1/31/16

1

Integrative Medical Approach to Common Clinical Problems

in Small Animals

Ronald Koh, DVM, MS, CVA, CCRP, CVCH, CVFT

rkoh@lsu.edu

Assistant Professor, Integrative Medicine School of Veterinary Medicine

Louisiana State University

Outlines

  Introduction to Complementary and Integrative Veterinary Medicine (CIVM)

  Guidelines using CIVM

  CIVM for common problems

  Osteoarthritis

  Cognitive Dysfunction Syndrome

  Separation Anxiety

  Atopic Dermatitis

  Bleeding

Unconventional Medicine

  Alternative Med

  Use of other modalities instead of conventional medicine

•  Integrative Med

–  Combines conventional medicine and CAM therapies for which there is some scientific evidence of safety and effectiveness

�  Complementary Med

� Use of other modalities in conjunction with conventional medicine

Complementary and Alternative Medicine “ A group of diverse medical and health care systems,

practices, and products that are not presently considered to be part of conventional medicine ”

Integrative Medicine

•  Mounting scientific evidence on the safety and efficacy

•  Combination of conventional

medicine with safe and

evidence-based CAM to

maximize therapeutic outcomes and achieve optimal

health and healing

� Whole body approach -“Wholistic” � Not just the disease or clinical signs � All aspects of life

� Relationships

� Physical

� Mental

� Emotional

� Spiritual

� Homeopathic medicine: “Like Cures Like”

� “additional to western medicine” � “not taught in medical schools” � “usually lies outside the official health

sector” (WHO) � “neither taught widely in US medical

schools nor generally available in US hospitals” (Eisenberg, NEJM, ’93)

� “practices of unregistered (non-licensed) practitioners” (GMC)

Integrative Medicine

Integrative Medicine in US Med & Vet Schools

  New wave in health care

  Part of curriculum at 50 major US med schools   Stanford, Yale, Johns Hopkins, Harvard, etc

  American Board of Integrative Medicine

  CVM: UF, UT, CSU, UC Davis, LSU, UMN, Cornell, Iastate*, MSU*, NCSU*, VA-MD*, WISC*, WSU*

  2000 survey: 10/24 schools that offered CIVM course

  2011 survey: 17/24 vet schools had CIVM course

This case exemplifies the adage “when your only tool is a hammer, every problem looks like a nail.” It clearly demonstrates the limits of a purely pharmaceutical approach to health issues.

Harvard Stanford Johns Hopkins Yale Duke Pennsylvania UCSF

Americans are using complimentary and alternative medicine (CAM) with increasing frequency and top hospitals and leading medical schools in the U.S. are adding integrative medicine to their programs in response to this demand. In his article “Top Hospitals Embrace Alternative Medicine”, US News & World Report contributor Avery Comarow names just a few of the hospitals that have integrative programs -Mayo Clinic, Duke University Medical Center, Children’s Memorial Hospital and the University of California-San Francisco Osher Center for Integrative Medicine. You can read more about Mr. Comarow’s report on the widespread use of complementary and integrative therapies here. There are currently 44 academic medical centers that comprise The Consortium of Academic Health Centers for Integrative Medicine. The Consortium is charged with advancing the practices of integrative healthcare within academic institutions. Some of these members include Stanford University, Yale University, Johns Hopkins University and Harvard Medical School. This entry was posted on Thursday, May 27th, 2010 at 7:04 pm and is filed under Recent News. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.

1/31/16

2

Goals of CIVM Integrative Medicine: a combination of the best and most appropriate therapies for you from the worlds of both traditional western medicine (Allopathy), Functional Medicine and Alternative Medicine. Sometimes Integrative Medicine is called Complementary Medicine in that it works alongside Allopathy, each bringing valuable therapies to you. Dr. Andrew Weil pioneered the introduction of Integrative Medicine to most Americans.

Comprehensive approach to health care Enhance conventional medical care

� Wellness and illness prevention

� Evidence-based, safe, and ethical CIVM therapies

�  Individualized plan for patient using the best of all available modalities

� Minimize the use of prescription drugs and conventional therapies

� Cost savings and less side effects

�  Integrated NOT replacement!

