Managing Purrticulars of Feline Poisonings · . 3600 American Blvd. W., #725 Bloomington, MN 55431. Pet Poison Helpline ©2018. Managing Purrticulars of . Feline Poisonings

Pet Poison Helpline ©20183600 Amer i can B l vd . W. , #725 B looming ton , MN 55431www.petpo i sonhe lp l i ne . com

Managing Purrticulars of Feline Poisonings

Heather Handley, DVMSenior Consulting Veterinarian, Clinical ToxicologyPet Poison [email protected]

November 6, 2018

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Speaker Introduction

Heather Handley, DVM

Senior Consulting Veterinarian, Clinical Toxicology

Cats are Special• Fantastic at conserving heat• Hemoglobin contain eight oxidizable sulfhydryl groups, which

make them susceptible to oxidative damage• Can hear better then most dogs• Can judge the size of openings with their whiskers• May have a dysfunction of ABCG2 gene resulting in a

functional transporter protein defect which limits efflux transporter of fluoroquinolones from retinal space

• Have the cutest toe beans• Have deficient glucuronidation

https://twitter.com/toesofacat

Glucuronidation• A significant pathway needed to metabolize many drugs• Reduced metabolism leads to increased drug

concentration in the body for a longer time– Acetaminophen (APAP)– Aspirin (ASA)– Benzocaine– Donepezil (Aricept)– Diazepam– Carprofen

https://imgflip.com/i/1e8mry

Special Decontamination• Emesis

– Dexmedetomidine • 7.0 mcg/kg IM or IV• Vomiting in 5 minutes • Reverse with atipamezole (Antisedan) 25 -50 mcg/kg IM or slow IV

– Xylazine • 0.44 mg/kg IM or SQ• Vomiting within 5-15 minutes• Reverse with atipamezole (Antisedan) or yohimbine 0.1 mg/kg IV.

– Do Not Use apomorphine orhydrogen peroxide

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For an in-depth review on feline decontamination, see PPH webinar Decontamination of the poisoned patient: What , Why, When and How by Dr. Renee Schmid

What do cats get exposed to?

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Cases from 9/1/16-9/1/18

Plants• Any plant can cause gastro-intestinal upset/vomiting• Insoluble calcium oxalate (CaOx) can cause mucosa irritation

swelling, and ulceration– Arrowhead vine, Caladium, Calla lily, Dieffenbachia spp., Peace lily,

Philodendron, Pothos

– Wash mouth with cool water or offer tuna water, chicken broth, etc.

– Dilute milk or yogurt (1:1 ratio) to bind oxalate crystals

– Pain meds, anti-emetic

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https://www.rd.com/advice/pets/can-cats-drink-milk/

Plants• Soluble CaOx plants with oxalic acid and soluble oxalate salts

– Irritation like insoluble CaOx

– Large amounts can also cause hypocalcemia and acute kidney injury

– Shamrock, Rhubarb» Induce emesis, activated charcoal with sorbitol (AC/C), monitor

renal values and calcium on IV fluids» Calcium gluconate» Analgesia» GI protectants

https://www.ourhouseplants.com/plants/purple-shamrock

A lily by any other name…• “True lily” vs. an imposter• Renal-toxic lilies are Lilium sp and

Hemerocallis sp.– Leafy stems– Scaly bulbs– Narrow leaves (usually)– Flowers have six petallike segments– Trumpet shape (variable)

• ALL parts of the plant are toxic

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Alstroemeria Peruvian Lily –Imposter!

True Lily Characteristics

http://z5suburbangardener.blogspot.com/2011/11/

Scaly Bulb

https://www.ebay.com.au/itm/50pcs-Blue-Heart-Lily-Flower-Seeds-Elegant-Potted-Perennial-Plant-Lily-Seed-Bulb-/152109950334

Six petallike segments

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Leafy stems

https://www.crocus.co.uk/plants/_/lilium-regale/classid.1000000399/

Trumpet shape

https://www.whiteflowerfarm.com/31156-product.html

Narrow leaves

https://garden.org/plants/photo/356142/

IMPOSTER

Lily Treatment• Decontamination

– Bathe– Dexmedetomidine, anti-emetic, 1g/kg AC/C

• Obtain baseline CBC, Chem, urinalysis

• Run aggressive IV fluids x 48h or until asymptomatic

• Check renal values and PCV/TP daily

• Treat for acute renal failure if needed

https://www.allure.com/story/plastic-surgery-national-iv-fluid-shortage

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What do cats get exposed to?

