outcomes. This is a common condition in a common breed… and you won’t want to miss this episode!

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Purdue University College of Veterinary Medicine: vet.purdue.edu/

Dr. Andy Roark Exam Room Communication Tool Box Course: drandyroark.com/on-demand-staff-training/

What’s on my Scrubs?! Card Game: drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. McManamey (aka Dr. Mac) is a veterinary cardiologist. She received her degree of veterinary medicine from the University of Missouri. She then completed a rotating internship at the Ohio State University followed by an emergency and critical care internship at North Carolina State University. She finished her cardiology residency at North Carolina State University and became an ACVIM diplomate in 2021. Dr. Mac is currently an assistant clinical professor at Purdue University in Indiana. Cardiology is her favorite subject because it can be made as simple or as complex as needed. Furthermore, every animal has a heart and that means Dr. Mac gets to work with all kinds of species. Her areas of interest within cardiology are echocardiogram, congenital heart disease and interventional procedures, as well as emergency management of cardiac disease. She has a very supportive and patient husband along with three canine fur-children, one of which had a patent ductus arteriosus (of course).

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:
Hey guys, if you’ve listened to this podcast for any time at all, you know how much I care about keeping pet care accessible to pet owners and how much I hate when people don’t have the resources they need to take care of their pets or staff included. Guys, if you are here, you are probably pretty hardcore about pet healthcare. FIGO Pet Insurance helps you and your clients prepare for the unexpected so that you never have to make the tough choice between your pet’s health and your wallet. Whether these pets are eating out of the trash or diving off of furniture, pets, don’t always make the best decisions. We know that, but with FIGO, you can, and pet owners can. Designed for pets and their people, FIGO allows you to worry less and play more with customizable coverage for accidents, illness, and routine wellness. To get a quick and easy quote, visit figopet.com/coneofshame. That’s F-I-G-O-P-E-T.com/coneofshame. FIGO’s policies are underwritten by Independence American Insurance.

Dr. Andy Roark:
Welcome, everybody, to the Cone Of Shame veterinary podcast. I am your host, Dr. Andy Roark. Guys, I have a great episode for you today with my friend, cardiologist and rising legend, Dr. Anna McManame or Dr. Mac, as she is known at Purdue, where she is an assistant clinical professor. Gosh, she’s awesome. She is such an excellent teacher. I met her just by chance early this year. This is her third episode of the Cone Of Shame and I can’t get enough of her. She is so matter-of-fact, and to the point and just a good teacher. She just reigns pearls of wisdom down on me as I ask her these questions, and I am a better doctor having talked to her.

Dr. Andy Roark:
Guys, today, we are talking about a young bulldog who comes in to have brachycephalic airway surgery and that’s when we find the heart murmur. Ultimately, we end up talking about pulmonic stenosis in the bulldogs. Super fascinating conversation, really interesting. Man, bunch of stuff I’m going to be looking out for in the future that I’m not looking out for in the past. You learn. You know better and you do better. That’s what medicine is. Guys, you’re going to love this. Let’s get into it.

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. Anna McManame. How are you?

Dr. Anna McManamey:
I’m good. How are you, Andy?

Dr. Andy Roark:
I’m so great. Thanks for being back. This is your third time’s on-

Dr. Anna McManamey:
It’s been fun. Yeah.

Dr. Andy Roark:
… on the podcast. Well, you have been a very popular guest in the past, as I looked at our YouTube. As we’re recording this, your video with me came out less than a week ago, and it’s got like 100 and something views already. That’s pretty good since we just started doing YouTube. You’re doing good stuff. You’re fun to talk to so thanks for being here.

Dr. Anna McManamey:
Thanks for having me.

Dr. Andy Roark:
Man, always. I’m just going to apologize right ahead of time. I might not be at my best today because I’m going through some stuff and this is going to be hard to hear but my wife used the last of the almond milk that I was planning on for my smoothie. She didn’t say anything. She just left.

Dr. Anna McManamey:
She just left.

Dr. Andy Roark:
She just left. I found a recycling bin. I was like time for my smoothie and it wasn’t there, and so my world is kind of on fire. My love is to lie. It is what take away. I just want to apologize for that. While I get over my feelings of loss and contemplate a smoothie with tap water, like a peasant would have. Yeah, exactly. Anyway, I have a case that I would like to change the topic to, and talk to you about. Are you ready for it?

Dr. Anna McManamey:
I’m ready.

Dr. Andy Roark:
All right. Cool. I have a bulldog, a little-ish bulldog. She’s about two years of age. Her name is Baguette, which is a fun bulldog name. Baguette, the two-year-old bulldog. Her face kind of looks like a baguette. I guess kind of a squish, maybe a croissant face.

Dr. Anna McManamey:
Is she a French bulldog?

Dr. Andy Roark:
She’s not. She’s an English bulldog, which is really… Someone missed a trick there. She’s in for a stenotic airway surgery. Her little nostrils are just completely pinched closed. She’s about years and this was recommended. She has come in, and we’re getting ready for the surgery. I’m sculpting a heart murmur on this two-year-old dog. She seems asymptomatic. She’s bouncing around. There’s no coughing. There’s no nothing. I just wanted to go ahead and pull this out for you and sort of say, what are your thoughts when I’m looking at this little brachycephalic dog that’s got a heart murmur. Are those things related? Is this something I need to be worried about? What kind of monitoring should be looking at? Just start to unpack for me, how do you treat that?

Dr. Anna McManamey:
Yeah. I would say that we actually see this scenario, not uncommonly. Some of these dogs, maybe they’ll even have a clinical sign of “exercise intolerance”. They get out of breath quickly. The most logical thing is it’s their airway because these breeds-

Dr. Andy Roark:
Yeah, because she can’t breathe. I would 100% be like, I know what I got. Ding, ding, I know what this is.

Dr. Anna McManamey:
Got it. Done. On really close examination, once they’re either sedated, pre-anesthetically or they just stopped wiggling, someone hears a murmur. I usually have a rule that if I ever have someone that says, “I hear murmur in a dog younger than about three to five,” I keep inching my ears up because sometimes we’re not catching these congenital murmurs as early, but I’d say solidly if the patient’s less than three years of age and the murmur is a three or more, I consider that likely congenital heart disease that warrants further evaluation.

Dr. Anna McManamey:
I’ll say with bulldog, their anatomy just doesn’t lend itself nicely towards clean auscultation. Some murmurs are really hard to hear. You can’t tell over their referred airway noise, they’re snorting or their chest confirmation that you can’t hear the noise loud enough. Any time, I have a brachycephalic that’s a bulldog in particular, or any of these pity terriers that are now getting more and more bully-like. My top differential’s pulmonic stenosis in those dogs. We’re seeing it happen so commonly that even if they’re asymptomatic or we think they’re asymptomatic and I hear murmur that’s louder than a three, it’s a young dog, I’d be worried about pulmonic stenosis. That murmur is usually on the left side of the chest, but can radiate to the right side of the chest. I would recommend a further workout before anesthetizing that dog.

Dr. Andy Roark:
Okay, cool. Let’s start to unpack what that workout looks like in general practice. I agree with that. I would say to the owners, “Hey, I’m a bit concerned about this.” They’ve been great. They’re here for airway surgery. They’re invested in the pet. I’m happy to talk to them about taking a closer look. What does that look like in your mind?