Emphasis on prevention, nutritional diet and lifestyle change

Reasons for CIVM

  Enhance the effectiveness of conventional medicine

  Provide relief of clinical signs

  Treat conditions that failed to respond to medicine

  Avoid or reduce the side effects of some medicines

  Minimize the use of medicines

  Enhance mental and physical health

  Hospice and palliative care

Common CIVM Therapies

Current examples of CIVM, not limited to:

•  Aromatherapy, Bach flower remedy therapy

•  Low-energy photon therapy, magnetic field therapy

•  Chinese Medicine, acupuncture, acupressure

•  Homeopathy

•  Rehabilitation, manual or manipulative therapy

•  Nutraceutical therapy, phytotherapy

•  Stem cell therapy, prolotherapy

What Do We Do In CIVM?

  As a specialty referral   First seen by rDVM: Hx, PE, Dx tests, Dx

  Full History & PE

  Discuss all treatment options

  Have owner consent

  Safe, effective and proven   Nutritional supplements and botanicals

  Veterinary devices

  Critically evaluate literature

Integrative Medicine for Osteoarthritis

OA: The Vicious Cycle

Decreased exercise

Muscle atrophy

Increased stress on joint capsule, ligaments and cartilage

Cartilage damage

Inflammatory mediators

Decreased nociceptive threshold and hyperalgesia

Acute pain is a symptom,

Chronic pain is a disease

PAIN

1/31/16

3

OA: The Vicious Cycle

Decreased exercise

Muscle atrophy

Increased stress on joint capsule, ligaments and cartilage

Cartilage damage

Inflammatory mediators

Decreased nociceptive threshold and hyperalgesia

Acute pain is a symptom,

Chronic pain is a disease

PAIN

Physical Therapy

PT

Weight Loss

Adequan Glucosamine Chondroitin

MSM HA

GLM

Drugs Acupuncture

Laser T. Ultrasound Shockwaves Omega-3 FA

Acupuncture

Insertion on needles into specific points on the body to cause a desired healing effect

Acupoint body

needle

Physiological Changes

Beta-endorphin Nerve regeneration

Unblock Qi Balance Yin Yang

Immune cells

Tian He. Autonomic Neuroscience. 2015

  29 RCTs, 17,922 patients

  Back & neck pain, osteoarthritis, chronic headache, shoulder pain

  ACP is effective for the treatment of chronic pain

  True ACP significantly different from control and sham ACP

Laser Therapy

é Blood flow

é ATP production é angiogenesis and capillary production

Wavelength-specific form of photobiomodulation 660, 810, 980 nm

Use laser diode to create wavelengths

Interacting chemically and biologically with tissue

•  Relieve pain •  Reduce inflammation

•  Accelerate wound healing •  Stimulates cartilage growth

ê prostaglandins & inflammatory mediators é macrophage activity & leukocytic phagocytosis é  blood flow

é endorphin

ê inflammatory mediators

é fibroblast activity and collagen production

! nociceptors

Favors LLLT Favors Placebo

  7 RCTs (N=394)

  VAS for pain after treatment was significantly lower in the LLLT group compared with placebo

1 day after LASER 3 days after surgery

3 day after LASER 4 day after LASER

1/31/16

4

Therapeutic Ultrasound

  Utilizes sound waves to cause vibrations to relieve pain and improve joint function   Improve blood flow

  Increases protein synthesis

  Stimulates fibroblast activity

  Aids in soft tissue and bone remodeling

  Breakdown scar tissues

ò  Studies show that it can improve strengthening benefits when combined with exercise in OA in knees. (Huang & Yang 2005; Huang & Lin 2005)

ò  Activates chondrocytes to increase collagen synthesis (Korstjens et al 2004 & 2008; Naito 2010)

ò  Improves fracture healing (Santana-Rodriguez 2010; Shakouri 2010; Esteki 2010; Korstjens 2004; Gebauer 2002)

