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LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300...

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1 C. A. Tony Buffington, DVM, PhD Professor of Veterinary Clinical Sciences The Ohio State University [email protected] LUTS in Cats - From FUS To Pandora Syndrome 1
Transcript
Page 1: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

1

C A Tony Buffington DVM PhDProfessor of Veterinary Clinical Sciences

The Ohio State University buffington1osuedu

LUTS in Cats -

From FUS

To

Pandora

Syndrome

1

2

Plan

1 Introduction background diagnosis

2 Treatment ndash acute chronic

3 Follow-up amp prognosis

4 Conclusions

3

Lower Urinary Tract Signs (LUTS) -

common in catsTop 10 Feline VP Insurance Claims ndash 2013

1 Bladderurinary tract2 PeriodontitisDental disease

3 Chronic kidney disease

4 Excessive thyroid hormone

5 Upset stomachVomiting

6 Diabetes

7 DiarrheaIntestinal upset

8 Lymphoma

9 Upper respiratory virus

10Skin allergies

4

Signs vs Causes

Signsbull Frequency

bull Inappropriate

bull Straining

bull Hematuria

9

7

6211

11 63

IC

Anatomy

Behavior

MAP

CaOx

TCC

StoneUTI

Pathology

Introduction

5

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

Introduction

6

6

We Need YOU

If you have a client who might

donate an IC cat they intend to

euthanize please call

614-292-7987

Introduction

7Outside influences cause disease

The ldquoBrickrdquo Model

Infection Injury

InfestationDiet

8

Introduction

8

Bladder abnormalities -Keay SK Birder LA Chai TC

Evidence for Bladder Urothelial

Pathophysiology in Functional Bladder

Disorders BioMed Research

International 2014

9

There is alteration in expression of components of the

nonneuronal acetylcholine machinery in FIC esophageal

epithelium as well as bladder urotheliumrdquoWolf-Johnston AS Hanna-Mitchell AT Buffington CAT et al ldquoAlterations in the non-

neuronal acetylcholine synthesis and release machinery in esophageal epitheliumrdquo Life

Sciences 201291(21-22)1065ndash1069

Bladder abnormalities

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 2: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

2

Plan

1 Introduction background diagnosis

2 Treatment ndash acute chronic

3 Follow-up amp prognosis

4 Conclusions

3

Lower Urinary Tract Signs (LUTS) -

common in catsTop 10 Feline VP Insurance Claims ndash 2013

1 Bladderurinary tract2 PeriodontitisDental disease

3 Chronic kidney disease

4 Excessive thyroid hormone

5 Upset stomachVomiting

6 Diabetes

7 DiarrheaIntestinal upset

8 Lymphoma

9 Upper respiratory virus

10Skin allergies

4

Signs vs Causes

Signsbull Frequency

bull Inappropriate

bull Straining

bull Hematuria

9

7

6211

11 63

IC

Anatomy

Behavior

MAP

CaOx

TCC

StoneUTI

Pathology

Introduction

5

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

Introduction

6

6

We Need YOU

If you have a client who might

donate an IC cat they intend to

euthanize please call

614-292-7987

Introduction

7Outside influences cause disease

The ldquoBrickrdquo Model

Infection Injury

InfestationDiet

8

Introduction

8

Bladder abnormalities -Keay SK Birder LA Chai TC

Evidence for Bladder Urothelial

Pathophysiology in Functional Bladder

Disorders BioMed Research

International 2014

9

There is alteration in expression of components of the

nonneuronal acetylcholine machinery in FIC esophageal

epithelium as well as bladder urotheliumrdquoWolf-Johnston AS Hanna-Mitchell AT Buffington CAT et al ldquoAlterations in the non-

neuronal acetylcholine synthesis and release machinery in esophageal epitheliumrdquo Life

Sciences 201291(21-22)1065ndash1069

Bladder abnormalities

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 3: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

