Podcast: Treatment for Foreign Body-Induced Esophagitis in a Dog with Dr. Tolbert

In this episode, host Alyssa Watson, DVM, is joined by Katie Tolbert, DVM, PhD, DACVIM (SAIM), to talk about her recent Clinician’s Brief article, “Treatment for Foreign Body-Induced Esophagitis in a Dog.” Dr. Tolbert explains the differences between gastroesophageal reflux and true esophagitis, with the latter being a painful condition. She then details therapeutic options ranging from famotidine to omeprazole, Tums to sucralfate, and even … Tylenol.

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Episode Transcript

This podcast recording represents the opinions of Dr. Watson and Dr. Tolbert. Content, including the transcript, is presented for discussion purposes and should not be taken as medical advice. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast. The transcript — which was prepared with the assistance of artificial intelligence — is provided as a service to our audience.

Dr. Watson [00:00:07] Hi everyone, and welcome back to Clinician's Brief: The Podcast, where we give you an insider's view into the conversations behind our Clinician's Brief content. I'm the host of this show, Doctor Alyssa Watson, and joining me today is Doctor Katie Tolbert. Doctor Tolbert is a clinical professor at Texas A&M University, as well as a clinical veterinary instructor at North Carolina State University. Together, we are going to be looking at a case of esophagitis in a small dog today, following the ingestion of a chicken wing that ended up causing an esophageal foreign body. And we're particularly going to be looking at, therapeutic drug choices for cases like this and hopefully offer some guidance on navigating the balance between safety and efficacy when it comes to these medications in clinical scenarios like this. So thank you so much for taking the time to join us today. Doctor Tolbert, we're really excited to have this conversation. But before we jump in, if you could just let the audience know a little bit about yourself, maybe just a quick bio and how you ended up teaching at two different universities at the same time.

Dr. Tolbert [00:01:14] Sure. Yeah. So I, I have my, you know, I did a residency in internal medicine at NC State, as well as a Ph.D. in comparative biomedical sciences. I also did an alternate track nutrition residency that I recently completed with the University of Tennessee. Which is great because I feel like now I can bring sort of medicine and nutrition to, to my patients to benefit them. How I ended up at two universities is a strange situation, in that I have family that lives in Raleigh, and so I live in Raleigh as well. And then I just sort of work mostly virtually for Texas A&M, but in there about eight weeks out of the year.

Dr. Watson [00:01:51] So all right. Excellent. So we're going to talk, like I said in the introduction about a small dog, a Chihuahua that ingested a chicken chicken wing foreign body. So not an uncommon thing to have happen. And then this became lodged in the esophagus, and it was able to be removed. They went in and removed the foreign body. But when they did that, they did notice that this foreign body that had been present about 24 hours had caused some significant esophagitis. And so we're going to talk about medications to use. But could you just speak to, is the treatment for esophagitis, regardless of underlying cause. Is it always the same, or is this going to be a little bit different because of the fact that we had a foreign body versus other causes of esophagitis, like gastroesophageal reflux disease?

Dr. Tolbert [00:02:48] Yeah, the treatment of esophagitis or, you know, esophageal inflammation versus esophageal signs that might manifest as like lip licking or dysphasia regurgitation definitely differ depending on what you think the underlying cause is. Sometimes you don't know and you sort of just throw everything at the animal, obviously, to try to improve the situation. But if you do know, like your example of esophagitis versus gastroesophageal reflux disorder, we know that esophagitis is quite painful, and that we need to direct our therapies not only on using things like acid suppressants to help promote healing, but also pain medications are really important for those animals, versus gastroesophageal reflux disease are not always painful. And so our pain medications may not be as needed as other, as other causes of things like esophagitis. But certainly we need to do something to, to stop that reflux.

Dr. Watson [00:03:40] Okay, so effective acid suppression is something that is vital when we're talking about esophagitis treatment. But there's pretty significant differences between acid suppressors and antacids. So could you walk us through that?

