Download Vetoquinol Liver disease and Zentonil XL Vets Ireland

Liver Disease in the Older Patient
Agenda
• Liver Disease in the ageing patient
• Types
• Investigation
• Blood tests
• Others
• Treatment
• Antioxidants and Zentonil in Liver Disease
• Role
• Benefits of formulation
• Silybin
Types of Disease Affecting the Older Patient
• Inflammatory
• Chronic hepatitis (dogs)
• Lymphocytic hepatitis (cats)
• Infectious
• Leptospirosis
• Bacterial – Cholangiohepatits (cats)
• Toxic
• Drugs – NSAIDS (incl ibuprofen), steroids, paracetamol, carbimazole,
phenobarbitone, azothioprine
• Metals – Copper, iron
• Vascular
• Acquired portal shunts
Types of Disease Affecting the Older Patient
• Metabolic
• Cushings disease
• Diabetes mellitus
• Hepatic lipidosis (cats)
• Neoplasia
• Primary
• Eg hepatic adenoma/carcinoma
• 26% tumours affecting liver in dogs, 20% in cats
• Haemolymphatic
• Eg lymphosarcoma, mast cell tumour
• 28% dogs, 60% cats
• Metastatic - 46% dogs, 20% cats
• Ideopathic
Investigation – Blood Tests
• Liver Enzymes
• ALT (AST, LDH) – hepatic leakage enzymes
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Released as a result of hepatocellular membrane damage
Rise in serum concentration is proportional to hepatic insult
Rarely, get decrease in end stage cirrhosis
ALT pretty liver specific (some muscle) and short ½ life (cat-24h, dog-60h)
AST and LDH poor liver specificity (heart and skeletal muscle)
• ALP, GGT – Induction enzymes
• Production induced by cholestasis
• No increase after liver injury (c.f. ALT) but many liver diseases cause
cholestasis
• Mild increases significant in cats
• Cats do not have the steroid induced isoenzyme c.f. Dogs
• GGT maybe more sensitive for cholestasis in cat but less specific
(intestine, kidney, pancreas)
Investigation – Blood Tests
• Bile acids
• Healthy liver good at extracting BA from portal circulation
• BAST more useful and is indicator of liver function
• Serum proteins
• Albumin synthesised by the liver
• Needs to be severe, prolonged liver disease to cause a decrease (long
½ life – 20d)
• Clotting factors
• Many synthesised by liver and many need Vit K which is decreased if
cholestasis
• Important if considering liver biopsy
• CBC
• Anaemia
• Inflammation, infection
Investigation - Other
• Urinalysis
• Bilirubinuria – any is abnormal for cat
• Ammonia biurate crystals if PSS
• Ultrasound
• Radiography
• Liver biopsy
Treatment
• Diet
• Highly digestible, high quality protein (cottage cheese)
• Highly digestible carbohydrate
• Fibre – helps to trap ammonia
• Steroids
• Use if biopsy evidence of ongoing inflammation
• Not if ascites (portal hypertension) or extensive fibrosis
• Not if acute or infectious hepatitis
• Antibiotics
• To treat primary cause if infectious (cephalexin, FQs, metronidazole)
• Or secondary complication eg HE (ampicillin, amoxicillin)
• Avoid those that rely on hepatic clearance
Treatment
• Antifibrotic drugs eg Colchicine
• Consider if marked fibrosis
• Side effects common – anorexia (50%), bone marrow suppression
• Bile acid modifyers/choleretics
• Eg ursodeoxycholic acid (Destolit)
• Stimulates bile flow and displaces toxic bile acids
• Indicated in cholestatic liver dz (but not if complete obstruction)
• Antioxidants
• Eg S-adenosylmethionine and silybin
Zentonil®
The Role of Anti-oxidants in Liver Disease
Perfect SAMe product
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Pure stabilised SAMe
Correct Isomer
Protected from the harmful effects of stomach acid
Palatable
Divisible/Crushable
Chewable
Accurate dosing
Bioavailability data
SAMe stable in multipharmacy products
Cost effective
• Problem
• Enteric coating is required as digestion by stomach acid
may reduce bioavailability. This means tablets cannot be
split as coating is on the outside of the tablet
• The Solution is Zentonil® Advanced
• Patent pending microencapsulation technique that
enterically coats tiny particles of SAMe, allowing tablets
to be broken and chewed whilst protecting the SAMe
molecules from the harmful effects of stomach acid
• Problem
• SAMe must be given on an empty stomach
• and therefore manual administration (pilling) is
required
• The Solution is New Zentonil®
• Proven palatability makes administration
without food, and therefore ‘compliance’, easier
• Problem
• Inability to split tablets due to enteric coating:
• makes administration expensive for certain weights of animal
• leads to a wide variation in SAMe levels received between
different weights
• The Solution is New Zentonil®
Advanced
• Divisible, scored tablets allowing
• Accurate tablet to weight administration which
limits costs
• Problem:
• Lack of data on
bioavailabilty
• The New Zentonil®
Advanced solution
• Proven bioavailability
• After oral administration of
Zentonil®, SAMe is available
for use by the body within
10 minutes of
administration and peak
levels are achieved between
1 to 4 hours after
administration. The
bioavailability curves were
constant between test
subjects
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SAMe should be given on an empty
stomach for optimal effectiveness
Feeding one hour after administration of
Zentonil® allows optimal SAMe absorption
and the levels will be at their highest to
support the liver through the time when
digestion is occurring
Zentonil® Advanced
• Zentonil® Advanced is a divisible, palatable
formulation of SAMe with the additional benefits of
silybin
• SAMe plus silybin
Zentonil® Advanced
• Silybin in Zentonil® Advanced is complexed with
phosphatidylcholine.
• Oral bioavailability of silybin is very low but is
significantly increased when complexed with
phosphatidylcholine (PC).
• PC coats the silybin and makes it easier to be
absorbed across the intestines
• By providing silybin in this form, bioavailability of
silybin is up to 10 times higher than that achieved by
giving silymarin.
• Vetoquinol’s microencapsulation technique ensures
optimal bioavailability of SAMe.
Administration
• When should I use Zentonil®?
• Zentonil® can be used in all cases when the liver is
known or expected to require support in both dogs
and cats
• Administration
• Tablets should be given on an empty stomach at
least one hour before or two hours after feeding for
optimal effectiveness
Administration
Ask the expert scheme
• Got a liver case and want advice from a specialist?
• Email [email protected] and you will get a
response from:
• Penny Watson MA VetMB CertVR DSAM DipECVIM
MRCVS from Cambridge University