Effect of oral or injectable supplementation with cobalamin in dogs with hypocobalaminemia caused by chronic enteropathy or exocrine pancreatic insufficiency.

BACKGROUND: Recent studies have shown similar efficacy of oral supplementation of cobalamin compared to injectable supplementation in dogs, but few prospective, randomized studies have been published. OBJECTIVES: To evaluate efficacy of oral or injectable supplementation with cobalamin in normalizing serum cobalamin and methylmalonic acid (MMA) concentrations in dogs with hypocobalaminemia caused by either chronic enteropathy (CE) or exocrine pancreatic insufficiency (EPI). ANIMALS: Forty-six client owned dogs with hypocobalaminemia. METHODS: Prospective randomized clinical trial. Dogs were divided into 2 groups (CE or EPI), and randomized to receive oral or injectable supplementation of cobalamin. Each dog had 3 visits and serum cobalamin and MMA concentrations were measured at each visit. RESULTS: In dogs with CE, serum cobalamin concentrations increased with oral (P = .02; median 149 [range 149-231] to 733 [166-1467] ng/L, median difference 552 [95% CI: 181-899] ng/L) or injectable (P < .01; 168 [149-233] to 563 [234-965] ng/L, 367 [187-623] ng/L) supplementation. In dogs with EPI, serum cobalamin concentrations increased with oral (P = .01; 162 [149-214] to 919 [643-3863] ng/L, 705 [503-3356] ng/L) or injectable (P = .01; 177 [149-217] to 390 [243-907] ng/L, 192 [89-361] ng/L) supplementation. Serum MMA concentrations decreased with oral or injectable supplementation in dogs with CE, but only with oral supplementation in dogs with EPI. CONCLUSIONS AND CLINICAL IMPORTANCE: Oral supplementation is an alternative for cobalamin supplementation in dogs with hypocobalaminemia caused by CE or EPI.

Effects of oral cobalamin supplementation on serum cobalamin concentrations in dogs with exocrine pancreatic insufficiency: A pilot study.

The objective of this retrospective study was to evaluate serum cobalamin concentrations before and after oral cobalamin supplementation in dogs with low serum cobalamin concentrations and exocrine pancreatic insufficiency (EPI). Eighteen dogs with serum trypsin-like immunoreactivities between <1.0-2.7 µg/L (reference interval, 5.2-35 µg/L) and serum cobalamin concentrations ≤350 ng/L (reference interval, 244-959 ng/L) were enrolled. All dogs were treated with oral cyanocobalamin according to a previously described protocol (0.25-1.0 mg daily, depending on bodyweight). Median (range) serum cobalamin concentrations at inclusion was 188 ng/L (<111-350 ng/L), which increased significantly to 1000 ng/L (794-2385 ng/L; P < 0.001) after cobalamin supplementation for 19-199 days (median, 41 days). Oral cobalamin supplementation is a potential alternative to parenteral supplementation in dogs with EPI.

Serum concentrations of lipid-soluble vitamins in dogs with exocrine pancreatic insufficiency treated with pancreatic enzymes.

BACKGROUND: In humans, exocrine pancreatic insufficiency (EPI) is associated with deficiencies in lipid-soluble vitamins. Little is reported regarding lipid-soluble vitamin status in dogs with EPI. HYPOTHESIS/OBJECTIVES: Compare serum concentrations of retinol, 25-hydrocholecalciferol (25OHD), and α-tocopherol among dogs with EPI, those with subclinical EPI (sEPI), and healthy dogs. Detect associations between serum concentrations of lipid-soluble vitamins and residual clinical signs in treated dogs with EPI and sEPI. ANIMALS: Twenty dogs with EPI and five dogs with sEPI receiving pancreatic enzyme replacement therapy. Ten healthy dogs sampled before and after 10 days of pancreatic enzyme supplementation. METHODS: Case-control study. Serum retinol and α-tocopherol concentrations were measured by high-performance liquid chromatography. Serum 25OHD concentrations were measured by radioimmunoassay. RESULTS: Serum retinol concentration was significantly lower in dogs with EPI (median, 490 ng/mL; range, 322-990 ng/mL) and serum α-tocopherol concentration was significantly lower in dogs with EPI (median, 11.51 µg/L; range, 4.8-27.1 µg/L) and sEPI (median, 12.66 µg/L; range, 10.21-21.03 µg/L) compared with healthy dogs (median, 1203 ng/mL; range, 637-1768 ng/mL and median, 43.54 µg/L; range, 34.26-53.97 µg/L, respectively). Dogs with weight loss had significantly lower 25OHD (mean, 243.50 nmol/L; standard deviation [SD], 3.54 nmol/L) than dogs with stable weight (314.0 nmol/L; SD, 138.38 nmol/L). CONCLUSIONS AND CLINICAL IMPORTANCE: Altered homeostasis of lipid-soluble vitamins is present in dogs with EPI and sEPI, despite enzyme replacement therapy. Additional studies are needed to determine the clinical relevance of these findings and the therapeutic potential of lipid-soluble vitamin supplementation in dogs with EPI and sEPI.