3

Lower Urinary Tract Signs (LUTS) -

common in catsTop 10 Feline VP Insurance Claims ndash 2013

1 Bladderurinary tract2 PeriodontitisDental disease

3 Chronic kidney disease

4 Excessive thyroid hormone

5 Upset stomachVomiting

6 Diabetes

7 DiarrheaIntestinal upset

8 Lymphoma

9 Upper respiratory virus

10Skin allergies

4

Signs vs Causes

Signsbull Frequency

bull Inappropriate

bull Straining

bull Hematuria

9

7

6211

11 63

IC

Anatomy

Behavior

MAP

CaOx

TCC

StoneUTI

Pathology

Introduction

5

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

Introduction

6

6

We Need YOU

If you have a client who might

donate an IC cat they intend to

euthanize please call

614-292-7987

Introduction

7Outside influences cause disease

The ldquoBrickrdquo Model

Infection Injury

InfestationDiet

8

Introduction

8

Bladder abnormalities -Keay SK Birder LA Chai TC

Evidence for Bladder Urothelial

Pathophysiology in Functional Bladder

Disorders BioMed Research

International 2014

9

There is alteration in expression of components of the

nonneuronal acetylcholine machinery in FIC esophageal

epithelium as well as bladder urotheliumrdquoWolf-Johnston AS Hanna-Mitchell AT Buffington CAT et al ldquoAlterations in the non-

neuronal acetylcholine synthesis and release machinery in esophageal epitheliumrdquo Life

Sciences 201291(21-22)1065ndash1069

Bladder abnormalities

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 4: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

4

Signs vs Causes

Signsbull Frequency

bull Inappropriate

bull Straining

bull Hematuria

9

7

6211

11 63

IC

Anatomy

Behavior

MAP

CaOx

TCC

StoneUTI

Pathology

Introduction

5

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

Introduction

6

6

We Need YOU

If you have a client who might

donate an IC cat they intend to

euthanize please call

614-292-7987

Introduction

7Outside influences cause disease

The ldquoBrickrdquo Model

Infection Injury

InfestationDiet

8

Introduction

8

Bladder abnormalities -Keay SK Birder LA Chai TC

Evidence for Bladder Urothelial

Pathophysiology in Functional Bladder

Disorders BioMed Research

International 2014

9

There is alteration in expression of components of the

nonneuronal acetylcholine machinery in FIC esophageal

epithelium as well as bladder urotheliumrdquoWolf-Johnston AS Hanna-Mitchell AT Buffington CAT et al ldquoAlterations in the non-

neuronal acetylcholine synthesis and release machinery in esophageal epitheliumrdquo Life

Sciences 201291(21-22)1065ndash1069

Bladder abnormalities

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 5: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

5

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

Introduction

6

6

We Need YOU

If you have a client who might

donate an IC cat they intend to

euthanize please call

614-292-7987

Introduction

7Outside influences cause disease

The ldquoBrickrdquo Model

Infection Injury

InfestationDiet

8

Introduction

8

Bladder abnormalities -Keay SK Birder LA Chai TC

Evidence for Bladder Urothelial

Pathophysiology in Functional Bladder

Disorders BioMed Research

International 2014

9

There is alteration in expression of components of the

nonneuronal acetylcholine machinery in FIC esophageal

epithelium as well as bladder urotheliumrdquoWolf-Johnston AS Hanna-Mitchell AT Buffington CAT et al ldquoAlterations in the non-

neuronal acetylcholine synthesis and release machinery in esophageal epitheliumrdquo Life

Sciences 201291(21-22)1065ndash1069

Bladder abnormalities

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 6: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