Dr. Tolbert [00:03:55] Yes. So both can be used for the treatment of acid-induced disorders, but their mechanism of action is quite different. So antacids are essentially acid-neutralizing drugs. So you give them medication, they work immediately on the existing acid that's in the stomach, and they help to neutralize that acid, but they don't do anything to stop acid secretion. Indeed we know that if you don't use them with good frequency, that you can actually have rebound gastric acid hypersecretion, because there's a really important feedback loop that happens in the stomach, whereby if the pH of the stomach drops, you decrease the amount of acid that you're secreting. When the pH of the stomach increases, then your body is stimulated to produce more acid. So if you give an antacid, you neutralize that gastric acid, the pH of the stomach raises, arises and then your body is stimulated to produce more acid. So you need to make sure to take care of the acid pump in those situations. And that's what an acid suppressant will do. It actually will directly go to the proton pump of the stomach and will inhibit gastric acid secretion.

Dr. Watson [00:05:02] So there are different types of acid suppressors though as well. So you just mentioned the proton pump and the one that I always think of there is omeprazole. But how does the mechanism of action of omeprazole differ from something like famotidine in terms of suppressing gastric acid?

Dr. Tolbert [00:05:19] Good question. So we know that acid secretion is largely controlled by three different secretagogues, things that stimulate acid secretion. Those are gastrin acetylcholine histamine. And we know that histamine is the most potent of those three at stimulating acid production. And so that's why histamine-2 receptor antagonists were created in the first place. They were created first because it was like, okay, we know that histamine is the most important in terms of gastric acid secretion. So if we inhibit the action of histamine on the proton pump, then we should be able to decrease gastric acid secretion quite dramatically, which is true. But proton pump inhibitors were developed next. And those worked directly at the proton pump. So they're going to inhibit gastric acid secretion independent of the stimulus, so they're going to inhibit independent of gastrin, acetylcholine, and histamine. And so they're more effective obviously for that reason than histamine-2 receptor antagonists.

Dr. Watson [00:06:14] That makes perfect sense. There, what are some of the potential benefits or drawbacks from using famotidine. Because sometimes it is indicated. And can you can you talk us about talk to us about that? And I know there's some differences too when you're using famotidine short term versus long term.

Dr. Tolbert [00:06:33] So I mean, it's clear that famotidine is a very effective, effective acid suppressant in dogs, specifically when used short term. So if you give injectable famotidine, it works really, really fast. So it has a very, fast Tmax versus pantoprazole, an injectable omeprazole, if you will, an injectable proton pump inhibitor, takes some time to work to maximal efficacy. So one advantage of famotidine would be if you know that you need a drug to work really quickly, but you don't necessarily need it to be sustained for days, then famotidine is a good choice because it's going to work, you know, within 30 minutes to an hour of giving the medication. So a good example would be, you know, a dog who or a cat who you notice reflux under anesthesia or if you're having to do an emergency surgery and the dog's stomach is very full of food and you're worried about them having some reflux esophagitis then giving famotidine makes perfect sense. Versus if you want to give, sort of more long-term acid suppression, the treatment of maybe a really bad gastroduodenal ulcer or a secondary to NSAID toxicicosis. Those are the cases where you want to reach for a proton pump inhibitor, because they're more effective over time for two reasons. One being, as we mentioned, they're more effective because of the way that they inhibit gastric acid secretion. But also what we know about famotidine is that it has a diminished effect over time. So at the same dose, when you continue to give it, there are other drugs that do this as well. But if you give the same dose over time, over time, the ability to inhibit gastric acid secretion lessens. And so after a few days of giving famotidine, it's not working as effectively. And so it's not a good choice for long-term gastric acid secretion inhibition.

Dr. Watson [00:08:25] Can you overcome that by increasing the dose or is there a max dose that we should be avoiding?

Dr. Tolbert [00:08:33] That's the two great questions that we don't have answers to. My impression is that, yes, you probably can give more and get a better effect. But that that then too lessons over time. So you'll still have the same problem where you sort of get an initial effect, but then over time of that same dose, so you'll start to have tachyphylaxis or some sort of tolerance. So that was your first question. Your second question. Remind me what that one was.

Dr. Watson [00:09:00] Just is there a max dose that you kind of say, okay, we're not going to go over this?