Dr. Anna McManamey:
Yeah. One of the things that, I think not many people think to do, but something that I actually recommend doing is if you have even just a lead to ECG. Just an ECG machine that you would use for an anesthetic patient, it doesn’t have to be diagnostic. Doesn’t have be anything fancy but if you have that ECG lead, I’m looking for access deviations. I expect a sinus rhythm, so P, Q, R, S and T, but dogs with significant right heart remodeling, we can see that the QRS complex, it looks inverted, so they have a really deep S wave, even in lead two. It tells us that more of their electrical energy is actually going towards the right side of their heart rather than the left side. That can sometimes be a nice tip-off that they might have right side of the margin.

Dr. Anna McManamey:
Now, there definitely can be false negatives. It’s just something that’s relatively cheap and usually, if you’re there contemplating anesthesia, you have the equipment anyway. Something that’s relatively cheap, doesn’t cause any invasive procedures at all. It’s something I’d consider. I think that doing chest x-rays has its place, but sometimes can be not really any superior than just sending them straight for echo. If you’ve got a client where they’re not really convinced that they want to move forward with a cardiology assessment, with an echocardiogram, you could offer baseline chest radiographs. The purpose is to try and see, is there severe cardiac enlargement? If we’re looking for pulmonic stenosis, it’s going to be right-sided enlargement. This is going to be a widened cardiac silhouette on the lateral views. It’s going to be a loss of a cranial waste. Then on the dose eventual projection, we’re going to look for a big MPA bulge. There’s a big bulge that we see over there, but nothing is going to surpass the ability of an echocardiogram to really diagnose the cause of that murmur.

Dr. Andy Roark:
Yeah, I’ve not heard anyone say the phrase loss of a cardiac waste in 14 years. It’s like I remember that phrase and no one said it to me a long time.

Dr. Anna McManamey:
Well, coming back from the-

Dr. Andy Roark:
Really, it just came flashing back. I was in a classroom in Gainesville, Florida. I was like, oh yeah. My recollection of radiographs, just stepping to that, yes, cardiac enlargement. Do you see the actual stenosis in these? Can you see in the vessels, anything like that as 100% just looking for signs of change in the heart itself? I’m just trying to get my head around… I’m just trying to remember back to what that looks like in severe, so pause. In my recollection, there were radiographs in that school that I looked at that 100% showed the pinch stenotic of vasculature coming out. Is that is a thing that we’re ever going to see, or are we a 100% assessing the heart itself?

Dr. Anna McManamey:
With traditional radiography, you’re not going to see that because you’re just going to see soft tissue and blood superposed. Those are going to be the same opacity. In the good old days, they did radiograph angiograms. In school, they probably showed you some really cool images where they did an injection of contrast and then looked at a radiograph. You can see that level of stenosis and you can see the heart chambers. Now we use echo for those things. Then we do angiograms in our cath labs when we’re doing procedures.

Dr. Andy Roark:
Got you. Okay. Talk to me a little bit about the echocardiogram. I know that most of the GPs are probably not running them. Just easy to find. Is there any pearls or words of wisdom, anything that I want? When I refer this, if I have an internist come and look at things like that, do I want to say anything to them or just go, it’s an echo and they’re going to look and they’re going to be, here’s your problem.

Dr. Anna McManamey:
Yeah. No, it’s a great question. I think this is sometimes a little bit of a delicate subject, especially amongst cardiologists and other specialists that do have the ability to do advanced imaging. I think most cardiologists feel that any congenital case, it’s probably best served by being echoed by somebody that has a lot of practice or has the ability for, even if they’re a radiologist that’s variable trained or an internist, sending those out for review by a cardiologist, just because some things are very basic and very simple about it, but there are other little nuances that are really important. Just because they only have one congenital heart disease, doesn’t mean they couldn’t have a second one that’s hiding. That’s really important for us because that is going to impact the way we treat those cases, the prognosis we give and the interventions we recommend. Ideally a cardiologist, if you can. Otherwise, someone with good echo technique, has a machine that’s specifically for echo and then has the ability to get that read by for you.

Dr. Andy Roark:
Got you. No, that’s a good reminder. That makes a ton of sense. Hey guys, I just want to jump in here real fast and give a shout out to Banfield Pet Hospital, for making our transcripts available. That’s right. We have transcripts for the Cone Of Shame vet podcast and the Uncharted veterinary podcast. You can find them at drandyroark.com and at unchartedvet.com. This is part of their effort to increase inclusivity and accessibility in vet medicine. We couldn’t do it without them. I got to say, thanks. Thanks for making the content that we put out more available to our colleagues. Guys, that’s all I got this time. Let’s get back into this.

Dr. Andy Roark:
Am I going to see anything if I do a blood pressure check on this patient? A lot of times, we’ll get patients in and just first thing we do, is check their blood pressure as we’re surgery prepping them. Am I going to see abnormalities there?

Dr. Anna McManamey:
That’s a great question. For better or for worse, the pulmonic and the systemic circulations are completely separated by the lungs. There’s no way to check what the pressure in the right side of the heart is with a systemic blood pressure. We have to rely on using our central venous pressures. A chief way to do it is look at the jugular veins. If the jugular veins are distended or bounding, where you can see the pulses, which is challenging in English bulldogs, I will say, but if you can see those things, that tells us there’s elevated right atrial pressure. If they have ascites already, distended abdomen, that would be an indication, but sadly, there’s no way short of really sticking something down into the heart to get a measurement of those pressures.

Dr. Andy Roark:
Got you. Okay. Are there breeds where you can pretty easily see the bouncing jugular veins, because I’m like, that’s a diagnostic test that I want to do now. I want to see that.

Dr. Anna McManamey:
Yeah. Yeah. It’s really cool. It’s kind of like horses. They can be normal up to about a third of the neck, out of the thoracic inlet. If you’ve got a really fit athletic dog that comes in and they’re super excited, you’ll actually see them sometimes just pulsing in the neck, but the ones that we’re looking for, the pulses that go all the way up the neck or where the jugular veins are so distended, you can see them just by wetting the fur with alcohol. You can actually see them standing up. My trick for the ones that are more difficult is to hold off the jugular vein like I would for venipuncture, so hold off at the thoracic inlet, find the vessel and then let go with my thumb. If I can still feel the vessel the same, it’s still that distended, I know it’s abnormal.

Dr. Andy Roark:
That’s super cool. I’m desperate now to see that so I can point across the treatment room and say to my technicians, “That dog has elevated right systolic pressure,” and they would look at me like Merlin walked in. I’ll be like, I can tell. I won’t tell, no, I didn’t. Just no. I can smell it.

Dr. Anna McManamey:
Exactly. Just wave your hand over. This dog has very systolic pressure.

Dr. Andy Roark:
Yes, exactly.

Dr. Anna McManamey:
It’s really helpful. It’s really helpful it and it’s for any cost. This could be a patient with bad heart disease. This could be a patient with bad [inaudible 00:14:48] disease, pulmonary hypertension. The same is true with the only tricky one is with tamponades. If you’ve got pericardial effusion in tamponades, you’ll likely see jugular pulsations, so helpful too.

Dr. Andy Roark:
Well, let’s fix this. What are my treatment options? What am I going back to the pet owners with when I say, Hey, unfortunately, this is what I found? Obviously, we’re not going to go do this procedure today. Instead, we’re going to work up a new treatment plan. What do you think that treatment plan looks like?