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Pyrethrin/Pyrethoid

• Pyrethrins are derived from chrysanthemum flowers

• Pyrethroid refers to synthesized pyrethrins

• Ends with -thrin

• Flea control products (shampoos, spot-on topical products, dusts, foams, collars, sprays)

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Pyrethrin/Pyrethoid• Cats are very sensitive due to lack of glucuronidation and

other unknown reasons• Common exposure of cats

– treated with topical spot-on products labeled for dogs – groom or are in close contact with treated dogs

• Severity depends on individual animal and dose• Central neuropathies

– tremors, seizures, ataxia

• Peripheral neuropathies – skeletal muscle weakness, twitching skin, shaking, agitation

http://www.mcahonline.com/news/topical-flea-tick-toxicity-in-cats

Pyrethrin/Pyrethoid• Low concentration shampoos and sprays pose little risk

• Concentrations >3-4% can be toxic– Many spot-ons are >45%

• Before signs start, bathe in luke-warm water with mild, liquid dish soap.

• If twitching, then sedate first• Towel dry and prevent hypothermia

http://www.kittenlady.org/fleas/

Pyrethrin/Pyrethoid• Maintain hydration & perfusion with IV fluids• Keep in a dark, quiet cage where the cat can be monitored• Use methocarbamol to treat tremors

– Draw up 40mg/kg then give ½ over 1-2 min. Give the remaining slowly to effect.

– Give more if needed using level of relaxation as the dosing indicator

• Use phenobarbital to treat seizures• Monitor for at least 48-72 hours

Intralipid emulsion (ILE) for Pyrethroid Poisoning

• Results are mixed. • Can be helpful when used as an adjunct to traditional treatments. Not

recommended as sole agent. – May help to more quickly resolve clinical signs and/or prevent more serious

signs after cat is stabilized with methocarbamol or anti-seizure agents– ILE may compromise effect of other treatments.– PPH reserves ILE for moderate-severe cases.

• Avoid ILE if cat is obese (body condition score 7-9/9), has diabetes mellitus, or cardiac, or renal disease as the use is riskier—stick to traditional treatments instead.

• For in-depth use of ILE for pyrethroid intoxication, see previous webinar: – Let’s chew the fat: Updates on the use of intravenous lipid emulsion by Ahna

Brutlag, DVM, MS, DABT, DABVT– https://www.petpoisonhelpline.com/webinar/lets-chew-the-fat-updates-on-

the-use-of-intravenous-lipid-emulsion/

What do cats get exposed to?

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Amphetamine Salts• Adderall and Adderall XR (amphetamine and dextroamphetamine)• Dexedrine and Dexedrine spansules (dextroamphetamine)• Dextrostat (dextroamphetamine)• Dyanavel XR – Extended release amfetamine• Evekeo – 1:1 ratio of dextroamphetamine and levoamphetamine• Methamphetamine (D or D+L form) – street drug• Methamphetamine (L form only) – Vicks Vapor Inhaler and generics • Vyvanase (lisdexamphetamine) • Adzenys XR-ODT – Extended release oral disintegrating tablet

– Coated and uncoated microparticles!

https://adf.org.au/drug-facts/amphetamines/

Amphetamine Salts• Clinical signs

– Mydriasis– Tachycardia– Agitation– Disorientation– Vocalization– Hyperactivity– Hyperthermia– Tachypnea– Panting– Pacing– Lethargy– Hypertension– Circling– Tremors– Seizures https://www.royalcanin.se/app/uploads/2015/11/Vet-Focus-25.3.pdf

• Onset of Action: • Within 1-3 hours

• Duration of Action: • 7-34 hours depending on product

(longer for XR) • Chewing the pill can hasten

onset of action

Amphetamine Salts• Decontamination

– Dexmedetomidine, anti-emetic, 1g/kg AC/C• Baseline CBC, chem

– Potential for hypoxic/hypoperfusion events• IV balanced crystalloid • Therapy

– Acepromazine if the BP normal or high• Starting at 0.05mg/kg IV and increase the dose if needed

– Methocarbamol works well for tremors – If seizures occur, use a barbiturate (over diazepam/midazolam) – If heart rate and blood pressure are >180 after good sedation, a

beta-blocker is indicated

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What do cats get exposed to?

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Essential Oils• Many contain terpenes

– Rapidly absorbed orally and dermally and then metabolized in the liver by glucuronidation

• Many contain phenol or phenolic compounds– Alcohols that are highly reactive and caustic topically

• Liquid potpourri: – Concentrations > 7.5% are associated with corrosive injury in cats– Cats may develop clinical signs at 2%

http://canacopegdl.com/keyword/liquid-potpourri.html

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Essential Oils• Specific oils of concern:

– Oil of wintergreen and oil of sweet birch (methyl salicylate)• Aspirin: Gastrointestinal, hemic, hepatobiliary, respiratory signs

– Citrus oil (d-limonene)• Hypersalivation, muscle tremors, ataxia, lateral recumbency, coma,

death

– Pine oils (terpenic oils)• Early - anorexia, salivation, vomiting, oral or pharyngeal pain and

ulcers• Later – ataxia, pulmonary edema, Heinz body anemia & other blood

abnormalities, hepatic and renal failure, death

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Essential Oils• Ylang ylang oil (benzyl alcohol, benzyl acetate, benzyl

benzoate)– GI irritation

• Peppermint oil (menthol)– Vomiting, diarrhea, and depression– Seizures are possible with large ingestions

