Good evening, everybody, and welcome to tonight's webinar. My name is Bruce Stevenson, and I have the honour and privilege of chairing tonight's webinar. A big thank you to Burgess, as always, for their sponsorship.
It is great to have them on board, and, we really do appreciate them supporting us and being able to bring us fantastic speakers like John Titti that we have again tonight. Little bit of housekeeping if you've just joined us for the first time. If you have a question for us, or for the presenters, please just move your mouse over the screen.
You'll see that the control bar pops up. There's a little, normally a black bar at the bottom of the screen. There's a Q&A box there.
Just drop the questions into there, and, we will get to as many of those as we possibly can, at the end of the evening. If we don't get all of them, we will ask, Dawn to get them over to John and, To give you as many answers as we can. So John is an RCVS advanced practitioner in zoological medicine.
He qualified from the Royal Veterinary College in 1990 and gained his RCVS certificate in zoological medicine in 2000. Until recently, John was employed in a small animal exotic practise in Andover, in Hampshire, with a 100% avian exotic small mammal case load, both referral and first opinion, as well as consulting to various zoos and reintroduction projects. John now provides a consultancy and advisor advisory service for zoos, local authorities, and vets alike.
He is co-editor of 3 textbooks on avian medicine, 1 on rabbit surgery, and a co-author of a textbook on tortoise medicine. He's author of various book chapters and papers on a whole range of species. John was the president of the European Association of Avian Veterinarians from 2015 to 2017 and on the editorial board of the Journal of Exotic Pet Medicine and Veterinary Record as well as veterinary evidence.
John was president of the British Small Animal Veterinary Association 2017 to 2018. And then one of his proudest achievements that I always love to chat to him about is that John is a trustee and honorary secretary of VET Life. John, welcome back to the webinar, vet and over to you.
Thanks so much, Bruce. And I to be online again, be nice when these evenings are light again, won't it, but anyway, on a dark January, we can talk about rabbits. So, thank you very much for all the questions.
I really do enjoy doing these. I never know quite what's gonna come up. And we've got some interesting ones tonight, being able to group them into different areas.
We can start with the airbase, . Disease, which is absolutely one of my favourite things as you all know from past webinars. We're gonna talk about some dose rates.
I, I was asked about 3, but we're gonna talk about dose rates in general. And I was asked about sedation protocols, particularly for neutering and radiography, and also whether ovarectomy or ovarian hysterectomy is the way to go. So plenty to get through tonight, and so we're gonna start with ear, base abscesses.
And here's the basic thing. Earbase abscesses are rarely abscesses. These are the swellings of the ear base and lopid rabbits, always lopid rabbits.
They relate to the anatomy of the lob. And basically, there are, well, I said they're rarely opposite. They in very few cases they are, and we'll talk about where, how to distinguish and what those look like and why they're different and why they need different treatment in a second.
But in most cases they're not abscess it. Now, the basic thing of an ear-based swelling, which I think is a better way to start it when we just find a lump there, is you're diagnosed by palpation. And sometimes people come in for those, and sometimes people with babies are found incidentally on, on, checkovs and examinations.
Very rarely do they come in actually causing any bother. But we diagnosed by palpation. There we go.
Very easy. At the base of the ear, we can feel these big round swellings, which may be slightly fluctuant or they may be rock hard, they do vary. So not abscess in general.
And a better way to describe this is oral diverticulosis. So looking at this stunning drawing, which I managed to do, and I haven't changed because I still can't do any better, basically looking at cross section rapidly and we've got these sections of cartilage. Now, in a normal sort of pricky rabbit, these sections of cartilage will interlock like a telescope.
But in a lopid rabbit, to get the lop, there is a gap. It's only about 2-3 millimetres, but between these two cars there's a little gap there, and that of course means it just folds over a bit like a cardboard tube when you bend it. But what does it mean with with things like corrument and discharges being produced?