Meta-analysis suggested US is more effective

than control for pain relief and function

improvement in knee OA (Zeng C, et al, 2014)

Other Modalities

TENS   Low electrical current (2-4 or 60-200Hz)

  Affect NERVES

  Decrease pain perception

  Gate theory

  2-5 times/week

ò  “TENS”

ò  Affect NERVES

ò  Pain relief

ò  Gate-theory

ò  Acute pain: 60-200 Hz

ò  Relief is short-lasting

ò  Chronic pain: 2-4 Hz

ò  Longer lasting pain relief

  (takes a chronic condition and changes it back to its acute phase).

Extracorporeal Shockwave   ~1,000X the magnitude of ultrasound

  Modulates a change in inflammatory response

  3 treatments every 2–3 weeks.

  Requires sedation (painful)

Therapeutic Exercises

  Pain relieve

  Minimize disuse changes

  Return to normal activities   Range of motion (ROM)   Balance   Strength   Endurance

Fletcher, 13 y/o, MN, Border Collie

  Chronic hip dysplasia & OA

  Carprofen caused increased BUN & Creatinine

  Tried Tylenol, Gabapentin, Tramadol, etc

  Walking very slowly, stumbling, acting disoriented

  Cognitive dysfunction?

  QOL

pain on hip & lumbar palpation

“Fletcher”

Plan

  Acupuncture 1X/week

  Add Rehab in 2nd visit

  Outcomes:

  Significant less pain

  Get up easier & walk better

  More alert

  “new dog”

Integrative Medicine for Cognitive Dysfunction Syndrome

and Separation Anxiety

1/31/16

5

Cognitive Dysfunction Syndrome

  13% of dogs age 8-11; 50% of dogs age of 11-12; 68% of dogs over 15 year old

  Brain atrophy, increased amyloid plague, reduced blood flow

  Inflammation?

  Assessment: DISHA   Disorientation   Interaction   Sleep/wake   House-soiling (learning/memory)   Activity (increase or decline)   ANXIETY!   DISHA-A

Start Tx as early as possible!

CDS Management

  Slow neuronal damage and cell death

  Multimodal approach:   Drugs

  Diet   Supplements

  Exercises / Rehabilitation

  TCVM: Acupuncture, Herbal medicine

Diet: Hill’s b/d Ω-3 FA, vitamins C and E, b-carotene, selenium, flavonoids, and carotenoids, DL-α-lipoic acid, L-carnitine

CDS Management: Drugs

  Selegiline   MAOB inhibition, antioxidant   Increase dopamine level in brain   Vomiting and diarrhea; restlessness, lethargy   Contraindicated with numerous drugs   0.5 - 1 mg/kg PO once daily

Diet: Hill’s b/d Ω-3 FA, vitamins C and E, b-carotene, selenium, flavonoids, and carotenoids, DL-α-lipoic acid, L-carnitine

  Propentofylline   Vasodilator and anti-inflammatory

  Improve blood circulation in brain

  <10 kg: 200 mg/day

  >10kg: 400 mg/day

CDS Management: Diet

  Hill’s b/d   Mitochondrial co-factors, Ω-3 FA

  Antioxidants (vit. E, flavonoids/carotenoids, l-carnitine, α-lipoic acids)

  Effects of diet 8 weeks (Landmark); 6 months (Attention)

  Effect of diet plus enrichment > enrichment > diet

  Purina Bright Minds   Antioxidant, OFA, MCT

Diet: Hill’s b/d Ω-3 FA, vitamins C and E, b-carotene, selenium, flavonoids, and carotenoids, DL-α-lipoic acid, L-carnitine

CDS Management: Supplements

  Omega-3 Fatty Acids   DHA>EPA, 70-150mg/kg SID

  S-adenosyl-methionine

  Regulate neurotransmitter levels, increase glutathione

  Improved both CDS dogs and cats, 20mg/kg SID

  Medium chain triglycerides (coconut oil)

