Wellness: Health Care
Excessive levels of steroids in the body leading to disease
Hyperadrenocorticism, known as Cushing's disease, is a hormone imbalance that results from excessive cortisol in the bloodstream over a long period of time. Cortisol is produced and stored in the adrenal glands, which are two little glands that “sit” on top of the kidneys and is what is released in times of stress, preparing for a “flight or fight” response. However, if this system goes awry, and a dog's body is exposed to this hormone for a majority of the time instead of just in times of stress, it can become chronically debilitating.
There are 3 main ways that a dog can get Cushing's Disease. The first way is from a tumor forming on the pituitary gland, and is known as Pituitary-dependent hyperadrenocorticism (PDH). These tumors are generally small and non-cancerous, although rarely a cancerous tumor can occur. The pituitary gland is located in the brain and is the “master gland” of the body. One of its jobs is to detect when cortisol levels are declining, and in response, secrete a stimulating substance, called ACTH, that kicks the adrenal gland into gear causing it to secrete more cortisol. When the body reaches normal levels of cortisol, the pituitary gland stops this message from being sent, and production is halted. In the case of PDH, a tumor causes the pituitary gland to go into overdrive, telling the adrenals to produce excessive amounts of cortisol, despite there already being too much in the body. This is the most common form of Cushing's and accounts for about 85% of dogs with disease.
Adrenal gland tumors are the next common cause, account for approximately 15% of dogs affected. This is a situation where a tumor is on the adrenal gland instead of the pituitary, and puts the gland into overdrive. The adrenals begin making excessive steroids all on their own, no longer “listening” to the pituitary when it tells the adrenals to shut off. These tumors are generally larger in size (usually detectable on ultrasound) and both cancerous and non-cancerous tumors are possible. Another problem that can happen with this type of tumor is that the pituitary “sees” that there is enough cortisol in the body, and subsequently stops producing ACTH. As a result, the other adrenal gland (the one without the tumor) becomes shrunken due to nonuse.
The last major cause is what is known as Iatrogenic Cushing's and is the result of the long-term use of steroids, or medications containing steroids. This is not from any inherent disease in the pet's system, but from the effects of the hormones given over the long term. Over time, the pituitary gland perceives that the body is getting enough steroids (thinking it is being produced from the adrenal glands-not knowing it is coming from medications) and quits sending its signal to produce more. In turn, the adrenal glands stop doing their job and also begin to shrink, temporarily loosing their ability to release cortisone on their own should their body require it to do so. This inability to produce steroids naturally in the body can last for several months following the stopping of medication. This is why your veterinarian will instruct tapering doses of steroids instead of an abrupt stop: this gives these important glands time to recover and begin working on their own again.
There are a multitude of clinical signs that can be seen, and as always, can mimic many other disease processes. Signs are generally gradual, and because of this, they are often attributed to “normal aging” and disregarded. The most common signs that are easily observed in pets by their owners are increased drinking and urination, increased appetite (a good reminder that eating well is not always a sign of normal health), a “pot-bellied” appearance, thin skin and sparse hair coat, blackheads and/or darkening of the skin, and loss of muscle mass or muscle weakness. Aside from these symptoms described, advanced or untreated Cushing's disease can also put a dog at risk for the development of bladder stones, diabetes and blood clots to the lungs.
If you notice any of these signs in your pet, a veterinary exam is in order. Your veterinarian can begin the process of testing for the disease, ensuring your pet is appropriately treated. If your veterinarian has reason to suspect Cushing's (based on history, physical exam and initial blood work), it will then be necessary to perform confirming blood tests and ideally, an ultrasound. This is not an easy diagnosis to make, and it requires several specific tests to positively identify not only the presence of Cushing's, but whether the problem is in the pet's pituitary or adrenal glands, as there is a different treatment for each form of disease.
The expected course of disease depends on which type of Cushing's is present, as well as response to treatment. PDH generally carries a good prognosis, and survival time for a dog treated with appropriate therapy is 2 years, with at least 10% of dogs surviving 4 years (this is better than it sounds, as dogs are generally diagnosed at an older age, usually 10-12 years old). Dogs with non-cancerous adrenal gland tumors usually have a good to excellent prognosis; those with cancerous tumors that have not spread can have a fair to good prognosis, making early detection important.
Other tips and sidenotes:
Wellness: Health Care
Dog? Check. Buccal swab? Check. Apply the latter to the former, inside of cheek. Rub for 10 seconds. Voilà. DNA collected.