• Cinnamon oil (alcohols and aldehydes)– Mild gastro-intestinal upset – Large ingestions: tachycardia, diarrhea, tachypnea, depression

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Essential Oils – Oral• Signs:

– Irritation of tongue and mucous membranes – Possible erosions, ulcers, and chemical burns – Visible within 4-6 hours, with full extent seen by 12 hours

• Treatment– Dilute. Flavor water with tuna juice to encourage drinking– Opioid analgesia– Antibiotics– Soft food/feeding tube– Oxygen

http://pettalkinillinois.blogspot.com/2015/05/toxin-tuesday-potpourri-and-essential.html

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Essential Oils – Topical• 100% Tea tree oil

– Hypothermia, ataxia, weakness, CNS depression, tremors, bradycardia, increased live enzymes

• Treatment– Bathe well with mild hand dish-washing detergent – Examine exposed areas for signs of irritation or ulceration – Multi-dose activated charcoal for enterohepatic recirculation

https://www.thehappycatsite.com/is-lavender-oil-safe-for-cats/

Essential Oils – Topical• Tea tree oil treatment, cont.

– IV crystalloids to maintain hydration and tissue perfusion– Nursing care (heat support, flipping) – Monitor blood pressure closely until stable – With severe CNS depression, intubation and mechanical

ventilation may be needed– Hepatoprotectants if indicated based on increased liver

enzymes – Recheck liver enzymes every 5-7 days until clinical signs and liver

enzymes return to normal

http://www.brassunicorn.com/essential-oils/tea-tree

Bromethalin• Bromethalin

– Feline oral LD50 0.54 – 1.8 mg of bromethalin/kg Dorman,2013

– Canine oral LD50 2.38 – 4.7 mg of bromethalin/kg Dorman,2013

• Paralytic Syndrome– 2 hrs to 1-2 days post exposure – Paralysis with deep pain loss 2-3 days– Hind limb weakness & ataxia– CNS depression– Hind limb paralysis (hyper-reflexive), ↓ conscious proprioception, loss of deep pain– Gastro-intestinal stasis– Anisocoria, nystagmus– Opisthotonos– Seizures– Coma

• Signs last up to 8 weeks

https://thesocialmediamonthly.com/cyber-attacks-are-a-game-of-cat-and-mouse/

Alpha Lipoic Acid (Thioctic Acid)• Cats are 10X more sensitive than dogs• Clinical signs:

– Hypoglycemia– Increased liver enzymes– Hypersalivation– Vomiting – Ataxia– Tremors– Seizures– Renal failure

• Decontaminate >5mg/kg– If asymptomatic, induce emesis and give AC/C x 1

https://www.target.com/p/nature-made-alpha-lipoic-acid-dietary-supplement-softgels-30ct/-/A-15070635

ALA Treatment• Monitor glucose, liver, kidneys• Dextrose + isotonic fluids such as lactated Ringer’s

solution (LRS), PlasmaLyte®, and Normosol® • Thiamine may reduce toxic effects

– 100-250 mg total SQ BID

• Treat CNS signs– Methocarbamol for tremors– Diazepam for seizures– Phenobarbital for seizures

https://www.google.com.au/search?q=dextrose&rlz=1C1GCEB_enAU814AU814&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjUtMnM9JDeAhVJ64MKHf86Bu8Q_AUIDygC&biw=1600&bih=758#imgrc=5Q5tR2E7NAHccM:

Resistance! (?)• Xylitol

• No published cases• PPH cases of 2 cats with BG ~70mg/dL

• Grapes/Raisins• No published cases

• Long acting anticoagulants• LD50 10-100X higher than dogs

MeowchasGracias!!

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Blackwell’s Five-Minute Veterinary Consult Clinical Companion:

Small Animal Toxicology 2nd Edition

Drs. Lynn Hovda, Ahna Brutlag, Robert Poppenga, Katherine Peterson

www.wiley.com/go/vetPaperback | May 2016 | 960 pages | 978-1-119-03654-8 | $109.99 · CAN $120.99

• Provides concise, bulleted information focused on the most important facts needed when treating a poisoned cat or dog

• Carefully organized for ease of use in an emergency, with important toxicants arranged alphabetically within categories

• Details clinically relevant information on the most common toxicants encountered by small animals

• Presents a wealth of color photographs to aid in plant identification• Includes 14 new topics to this edition covering cyclosporine A, sleep

aids, tacrolimus, bath salts, synthetic marijuana, poisonous lizards, imidacloprid, spring bulbs, and sodium monofluoroacetate

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