Comparison of diet, lactulose, and metronidazole combinations in the control of pre‐surgical clinical signs in dogs with congenital extrahepatic portosystemic shunts

summary of:
Comparison of diet, lactulose, and metronidazole combinations in the control of pre‐surgical clinical signs in dogs with congenital extrahepatic portosystemic shunts
Author(s):
G. Serrano, N. Devriendt, H. de Rooster and D. Paepe
Published in:
Date:
July 2022
DOI:
Type of access:

Open access

In our edition of: Aug 2022
In our categories of: small animals

our summary:

Serrano, G. et al. (2022) Comparison of diet, lactulose, and metronidazole combinations in the control of pre‐surgical clinical signs in dogs with congenital extrahepatic portosystemic shunts. Journal of Veterinary Internal Medicine, 36 (4), pp. 1258-1266

The aim of this randomised clinical trial was to compare the effect of a hepatic supportive diet (HSD), HSD and lactulose, or HSD and metronidazole, on clinical signs and fasting ammonia (FA) and C-reactive protein (CRP) concentrations in dogs recently diagnosed with a congenital extrahepatic portosystemic shunt (cEHPSS).

Dogs were randomly assigned to one of the three diet treatment groups with equal numbers of dogs in each group at the start of the trial (time point 0, T0): group 1 HSD (Royal Canin hepatic, daily portion divided into 4-5 meals), group 2 HSD + lactulose (0.5 mL/kg PO q8h) or group 3 HSD + metronidazole (7.5-10 mg/kg PO q12h), for four weeks (T1). All dogs were then given the combined treatment (HSD + lactulose + metronidazole) for a further two weeks or until surgical cEHPSS attenuation (T2).

Thirty-six dogs were enrolled in the study, twelve in each group. Between T0 and T1, two dogs had to be excluded, one in the HSD + metronidazole group and one in the HSD + lactulose group. A further five dogs were excluded between T1 and T2, therefore 29 dogs completed the study; eight in the HSD group, 11 in the HSD and lactulose group, and 10 in the HSD and metronidazole group.  The results presented were on either 34 dogs (all included) or 29 dogs (excluding treatment failures).

Dogs presented at T1 a median of 29 days (range, 3-54) after T0. Two dogs in group HSD and one in group HSD + metronidazole had to be started earlier on combined treatment because of unsatisfactory control of clinical signs. Another dog in the HSD + metronidazole group had to have the metronidazole discontinued after 15 days due to the development of tremors when metronidazole was administered. One dog in the HSD group died after developing severe neurologic signs which were considered likely secondary to Hepatic Encephalopathy. These five dogs were considered treatment failures.

The combined HSD + lactulose group had a significant decrease in clinical score at T1 compared to T0 either when all dogs were included (P = .01) or when dogs considered treatment failures were excluded (P = .002). The HSD group did not show significant clinical score changes between T0 and T1 and the HSD + metronidazole group had a significant decrease in clinical score at T1 compared to T0 only when dogs considered to be treatment failures were excluded.

Twenty-nine dogs reached T2, a median of 18 days (range: 3-46) after T1. No differences in median clinical score among groups were present at T2, either when all dogs (P = .74) or only the dogs not considered treatment failures (P = .97) were included in the statistical analysis.

No clinically significant score changes were present between T2 and T1 in any of the groups. Adding metronidazole to the HSD + lactulose combination did not further improve the clinical score.

There was a moderate and weak correlation between clinical score and FA, and clinical score and CRP concentrations.

Limitations of the study were the small sample size in each group, the owner assessed clinical scores and the variation in timing between assessments.

Take Home

This study provides some evidence that a combination of HSD and lactulose provided appropriate control of the clinical signs of cEHPSS in dogs, and that metronidazole can be omitted from treatment protocols of dogs with cEHPSS awaiting surgical cEHPSS attenuation.

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