Post on 26-Feb-2021
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
78
Questions
Comments
78