Dr. Tolbert [00:09:05] Yeah. Good question. So we don't know of any potential adverse effects in terms of high doses of famotidine. In fact, we use a high-dose famotidine CRI for dogs and cats when we need really potent gastric acid secretion inhibition. So we use an eight mg per kg per day dose. And dogs and cats seem to tolerate just fine. My guess, though, is that you reach a point where there's no reason to give anymore because it's not working. You can't. You can't give enough to sort of overcome the diminished effect.

Dr. Watson [00:09:34] Sure, sure. Now, you had talked about magnesium hydroxide as being an antacid, and we already talked about the fact that that mechanism of action, they do not inhibit gastric acid secretion at all. So how do those work, you know, in conjunction or centered synergistically with something like a proton pump inhibitor, like omeprazole?

Dr. Tolbert [00:09:58] Good question. So it's pretty rare that I will use antacids, to be honest with you. They have some complications of that themselves. You know, aluminum hydroxide being you know, we know that aluminum hydroxide can interfere with other drugs, that it can cause constipation. Magnesium hydroxide can cause diarrhea due to that magnesium component. So it's not common that I use them. When I do think about using antacids or cytoprotectants like sucralfate, it's when my patient is particularly painful. So it has a very nice sort of antinociceptive effect where if you've ever had gastroesophageal reflux disorder, which I definitely had for one time or another during my residency or PhD, I found that acid suppressants weren't very helpful for me for my pain, but if I took something like sucralfate or an antacid, then it really quickly helped kind of coat, if you will, and help, help that painful response that I was having. So in animals that you think maybe they're not eating or they show signs of dysphagia, lip licking, hypersalivation, those are the animals where you might say, okay, do you need a pain medication? Do you need a coating agent to help make you feel better, make you want to eat.

Dr. Watson [00:11:04] And then in terms of when you're giving those timing, is there a certain amount of time between giving those medications or giving a meal, like you said, because we're trying to get them feeling better so that they'll eat? Should we be worried about affecting absorption of other medications or nutrients?

Dr. Tolbert [00:11:24] Yeah. So you definitely that is the challenge, right, with using antacids. So if you're using them alone, the challenges that you have to give them very frequently and very frequently means probably they need to be administered 4 to 6 times a day, which in a cat I can't even imagine going in a drug four to six times a day, let alone one. So but then when you're using with them with an acid suppressant because acid suppressants are really dependent on gastric acidity to sort of work, they need to be separated from the antacid or the cytoprotectant by at least two hours. In terms of separation from the meal, that's really important for gastric acid suppressants, less important for those acid-neutralizing drugs. So gastric acid suppressants, particularly the proton pump inhibitors, not so much. The histamine-2 receptor antagonists, need to be administered at least 30 minutes to an hour before the meal. And that just has to do with how they work on acid secretion.

Dr. Watson [00:12:18] Sure. And then let's talk a little bit about misoprostol. So how does the mechanism of action of that medication differ from acid suppressing actions of omeprazole or famotidine? And you had mentioned, you know, in this article that it's really not considered beneficial for esophageal mucosal repair, at least in this context.

Dr. Tolbert [00:12:42] So misoprostol is a prostaglandin E1 agonist. And essentially what it's important for is helping with mucosal healing. But you have a lot of prostaglandin E1 in your body naturally and especially in times of erosive or ulcerative disease. The time where you need that agonist is when there has been some sort of removal of that prostaglandin or inhibition of its production. And that's specifically with nonsteroidal anti-inflammatory drugs, where we know that they actually decrease the production of PGE1. And so in those cases, misoprostol is absolutely indicated. And in other situations you probably have plenty of PGE1, so giving misoprostol in context of like esophagitis or other causes of gastroduodenal ulceration is not that helpful.

Dr. Watson [00:13:25] Is it really going to kind of help you out because you've already got it?

Dr. Tolbert [00:13:29] Yes. And it might cause complications such as cramping.

Dr. Watson [00:13:32] Yeah. And that was going to be there's definitely some very specific concerns for handling those medications. And if we could maybe remind our audience about those.