Dr. Anna McManamey:
Typically, it all starts with diagnosis. Again, going back, getting that echo, finding our formal diagnosis and then probably, the more important parts of how significant is it? There’re grades of pulmonic stenosis and there’re types of pulmonic stenosis. The most common kind of pulmonic stenosis we see is truly of the valve itself. It’s where the valves leaflets, they all formed like they were supposed to, except they never separated into three leaflets. We just have this mush of leaflets that are doming. They never open all the way so it’s a valvular pulmonic stenosis. We used to call these type A, meaning they were very amenable to going in and doing a balloon procedure, which we’ll come back to in a second. The other type is this type B morphology, which is, unfortunately, what the bulldog seemed to be plagued with more often.

Dr. Anna McManamey:
That’s where the whole anulus itself, so the circumference of the valve is smaller than normal. The whole thing just is underdeveloped. Those animals may not be as amenable to balloon procedure, but we have to echo to find that out. There’re other levels of obstruction but again, the valve is the most common. French bulldogs are in a class of their own. They get this obstruction above the valve as well. We call it a supravalvular stenosis but again, echo answers that question for us. Once we know what kind, we have to know how bad is it? We use a few variables to help us with that. We’re basically just trying to say, is this obstruction mild, moderate, or severe? The easiest way is to use the speed of blood leaving the right ventricle tract obstruction, so it’s just like the garden hose effect.

Dr. Anna McManamey:
If you take your thumb over the edge of a garden hose, blood, or excuse, water speeds up, and it creates a turbulent jet. Same thing in the heart. The smaller that opening is, the more turbulent the blood flow is. We can use the speed of blood flow to tell us how severe the obstruction is. Classically, anything over a pressure gradient of 80 millimeters of mercury is considered severe. Normal, to put it in perspective is less than five millimeters of mercury. We’re talking way, way, severe. These animals have thick right hearts. They might be symptomatic. They may not at the time of diagnosis, but the concern is that they will become symptomatic. They could develop congestive heart failure in their life. Honestly, by the time they’re five to six years of age, they could die suddenly from arrhythmia.

Dr. Anna McManamey:
It’s these severe categories that we want to treat. The two mainstays of treatment are medical versus interventional. The medical tried and true drug that we usually put these guys on is one called Atenolol, for some type of beta blocker. This is common throughout literature and things. I think there’s a common misconception that when we put them on Atenolol, it makes their stenosis better. It doesn’t do anything to the anatomy of the valve. What it does, is it reduces the workload on that heart and the myocardial oxygen demand in the heart. Beta blockers slow heart rate. They reduce contractility. Those are two determinants of cardiac oxygen demand. We’re trying to protect the heart muscle from arrhythmias, from progressive changes and trying to prevent their heart rates from getting too fast., so that way they hopefully have a longer prognosis and a better survival time.

Dr. Anna McManamey:
Ideally, we take them to the cath lab. That’s one of my favorite things to do. We take them to the cath lab and we do the balloon valvuloplasty. This is where we actually take our special catheters, go in through the heart and we can access through the jugular vein or the femoral vein. We go in and we basically inflate these special catheters. It’s a balloon. Inflate it across the bowel and we tear open those leaflets. The medical management is, of course, very cheap. Atonolol is a very readily available drug. It’s very cheap. Minimal side effects. Again, it doesn’t change their anatomy. It just protects their heart muscle from the negative effects of that disease.

Dr. Anna McManamey:
The interventional approach is usually going to be a few thousand dollars. It’s usually only available at specialty hospitals with cardiologists that also have a cath lab. Almost every academic institution does it. Not as many private practices do, but this is our bread and butter. We’re usually doing two to three of these a week at [inaudible 00:19:25], for example. Those dogs, we think, typically, have a success rate of about 80% of the time. Sometimes that valve stenosis re-narrows, and we have to do it a second time. Sometimes the anatomy is such that we can’t inflate the balloon appropriately or despite our best efforts, that valve doesn’t want to budge. Now, there’s even newer techniques like placing stents in there and doing some really cool stuff, but that’s all something that can be discussed with the cardiologists and that client at the time of the appointment.

Dr. Andy Roark:
Got you. Okay. Let me ask a potentially silly question, but it makes some sense to me anyway. If I have this dog and they have pulmonic stenosis and we’re talking about, let’s say medical management. We’re not going to go in surgery but we repair this. Is there clinical benefit to, at some point, when the patient is a stable, solid surgical candidate to doing this brachycephalic airway surgery, to open it up, to increase oxygenation to the dog. As I think about that, and I get 100% see in my mind, talking to the pet owners and saying, “Hey, this is where we are and we’re going through the process.” Then they panic and say, “Oh my God. Well, she’s so fragile. We definitely don’t want to do surgery.”

Dr. Andy Roark:
Is there a place where I say, “Well, let’s manage this. There’s still benefit to doing this airway surgery.” I believe that for the comfort of the patient. I do believe that but let me ask you, is there clinical benefit to a pulmonic stenosis patient, that’s a bulldog, to be able to breathe?

Dr. Anna McManamey:
Yeah. No, I think absolutely there is. It becomes this very delicate balance of, okay, well I found a heart disease in this pet. If it’s mild to moderate stenosis, you’re done. They can go get their procedure. They’re on some Atenolol. It’s fine. Well, then that severe category, you really think, wow, ballooning, this dog would make it a more stable anesthetic candidate. Doing its airway would make it a more stable anesthetic candidate. Actually, there are a number of these dogs where they have severe enough problems of both that I have them come to me. I balloon them and then have my surgeon do their airway before they wake up.

Dr. Andy Roark:
Wow.

Dr. Anna McManamey:
That’s what I’ll do. If I have a client that is dedicated to doing those things, we’ll do it. It makes my anesthesiologist happy because these dogs are not the fun ones to anesthetize. They’re hypotensive. Some of them have intra cardiac shunts. They’ve got shunting across their atrial levels. They’re not very fun to anesthetize if they have severe, severe stenosis, but you’re exactly right. A lot of these dogs, I do think can be more clinically affected from their airway than from their heart, at least at that point in time. Maybe there’s that acceptable risk that you have a skilled anesthetist who’s comfortable with a quick procedure, a surgeon who’s comfortable with a quick procedure to just make that dog clinically better in the short term.

Dr. Andy Roark:
Can you give me an idea of prognosis for mild, moderate and severe with and without surgery?

Dr. Anna McManamey:
Yeah.

Dr. Andy Roark:
Six answers. That’s a six-answer question.

Dr. Anna McManamey:
Well, I’ll lump it into three. If it’s mild to moderate stenosis, we rarely recommend interventional procedures for those dogs. There’s been enough evidence that for most dogs, as long as they’re in the mild to moderate category, they’re not expected to have negative side effects from their heart disease in their lifetime. It’s very uncommon. There are some exceptions to that, like larger breed dogs. It seems they seem to be a little bit more sensitive to even moderate degrees of stenosis. We use the changes to the heart more than anything. If their heart looks like it’s thick, we’ll say, let’s go do this and get rid of it, and try and give them their best chance at life for the severe dogs, so gradients over 80. This is, honestly, a very wide range of dogs because we’ve got tons of dogs that have gradients over 200.