Until fairly recently, the garden-variety dog owner could only wonder if potential problems lurked in her dog’s DNA. Now, however, it’s possible to know—maybe not everything, but at least the possibilities. Which can be kind of comforting, since it allows you to focus your anxiety where it might be more useful.
As dogs age, they display a number of signs similar to those experienced by aging humans, among them, loss of muscle tone and strength. And, like humans, those symptoms can be chalked up to simple aging. For the prone-to-worry among us, they can also be signs of something more dire, such as degenerative myelopathy, or DM (see Nick Trout’s column in the Spring 2013 issue for more on that).
For answers, we turn to our vets, and increasingly, to science. The Orthopedic Foundation for Animals offers much, much more than insights into a dog’s predilection for, say, dysplasia or subluxations. This nonprofit, which was incorporated in 1966 and began with the mission of evaluating and genetic counseling for those whose dogs were at risk of hip dysplasia, has evolved its objective: “To improve the health and well being of companion animals through a reduction in the incidence of genetic disease.” (They’re also including other companion animals these days, cats, for instance.)
So, when I started noticing hesitations and missteps in my large-breed, 14-year-old dog’s gait, I wasted no time. Going to the OFA website, I was able to request the DNA test for DM, pay for it online and have the kit sent to me. Once I received it, it was comparatively easy to do the cheek swab required (it would’ve been easier with just the tiniest bit more cooperation from the dog in question, but then, that would’ve been out of character). Some DNA tests require a blood draw, which needs to be done at a vet clinic, but many are equally reliable via cheek swab, which pretty much anyone can do at home.
The instructions were simple, as was the return. Within in days, I had a response from the University of Missouri’s Animal Molecular Genetics Lab, where the DNA was evaluated. I was glad to see that the test came back N/N, or no genetic markers for DM. But even if the results had been different, I would have at least known, and knowing is always better. Having this test done also meant I could provide my vet with one more piece of information that he could factor in to his diagnostic consideration.
Another benefit is that by having this sort of evaluation done, you—via your dog—are contributing to the larger body of knowledge on genetic diseases. The samples and associated information about the dog become part of a DNA repository, which may in the future provide answers to some of dogs’ more vexing health issues.
Wellness: Health Care
Q&A with Denis Marcellin-Little, DEDV
Denis Marcellin-Little is an orthopedic surgeon at the College of Veterinary Medicine at North Carolina State University. Over the last seven years, he has been pioneering a remarkable intervention for dogs with missing legs, giving them prosthetic limbs that are permanently attached to their bodies. In the procedure, known as transdermal osseointegration, Marcellin-Little implants one end of a titanium rod into whatever remains of a dog’s leg, attaching the metal directly to the bone. The other end of the metal implant attaches to an artificial foot. So far, he’s outfitted six dogs and two cats with these bionic limbs, and he’s currently preparing three more canines for the procedure. We caught up with Marcellin-Little to ask him what it takes to build a pooch a brand new leg.
Bark: How did you get interested in osseointegration?
B: What kinds of injuries or ailments have your osseointegration patients had?
B: We know each case is a little different, but what’s the general procedure like? When a dog gets one of these implants, what happens?
The patient will get a CT scan, a good orthopedic exam, maybe some radiographs. And then we get to work. We make implants that are customized to the patient—what we call “freeform implants”—that are designed to merge with the bone. The next time we see the patient, we will be ready to do the surgery. By then, we have rehearsed that surgery, we know the implant is a perfect fit on the bone. And then we will do our surgery. We prepare the tissues, then we place the implant on the bone, and then we reconstruct the soft tissues.
B: How do you attach the implant?
B: After the dog heals, you attach some sort of external foot to the prosthesis?
B: Some dogs get socket prostheses, which just slip on over their stumps. What’s the advantage of an osseointegrated prosthesis?
B: How do you think the procedure and approach will improve as time goes on?
One challenge would be to design a foot that is very ergonomic: it’s easy to put on and [take] off, it’s very stable when it’s on, it’s light, it’s strong, it’s wear-resistant, it has good traction. We could imagine that these things could become more sophisticated over time.
I foresee that the process will become more standardized; I also think that it will become more rapid. And, of course, we will know more about it. Right now, we don’t know much—it’s just one case here, four cases there. As you can imagine, the field can be greatly improved. I think it’s going to play a big role in medicine. I spend a lot of time and energy for a few patients that have very big problems, thinking that it will trickle down to other patients in the future. I would like people to know that there are options if a dog is missing a foot or two—or maybe three or four.