Dr. Tolbert [00:13:41] The biggest one being abortion, obviously. So if you're pregnant, like you would never want to handle misoprostol, ideally you wouldn't handle it all. But if you're going to have to handle it, then you would handle it with gloves and be very mindful of that, of that specific complication.

Dr. Watson [00:13:55] And then you talked a little bit already about sucralfate, but I want to talk quite a bit more about it. So that's, you know, GI mucosal protectant, as in my experience, anyway, it's very well tolerated in dogs and cats. Are there any contraindications to sucralfate that I should be aware of, or that our audience should be aware of?

Dr. Tolbert [00:14:16] There's no known lethal dose. So that's the good news. You can't really overdose it so much. It can cause constipation. And it has been shown through Jessica Quimby's work, who is at Ohio State, if you use it in cats with chronic kidney disease, it might cause so much constipation that they actually, you know, don't feel well, they don't drink water, they became become azotemic. So you want to be careful about the hydration status of your patient when using sucralfate. The biggest thing that we know about sucralfate, in terms of, I guess, adverse effects, for lack of a better word, is the drug interactions. So just like we talked about with antacids, sucralfate can have a number of different drug interactions, not only because of its effects on gastric pH, but also because of the aluminum component that's in sucralfate. So you really want to be mindful of the potential for drug interactions. The big one that we think about is obviously acid suppressants, but also some antibiotics as well. It can interfere with the efficacy of some antibiotics. The other thing that I see with sucralfate that people make the mistake of is that you really need to give it as a slurry. If you give it as an intact tab, it's not going to work. So you're just, you know, it's not that expensive sucralfate tabs, but you're wasting the client's money a little bit. So you can either buy the sucralfate suspension, which is pretty expensive. So I don't usually recommend that. If you're going to buy the tablet and you want to just make sure to have the client mix it with water, and generally you would like to let that sit for about 15 minutes before they administer it. So they need to have a lot of, clear instructions about when to administer the medications, how to administer them that sort of thing.

Dr. Watson [00:15:46] Okay. So yeah, I was absolutely going to ask that next to that. You know, I did know that that the slurry is the preferred administration, you know, vehicle, if you will. And so but yeah, we definitely don't, don't order the suspension already mixed up because it is so, so expensive. And so, generally I send it home with like a six mL syringe and tell people, put it on the counter put the tablet in there, you know, fill it with tap water, let it sit. But I, you know, I kind of have come up with that by myself over time. And I wanted to know if that was, is it very important that we're pre-mixing the tablet or creating that suspension, you know, in 15 to 20 minutes before we give it or I guess never even occurred to me to maybe like make a whole bottle of them for people and refrigerate it I don't know.

Dr. Tolbert [00:16:41] Yeah, that's a fair question I think. I mean, this was something that this is a Papich-ism, I guess. Mark Papich is the pharmacologist at NC State, and he's taught me well that that's what I recommend for sucralfate. But to be honest with you, I've never questioned him on why. Like why that specific amount of time of 15 minutes? And what happens if you don't do that? Like it doesn't not work as well? I'm not really sure.

Dr. Watson [00:17:02] That's okay though. I'm glad that we at least have some guidelines and I'm not way, way off in what I've been recommending for years. I will tell you, one thing that I sometimes struggle with is, is the appropriate length of time to be giving it. And so can you just talk about just a few kind of specific cases or scenarios where you would want to use sucralfate, you know, for a longer duration, or what is the average length of time you're giving this?

