Categories
Drugs

Aminocaproic Acid (Amicar)

Fibrinolysis Inhibitor/Antiprotease

Highlights Of Prescribing Information

May be useful for treating degenerative myelopathies in dogs; efficacy not well documented

Treatment may be very expensive, especially with large dogs

Contraindicated in DIC

Infrequently causes GI distress

What Is Aminocaproic Acid Used For?

Aminocaproic acid has been used as a treatment to degenerative myelopathy (seen primarily in German shepherds), but no controlled studies documenting its efficacy were located. There is interest in evaluating aminocaproic acid for adjunctive treatment of thrombocytopenia in dogs, but efficacy and safety for this purpose remains to be investigated. In humans, it is primarily used for treating hyperfibrinolysis-induced hemorrhage.

Pharmacology/Actions

Aminocaproic acid inhibits fibrinolysis via its inhibitory effects on plasminogen activator substances and via some antiplasmin action. Aminocaproic acid is thought to affect degenerative myelopathy by its antiprotease activity thereby reducing the activation of inflammatory enzymes that damage myelin.

Pharmacokinetics

No pharmacokinetic data was located for dogs.

In a study where 70 mg/kg doses were given IV to horses over 20 minutes, the drug was distributed rapidly and plasma levels remained above the proposed therapeutic level of 130 mcg/mL for one hour after the end of the infusion. Elimination half-life was 2.3 hours. The authors proposed that a constant rate infusion of 15 mg/ kg/hr after the original infusion would maintain more prolonged therapeutic levels ().

In humans, the drug is rapidly and completely absorbed after oral administration. The drug is well distributed in both intravascular and extravascular compartments and penetrates cells (including red blood cells). It is unknown if the drug enters maternal milk. It does not bind to plasma proteins. Terminal half-life is about 2 hours in humans and the drug is primarily renally excreted as unchanged drug.

Before you take Aminocaproic Acid

Contraindications / Precautions / Warnings

Aminocaproic acid is contraindicated in patients with active intravascular clotting. It should only be used when the benefits outweigh the risks in patients with preexisting cardiac, renal or hepatic disease.

Adverse Effects

In dogs treated, about 1% exhibit clinical signs of GI irritation. It potentially can cause hyperkalemia particularly in renal impaired patients.

Reproductive / Nursing Safety

Some, but not all, animal studies have demonstrated teratogenicity; use when risk to benefit ratio merits. In humans, the FDA categorizes this drug as category C for use during pregnancy (Animal studies have shown an adverse effect on the fetus, hut there are no adequate studies in humans; or there are no animal reproduction studies and no adequate studies in humans.)

Overdosage / Acute Toxicity

There is very limited information on overdoses with aminocaproic acid. The IV lethal dose in dogs is reportedly 2.3 g/kg. At lower IV overdosages, tonic-clonic seizures were noted in some dogs. There is no known antidote, but the drug is dialyzable.

How to use Aminocaproic Acid

Aminocaproic Acid dosage for dogs:

For adjunctive treatment of degenerative myelopathy (seen primarily in German shepherds):

a) In combination with exercise, vitamin support (vitamin B-complex, vitamin E), and analgesia (if required; using acetaminophen): Aminocaproic acid: 500 mg (regardless of size of animal, approximate dose is 15 mg/kg) PO q8h. Mix 192 mL of the 250 mg/mL injection with 96 mL of hematinic compound (e.g., Lixotinic) producing a 288 mL final volume. Give 3 mL per dose (500 mg). Store solution in refrigerator. Clinical improvement seen within 8 weeks. ()

b) Aminocaproic acid 500 mg/dog PO q8h indefinitely. Used in conjunction with acetylcysteine at 25 mg/kg PO q8h for 2 weeks, then q8h every other day. The 20% solution should be diluted to 5% with chicken broth or suitable diluent. Other treatments may include prednisone (0.25-0.5 mg/kg PO daily for 10 days then every other day), Vitamin C (1000 mg PO q12h) and Vitamin E (1000 Int. Units PO ql2). Note: No treatment has been shown to be effective in published trials. ()

As an antifibrinolytic:

a) No published doses for dogs, but has been used anecdotally at 50-100 mg/kg IV or PO q6h. ()

Client Information

■ Aminocaproic Acid costs to treat a German shepherd-sized dog can be substantial

■ As no well controlled studies have documented that this drug is effective for treating degenerative myelopathy, its use should be considered investigational

Chemistry / Synonyms

An inhibitor of fibrinolysis, aminocaproic acid is a synthetic monamino carboxylic acid occurring as a fine, white crystalline powder. It is slightly soluble in alcohol and freely soluble in water and has pKa’s of 4.43 and 10.75. The injectable product has its pH adjusted to approximately 6.8.

Aminocaproic acid may also be known as: acidum aminocaproicum, CL-10304 CY-116, EACA, epsilon aminocaproic acid, JD-177, NSC-26154, Amicar, Capracid, Capramol, Caproamin, Caprolisin, Epsicaprom, Hemocaprol, Hemocid, Hexalense, or Ipsilon.

Storage / Stability/Compatibility

Products should be stored at room temperature. Avoid freezing liquid preparations. Discoloration will occur if aldehydes or aldehydic sugars are present. When given as an intravenous infusion, normal saline, D5W and Ringer’s Injection have been recommended for use as the infusion diluent.

Dosage Forms / Regulatory Status

Veterinary-Labeled Products: None

The ARCI (Racing Commissioners International) has designated this drug as a class 4 substance. See the appendix for more information.

Human-Labeled Products:

Aminocaproic Acid Tablets: 500 mg & 1000 mg; Amicar (Xanodyne); Aminocaproic Acid (VersaPharm); (Rx)

Aminocaproic Oral Solution: 250 mg/mL in 237 mL & 473 mL; Aminocaproic Acid (VersaPharm); (Rx)

Aminocaproic Syrup: 250 mg/mL in 473 mL; Amicar (Xanodyne); (Rx)

Aminocaproic Acid Injection for Intravenous Infusion: 250 mg/mL in 20 mL vials; generic; (Rx)

Categories
Drugs

Acetylcysteine (N-acetylcysteine, Mucomyst, NAC)

Antidote; Mucolytic

Highlights Of Prescribing Information

Used primarily as a treatment for acetaminophen or phenol toxicity & for its mucolytic effect; used anecdotally for treating degenerative myelopathy

Also used as a topical ophthalmic ()

Has caused hypersensitivity & bronchospasm when used in pulmonary tree

Administer via gastric- or duodenal tube for acetaminophen poisoning in animals

What Is Acetylcysteine Used For?

Acetylcysteine is used in veterinary medicine as both a mucolytic agent in the pulmonary tree and as a treatment for acetaminophen or phenol toxicity in small animals. It has been used anecdotally with aminocaproic acid to treat degenerative myelopathy in dogs.

In horses with strangles, acetylcysteine instilled into the gutteral pouch has been used to help break up chondroids and avoid the need for surgical removal. Acetylcysteine enemas have been used in neonatal foals to break up meconium refractory to repeated enemas.

Before you take Acetylcysteine

Contraindications / Precautions / Warnings

Acetylcysteine is contraindicated (for pulmonary indications) in animals hypersensitive to it. There are no contraindications for its use as an antidote.

Because acetylcysteine may cause bronchospasm in some patients when used in the pulmonary system, animals with bronchospastic diseases should be monitored carefully when using this agent.

Adverse Effects

When given orally for acetaminophen toxicity, acetylcysteine can cause GI effects (nausea, vomiting) and rarely, urticaria. Because the taste of the solution is very bad, use of taste masking agents {e.g., colas, juices) have been used. Since oral dosing of these drugs may be very difficult in animals, gastric or duodenal tubes may be necessary.

Rare adverse effects reported when acetylcysteine is administered into the pulmonary tract, include: hypersensitivity, chest tightness, bronchoconstriction, and bronchial or tracheal irritation.

Overdosage / Acute Toxicity

The LD50 of acetylcysteine in dogs is 1 g/kg (PO) and 700 mg/kg (IV). It is believed that acetylcysteine is quite safe (with the exception of the adverse effects listed above) in most overdose situations.

How to use Acetylcysteine

Acetylcysteine dosage for dogs:

For acetaminophen toxicity:

a) A 2-3 hour wait between activated charcoal and PO administration of acetylcysteine (NAC) is necessary. Give NAC as an initial oral loading dose of 140 mg/kg (dilute to 5% in dextrose or sterile water), followed by 70 mg/kg PO four times daily (q6h) for 7 treatments. With ingestion of massive quantities, some authors suggest using a 280 mg/kg loading dose and continuing treatment for 12-17 doses. May also be given IV after diluting to 5% and given via slow IV over 15-20 minutes. Additional therapy may include IV fluids, blood or Oxyglobin, ascorbic acid and SAMe. ()

b) 150 mg/kg PO or IV initially, then 50 mg/kg q4h for 17 additional doses ()

c) Loading dose of 140 mg/kg PO, then 70 mg/kg PO every 6 hours for 7 treatments ()

For phenol toxicity:

a) 140 mg/kg PO or IV initially, then 50 mg/kg q4h for 3 days. May be partially effective to reduce hepatic and renal injury. Resultant methemoglobinemia should be treated with ascorbic acid or methylene blue. ()

For respiratory use:

a) 50 mL/hr for 30-60 minutes every 12 hours by nebulization ()

For degenerative myelopathy:

a) 25 mg/kg PO q8h for 2 weeks, then q8h every other day. The 20% solution should be diluted to 5% with chicken broth or suitable diluent. Used in conjunction with aminocaproic acid (500 mg per dog PO q8h indefinitely). Other treatments may include prednisone (0.25-0.5 mg/kg PO daily for 10 days then every other day), Vitamin C (1000 mg PO q12h) and Vitamin E (1000 Int. Units PO q12h). Note: No treatment has been shown to be effective in published trials. ()

Acetylcysteine dosage for cats:

For acetaminophen toxicity:

a) A 2-3 hour wait between activated charcoal and PO administration of acetylcysteine (NAC) is necessary. Give NAC as an initial oral loading dose of 140 mg/kg (dilute to 5% in dextrose or sterile water), followed by 70 mg/kg PO four times daily (q6h) for 7 treatments. With ingestion of massive quantities, some authors suggest using a 280 mg/kg loading dose and continuing treatment for 12-17 doses. May also be given IV after diluting to 5% and given via slow IV over 15-20 minutes. Additional therapy may include IV fluids, blood or Oxyglobin9, ascorbic acid and SAMe. ()

b) 150 mg/kg PO or IV initially, then 50 mg/kg q4h for 17 additional doses ()

For phenol toxicity:

a) 140 mg/kg PO or IV initially, then 50 mg/kg q4h for 3 days. May be partially effective to reduce hepatic and renal injury. Resultant methemoglobinemia should be treated with ascorbic acid or methylene blue. ()

For respiratory use:

a) 50 mL/hr for 30-60 minutes every 12 hours by nebulization ()

For adjunctive treatment of hepatic lipidosis (see also Carnitine):

a) Identify underlying cause of anorexia and provide a protein replete feline diet, give acetylcysteine (NAC) at 140 mg/kg IV over 20 minutes, then 70 mg/kg IV q12h; dilute 10% NAC with saline 1:4 and administer IV using a 0.25 micron filter; correct hypokalemia and hypophosphatemia, beware of electrolyte changes with re-feeding phenomenon ()

Acetylcysteine dosage for horses:

To help break up chondroids in the gutteral pouch:

a) Instill 20% solution ()

In neonatal foals to break up meconium refractory to repeated enemas:

a) 8 grams in 20 g sodium bicarbonate in 200 mL water (pH of 7.6), give as enema as needed to effect ()

b) With foal in lateral recumbency, insert a 30 french foley catheter with a 30 cc bulb for a retention enema. Using gravity flow, infuse slowly 100-200 mL of 4% acetylcysteine solution and retain for 30-45 minutes. IV fluids and pain medication should be considered. Monitor for possible bladder distention. ()

Monitoring

When used for acetaminophen poisoning:

■ Hepatic enzymes (particularly in dogs)

■ Acetaminophen level, if available (particularly in dogs)

■ Hemogram, with methemoglobin value (particularly in cats)

■ Serum electrolytes, hydration status

Client Information

■ This agent should be used in a clinically supervised setting only

Chemistry / Synonyms

The N-acetyl derivative of L-cysteine, acetylcysteine occurs as a white, crystalline powder with a slight acetic odor. It is freely soluble in water or alcohol.

Acetylcysteine may also be known as: N-acetylcysteine or N-acetyl-L-cysteine, NAC, 5052 acetylcysteinum, NSC-111180, Acetadote, Mucomyst or ACC.

Storage / Stability/Compatibility

When unopened, vials of sodium acetylcysteine should be stored at room temperature (15-30°C). After opening, vials should be kept refrigerated and used within 96 hours. The product labeled for IV use states to use within 24 hours.

Acetylcysteine is incompatible with oxidizing agents; solutions can become discolored and liberate hydrogen sulfide when exposed to rubber, copper, iron, and during autoclaving. It does not react to aluminum, stainless steel, glass or plastic. If the solution becomes light purple in color, potency is not appreciably affected, but it is best to use non-reactive materials when giving the drug via nebulization. Acetylcysteine solutions are incompatible with amphotericin B, ampicillin sodium, erythromycin lactobionate, tetracycline, oxytetracycline, iodized oil, hydrogen peroxide and trypsin.

Dosage Forms / Regulatory Status

Veterinary-Labeled Products: None

Human-Labeled Products:

Acetylcysteine injection: 20% (200 mg/mL), (0.5 mg/mL EDTA in 30 mL single-dose vials, preservative free; Acetadote (Cumberland); (Rx)

Acetylcysteine Solution: 10% & 20% (as sodium) in 4 mL, 10 mL, 30 mL & 100 mL (20% only) vials; Mucomyst (Apothecon); (Rx) Note: If using this product for dilution and then intravenous dosing, it is preferable to use a 0.2 micron in-line filter.

Categories
Veterinary Drugs

Dimenhydrinate

Chemistry

An ethanolamine derivative antihistamine, dimenhydrinate contains approximately 54% diphenhydramine and 46% 8-chlorotheophylline. It occurs as an odorless, bitter and numbing-tasting, white crystalline powder with a melting range of 102°-107°C. Dimenhydrinate is slightly soluble in water and is freely soluble in propylene glycol or alcohol. The pH of the commercially available injection ranges from 6.4 to 7.2.

Storage – Stability – Compatibility

Dimenhydrinate products should be stored at room temperature; avoid freezing the oral solution and injectable products. The oral solution should be stored in tight containers and tablets stored in well-closed containers.

Dimenhydrinate injection is reportedly compatible with all commonly used intravenous replenishment solutions and the following drugs: amikacin sulfate, atropine sulfate, calcium gluconate, chloramphenicol sodium succinate, corticotropin, ditrizoate meglumine and sodium, diphenhydramine HCl, droperidol, fentanyl citrate, heparin sodium, iothalamate meglumine and sodium, meperidine HCl, methicillin sodium, metoclopramide, morphine sulfate, norepinephrine bitartrate, oxytetracycline HCl, penicillin G potassium, pentazocine lactate, perphenazine, phenobarbital sodium, potassium chloride, scopolamine HBr, vancomycin HCl and vitamin B-complex w/ vitamin C.

The following drugs are either incompatible or compatible only in certain concentrations with dimenhydrinate: aminophylline, ammonium chloride, amobarbital sodium, butorphanol tartrate, glycopyrrolate, hydrocortisone sodium succinate, hydroxyzine, iodipamide meglumine, pentobarbital sodium, prochlorperazine edisylate, promazine HCl, promethazine HCl, tetracycline HCl, and thiopental sodium. Compatibility is dependent upon factors such as pH, concentration, temperature, and diluents used and it is suggested to consult specialized references for more specific information.