Feline Exocrine Pancreatic Insufficiency: A Retrospective Study of 150 Cases.

BACKGROUND: Little information is available about the clinical presentation and response to treatment of cats with exocrine pancreatic insufficiency (EPI). OBJECTIVES: To describe the signalment, clinical signs, concurrent diseases, and response to treatment of cats with EPI. ANIMALS: One hundred and fifty cats with EPI. METHODS: Retrospective case series. RESULTS: Questionnaires were sent to 261 veterinarians, and 150 (57%) were returned with data suitable for statistical analysis. The median age of the cats with EPI was 7.7 years. The median body condition score was 3 of 9. Ninety-two of 119 cats (77%) had hypocobalaminemia, and 56 of 119 cats (47%) had increased and 6 of 119 cats (5%) had decreased serum folate concentrations. Clinical signs included weight loss (91%), unformed feces (62%), poor hair coat (50%), anorexia (45%), increased appetite (42%), lethargy (40%), watery diarrhea (28%), and vomiting (19%). Eighty-seven cats (58%) had concurrent diseases. Treatment response was reported to be good in 60%, partial in 27%, and poor in 13% of 121 cats. Trypsin-like immunoreactivity <4 µg/L was associated with a positive response to treatment (OR, 3.2; 95% CI, 1.5-7.0; P = .004). Also, cobalamin supplementation improved the response to treatment (OR, 3.0; 95% CI, 1.4-6.6; P = .006). CONCLUSIONS AND CLINICAL IMPORTANCE: Exocrine pancreatic insufficiency in cats often has a different clinical presentation than in dogs. The age range for EPI in cats is wide, and many cats can be ≤5 years of age. Most cats respond well to appropriate treatment for EPI, and cobalamin supplementation appears to be necessary for a good response.

Manual ventilation therapy and aggressive potassium supplementation in the management of respiratory failure secondary to severe hypokalaemia in a cat with exocrine pancreatic insufficiency.

A domestic shorthair cat was referred for progressive muscle weakness and dyspnoea. The cat had a 2-month history of severe weight loss, small intestinal diarrhoea, polyphagia and polyuria/polydipsia. Biochemical analysis and venous blood gas evaluation revealed severe hypokalaemia [1.7 mmol/l; reference interval (RI): 3.5-5.1 mmol/l] and hypoventilation (partial pressure of carbon dioxide = 68 mmHg; RI: 34-38 mmHg). Aggressive potassium supplementation was initiated. The cat was manually ventilated until serum potassium increased to 3 mmol/l. A diagnosis of exocrine pancreatic insufficiency (EPI) was made based on clinical signs and serum feline trypsin-like immunoreactivity (0.1 µg/l; RI: 12-82 µg/l). Medical management of the EPI resulted in clinical recovery.

Exocrine pancreatic insufficiency in the dog: breed associations, nutritional considerations, and long-term outcome.

Canine exocrine pancreatic insufficiency (EPI) is an alimentary tract disorder causing malabsorption and debilitations in affected individuals. This article covers predisposing factors to EPI and response to therapy. Although relatively easy to diagnose, knowledge of breed predispositions (and also of those breeds where the disease is less common) can guide the clinician. Numerous studies have examined therapy for EPI, and a key finding is the variability in response among affected dogs. This implies that close monitoring and individual tailoring of therapy is needed to maximize the chance of success. Important factors affecting outcome are the choice of enzyme preparation, presence of hypocobalaminemia, and the response to the first 2 to 3 months of therapy.

Exocrine pancreatic insufficiency in the cat.

Exocrine pancreatic insufficiency (EPI) is a syndrome caused by an insufficient amount of pancreatic digestive enzymes in the small intestine. Clinical signs most commonly reported in cats with EPI are weight loss, loose and voluminous stools, steatorrhea, polyphagia, and in some cases a greasy soiling of the hair coat in the perianal region. Serum feline trypsin-like immunoreactivity concentration is the diagnostic test of choice for the diagnosis of affected cats. Treatment of cats with EPI consists of enzyme supplementation with either a powdered pancreatic extract or raw pancreas. Most cats with EPI also have severely decreased serum cobalamin concentrations and may require lifelong parenteral cobalamin supplementation. Most cats respond well to therapy and can have a normal life expectancy and quality of life.

Hyperammonaemia due to cobalamin malabsorption in a cat with exocrine pancreatic insufficiency.

A 10-year-old domestic shorthair cat showed anorexia, lethargy and ptyalism with hyperammonaemia. Portosystemic shunts were not identified by computed tomography angiography. Biopsy results revealed mild interstinal nephritis and no lesion in the liver. Analysis of urine revealed the presence of a high methylmalonic acid (MMA) concentration. Serum cobalamin (vitamin B(12)) and serum feline trypsin-like immunoreactivity levels were also markedly low. The cat was diagnosed as having exocrine pancreatic insufficiency (EPI). After 5 weeks of parenteral cobalamin supplementation, serum cobalamin concentration had increased and urinary MMA concentration had decreased. This case suggests that hyperammonaemia may be caused by accumulation of MMA due to cobalamin malabsorption secondary to feline EPI.