Dr. Tolbert [00:17:32] This a great question. And I think, that's one of the things that we struggle with in terms of even with gastric acid suppressants, oftentimes people are not giving them long enough to see a response. An example of that would be sometimes we suspect an animal has gastroesophageal reflux disorder, because, again, those symptoms of dysphagia or lip licking or regurgitation or sometimes even a soft cough where we think maybe they've been reflux thing and they have laryngitis. What we know is that to treat gastroesophageal reflux disease and see improvement in those symptoms, it takes maybe even 2 to 3 weeks before you even start to see improvement. Kind of similar to the use of probiotics for our chronic diarrhea state, right? We know that you have to use them for sometimes 4 to 6 weeks before you see any improvement in their signs. So the problem is that when you send these drugs home, the owners don't see an improvement within a week. They're going to stop giving it because it's annoying. Like you give a medication to a pet and you have to remember these specific guidelines 30 minutes before a meal, separated from sucralfate by two hours. They're not really going to be motivated to continue that if they don't see an improvement if you don't tell them that they need to give that for 2 to 3 weeks before they see anything. So you have to think of, okay, what is the reason for the animal signs? Or what do I think is the underlying cause? Is it reflux disorder? Am I able to treat the reflux disorder, or is it maybe even an inflammatory bowel disease or something like this versus it's a nonsteroidal anti-inflammatory inflammatory drug ulceration? Maybe it's reflux esophagitis. So thinking about the reason why you have the injury and then what is the duration of treatment that I need? So if it's something where you went in for a foreign body didn't look like there was severe esophagitis, you're more worried just, you know, making sure there's not going to be something that happens later that you weren't able to see. In that case, maybe you just need a week or, you know, ten days of acid suppressant therapy. Maybe you don't even need sucralfate. Versus the case that we described in this article where the dog had really severe esophagitis, and we were quite worried that the dog was going to develop an esophageal stricture in those cases. Like, I might give the drug for 3 to 4 weeks before I stop it.

Dr. Watson [00:19:35] That's very helpful. Thank you.

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Dr. Watson [00:20:31] Let's move on and talk a little bit about anti-inflammatories and more pain control. Because, you know, I it was encouraging to hear that the sucralfate and the antacids can, can help, you know, mitigate pain in these cases because really, things like NSAIDs and steroids are not really recommended. Can you talk to us about why?

Dr. Tolbert [00:20:58] Yeah. So nonsteroidal drugs particularly can be harmful for mucosal healing. We know that not only can they potentially induce gastroduodenal ulceration for a number of reasons. One, some of the preparations are quite acidic, so they can cause, you know, injury to the stomach if sitting in the stomach for a long time. In addition to that, like we talked about, they can inhibit the production of prostaglandin that are really important for mucosal repair. So anytime that you have an erosive or ulcerative disease, you don't want to give something that's going to delay mucosal healing and maybe even make that ulceration worse in the case of NSAIDs. And steroids are the same thing. We know that they can delay healing. Steroids certainly have their time and place in certain disease states, but for the most part, we try to avoid them, and we try to get away with some of these, you know, cytoprotectants that might help with some local pain. There are cases, obviously, where you have a very severe esophagitis due to, again, that foreign body case where they may need more than just cytoprotectants, like they may benefit from something like an opioid or or other medications such as that, but hopefully most of them would do okay just with the combination of acid suppressants and cytoprotectants and avoid it, and avoiding some of those anti-inflammatory drugs like we talked about.

Dr. Watson [00:22:17] Sure, when you do need something stronger, you mentioned an opioid. So why what about the mechanism of action of opioids makes them safer? And and how do you determine optimal dosage like in the hospital frequency of administration? And are you going to send these home? Because I find that's when things become a little bit dicey. And I'm, you know, we're we're talking about prescribing controlled substances and things like that.

Dr. Tolbert [00:22:48] Yeah, which has gotten really hard these days to prescribe controlled substances to go home. So I mean, that's the problem, right? We don't have great pain medications for dogs and cats, cats particularly that we really lack a good pain medication control for them. I find it to be easier in the hospital. Obviously, I'm very like, I hate the word blessed, but lacking a word for blessed. Like being in an academic setting where I have all the tools that I can that I, that I want. And oftentimes I have referral patients that have the ability or the desire to spend more money. And so we can use, you know, very short-acting drugs like fentanyl, where we can sort of tightly regulate the use of, of that and see what the response is. Sending, sending opioids home, I agree is really, really difficult and challenging. They're expensive. Even something like Buprenex, which sometimes works really well for cats and dogs, it's not overly sedating and can be quite a good pain medication in certain states. But it's expensive, and it sort of runs up the bill. So getting creative with other things like gabapentin, amantadine, if the pain is not as severe, those are options as well.

Dr. Watson [00:24:00] Just as a quick aside, what about acetaminophen? I mean, it's technically not an NSAID. So do you have the same concerns with acetaminophen for delayed mucosal healing?