Wellness: Health Care
Emergency help only a phone call away
ASPCA Poison Control Center, 888-426-4435: 10 digits every dog owner should know!
A number of calls we receive in the ER are inquires about whether or not a substance is toxic to their pets. These inquires can include questions about specific pet or people medications, vitamins and supplements, both common and unusual household items, as well as various food stuffs.
With literally thousands of medications and oddities that our pets can get into, it becomes nearly impossible to know what is toxic, at what dose toxicity becomes a concern, and the treatment for each of these substances. Because of this, when we receive a call, we frequently refer pet parents to the Animal Poison Control Center for further information regarding the “dietary indiscretion.” This amazing service provided by the ASPCA is truly invaluable when there are questions or concerns about the potential for toxicity of any given substance. The center is staffed 24/7 by veterinary toxicologists who have at their disposal an expansive data base that includes every imaginable substance ever to have been known to meet a dogs mouth.
There is a nominal fee of $65 for this service, but a call might actually save you a trip to the ER or to your veterinarian, as well as give priceless peace of mind. When you call from home, you will actually be able to find out whether or not your pet needs medical attention, if you can induce vomiting at home (this becomes especially important for those people who live far away from veterinary care), or if you can potentially give some other home treatment. At the completion of the call, owners are given a case number that can be referenced again later should your pets condition change or clinical signs develop. If your pet does happen to need medical attention, once you arrive at the hospital for treatment, your veterinarian can call the center, also referencing this number, and can continue your pets care based on the toxicologist's recommendations.
This is truly priceless information, especially considering all the misinformation you can come across during a consult with Dr. Google. In fact, I have had to treat pets whose condition actually worsened because of an inappropriate treatment given at home. A situation that comes to mind was a good-intentioned owner who induced vomiting at home, based on what she read, after her dog ate Tide laundry detergent. Detergents can be very caustic (making vomiting a big no-no) and her dog subsequently suffered from erosive ulcers along the entire length of its esophagus as a result. Her pup required the placement of a feeding tube to bypass the esophagus, allowing it to heal.
I would also like to add that part of our responsibility as veterinarians is to call back the toxicologist and report the response to treatment. This follow-up information continues to help others in the future as each toxic exposure, treatment and response to treatment gets added and stored in the ever-growing data base.
I cannot say enough good things about this invaluable pet resource. Every pet owner should have the ASPCA Poison Control number (888-426-4435) on their speed dial or refrigerator—this number may save your pets life as well as help other pets in the process.
Wellness: Health Care
What would you give to be able to spend another month, another week, or just another precious day with your best friend? Anyone who has ever loved and lost a pet has probably had such a wish.
Pets are no longer just pets; they fill the role of family, child, companion and guardian. As such, their dying process can carry a burden equal to the loss of our two-legged loved ones, and it is during this time that both pets and their people can benefit from animal hospice. Hospice allows our pet’s final journey to be experienced with dignity while surrounded by love in the familiarity of their home. It allows our pets to live out the remainder of their lives as fully as possible until the time of death, whether a “natural death” or compassionate euthanasia is elected.
As with human hospice, animal hospice exists to provide support and care for pets in the last phases of incurable disease or at the natural end of their lives. It helps facilitate the availability of resources to educate, support comfort care, manage pain and allow for a good quality of life, whether that is days, weeks or months. Hospice care also grants pet parents time to plan, grieve and say good-bye to their companions while providing a way for them to bring their pets home for their final days instead of being in the confines of a hospital setting or an unfamiliar exam room.
These are just a few reasons why I feel hospice care is so incredibly important and why it has always resonated with my heart. Prior to my veterinary career, I worked as a registered nurse, and it was during this time that I was first exposed to the concept of hospice care. Over the past several years, I have found myself drawn back to these roots, and have since started a pet hospice service within the referral hospital where I practice emergency medicine.
To highlight what a difference hospice care can make to a pet and a family, I would like to share the story of my first hospice patient, Sunny, who was one of the most loving and happy girls I have ever met. She quickly earned the nickname “Kissy Girl,” as I couldn’t be within a tongue’s length of her lest I be the receiver of her spirited attempts to lavish an endless stream of wet and cold-nosed kisses on me.