Dimenhydrinate: Pharmacology

Dimenhydrinate has antihistaminic, antiemetic, anticholinergic, CNS depressant and local anesthetic effects. These principle pharmacologic actions are thought to be a result of only the diphenhydramine moiety. Used most commonly for its antiemetic/motion sickness effects, dimenhydrinate’s exact mechanism of action for this indication is unknown, but the drug does inhibit vestibular stimulation. The anticholinergic actions of dimenhydrinate may play a role in blocking acetylcholine stimulation of the vestibular and reticular systems. Tolerance to the CNS depressant effects can ensue after a few days of therapy and antiemetic effectiveness also may diminish with prolonged use.

Dimenhydrinate: Uses – Indications

In veterinary medicine, dimenhydrinate is used primarily for its antiemetic effects in the prophylactic treatment of motion sickness in dogs and cats.

Pharmacokinetics

The pharmacokinetics of this agent have apparently not been studied in veterinary species. In humans, the drug is well absorbed after oral administration with antiemetic effects occurring within 30 minutes of administration. Antiemetic effects occur almost immediately after IV injection. The duration of effect is usually 3-6 hours.

Diphenhydramine is metabolized in the liver, and the majority of the drug is excreted as metabolites into the urine. The terminal elimination half-life in adult humans ranges from 2.4 – 9.3 hours.

Contraindications/Precautions

Dimenhydrinate is contraindicated in patients who are hypersensitive to it or to other antihistamines in its class. Because of their anticholinergic activity, an-tihistamines should be used with caution in patients with angle closure glaucoma, prostatic hypertrophy, pyloroduodenal or bladder neck obstruction, and COPD if mucosal secretions are a problem. Additionally, they should be used with caution in patients with hyperthyroidism, seizure disorders, cardiovascular disease or hypertension. It may mask the symptoms of ototoxicity and should therefore be used with this knowledge when concomitantly administering with ototoxic drugs.

Dimenhydrinate: Adverse Effects – Warnings

Most common adverse reactions seen are CNS depression (lethargy, somnolence) and anticholinergic effects (dry mouth, urinary retention). GI effects (diarrhea, vomiting, anorexia) are less common, but have been noted.

The sedative effects of antihistamines, may adversely affect the performance of working dogs. The sedative effects of antihistamines may diminish with time.

Dimenhydrinate: Overdosage

Overdosage may cause CNS stimulation (excitement to seizures) or depression (lethargy to coma), anticholinergic effects, respiratory depression and death. Treatment consists of emptying the gut if the ingestion was oral. Induce emesis if the patient is alert and CNS status is stable. Administration of a saline cathartic and/or activated charcoal may be given after emesis or gastric lavage. Treatment of other symptoms should be performed using symptomatic and supportive therapies. Phenytoin (IV) is recommended in the treatment of seizures caused by antihistamine overdose in humans; use of barbiturates and diazepam are avoided.

Dimenhydrinate: Drug Interactions

Increased sedation can occur if dimenhydrinate (diphenhydramine) is combined with other CNS depressant drugs. Antihistamines may partially counteract the anticoagulation effects of heparin or warfarin. Diphenhydramine may enhance the effects of epinephrine. Dimenhydrinate may potentiate the anticholinergic effects of other anticholinergic drugs. Dimenhydrinate has been demonstrated to induce hepatic microsomal enzymes in animals (species not specified); the clinical implications of this effect are unclear.

Laboratory Interactions – Antihistamines can decrease the wheal and flare response to antigen skin testing. In humans, it is suggested that antihistamines be discontinued at least 4 days before testing.

Dimenhydrinate: Doses

Doses for dogs:

For prevention and treatment of motion sickness:

a) 8 mg/kg PO q8h

b) 25 – 50 mg PO once to 3 times a day

c) 4 – 8 mg/kg PO q8h

Doses for cats:

For prevention and treatment of motion sickness:

a) 12.5 mg (total dose) PO q8h

b) 12.5 mg PO once to 3 times a day

c) 8 mg/kg PO q8h

d) 4 – 8 mg/kg PO q8h

Monitoring Parameters

1) Clinical efficacy and adverse effects (sedation, anticholinergic signs, etc.)

Dosage Forms – Preparations – FDA Approval Status – Withholding Times

Veterinary-Approved Products:

None

Human-Approved Products:

Dimenhydrinate Tablets or capsules 50 mg; Commonly known as Dramamine® (Upjohn) (OTC); Many other OTC products also available

Dimenhydrinate Oral Liquid 12.5 mg/4 ml, 12.5 mg/5 ml and 15.62 mg/5 ml; in pints and gallons and in 90 ml, 120 ml and 480 ml bottles Children’s Dramamine® (Upjohn) (OTC); generic (OTC)

Dimenhydrinate Injection 50 mg/ml; in 1 ml amps and vials, 5 & 10 ml vials; Dramamine® (Upjohn); Generic; (Rx)

Categories
Diseases

Small Intestinal Bacterial Overgrowth

Normally the bacterial population of the small intestine is controlled by a number of mechanisms (see above). Bacterial overgrowth is the uncontrolled proliferation of these bacteria and, in humans, occurs secondary to a number of underlying disorders that interfere with the control mechanisms. Although the existence of small intestinal bacterial overgrowth in humans is not disputed, the subject is a source of controversy in small animal gastroenterology. In dogs, small intestinal bacterial overgrowth is best considered a clinical sign or a pathogenetic mechanism rather than a diagnosis. Historically, the term idiopathic small intestinal bacterial overgrowth was used to describe an antibiotic-responsive condition of large breed (especially German shepherd) dogs for which no underlying cause could be recognized. However, given concerns as to whether a true overgrowth exists in these cases, the alternative name of antibiotic-responsive diarrhea has been suggested. Although cats might feasibly suffer from secondary SIBO, an idiopathic antibiotic-responsive condition similar to that seen in German shepherds has not been documented in this species.

Definition

Genuine bacterial overgrowth is defined by an increase in the absolute number of bacteria in the upper small intestine during the fasted state (i. e., the number of colony-forming units cultured per milliliter of duodenal juice (CFU / mL]). The upper limit for normal bacterial numbers was defined in humans, and that number has been extrapolated to dogs. Controversy exists as to its validity, however, because the original work used a small number of dogs and questionable bacteriologic techniques. Subsequent studies with different collection methods and improved anaerobic culture techniques have demonstrated that a count equal to or greater than 107 CFU / mL total bacteria is commonly found in asymptomatic dogs. Therefore, although a genuine bacterial overgrowth may exist in conditions equivalent to those in humans, defining the presence of small intestinal bacterial overgrowth based on the original numeric limit is flawed. In this chapter, cases with a documented underlying cause are defined as secondary SIBO, and the term idiopathic antibiotic-responsive diarrhea is used for idiopathic antibiotic-responsive conditions without an obvious underlying cause.

Etiology and Pathogenesis

Secondary small intestinal bacterial overgrowth SIBO can occur secondary to (1) diseases that result in excess substrate in the intestinal lumen (e. g., EPI, motility disorder, blind loop), (2) diseases that affect the clearance of bacteria (e. g., partial obstruction, abnormal motility), or (3) morphologic or functional derangement of the mucosa (Box Causes of Secondary Small Intestinal Bacterial Overgrowth). Increased numbers of bacteria in the upper small intestine cause malabsorption and diarrhea through several mechanisms. First, bacteria compete for nutrients; for example, by binding cobalamin and reducing its availability for absorption. Second, bacterial metabolism of nutrients can create products that provoke diarrhea (e. g., hydroxylated fatty acids and deconjugated bile salts), leading to diarrhea from fat malabsorption and stimulation of colonocyte secretion. Finally, the bacterial flora may damage the mucosal brush border, and alterations in enzyme activity, which reverse on antibiotic treatment, can be detected.

Causes of Secondary Small Intestinal Bacterial Overgrowth

Achlorhydria

  • Spontaneous (atrophic gastritis)
  • Acid blockers

Exocrine pancreatic insufficiency

Partial intestinal obstruction

  • Chronic intussusception
  • Stricture
  • Tumor

Abnormal anatomy

  • Surgical resection of ileocolic valve
  • Blind loop

Motility disorder

  • Primary
  • Hypothyroidism

Mucosal disease

  • Latent primary pathogens (?)
  • Inflammatory bowel disease (cause or effect?)
  • Chronic giardiasis

Dietary sensitivity (?)

Idiopothic antibiotic-responsive diarrhea A number of hypotheses exist as to the cause of idiopathic antibiotic-responsive diarrhea. Historically, hypotheses were based on the belief that a genuine increase in small intestine bacterial numbers was present and therefore pathogenesis was related to the mechanisms described above. An underlying defect allowing overgrowth was not obvious, and suggested mechanisms such as abnormal intestinal motility or achlorhydria were not proved.

Given that recent studies have questioned whether a genuine increase in bacterial numbers occurs, recent hypotheses now focus on host-bacterial interactions. As was suggested for mouse models of enteric inflammation, antibiotic-responsive diarrhea may develop secondary to defects in the mucosal barrier, aberrant mucosal immune responses, qualitative changes in the enteric bacterial flora, or a combination of these mechanisms. Defects in the mucosal barrier are supported by studies documenting abnormal permeability and the presence of brush border enzyme defects. A possible underlying selective IgA deficiency in the German shepherd breed has been postulated. German shepherds with intestinal disease have defective small intestinal IgA production, although mucosal IgA+ plasma cell numbers in affected dogs are either normal or increased. The cause of this IgA deficiency is not clear, but a complex defect is likely, involving abnormalities either in the production and release of IgA from the plasma cell or in the pathway of translocation of IgA across the epithelium during secretion.

Studies demonstrate that dogs with antibiotic-responsive diarrhea have increased lamina propria CD4+ T cells and increased expression of certain cytokines. It therefore is tempting to speculate that this represents immune dysregulation and perhaps a loss of tolerance toward endogenous bacterial antigens. Such a hypothesis is supported by the fact that antibacterials lead to resolution of clinical signs and decreased cytokine expression but not to a decline in bacterial numbers. The fact that the most effective antibacterials are those with immune-modulating properties (e. g., oxytetracycline, metronidazole, tylosin) may support this hypothesis.

An alternative hypothesis is that an unidentified pathogen is involved; candidates include intestinal Helicobacter spp. or enteropathogenic E. coli. The predisposition of German shepherds to this syndrome could therefore be explained by genetic susceptibility to infection as a result of MHC II antigen expression.

Clinical Presentation

Idiopathic antibiotic-responsive diarrhea Idiopathic antibiotic-responsive diarrhea is most commonly recognized in young German shepherds, although cases have been reported in other dog breed? (but not in cats). Affected dogs show signs of chronic intermittent diarrhea accompanied by weight loss and / or stunting. Intermittent, watery diarrhea, often associated with excessive gas production (manifested as borborygmi and flatus), is seen most frequently. However, vomiting and signs of colitis are sometimes reported, and occasionally dogs are stunted yet do not have diarrhea. Activity levels are normal, and appetite is variable; most affected dogs have polyphagia, pica, or coprophagia, but few are anorectic. A positive response to antibiotics is expected, and the clinical condition may deteriorate if corticosteroids are given. The major differential diagnoses are exocrine pancreatic insufficiency and inflammatory bowel disease, both of which are common in German shepherds.

Secondary small intestinal bacterial overgrowth SIBO may occur secondary to numerous primary conditions (see Box Causes of Secondary Small Intestinal Bacterial Overgrowth), and clinical signs usually relate to the underlying condition. However, signs of secondary small intestinal bacterial overgrowth also can been seen and are indistinguishable from those of idiopathic antibiotic-responsive diarrhea, with diarrhea predominating. When small intestinal bacterial overgrowth develops secondary to a partial obstruction or focal dysmotility, bacterial numbers can exceed 109 CFU / mL. Clinical signs may be noted intermittently, because recurrent diarrhea can temporarily flush out the overgrowth.

Using the historical numeric cutoff of 105 CFU / mL total bacteria, secondary small intestinal bacterial overgrowth was considered common in chronic enteropathies. In reality, true secondary small intestinal bacterial overgrowth is uncommon, with the exception of small intestinal bacterial overgrowth secondary to EPI. An increase in small intestine bacterial numbers has been documented in experimentally induced EPI, although bacterial numbers decrease upon treatment of exocrine pancreatic insufficiency with enzyme replacement. Therefore in many cases the small intestinal bacterial overgrowth itself is of no significance. However, a proportion of naturally occurring exocrine pancreatic insufficiency cases respond suboptimally to pancreatic enzyme supplementation alone and may require concurrent antibiotic therapy. Given that the majority of dogs affected with exocrine pancreatic insufficiency are German shepherds, it is not clear whether this is the result of secondary small intestinal bacterial overgrowth or of a concurrent idiopathic antibiotic-responsive diarrhea.

Diagnosis

The diagnosis of small intestinal bacterial overgrowth and antibiotic-responsive diarrhea is controversial. In all cases it is critical that a thorough investigation be conducted to eliminate causes of secondary small intestinal bacterial overgrowth before the patient is treated with antibacterials. In this regard, diagnostic imaging, especially ultrasonography, is useful for ruling out partial intestinal obstructions. Systemic disorders should be ruled out with a minimum database, and exocrine pancreatic insufficiency is eliminated by serum TLI assay. Fecal examination for parasitic and bacterial diseases is also mandatory.

Idiopathic antibiotic-responsive diarrhea Although both direct and indirect tests were previously advocated for idiopathic SIBO, recent studies have suggested that they are all of limited value. One recent study demonstrated that neither indirect biochemical markers (folate, cobalamin, unconjugated bile acids) nor quantitative bacterial culture could reliably identify cases of antibiotic-responsive diarrhea. Therefore the only available diagnostic test for antibiotic-responsive diarrhea is response to an antibacterial trial. However, such a diagnostic modality is appropriate only after thorough diagnostic investigations have eliminated all other causes of an antibacterial responsiveness.

Secondary small intestinal bacterial overgrowth Although numerous tests are available to document secondary overgrowth, in practice it is more important to identify the underlying cause.

Duodenal juice culture Quantitative aerobic and anaerobic culture of duodenal juice previously formed the gold standard for diagnosis. For dogs, increases in either total or anaerobic bacteria above the upper cutoff (105 CFU / mL total bacteria or 104 CFU / mL anaerobic bacteria) were considered diagnostic. However, the validity of these cutoffs has been questioned. A count of 107 CFU / mL total duodenal bacteria has been documented commonly in healthy dogs, and numbers as high as 109 CFU / mL have been found occasionally in cats and asymptomatic dogs. Some of the discrepancies may reflect difficulties and differences in the methodology, because numbers vary widely when individual animals are repeatedly sampled. Use of an inappropriately low cutoff value leads to overdiagnosis of SIBO, which probably explains why it has been reported in 50% of dogs with chronic intestinal disease. Culture of endoscopic biopsies has not been shown to be of greater diagnostic utility.

The flora present in idiopathic antibiotic-responsive diarrhea may be comprised predominantly of either aerobic or anaerobic bacteria, but it tends to be a mixed population, with staphylococci, streptococci, coliforms, enterococci, and corynebacteria and anaerobes such as bacteroids, fusobacteria, and clostridia. These bacteria generally are commensals found normally in the oropharynx, small intestine, and large intestine. However, culture of fecal bacteria cannot be correlated with small intestine bacterial numbers and cannot be used to diagnose this condition.

Indirect tests for small intestinal bacterial overgrowth / antibiotic-responsive diarrhea Indirect tests include serum biochemical markers and breath hydrogen analysis.