Dr. Tolbert [00:24:11] Good question. So obviously if we're talking about acetaminophen, we would never give that to a cat.

Dr. Watson [00:24:15] Oh obviously. Yes.

Dr. Tolbert [00:24:16] Yeah. To a dog, I actually really like acetaminophen, with codeine sometimes. I mean, we know that there are studies that would suggest some dogs don't respond well to codeine as others similar to tramadol. But I do find I do really like acetaminophen with codeine. People feel very strongly about that one, so I generally don't mention it because people have such strong opinions. Again, obviously be very careful in a dog that you think might have hepatic dysfunction, we would never use it in those cases. But yeah, it's it's a great one because it doesn't seem to inhibit mucosal healing. So it would be very appropriate in that instance.

Dr. Watson [00:24:50] I do some in-home end-of-life care, and just like short hospice, you know, if people aren't quite ready to say goodbye. And so I use a lot of acetaminophen too, but I definitely put that right on the label. Never use in cats. So because, you know, clients a lot of times will assume that if it's safe for their dog, it's safe for their cat. So it's definitely a good disclaimer. We should have said that right up front. So let's talk about antibiotics. So antibiotic stewardship obviously a hugely hot topic both on the human side and in veterinary medicine. What guidelines should we be using to ensure judicious antibiotic use? And when should we be using antibiotics in cases of esophagitis?

Dr. Tolbert [00:25:37] It's pretty rare that I need to use antibiotics in the case of esophagitis. And oftentimes I try not to because if they're needing an antibiotic, it would really suggest that they had a deeper injury than I otherwise knew about and have the potential to have really severe complications that might actually be surgical. So I'd rather have the early warning of something's not quite right that might be masked by antibiotics for a couple of days. So it's, it's it would be very, very uncommon that would I would use an antibiotic for esophagitis, in addition to the fact that we know the antibiotics, certain antibiotics, if they don't have very good transit into the stomach quickly, can make esophagitis worse just due to a local effect. Right? Just like we talked about with NSAIDs, in terms of sitting on the gastric mucosa and how that can cause a gastroduodenal ulceration, same is true of certain antibiotics. And so, it's pretty uncommon that I would, that I would use one.

Dr. Watson [00:26:28] And, and some of those antibiotics, I mean certainly tetracyclines come to mind for me. If we need to use those, not for some other reason, say we've, you know, we we have an indication for, for a tetracycline type antibiotic, how should those be prepared and given to decrease the risk of esophageal, you know, stricture or damaging that mucosa?

Dr. Tolbert [00:26:54] Yeah, doxycycline definitely gets a bad rap, as it should for especially cats with esophagitis. So we can see them with other antibiotics as well. So like fluoroquinolones for example. Clindamycin has been reported as a cause of esophagitis in both dogs and cats. So really any antibiotic the problem is that, they're probably dogs and cats that have altered esophageal transit, and we can't predict who those are going to be. We think that cats are at higher risk for esophagitis and strictures with oral antibiotic administration because their esophageal transit is slower than dogs. And so particularly in cats, those particularly that I worry that I already have esophagitis. But really any animal where I suspect esophagitis the ideal would be if I can deliver it with a liquid, that's not always going to be possible, but that would be ideal. If you can't deliver it with a liquid, then, you know, giving it with food and with water, if that's possible. You have to give quite a lot of water to get the, based on some studies looking at sort of the transit of pills following water administration, which can be quite challenging in cats to give, you know. We did a study where it was it was a different study that I don't need to go into, but we're trying to get 15 mLs of water to the cat after we administered this capsule. And I can't tell you how challenging that was. I was like this, I can't believe I make this recommendation to clients, this must be awful for them. But, so anytime you have a cat, if you can, if you can give a liquid, I think that's ideal.

Dr. Watson [00:28:23] Yeah, absolutely. Yeah. Because I do that too. We say, well, we'll just chase it with some water. I always say either a tablespoon because that just seems less to me.

Dr. Tolbert [00:28:34] It seems less than 15 mLs, even though it's exactly the same.