Our paths first crossed during a typical Sunday in the ER. As I was getting ready to see my next patient, who was having trouble urinating, I thought: diagnosis, UTI. But during the physical exam, my heart sank as I realized that the source of her straining to urinate was not an infection, but rather, a tumor that was compressing her urethra. An ultrasound revealed that it was inoperable, and chest X-rays confirmed that the cancer had already spread to her lungs. Looking at that sweet and happy face, you would never guess that all that badness was living inside her.
Bad turned to worse when I found out that Sunny’s dad, Jeff, was in another state attending his own father’s funeral. Besides the devastating news of her cancer, the most difficult thing for Jeff to endure was the fact that he would not have a chance to say goodbye, nor be by her side when she passed away. He was torn: in his heart he wanted to be with her once more, while in his mind, he did not want to delay the inevitable and risk her being in discomfort. This broke my heart, and I shared his sense of helplessness.
My hospice service wasn’t set to officially begin until the following month, but I could not let Sunny pass without her dad having had the chance to see her just one more time. I offered a hospice situation for her, and helped her by placing a catheter so she could urinate despite the tumor. Jeff took a red-eye flight home that very night and reunited with her the following morning. She erupted in sheer joy the moment she saw her dad, and Jeff easily learned how to manage her urinary bag.
Hospice care allowed Sunny to have another amazing week at home—one that included heaps of love, trips to the park and her favorite beaches, and a doggy party where filet and ice cream were served. It also allowed Jeff time to return home, spend more quality days with her and begin the process of saying good-bye to his best friend.
At the end of the week, I spent an incredible afternoon with Sunny’s family, celebrating and toasting her life, as well as getting more of those famous kisses. I helped her cross the Rainbow Bridge from her favorite sunshine-filled spot in the back yard, surrounded by those who loved her. You see, Sunny was not just “any dog”: she was also the rock who helped Jeff through the death of his first wife due to cancer.
As I reflect on my life’s path, it seems strangely paradoxical: I spent the first eleven years of my veterinary career doing everything possible to save lives in an ER setting, and now I am working just as fervently to end them as beautifully and as peacefully as I possibly can.
I am often asked, “Aren’t you always sad? Isn’t this just so difficult to do?” The short answer to this multi-layered question is “yes,” and in fact, I still cry during every euthanasia. Although it can be a heart-wrenching journey to take with another, it is through these experiences that my life becomes more blessed and made richer. For what people often don’t realize is that my tears well from being in the midst of great love, from experiencing the tremendous bond between family and pet, and from being able to give another the precious gift of good-bye.
Wellness: Health Care
A bacterial disease that's spreading
Leptospirosis is a bacterial disease of great importance as it can affect both humans and animals, and can readily be spread from one species to another (i.e., from our dogs to us). For many years the occurrence in pets was rare, however, in the past few years, the disease has become diagnosed more frequently-I myself have treated four dogs suspected of having Leptospirosis just this past year. The disease is caused by a bacteria that is spread through the urine of infected animals into the soil and water where it can survive for up to 180 days, given the right conditions. Then, as other animals come in contact with this contaminated area, the bacteria can then be taken up through their skin and mucus membranes (gums, nose, eyes) or through drinking the contaminated water (another reason to stay clear of puddles!).
There are several environmental factors conducive to letting this bacteria flourish and increase risk of exposure. Warm, moist environments favor this bacteria, and they especially love stagnant water. With that being said, Leptospira do need water or damp soils to survive, and they will rapidly die on dry surfaces. The density of animal population, such as kennels and urban settings, also increases urine contamination and thus exposure. Also, areas that are heavy populated with rodents or wildlife also increases risk; they serve as “innocent hosts” meaning they are not affected by disease, but they continue to spread it to the environment through urination.
The clinical signs of disease can be vague and mimic many other disease processes. Signs can include fever, lethargy, loss of appetite, muscle stiffness or soreness, or vomiting and diarrhea to name a few. If the liver is involved, a yellowish discoloration of the gums or whites of the eyes can also be observed. Because Leptospirosis can look like any other disease, confirming the infection is generally not an “ah ha!” diagnosis when your pet walks into the exam room. This is something I tend to diagnosis by a “second round of tests” when the initial blood work and urinalysis look suspicious for disease. What can raise a suspicion of a Leptospira infection is an elevation in both kidney and liver values and sometimes the white blood cell count. If this is observed, your veterinarian will then recommend a special blood and urine test be sent to an outside laboratory. These results can take several days, and so antibiotic treatment is often started prophylactically pending the confirming results.
