Editor’s Note: This is an excerpt from Research Wrapped, a free monthly newsletter that collects the latest scientific research relevant to small animal veterinarians and pulls out practical takeaways. To be the first to receive this newsletter each month, subscribe here.
This month, Dr. Alison Manchester, an internal medicine specialist who focuses on gastrointestinal disease, weighs in on an interesting study published in the latest issue of the Journal of Veterinary Internal Medicine.
The study evaluates data collected retrospectively from 60 client-owned dogs diagnosed with chronic inflammatory enteropathy. Researchers looked at medical records at the time of diagnosis (intestinal biopsy), the initial response to treatment (time of first clinical improvement after diagnosis, according to owners), and at least 1 year after diagnosis. At those 3 time points, researchers assessed the categorization of chronic inflammatory enteropathy into food-responsive enteropathy, antibiotic-responsive enteropathy, immunomodulator-responsive enteropathy, and nonresponsive enteropathy.
Do the study’s findings align with your clinical experience? If not, what did you find most surprising?
Dr. Manchester: First, I want to say that I really appreciate that the authors collected all of this information, which is no small feat. It is important to have this long-term information to help clinicians navigate these cases long-term and set appropriate expectations for clients.
Many aspects concur with our clinical experience, including the high proportion of dogs that can improve their quality of life and achieve clinical remission with diet, the wide variety of diets that can help individual dogs, and the low doses of budesonide and/or prednisolone that may confer a clinical benefit. We also try to taper immunomodulatory drugs to the lowest effective dose.
In contrast to these findings (perhaps related to the strict antimicrobial prescribing rules in Europe), we may use antibiotics before immunosuppressive drugs and do see a persistent, yet small proportion of dogs that seem to “need” chronic antibiotics. We also use probiotics less frequently than these authors.
Do you recommend a client reevaluate their dog’s diagnosis and categorization of chronic inflammatory enteropathy at certain periods? More frequently or less frequently depending on a certain type?
Dr. Manchester: I suppose I have always been skeptical of these treatment response categories; I see them more as descriptors rather than official diagnoses. We have many studies that fail to differentiate these different treatment categories in terms of biomarkers, histologic lesions, and clinical signs. That is in line with our clinical experience in which many dogs require a combination of interventions that morph over time. Thus, regular follow-up (via phone, email, or in-clinic visits) is advised. We want to ensure we are controlling clinical signs to the best of our ability, screening for medication side effects, and tailoring interventions to what is most impactful for the patient and client. Practically speaking, I most often hear from clients with dogs that are not responding to interventions. And I am more adamant about having patients come back who are on medications associated with side effects. Luckily, much of the clinical monitoring can be done remotely via owner interviews, as was done in this study.
Editor’s Note: This article is an excerpt from the Research Wrapped monthly newsletter. Subscribe here for free.
Do you have any pointers, or cautionary words, for primary care veterinarians on how to manage a dog diagnosed with a chronic inflammatory enteropathy?
Dr. Manchester: One pointer would be that patience pays off. If your first attempt fails, try something else. However, I would caution against repeating the same thing and expecting a different result. If you find that your patient does not respond to a hydrolyzed protein diet, I probably would not reach for 3 other hydrolyzed protein diets as options 2, 3, and 4. As exhibited in this study, working with a client’s desires and abilities is key. (The authors noted that many owners seemed unenthusiastic about the prospect of “another diet trial.”) Also, note that a large percentage of dogs were on “other diets” at long-term follow-up (T≥1y). Because a dog improves on 1 diet does not necessarily mean it needs to be fed that single diet for the rest of its life. Keeping an open mind, as well as knowing what clients are willing and not willing to do, will ensure that you stay on the same team as the client.
What is the most important takeaway from this study for private practice veterinarians?
Dr. Manchester: My most important takeaways are that the importance of diet cannot be overstated and that there is no one-size-fits-all approach to these patients.
Is there anything you would like our readers to know that has not been mentioned?
Dr. Manchester: I would just reemphasize that there is no set cutoff in terms of disease severity or age at which a dog can be diet-responsive. Also, if things are not going well clinically (i.e., the dog is losing weight, seeming to feel worse, or having uncontrolled clinical signs despite your best efforts), further diagnostics such as GI endoscopy and biopsy are indicated.
The Study:
Long-term evaluation of the initial response to therapy in 60 dogs with chronic inflammatory enteropathy
Hodel S, Brugger D, Kook PH. J Vet Intern Med. doi.org/10.1111/jvim.17161