  Provide ketone bodies for aging neurons

  Improved CDS in dogs

  Environment enrichment & Exercises

  Housing with another dog, playing daily with toys

  Hill’s B/D – mitochondria, antioxidant, OFA

  Purina Bright Minds – antioxidant, OFA

  Omega-3 Fatty Acids – DHA>EPA, 70-100mg/kg SID

  Apoaequorin (Neutricks) – Calcium Buffer

  S-adenosyl-methionine – methyl donor

  Medium chain triglycerides (coconut oil) – mitochondria

  Environment enrichment

  Acupuncture – opiates, GABA, serotonin, blood flow   Provide ketone bodies as an

alternate source of energy for aging neurons

CDS Management: Supplements

Senilife® (CEVA) Phosphatidylserine, Gingko biloba, vit E, vit B6, resveratrol

Aktivait (Vetplus) Phosphatidylserine, omega-3 FA, vit E & C, l-carnitine, alpha-lipoic acid, coenzyme Q and selenium

  Apoaequorin (NeutricksTM)   Calcium buffering protein found in jellyfish

Neuroprotection against aging

  Shen Calmer (JingTang)   0.5 g per 10 pounds BID

  Hill’s B/D – mitochondria, antioxidant, OFA

  Purina Bright Minds – antioxidant, OFA

  Omega-3 Fatty Acids – DHA>EPA, 70-100mg/kg SID

  Apoaequorin (Neutricks) – Calcium Buffer

  S-adenosyl-methionine – methyl donor

  Medium chain triglycerides (coconut oil) – mitochondria

  Environment enrichment

  Acupuncture – opiates, GABA, serotonin, blood flow

1/31/16

6

Separation Anxiety & Phobia

  Very common conditions in young, elderly, CDS   Barking and howling   Chewing, digging and destruction   Escaping   Pacing

  Often need anti-depressants   Fluoxetine, paroxetine   Diazepam, alprazolam   Clomipramine, amitriptyline

Trazodone   Selegiline

  Behavioral modification program

Diazepam (valium), alprazolam (xanax) Amitriptyline (Elavil), clomipramine (clomicalm) Fluoxetine (prozac),

Integrative Medicine for Separation Anxiety

  Pheromone

  L-Theanine – GABA, dopamine

  Alpha-casozepine – GABA

  L-tryptophan – serotonin

  Melatonin – sleep aid

  Thunder-shirt/ Static cape

  Music – classical (through a dog’s ear)

  Catnip

Aromathepray – chamomile, lavender

Zylkene is a complementary feed for cats and dogs which contains a natural product, derived from casein, a protein in milk. It is a molecule well known to promote the relaxation of newborns after breastfeeding. Launched in October 2013, Zylkene has become a familiar product for veterinary surgeons, behaviorists, nurses and pet owners for use in helping pets cope when facing unusual and unpredictable situations or before occasions such as a change in their normal environment.

GABA 100 mg, L-tryptophan 100 mg, L- theanine 100 mg, B vitamins

Thiamine 62.5 mg L-Theanine 21.12 mg

Colostrum Calming

Complex 10.56 mg

Thiamine 134 mg Colostrum Calming Complex 22 mg L-Theanine 21 mg

Magnolia & Phellodendron 75 mg L-Theanine 35 mg

Dried Whey Protein Concentrate†

25 mg

L-theanine   <10 kg received 25 mg   >10 kg received 50 mg   30 min before stressful event

Acupuncture for CDS

  12 Studies : 3 human, 9 animals

  Showed to be effective in improving

intelligence and ameliorating

depression and anxiety in various pathological conditions

  Improve cerebral blood flow

  Promote dopamine

  Enhance neurotrophin signaling

  Reduce oxidative damages

  Regulate glucose metabolism

  Decrease Aβ proteins level in the brain

Integrative Medicine for Atopic Dermatitis

Atopic Dermatitis

  Affect 10-15% of the canine population

  Itching, smelling, erythema, hair loss

  Relieving skin itch and inflammation remains a challenge

  Integrative therapies reduce inflammation and pruritus, and prevent relapse   Supplementation