Dr. Anna McManamey:
That dog is going to have a worse prognosis than the dog of 85, but they’re still both severe, so it’s a little bit fuzzy there, but the median survival time for dogs with severe stenosis without intervention is about five to seven years of age. Usually, those dogs are dying from their heart disease. That’s when we talk about its cardiac causes of death so it’s refractory heart failure, progressive syncarpy that can’t be controlled, exercise intolerance or arrhythmias and sudden death. Those are the more common outcomes that we’ll see, but usually, it’s probably around five years of age is when it really starts seeing to be the worst. With intervention, if we are successful, meaning we get them into at least a 50% reduction of their initial gradient, or whole [inaudible 00:23:52] to get them out of the severe category. If we do that, then they have, essentially, a normal life expectancy. That’s the cell. It sounds like a lot upfront, even if the dog is asymptomatic at that time, but we’re trying to get you years of quality of life with the dog dying from something other than the heart disease.

Dr. Andy Roark:
That makes total sense. Dr. Mac, thank you so much. Are there any final pearls, words of wisdom or pitfalls that I need to look out for as I head forward with this case?

Dr. Anna McManamey:
I would just say, I think you’ve done the best things. Everything else can be done, honestly, under the guidance of the cardiologist and just a team approach with everything, but the breeds I’d watch out for, every bulldog. Frenchy, English doesn’t seem to matter. Any terrier breeds, pit bull terriers, Norfolk terriers, west highland white terriers. Those ones are the most commonly affected. It could be any breed. Just every time you’ve got that new puppy in the room, listen really high up in the axilla region at the base of their heart to find these murmurs early.

Dr. Andy Roark:
That’s fantastic. Thanks again.

Dr. Anna McManamey:
You’re welcome.

Dr. Andy Roark:
That is our episode. Guys, I hope you enjoyed it. I hope you got a ton out of it. I know I did. Thanks to Dr. Mac for being here. Guys, take care of yourselves. Be well, talk to you soon. Bye.

Hypoglycemia trips veterinarians up in a number of ways. It has a variety of causes and some can be more challenging to pinpoint than others. In this episode, Veterinary Medical Internist Dr. Andrew Woolcock joins Dr. Andy Roark to discuss the case of a young hypoglycemic yorkie, before expanding the conversation to discuss hypoglycemia in general.

This discussion covers causes of hypoglycemia, appropriate diagnostic workups, and practical treatment approaches.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

https://www.vet.purdue.edu

GSD Shorthanded Virtual Conference: https://unchartedvet.com/gsd-shorthanded/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/on-demand-staff-training/

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. 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:
Hey, guys. If you’ve listened to this podcast for any time at all, you know how much I care about keeping pet care accessible to pet owners and how much I hate when people don’t have the resources they need to take care of their pets, our staff included. Guys, if you are here, you’re probably pretty hardcore about pet healthcare. Figo Pet Insurance helps you and your clients prepare for the unexpected so that you never have to make the tough choice between your pet’s health and your wallet.

Dr. Andy Roark:
Whether these pets are eating out of the trash or diving off of furniture, pets don’t always make the best decisions, we know that, but with Figo, you can, and pet owners can. Designed for pets and their people, Figo allows you to worry less and play more with customizable coverage for accidents, illness, and routine wellness. To get a quick and easy quote, visit figopet.com/coneofshame. That’s F-I-G-O-P-E-T.com, slash cone of shame. Figo’s policies are underwritten by Independence American Insurance.

Dr. Andy Roark:
Welcome everybody to The Cone of Shame veterinary podcast. I am your host, Dr. Andy Roark. I am back with internal medicine specialist, Dr. Andrew Woolcock, and we are talking about hypoglycemia today. We first start and talk about a little itty bitty young dog that has it, and then we go into the other reasons that you see patients that have hypoglycemia. This is a great short, to the point overview of a very common condition that can come from a lot of different places, so guys, again, I love this. This is one of those pearl episodes where you just breeze through it. It’s only about 15 minutes of actual interview, and you’re just going to get a lot out of it in a short amount of time. Again, thanks to Dr. Woolcock for being here. He’s amazing. Gang, 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. How are you?

Dr. Andrew Woolcock:
I’m doing very well. Thank you for having me.

Dr. Andy Roark:
Oh, man, my pleasure. I love having you on the podcast. You are, for those who don’t know, an internist at Purdue University’s College of Veterinary Medicine, residency at University of Georgia. You have been on the podcast not too long ago talking about, oh gosh, what did we talk about? IMHA.

Dr. Andrew Woolcock:
Yes.

Dr. Andy Roark:
Yes. It’s been so long it just disappeared from my brain. I wanted to get you back. I’ve got a case I want to talk to you about, and it’s sort of a general, general subject matter. Let’s just start with the case. I have got a young, like eight-month-old Yorkshire Terrier male, neutered, named Taz, and he is not looking good. He’s lethargic, trembling. Owners are really freaking out. He does not look like a normal happy, healthy dog. I did a little bit of blood work on him and the main finding that I have is hypoglycemia.

Dr. Andy Roark:
His glycemic index is low. His glucose is down there. I just wanted to go ahead and ask you about this. As I’m looking at this little dog and thinking okay, what am I looking at here? Why does this happen? I just want to make sure I’m not missing anything. Mom and dad are like what does this mean for the longevity of our dog? Is this dog defective? Did we get a lemon? All of those sorts of questions that you might have if your eight-month-old dog just suddenly stopped working. How do you treat that? Let’s go ahead and start to sort of set this up. What do you think about when you see hypoglycemia in a young dog?

Dr. Andrew Woolcock:
Yeah, so I think thankfully their young dog has not stopped working. It’s just that their young dog is working really hard and has a really rapid metabolism that needs a lot of glucose all the time to keep things running. In very young, very small breed dogs, think like hummingbird metabolism. We’re talking small, so things are moving quickly, so these are the breeds and at the age where they just need frequent access to food to be able to keep their glycemic index up.

Dr. Andrew Woolcock:
The reality is maybe this family’s been feeding the dog the same way, and ever so slightly this dog’s been really holding steady right at the cusp of being hypoglycemic and then skipped a meal, missed a meal, ate a little less, something like that, and that’s why the dog looks like it in this moment and they’re freaking out. Thankfully this is hopefully a very easy to address issue for this Yorkie, and you’re probably going to end up doing more client care in this scenario to help them understand that this is a problem that is very addressable and fixable.

Dr. Andy Roark:
Okay. I have a lot of Yorkies that are small and they stay small. Is the fact that I see this in young dogs, is that attributed to the fact that their metabolism slows down as they get a little bit older? Is that why I’m not seeing this in four and five-year-old Yorkies?

Dr. Andrew Woolcock:
I think it’s a combination of things. One is sure, yes, as they age their metabolism changes, but also when they are very young, their machinery to store glucose in the form of glycogen, their liver to respond to all the different hormonal influences that can regulate glucose nicely, their fat stores and muscle stores, which are a huge storage for energy, are just not quite as robust as they are once they’re at their adult size. They don’t have all the other machinery in place yet to kind of keep them balanced like they do as they reach adulthood.

Dr. Andy Roark:
Talk to me about how the presentation here is going to differ, how my thought process is going to differ when I’m looking at this eight-month-old dog versus when I’m looking at a six-year-old dog or a 10-year-old dog. Hypoglycemia presents for a number of different ways. Help me get my head around that. Let’s just jumping ahead and looking at other patients. What am I looking out there? What are my differentials? Just start to unbox the metabolic phenomena of hypoglycemia for me.