Serum folate and cobalamin concentrations Bacteria synthesize folate and bind cobalamin, preventing its absorption. Therefore small intestinal bacterial overgrowth would be predicted to be associated with an increased serum folate concentration or a decreased cobalamin concentration, or both. Although such results would be expected in cases of genuine small intestinal bacterial overgrowth (e. g., secondary SIBO), no studies have specifically assessed the usefulness of these tests in those diseases. Alterations of serum folate and cobalamin noted in exocrine pancreatic insufficiency may reflect pancreatic dysfunction rather than secondary SIBO.

Furthermore, recent studies have demonstrated that these tests are of limited value in the diagnosis of idiopathic antibiotic-responsive diarrhea. This poor performance may be related to dietary factors, the presence of concurrent disease, or the use of drugs that alter serum vitamin concentrations. The other possibility (for idiopathic antibiotic-responsive diarrhea) is that disease pathogenesis is not related to genuine increases in bacterial numbers. Although these tests are often the only tests available to practitioners, they are generally unhelpful in the diagnosis of idiopathic antibiotic-responsive diarrhea.

Serum unconjugated bile acids Bile acids are synthesized and conjugated in the liver and excreted into the intestine via the biliary tract. Some small intestine bacterial species can deconjugate bile acids, which then are absorbed passively by the small intestine. Studies in humans have suggested that increased serum unconjugated bile acid (SUBA) concentrations are an indirect indicator of SIBO. A preliminary study in dogs suggested that SUBA concentrations increased in SIBO. However, these results have been contradicted by another recent study, which demonstrated that SUBA concentrations were neither sensitive nor specific for diagnosis of idiopathic antibiotic-responsive diarrhea. Further work may be required to clarify the diagnostic value of SUBA concentrations in dogs.

Other biochemical tests Measurement of increased amounts of a bacterial product made either naturally or after oral administration of a test substance could be used to diagnose SIBO, but none of these are reliable.

Breath hydrogen excretion Bacterial fermentation in the intestinal tract releases hydrogen which, after systemic absorption, is exhaled and can be measured in breath samples. Theoretically, small intestinal bacterial overgrowth can result in a high resting breath hydrogen concentration or an early (or double) hydrogen peak after ingestion of a test meal. However, increased breath hydrogen can also be seen with carbohydrate malabsorption or decreased orocecal transit time. Given these problems with interpretation and the fact that protocols have not been standardized, breath hydrogen testing has not been widely adopted.

Intestinal permeability Intestinal permeability, as measured by 51Cr-EDTA and differential sugar absorption, can be abnormal in small intestinal bacterial overgrowth and can improve after antibiotic treatment. However, such findings are not pathognomonic for either secondary small intestinal bacterial overgrowth or idiopathic antibiotic-responsive diarrhea.

Lack of histologic changes on intestinal biopsy Histopathologic examination of intestinal biopsies is most often normal or demonstrates only subde abnormalities. However, such findings are not pathognomonic, because other conditions yield similar results. Despite the lack of histologic evidence of inflammation, disturbances in immune cell populations have been noted, most notably increases in IgA+ plasma cells and CD4+ cells. However, such techniques have not been applied for routine diagnostic purposes.

Empiric response to antibiotics Currendy, the best diagnostic test for idiopathic antibiotic-responsive diarrhea is, logically, the response to empirical therapy. However, a response to antibacterials is not specific and indeed may be beneficial in inflammatory bowel disease, infectious diarrhea, and even a range of nonenteric diseases such a portovascular anomalies. Furthermore, response to antibiotic therapy does not discriminate idiopathic antibiotic-responsive diarrhea from secondary SIBO. Therefore an empirical response to antibiotics is valid only after thorough diagnostic investigations have eliminated other possible causes.

The suggested criteria for a diagnosis of idiopathic antibiotic-responsive diarrhea are (1) a positive response to the antibiotic trial based on resolution of relevant clinical signs; (2) relapse of signs upon withdrawal of treatment; (3) remission on reintroduction of antibiotics; and (4) elimination of other etiologic causes based on the results of other diagnostic tests and histopathologic assessment.

Treatment

Secondary small intestinal bacterial overgrowth Although antibacterial therapy improves clinical signs, appropriate treatment for the underlying condition is preferable. For EPI, pancreatic enzyme supplementation can reduce bacterial numbers because exogenous proteases have antibacterial properties.

Idiopathic antibiotic-responsive diarrhea No cure is available for idiopathic antibiotic-responsive diarrhea, but signs can be controlled with antibacterials. A broad-spectrum antibiotic is indicated; suitable choices include oxytetracycline (10 to 20 mg / kg given orally every 8 hours), metronidazole (10 to 20 mg / kg given orally every 8 hours), and tylosin (20 mg / kg given orally every 8 or every 12 hours). Oxytetracycline (OTC) is cheap, and because systemic absorption is not required, it can be given with food. It cannot be used before permanent tooth eruption because it causes staining of tooth enamel. Some authors have criticized the use of oxytetracycline because it is associated with rapid development of plasmid-mediated antibiotic resistance. However, given that long-term efficacy is maintained in most cases, oxytetracycline may not be acting through its antibacterial properties, because it does not significantly reduce small intestine bacterial numbers. Rather, it may provide a selective pressure on the intestinal flora, encouraging the establishment of less harmful bacteria, or it may exert immunomodulatory effects, which this antibiotic group has. Immunomodulatory activity has also been suggested for other antibacterials commonly used to treat antibiotic-responsive diarrhea, namely metronidazole and tylosin.

Whichever antibacterial is chosen, a 4- to 6-week course is appropriate initially, although the antibiotic should be changed after 2 weeks if the response has been suboptimal. In some cases, premature cessation of treatment can lead to relapse, and prolonged therapy often is necessary. In some animals a delayed relapse occurs several months after cessation of antibiotics, and such cases require either repeated courses or indefinite therapy. Efficacy is often maintained despite a reduction in dosage frequency from three times to even once daily. Dogs may also “outgrow” the problem with age, either as a result of a decrease in caloric intake or because of developing maturity of the mucosal immune system. It has also been suggested that idiopathic antibiotic-responsive diarrhea in German shepherds may predispose some of these dogs to inflammatory bowel disease later in life, but currently no direct evidence supports this supposition.

Ancillary treatments Dietary manipulation can be a useful adjunct to the treatment both of idiopathic antibiotic-responsive diarrhea and of secondary SIBO. In general, a highly digestible, low-fat diet is desired to reduce the substrate available for bacterial use. Addition of FOS has been advocated to reduce small intestine bacterial numbers, although evidence of efficacy is conflicting. Administration of probiotics has not been thoroughly assessed in idiopathic antibiotic-responsive diarrhea. Finally, if low cobalamin concentrations are documented, parenteral cobalamin therapy is warranted.

Categories
Complementary Medicine

Mange

Mange (Demodectic / Sarcoptic)

Definition and cause

Demodex is a localized or generalized parasitic disease caused by Demodex spp. mites. The underlying cause is believed to be genetic or related to immune deficiency or imbalance. In cats it is most often associated with other systemic disease such as FIV. Sarcoptic mange is a highly pruritic parasitic disease caused by the mite Sarcoptes scabiei.

Medical therapy rationale, drug(s) of choice, and nutritional recommendations

For demodex the medical therapies of choice are Amitraz, Ivermectin, or Milbemycin, all of which have potential side effects and are potentially toxic. Amitraz is particularly toxic to humans, and proper precautions should be taken to protect humans from exposure to its active ingredient. None of these treatments address the underlying immune imbalance. Therapy for sarcoptic mange involves mitocidal shampoos or dips along with the medications used in demodex, and / or the use of Selamectin. In addition, antipruritic medications such as antihistamines and corticosteroids are often recommended.

Anticipated prognosis

Localized demodectic mange usually carries a good prognosis. Generalized demodecosis in immune-compromised animals often has a more guarded prognosis. Sarcoptic mange has a good prognosis.

Integrative veterinary therapies

Mange is a nondescript term meaning infestation with one of several mite ectoparasites. These ectoparasites cause irritation through their waste products and physical injury to the host (burrowing), and by their physical presence on the host, which triggers various responses directed at elimination of the mites (pruritus, grooming, self destructive behavior). Damage directly from the mite’s activities and or from the host response leads to a worsening condition.

The integrative approach expands the medical therapy to include the immune system. The integrative approach is cellular protective for the potential toxic effects of medication and mitacidal dips, and helps improve immune function and its ability to rid the body or prevent re-infestation of the mites and lessens inflammation, pruritus, and discomfort.

Nutrition

General considerations / rationale

While medical therapy is focused locally upon destruction of the mite and the skin (inflammation and / or pruritus), the nutritional approach adds gland support for the organs of the immune system as well as nutrients to help decrease local inflammation and improve waste elimination. Because mange, especially demodex, can range in severity from local to generalized and can affect other organs, it is recommended that blood be analyzed both medically and physiologically to determine associated organ involvement and disease. This gives clinicians the ability to formulate therapeutic nutritional protocols to address the skin and organ involvement such as liver inflammation secondary to medication or chemical dips (see site, Nutritional Blood Testing, for more information).

Appropriate nutrients

Nutritional / gland therapy: Glandular adrenal, thymus and lymph provide intrinsic nutrients and help neutralize cellular immune organ damage and protect organs from ongoing inflammation and eventual degeneration (See site, Gland Therapy, for more information).

Sterols: Plant-derived sterols such as betasitosterol show antiinflammatory properties, which appear to be similar to corticosteriods. A cortisone-like effect without the associated immune suppressing effects is beneficial in inflammatory skin conditions. Bouic (1996) reports on the immune-enhancing and balancing effect that plant sterols have on the body.

Quercetin: Quercetin functions like an antihistamine and an antioxidant, and is beneficial for the skin. In its antihistamine role, quercetin has been shown to inhibit cells from releasing histamines, which makes it helpful in treating inflammatory dermatitis.

Lecithin / phosphatidyl choline: Phosphatidyl choline is a phospholipid that is integral for cellular membranes. It is an essential nutrient required by the skin, which is the body’s largest cellular organ.

Essential fatty acids: Much research has been conducted on the importance of essential fatty acids on the clinical management of allergic dermatitis. In addition, the importance of the ratio between omega-6 and omega-3 fatty acids has been substantiated. Research on the use of poly-unsaturated fatty acids has shown their beneficial and antipruritic effects on skin.

Vitamin C: De la Fuente (1998) and Penn (1991) showed that vitamin C in combination with other vitamins significantly improved immune function as compared with a placebo.

Chinese herbal medicine / acupuncture

General considerations / rationale

Mange is a result of parasites in both Western and traditional Chinese medicine theory. Both modalities have the same treatment objectives: kill the parasite, decrease discomfort, and prevent secondary infections. It may also be prudent in some patients to improve immune function to allow the patient to clear the parasite.

Appropriate Chinese herbs

For topical application:

Alumen (Ming fan): Has been shown to inhibit bacterial growth, which may help to prevent secondary bacterial infections in lesions caused by scratching.

Cnidium (She chuang zi): Has antibiotic properties. It also decreases itching. In a study involving 607 patients with severe pruritis, it stopped itching in 84% of the participants.

Prickly ash (Hua jiao): Possesses antibacterial and antidermatophyte properties. This may help prevent secondary infections.

Realgar (Xiong huang): Has traditionally been used to kill internal and external parasites by traditional Chinese medicine practitioners. It has been shown to treat pinworms and malaria, which are internal parasites. The efficacy shown against internal parasites suggests that it would also be effective topically against external parasites.

Sulfur (Liu huang): Is commonly used topically in Western medicine for mange, often as a lime sulfur dip. It has been used as a component for the treatment of psoriasis. For immunosuppression:

Angelica root (Dang gui): Increases the phagocytic activity of macrophages.

Astragalus (Huang qi): Stimulates the cellular and humoral immune systems. It contains astragalan, which enhances phagocytic activity of macrophages and antibody synthesis.

Codonopsis (Dang shen): Enhances the immune system by increasing the weight of the spleen and thymus and the total number of white blood cells and lymphocytes.

Dioscorea (Shan yao): Enhances both the cellular and humoral immune systems.

Fleece flower root (He shou wu): Increases the total white cell count, especially the T-cells, and increases the phagocytic activity of macrophages.

Licorice (Gan cao): Can enhance the phagocytic activity of macrophages.

Lotus seed (Lian zi): Was shown to increase the number of T cells in the thymuses in mice, which implies that it may be useful in treating immunosuppression.

Poria (Fu ling): Contains pachman, which increases the phagocytic function of macrophage.

Psoralea (Bu gu zhi): Stimulates the phagocytic actions of macrophages.

Rehmannia (Shu di huang): Increases the phagocytic activity of macrophages.

Schizandra (Wu wei zi): Can prevent cyclophosphamide-induced decrease in the white blood count.

White atractylodes (Bai zhu): Increases the TH cell count and the TH / TS ratio. It increases the phagocytic function of macrophages.

Wolfberry (Gou qi zi): Increases the phagocytic activity of macrophage phagocytic and raises the total T cell count.

Zizyphus (Suan zao ren): Enhances cellular and humoral immunity.

Homotoxicology

General considerations / rationale

A genetic predisposition (Degeneration Phase) is involved with demodectic mange, and affected individuals should not be used for breeding.

Palmquist relies on conventional therapy to treat most of these (lyme dip and Ivermectin in breeds which can tolerate the drug), but in certain cases it may prove helpful to support immune function, detoxification, and repair of tissues injured by homotoxins. Antihomotoxic agents may have a place in therapy in such cases. The authors are unaware of any work reporting single use of homo-toxicology in the management of veterinary mange cases.

Appropriate homotoxicology formulas

BHI-Hair and -Skin: May help repair skin and hair in recovery phase and detoxification, provide support in cases of damage from vaccines, and promote vicariation of chronic diseases.

BHI-Skin: Treats eczema on elbows, scaly scratchy dermatitis, ulcerations, and urticarial reactions.

Coenzytne compositum: Contains cis-Aconitum acidum for pruritus, skin diseases, and psoriasis. Several of the active skin catalysts in Coenzytne compositum are common to Cutis compositum.

Cutis compositum: Provides support of all skin conditions. This is a critical skin remedy, named primarily for Cutis suis, and indicated in allergic reactions, dermatoses, eczema, seborrheic conditions, pemphigus, psoriasis, dermatomycoses, neurodermatitis, and other skin conditions, as well as disturbances of renal excretion. Contains Ichthyolum, which has pustular acne and violent pruritus (facial) as its main indications. Ichthyol ointment serves to soften and clear out abscesses and is a stimulative treatment in inflammations. Sulphur is also a critical component (See Sulphur-Heel). The remedy contains Cortisone in homeopathic dilution, which is indicated for diseases manifested in the connective tissue, such as disorders of the skin, blood, and vascular systems. Fumaricum acidum, Alpha ketoglutaricum, and Natrum oxalaceticum included are for pruritus, skin diseases, and psoriasis. These catalysts are also found in Coenzytne compositum. Funiculus umbicalis suis is indicated for rehabilitation of tissue. This is a connective tissue remedy indicated in almost all chronic diseases. It repairs damage to connective tissue, and is used for psoriasis, skin eruptions, and dermatitis.

Echinacea compositum: Used for secondary infections. Arsenicum is indicated for skin eruptions and other symptoms of a stubborn nature that may border on the phase of Degeneration. It also contains Sulphur (see Sulphur Heel) and Cortisonum acidum (see Cutis compositum).

Engystol N: Is immune supportive in allergic and viral cases, and contains sulfur, which is indicated in chronic issues.

Graphites homaccord: Treats pigmented, greasy lesions without hair.

Hepar compositum: Improves detoxification status by its action on the liver.

Psorinoheel: A phase remedy in Excretion and Impregnation cases. Psorinum is an extract of scabies mange excretions and has been used in classical homeopathy for many years. This also contains Sulfur, which is indicated in chronic conditions (see Sulphur-Heel). May be helpful in so-called constitutional cases.