Most infections are subclinical, which means no signs of disease will ever develop and your pet will never experience illness. However, if your pet does develop sudden signs of disease, and those signs appear severe, we generally give a guarded prognosis (50/50 chance of survival). If your pet becomes ill, the extent of care needed depends on the severity of disease, but in my personal experience, the treatment generally requires a hospital stay with extensive supportive therapy. Without treatment, Leptospirosis can lead to kidney failure, liver failure, and even death. Blood or plasma transfusions are sometimes needed if the body losses its ability to clot due to liver compromise. Yes: this can be one bad bug.
So, how can you keep you and your pets safe? In addition to good sanitation practices and limiting your pets access to areas with standing water, there is a vaccine available. Vaccines contain what are known as “serovars,” which are “components” of the bacteria used to stimulate protection from disease. However, there is a catch. There are at least nine serovars, or strains, that can cause disease, yet the vaccine contains only a fraction of these, offering incomplete protection. Often people think their dog is safe from disease because it has been vaccinated, but sadly, this is not the case. Additionally, immunity may only last 6-8 months, and some veterinarians recommended that you should vaccinate high-risk dogs (such as dogs who hunt, show dogs, dogs with access to lakes and ponds, and endemic areas) every 4-6 months. Vaccines do not come without risk, and the use of this vaccine with regards to risk vs. benefit is definitely a conversation to have with your veterinarian. Your veterinarian can assess your dog's risk of exposure, discuss the most common “local” serovars found in your specific area and can recommend a vaccine protocol that makes sense for your pet.
Wellness: Healthy Living
Scratch, scratch, scratch....
The sound of Cricket's toenails digging into his belly woke me last night at 3:00 AM. How annoying. The little guy has a flea, and that means today's bath day. Our dogs recognize the bath day ritual pretty quickly. When their beds get stripped and everything goes into the washing machine, they both get that worried look. Then when I put on the red running shorts, they know the time has come. In the past, Cricket - the little scamp - would try to flee and we'd have to chase him down, corner him, scoop up his 30 pounds of indignation, and carry him into the shower. Kanga had a more Gandhi-esque approach to the whole thing. She would curl up on the couch and refuse to move. Since she weighs a full 60 pounds, we'd sometimes practically need a crowbar to get her up and prod her toward the bathroom. Now they seem to recognize the inevitability, so both dogs come - heads hanging low - and submit to the indignity. Afterwards they cavort in gleeful joy for having survived yet again. That night Cricket asks to hop up on the bed, and sometimes we let him because he's so clean, fresh and fluffy...not to mention cute.
Lots of people ask me how to control fleas on pets, and as a pet owner I can relate. I hate fleas. But a trip to the pet store can be a bewildering experience, with all kinds of pesticide products on the shelves marketed to protect our best friends from vermin. Over the past year or so, my team of researchers at NRDC has been looking at these products and we've learned a few things that made me go with my current shower plan.
First of all, just because a pesticide is legally on the shelves doesn't mean it's safe. Many of these products contain potent chemicals that can have adverse effects on pets and kids. I'm especially concerned about flea collars because many of them contain really toxic chemicals - such as tetrachlorvinphos and propoxur - that should probably not be on the market anymore. The collars are designed as a 'slow release' device for the pesticide, and spread a pesticide residue across the animal's fur for weeks. That's fine unless you ever touch your pet. The problem is that the residue gets on your hands (or worse still children's hands) and then can be absorbed through the skin or accidentally ingested.
Even some of the "natural" flea control products can be a problem, since some of these chemicals can cause allergic reactions such as dermatitis and even asthma in sensitive people. There are lots of products out there, but we found relatively few that we can really recommend as safe. For information about specific flea control products that you use, check out the product guide on the "Green Paws" website.
In medical school, I took a course on the history of medicine. I learned the disgusting fact that in the past people were routinely infested with vermin such as lice and fleas. All kinds of chemicals, including DDT, were used for de-lousing humans even within the past 50 years. Fortunately, vermin on people isn't generally a problem in the United States today. That's because most of us bathe and wash our clothes on a regular basis. So why not apply this same rule to our pets? In my house, every two weeks, the dogs get a bath and all of their bedding gets cleaned. Every week the carpets get vacuumed well to remove any possible flea eggs. Guess what - it works! Every so often one of them picks up a flea at the dog park, but as soon as we see the scratching, out comes the flea comb, and that little blood sucker is soon drowned in a cup of soapy water. It's really easy once the whole family has the routine down. And it's great to have dogs that smell and feel clean. Better still, it's great to have dogs that aren't covered with a toxic residue.
