Treatment of accidental ethanol intoxication with hemodialysis in a dog

Impact of concerning excipients on animal safety: insights for veterinary pharmacotherapy and regulatory considerations

OBJECTIVES

Veterinarians and pharmacists are familiar with the efficacy and safety aspects attributed to active pharmaceutical ingredients included in medicines, but they are rarely concerned with the safety of excipients present in medicines. Although generally recognized as safe, excipients are not chemically inert and may produce adverse events in certain animal populations. This review aims to present excipients of concern to these populations and highlight their relevance for rational veterinary pharmacotherapy.

EVIDENCE ACQUISITION

A comprehensive review of the literature about the existence of adverse reactions in animals caused by pharmaceutical excipients was carried out based on an exploratory study. An overview of the correct conditions of use and safety of these excipients has also been provided, with information about their function, the proportion in which they are included in the different pharmaceutical dosage forms and the usual routes of administration.

RESULTS

We identified 18 excipients considered of concern due to their potential to cause harm to the health of specific animal populations: bentonite, benzalkonium chloride, benzoic acid, benzyl alcohol, ethanol, lactose, mannitol, mineral oil, monosodium glutamate, polyethylene glycol, polysorbate, propylene glycol, sodium benzoate, sodium carboxymethylcellulose, sodium lauryl sulfate, sulfites, polyoxyethylene castor oil derivatives, and xylitol. Among the 135 manuscripts listed, only 24 referred to studies in which the substances were correctly evaluated as excipients.

CONCLUSIONS

Based on the information presented in this review, the authors hope to draw the attention of professionals involved in veterinary pharmacotherapy to the existence of excipients of concern in medicines. This information contributes to rational veterinary pharmacotherapy and supports veterinary pharmacovigilance actions. We hope to shed light on the subject and encourage studies and new manuscripts that address the safety of pharmaceutical excipients to the animal population.

Extracorporeal blood purification in acutely intoxicated veterinary patients: A multicenter retrospective study (2011-2018): 54 cases

OBJECTIVE

To investigate the clinical outcome and complications associated with extracorporeal blood purification (EBP) using either hemodialysis (HD), hemodialysis and hemoperfusion (HD + HP), or therapeutic plasma exchange (TPE) for the management of acute toxin ingestion in small animals.

DESIGN

Retrospective, multicenter study from January 2011 to July 2018.

SETTING

One university teaching hospital and one private specialty hospital.

ANIMALS

Fifty-one dogs and 3 cats with a history of acute toxin exposure that could lead to severe morbidity and mortality, managed with different EBP techniques.

MAIN RESULTS

Nonsteroidal anti-inflammatory drugs (38/54, 52%), baclofen (8/54, 15%), and ethylene glycol (7/54, 13%) were the most common toxicities treated with EBP. Membrane-based TPE was used most commonly (22/54, 40.7%), followed by HD (17/54, 31.5%) and then HD + HP (15/54, 27.8%). There was an 83.3% (45/54) overall survival, with 88.9% (8/9) of nonsurvivors having clinical signs prior to therapy. One third (18/54) of the patients never developed clinical signs of toxicity. Treatment complications occurred in 44.4% (24/54) of the animals, although only 18.5% (10/54) of these complications, such as mild hypotension, thrombocytopenia secondary to the HP cartridge, facial swelling after plasma transfusion for TPE, bleeding from catheter size secondary to heparinization, or clotting of the system, could be attributed to the EBP treatment. None of the nonsurvivors died because of EBP complications.

CONCLUSIONS

Early initiation of EBP therapy might be considered as an alternative route of decontamination in severe acute toxicities with high potential for significant morbidity and mortality. The survival rate in small animals undergoing EBP is high despite exposure to potential lethal doses of toxins, and survival appears to be more likely if clinical signs of toxicity are not present at the time of EBP. Continued research is warranted with randomized controlled clinical trials to further evaluate the clinical efficacy and benefit of EBP.

Retrospective evaluation of the use of hemodialysis in dogs with suspected metaldehyde poisoning (2012-2017): 11 cases

OBJECTIVE

To evaluate dogs treated with hemodialysis for severe metaldehyde intoxication and to compare them with conventionally-managed patients.

DESIGN

Retrospective study (2012-2017).

SETTING

University teaching hospital.

ANIMALS

Data from 18 dogs with severe metaldehyde intoxication were analyzed. Eleven dogs were treated with intermittent hemodialysis and 7 managed conventionally.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Metaldehyde poisoning was diagnosed based on clinical signs and toxicological analysis or presence of turquoise material in the gastrointestinal content. Clinical signs, additional treatments, dialysis prescription, duration of anesthesia and hospitalization, complications, and outcome were documented. Results were analyzed by t-test, Mann-Whitney U-test, and Chi-square test. P < 0.05 was considered significant. Dialysis was performed for median (range) 180 min (150-420 min) with median of 2.28 L/kg (1.66-4.48 L/kg) blood volume processed. In the hemodialysis group, anesthesia was discontinued at a median of 3.0 hours (1.5-6.7 h) after starting dialysis. The conventional-group received general anesthesia for a median of 17.5 hours (7.0-30.5 h). No further anticonvulsive treatment was necessary for the hemodialysis group. Time to hospital discharge was shorter in dialyzed dogs (median 18 h; 15-41 h) compared to conventionally treated dogs (median 89 h; 61-168 h; P = 0.0014). Aspiration pneumonia was reported in 5 conventionally treated dogs and none of the dialyzed dogs (P = 0.001). Five dialyzed dogs developed hematoma at the dialysis catheter site. One dog in each group was euthanized.