Well, if corrumen's produced in here, if that closes over, nothing can flow out. And we have a soft wall on the outside here, so material builder pushes on it, and we start getting this diverticulum forming in the wall of the ear canal. And that's what the swelling is, we can feel it from outside of the skin as well.
So why do we think it's an abscess? Well, this is about what you see if you look down that ear. It looks like puss.
So therefore it must be an abscess. But puss and Karumen look exactly the same in rabbits. So how do you distinguish?
You can culture it and yes, you're gonna get bacteria of both. Probably more likely to get bacteria from coummen than you are from pus because rabbit pus has so many different, antibacterial components in it that very little grows. So probably coroa's gonna give you more culture results, big culture.
The complication is that normal rabbit ears have an awful lot of bacteria and yeast down there normally and a huge range. So even things like Pseudomonaser may not be anything other than commensa. Do cytology.
Cytology is really gonna show you that difference between acellular corrumen versus pus versus the bacterial overgrowth within that corrumen. So here's a couple of slides. We can look on this left-hand side here, and this is just straightforward corrumen, there's virtually nothing there, a few bits of amorphous grot, and that's it.
Look on this one, we can see bacterial bits, we can see some long filamentous structures, there's cellular debris, there's all sorts of things. And this is a much more . Pussy sort of look to it.
So really quick, simple, easy test to do. Decide what we've got down there. But most cases it's gonna be currumen.
But big big line is, if you're culturing, always do cytology too, because that's really gonna give you, firstly, much quicker results, but also it's gonna put those bacteria in context and tell us whether we have got corromen or pus or bacterial overgrowth. Oh, Tyson rabbits is actually quite unusual other than mites, and it's really important to remember with these, these, if you find these earba swellings. It's not a sign of otitis.
And the earba swelling, a sign of an anatomical change, an anatomical formation for for that lop and they're not part of an otitis picture. You may have otitis as well and we'll show you that in a moment, but they're not part of otitis. So we image them.
They're really important to image these things. Back to original questions about ultrasounding, but we can do a bit more imaging on other things too. And why do we do that?
And that's because the primary treatment is flushing and air cleaners or potentially to operate and open up the side of a canal. And what we need to know before we do that is, is the bullet intact? In other words, is there a degree of otitis media as well, which does definitely occur in some of these cases because those rabbits prone to earba swellings are also a bit prone to otitis media as well.
And in those cases we may see this true ear-based abscess, which we'll go on to. The best imaging is CT. Sorry, but it's just so much better.
This is what ear-based swellings look like on CT. We can see these lovely great lumps of corrumen coming out from the ear, some bit of calcium in there before for long enough, so it can get really hard. And we can see this out there stretching the skin, and they're coming from this very intact middle ear there.
We can put it in 3D with these lovely picture show owners and things we can see the lumps of lumps of ear wax coming away. But this is what we, the axis sections are, are, are really the ones which, which give us our, our diagnosis and give us our pictures. So here on the left we have a proper oral diverticulum, and we can see we've got an intact .
Tympanum, we've got an intact bulla. The bone of a bullet is perfectly normal, even the inner ear is looking pretty normal here. But if we look through here, we've got a filling of of the outer ear, and we've got the, the swelling, we've got the formation of that diverticulum.
Contrast this with a true abscess. And here we have otitis media. We've got some otitis intern it too if you look at the state of that in your ear.
But here we've got bone breakdown, we've got a scape of material with the middle ear is filled, got a scape of material into the subcutaneous areas here. So first of all we can see this is going to any swelling here is going to be reflecting an abscess because we've got that material escaping into into subcutaneous tissues. But also, if we flush that from down here, all we're gonna do is push more parallel material into that space and we're gonna make things a hell of a lot worse.
And that's why imaging is so important here. If we flush this, we can clean that outside and get rid of the material. We flash this, we're gonna make it much, much worse.
So don't flush a true earba abscess. It'll make this worse, but instead of what do you do? Well, sometimes you have to do palliative care, that's all you can do.