Schwef-Heel: Works through its higher potency of Sulfur.

Solidago compositum: Used in Deposition phases, this remedy assists the skin by its support of the kidney.

Sulphur-Heel: Primarily named for the contained remedy, Sulphur, known for its use in various skin diseases, especially those of chronic nature, and pruritic eczema and suppurative skin diseases. Sulphur is one of the most important components of tissue in the body. Therefore, Sulphur is the major remedy in practically all cellular phases, particularly in the Impregnation Phase, which still displays a tendency to turn regressive. This also contains Mezereum, which is useful for pruritic skin irritations and skin suppuration, and has several other skin-active remedies as components.

Traumeel S: Treats inflammatory lesions with much inflammation.

Authors’ suggested protocols

Nutrition

Skin and immune support formula: 1 tablet for every 25 pounds of body weight BID.

Lymph support formula: One-half tablet for every 25 pounds of body weight BID.

Betathyme: 1 capsule for every 35 pounds of body weight BID. (maximum 2 capsules BID.)

Lecithin / phosphatidyl choline: One-fourth teaspoon for every 25 pounds of body weight BID.

Eskimo fish oil: One-fourth to 1 teaspoon per meal for cats. 1 teaspoon for every 35 pounds of body weight per meal for dogs.

Oil of evening primrose: 1 capsule for every 25 pounds of body weight SID.

Additional vitamin C: 100 mg for every 25 pounds of body weight BID.

Quercetin: 50 mg for every 10 pounds of body weight SID.

Chinese herbal medicine

To kill the mites, the authors use a combination of sulfur (Liu huang), 30g; realgar (Xiong huang), 15g; Alumen dehydratum (Ming fan), 45g; prickly-ash (Hua jiao), 25g; and Cnidium seed (She chuang zi), 25g. Mix well and apply topically daily for 2 to 3 weeks.

The authors also recommended H7 Immune Stimulator for 6 months in conjunction with Mitaban dips, daily Interceptor, Ivermectin, or herbal parasite dips to counteract immunosuppression. The H7 ImmuneStimulator is dosed at 1 capsule for every 10 to 20 pounds twice daily. In addition to the herbs mentioned above, Immune Stimulator contains euryale (Qian shi), longan fruit (Long yan rou), saussurea (Mu xiang), and white peony (Bai shao). These herbs increase the efficacy of the formula.

Homotoxicology

(Dose: 10 drops PO for 50-pound dog; 5 drops PO small dog or cat)

Psorinoheel and Schwef-Heel: Mixed and given twice daily orally.

Cutis compositum: Given initially, and then as needed.

Autosanguis Therapy:

1. Traumeel

2. Hepar compositum

3. Galium-Heel

4. Cutis Heel

5. Ubichinon compositum

Oral cocktail: Schwef homaccord, Psorinoheel, and Lymphomyosot, plus the remains of autosanguis in a syringe, taken orally BID to TID.

Echinacea compositum forte tabs: Use if needed.

Ivermectin: Give PO daily in breeds that can tolerate the drug.

Nutraceuticals: AFA Algae, GlutaDMG, vitamin E, fatty acids.

Product sources

Nutrition

Skin, immune and lymph support formula: Animal Nutrition Technologies. Alternatives: Immune System Support — Standard Process Veterinary Formulas; Immuno Support — Rx Vitamins for Pets; Immugen — Thorne Veterinary Products; Canine Dermal System Support — Standard Process Veterinary Formulas; Derma Strength — Vetri Science Laboratories.

Betathyme: Best for Your Pet. Alternative: Moducare — Thorne Veterinary Products.

Oil of evening primrose: Jarrow Formulas.

Eskimo fish oil: Tyler Encapsulations.

Lecithin / phosphatidyl choline: Designs for Health.

Quercetin: Source Naturals; Quercetone — Thorne Veterinary Products.

Chinese herbal medicine

Formula: H7 Immune Stimulator Natural Solutions, Inc.

Homotoxicology

BHI / Heel Corporation

Categories
Complementary Medicine

Spinal Arthritis

Spinal Arthritis / Spondylosis

Definition and cause

Spinal arthritis / spondylosis is a degenerative condition of the bony spinal column with associated osteophytic activity between vertebrae. It occurs in both dogs and cats and is believed to have an inherited predisposition or be the result of continual localized trauma and secondary inflammation to the bony vertebrae (see Arthritis). Spondylosis is often discovered radiographically with no associated clinical signs.

Medical therapy rationale, drug(s) of choice, and nutritional recommendations

Once clinical signs of pain, inflammation, and reduced mobility become evident, the treatment is corticosteroids or NSAIDs such as carpofen, deracoxib, meloxicam, or aspirin. Nothing has been reported to prevent progression of the condition.

Anticipated prognosis

The prognosis depends upon the extent of the arthritis and the resultant pain and impact upon the spinal cord. Pain and inflammation control offer good control of the signs. When the disease is progressive and has impacted the spinal cord and is causing neurological symptoms, the prognosis is more guarded.

Integrative veterinary therapies

Spinal arthritis occurs at the articular surfaces and has the same underlying mechanism as degenerative arthritis of the limbs. Medical treatment is directed toward the pain and inflammation, while integrative therapies are directed at the underlying cause of the inflammation and the associated degeneration that leads to the osteophytic process and potential compression of spinal nerves. Conventional medications address the inflammation and pain; however, they do not correct the underlying initiating inflammatory process.

Nutrition

General considerations / rationale

Nutritional and gland support are directed at reducing inflammation, protecting cells and tissue, and slowing the degenerative process.

Appropriate nutrients

Nutrition / gland support: Several studies have demonstrated the effectiveness of glucosamine and chondroitin in the management of arthritis in dogs. Setnikar et al (1986) has described how these compounds actually stimulate the body’s own repair mechanism and help in the process of developing new cartilage. Numerous double-blind studies have compared the effectiveness of glucosamine against various NSAIDs, resulting in as good or, in many cases, even better pain control and removal of the clinical signs associated with osteoarthritis.

Fatty acids: In a double-blind study of people with rheumatoid arthritis, Joe (1993) showed that a number of people had significant benefits from the addition of evening primrose oil (EPO). Kremer (1995) has shown that fish oil helps to reduce inflammation in people with arthritis.

Botanical cox2 inhibitors: Botanical Cox2 inhibitors have been shown to have antioxidative and antiinflammatory effects. Botanical Cox2 inhibitors offer the benefit of inflammation reduction without the inherent side effects of Cox2 medications.

Vitamin C: Vitamin C has been studied clinically in animals. Brown (1994), Berg (1990), and Newman (1995) reported on the benefits of vitamin C in the treatment of degenerative joint disease and movement in dogs and horses. Belfield (1981) reported on the beneficial effects of using vitamin C in treating and preventing hip dysplasia in dogs.

Lecithin / phosphatidyl choline: Lecithin / phosphatidyl choline is a phospholipid that is integral to cellular membranes. Lecithin / PC is an essential nutrient for the membranes of nerve cells and is essential for the proper conduction of nervous impulses.

Chinese herbal medicine / acupuncture

General considerations / rationale

Spinal arthritis is due to Wind, Damp, and Cold invading the body. This causes Kidney Qi and Yang deficiency, and Qi and Blood stagnation. Wind both blows the pathogen into the body and blows it around the body so the pain may wander from joint to joint. Damp causes stiffness and Cold implies that the condition tends to respond well to heat. Most people with degenerative skeletal conditions report that heat soothes the pain. Qi and Blood stagnation cause pain. The Kidney is charged with controlling bones, so when the Kidney suffers deficiency, arthritis may result. Again, as Yang is heat, a Kidney Yang deficiency may result in a sore skeletal lesion that responds well to heat therapy. Older patients are more likely to have degenerative spinal conditions and they are also more likely to have Kidney Yang deficiency. The Yang of the Kidney is used over the life of the individual.

Treatment options are designed to increase mobility and decrease pain and inflammation.

Appropriate Chinese herbs

Atractylodes (Cang zu): Increases the pain threshold. In addition, it can counteract xylene-induced ear swelling and carrageenin-induced foot swelling, which indicates that it may be useful in decreasing inflammation at the site of degenerative changes.

Aconite root (Fu zi): Reduces swelling and inflammation in joints. It has been shown to have analgesic properties.

Angelica (Bai zhi): Has been shown to have antiinflammatory and analgesic effects in mice.

Angelica root (Dang gui): As strong as aspirin at decreasing inflammation and is 1.7 times as strong as aspirin for pain relief.

Astragalus (Huang qi): Has demonstrated mild analgesic effects in mice.

Cinnamon twigs (Gui zhi): Have analgesic properties. Cinnamon twigs were part of a formula used in 30 patients with arthritis. There was complete recovery in 50% of those treated, marked improvement in 20%, and some improvement in 17%. Thirteen percent did not respond.

Coix (Yi yi ren): Has analgesic and antiinflammatory effects. It suppresses dimethylbenzene-induced auricular swelling and carrageenin-induced foot swelling in mice. It was shown to help women with severe menstrual cramps, which may indicate that it would be useful in treating the pain associated with spinal arthritis and spondylosis.

Earthworm (Di long): Has a significant analgesic effect.

Jujube fruit (Da zao): Decreases inflammation. It was shown to reduce dimethylbenzene-induced auricular inflammation in mice and egg-white-induced toe swelling in rats. This implies that it may be useful for decreasing the inflammation involved with degenerative vertebral conditions.

Licorice (Gan cao): Contains glycyrrhizin and glycyrrhetinic acid, which have antiinflammatory effects. They have approximately 10% of the corticosteroid activity of cortisone. They decrease edema and have antiarthritic effects. Licorice has demonstrated analgesic effects in mice, especially when combined with white peony (Bai shao).

Notopterygium root (Qiang huo): Has antiinflammatory and analgesic effects. In mice it was shown to decrease xylol-induced ear lobe swelling and carrageenin-induced foot pad edema, and increase the thermal pain threshold.

Sichuan aconite (Chuan wu): Seems to have a centrally mediated analgesic effect. In mice it was shown to be effective at decreasing inflammation and pain. It is stronger than aspirin at reducing inflammation. It controlled the signs in 92% of 150 human patients with arthritis when given in combination with Cao wu, Qiang huo, Du hua, Fu zi, Mo yao, Ru xiang, Dang gui, Chuan niu xi, Ma huang, Gui zhi, Wu gong, Chuan xiong, and Ma qian zi.

White peony (Bai shao): Contains paeoniflorin, which is a strong antiinflammatory. It has demonstrated specific effects on pain in the lower back.

Acupuncture

The World Health Organization (2006) lists lower back pain as one of the indications for acupuncture. One study looked at the use of abdominal acupuncture and electroacupuncture for treatment of prolapsed lumbar intervertebral discs. In this study there was complete relief from symptoms in 35% of the patients, significant improvement in 45% of the participants, slight improvement in 16%, and no response in 4%.

Homotoxicology

General considerations / rationale

Arthritis is a Deposition Phase disorder wherein material accumulates and eventually impedes the function of the joint. True arthritis of the spine occurs on the articular surfaces of the vertebral facets and is potentially painful. Spondylosis indicates degeneration of the spinal anatomy and is classified as a Degeneration Phase homotoxicosis. Spondylosis must be differentiated from spondylitis, and appropriate diagnostics conducted to rule out infectious agents.

Appropriate homotoxicology formulas

Also See Arthritis protocols, above, for a more detailed discussion of these remedies.

Atropinum compositum: Used for muscle spasm and pain. Currently only available in the United States as a tablet, but is extremely useful for acute, severe back pain.

BHI-Back: An important and commonly used formula supportive of the spinal column, and particularly the lower back. The component Colocynthis is indicated for sharp, tearing pain in the back that improves with warmth and deep pressure. Anger may be involved in these cases, and colitis may be an associated sign as well. Gnaphalium polycephalum is included for pain and / or numbness of the back and pelvis. Gelsemium sempervirens is included for neurologic weakness and muscle stiffness. Rhus toxicodendron is an important classical remedy for pain in tendons, ligaments, and soreness of condyles. Arsenicum album and Chamomilla complete this formula, with indications for cramps and neuralgia.

BHI-Sciatic Rx: Used for sciatica and neuralgia of the legs.

BHI-Spasm-Pain: Treats muscle spasm and back pain. Components of this formula help with sharp pains and spasms. This is a good alternative due to Atropinum compositum. Febrile conditions with back pain may respond due to Aconitum nepellus. Treats inflammation of other serosal membranes (joints and the abdomen) due to Bryonia alba. Colocynthis and Cuprum sulfuricum are included for sharp pains and menstrual-like cramps and other muscle spasms.

Cimicifuga homaccord: Treats pain and spasm of the cervical spine.

Coenzyme compositum: Supports energy metabolism.

Colocynthis homaccord: Treats lower back pain.

Discus compositum: Supports connective tissue that is associated with the spine.

Neuralgo-Rheum-Injeel: Contains Silicea, which is a major remedy for vaccinosis. Silicea is also contained in BHI-Alertness, BHI-Migraine, BHI-Neuralgia, Crurobeel, Discus compositum, Spigelon, Strumeel, and Zeel.

Osteoheel: Stimulates bone healing.

Spascupreel: Indicated for muscle spasm and pain. Compare its use to that of Atropinum compositum and BHI-Spasm-Pain. Contains Agaricus, a toxic mushroom indicated in homeopathic dilution for seizures, excitable conditions, motor tics, and sensitivity to cool air, among many other signs. It is helpful for migraine headaches and a wide variety of muscular spasmodic issues.

Testes compositum: Used for strengthening and draining the matrix in male patients with weakness. Contains Conium maculatum, which is useful in ascending hind-limb ataxia, weakness, and hemiplegia. Conium is also possibly useful in an older dog, and is also found in Cerebrum compositum, Cocculus compositum, Ginseng compositum, Rauwolfia compositum, Tbyroidea compositum, Tonsilla compositum, Ubichinon compositum, Vertigobeel, BHI-Circulation, BHI-Dizziness, BHI-Ligbtbeaded, and BHI-Stramonium complex. This remedy may cause detoxification / vicariation reactions and should be given with good observation and client education. It is highly useful in geriatric, male patients.

Traumeel S: A critically important formula that activates blocked enzymes. It is a nonsteroidal antiinflammatory agent (See the homotoxicology) for more extensive citations).

Zeel: A commonly used antiinflammatory that reduces pain and improves mobility (see the homotoxicology chapter for more extensive citations).

Authors’ suggested protocols

Nutrition

Cartilage / ligament / muscle / skeletal support and brain / nerve support formulas: 1 tablet for every 25 pounds of body weight BID.

Eskimo fish oil: One-half to 1 teaspoon per meal for cats. 1 teaspoon for every 35 pounds of body weight for dogs.

Evening primrose oil: 1 capsule (500 mgs) per 25 pounds of body weight daily.

Zyflamend: One-half dropper for each 25 pounds of body weight BID.

Lecithin / phosphatidyl choline: One-fourth teaspoon for every 25 pounds of body weight BID.

Chinese herbal medicine

Formula H39 Backrelief: 1 capsule per 10 to 20 pounds twice daily. It can be combined with NSAIDs and nutraceuticals if desired. It generally takes 2 to 4 weeks to see a response. In addition to the herbs listed above, Backrelief also contains aconite / cao (Cao wu), allium (Cong bai), carthamus (Hong hua), papaya (Mu gua), poria (Fu ling), and siler (Fang feng). These herbs increase the efficacy of the formula.

Recommended acupuncture points include BL23, BL40, GV4, ST36, Baihui, and GV3 (Handbook of traditional Chinese medicine Practitioners).