6

6

We Need YOU

If you have a client who might

donate an IC cat they intend to

euthanize please call

614-292-7987

Introduction

7Outside influences cause disease

The ldquoBrickrdquo Model

Infection Injury

InfestationDiet

8

Introduction

8

Bladder abnormalities -Keay SK Birder LA Chai TC

Evidence for Bladder Urothelial

Pathophysiology in Functional Bladder

Disorders BioMed Research

International 2014

9

There is alteration in expression of components of the

nonneuronal acetylcholine machinery in FIC esophageal

epithelium as well as bladder urotheliumrdquoWolf-Johnston AS Hanna-Mitchell AT Buffington CAT et al ldquoAlterations in the non-

neuronal acetylcholine synthesis and release machinery in esophageal epitheliumrdquo Life

Sciences 201291(21-22)1065ndash1069

Bladder abnormalities

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 7: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

7Outside influences cause disease

The ldquoBrickrdquo Model

Infection Injury

InfestationDiet

8

Introduction

8

Bladder abnormalities -Keay SK Birder LA Chai TC

Evidence for Bladder Urothelial

Pathophysiology in Functional Bladder

Disorders BioMed Research

International 2014

9

There is alteration in expression of components of the

nonneuronal acetylcholine machinery in FIC esophageal

epithelium as well as bladder urotheliumrdquoWolf-Johnston AS Hanna-Mitchell AT Buffington CAT et al ldquoAlterations in the non-

neuronal acetylcholine synthesis and release machinery in esophageal epitheliumrdquo Life

Sciences 201291(21-22)1065ndash1069

Bladder abnormalities

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 8: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

8

Introduction

8

Bladder abnormalities -Keay SK Birder LA Chai TC

Evidence for Bladder Urothelial

Pathophysiology in Functional Bladder

Disorders BioMed Research

International 2014

9

There is alteration in expression of components of the

nonneuronal acetylcholine machinery in FIC esophageal

epithelium as well as bladder urotheliumrdquoWolf-Johnston AS Hanna-Mitchell AT Buffington CAT et al ldquoAlterations in the non-

neuronal acetylcholine synthesis and release machinery in esophageal epitheliumrdquo Life

Sciences 201291(21-22)1065ndash1069

Bladder abnormalities

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 9: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

9

There is alteration in expression of components of the

nonneuronal acetylcholine machinery in FIC esophageal

epithelium as well as bladder urotheliumrdquoWolf-Johnston AS Hanna-Mitchell AT Buffington CAT et al ldquoAlterations in the non-

neuronal acetylcholine synthesis and release machinery in esophageal epitheliumrdquo Life

Sciences 201291(21-22)1065ndash1069

Bladder abnormalities

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 10: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

1010

Normal Cat

(s)

0 100 200 300

(pA

)

-1500

-1200

-900

-600

-300

0

IC Cat

(s)

0 100 200 300

-1500

-1200

-900

-600

-300

0CAP

PDBDeltamethrin

CAP

Naphthyl ac posph

Saline distention (MeanplusmnSEM)( Plt 005 for Group lt0001 for Pres)

0 10 20 30 40 50 60 70 800

5

10

15

20

25

30

35

FIC (13 fibers from 7 cats)

Normal (6 fibers from 2 cats)

Bladder Pressure (cm H2O)

PP

S

Nervous System

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 11: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

11

Acoustic Startle Responses

PrePost

20

25

30

35

Enrichment

mV

(lo

g10)

Acoustic Startle

Healthy (n=11)

FIC (n=16)

Nervous System

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 12: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

12

Autonomic Alterations - StructuralChelimsky et al compared the structural integrity of the autonomic

nervous system (ANS) in IC and control females using CV response to

deep breathing Valsalva maneuver 30 min head up tilt amp sudomotor test

Results The two groups did not differ except for elevated average peak

heart rate at baseline (supine p = 006) for IC subjects prior to a tilt test

Conclusions - No structural ANS abnormalities were found in IC

subjects Higher baseline HR supports the concept of functional rather

than structural ANS changes such as an abnormality of

sympatheticparasympathetic balance that will require further evaluation

Nervous System

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 13: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

13

Autonomic Alterations - Structural

Nervous System

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 14: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