This article originally appeared on Gina Solomon's Blog on Switchboard, from the NRDC website, in Oct 2008.
Wellness: Health Care
Old Dog Senility
Cognitive Dysfunction Syndrome, also referred to as “old dog senility” or “sundowner syndrome” is a common syndrome that is categorized as a slow, degenerative and progressive disorder in our aging pets. This process leads to changes in awareness, a decreased responsiveness to normal surroundings, and potentially increased signs of anxiety that usually worsen in the night hours.
There are many signs observed with cognitive changes and they can be lumped into some general symptoms as follows:
The above changes generally begin very gradually, so much so, that many pet parents fail to recognize the early stages of the disease and often attribute their pets subtle alterations in behavior to “simply getting older.” A recent study at the University of California School of Veterinary Medicine demonstrated just how common these observations are: out of 69 dogs participating, 32% of the 11-year old dogs were affected by this syndrome and 100% of the dogs 16 years of age older were affected (source: Veterinary Information Network).
The exact reason for this change in our geriatric pets is unknown, but it is thought that the body’s normal degenerative and age-related changes contribute to the dysfunction. These changes include central nervous system deterioration, oxidative stress, accumulation of free radicals, and cell death. Signs are unfortunately progressive and treatment is aimed at prevention and/or slowing the progression of disease for which lifelong therapy is required once diagnosed.
Treatment is the utilization of a multi-modal approach to managing signs, meaning, a combination of synergistic therapies that are based on the severity of the clinical signs. Selegiline is a prescription medication that is used to help control more severe symptoms, and it is thought to improve transmission of brain chemicals (dopamine) as well as have protective effects on the brain’s nerve cells.
There has also been the development of commercial and prescription “senior diets” that have demonstrated improvements in cognitive function, such as Hill’s b/d ("brain diet"). Natural supplements have shown promise in managing signs and slowing the course of disease by reducing the neurological damage caused by free radicals.They include antioxidants (vitamins C and E, selenium, flavonoids), gingko bilboa, Omega-3 fatty acids, and medium chain triglycerides to name a few. Pheromone therapy and melatonin may ease anxiety and promote a feeling of well being for dogs that experience increased anxiety at night. And finally, environmental enrichment such as brisk brushing sessions, massage therapy, interactive toys, and stimulating walks is thought to be an important cornerstone in slowing the progression by stimulating brain activity. Maintaining a stimulating environment, and engaging in as much activity as is practical for your pet’s age and health, may help prevent or delay the onset of cognitive decline as your pet moves into its golden years.
I will end with one of my favorite veterinary mantras, which is: “Old age is not a disease” (for which I am personally more thankful for each day), and with proper care, our senior “babies” can go on experiencing a good quality of life as cognitive changes develop.
Wellness: Health Care
A Kinder Cut? Advances in spay procedures
As a colleague of mine once said, “a spay is a procedure routinely performed, but it is not a routine procedure.” In the U.S., “spay” refers to the surgical removal of the ovaries and uterus. In Europe, however, removal of just the ovaries (ovariectomy) appears to be the most popular sterilization technique. Why are my European colleagues doing things differently, and is there evidence to suggest that they’re right? Is it possible to achieve the same surgical result using a less-complicated, less-involved procedure?
It’s been proven that an ovariectomy, which can be done via laparoscopy (or “keyhole” surgery), requires a smaller incision. Still, to date, no one has proven that removing both the uterus and the ovaries is more painful than taking just the ovaries, and no one has compared complication rates between the two surgical techniques.
However, other aspects have been assessed. In the Journal of the American Veterinary Medical Association, Michael DeTora, DVM, and Robert J. McCarthy, DVM, MS, DACVS, examined the two approaches.* Judging by their report, removing only the main hormone producers — the ovaries — has a lot going for it. Here are a few of their leading points.
One of the big benefits to spaying is the decreased incidence of mammary gland tumors, the most common tumor in female dogs. Sterilize before the first heat and your dog is 200 times less likely to develop breast cancer when compared to a sexually intact dog. Taking or leaving the uterus will not change this risk; rather, the benefit comes from removing the ovaries and their sex hormones.