Homotoxicology

Symptom cocktail: Traumeel, Aesculus compositum, Cimicifuga homaccord (neck) or Colocynthis homaccord (lower spine), and Zeel, and / or BHI-Back mixed together and given orally BID to TID. Discus compositum given initially by injection and then orally 1 to 3 times weekly. Spascupreel, as an initial injection, then Atropinum compositum PRN (if available). Consider Dulcamara homaccord and Causticum compositum, if indicated, and Rhododendroneel, particularly if condition is worse with weather changes. Give Atropinum compositum tablets PRN.

Deep detoxification formula: Galium-Heel, Lymphomyosot, Hepar compositum, Solidago compositum, Thyroidea compositum, Coenzyme compositum, and Ubichinon compositum mixed together and given orally twice weekly for 2 to 4 weeks and then every other day. Adjust dosing based upon detoxification reactions observed.

Product sources

Nutrition

Cartilage / ligament / muscle / skeletal and brain / nerve support formulas: Animal Nutrition Technologies.

Alternatives: Cosequin — Nutramax Labs; Glycoflex — Vetri Science; Musculoskeletal support — Standard Process Veterinary Formulas; Nutriflex — Vet Rx Vitamins for Pets; Arthragen — Thorne Veterinary Products.

Evening primrose oil: Jarrow Formulas.

Eskimo fish oil: Tyler Encapsulations.

Zyflamend: New Chapter. Alternative: Botanical Treasures — Natura Health Products.

Lecithin / phosphatidyl choline: Designs for Health.

Chinese herbal medicine

Formula H39 Backrelief: Natural Solutions, Inc.

Homotoxicology

BHI / Heel Corporation

Categories
Complementary Medicine

Osteochondrosis

Definition and cause

Osteochondrosis is a growth disturbance, often leading to an overproduction of cartilage. This thickened cartilage leads to degeneration and necrosis. Coupled with improper nutrition and trauma, this excessive cartilage can lead to ostechondritis dessecans in the shoulder, elbow, or stifle joint. In addition, it is believed that improper nutrition and trauma to the cartilage surface contributes to the disease, often leading to a degenerative joint.

Medical therapy rationale, drug(s) of choice, and nutritional recommendations

Anti-inflammatory medications are used to control symptoms. They do not address the underlying degeneration, nor do they help to promote healing. Surgery is often indicated, especially when a flap of cartilage has formed. While surgery is often beneficial, it also does not address the underlying process and continual degeneration of the joint.

Anticipated prognosis

Shoulder disease responds well to surgery and often results in pain-free and full mobility. The prognosis for other joints such as the stifle and elbow is more guarded. This depends upon the progression of the lesion and the extent of the associated degenerative joint disease.

Integrative veterinary therapies

The cause of osteochondrosis is linked to developmental and nutritional factors. Suggested remedies include weight loss to ease the stress on the joint as well as chondroprotective agents that protect and strengthen the cartilage surfaces. In addition, the use of nutrients, antioxidants, phytonutrients, and antiinflammatories that nourish tissues and reduce free radical cellular reaction as compared to medical suppression of the inflammation are beneficial for short- and long-term prognosis. Medicinal herbal and homeopathic remedies also further improve the prognosis.

Nutrition

General considerations / rationale

The focus of nutritional support is on reducing inflammation, nourishing joint cells and tissues, improving circulation, and enhancing healthy cellular and tissue formation.

Chondroprotective agents: Several studies have demonstrated the effectiveness of glucosamine and chondriotin in the management of arthritis in dogs. Numerous double-blind studies have compared the effectiveness of glucosamine against various NSAIDs, resulting in as good or, in many cases, even better pain control and removal of the clinical signs associated with osteoarthritis. Additionally, the newer trend in the management of arthritis is toward chondroprotective agents such as glycosaminoglycans, pain-relieving agents such as methyl sulfonyl methane (MSM), and free radical scavengers such as superoxide dismutase (SOD).

Super oxide dismutase: Super oxide dismutase (SOD) is a potent destroyer of free radicals that can protect cells against oxidative damage. McCord (1974) reported that SOD can protect hyaluronate from free-radical damage and that it may have an antiinflammatory effect.

Vitamin C: Vitamin C has been studied clinically in animals. Brown (1994), Berg (1990), and Newman (1995) reported on the benefits of vitamin C in the treatment of degenerative joint disease and movement in dogs and in horses. Belfield (198) reported on the beneficial effects of using vitamin C in treatment and prevention of hip dysplasia in dogs.

Botanical Cox2 inhibitors: Botanical Cox2 inhibitors have been shown to have antioxidative and antiinflammatory effects. Botanical Cox 2 inhibitors offer the benefit of inflammation reduction without the inherent side effects of Cox2 medications.

Chinese herbal medicine / acupuncture

General considerations / rationale

Osteochondrosis is the result of Kidney Qi and Yang Deficiency. Wind, Cold, and Damp invade the body, leading to Qi and Blood stagnation. The Kidneys control the bones in traditional Chinese medicine theory. When the Kidney is deficient in energy (Qi) and heat (Yang), the bones can suffer. Wind can blow pathogens into the body and from one joint to the other. Cold and Damp make the joint stiff and painful. Application of warmth eases discomfort. When Qi and Blood cannot flow they accumulate and cause pain. Treatment involves decreasing inflammation and pain. Traditional Chinese medicine is different from Western medicine as different areas of the body are treated differently, even in the face of a single Western diagnosis. Therefore, separate formulas and acupuncture points are given for forelimb verses hindlimb disease.

Appropriate Chinese herbs for hindlimb osteochondrosis

Achyranthes (Niu xi): Has analgesic effects. This was demonstrated in body torsion and hot plate experiments in mice. It also has antiinflammatory effects. It can prevent egg-white-induced foot swelling and formaldehyde-induced arthritis.

Aconite / chuan (Chuan wu): Has a centrally mediated analgesic effect. In mice it was shown to be effective for decreasing inflammation and pain. It is stronger than aspirin at reducing inflammation. It controlled the signs in 92% of 150 human patients with arthritis when given in combination with Cao wu, Qiang huo, Du hua, Fu zi, Mo yao, Ru xiang, Dang gui, Chuan niu xi, Ma huang, Gui zhi, Wu gong, Chuan xiong, and Ma qian zi.

Angelica (Bai zhi): Has demonstrated antiinflammatory effects in mice. It also decreases pain.

Angelica root (Dang gui): As strong as aspirin at decreasing inflammation and is 1.7 times as strong as aspirin for pain relief. Dang Gui plus ligusticus (Chuan xiong) was 97% effective in treating lower back and leg pain.

Atractylodes (Cang zhu): Has analgesic effects. This was demonstrated using body torsion and heat-induced pain tests. It also has antiinflammatory effects. It has been shown to prevent xylene-induced ear swelling and carrageenin-induced foot swelling.

Cinnamon bark (Rou gui): Inhibits both acute and chronic inflammation. It has demonstrated the ability to inhibit carrageenin-induced foot swelling and prevent adjuvant-induced arthritis.

Corydalis (Yan hu suo): Has antiinflammatory properties. It inhibits histamine release and formation of edema in rats and has been shown to be effective for both acute and chronic inflammation. It increases the efficacy of acupuncture in inducing analgesia.

Dipsacus (Xu duan): Has antiinflammatory properties. It can inhibit foot swelling in hamsters and dimethyl benzene-induced ear inflammation.

Dragon’s blood (Xue jie): Has been used to treat arthritis. In one study involving 150 participants with arthritis, 84% reported marked reduction in symptoms and 10% more reported some pain relief.

Drynaria (Gu sui bu): Was used to treat 160 mice with osteoarthritis with good results.

Eucommia bark (Du Zhong): An effective analgesic.

Jujube (Da zao): Has antiinflammatory effects. It has been shown to prevent dimethylbenzene-induced ear swelling in mice and egg-white-induced toe swelling in rats.

Lycopodium (Shen jin cao): Has antiinflammatory and analgesic effects. It ameliorates heat-induced pain and reduces dimethylbenzene-induced ear swelling.

Mastic (Ru xiang): Contains boswellic acids, which have antiinflammatory effects in vivo and in vitro. Mastic decreases signs of arthritis in dogs.

Myrrh (Mo yao): A very good analgesic, especially when combined with ru xiang.

Pubescent angelica root (Du hou): Has demonstrated analgesic and antiinflammatory effects in mice.

White atractylodes (Bai zhu): Has been used with some success in patients suffering from chronic leg pain.

White peony (Bai shao): Contains paeoniflorin, which is a strong antiinflammatory. In one trial, 65% of people suffering from painful conditions experienced relief when given white peony.

Appropriate Chinese herbs for forelimb osteochondrosis

Aconite / chuan (Chuan wu): See above.

Angelica (Bai zhi): See above.

Cinnamon twigs (Gui zhi): Have analgesic properties. In one trial, 30 patients were treated with a formula containing cinnamon twigs and other herbs. There was complete recovery in 50%, marked improvement in 20%, and some improvement in 17%. Thirteen percent did not respond.

Ginger (Sheng jiang): Has antiinflammatory effects. It decreases dimethylbenzene-induced ear swelling in mice and egg-white-induced toe swelling in rats. It has been used to treat patients with arthritis. In one trial 113 of 125 people with arthritis responded to injections of ginger into acupoints.

Jujube fruit (Da zao): See above.

Licorice (Gan cao): Has analgesic effects, especially when administered with white peony (Bai shao).

Lycopodium (Shen jin cao): See above.

Mastic (Ru xiang): See above.

Myrrh (Mo yao): See above.

Notopterygium (Qiang huo): Has both antiinflammatory and analgesic effects. It can inhibit xylol-induced ear lobe swelling and carrageenin-induced foot swelling in mice, and increase the thermal pain threshold.

White peony (Bai shao): See above.

Acupuncture

Many people seek acupuncture therapy for musculoskeletal pain. Clinical trials have shown that arthritis can be treated successfully using acupuncture.

Homotoxicology

General considerations / rationale

Osteochondrosis represents a Deposition or Degeneration phase homotoxicosis. Therapy is directed at improving the status of the mesenchymal tissues. In early cases, these lesions may heal without surgery, and early intervention with antihomotoxic medications may assist the body in its innate reparative processes. Early diagnosis through radiography, MRI, or bone scans may assist in determining the optimal therapy for each patient.

Appropriate homotoxicology formulas

See Arthritis and Autoimmune Arthritis for a more complete discussion of remedies.

No controlled studies exist at this time for use of antihomotoxic agents in osteochondrosis, but appropriate selections include:

Coenzytne compositum: Supports energy metabolism. Succinate is useful in retarded development, which this condition may represent.

Discus compositum: Treats inflammation and degeneration of mesenchyme.

Lymphomyosot: Reduces swelling and improves lymphatic drainage with a corresponding decrease in local homotoxin levels.

Osteoheel: Supports bony structures. Can be alternated with Traumeel for maximal effect.

Placenta compositum: Provides support of stem cells and vasculature.

Molybdan compositum: Provides trace elements in degenerative conditions.

Thyroidea compositum: Acts on the thymus and therefore may assist in growth irregularities and support a wide variety of endocrine tissues. It is also a powerful agent in drainage of the mesenchyme.

Traumeel S: Used for inflammation and to unblock inactivated enzymes.

Ubichinon compositum: Provides support of energy metabolism in deeper homotoxicoses.

Zeel: An antiinflammatory agent with regenerative potential through activation of stem cells.

Authors’ suggested protocols

Nutrition

Cartilage / ligament / muscle / skeletal support formula: 1 tablet for every 25 pounds of body weight BID.

Eskimo fish oil: One-half to 1 teaspoon per meal for cats. 1 teaspoon for every 35 pounds of body weight for dogs.

Evening primrose oil: 1 capsule (500 mgs) per 25 pounds of body weight, daily.

Zyflamend: One-half dropper for every 25 pounds of body weight BID.

SOD: Follow manufacturer’s suggested dosage.

Chinese herbal medicine

The author recommends Formula H3 ElboPhlex for osteochondrosis of the front legs and H97 HipGuard for osteochondrosis of the hind legs at a dose of 1 capsule per 10 to 20 pounds, twice daily. They can be combined with NSAIDs and / or nutraceuticals as needed. Generally speaking, it takes up to 3 to 6 months for complete resolution of signs in most cases.

H97 HipGuard: Contains achyranthes (Niu xi), aconite / chuan (Chuan wu), angelica (Bai zhi), angelica root (Dang gui), astragalus (Huang qi), atractylodes (Cang zhu), cinnamon (Rou gui), citrus (Chen pi), corydalis (Yan hu suo), curcuma (Yu jin), dioscorea (Chuan shan long), dipsacus (Xu duan), dragon’s blood (Xue jie), drynaria (Gu sui bu), eucommia bark (Du Zhong), eupolyphaga (Tu bie chong), jujube (Da zao), lycopodium (Shen jin cao), mastic (Ru xiang), morinda (Ba ji tian), myrrh (Mo yao), pubescent angelica root (Du huo), white atractylodes (Bai zhu), and white peony (Bai shao). The herbs not mentioned above (under Appropriate Chinese Herbs) help increase the efficacy of the formula.

H3 ElboPhlex: Contains aconite / chuan (Chuan wu), angelica (Bai zhi), centipede (Wu gong), cinnamon twigs (Gui zhi), codonopsis (Dang shen), dioscorea (Chuan shan long), ginger (Sheng Jiang), jujube fruit (Da zao), licorice (Gan cao), lycopodium (Shen jin cao), mastic (Ru xiang), mulberry twig (Sang zhi), myrrh (Mo yao), not-opterygium (Qiang huo), papaya (Mu gua), pueraria (Ge gen), and white peony (Bai shao). The additional herbs not discussed above (under Appropriate Chinese Herbs) increase the efficacy of the formula.

For the hindlimbs, the author recommends the following acupuncture points: ST36, ST37, Baihui, BL60, GV4, and BL23. For the forelimbs, the author recommends LI11, PC6, SI9, Baihui, and BL23.

Homotoxicology

Discus compositum: Give every 3 days PO or SQ, alternating with Thyroidea compositum. Give Ubichinon compositum twice weekly.

Aesculus compositum, Traumeel, and Lymphomyosot: Mix together and give orally BID.

Osteoheel, Calcoheel, and / or BHI-Bone: Give orally BID as indicated by the individual case.

Zeel: Give tablets BID, and / or Zeel P vials injected into acupoints for the affected joint every week.

Molybdan SID: Use for mineral donor support.

Product sources

Nutrition

Cartilage / ligament / muscle / skeletal support formula:

Animal Nutrition Technologies. Alternative: Cosequin — Nutramax Labs; Glycoflex — Vetri Science; Musculoskeletal support — Standard Process Veterinary Formulas; Nutriflex — Vet Rx Vitamins for Pets; Arthragen — Thorne Veterinary Products.

Evening primrose oil: Jarrow Formulas.

Eskimo fish oil: Tyler Encapsulations.

Zyflamend: New Chapter. Alternative: Botanical Treasures — Natura Health Products.

SOD: Cell Advance — Vetri Science; NaturVet SOD; BioPet International; N-Zymes.com.

Chinese herbal medicine

Formulas H3 ElboPhlex, H97 HipGuard: Natural Solutions, Inc.

Homotoxicology

BHI / Heel Corporation

Categories
Complementary Medicine

Arthritis

Definition and cause

Arthritis is a degenerative, progressive disease of the cartilage and synovial surface of the joint. Although arthritis is distinguished from immune-mediated arthritis because it is classified as non-inflammatory, inflammation is believed to be an important part of the initiation and ongoing breakdown of tissue in the joint. Arthritis in dogs and cats is assumed to be related to the aging process as well as secondary to other factors such as injury, physical deformity, overuse, and other diseases such as dental disease. Continual loss or breakdown of the joint surface often leads to pain, inflammation, and permanent deformity.