14

Autonomic Alterations - Functional

HC MPP ICBPS+MPP

ICBPS0

200

400

600

800

1000

1200

HF

-HR

V

H H

F

FIC H

F

0

1

2

3

4

Group

HF

HR

V

Nervous System

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 15: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

15

Immune System

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 16: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

16

Inflammation (salivary cort)

correlated with pain

Immune System

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 17: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

17

Sickness Behaviors

17

1 Nonspecific clinical and behavioral signs such as

vomiting diarrhea decreased food and water intake

fever lethargy somnolence enhanced pain-like

behaviors and decreased activity grooming and

social interactions Seen in all species

2 Can occur in response toa Infection

b Inflammation

c Threat

Behavior System

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 18: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

18

SB - by system

Behavior System

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 19: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

19

Effect of Stress on SB

19H-C

H-S

tres

s

FIC-C

FIC-S

tres

s

00

05

10

15

20

25

30

P=00005 P=00001

Avera

ge

SB

sw

eek

Behavior System

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 20: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

20

Endocrine System

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 21: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

21

Endocrine System

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 22: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

22

Small Adrenal Glands

40

20

=

140

FIC

200Weight (mg)

P=0004Fasc+Retic

P=007Glomerulosa

Medulla

H

Endocrine System

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 23: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

23

bull Neurological

bull Immune

bull Sickness Behaviors

bull Somaticbull Gastrointestinalbull Skinbull Cardiovascularbull Respiratory

bull Centralbull Fearbull Anxietybull Attached

bull Endocrine ndash adrenal abnormalities 23

Do LUTS come first

Comorbidities

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 24: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

24

Synthesis

Anes Clin NA 200624325-40

Mol Psych 200510239-250

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 25: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

25

Early life environments epigenetically shape stress responses

later in life in both rodents and humans

Graumlff J et al Physiol Rev 201191603-649copy2011 by American Physiological Society

Synthesis - DOHaD

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 26: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

26

Epigenetics

Genetics ndash genes you have

Epigenetics - genes you use

Sculpted by environment

26

Synthesis

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 27: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

27

Epigenetic Processes

Gluckman P et al N Engl J Med 200835961-73

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 28: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

28

Mutation variation selectionhellip

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 29: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

29

LUTS +

bull Systemic pathology

bull Co-morbidity

bull Order of onset

bull EAE

bull Epigenetics

bull Environment

Pandora Syndrome Ho

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 30: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

30

RECOVERY

VULNERABILITY

RESILIENCE

Genetic

Predisposition

Epigenetic

Effects

ldquoEventrdquo

EV

OL

OL

UT

ION

DE

VE

LO

PM

EN

T

ENVIRONMENT

The Journal of the Norwegian Medical

Association 20071273228-31

Synthesis - PS

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 31: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

31

LUTS Diagnosis LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 32: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

32

LUTS Diagnosis

LUTS

FIC

Acute IdiopathicCystitisUrethritis

History PE UA Micro Imaging Biopsy

StressedHealthy

RecurrentLUTS

PandoraSyndrome

Urolithiasis

UTI

Neoplasia(TCC)

Behavioral

Neurogenic

PandoraSyndrome

YES No

YES No

Incontinence(No Urge)

UrethalObstruction

Persistent

Self-Limiting

Frequently Recurrent

Urethral Obstruction (males)

Trauma

Iatrogenic

Brain

Immune Endocrine Autonomic

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 33: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

33

LUTS ~ 100 years of Historybull 1920s ndash Environment diet weight

bull 1950s ndash Ash (mineral)

bull 1970s ndash Mg infection H2O environment

bull 1980s ndash Alkali

bull 1990s - ldquoInterstitial Cystitis (IC)rdquo

bull 2000s ndash Comorbidities Early adverse experience DOHaD epigenetics environment

bull 2010 ndash Pandora Syndrome ()

bull 2010s ndash more research

Summary

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 34: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

34

Environmental effects on Cats

not just LUTSbull CaOx stones

bull FORL

bull Obesity

bull Type 2 DM

bull Behavior

bull Others

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 35: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