Dr. Andrew Woolcock:
Sure, yeah. I think at its very stripped down level you can think about hypoglycemia as being caused by one of three very broad categories. It’s either going to be insulin related, and we can talk about that separately, but it’s either going to be an increase in insulin, whether that’s naturally occurring like an insulin secreting tumor or something like that or it’s your classic diabetic dog who was given too much insulin. Either that hypoglycemia is related to insulin specifically or they’re hypoglycemia either because they have something that needs more glucose than they’re providing it, like in sepsis or with certain tumors or something like that, so there’s an increase in utilization of their glucose, or there’s a decrease in the production of glucose.

Dr. Andrew Woolcock:
That can come in your neonatal Yorkie that we were just talking about, very young where they’re just not eating enough, or other things that can cause a decrease of production of glucose are things like liver failure, since the liver is so integral to glucose metabolism, or even things like Addison’s Disease because we know that cortisol is a counter-regulatory hormone, basically does the opposite things of insulin. It is there to help continue the production and storage of glucose. In Addison’s Disease where you’re cortisol deficient, hypoglycemia would be a common presentation. Then certainly toxins and things can manipulate glucose as well.

Dr. Andy Roark:
Okay. What does your sort of general diagnostic workup look like for an older dog that comes in, main presentation is hypoglycemia?

Dr. Andrew Woolcock:
Yeah. I think if it’s an older dog presenting with hypoglycemia, maybe you find it just on your alpha track or bedside blood glucose, so that’s the piece of information you have. The best next thing to be doing is full lab work because on a CBC you’re already going to be able to identify let’s say a really severe inflammatory leukogram, maybe left-shifted toxic changes to your neutrophils that are going to move you in the direction of the septic cause for that hypoglycemia. On your chemistry profile maybe you’re going to see changes that would indicate liver dysfunction or maybe you see electrolyte changes that push you towards an Addison’s diagnosis and things like that.

Dr. Andrew Woolcock:
Really, those pieces of blood work are going to be extremely helpful just to start moving you in the direction of which of those you’re dealing with. Then I think if you’re not finding evidence on CBC or chemistry to move you in the direction of toxin, sepsis, Addison’s, liver disease, then just make sure you’ve got some serum saved that you can test insulin levels on that serum because a paired insulin/glucose ratio is the way to start thinking about insulin secreting tumors or something like that. I don’t think I would ever do that straightaway, but one of the pitfalls I see people run into is that by the time they start thinking about testing serum for insulin, they’ve already given the dog a bunch of dextrose and they’ve already supplemented, and they’ve already manipulated the whole glycemic index, and then it becomes a lot more difficult to test for that or evaluate that, so just make sure you save a little bit right at the beginning when you’ve got that hypoglycemic pet.

Dr. Andy Roark:
That makes sense. Hey everybody, I’m just jumping in with two lightning fast updates. Number one, if you have not gotten signed up for the Get (beep) Done Shorthanded virtual conference in October, it’s October 6th through the 8th, you need to do that. If you are feeling overwhelmed in your practice and you want things to go smoother and faster, if you do not want to watch webinars, you want to actually talk about your practice. You want to do some discussion groups, you want to do some workshops where you actually make things and work on things and ask questions as we go along, and have round table discussions and things like that that’s really going to energize you and help you figure out actionable solutions that you can immediately put into practice to make your life simpler and more relaxed, I got you covered, buddy.

Dr. Andy Roark:
But you don’t want to miss it. Go ahead and get registered. Mark yourself off at the clinic for the time so that you can be here and be present and really take advantage of this. I don’t want it to sneak up on you. I know October seems like a long way away. It’s not. But go ahead. I’m going to put a link down below and then when registration opens we’ll let you know it’s open and you can grab your spot. But you do not want to let this sneak up on you.

Dr. Andy Roark:
Check out our Get (beep) Done Shorthanded conference. It’s going to be a great one. This second thing I’m going to tell you about is Banfield. Thank you to Banfield Pet Hospital for making transcripts of this podcast available. You can find them at drandyroark.com. They are totally free and open to the public and Banfield supports this to increase accessibility and inclusion in our profession. It’s a wonderful thing that they do. Guys, that’s all I got. Let’s get back into this episode. Let’s talk about emergency presentation of hypoglycemia. How aggressive do you get on this? Where are your levels? Where do you go from a one alarm fire to a two alarm fire to a five alarm fire?

Dr. Andrew Woolcock:
Yeah. I think your one alarm fire is maybe the young Yorkie, Taz, that you presented at the beginning, who presumably has an appetite and whose hypoglycemia so far is presenting as yes, the dog looks rough but he’s just lethargic and not acting himself, and so as long as he seems neurologically with it and normal mentation, then in that dog, the emergency stabilization may be as simple as let’s offer him a food that has a high glycemic index, high calorie, and get him eating.

Dr. Andrew Woolcock:
I do not think that every hypoglycemic patient, even in the ER, I don’t think every single one needs immediate dextrose bolusing and things like that because in fact, sometimes that kind of messes with the system a little bit and causes insulin surges and all these things that you aren’t intending. If you have a patient that has a normal mentation and has an appetite and wants to eat, whose hypoglycemic signs are mild, food may be all you need in the emergency stabilization.

Dr. Andrew Woolcock:
But that two, three, five alarm fire, those are going to be the patients that really present with some severe neurologic side effects from their hypoglycemia or have already suffered a hypoglycemic seizure, whether they do that in your clinic or they come in postictal. That’s going to be a patient that you aren’t going to really want to rely on consuming food, because that may not be safe for them and that’s where dextrose supplementation becomes key.

Dr. Andy Roark:
Let’s talk about that. Any words of advice, guidance, on dextrose supplementation? I always have a little bit of panic as I’m getting ready to give IV dextrose and always go, “I want to make sure I do this just right.” Give me some pearls on doing a good job in dextrose supplementation that are going to get me the results that I want with the lowest stress on me and the team.

Dr. Andrew Woolcock:
Yeah. I think that thankfully this is a medication that is readily accessible in most clinics and has a very wide safety margin, so you can feel good even if you can’t remember the dose and you’re scrambling, and you’re looking around, give some and you’re fine, but a great general rule is half a mil to one mil per kg of 50% dextrose is a wonderful place to start as a bolus. Then something that I think would help a lot of clinics so that they’re not in that nervous state between boluses of how are they going to handle this, is their glucose just going to drop again, how often do I need to be checking, is once you’ve identified that they need a dextrose bolus, then it’s very reasonable to start them on a constant rate infusion of an IV crystalloid.

Dr. Andrew Woolcock:
Start them at a maintenance fluid rate or higher if you think they’re dehydrated, and add dextrose to those fluids. We often start them on 2.5% dextrose because then at least you know that you can attend to other emergencies that come into your clinic, things like that, and you’re not going to be feeling that anxiety about are they just going to plummet again and am I going to miss it? Are they going to have another seizure? When do I need to reach for another bolus? Starting them on a CRI gives you a push-in to then recheck, and the 2.5% CRI that you start may not be enough and maybe you’ll increase that over time, but I think that’s a nice way to continue to address the problem while you’re realistically waiting on maybe that CBC chemistry to be performed or things like that.

Dr. Andy Roark:
Right. That makes sense. I’m assuming that the amount of time that we’re going to have them on a CRI treatment schedule is probably going to depend largely on what we decide the underlying cause is. Correct?

Dr. Andrew Woolcock:
Yeah, absolutely correct. I think if this is a patient who you do ultimately identify as septic, and now you’re searching for a source of sepsis, then they may remain on some kind of dextrose supplementation for awhile as you identify that septic source, but if it’s a dog who ate something that had xylitol, an artificial sweetener that causes hypoglycemia, then maybe they just need their supplementation overnight while you deal with the toxicity and get them through a shorter period. I think it really just depends on the cause.