Medical therapy rationale, drug(s) of choice, and nutritional recommendations

More integrative options exist for arthritis than any other disease condition. The conventional approach is the use of antiinflammatory and pain-suppressing drugs such as corticosteroids and NSAIDs. The potential side effects from the chronic use of these drugs have led to alternative approaches such as reconstructive surgical procedures and joint replacement. Dietary management is most commonly used for weight reduction. The newer trend in arthritis management is toward chondroprotective agents such as Adequan®, and nutraceuticals such as glycosaminoglycan (glucosamine), pain-relieving agents such as methyl sulfonyl methane (MSM), and free radical scavengers such as superoxide dismutase (SOD).

Anticipated prognosis

Arthritis is a progressive degenerative disease. The approach of medically addressing the symptoms and surgically correcting the problem simply corrects the associated symptoms. The addition of chondroprotective agents, nutraceuticals, and a weight loss program greatly increases the likelihood of control of the disease and offers a much improved prognosis. Arthritis offers a good example of the proven effects of the integrative approach to treating a disease condition.

Integrative veterinary therapies

The conventional medical approach to arthritis focuses upon the signs and symptoms of the disease. While the degenerative process is physically located in the joints, the underlying mechanism begins with an inflammatory process at the cellular level. This process initiates the pain and swelling, but also results in the decrease in synovial fluid production, leading to further friction, inflammation, and degeneration. Adding nutritional and alternative therapies helps to reduce free radical production, decrease inflammation, enhance synovial fluid production, and slow or prevent further degeneration. In addition, if started early, it can reduce the dependence upon or minimize the use of medications.

Nonsteroidal antiinflammatory drugs frequently have adverse effects, now more commonly known by consumers. They are useful for short-term therapy and in cases of severely advanced osteoarthritis in which safer therapies no longer suffice.

Nutrition

General considerations / rationale

Nutritional and gland support are directed toward reducing inflammation and protecting cells and tissue. Medication, on the other hand, covers up the inflammation; however, it does not get to the underlying cause nor does it confer cellular protection. Nutritional therapies also focus upon improving nutrient flow to the cells and tissues of the joints and help to prevent a decrease in the production of synovial fluid.

Appropriate nutrients

Chondroprotective agents: The body uses glucosamine to make and repair joint tissue and cartilage. Glucosamine has been clinically proven to significantly reduce the pain, inflammation, and swelling associated with osteoarthritis in both people and animals. Glucosamine has been shown to have none of the side effects of drugs, and can be as effective as prescribed medications.

Several studies have demonstrated the effectiveness of glucosamine and chondroitin in the management of arthritis in dogs. Setnikar et al. (1986) has described how these compounds actually stimulate the body’s own repair mechanism and help in the process of developing new cartilage. Numerous double-blind studies have compared the effectiveness of glucosamine against various NSAIDs, resulting in as good or, in many cases, even better pain control and removal of the clinical signs associated with osteoarthritis.

Chondroitin sulfate (CS) is found in the lining of the joints, and clinical evidence in double-blind studies shows that supplementation with CS reduces pain and inflammation and increases joint mobility. In the veterinary field, Anderson (1999) and Canapp (1999) showed that there was significant reduction in pain and improved mobility as reported by survey veterinarians.

Fatty acids: In a double-blind study of people with rheumatoid arthritis, Joe (1993) showed that a number of people had significant benefits from the addition of evening primrose oil (EPO). Kremer (1995) has shown that fish oil helps to reduce inflammation in people with arthritis.

Botanical Cox2 inhibitors: Botanical Cox2 inhibitors have been shown to have antioxidative and antiinflammatory effects. Botanical Cox 2 inhibitors reduce inflammation without the inherent side effects of Cox2 medications.

Vitamin C: Vitamin C has been studied clinically in animals. Brown (1994), Berg (1990), and Newman (1995) reported on the benefits of vitamin C in the treatment of degenerative joint disease and movement in dogs and horses. Belfield reported on the beneficial effects of vitamin C in treating and preventing hip dys-plasia in dogs.

Chinese herbal medicine / acupuncture

General considerations / rationale

Practitioners of traditional Chinese medicine consider arthritis to be a combination of Wind, Damp, and Cold. The Kidney, which has the function of controlling the bones, is the main organ that is involved. Wind is a traveling pathogen, according to traditional Chinese medicine (traditional Chinese medicine). It refers to the tendency of arthritis to manifest in various joints on different days. Wind also refers to motion. Some animals with arthritis may have twitching of the muscles, spasms, or trembling in the affected area. Cold causes stiffness, as many practitioners note. Animals tend to have more trouble getting up and mobilizing on colder days. Cold also causes pain. The animals often prefer warm areas on cold days. People know from experience that a heating pad helps decrease the pain associated with arthritis. Damp refers to swelling in the joint, i.e., the accumulation of fluids in the joint.

In addition to treating the signs of arthritis, it is important to address the underlying cause, such as rickettsial diseases, bacterial infections, and excess weight. Immune-mediated arthritis must be treated differently than degenerative arthritis.

Appropriate Chinese herbs

Aconite (Fu zi): Effectively decreases joint inflammation and has analgesic properties.

Angelica (Bai zhi): Has antiinflammatory and analgesic properties. It contains scopoletin, an effective muscle relaxant.

Atractylodes (Bai zhu): Has been shown to decrease pain related to chronic back and leg arthritis in humans.

Bupleurum (Chai hu): Contains saikosaponin, which has analgesic properties.

Cinnamon twigs (Gui zhi): Have analgesic effects. Licorice contains two compounds, glycyrrhizin and glycrrhetinic acid, which have shown efficacy in treating arthritis.

Ginger (Sheng jiang): Has been shown to be effective in decreasing arthritis pain in several studies.

Notopterygium (Qiang huo): Has been shown to relieve muscular pain in mice.

Pubescent angelica root (Du huo): Has demonstrated antiinflammatory and analgesic effects.

White peony (Bai shao): Contains paeoniflorin, which is a strong antiinflammatory. It is an effective pain reliever, and in combination with gan cao is excellent for muscle spasms.

Acupuncture

Musculoskeletal disease is one of the most common reasons for seeking acupuncture treatment in this country. Acupuncture has been used extensively and effectively in all types of arthritic conditions. There are generalized points one can choose for acupuncture. For example, bai hua is a good choice for treating generalized weakness associated with muscle atrophy. In addition to being a good point to increase the body’s energy, it also serves as a local point for the hip joint, lumbar spine, and hind legs.

Local points also may be chosen. The following is a list of specific areas and possible point choices according to the author’s experience:

Neck: SI16, LI18, BL10

Shoulders: SI9, SI10, TH14

Elbow: LI11, Qiang Feng.

Carpus: PC6, TH5

Back: Hua tuo jia ji (points just lateral to each vertebrae chosen according to the location of the pain)

Hip: BL54, GB28, GB29

Stifle: GB34, ST35

Hock: BL60, KI3

Homotoxicology

General considerations / rationale

Osteoarthritis, a degenerative, nonautoimmune form of arthritis, represents homotoxicoses in the Inflammation, Deposition, and Degenerative phases, and is a common entity in veterinary medicine. Therapy is aimed at reducing homotoxin levels, improving circulation and lymphatic flows, reducing inflammatory pain, and improving mobility. Proper diet, adequate exercise, and weight management are critical to the success of any program designed to assist the osteoarthritis patient. Agents should be chosen initially that have minimal risk to the patient. An initial treatment period of 5 to 8 weeks is needed to properly assess response. Biological agents frequently require a longer window to demonstrate their effects, and clients should be advised of this fact at the initiation of therapy.

Homotoxicology has many biological agents that assist in managing arthritis with a minimum of harmful side effects, and consumers appreciate this immensely. Many clinicians take their first steps toward biological therapy in pursuit of better methods of pain management and rehabilitation for their patients, as well as for themselves. Some evidence for the effectiveness of antihomotoxic pain medications is discussed in the homotoxicology chapter of this text.

Appropriate homotoxicology formulas

Homeopathic strategies vary depending upon the anatomical location of the osteoarthritis as well as the presence or absence of other aggravating factors (cold, damp, skin rashes, etc (also see Autoimmune Arthritis in site). The following remedies have proven themselves in hundreds of cases in the authors’ clinics:

Aconitum homaccord: Treats polyarthrtis, particularly when combined with Rbododendroneel S and Bryaconeel.

Aesculus compositum: Is primarily a peripheral circulatory agent, but contains Rhus tox, Ruta graviolens, and Arnica, which are all excellent arthritis remedies.

Atropinum compositum: Treats painful muscle spasms associated with arthropathy.

BHI-Arthritis: Used for swollen, painful joints and muscle stiffness. Particularly useful for patients that are more affected in cold, wet weather.

BHI-Back: Treats back pain, muscle spasm, arthropathy.

Bryaconeel: Treats polyarthritis, particularly when combined with Rbododendroneel S and Aconitum homaccord.

Calcoheel: Used for disordered calcium metabolism.

Cimicifuga homaccord: Treats neck pain and chronic luxations of pedal joints.

Colnadul: Used for arthritis that worsens with wet weather. It is particularly suited to knee problems, e.g. chronic dislocations. The authors use this in stifle issues.

Colocynthis homaccord: Used as an initial therapeutic agent, particularly for acutely painful conditions involving the lower back and hips. Initially use it every 15 to 30 minutes, until relief is noted.

Cruroheel: Used particularly for afflictions of the hind limbs.

Discus compositum: Treats spinal arthropathy.

Dulcamara homaccord: Used for arthritis worsened by wet weather.

Ferrum homaccord: Treats shoulder pain and shoulder-hand syndromes.

Gelsemium homaccord: Treats head and neck pain and lower limb weakness.

Graphites homaccord: Used for deforming arthropathies.

Lithiumeel: Treats osteoarthritis of the hip joints, and is useful in conjunction with Graphites homaccord in hipdysplasia-induced osteoarthritis.

Osteoheel: Treats ankle pain.

Psorinoheel: Indicated in chronic polyarthritis. There is some evidence for microbial causes of arthritides, e.g., mycoplasmas, and this remedy may have applicability for therapy.

Rheuma-Heel: Treats left-sided arthritis of the shoulder or knee.

Rhododendroneel S: Treats polyarthritis, particularly when combined with Bryaconeel and Aconitum homaccord.

Traumeel S: Useful in the form of vials, drops, tablets, ointment, and gel in many applications in osteo-arthritis cases, particularly in the early phases for control of acute pain. This formula has more scientific research than any other homeopathic remedy and is listed in the Physician’s Desk Reference as a nonsteroidal antiinflammatory agent (see the homotoxicology chapter for references).

Zeel: Useful in the form of ampules, tablets, ointment, and gel as the main long-term remedy for osteoarthritis. Revitalizes tissues through Catilago suis, Funiculus umbilicus, and Placenta suis. It includes a number of homeopathic botanicals that are useful in arthritis (Rhus tox, Arnica, Solanum dulcamara, Symphytum officinale, and Sanguinaria). It also has agents that assist in metabolism (Sulphur, Nicotinamide adenine dinucleotide [NAD], Coenzyme A, alpha-lipoic acid, and sodium oxalacetate). It is useful for arthritic pathology in any location, but it is best for stifle arthritis. Combine with other agents to target specific anatomical areas (See the homotoxicology chapter references).

Authors’ suggested protocols

Nutrition

Cartilage / ligament / muscle / skeletal support formula: 1 tablet for every 25 pounds of body weight BID.

Eskimo fish oil: One-half to 1 teaspoon per meal for cats. 1 teaspoon for every 35 pounds of body weight for dogs.

Evening primrose oil: 1 capsule (500 mgs) for every 25 pounds of body weight daily.

Zyflamend: One-half dropper for every 25 pounds of body weight BID.

Chinese herbal medicine / acupuncture

JointGuard: 1 capsule per 10 to 20 pounds twice daily. This supplement has analgesic, antiinflammatory, and antipyretic effects. In addition to the herbs mentioned above, JointGuard also contains amenarrhena (Zhi mu), allium (Cong bai), siler (Fang feng), cnidium (Chuan xiong), platycodon (Jie geng), bitter orange (Zhi ke), peu-cedanum (Qian hu), poria (Fu ling), and jujube fruit (Da Zao).

Homotoxicology

Initial therapy: Traumeel S drops BID and Zeel tablets twice daily; recheck in 3 weeks. Injection therapy, bio-puncture, or autosanguis with these agents can be very useful and can be repeated every 2 weeks to speed up response. Select other agents to target specific locations or symptoms.

Product sources

Nutrition

Cartilage / ligament / muscle / skeletal support formula:

Animal Nutrition Technologies. Alternatives: Cosequin — Nutramax Labs; Glycoflex — Vetri Science; Musculoskeletal support — Standard Process Veterinary Formulas; Nutriflex — Vet Rx Vitamins for Pets; Arthragen — Thorne Veterinary Products.

Evening primrose oil: Jarrow Formulas.

Eskimo fish oil: Tyler Encapsulations.

Zyflamend: New Chapter. Alternative: Botanical Treasures — Natura Health Products.

Chinese herbal medicine

HI and H95: Natural Solutions, Inc.

Homotoxicology

BHI / Heel Corporation

Categories
Complementary Medicine

Tooth Extraction

Definition and cause

Most common causes that necessitate tooth extraction are secondary to trauma or periodontal disease. Causes of periodontal disease include plaque, tartar, calculus buildup, and bacterial contamination. Underlying causes are related to genetic predisposition, age, and status of the immune system, as well as oral hygiene. Causes secondary to other disease such as neoplasia or parathyroid disease also occur. Signs range from mild redness and halitosis to purulent discharge, anorexia, and bleeding.

Medical therapy rationale, drug(s) of choice, and nutritional recommendations

Tooth extraction is generally curative for local infections and generally requires antimicrobial and possible antiinflammatory medications post-operative. Dietary recommendations include feeding a soft diet.

Anticipated prognosis

Traumatic injuries generally heal well postextraction. Extraction with early periodontal disease usually has a good prognosis, while more advanced periodontal disease has a more guarded prognosis. Oral tumors generally carry a poor prognosis.

Integrative veterinary therapies

An integrative approach to dental care emphasizes prevention. Because the most common cause of tooth extraction is periodontal disease, improvement of oral health directly impacts other organ systems such as the heart and kidney. While extraction is generally curative for the local condition, the integrative approach focuses upon general immune competence, the prevention of future periodonatal disease, and avoiding tooth extractions.

Nutrition

General considerations / rationale

The nutritional approach to oral health consists of reducing inflammation, improving immune competency, and preventing infection.

Appropriate nutrients

Nutrition / gland therapy: Nutrition and glandular adrenal, thymus, and bone marrow can help neutralize a cellular immune attack and provide antioxidants to reduce inflammation and specific nutrients to improve oxygenation (see Gland Therapy, site, for additional information)

Coenzyme Q10: CoQ10 is a strong antioxidant and help reduce the associated inflammation that is the predecessor to many chronic diseases. It has indications in the prevention and treatment of chronic diseases such as gingivitis and periodontal disease.

With regards to periodontal disease, double-blind clinical trials show that people who supplemented with Coenzyme Q10 had improved results as compared to those taking only a placebo. Research suggests that periodontal disease is directly linked to a Coenzyme Q10 deficiency. In addition, double-blind studies show that 50 mg given daily for 3 weeks significantly reduced the symptoms of periodonatal disease.

Vitamin C: Vaananen (1993) showed that people who are vitamin-C-deficient are more prone to periodontal disease. Aurer-Kozelj (1982) showed that increasing the daily dose of vitamin C from 20 to 35 mg to 70 mg showed a significant improvement in periodontal disease.