35

Conclusions

1 Take a thorough history (Look beyond the organ)

2 Pandora Syndrome Ho

a Not just ldquoFICrdquo ()

b Not just cats

c Currently testing it

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 36: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

36

Questions

Comments

36

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 37: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

37

Approach to Therapy

Acute

bull Environment

bull Analgesia

Chronic

bull Client

bull Environment

bull Cat

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 38: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

38

Captive

Dependent

bull Food amp water

bull Elimination

bull Safety

Scared

Cats in cages arehellip

Environment

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 39: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

39

Chronic Treatment

bull Treating the Client

bull Treating the Environment

ldquoMultimodal Environmental

Modification (MEMO)rdquo

bull Treating the Cat

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 40: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

40

Communicating with Clients

about chronic care

bull Clients expect us to

ldquofind it amp fix itrdquo

bull We expect ldquoone ill

one pill amp one billrdquo

40

Treating the Client

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 41: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

41

Chronic care is a little Differenthellip

bull Manage vs Cure

bull Clients do the work

bull We can help

41

Treating the Client

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 42: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

42

Communication Goals

bull anxiety

bull trust

bull Empathize

bull Educate

bull Enlist 42

Treating the Client

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 43: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

43

ldquoExpertrdquo vs ldquoCoachingrdquo approaches

Expert CoachTreats patients Helps clients help themselves

Tells clients what to do Builds motivation confidence

and engagement

Relies on expert skills and

knowledge

Relies on client self-awareness

and insights

Strives to have all the answers Strives to help clients find their

own answers

Focuses on the problem Focuses on what is working

well

Dictates Collaborates

Treating the Client

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 44: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

44

EnvironmentHealth

Barren Chaotic

Good

Poor

Where Are We

Treating the Environment

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 45: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

45

Treating the Environment

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 46: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

46

Multimodal Environmental MOdification

Goals ndash to help clients1Understand how they contribute to their catrsquos health

and wellbeing

2Manage their catrsquos environment

3Improve the catrsquos pControlpThreat (amp activation of

stress response system)

Treating the Environment

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 47: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

47

Multimodal Environmental MOdification

Methods

1 Client education

2 Environmental Enrichment

a Resources ndash food water litter box toys

b Interactionsi Other cats

ii Other animals

iii Humans

Treating the Environment

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 48: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

48

48

Treating the Environment

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 49: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

49

Understanding ndash

How cats learn

+ Reinforcement

bullPraise

bullTreats

bullPraise

What Cats Need

+ Punishment

bullSticky tape

bullAluminum foil

bullCarpet runner

bullCitrus scent

bullYelling

bullHitting

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 50: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

50

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 51: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

51

What Cats Need

An Indoor Cat

Resource List

Understanding

Safety

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 52: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

52

52

Outdoor access

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 53: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

53

An Indoor Cat Resource List

Understanding

Safety

Choice

Food amp Water

What Cats Need

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 54: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

54

Foodbull Cat ndash appropriate food for

life stage

BCS

bull Diet

Satisfactory

Agreeable to owner

AND cat

bull Feeding ndash safe amp enriched

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 55: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

55

Com

m te

st (14)

Vet Test (

11)0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

12 Month Study

Dry amp Canned

Combined

Both ldquoenrichedrdquo

Dramatic difference

Between test Foods

No ldquoenrichedrdquo or ldquousual carerdquo

control groups

Recent Diet Study

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 56: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

56

Com

m te

st (14)

Vet Test (

11)

Usual

Car

e (8)

0

2

4

6

8

10

Treatment ( of Cats)

inc

ide

nc

e R

ate

pe

r 1

00

0 s

tud

y d

ay

s

FIC Recurrence

Dramatic difference

between test foods

NSD between ldquovet testrdquo

and ldquousual carerdquo

(or other studies)

Recent Diet Study

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 57: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

57

Working for Food

57

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 58: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