CONCLUSION

Hemodialysis significantly decreases the requirement for anesthesia and length of hospitalization in dogs with metaldehyde intoxication. Aspiration pneumonia occurred less often in dialyzed patients. Prospective studies are warranted to confirm the clinical utility of hemodialysis in dogs with metaldehyde poisoning.

Pathophysiology and aetiology of hypoglycaemic crises

Hypoglycaemia is a common, life-threatening complication that occurs as a component of a wide variety of disease processes. Despite its frequent occurrence, information concerning the aetiology, characteristics and outcomes of hypoglycaemic crises in veterinary medicine is limited. This review summarises the current understanding of the pathophysiology of hypoglycaemia, the body's counter-regulatory response, underlying aetiologies, diagnosis and treatment. Disease mechanisms are discussed and published evidence in veterinary literature regarding prognostic indicators, prevalence, diagnosis and treatment is examined for hypoglycaemia-related disease processes including insulinoma, glucose-lowering toxins and medications.

Treatment of acute kidney injury associated with cyclosporine overdose in a dog using hemodialysis and charcoal hemoperfusion

OBJECTIVE

To describe the management of cyclosporine overdose using hemodialysis and hemoperfusion in a dog.

CASE SUMMARY

A 6-year-old, spayed female Australian Shepherd was presented for treatment of cyclosporine overdose and acute kidney injury. Five days prior to presentation, the dog had been diagnosed by its referring veterinarian with immune-mediated thrombocytopenia. Treatment was initiated with prednisone, but since no response was noted, azathioprine (50 mg PO q 24 h) and cyclosporine (6 mg/kg IV q 24 h) were added. On day 4, an overdose of cyclosporine (33 mg/kg IV) was administered accidentally. Upon presentation, serum biochemistry panel revealed azotemia [creatinine, 521.6 μmol/L (5.9 mg/dL); BUN, 59.3 mmol/L (166 mg/dL)], increased activities of liver enzymes, and hyperbilirubinemia. Due to the presumed diagnosis cyclosporine overdose and acute kidney injury, a combined hemodialysis and charcoal hemoperfusion treatment was planned. Hemosorba CH-350 charcoal hemoperfusion cartridge was placed in series upstream in the extracorporeal circuit from the hemodialyzer. A 3-hour treatment was performed and a total of 0.74 L/kg of blood was processed. Pretreatment blood cyclosporine concentration was 960 nmol/L (1154 ng/mL) and decreased to 440 nmol/L (529 ng/mL) posttreatment (54% fractional reduction, 18% per hour). Thirty-one hours following treatment, blood cyclosporine concentration was 220 nmol/L (265 ng/mL; 1.5% decrease per hour). Twelve days following presentation to our hospital, the dog was euthanized due to lack of response to medical management.

NEW OR UNIQUE INFORMATION PROVIDED

Combined hemodialysis and charcoal hemoperfusion treatment can significantly reduce blood cyclosporine concentrations following acute intoxication or overdosage, and should be considered as an option for decontamination in such cases.

Clearance of plasma ivermectin with single pass lipid dialysis in 2 dogs

OBJECTIVE

To describe the use of single pass lipid dialysis (SPLD) for treatment of ivermectin toxicosis in 2 Australian Shepherd dogs with the ABCB1-1Δ gene mutation.

CASE SERIES SUMMARY

Two Australian Shepherd dogs were presented for treatment of ivermectin toxicosis. Dogs were initially treated with intravenous lipid emulsion and supportive care, without improvement of clinical signs. They both developed respiratory paralysis and required mechanical ventilation. In order to increase the clearance of circulating ivermectin, SPLD was performed using dialysate containing 5% lipid. Blood samples were obtained immediately before and after dialysis and analyzed for serum ivermectin concentration. Ivermectin reduction ratio was calculated at 29% and 39% for each dog, respectively. When compared to intrinsic total body ivermectin clearance, only the second dog had a relative improvement of plasma clearance following SPLD. Both dogs were confirmed to be homozygous for ABCB1-1Δ gene mutations. Both dogs remained ventilator dependent for several days and ultimately made a full recovery.

NEW OR UNIQUE INFORMATION PROVIDED

SPLD may be an adjunctive detoxification strategy for highly lipophilic toxins such as ivermectin.

Household Food Items Toxic to Dogs and Cats

Several foods that are perfectly suitable for human consumption can be toxic to dogs and cats. Food-associated poisoning cases involving the accidental ingestion of chocolate and chocolate-based products, Allium spp. (onion, garlic, leek, and chives), macadamia nuts, Vitis vinifera fruits (grapes, raisins, sultanas, and currants), products sweetened with xylitol, alcoholic beverages, and unbaked bread dough have been reported worldwide in the last decade. The poisoning episodes are generally due to lack of public knowledge of the serious health threat to dogs and cats that can be posed by these products. The present review aims to outline the current knowledge of common food items frequently involved in the poisoning of small animals, particularly dogs, and provides an overview of poisoning episodes reported in the literature.