It has been argued that there are two important reasons to remove the uterus. The first is the risk of developing pyometra, a uterine infection. Typically, pyometra occurs in dogs who have not been spayed and is attributed to the long-term influence of sex hormones, particularly progesterone, produced by the ovaries. In a study of 135 dogs, 66 had a regular spay and 69 had only the ovaries removed. There were no episodes of pyometra in either group up to 11 years after the surgery. In other words, leaving the uterus does not mean your dog will get a uterine infection. Remove the ovaries and you remove the source of progesterone, which means that pyometra cannot occur.
The second concerns the risk of leaving a redundant organ behind, potentially exposing the dog to a future uterine tumor. This appears reasonable until you consider that uterine tumors are extremely rare. In one study, just 11 of nearly 35,000 female dogs had a tumor of the uterus, and only one of these was cancerous. Benign uterine tumors are slow growing, don’t spread to other organs and are easily cured with surgery. The chance of your dog succumbing to uterine cancer is a lot slimmer than your lifetime risk of being killed in a car crash.
This leaves urinary incontinence, one of the most frustrating side effects of spaying. Reportedly, as many as one in five sterilized female dogs will have a tendency to dribble urine after surgery. Exactly why this happens is poorly understood, but the presence or absence of the uterus appears to make no difference.
As a veterinarian, one of my most important roles is to help owners make informed health-care decisions for their companion animals. Evidence-based medicine suggests that there is no recognized disadvantage to taking just the ovaries and leaving the uterus behind. Though inertia is always the biggest barrier to change, I may have a chance to influence the choice when asked the time-honored question, “What would you do if this were your dog?”
“Easy. Take the ovaries. Leave the uterus.”
Wellness: Healthy Living
Greater choice made available to pet owners
As politicians and voters squared off this fall, a little bill sat in committee on Capitol Hill, awaiting action that in all likelihood won’t happen. If it expires, it will probably be reintroduced at the next Congressional go-around in 2013. But even if it dies on the vine, the bill has opened debate on an issue that affects virtually every pet owner — the cost and availability of veterinary medications — and promises to keep the discussion going for years to come.
If passed, the legislation (officially known as HR 1406: Fairness to Pet Owners Act of 2011-IH) will require vets to give clients a written copy of all prescriptions. It also will require them to notify clients, in writing, of the client’s option to have the prescription filled elsewhere, and to confirm (via fax or other means) any prescriptions sent to outside pharmacies. This is not a novel concept; a majority of veterinarians already do this for those who request it. The act would, however, make it mandatory for vets to provide the prescriptions without being asked.
The bill is modeled on the Fairness to Contact Lens Consumers Act of 2003, which required eye doctors to give their patients a copy of their prescriptions, thus breaking the medical monopoly on those lucrative little bits of polymer. This “prescription portability” was credited with changing the entire contact-lens market, giving consumers freedom to comparison shop (making prices more competitive) and also improving the quality and safety of the products themselves by streamlining the supply chain and distribution system. In the world of veterinary medicine, prescription portability would, at least in theory, reassure bargainhunting consumers that they’re shopping around in a truly open (and safe) marketplace.
HR 1406 was introduced April 2011 under the sponsorship of Representatives Jim Matheson (D-UT) and Lee Terry (R-NE) and was immediately sent to the Health subcommittee of the House Committee on Energy and Commerce, which must approve the bill before it can be voted upon by Congress. But because 2012 is an election year — one that most certainly hasn’t been dominated by debates over pet prescriptions — few observers predict any action. The legislative monitoring service GovTrack gives the bill a 1 percent chance of passing before the end of the 2012 session; not great odds, obviously, but not particularly bad, either, given that only about 4 percent of the bills introduced in 2009–2010 were enacted.
“Most often, bills like this take five to seven years to get passed,” says Andrew Binovi, federal legislative manager of government relations for the ASPCA, which is supporting the bill. Alyson Heyrend, communications director for Rep. Jim Matheson, adds, “There is no action expected on the bill before the end of the session — it’s an election year. But we’ll most likely be reintroducing the bill next time. It’s a good bill, good for pet owners, good for consumers. In this economy, every little bit helps, and lots of people aren’t even aware that they have options when it comes to pet medications.”
