It s all about living. Preventive Medicine. Core Vaccinations. Core Vaccinations 2/3/2015. As veterinarians, we do this well!

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1 It s all about living Wellness exams and testing, vaccines, parasite control, and comprehensive pain management Mark D. Freeman, DVM, DABVP, CVA Assistant Professor, Community Practice VA-MD College of Veterinary Medicine Preventive Medicine As veterinarians, we do this well! Vaccinations Dental care Weight management and fitness Behavior Core Vaccinations AAHA/AAFP recommended 3 year core vaccine interval has strong supporting evidence But now we have to ask: Should geriatric patients be vaccinated? Core Vaccinations Through serologic or challenge studies with MLV vaccines for CDV, CAV-2. and CPV, duration of immunity (DOI) studies have demonstrated protection to a minimum of 6-7 years Fewer studies available for cats In 1999, Scott and Geissinger showed through challenge that killed FVRCP vaccine gave DOI to at least 7.5 years In 2004, Mouzin et al demonstrated through serology a minimum DOI of 4 years for core vaccines 1

2 Core Vaccinations Estimated minimum DOI of commercially available canine core vaccines based on challenge (C) and/or serology (S) Vaccine estimated minimum DOI (years) Canine distemper virus Rockborn/Snyder Hill strains (MLV) 7 (C) 15 (S) Onderstepoort strain (MLV) 5 (C) 9 (S) rcanine distemper virus (R) 3 (C) 3 (S) Canine adenovirus-2 (MLV) 7 (C) 9 (S) Canine parvovirus-2 (MLV) 7 (C) 9 (S) Rabies virus (K) 3 (C) 7 (S) Modified from Schultz RD. Duration of Immunity for Canine and Feline Vaccines: A Review. Veteirnary Microbiology. 117 (2006): Dogs Lyme disease a new bivalent bacterin (adjuvanted) is available; it induces antiborreliacidal antibodies to both Osp A and Osp C; provides 100% protection Canine Influenza Virus a new killed (adjuvanted) vaccine is available; conditionally licensed; non-sterile immunity Cats Adult cats are very resistant to FeLV Annual vaccination should be reserved for cats allowed outdoors, or potential exposure to FeLV positive cats FPV vaccines are highly effective and prevent disease FVR and FCV vaccines are less effective and attenuate rather than prevent Intranasal FVRCP vaccine highly effective Cats Virulent Systemic FCV vaccine is a killed adjuvanted vaccine and should only be used for cats in high risk environments such as group housing Cats Injection site sarcomas (ISS) have changed location a 2009 study showed interscapular ISS decreased from 53 to 39.5%, and right and left thoracic regions from 10.2 to 3.6% and 9.1 to 1.3% respectively ISS in combined region of right pelvic limb/lateral abdomen increased from 12.5 to 25% and in region of left pelvic limb/lateral abdomen increased from 11.4 to 13.8% Cats From the Feline Vaccine Associated Sarcoma (VSA) Task Force when to be concerned about an injection site mass Rule 1 = mass increases in size after 1 month 2 = mass size is 2 cm or greater 3 = mass persists for 3 months or longer Sources of persistent inflammation (adjuvanted vaccines, repository injections) should be avoided in cats 2

3 Vaccination VAAEs Cats ISS Inflammation PDGF Vaccine Associated Adverse Events 2007 JAVMA VAAEs in cats: 51.6/10, JAVMA VAAEs in dogs: 38.2/10,000 Sarcoma development Defects in p53 upregulation SIS oncogene activation Are there alternatives? Extended vaccine intervals for dogs and cats over years of age Annual titers to predict duration of immunity Potentially expensive Not readily available for every antigen Do positive titers = protection? Rabies vaccine must be given according to state laws State veterinarians office Annual Wellness Tests Which ones are important? AAFP 2008 Senior Care Guidelines and AAHA 2205 Senior Care Guidelines for Dogs and Cats Detailed recommendations Annual to semiannual examination are recommended for seniors (7-10 yr), and semiannual or more frequently for geriatric (>10 yr) patients Annual Wellness Tests Annual minimum database is recommended in patients over 7-8 yr CBC Serum biochemistries Urinalysis including protein (P:C or microalbuminuria) T4 for cats Blood pressure 3

4 Annual Wellness Tests Monitor for trends, even in regard to normal values Monitoring may be needed more frequently than annually depending on underlying disease Additional tests such as diagnostic imaging, complete ocular examination, echocardiography, etc. may be indicated Photos courtesy of S.J. Upton Photos courtesy of Dr. Ray Dillon Fecal exams are important! Once yearly is recommended for routine analysis More frequent checks are recommended if clinical signs occur Check your technique Minimum of 1 gm of feces required about 1 cc most fecal loops only obtain 0.1 gm Centrifugal flotation technique maximized parasite recovery CAPC recommends: The Companion Animal Parasite Council (CAPC) considered the independent authority on pet parasites Excellent technique training videos at TSOP_Part_01_content.html Year round treatment with broad-spectrum heartworm anthelmintics Year round flea and tick preventative Annual heartworm testing is ideal for dogs, while periodic testing for cats should be considered 4

5 Feline Heartworm Disease Feline heartworm disease and heartworm associated respiratory disease (H.A.R.D.) in felines is likely considerably underestimated in association with low testing levels A recent study found the overall average feline heartworm antigen-positive rate was 0.9% compared to an average canine heartworm prevalence rate of 1.2%, an FeLV prevalence rate of 1.9%, and an FIV prevalence rate of 1.0% Heartworm associated respiratory disease in cats Photos courtesy of Dr. Ray Dillon, Auburn University Canine heartworm disease The American Heartworm Society recommends the use of a steroidal antiinflammatory, an ivermectin based preventive, and doxy- or minocycline along with the melarsomine as an effective multimodal treatment protocol A 2008 study showed significantly less severe arterial lesions and near absence of thrombi in dogs treated with doxycyline/ivermectin/melarsomine* *Kramer et al. Veterinary Parasitology, 158(2008):