Dr. Andy Roark:
Say that we’ve got that dog that ate xylitol, or we’ve got that dog that’s been septic, and we’ve been treating with antibiotics and we feel like the patient’s getting better and starting to eat again. Do you look at the patient and say he’s looking pretty good at this point or do you use diagnostics to guide you as you withdraw dextrose supplementation?

Dr. Andrew Woolcock:
I think probably a combination of both. I think absolutely clinical signs are going to be the biggest part of it, but certainly once you’re making the decision to stop dextrose supplemenation there’s going to be a window of time between stopping it and them getting low enough to show you anything clinically that you would love to see that trend before you allow them to get lethargic and seizuring and things like that.

Dr. Andrew Woolcock:
Monitoring blood glucose is going to be important and something that we have started doing more of for people that are doing this or may not be familiar, are using interstitial glucose monitors. Those are like the FreeStyle Libre, something that can be placed on the skin that can measure the glucose in the interstitium and it saves you from having to poke or draw more blood or things like that. If you’ve got that patient who you think this is going to be a long-term issue that can be really helpful in the hospital.

Dr. Andy Roark:
Yeah. That’s super cool. That’s not something I’ve gotten to try yet, but I think that’s pretty fantastic.

Dr. Andrew Woolcock:
Yeah, and obviously the accessibility of small capillaries to use a glucometer are very easy, but those patients that are very small, that you’re finding yourself drawing blood four or six times a day and you think gosh, I’m a vampire at this point I’m taking so much blood, it’s a really nice way to sort of move away from the blood product and be looking at the interstitium.

Dr. Andy Roark:
What are the pitfalls? What are common mistakes? What are things that trip up doctors, technicians, when we start talking about hypoglycemia?

Dr. Andrew Woolcock:
Yeah. I think that to me, probably the biggest pitfall is to get too much tunnel vision about how critical the acute phase of hypoglycemia is and therefore assume that the underlying cause must also be quite severe, because I think a lot of times people worry. In the Yorkie, the young Yorkie, people feel at least comfortable with that setting, but the dog that comes in that’s unexpectedly hypoglycemic, I think it’s natural to assume that they may be septic or have an infection and it may be natural to reach immediately for antibiotics and hope that you’re going to clear it up that way. I think one thing I just encourage people to do is take a step back and really make sure that the remaining blood work you do continues to support that assumption of critical disease because in a lot of cases it doesn’t.

Dr. Andrew Woolcock:
You can start to suspect something less concerning or something that is not necessarily critical like a septic patient and maybe that starts to take you down the pathway of Addison’s Disease or maybe starts to move you towards an insulinoma, which of course is still not a great diagnosis, but is one that you can take a little bit of time with to assess and to start to think about imaging and things like that. I think the biggest advice I would have is to not just assume hypoglycemia means infection and make sure that the rest of your evaluation supports that if that’s where you’re headed.

Dr. Andy Roark:
That makes total sense. Are there any other resources that you would point people towards, anything, I just sort of think of nutritional management, things like that, that you’ve found particularly valuable?

Dr. Andrew Woolcock:
I would not say not something specific for hypoglycemia. However, I think nutritional management or nutritional textbooks are really good to have and then also even a clinic that doesn’t have an ER component to their clinic, having some kind of critical care textbook, whether that’s physically or an eBook version, are really helpful for those settings where your a day general practice and you’re hit with a true emergency situation, and you’re going, “Gosh, I don’t remember what the stabilization plan is for this or the dose for this drug that’s in my crash cart that I never use,” stuff like that. I think making sure you’ve got that resource available is great.

Dr. Andy Roark:
That’s awesome. Andrew, thanks for being here. I really appreciate it.

Dr. Andrew Woolcock:
Sure thing. Thank you.

Dr. Andy Roark:
And that’s it. That’s what I’ve 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 podcasts, if you’d love to leave us a little review that means the world to me. Yeah, if you like learning, check out the drandyroark.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 are 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.

Veterinary cardiologist Dr. Mac is back on the podcast! We are talking about an 8 year-old Maine Coon Cat named Jerry who came in for limping… and who happens to have a very large heart on radiographs. How concerned should we be? How much deeper should we investigate? What do we tell the owners? This and more coming up in this episode of the Cone of Shame!

LINKS

Purdue University College of Veterinary Medicine: https://vet.purdue.edu/

Believing We Can – Leading a Solution Oriented Team: https://unchartedvet.com/product/solution-oriented-team-workshop/

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. McManamey (aka Dr. Mac) is a veterinary cardiologist. She received her degree of veterinary medicine from the University of Missouri. She then completed a rotating internship at the Ohio State University followed by an emergency and critical care internship at North Carolina State University. She finished her cardiology residency at North Carolina State University and became an ACVIM diplomate in 2021. Dr. Mac is currently an assistant clinical professor at Purdue University in Indiana. Cardiology is her favorite subject because it can be made as simple or as complex as needed. Furthermore, every animal has a heart and that means Dr. Mac gets to work with all kinds of species. Her areas of interest within cardiology are echocardiogram, congenital heart disease and interventional procedures, as well as emergency management of cardiac disease. She has a very supportive and patient husband along with three canine fur-children, one of which had a patent ductus arteriosus (of course).

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:
Hey guys, if you’ve listened to this podcast for any time at all, you know how much I care about keeping pet care accessible to pet owners and how much I hate when people don’t have the resources they need to take care of their pets, our staff included. Guys, if you are here, you are probably pretty hardcore about pet healthcare. Figo Pet Insurance helps you and your clients prepare for the unexpected, so that you never have to make the tough choice between your pets health and your wallet. Whether these pets are eating out of the trash or diving off of furniture, pets don’t always make the best decisions, we know that, but with Figo you can, and pet owners can. Designed for pets and their people Figo allows you to worry less and play more with customizable coverage for accidents, illness, and routine wellness. To get a quick and easy quote, visit figopet.com/coneofshame. That’s F-I-G-O-P-E-T.com/coneofshame. Figo’s policies are underwritten by Independence American Interest.

Dr. Andy Roark:
Welcome everybody to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark. Guys, I am back with my friend, cardiologist Dr. Mac from Purdue University’s College of Veterinary Medicine. She is amazing. Guys, we are talking about big cats and big hearts. We’re talking about a Maine Coon cat who’s in for limping, and when we take a radiograph of the shoulder, we see his heart’s really big. What do we do with big hearts in cats? Heart disease, cardiomegaly, in cats is a interesting subject area. It’s a point of a lot of debate for cardiologists. I want to make sure I’m getting it right, or at least starting my clients off down the right path so that we can figure out what to do together. Gang, super great episode. Really good information, so many pearls. Dr. Mac is amazing, I hope you agree. 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 back to the podcast, Dr. Anna McManamey. How are you?

Dr. Anna McManamey:
I’m good. How are you?

Dr. Andy Roark:
I am so good. I am so thrilled to have you back. How have you been?

Dr. Anna McManamey:
I’ve been good. How are you doing?

Dr. Andy Roark:
I am okay. My mom is coming to visit this weekend and she’s supposed to be here anytime, and so-

Dr. Anna McManamey:
Don’t mind me.

