Pancreatitis: Achieving a Diagnosis & New Treatment Options
Sponsored by Ceva Animal Health, LLC
Mitzy, a 6-year-old female spayed miniature schnauzer, was presented with a 2-day history of vomiting, inappetence, and progressive lethargy. Mitzy had always been fed a commercial dry dog food and had not had any recent dietary changes.
On physical examination, Mitzy had a BCS of 7/9. She was hypersalivating, making mucus membrane evaluation difficult, but skin turgor was increased and she was estimated to be 5% to 7% dehydrated. Auscultation was unremarkable, and she appeared to be uncomfortable on cranial abdominal palpation.
CBC, serum chemistry with electrolytes, urinalysis, and radiography were recommended and approved by the owner. CBC showed mild hemoconcentration and mild leukocytosis characterized by neutrophilia and occasional band neutrophils. Serum chemistry profile revealed prerenal azotemia and mild ALT elevation but was otherwise unremarkable. Urine was well concentrated with a quiet sediment. Three-view abdominal radiographs were unremarkable and did not show an obvious cause of vomiting.
Making the Diagnosis of Pancreatitis
In Mitzy's case, pancreatitis was a top differential diagnosis based on history, clinical signs, and initial diagnostics. Abdominal ultrasonography was recommended but declined due to cost and logistical factors.
Pancreatitis is a common gastrointestinal disease of dogs. Although the etiology is not fully understood, most cases are idiopathic and several risk factors are recognized, including hypertriglyceridemia, pre-existing endocrine disease, feeding high-fat diets, small-breed dogs, and overweight dogs.1 Pancreatitis varies in severity and has the potential to be life-threatening, often requiring costly and intensive medical care.
There is no gold standard test for the diagnosis of pancreatitis and no pathognomonic changes on blood work indicative of pancreatitis.1 The most common clinical signs include vomiting, dehydration, abdominal pain, inappetence, and lethargy.1 Breed predispositions include schnauzers, Yorkshire terriers, poodles, and cocker spaniels.2
Laboratory work and imaging can assist in making a clinical diagnosis of acute pancreatitis.1 Laboratory abnormalities are nonspecific, can vary due to severity, and may include hemoconcentration, leukocytosis with neutrophilia and left shift, azotemia, elevated liver enzymes, and hyperbilirubinemia.1 Abdominal radiography has low sensitivity for pancreatitis but can be helpful in ruling out other causes of clinical signs (eg, neoplasia, GI obstruction).1 It should not be used in isolation to diagnose pancreatitis.3,4
Canine pancreatic lipase immunoreactivity (cPLI) can aid in diagnosis when used in conjunction with history and clinical signs. A quantitative (spec cPL) test is available and a pet-side qualitative SNAP cPL correlates well with spec CPL.5 A normal SNAP cPL result can be used to rule out pancreatitis due to the assay’s high sensitivity, but an abnormal test result may or may not be definitively diagnostic of pancreatitis.5
For Mitzy, a SNAPcPL was run and was abnormal, supporting a high degree of suspicion for pancreatitis.
Supportive care has been the cornerstone of pancreatitis management and should be instituted early in the course of disease.1 IV fluids should be initiated to correct dehydration, account for ongoing losses, and support circulation to the pancreas. Pain management (excluding NSAIDs, which are contraindicated) should be considered in all cases, as abdominal pain is likely underrecognized. Antiemetics can help reduce vomiting and nausea.1 Early enteral nutrition is important and a low-fat, bland diet is recommended.1 Although antibiotics are often prescribed, they are not necessary unless there is evidence of sepsis.6 The use of steroids to address pancreatic inflammation is controversial.1
A new injectable drug, PANOQUELL®-CA1 (fuzapladib sodium for injection), is the first and only conditionally approved medication for treating clinical signs associated with the acute onset of pancreatitis in dogs.2 Fuzapladib sodium is a leukocyte function-associated antigen-1 (LFA-1) activation inhibitor. LFA-1 is required for extravasation of neutrophils, which is the process by which neutrophils leave the blood vessels and enter the tissue in response to cellular signaling of tissue injury. Blocking the activation of LFA-1 decreases the extravasation of neutrophils in the pancreas that occurs with this disease, thus addressing the inflammation associated with pancreatitis.2
Appropriate patient selection is important for the administration of PANOQUELL-CA1. Appropriate candidates for PANOQUELL-CA1 include dogs with clinical signs associated with the acute onset of pancreatitis when the clinician has included acute pancreatitis as a top differential for that patient (hypersensitivity is the labeled contraindication).2
In a well-controlled pilot study, patients receiving PANOQUELL®-CA1 with supportive therapy (eg, fluid therapy, antiemetics, pain medication) showed statistically significant improvement in clinical signs over 3 days as compared with placebo. PANOQUELL-CA1 can be used both for hospitalized patients and in outpatient situations.
Mitzy was hospitalized on IV fluids, buprenorphine, maropitant, and ondansetron. PANOQUELL®-CA1 was administered IV as a bolus at the label dose of 0.4 mg/kg, and Mitzy responded well to supportive care and was voluntarily eating a low-fat bland diet after 24 hours.
Mitzy received her second dose of PANOQUELL®-CA1 and was discharged with a prescription for gabapentin and ondansetron. A recheck examination was scheduled for 24 hours postdischarge to ensure Mitzy was continuing to improve. On day 3, she was eating well and comfortable, with no further vomiting, and the third dose of PANOQUELL®-CA1 was administered.
Although pancreatitis remains a serious and often frustrating condition, PANOQUELL®-CA1 offers a solution that addresses the inflammation associated with the acute onset of canine pancreatitis. By addressing the inflammation along with offering traditional supportive care, outcomes for canine pancreatitis patients can be improved.
PANOQUELL®-CA1 is indicated for the management of clinical signs associated with acute onset of pancreatitis in dogs.
Important Safety Information
The safe use of PANOQUELL®-CA1 has not been evaluated in dogs with cardiac disease, hepatic failure, renal impairment, dogs that are pregnant, lactating, intended for breeding or puppies under 6 months of age. PANOQUELL®-CA1 should not be used in dogs with a known hypersensitivity to fuzapladib sodium. PANOQUELL®-CA1 is a highly protein bound drug and its use with other highly protein bound medications have not been studied. The most common side effects in the pilot field study were anorexia, digestive tract disorders, respiratory tract disorders and jaundice. PANOQUELL®-CA1 is not for use in humans. Limited data is available on the potential teratogenic effects of fuzapladib sodium. Therefore, anyone who is pregnant, breast feeding or planning to become pregnant should avoid direct contact with PANOQUELL®-CA1. For additional information on the use of PANOQUELL®-CA1, please refer to the product insert.
Conditionally approved by FDA pending a full demonstration of effectiveness under application number 141-567. It is a violation of Federal law to use this product other than as directed in the labeling.
PANOQUELL® is a registered trademark of Ishihara Sangyo Kaisha, Ltd.