A Pocketbook Issue
Like everything else in Washington, the Pet Owners Act has both fans and foes. According to the Center for Responsive Politics, eight organizations are registered to lobby on HR 1406, including Walmart and the National Association of Chain Drug Stores. “This bill allows consumers a choice when it comes to prescription medications for their pets, and Walmart supports efforts that give our customers a say where they purchase medicines and enable them to save money,” says Molly Philhours, a media relations rep. This support is hardly surprising, as the act would be a boon for Walmart and other big retailers, drug and grocery stores, says David Sprinkle, research director for Packaged Facts, a market research firm. “What we’re seeing is a natural progression, as the pet-health market moves toward greater parallelism with human healthcare.”
However, the number of pets covered by health insurance is miniscule, arguably making the out-of-pocket cost of a pet’s prescription drugs an even bigger concern for consumers than their own meds. “Less than 1 percent of the cats and dogs in America are insured, so this is a huge issue for owners,” says Laura Bennett, CEO of Embrace Pet Insurance. “Even if this bill doesn’t go through, it’s already had a big impact.”
Bones of Contention
The proposed legislation has another downside for vets: loss of revenue. While the impact will vary among individual practices, Morgan says, most veterinarians today make between 14 and 28 percent of their income from in-house drug sales. In addition, vets typically charge fairly high mark-ups, an average of 129 percent over wholesale, according to the American Animal Hospital Association. Many also charge a “dispensing fee,” typically an average of $9 per script. Morgan adds that the proposed law would drown vets in paperwork, and require clinic staff to spend an inordinate amount of time communicating with outside pharmacies. Most veterinarians will be forced to pass those extra expenses on to their clients.
Until fairly recently, veterinarians were the sole source for prescription pet medications. But with the advent of online pet pharmacies, such as Drs. Foster and Smith (which began selling medications and other pet care products through its catalog in 1983 and online in 1998), price-conscious owners started taking their drug business elsewhere. And in 1994, with the passage of the Animal Medicinal Drug Use Clarification Act (AMDUCA), veterinarians could prescribe certain approved human drugs for animals. In many cases, this gave veterinary clients an option to choose between the animal and the human drug, and to buy those drugs from outside pharmacies.
But this just means that vets are behind the times when it comes to setting their prices, says Bennett. She notes that many veterinarians deliberately undercharge for some services to keep clients happy; like restaurateurs who exponentially mark up the wine they sell to make up for value-priced entrees, these vets count on the sale of medications to make the balance sheet work. “If you’ve been relying on drug sales all this time, this is a wake-up call,” she says.
Competition — and Choices
All of these outlets offer incentives to pet owners. Kroger, for example, sells a long list of generic pet drugs, including some of the most-prescribed for dogs — pain-relievers like tramadol and meloxicam and antibiotics like amoxicillin and cephalexin — at $4 per 30-day supply. Target’s PetRx program, available in more than 1,200 of its instore pharmacies, can fill veterinary prescriptions for animal-specific medications, and all Target pharmacies will fill pet scripts for human drugs (they offer many $4 generics, as well). At Walgreens, you can add your dog to your $35-a-year family membership in the discount pharmacy program. With that, you get reduced prices on pet prescriptions and access to over 400 generic medications priced at $12 for a 90-day supply. Stop ‘n Shop and Winn-Dixie stores fill human-equivalent scripts, and have arrangements with online pet pharmacies to get your dog’s meds to you in one to two days.
For those who’d rather shop online, there are currently 18 web-based pet pharmacies accredited with the National Association of Boards of Pharmacy through its Veterinary-Verified Internet Pharmacy Practice Sites (Vet-VIPPS) program, each of which has its own offers and incentives. (There are also countless websites that aren’t accredited — or properly licensed — which the Food and Drug Administration and other groups strongly suggest you avoid.)
All this competition is good news for consumers, says ASPCA’s Binovi, because it guarantees that pet owners will be able to fill prescriptions as cheaply as possible. “There are big benefits here for both pets and their guardians,” he says. “It’s not that the veterinarians were a problem, just that this bill would harmonize all the different state laws to guarantee that everyone has better access to these medications.”
Keeping the cost of pet ownership down is especially important in this economy, he adds. “We know that economics weighs into the decision to adopt an animal and even, in some cases, to surrender an animal to a shelter.” There are no statistics on the number of owners citing the high cost of prescription drugs — or any other expense associated with keeping a pet — as the reason for surrender, but it’s not a great leap to suggest that someone who’s facing serious financial problems might see the family dog as an expense that could be eliminated. And even for an owner who’s not in dire straights, every little bit helps. “It’s always good to have more choices and better access, no matter what you’re buying,” he says.
You can verify an online vendor’s Vet-VIPPS standing on the NABP website: nabp.net.
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