Dr. Watson [00:28:35] It seems less than 15mLs. It looks less too.

Dr. Tolbert [00:28:40] It sounds like a plus, for sure. I'll have to start using that trick. That's great.

Dr. Watson [00:28:47] Stick with my podcast for more tips. So okay, let's talk. The last drug we're going to talk about is cisapride. All right. So so cisapride, how does cisapride decrease the potential, the potential for esophageal stricture?

Dr. Tolbert [00:29:06] Good question. We don't have any evidence to say that it does. So that's the first caveat, but it is a promotility drug, and it's probably one of the only drugs that really works well on esophageal transit as compared to things like metoclopramide or other drugs that we use as prokinetics. So the idea is that especially if you're, worried about maybe you're giving an oral antibiotic and you don't have a choice in a patient that has reduced esophageal transits, cisapride would be helpful in those cases. Particularly when we use it is with gastroesophageal reflux disorder, where we think part of the problem is a motility issue. So, we used cisapride quite a lot there. Obviously the downside to cisapride use would be diarrhea would be the big one that we tend to see.

Dr. Watson [00:29:52] Certainly. It's not commercially available because it causes a I believe the reason is, is because there there's the potential for arrhythmias in people. Do we have this concern with our veterinary patients?

Dr. Tolbert [00:30:06] No. We don't. They don't get the same prolonged QT interval that humans do. But thankfully we've been able to get it compounded and haven't had difficulty. There was a period of time a decade ago where we had some struggles to get it. I think initially when it went off the market for people, but since then I haven't had a problem. Have you? Have you had a problem in getting it?

Dr. Watson [00:30:25] No, I haven't had a problem getting it compounded. But, you know, definitely not something that I'm just going to be able to call in to a regular pharmacy because "we don't make that anymore."

Dr. Tolbert [00:30:36] Good. Good point. Haven't you heard?

Dr. Watson [00:30:43] You talked about diarrhea as one of the potential, you know, adverse events or risks with it. I know certainly one of the times I use cisapride as kind of long-term use to manage, like megacolon in cats. So what are the specific considerations or indicators to, to decide how long to use it? And, and more than that, when should I be concerned and stop?

Dr. Tolbert [00:31:11] So this is a hard question to answer because it's so individualized. One thing that I worry about in some of these cases is overwhelming the client. Often times if we have multiple medications that are going home, particularly for cats, but in some dogs too that don't feel very well, you know, for like sending home omeprazole and sucralfate and maybe a pain medication and cisapride. The question I always have is like, how many of these are getting in every day? So I think that's the first thing, is, do I actually need the cisapride or not? And, and then a lot of cases of esophagus, you might not or you might give the acid suppressants for a few days and some pain medication and see how the animal does and then decide if you need to. Especially in the context of reflux disorder, if you're like, not sure that they need cisapride or not, you might just wait and then add cisapride on later versus that scenario of the really severe esophagitis or like oh gosh, like if anything else hits this esophagus, that's injurious this patient is definitely going to develop a stricture or even esophogeal perforation. So those are the cases where I would immediately say, listen, for the next few days, you gotta hang with me. I know this is not going to be fun, but we need to get all these medications into this dog.

Dr. Watson [00:32:21] Okay. Yeah. I developed a lot of empathy for our clients when I went, I was having I have bad sinuses. And I finally went and got a CT scan and saw somebody, and he prescribed me, ten different things to do. An antibiotic and a probiotic and a nasal flush and, and two different sprays. And I went home with all these, and I didn't do any of them because I was so overwhelmed.

Dr. Tolbert [00:32:46] Right. Exactly.

Dr. Watson [00:32:46] Like I'll just live with being stuffy.

Dr. Tolbert [00:32:50] Yeah. It's interesting. In people, they've done some pretty good studies to show, that the, the once you get to sort of four medications and above, the compliance really drops off quite dramatically. We don't have as good of those studies in, although there are a few, in veterinary medicine, but I'm sure we experience the same thing where if you get above a certain number, the like, never mind, I'm not going to do any of this.