58

Water

What Cats Need

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 59: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

59

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

What Cats Need

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 60: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

60

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

What Cats Need

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 61: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

61

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

What Cats Need

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 62: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

62

62

Toys

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 63: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

63

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation ndash C amp S

What Cats Need

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 64: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

64

Your results may varyhellip

What Cats Need

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 65: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

65

An Indoor Cat

Resource List

Understanding

Safety

Choice

Food amp Water

Toilet

Interactions

Stimulation

Making Changes

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 66: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

66

66

Drug TherapyAmitriptyline ldquoalt to euthrdquo

NSAIDS Be careful about hydration amp kidney

No benefit (NB) in humans cats

Glucocorticoids - NB

Antispasmodics (Valium propantheline) NB

Antiadrenergics (phenoxybenzamine

prazosin clonidine etc) - NB

Treating the Cat

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 67: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

67

67

Chronic TherapyOther Drugs - NB

bull Antibiotics

bull Anti SP

bull Elmiron

Other Tx - bull ldquoalternativerdquo

bull ldquocomplementaryrdquo

Treating the Cat

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 68: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

68

Chronic Therapy

Research findings

bull Laboratory

bull Clinical

bull RCT

bull Observational

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 69: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

69

Sickness BehaviorsJAVMA 201123867-73

Laboratory Study

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 70: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

70

Randomized Placebo-Controlled Clinical

Trial of Pentosan Polysulfate (PPS) for

Treatment of Recurrent LUTS

ACVIM Forum 2009

Dennis J Chew DVM Dipl ACVIM

Joseph W Bartges DVM PhD Dipl ACVIM

Larry G Adams DVM PhD Dipl ACVIM

John W Kruger DVM PhD Dipl ACVIM

CA Tony Buffington DVM PhD Dipl ACVN

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 71: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

71

Methodsbull 107 cats with history of recurrent LUTS

bull DX based on LUT evaluation including

cystoscopy pre amp post treatment

bull Randomized to 0 2 8 16 mgkg PPS given

BID on treat by owner

bull Weekly 0-3 owner rating of LUTS ndash

frequency not using box straining

hematuria and vocalization for 26 weeks

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 72: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

720 2 4

0

3

6

9

4 6 8 10 12 14 16 18 20 22 24 26

9

12

15

0 2 8 16

Time - weeks

To

tal L

UT

S S

co

re

81 05

14 07

Results ndash LUTS ndash 83

Clinical - RCT

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 73: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

73

Plt001 (n=46)

P=001 (n=8)

P=003(n=15)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before AfterBefore After Before After

LUTS Lower GI Resp

Plt001(n=33)

Plt001(n=31)

Never

Once

Yearly

Monthly

Weekly

Daily

Before After Before After

Fear Nervousness

Ten months of MEMOJFMS 20068(4)261-8

Observational Study

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 74: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

74

The endogenous pharmacotherapy of MEMO

Sale A et al Physiol Rev 201494189-234copy2014 by American Physiological Society

Treatment

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 75: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

75

Prognosis ndash

bull Cat

bull Client

bull Environment

75

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 76: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

76

1 Chronic LUTS common

in confined cats

2 Many cats also have

other problems as well

3 Pandora Syndrome may

explain some cases

4 Responsive to MEMO

5 Benefit from ongoing

(chronic) care approach

Summary

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 77: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

77

bull Cats can thrive indoors ndashbull Because changing context

bull Changes expectation

bull Which changes history

bull Enrichment needs varybull Provide choice

bull Positive feedback

bull Promotes health amp wellbeing for both

Conclusions

78

Questions

Comments

78

Page 78: LUTS in Cats - From FUS To Pandora SyndromeNormal Cat (s) 0 100 200 300 (p A)-1500-1200-900-600-300 0 IC Cat (s) 0 100 200 300-1500-1200-900-600-300 CAP 0 PDB Deltamethrin CAP Naphthyl

78

Questions

Comments

78


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