  Acupuncture

  Laser

  TCVM

  Skin disease is a COMMON reason that dogs are presented to a veterinary clinic

  Complaints of itching, smelling and hair loss are listed – most common is itching

  Regardless of presentation, all dogs with significant skin disease need a skin scrape, (superficial and/or deep) dermatophyte culture and surface cytology performed

  Integrative therapies reduce inflammation and

1/31/16

7

Integrative Medicine for Atopic Dermatitis

  Adjunct to standard treatment

  Omega 3 Fatty Acids – EPA > DHA

  Probiotic – regulate immunity

  Essential oil – anti-inflammation, anti-pruritic

  Chinese herbals – anti-inflammation

  Acupuncture – anti-inflammation, calm

  Laser – anti-inflammation

  Scientific evidence in dogs/cats is needed

Omega 3 Fatty Acids

  16 dogs with idiopathic atopy or flea allergy

  6-week crossover design with a 3-week washout period

  TX: 180 mg of EPA and 120 mg of DHA/10 lb

  Significant improvements in pruritis, self-trauma, and coat

character over time

Topical Unsaturated Fatty Acids And Essential Oils

  7 dogs with atopic dermatitis vs 5 normal dogs

  Spot-on once weekly for 8 weeks

  Validated lesion score (CADESI), VAS pruritus score

  Mean CADESI scores significantly decreased

  Pruritus scores significantly decreased

Chinese Herbal Medicine for Atopic Dermatitis

  120 dogs with perennial atopic dermatitis

  PYM00217 : R. glutinosa, P. Lactiflora, G. uralensis

  100, 200, or 400 mg/kg daily or placebo for 12 weeks

  CADESI evaluated at 0, 4, 8, and 12 weeks

  200 mg/kg dose had a statistically significant reduction

(23.4%) in CADESI

Probiotic for Atopic Dermatitis

  42 dogs with atopic dermatitis

  double-blinded, placebo-controlled trial

  L. sakei probio-65 (n = 32), or placebo (n = 10) once a day continuously for 8 weeks.

  1g (<5kg) or 2g (>5kg) of powder

  2x106 CFU/g of L. sakei

  CADESI & PVAS evaluated every 28 day

  Probiotic significantly reduced CADESI & PVAS

Acupuncture for Recurrent Otitis

  Randomised controlled trial, 1-year follow-up

  31 dogs with recurring otitis

  Rate of acute otitis episodes

  ACP: 14 (93%) dogs were free of relapses

  Placebo: 7 (50%)

1/31/16

8

Yunnan Baiyao

  Increases primary hemostasis through promotion of platelet adhesion and aggregation

  Treat and prevent external or internal bleeding

  Inhibitory effects on canine HAS cell lines

  Meta-analysis (55 RCT), helpful in treating uterine hemorrhage, ulcerative colitis and skin ulcer [Yang B. 2014]

  1 capsule (0.25 g) per 10-20 lb BID-TID

  87 patients

  Tx vs Ctrl

  Yunnan Baiyao, orally for 3 days before Sx

  Mean total blood loss:

  330.5 vs. 420.3 ml (p < 0.001)

  No allergic reactions, thromboembolic events or other side effects

Take Home Messages

  Growing specialty with high demand

  Complement conventional treatments

  Improve outcome and quality of life   Pain management

  Neurological disorders

  Behavioral problems

  Many chronic diseases

  Hospice care

  Safe and effective

  Quality control of supplements is needed

  High quality studies

Integrative Medicine

Veterinary Acupuncturists •  Ronald Koh, DVM, MS, CVA, CCRP, CVCH, CVFT

•  Rebecca McConnico, DVM, PhD, DACVIM, CVA

•  Martha Littlefield, DVM, MS, CVA

Rehabilitation Therapists •  Ronald Koh, DVM, MS, CVA, CCRP

•  Jennifer Bridges, MS, CCRP

Massage Therapist •  Maxon Graham, BS, ESMT/CSMT

Technician •  Suzie Dauzat, RVT