Feline exocrine pancreatic insufficiency: 16 cases (1992-2007).

Medical records of 16 cats diagnosed with exocrine pancreatic insufficiency (EPI) were reviewed. The diagnosis was confirmed with either a serum feline trypsin-like immunoreactivity (fTLI) concentration

Oral ulceration and bleeding associated with pancreatic enzyme supplementation in a German shepherd with pancreatic acinar atrophy.

A 20-month-old German shepherd with primary pancreatic acinar atrophy and exocrine pancreatic insufficiency that was treated with pancreatic enzyme supplementation, vitamin B12, and cimetidine developed oral bleeding. Following discontinuation of the cimetidine, increased preincubation of the enzymes with the food, and symptomatic therapy for the ulceration, the dog's condition improved.

Oral bleeding associated with pancreatic enzyme supplementation in three dogs with exocrine pancreatic insufficiency.

Three dogs with exocrine pancreatic insufficiency developed oral bleeding during treatment with pancreatic enzyme supplements. According to the owners of the dogs, bleeding from the oral cavity developed during or shortly after consumption of meals containing the pancreatic enzyme supplement. Oral bleeding stopped in all dogs when owners reduced the dose of the pancreatic enzyme supplement. In 2 dogs, the decrease in the dose of the pancreatic enzyme supplement did not affect fecal consistency. However, in the third dog, the decrease in dose led to a recurrence of clinical signs. Findings in these dogs suggest that high doses of pancreatic enzyme supplements can cause oral bleeding in dogs with pancreatic insufficiency, but that oral bleeding can be successfully managed by dose reduction in most dogs.

Subclinical exocrine pancreatic insufficiency in dogs.

OBJECTIVE: To study progression of autoimmune-mediated atrophic lymphocytic pancreatitis from the subclinical to the clinical phase (exocrine pancreatic insufficiency [EPI]) and determine whether progression of the disease could be halted by treatment with immunosuppressive drugs. DESIGN: Randomized controlled trial. ANIMALS: 20 dogs with subclinical EPI. PROCEDURE: Diagnosis of subclinical EPI was determined on the basis of repeatedly low serum trypsin like-immunoreactivity (TLI) in dogs with no signs of EPI. Laparotomy was performed on 12 dogs with partial acinar atrophy and atrophic lymphocytic pancreatitis. A treatment group (7 dogs) received an immunosuppressive drug (azathioprine) for 9 to 18 months, and a nontreatment group (13) received no medication. RESULTS: During the subclinical phase, serum TLI was repeatedly low (< 5.0 microg/L). Although a few dogs had nonspecific gastrointestinal tract signs, they did not need diet supplementation with enzymes. While receiving immunosuppressive medication, treated dogs had no clinical signs of EPI, but within 2 to 6 months after treatment was stopped, 2 dogs had signs of EPI, and diet supplementation with enzymes was started. Five of the 13 untreated dogs needed diet supplementation with enzymes within 6 to 46 months. During follow-up of 1 to 6 years, 3 of the 7 treated dogs and 8 of the 13 untreated dogs did not need continuous diet supplementation with enzymes. CONCLUSIONS AND CLINICAL RELEVANCE: Progression of atrophic lymphocytic pancreatitis varied widely. The subclinical phase may last for years and sometimes for life. The value of early treatment with an immunosuppressive drug was questionable and, because of the slow natural progression of the disease, cannot be recommended.

Response to long-term enzyme replacement treatment in dogs with exocrine pancreatic insufficiency.

OBJECTIVE: To study response to long-term enzyme replacement treatment in dogs with exocrine pancreatic insufficiency (EPI). DESIGN: Cross-sectional study. ANIMALS: 76 German Shepherd Dogs or rough-coated Collies with EPI and 145 clinically normal dogs of the same breeds. PROCEDURE: Questionnaires were sent to owners of dogs with EPI and owners of clinically normal dogs. Dogs with EPI had been given dietary enzyme supplements for at least 4 months. Relative frequency distributions of gastrointestinal tract and dermatologic signs, prevalences of typical signs of EPI (e.g., weight loss, ravenous appetite, yellow and pulpy feces, high fecal volume), feeding regimens, and dietary intolerances were compared between dogs with EPI and clinically normal dogs. RESULTS: Gastrointestinal tract signs considered typical for dogs with EPI were almost completely controlled with dietary enzyme supplements in half of the dogs with EPI, and their general health was similar to that of clinically normal dogs. A poor treatment response was found in a fifth of dogs with EPI that had several signs that were typical of EPI. Signs most often persisting were high fecal volume, yellow and pulpy feces, and flatulence. Dermatologic problems were common, especially in German Shepherd Dogs with EPI. Treatment response was irrespective of breed. Nonenteric-coated enzyme supplements, powdered enzyme, and raw chopped pancreas were equally effective in controlling clinical signs. Although dietary sensitivities were common, use of adjunctive dietary treatment was minimal. Antibiotics were occasionally administered to half of the dogs with EPI. CLINICAL IMPLICATIONS: Results of this study indicate that, with basically similar treatment regimens, response to long-term enzyme treatment in dogs with EPI varied considerably.