Dr. Watson [00:33:13] Yeah, yeah. And so it just gave me a different perspective. And I've been a little bit more careful about prescribing multiple medications at least all at the same time doing, you know, sometimes I'll say, well, let's start with this and then we'll add in something. But good to know what, you know what, those cases are where you absolutely want to, you know, start strong, like you said and just warn the client, hey, it's you know, we're going to do this just for a few days, and it's really, really important. And then it's going to ease up.

Dr. Tolbert [00:33:42] It's understandable. Right. We all want to help I mean I a common thing that happens in our intensive care unit as you'll come in and like every animal is on both ondansetron and maropitant and it's like can we can we try one of these and see if one is okay and then go from there? But I think it's just people are just desperate to help. And so it's it's it's very understandable. But yeah, I would I think it would help our clients more if we were more thoughtful in the approach.

Dr. Watson [00:34:08] Well, this has been a wonderful conversation and I got a lot of great pointers. So before I let you go, there is at the end of our episodes, we do like to ask just a few more questions. But they are. It's just a little game. They're fun. Would you rather questions. There's no right or wrong answers. It's just for fun.

Dr. Tolbert [00:34:32] Okay. All right. I'm in. I'm in.

Dr. Watson [00:34:34] Good. Excellent. Would you rather continue teaching, but no longer practice or continue practicing, but not be able to teach anymore?

Dr. Tolbert [00:34:44] Yeah, that's a tough one.

Dr. Watson [00:34:46] I didn't say that easy. I said there was no right answer.

Dr. Tolbert [00:34:50] I will take practice. Sorry, sorry. Sorry everyone back home. Yeah, that was practice.

Dr. Watson [00:34:57] Well, I tell you, when you're practicing, there's a lot of teaching that goes into that. So I think that's kind of like a cheat answer because you get both.

Dr. Tolbert [00:35:05] Yes. That's true. Okay. Thank you. I was able to get both. That's what I'm trying to do. Not answer the question.

Dr. Watson [00:35:13] If you had to pick one to practice without, would you rather practice without prednisone or maropitant?

Dr. Tolbert [00:35:20] Without maropitant.

Dr. Watson [00:35:22] Yeah. Got to have your steroids.

Dr. Tolbert [00:35:24] Yeah. I mean, I'm a gastroenterologist. Yes, I have to have steroids.

Dr. Watson [00:35:31] Would you rather treat your own pet, or would you rather have a trusted colleague do it?

Dr. Tolbert [00:35:36] Trusted colleague.

Dr. Watson [00:35:37] Yeah. Okay. Would you rather run a low-cost mobile clinic with limited resources, but maybe the ability to help a lot more pets, or like a state-of-the-art, full-service hospital where you could perform really advanced diagnostics and procedures?

Dr. Tolbert [00:35:56] Yeah. Unfortunately on that, like high cost, advanced diagnostics. I feel bad about answering it that way. I wish I could be the first that wants to do low cost and help so many people. Because I think that's the more, valiant pursuit.

Dr. Watson [00:36:11] I don't think so. I think that if we don't have the people doing those, you know, really advanced procedures, we're not going to move forward. And so it's always the people that have the vision to take that next step, and that ends up helping everybody else.

Dr. Tolbert [00:36:25] So it's true, although it's hard to walk out at the end of the day and see, see all that BMW in the parking lot and feel like you're doing great work, but I appreciate you giving me that little pat on the back.

Dr. Watson [00:36:40] All right, last question. If you could have dinner with a fictional veterinarian, would you choose Doctor Doolittle or would you choose Doctor Hershel Greene from The Walking Dead?

Dr. Tolbert [00:36:50] Oh, is this unpopular that I don't know either one of those, so I can't answer that question?

Dr. Watson [00:36:57] That's all right. I tell you, I didn't watch the show The Walking Dead. I do know Doctor Doolittle, though. From the children's stories, that's who I would have chosen.

Dr. Tolbert [00:37:06] I'm sorry, guys, I'm sorry I'm failing at this would you rather.

Dr. Watson [00:37:12] It's okay. That was it. That was the last question. So it's all good. We got great information about esophagitis, and I feel much more comfortable walking into one of these cases. So thank you for sitting down with us and thank you to our audience. We'll see you next time.

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