Chinese herbal medicine / acupuncture

General considerations / rationale

Periodontal disease is due to Stomach Heat rising, and Qi, Blood, and Yin deficiency in the Kidney. The Stomach “opens” to the Mouth, according to Traditional Chinese Medicine. This means that disease processes in the Stomach may be reflected in the Mouth. Heat in the Stomach can cause red, irritated, inflamed gingiva. (We now know that the “heat” is locally produced by reaction to bacteria in the oral cavity, not in the stomach). The Kidney controls the bones, so when the Kidney suffers from Yin and Blood deficiency it means the bones may not be nourished by the normal fluids. As a result, the bone may degenerate. Deficient Kidney Qi means the bone is not strong enough to hold the teeth in place. The teeth loosen when periodontal bone degenerates.

Treatment is aimed at relieving the inflammation and irritation and modifying the intraoral bacterial population.

Appropriate Chinese herbs

Alisma (Ze xie): Has dual functions of enhancing immunity and decreasing inflammation. Enhanced immunity controls overgrowth of oral bacteria.

Anemarrhena (Zhi mu): Increases the corticosterone level in serum and decreases inflammation.

Angelica (Dang gui): Has antiinflammatory action, yet does not cause immunosuppresion. In fact, it increases phagocytic activity of macrophages.

Cinnamon (Rou gui): Normalizes the immune system. It decreases production of nonspecific antibodies. At the same time it increases the reticuloendothelial system’s ability to phagocytize foreign material. Cinnamon has been proven to have antiinflammatory effects on both acute and chronic inflammatory conditions. It may help to decrease inflammation, yet not produce immunosuppression which would allow intraoral bacteria to proliferate and cause more destruction.

Crataegus (Shan zha): Enhances immunity. It increases serum lysozyme levels, serum antibody levels, and T cell activity. In addition to its effects on immunity, it has direct antibiotic activity on some bacteria.

Forsythia (Lian qiao): Reduces edema and inflammation by decreasing capillary permeability. It has demonstrated antiviral and antibacterial effects.

Honeysuckle (Jin yin hua): Has antibacterial activity mainly due to chlorogenic acid and isochlorogenic acid. Anti-inflammatory effects have been demonstrated experimentally in rabbits and mice.

Isatis root (Ban Ian gen): Possesses antiviral activity. In some cases it is as effective as ribavirin. It also has antibacterial efficacy. In addition to direct effects on pathogens, isatis root stimulates the immune system. It seems to affect both humoral and cellular immunity.

Licorice (Gan cao): Contains glycyrrhizin and glycyrrhetinic acid. These chemicals have approximately 10% of the steroid effects of cortisone. In addition, glycyrrhizin has shown activity against several viruses and therefore may be of use in viral-mediated stomatitis.

Ophiopogon (Mai dong): Has demonstrated the ability to inhibit several types of bacteria.

Oriental wormwood (Yin chen): Contains capillarin, which has antiinflammatory properties.

Phellodendron (Huang bai): Has antibacterial actions against a variety of bacteria.

Plantain seeds (Che qian zi): Decrease inflammation by decreasing capillary permeability.

Red peony (Chi shao): Stimulates cellular immunity by enhancing proliferation of T cells.

Rehmannia (Sheng di huang): Increases the plasma levels of adrenocortical hormone. This may increase the amount of cortisol in circulation and decrease inflammation in the oral cavity. Rehmannia has been shown to reduce swelling and inflammation.

Scrophularia (Xuan shen): Inhibits many strains of bacteria.

Sophora root (Shan dou gen): Stimulates the humoral immune system resulting in increased levels of IgM and IgG. It also has activity against several types of bacteria.

Acupuncture

Liu Zhong, et al. (1996) treated 98 people suffering from chronic periodontitis with a combination of blood letting and acupuncture. The following acupuncture points were used: ST45, LI2, and KI3. After acupuncture, 1 ml of blood was removed from Li dui and Er jian. Sixty-three people had total resolution of signs, 29 people improved, and 6 people did not respond.

Homotoxicology

General considerations / rationale

Tooth extractions become necessary when the condition of the tooth and / or periodontal structures decline to the Degeneration Phase. At this point the best treatment is removal of the tooth because it no longer serves its vital function of mastication and protection and has taken on a toxic quality due to infection and loss of architecture. Good surgical technique, appropriate anesthesia, and pain management are recommended. Following surgery, antihomotoxic drugs can greatly improve patient comfort and surgical outcomes.

Appropriate homotoxicology formulas

Belladonna homaccord: Used for right-sided, intensely red tonsillitis; pharyngitis; poor appetite; nausea and vomiting; stinging rectal pain; and focal and intense inflammatory lesions. Also used for cholangitis.

Coenzytne compositum: Includes Citricum acidum, which is useful for dental problems and gingivitis; scurvy; blackening of teeth and heavy deposits of dental plaque; painful, herpetic vesicles around the lips; nausea; painful cramping in the umbilical area; and distension.

Echinacea compositum: The natural alternative to antibiotics, this formula supports improved immune function and is appropriate in any infection. It is a phase remedy for the Inflammation Phase.

Galium-Heel: Treats all cellular phases, hemorrhoids, and anal fissures, and is a detoxicant.

Gastricumeel: Treats acute gastritis. It includes Anti-monium crudum, so it is indicated for tooth decay and toothache, and thus, may be useful when dental work is indicated.

Lymphomyosot: Provides lymph drainage and endocrine support, and treats edema. Contains Gentiana for chronic gastritis; flatulence; diarrhea; and distension of stomach with eructations, nausea, retching, and vomiting. It also contains Geranium robertianum, which is useful for nausea, particularly after eating, with distension or sensation of fullness. Myosotis arvensis is included and has indications for bloat and distension.

Mucosa compositum: Broadly supportive for repair of mucosal elements. Used in cellular cases and in recovery periods following active disease. This remedy contains a useful component in Kali bichromicum, which is indicated for ulcers found on the gums, tongue, lips, and even the gastric mucosa (gastric or duodenal ulcer). The tongue may have a thick, yellow, mucous coating, or, in ulcerative stomatitis or tonsillitis it may be dry, smooth, shiny, or fissured. Kali has been used effectively in acute gastroenteritis associated with vomiting of clear, light-colored fluid or quantities of mucous bile, and in cases with hematemesis, flatulent colics, and dysenteric stools with tenesmus.

It contains Hydrastis, with mucosal support for oral problems such as stomatitis and mucosal suppuration, accompanied by ulceration, inflammations and colic of the hepatobiliary system and the gastrointestinal tract, and polyp formation. The Kreosotum component can be used in chronic gastritis with gastric hemorrhages and vomiting of brown masses. Also has a dental implication in cases with spongy gums and carious teeth, neuralgias proceeding from them causing a burning toothache with deep caries, black patches on the teeth, and fetid discharges.

The single remedy Phosphorus is broadly useful for dyspepsia and for jaw problems in dental disease. Phosphorus is found in many other remedies, including Echinacea compositum and Leptandra bomoaccord. It is rich in suis organ preparations for mucosal support, plus a large variety of remedies with indications in the gastrointestinal sphere. Also contained in this broad remedy is Argentum nitricum (also in Atropinum compositum, Diarrheel, Duodenobeel, Gastricumeel, Momordica compositum, BHI-Nausea, and several other combinations). It is used for distension in the upper abdomen and the gastro-cardiac symptom-complex, and for amelioration from eructations. It is also used for gastric crises.

Nux vomica homaccord: Used for liver and gastrointestinal disease, and after smoke inhalation. It is useful in gingivitis. Nux vomica homaccord is a commonly used formula for detoxification as part of the Detox Kit. Recent research shows that one ingredient (Brucine) affects mitochondria in human hepatoma cells. Further research is needed to determine if homeopathic dilutions are more or less active.

Osteoheel: Facilitates healing of bone and reduction of pain involved with surgery and fracture. Contains Asa foetida for stabbing ostealgia and periostitis and Mercu-rius praecipitatus for bone fistula.

Traumeel S: Used as an antiinflammatory and for repairing blocked enzymes and regulating rigidity patients. It provides control of pain through speeded healing and homotoxin removal, according to human studies.

Ubichinon compositum: Contains Anthraquinone for swelling of the gums and GI symptoms such as distention, flatulence, and cramping abdominal pain. Treats constipation with straining or sudden diarrhea.

Authors’ suggested protocols

Nutrition

Immune and gingival / mouth support formulas: 1 tablet for every 25 pounds of body weight BID.

Coenzyme Q10: 25 mg for every 10 pounds of body weight daily.

Additional vitamin C: 100 mg for every 25 pounds of body weight BID.

Chinese herbal medicine / acupuncture

Formula H80 Gingival stomatitis / chronic: 1 capsule per 10 to 20 pounds twice daily. In addition to the herbs cited above, H80 Gingival stomatitis / chronic contains aurantium fruit (Zhi qiao), dendrobium (Shi hu), imperata (Bai mou gen), malt (Mai ya), melia (Chuan lian zi), polyphorus (Zhu ling), and sweet wormwood (Qing hao). These additional herbs increase the efficacy of the formulation.

Points that may be of benefit include LI4, GB20, LI11, KB, ST6, ST7, and ST44 (Handbook of traditional Chinese medicine 1987).

NOTE: If the condition is due to neoplasia, treatment is aimed at treating the cancer (see the section on neoplastic conditions.)

Homotoxicology (Dose: 10 drops PO for 50-pound dog; 5 drops PO for cat or small dog)

Symptomatic treatment: Mucosa compositum and Echinacea compositum, as a presurgical therapy. Traumeel hourly post-op on surgery day (injection or oral drops), then TID PO for 3 days and BID for 2 more days. Also consider Osteoheel alternated with Traumeel and Gastricumeel for 5 days post-operatively.

Resuscitation therapy: Use to reverse iatrogenic damage from anesthesia, antibiotic, and analgesic medications. Galium-Heel, Nux vomica homaccord, Coenzyme compositum, and Ubichinon compositum mixed together and taken BID orally for 3 to 4 weeks.

Product sources

Nutrition

Immune and gingival / mouth support formulas: Animal Nutrition Technologies. Alternatives: Immune System Support — Standard Process Veterinary Formulas; Immuno Support — Rx Vitamins for Pets; Immugen — Thorne Veterinary Products.

Coenzyme Q10: Vetri Science; Rx Vitamins for Pets; Integrative Therapeutics; Thorne Veterinary Products.

Chinese herbal medicine

Formula H80 Gingival stomatitis / chronic: Natural Solutions, Inc.

Homotoxicology

BHI / Heel Corporation

Categories
Complementary Medicine

Stomatitis

Stomatitis / Periodontal Disease

Definition and cause

Stomatitis represents an inflammatory condition of the oral cavity, and occurs in both dogs and cats. Mucosal inflammation in stomatitis can be generalized or focal involving any region of the mouth. This is a descriptive diagnosis. Successful therapy depends upon an accurate diagnosis, which means that diagnostic processes are usually necessary.

In this text we represent stomatitis and periodontal disease as the more chronic version of gingivitis, whereby the local tissue and the immune system and its response have progressed to the next phase of disease and continual vigilance and a combination of medical and alternative therapies may be required. In addition, because of the chronicity, other organs and systems may be in a similar state of inflammation and degeneration (see Gingivitis, above, for a more detailed description of the inflammatory process).

Medical therapy rationale, drug(s) of choice, and nutritional recommendations

Correction of underlying causes is essential for control. Treatment of periodontal disease (See gingivitis for medical rationale), removal of infected teeth, correction of nutritional deficiencies, and use of antibiotics to control infection and corticosteroids to reduce inflammation are all indicated.

Anticipated prognosis

Prognosis is related to the underlying cause, the compliance of treatment, and the animal’s immune status. In a chronic condition, there is often associated degeneration secondary to inflammation and or infection in other organ systems, which can affect the prognosis.

Integrative veterinary therapies

The oral cavity contains a wealth of autonomic nerve fibers and is integrated into the central control centers. Gastrointestinal, immune, neurological, endocrine, musculoskeletal, and vascular elements smoothly coordinate a large number of vital functions.

From a phylogenetic viewpoint this makes sense, as the jaw and tongue appear to originate with the development of bivalves. Neurological supply and coordination through the modern tongue and the bivalve’s muscular foot are similar in function. Numerous chemoreceptors exist in the mouth and transmit information to the brain, which in turn coordinates secretion of gastrointestinal organs of digestion, as well as hormonal events and blood supply.

The “DAMN IT” acronym is useful in approaching diagnosis of stomatitis (each letter stands for the following potential categories of disease causation: Degenerative, Anatomic, Metabolic, Nutritional, Neoplastic, Immune-mediated, Idiopathic, Infectious, Traumatic, and Toxic). A careful examination and history are necessary in all cases. Anatomic issues can predispose to development due to failure of the form to function properly. As an example, anatomic errors such as cleft palate, missing teeth, and malocclusion can lead to drying or damage of the mucosa and subsequent alteration of structure. Regional inflammations may reflect localized dental disease such as trauma (injury, electrical injury, foreign bodies, or envenomization), cervical dental lesions in cats, or periodontal disease in both cats and dogs.

Generalized patterns suggest systemic issues such as metabolic problems (diabetes, hypothyroidism, Cushing’s disease, hypoparathyroidism, hepatopathies, or renal disease), toxicities (chemotherapy, radiation therapy, caustic chemical exposure, metal poisoning, or phytotoxins), infectious immune disease (periodontal disease, bacterial infection, fungal infection, and viral infection), noninfectious immune disease (pemphigus vulgaris, systemic lupus, and other auto-aggressive conditions), nutritional diseases (poor nutrition or vitamin A toxicity), neoplasia (epulis, squamous cell carcinoma, melanoma, fibrosarcoma and osteosarcoma), and idiopathic issues (eosinophilic stomatitis, plasmocytic stomatitis, and vasculitis of other causes).

Laboratory evaluation is suggested in any case that fails to resolve or recurs. Testing for common etiologies can be helpful (FeLV, FIV, Bartonella, Leptospira, etc.).

The integrative approach to stomatitis and periodontal disease is to focus both locally and systemically. The use of therapeutic nutrition, medicinal herbs, and homotoxicology remedies either alone or in combination with medications such as antibiotics and cortisone may be required. The combination of therapies gives the clinician the opportunity to not only control local disease but also to prevent and control secondary disease and auto immune processes that were borne from the inflammatory process in the mouth.

Nutrition

General considerations / rationale

Therapeutic nutrition must be multifaceted and address the inflammatory process in the mouth along with immune system support. Note: Because stomatitis and periodontal disease often act as the nidus for the initiation of inflammation and disease in other organs, it is recommended that the clinician evaluate the blood both medically and physiologically to determine real and impending organ involvement and disease (see site, Nutritional Blood Testing, for additional information).

Appropriate nutrients

Nutrition / glandular: In addition to the nutritional remedies recommended in the gingivitis protocol (vitamin C, folk acid, betasitosterol, and coenzyme Q10), the following is recommended:

Colostrum: Colostrum has been shown to improve intestinal health and digestion and help balance intestinal flora. In addition, colostrum can improve the immune status of the intestinal tract, which can, via intestinal production of globulins, help the overall immune competency of the body. In addition, Giannobile (1994) showed that there is significant improvement in healing from surgery and improved osseous formation and periodontal regeneration in dogs supplemented with a combination product that contained colostrum.

Chinese herbal medicine / acupuncture

General considerations / rationale

According to traditional Chinese medicine, stomatitis is caused by Heat rising from the Stomach and Spleen, leading to Yin deficiency. This causes oral mucosal damage. The Stomach opens to the Mouth, in traditional Chinese medicine theory. When there is Heat, or inflammation in the Stomach, the Mouth, as the associated organ, may manifest the inflammation. This is revealed as red, swollen gingiva. Long-term inflammation damages the fluids (Yin), which upsets the balance between the Yin and Yang. The decrease in Yin makes the Yang seem excessive. More Yang means more Heat (inflammation). This, in Western terms, can be described as inflammatory mediators creating more inflammation, and worsening rather than resolving the condition. Thus, stomatitis tends to be chronic. Therapy is aimed at decreasing the inflammation and removing or controlling the cause of the inflammation.