Dr. Andy Roark:
… I sent her a message and I was like, “Don’t come in my room, Mom. I’m hanging out with my friends. I’m hanging with my friend.” It’s a language that she would understand and would come back to her from the past. So, we’ve got to get this done, because my mom’s coming over.

Dr. Anna McManamey:
Sounds good.

Dr. Andy Roark:
All right. Here we go. I’ve got a case for you. It’s probably nothing, it’s probably dumb, it’s probably nothing. I’ve this big, handsome, Maine Coon cat who thinks he’s a dog. You know those cats?

Dr. Anna McManamey:
My favorite cats.

Dr. Andy Roark:
My favorite cats, too. The cat people are like, “Oh, I thought you liked cats?” And I’m like, “I like cats who act like dogs,” and they’re like, “Shut up.” No, I’m kidding. I love cats. But there is something about the big cats that think that they’re dogs, it just makes me smile. And that is our friend. Jerry. Jerry is, I said eight years old, so middle-aged, getting on towards later senior years there. But anyway, Jerry’s in for limping, limping on one of the front legs, and we snapped shoulder rads and we got some chest in there. Jerry has a big heart, and I counted rib spaces, but just looking at Jerry he’s just got a big heart and it does not look normal. I look at a lot of cat chest in my time and I see a big heart and I know what a big heart looks like, and I think he’s got a big heart.

Dr. Andy Roark:
I don’t hear a murmur or anything when I listen to this, he’s not asymptomatic, he’s literally here for orthopedics in the front leg. What do you think when I tell you that I see that in Jerry, how do you treat this?

Dr. Anna McManamey:
Yeah, that’s a great question. So, the cardiomegaly in a cat, especially on radiographs, I think, always should alert to the possibility that there could be cardiac disease, especially because the most common kind of cardiac disease in a cat can be really difficult to pick up on radiographs alone. So, anytime I think there’s a big heart, for a cat, I think it’s worth further investigation. The fact that he came in for limping, I think we have to keep in mind, “Is this the weird presentation for an aortic thromboembolism?” So, tying the whole picture together. Again, I think it warrants for the workup of his heart a little bit. So, we have to figure out, “Well, what are we going to be to offer this cat in that setting versus future steps?” So, I would say the easiest things to do when you have a cat at your practice and you don’t have a cardiologist next door, would be to…

Dr. Anna McManamey:
You’ve already done the thoracic radiographs, you’ve seen the big heart. I’d say, “Ooh, cardiac disease is very possible. This is a breed of cat, this is an age of cat, this is a gender of cat that get heart disease,” so working that up a little bit further. It’s an old enough cat where we could see secondary changes from hyperthyroidism, we could see secondary changes from high blood pressure. So, a very basic screening for cats that are over the age of seven, honestly, for me, I do recommend a T4 and I do recommend a systemic blood pressure. Those are accessible, easy to do, just ruling out raging systemic disease that could be causing the heart changes. And then for this guy, the other things I would do, again, just because he’s breed, [inaudible 00:06:09], and gender at risk, he’s got limping and he’s got a big heart on radiographs, is this is a good time to do one of those NT-proBNP, so that biomarker that we talked a little bit about last time.

Dr. Anna McManamey:
So, the BNP, just as a reminder, is that B-type natriuretic peptides, something that’s released by the heart, by the ventricles, when they feel stretched. So, it can be a pressure overload, a volume overload, or a systemic disease process like hyperthyroidism or systemic hypertension. Anything that makes the heart unhappy, it can release this hormone. And so, the NT-proBNP is a send-out test, so it does take a little bit of time, but there are SNAP tests available. So, these are from IDEX, they’re just like a SNAP heartworm or SNAP parvo test. You take a few drops of their blood, put it in the well, wait three minutes, and you get your answer. That one is nice, I think, for these more time-sensitive cases. It basically gives you a qualitative answer, so it tells you, “Yes, there’s likely significant heart disease,” or, “No, there’s likely not significant heart disease,” whereas the send-out test is a quantitative, so it gives you an actual number. But those would be the things I would start with in that cat today, and we can talk a bit more about what I want to see, if you have any questions so far.

Dr. Andy Roark:
No, that totally makes complete sense to me. I have a couple of questions, but I want to go farther down the path before I come back around to them. So, I’m good with this. This all makes sense. This all seems very doable. I am 100% on board. Where do we go from here? What are you expecting to come back? What are you concerned about finding?

Dr. Anna McManamey:
Yeah. So, if I think this catch really has significant heart enlargement, I’ve ruled out hyperthyroidism, I’ve ruled out systemic hypertension. If my BMP result comes back as abnormal or greater than the reference range, at least greater than, honestly, 200 is my number, but the reference range goes to 100, but I just want it to be more [inaudible 00:08:10]-

Dr. Andy Roark:
Oh, gotcha. Okay.

Dr. Anna McManamey:
… if that makes sense. So, the SNAP test, the cutoff is 270, that’s the cutoff, picomoles per milliliter. So, if I get an abnormal BMP result in this cat, I’m going to say, “Your cat likely has structural heart disease.” The lameness, truly, it could be a musculoskeletal issue or a muscular issue, but it could have been a weird transient thrombotic event. So, you can decide, can I get this cat to a cardiologist quickly to make that final diagnosis, or am I going to hedge my bets and maybe even put this cat on a prophylactic blood thinner? Just because if it really is an ATE and we really get a high BNP result, the chances of that being from heart disease are much more likely. Otherwise, I would say we just need to get them seen by a cardiologist to determine what the severity of that heart disease is.

Dr. Anna McManamey:
If you take the lameness part out of this cat’s case altogether and you just took these radiographs as a screening for something else, same thing. If you get a high result, I’d say, “It’s time to go to the cardiologist,” if you get a normal result or a low result, I’d say, “The cardiac enlargement on radiographs is probably not significant for that animal.” There is still a chance, and I still think if that client is interested in a workup, always appropriate to refer, because we know that an echocardiogram is still the gold standard for diagnosing [inaudible 00:09:35] heart disease in a cat. But in that exact moment, having that tool to fall back on, I think is helpful.

Dr. Andy Roark:
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 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. One of them is all about charming angry clients, and the other one is all about building trust and relationships with vet owners.

Dr. Andy Roark:
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 5 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, a little team-building, educational activity that might make your people laugh. Anyway, I want you guys to know that that’s there, I hope that you will check it out. On Wednesday, August the 10th, my good friend, Senani Ratnayake, RVT is doing an Uncharted workshop. She is doing Believing We Can: Leading a Solution-Oriented Team. What do decision making processes actually look like in your practice?

Dr. Andy Roark:
Get your team to solve problems and find solutions with tips and tricks from this workshop. Guys, Senani is amazing at walking people through how to connect with their team, how to communicate positivity, how to get people in a positive and productive head space to move forward, and to solve their own problems. If you want that for your team, head over to unchartedvet.com, I’ll put a link down in the show notes, but get registered. It is on Wednesday, August the 10th, 8:30 PM Eastern time, 5:30 PM Pacific. It is $99 to the public. It is, as usual, almost always, free to Uncharted members. If you’re like, “Man, they do so many good workshops,” don’t forget to check out the Uncharted membership. I would love to have you in our community. I would talk to you if you were there, because we have a nice, vibrant, active community where we help each other. And if that sounds usual, check it out. All right, guys. And now, let’s get back into this episode.