6 Think multi-modal! Appropriate drug therapy Appropriate drug therapy Weight management Exercise and physical fitness Physical rehabilitation Complementary therapies NSAIDs COX-2 vs. COX-1 Inhibition NSAIDs Robenacoxib Deracoxib 48.5 Carprofen 17.6 Meloxicam 7.3 Etodolac 6.6 Ketoprofen 0.88 Tepoxalin LOX and non selective COX inhibitor Firocoxib COX 2 selective All NSAIDs have the potential to cause GI side effects ranging from gastric ulceration to erosion COX-1 sparing NSAIDs are associated with 50% less GI ulceration in humans and animal studies have yielded similar resutls NSAIDs should be used judiciously in patients who are dehydrated, or who are at risk for developing hypotension Hypoadrenocorticism Anesthetic related hypotension Hyopvolemic shock NSAIDs should also be used cautiously in senior or geriatric patients with co-morbid conditions Disease-modifying osteoarthritic agents PGAGs, chondroitin sulfate, glucosamine GLME (green lipped mussel extract) MSM Intention is to heal cartilage Stimulating cartilage matrix synthesis Inhibiting enzymatic degradation of cartilage 6

7 Other analgesics Opiods Butorphanol (mild to moderate pain) Methadone Hydromorphone Buprenorphine Morphine Tramadol Fentanyl Novel adjunctives Ketamine CRI NMDA receptor inhibitor Amantadine NMDA antagonist Amitriptyline TCA with pain modulating properties Gabapentin associated with NMDA receptors Lidocaine (transdermal patches or liposomal encapsulated lidocaine cream) Omega Fatty Acids Omega Fatty Acids Ω-3 Fas exert a range of anti-inflammatory actions Competitive inhibition of the inflammatory pathway Canine chondrocytes preferentially uptake eicosapentaenoic acid (EPA) Low Ω 6: Ω 3 FA ratio is desirable Omega Fatty Acids Physical rehabilitation Supplementation with EPA/DHA produces anti-inflammatory effects and helps break the cycle of cartilage destruction Approximate supplementation dose 180 mg EPA/120 mg DHA per 10 lbs body wt. Equals 1 gm fish oil capsule/10 lbs/day Joint diets are more client friendly Treatment modalities Cryotherapy Heat therapy Therapeutic ultrasound Low level laser therapy TENS (transcutaneous electrical nerve stimulation) NMES (neuromuscular electrical stimulation) 7

8 Cryo/Heat therapy Cryotherapy Local decrease in temp Decrease blood flow, metabolism, inflammatory response Arteriolar vasoconstriction Reduce edema Decrease lymph production, phagocytic activity, cell nutrition Heat therapy Local increase in temp Reflex vasodilation Increased capillary flow/pressure edema Increase supply of oxygen, nutrients, antibodies Increase clearance of metabolites Therapeutic ultrasound Therapeutic ultrasound Increased metabolic rate, enzyme activity, circulation, extensibility in tissues, and decrease in pain Increases joint ROM, reduces joint adhesions, increases tissue healing, decreases muscle spasms, resolution of chronic inflammation Pulsed vs. continuous continuous more likely to produce cavitation Must keep head moving to prevent burns tissue temp must be F for minimum 5 minutes Therapeutic ultrasound Contraindications Neoplasia Hemorrhage Application to eyes or gonads Application to ischemic tissue Suspected deep vein thrombosis Low level laser therapy Athermic modality Influences lymph, circulation, nervous system, wound/surgical healing Wavelength (W) of nm in therapeutic windows; Class 3 lasers Induces wide range of physiologic effects at cellular level Irradiance = W/cm 2 (intensity) Energy (J) = power (W) x time (sec) 8

9 Low level laser therapy Low level laser therapy Indications Wounds and ulcers Acute injuries/traumas tendon/muscle tears, ligament sprains Musculoskeletal conditions repetitive strain injuries, complex regional pain syndrome Inflammatory conditions Arthritis From Huang Y, et al. Low-level laser therapy: an emerging clinical paradigm TENS NMES (neuromuscular electrical stimulation) Use of electrical stimulation to induce muscle contractions Frequency, phase (pulse duration), amplitude, waveform, on/off time, ramp, polarity, treatment time Particularly useful in rehabilitation of fractures or in cases of paresis/plegia Transmission of small electrical pulses through the skin to the underlying peripheral nerves. Physical rehabilitation Treatment modalities Manual therapy Massage Therapeutic exercises Physioball ROM (range of motion), stretching Aquatherapy (swimming, water treadmill) Land treadmill, ground exercises Manual therapy Joint manipulation Joint mobilization Restoration of joint mobility through various forms of active or passive manipulation of joints Neural mobilization Gentle nerve stretching technique to reduce associated discomfort Relieves pain, increases function 9

10 Underwater treadmill Benefits of hydrotherapy Reduces loading (buoyancy), provides support Provides resistance without impact Increases muscle mass, strength Increased cardiovascular condition Provides increased ROM and relaxation Reduces joint pain Land treadmill has some similar benefits Complementary therapies Stem cell therapy Undifferentiated cells harvested from patient and then administering at affected site cytokines/growth factors, cell recruitment, differentiation Acupuncture 70% of points correspond to trigger points Characteristics free nerve ending associations, blood vessels beneath 71% Chiropractic Exam should include neuro exam, stance and gait analysis, motion and static palpation Questions? 10