Appropriate Chinese herbs

Alisma (Ze xie): Enhances immunity and decreases inflammation (Dai 1991).

Anemarrhena (Zhi mu): Increases the corticosterone level in serum and decreases inflammation.

Angelica (Dang gui): Has antiinflammatory action, yet does not cause immunosuppresion. In fact, it increases phagocytic activity of macrophages.

Cinnamon (Rou gui): Normalizes the immune system. It decreases production of nonspecific antibodies. At the same time it increases the reticuloendothelial system’s ability to phagocytize foreign material. It has been proven to have antiinflammatory effects on both acute and chronic inflammatory conditions.

Crataegus (Shan zha): Enhances immunity. It increases serum lysozyme levels, serum antibody levels, and T cell activity. It also has direct antibiotic activity on some bacteria.

Forsythia (Lian qiao): Reduces edema and inflammation by decreasing capillary permeability. It has demonstrated antiviral and antibacterial effects.

Honeysuckle (Jin yin hua): Has antibacterial activity, mainly due to chlorogenic acid and isochlorogenic acid. Anti-inflammatory effects have been demonstrated experimentally in rabbits and mice.

Isatis root (Ban Ian gen): Possesses antiviral activity. In some cases it is as effective as ribavirin. It also has antibacterial efficacy. In addition to direct effects on pathogens, isatis root also stimulates the immune system. It seems to affect both humoral and cellular immunity.

Licorice (Gan cao): Contains glycyrrhizin and glycyrrhetinic acid. These chemicals have approximately 10% of the steroid effects of cortisone. In addition, glycyrrhizin has shown activity against several viruses and therefore may be of use in viral-mediated stomatitis.

Ophiopogon (Mai dong): Has demonstrated the ability to inhibit several types of bacteria.

Oriental wormwood (Yin chen): Contains capillarin, which has antiinflammatory properties.

Phellodendron (Huang bai): Has antibacterial actions against a variety of bacteria.

Plantain seeds (Che qian zi): Decrease inflammation by decreasing capillary permeability.

Red peony (Chi shao): Stimulates cellular immunity by enhancing proliferation of T cells.

Rehmannia (Sheng di huang): Increases the plasma levels of adrenocortical hormone. This may increase the amount of cortisol in circulation, and corticosteroids are commonly used to treat stomatitis by Western practitioners. Rehmannia has been shown to reduce swelling and inflammation.

Scrophularia (Xuan shen): Inhibits many strains of bacteria.

Sophora root (Shan dou gen): Stimulates the humoral immune system, resulting in increased levels of IgM and IgG. It also has activity against several types of bacteria.

Homotoxicology

General considerations / rationale

Early presence of homotoxins leads to reaction by the mucosal elements in the form of Inflammation Phase disease. The mucosa recovers rapidly if these homotoxins are removed. This makes a massive case for early and aggressive home care, as well as competent professional prophylaxis. As homotoxins accumulate and are deposited the oral mucosal structure, function becomes altered. In Impregnation Phase homotoxicoses we see chronic and poorly responsive disease forms, which may not recover fully and frequently recur, frustrating client and veterinary professional alike. These conditions can progress into Degeneration Phase disease and resultant tooth loss. Degeneration Phase disorders include congenital malformation of the mouth and associated structures. Some homotoxins may lead to neoplastic changes in Dediffer-entiation Phase disease.

Because most cases represent advanced homotoxicoses, management of the chronic condition, rather than cure, is often a realistic treatment goal. Some cases resolve early and represent Excretion or Inflammation phase conditions, but most cases involving cats and elderly pets involve more significant disease. Consultation with an internist or veterinary dentist may prove helpful in cases that are poorly responsive. In addition to good quality dental and internal medicine practices, homotoxicology may assist these pets. Most need long-term detoxification and symptom support. A proper diet consisting of limited antigen diets can assist some cases, and this may be associated with true allergic responses as well as adverse reactions to food ingredients or additives. The author has seen several cases improve when a raw food diet of limited ingredients is fed. Clients opting for biological therapy should be informed that some cases will not respond, while other cases will begin to respond after therapy lasting more than a year, especially when they have been kept on the Deep Detoxification Formula for several months.

Pulsatilla compositum and Traumeel are used in regulation rigidity cases, and stomatitis frequently fits this description of a disorder that is unchanging or poorly responsive. These agents can sometimes shift cases toward healing. Engystol N seems helpful and makes one wonder about impregnated viral particles, which may trigger chronic inflammatory pathways as the immune system attempts eradication of viral elements from chronically infected tissues. Feline immunodeficiency virus, Feline leukemia virus, feline calicivirus, and Feline herpes virus may cause disease in this manner, but their individual roles are unclear. Because such viral elements are present in vaccine components, research is warranted into the involvement of vaccinations in this condition, and at least some cases may be adverse reaction to vaccinations. Most holistic doctors advise reduced use of vaccinations when faced with chronic, unresponsive conditions, a practice which is in agreement with most manufacturers’ written recommendation to avoid vaccinating unhealthy animals. This seems prudent considering what we currently understand about auto-aggressive pathogenesis.

So-called “Alternative Phase” disease can present as stomatitis. In these cases more severe disease lurks internally and signals its presence through inflammation near the body’s exterior. Many homotoxins can damage the GI system’s ability to perform its duties. Both toxins and other therapeutic agents can result in progressive vicariation. Corticoids and nonsteroidal antiinflammatory drugs both damage intestinal mucosal elements. This can result in frank ulcer or in “leaky gut syndrome,” which is linked to many other medical syndromes. In leaky gut, antigens are not properly digested into smaller molecular-weight polypeptides before gaining access to the immune system. This issue can lead to chronic inflammatory diseases such as inflammatory bowel disease and allergic syndromes, and, in this discussion, chronic stomatitis.

Successfully treating stomatitis involves providing a nonaggravating diet and clean water, while working at reducing stress, allowing homotoxins to be excreted successfully, supporting organ function, draining homotoxins, and providing metabolic support while repair occurs. Patients will be observed to cycle in and out of inflammatory states, and this is highly desirable. As in other discussions, the position of the patient on the phase table assists in determining proper therapy. In the first two phases, symptomatic treatment is often successful. As homotoxins gain deeper access and do further damage, the use of compositae class antihomotoxic agents becomes necessary to stimulate regressive vicariation.

Appropriate homotoxicology formulas

Anacardium homaccord: The namesake ingredient has been shown to have powerful antiinflammatory and immunomodulatory effects. Treats hunger pain, mucosal catarrh including laryngeal and pharyngeal inflammation, duodenal syndrome, constipation, oral vesicles, and gastric / duodenal ulcers. Anacardium as an herbal extract has been shown to be antiviral against simian rotovirus.

Arsuraneel: A cellular phase remedy that treats enteritis and diarrhea (Arsenicum album). May be useful in arsenic poisoning in areas with contaminated groundwater. Also used in chronic disease, tumors of mucous membranes (Marsdenia cundurango), and diabetes mellitus (Acidum phophoricum).

Belladonna homaccord: Indicated in intensely red and inflamed conditions, especially Inflammation Phase conditions. Supports immune function.

BHI-Nausea: Contains Anacardium orientale, a potent antiinflammatory agent.

Cantharis compositum: Contains Arsenicum album. Indicated in aphthous stomatitis; when the tongue is dry, red with raised papillae, and possibly coated white, brown, or black; and for violent gastroenteritis with prolonged vomiting and diarrhea, and with unbearable burning stomach-pains after eating. Also indicated for foul-smelling stools. Also contains Mercurius solubilis, indicated in ulcerative lesions of the mucous membranes, and Hepar sulphuris calcareum.

Coenzyme compositum: Contains Citricum acidum, which is useful for dental problems and gingivitis; scurvy; blackening of teeth and heavy deposits of dental plaque; painful, herpetic vesicles around the lips; nausea; painful cramping in the umbilical area; and distension.

Echinacea compositum: When used in infection, supports the immune reaction, particularly in bacterial infections. It is a phase remedy for Inflammation Phase disease. For more advanced conditions consider Tonsilla compositum.

Engystol N: Used for viral origin gastroenteritis (see Parvovirus).

Galium-Heel: Used in all cellular phases, hemorrhoids, and anal fissures, and as a detoxicant.

Hepar compositum: Provides detoxification and drainage of hepatic tissues, organ support, and metabolic support. It is useful in most hepatic and gall bladder pathologies. It is also an important part of Deep Detoxification Formula. Treats duodenitis, pancreatitis, cystic hepatic ducts, cholelithiasis, cholangitis, cholecystitis, vomiting, and diarrhea. This combination contains Natrum oxalaceticum (also found in Coenzyme compositum, Ubichinon compositum, and Mucosa compositum) for changes in appetite and stomach distension due to air. Indicated in nausea, stomach pain with a sensation of fullness, gurgling in abdomen, and cramping pain in the hypochondria. Also used for constipation, sudden diarrhea (particularly after eating), and flatus.

Lymphomyosot: Provides lymph drainage and endocrine support to treat edema. Contains Gentiana for chronic gastritis. Treats flatulence; diarrhea; and distension of stomach with eructations, nausea, retching, and vomiting. The component Geranium robertianum is also useful for nausea, particularly after eating, with distension or sensation of fullness. Myosotis arvensis is also contained, which also has indications for bloat and distension.

Mercurius-Heel S: Used for viral and bacterial issues, suppuration, and tonsillitis.

Mucosa compositum: Broadly supportive for repair of mucosal elements. Used in cellular cases and in recovery periods following active disease. This remedy contains a useful component in Kali bichromicum, indicated for ulcers found on the gums, the tongue, the lips, and even on the gastric mucosa (gastric or duodenal ulcer). The tongue may have a thick, yellow, mucous coating, or in ulcerative stomatitis or tonsillitis it may be dry, smooth, shiny, or fissured. Kali has been used effectively in acute gastroenteritis associated with vomiting of clear, light-colored fluid or quantities of mucous bile, and in cases with hematemesis, flatulent colics, and dysenteric stools with tenesmus.

It contains Hydrastis, with mucosal support for oral problems such as stomatitis, mucosal suppuration accompanied by ulceration, inflammations and colic of the hepatobiliary system and of the gastrointestinal tract, and polyp formation.

The Kreosotum component can be used in chronic gastritis with gastric hemorrhages and vomiting of brown masses. It also has a dental implication in cases with spongy gums and carious teeth, neuralgias proceeding from them causing a burning toothache with deep caries, black patches on the teeth, and fetid discharges. The single remedy Phosphorus is broadly useful for dyspepsia and for jaw problems in dental disease. Phosphorus is found in many other remedies including Ecbinacea compositum and Leptandra Homaccord. It is rich in suis organ preparations for mucosal support, plus a large variety of remedies with indications in the gastrointestinal sphere. Argentum nitricum (also in Atropinum compositum, Diarrheel, Duodenobeel, Gastricumeel, Momordica compositum, BHI-Nausea, and several other combinations) is included in this broad remedy for distension in the upper abdomen, gastro-cardiac symptom-complex, and amelioration from eructations. It is also used for gastric crises.

Nux votnica homaccord: Treats liver and gastrointestinal disease. Useful in gingivitis. It is also used after smoke inhalation, and is a commonly used formula for detoxification as part of the Detox Kit.

Osteoheel: Provides support of bony healing and treats periostitis and periodontal disease.

Phosphor homaccord: Treats hepatitis, icterus, tenderness over the liver region, pancreatic diseases, ulcerated gums, thirst but vomiting right after drinking occurs, and pale-clay colored stools.

Psorinoheel: Used for chronic illness, and is an Impregnation Phase remedy.

Schwef-Heel: Treats chronic diseases of skin and liver. This remedy should be interposed in most skin and liver cases. Patients that need this remedy may look dirty and have scruffy skin conditions, red lips, white tongue with red tip, and an itching and burning rectal area with morning diarrhea and prolapsed rectum. Sulfur is contained in several other antihomotoxic formulas including Coenzyme compositum, Ecbinacea compositum, Engystol, Ginseng compositum, Hepar compositum, Molybdan compositum, Mucosa compositum, Paeonia Heel, Proctbeel, Psorinoheel, Sulfur-Heel, Tbyroidea compositum, and Ubicbinon compositum.

Solidago compositum: Includes Berberis and other ingredients that support renal function. It is good in Deposition Phase cases.

Thyroidea compositum: A component of the Deep Detoxification Formula; drains matrix and supports endocrine function. It is a phase remedy for Impregnation Phase disease.

Tonsilla compositum: Supports immune organs in Impregnation, Degeneration, and Dedifferentiation phases.

Traumeel S: An antiinflammatory. It also repairs blocked enzymes. It is used for regulation rigidity patients. Human studies show that it controls pain through speeded healing and homotoxin removal.

Ubichinon compositum: Contains Anthraquinone for swelling of gums and GI symptoms such as distention, flatulence, and cramping abdominal pain. Also treats constipation with straining or sudden diarrhea.

Authors’ suggested protocols

Nutrition

Immune and gingival / mouth support remedies: 1 tablet for every 25 pounds of body weight BID.

Betathyme: 1 capsule for every 35 pounds of body weight BID. (maximum 2 capsules BID)

Coenzyme Q10: 25 mg for every 10 pounds of body weight daily.

Additional vitamin C: 100 mg for every 25 pounds of body weight BID.

Folic acid: 50 micrograms for every 35 pounds of body weight (maximum, 200 micrograms).

Colostrum: One-third teaspoon of powdered formula for every 25 pounds of body weight BID.

Chinese herbal medicine / acupuncture

Formula H80 Gingival stomatitis / chronic: 1 capsule per 10 to 20 pounds twice daily. This formula is useful for acute or chronic gingival stomatitis of bacterial, viral, or immune-mediated etiology. In addition to the herbs cited above, H80 Gingival stomatitis / chronic contains aurantium fruit (Zhi qiao), dendrobium (Shi hu), imperata (Bai mou gen), malt (Mai ya), melia (Chuan lian zi), polyphorus (Zhu ling), and sweet wormwood (Qing hao). These additional herbs increase the efficacy of the formulation.

Homotoxicology

(Dose: 10 drops PO for 50-pound dog; 5 drops PO for cat or small dog)

In addition to proper dental, surgical, and medical management, consider:

Symptom formula: Traumeel S, Echinacea compositum, Mucosa compositum, and Cantharis compositum, mixed together and given TID orally. Consider the following as indicated: BHI-Nausea or Anacardium homaccord (oral vesicles), Osteoheel (periodontal disease and bone loss), Engystol N or Euphorbium compositum (viral conditions), Belladonna homaccord (acute inflammation with intense redness), Mercurius-Heel S (viral or bacterial infections), and Nux vomica homaccord (general gastrointestinal drainage and detoxification).

Deep detoxification formula: Galium-Heel, Lymphomyosot, Hepar compositum, Solidago compositum, Thyroidea compositum (alternate with Tonsilla compositum), Coenzyme compositum, and Ubichinon compositum.

Product sources

Nutrition

Immune and gingival / mouth support remedies: Animal Nutrition Technologies. Alternatives: Immuno Support — Rx Vitamins for Pets; Immungen — Thorne Veterinary Products; Immune System Support — Standard Process Veterinary Formulas.

Betathyme: Best for Your Pet. Alternative: Moducare Thorne Veterinary Products.

CoEnzyme Q10: Vetri Science — Rx Vitamins for Pets for Pets; Integrative Therapeutics; Thorne Veterinary Products.

Colostrum: New Life Foods, Inc.; Saskatoon Colostrum Company.

Chinese herbal medicine

Gingival Stomatitis (Chronic-H80): Natural Solutions, Inc.

Homotoxicology

BHI / Heel Corporation