Dr. Andy Roark:
Let’s just say that we run these tests, we run the proBNP, we do all the things. We get normal results back and we say, “Okay. Still big heart, but we’re not seeing these abnormal structural change markers,” things like that. Do you recheck that cat? Are you going to get this cat back in a year or six months and recheck, what does that look like?

Dr. Anna McManamey:
I think it’s a great question. I think the follow-up’s really important and we can’t forget it. So, I would say 6 to 12 months, I would recheck the same things.

Dr. Andy Roark:
Repeat the rads and compare them, obviously, to the previous year. All right. That totally makes sense to me. When we look at this, we said we’ll probably need to do an echo to get any insight into this. So, I practice in South Carolina and we talk a lot about heartworm disease and we talk about heartworm disease in cats. Is there anything else you would do to differentiate cause, other than the echo, which it seems like that’s cutting to the chase and just saying, “Hey, look, we know we have a large heart. We know we’ve got some abnormalities in here”? I guess I’m dancing around the obvious next step, which is we’re going to get an echo, but anything else that you would add or consider in that phase?

Dr. Anna McManamey:
Yeah. So, heartworm disease in cats is relatively different from the dogs, enough so that it’d be unusual, but not impossible, to see just a big heart from it. So, typically with cats, we look for changes in the lungs a little bit more so, but you could heartworm antigen and antibody test that cat. It’s important to remember to do the antibody test, as well, for cats. But you totally could do that, to just further rule out some things. A lot of practices are getting point-of-care ultrasounds. It doesn’t have to be the full echo machine, I have to be careful of what I say, but if you have a point-of-care ultrasound and you’re just trying to rule other things out, like paracardial fusion. Does this cat have a fusion around its heart and that’s why the cardiac silhouette looks big? If you’re skilled and have the equipment to do that, you could always do that. But again, like you said, the frustrating things, usually, they have to come get an echocardiogram for the definitive diagnosis.

Dr. Andy Roark:
I want to explore the connection that you mentioned early on, just because it’s always worth looking into potentially simple answers. I’ve got a cat that’s limping and a cat with a big heart, are those things related? So, we talked about the aortic thromboembolism as a possibility. When I go back and talk to the pet owners and I say, “Hey, we’ve got a large heart. We’ve done our proBNP’s SNAP test and I want you to go see the cardiologist,” and they say, “Well, okay. But what about the fact that his leg still hurts?” What do you talk about that? Are there things that you would do for pain management in the meantime? Are there ways that you would investigate that intersectionality and say, “Yes, I think that this limping and this heart disease are together,” or, “I’m strongly suspicious of it, I’m mildly suspicious of it, or I’m not suspicious of it”? How do you tease that apart to give them some guidance why the cat is still not fully weight-bearing?

Dr. Anna McManamey:
That’s a great question. So, with the lameness alone, I guess it goes back to what a classic ATE looks like, a classic aortic thromboembolism. It can be in any leg, so it can be just a front leg, so we just can’t forget, it doesn’t have to be the back legs. But the classic things are they’re painful-

Dr. Andy Roark:
I was going to say, screaming pain. I would expect to really hear about this.

Dr. Anna McManamey:
Yeah. They’re painful, but they’re painful for the short term. They are really painful at the beginning and then they lose that sensation over a day or two. They usually have some change to their blood flow, so sometimes you can pick it up because their limb is cold or they don’t have a palpable pulse, where you can’t get a Doppler blood pressure to work on that leg. I try to use my physical exam more so than doing the diagnostics of lactates and blood glucose. I can totally use those things, but then it involves you poking a cat and risk [inaudible 00:16:43] to try and do that. But I think the biggest things that help differentiate a vascular event from a neurologic or an orthopedic event is that temperature of the leg is probably the most important, and then, unfortunately, that lactate and blood glucose differential, those can be helpful. But we see cats that have this partial emboli, they go very transient and they’re just lame.

Dr. Anna McManamey:
And so, I think you have to keep it on your list for that client, but in that moment, you need to take care of that patient, so some type of pain management. Typically, if I know it’s an ATE, I’m going to use some type of an opioid, but tons of people will use Onsior, for example, so some type of an NSAID. That’ll work really well for your musculoskeletal pain. You can do gabapentin, that could work for neuromuscular or just in general pain, but you’ve got to do something for the comfort of the animal. In terms of, if I really think this cat could have had an ATE, the most important thing for me to do, aside from the current management, is trying to prevent another one from happening. And so, the somewhat good news is that a typical dose of Plavix or clopidogrel in a cat, at least short-term, is probably not the end of the world. So, I think it’s just risk benefit again, of that client, of that patient, talking to them about the importance of trying, it versus the side effects of doing so.

Dr. Andy Roark:
So, treat the patient in front of you was basically what I heard. I’ll be honest, when you said ATE, I kind panicked and I was like, “Oh my God,” and everything I know about thromboembolism went out the window. I just forgot everything, I was like, “Ah, what do I do?” I’m back into control now. I feel like if this was a severe thromboembolism, I would know it, I would see it. I would recognize what it was. I would feel the cat’s foot. I would do all the things. I’m back to being comfortable again. I’m like, “Okay.” It’s like when you have limping cat and the specialist says, “Well, have you thought about this horrific thing?” And you’re like, “No,” it was that. The panic moment has passed, I’m back in control. I feel good. Okay. I have a plan. I think I know where to go with this. I still don’t feel like I have a lot of clear advice for the owner, other than we’re going to work this up and if it’s abnormal, we’re going to go down this pathway. It sounds like we have to see what this is.

Dr. Andy Roark:
But we’re going to go along for the ride and investigate. Are there any final words of advice that you have, or things that I should say to the pet owner to set expectations for what’s coming? Just because they’re going to start on this path and we’re going to start a cardiology workup, is there things that they should know before they get into this?

Dr. Anna McManamey:
Cat heart disease is always going to be challenging, and so I think you don’t want to scare a client, without the need to, but it’s important not to overlook some of those even subtle things, like the cardiomegaly and the lameness, could those be correlated or not? And so, I think just being honest, just being open and saying, “Look, we screened, we haven’t found any significant evidence that supports severe cardiac disease, but this is something we’re going to follow-up with in the future, and we’re going to do it by a recheck blood pressure, a recheck diet and recheck BMP level.” Say, “In the future, monitor for recurrent lameness, monitor for any collapsing episodes, shortness of breath.” Anything like that, you know where you’re going to go first. And you already have your baseline diagnostics, which, honestly, is going to be really helpful moving forward with this cat.

Dr. Andy Roark:
Yeah. I completely agree. I’m not a big fan of scaring people, I don’t like that. And at the same time, I really do feel like a lot of pet owners blow off health risks of their cat. I think it’s because cats are stoic and hide pain and illness and things like that. But I think leaning a little bit more heavily into, “Hey, you need to understand this is going on and we’re going to follow up on it,” that makes a lot of sense to me, as opposed to just overcomforting like, “Oh, don’t worry about it,” because I’m worried I’m not going to get that cat back if I don’t impress that on them. Okay. Awesome. This is so helpful, I really, really appreciate it. Thank you so much for being here.

Dr. Anna McManamey:
Thank you for having me.

Dr. Andy Roark:
And that’s it, guys. That’s what I’ve got for you. Thanks again to Dr. Mac for being with me. I’m such a fan of hers. Gang, take care of yourselves. Be well, enjoy practice, keep learning and growing as doctors and technicians, because, gang, that’s all there is. It’s continued growth, it’s lifelong learning. All right. See ya, everybody. Bye.