Other case we may marsupialize that and treat it as an abscess, and, and just manage it to scar in, and in some cases, particularly persistent ones, we may look at various options for ear canal ablation surgeries which may be required in these cases. If the bullet's intact and we have a true diverticulum, we'd look to flush it under anaesthesia. We'd teach ears, ear massage techniques to the owners, so they can carry on doing stuff.
No good just doing a flash, the material that we know, the the defect's still there, it's gonna build up again. So we need to teach something way of preventing this. And to help that, apply a millionant drops twice a week to assist that curum and removal, make it a bit more movable.
And we'd repeat flushing as required. If you can't control if these lots and lots and lots of flushings and stuff, or the cleaning is not being tolerated, not all rabbits will tolerate this well at all, and in fairness, not all owners will, will cope either. Then, you know, really we've got to look at doing some something like a lateral wall resection.
Terms of drops, you're looking to reduce that cream and viscosity, just like rabbit puss, it's really thick, disgusting stuff to move, especially been there for a while. Combine it with a massage, obviously, and you're trying to reduce interventions. Now I don't normally put product names.
But in this case, I've tried various ones, and this is the one that just was worked much better than the others. And the OOX's great, it's squarely base, whether the salicylic acid helps a bit of anti-inflammatory, I don't know, but this one just works so much better than the others and was usually pretty well tolerated. And if you redo resection, this is what you're looking at the problems in the wall in the lateral wall.
So you remove that and leave this stuff about a short, almost horizontal canal left. And those, those, those do work pretty well in the, in the real troublesome cases. So, we want an image with CT if we possibly can.
So what do you do if you don't have access to that? And it really is unwise to flush without knowing that Buller status. If you don't have any choice, then you've got to explain to the owners.
I'll be talking a lot tonight about getting informed consent. And you've got to explain, you know, if you can't do, do the imaging, if it can't be done, this is the risk you're taking and make sure you understand that's happening. But If you haven't got a CT, try x-ray and ultrasound.
Now, X-ray will give you some nice pictures. If you have got a rabbit with a head tilt, it can be difficult to get a straight x-ray, as evidenced by one on the left. And it's great, you know, you can see this rabbit here, we can pretty much see.
We probably got some change in that, that, buller. We've definitely got change in that bullet. You can see it's tilting towards that side as well.
Now, because you've got so much filling, the chance are you probably have got an intact buller, but you can't really see everything from that. And this view here, again, this rap, this one is slightly thickened, maybe some material in there, but on this side we can see the extension of the middle ear beyond this fissure, which is a good point if there's something going on. But we can't really say how intact that bullet is looking at that particular picture.
We can get a bit more information if we do a rostrocadal open mouth view. Now you can't open rabbit mouth very, very much, but you can open a little bit and you get some lovely views along the dental, routes, but you also get to see the bullet, you can see one there, and we can see one there. They're both thick and there's some material in both, we can see air pocket just there.
And you can get some more idea, this is pro both sides are probably intact. So you get a better view with that, but it's not again, not perfect. Now we improve that by by putting some an ultrasound and probe on the outside of the ear, just put it straight onto that that ear base swelling, a little bit of shaving, a little bit of gel, and we get some pictures.
And here we get our usual ultra sonograms, they're shades of grey. So please turn your imaginations on and we'll see whether we can actually get something from these. So if you look along the canal, we can actually see, we can see the the the the the corrumen in there, and we can see we've got a canal walls here and we've got filling in that.
And this should be the ear base itself but going towards Malia actually, we should see the bony base there and hopefully you can just about make up . That we've actually got hopefully an intact wall there, so. The ultrasound, because the core and it is fluid, is gonna give us a lot of extra information on top of the X-ray.
Again, it's not absolutely perfect, it's not CT level, but you can have a lot more assurance that you're going into something that's safe to flush at that point. So that's where ultrasonography really adds into the X-ray. So fluid assists there, you're getting some more idea the two, and it, and importantly you're adding into information those radiographs.
Again, I wouldn't rely solely on the ultrasound. I'd use that as an additive test to the to the radiography. So summarising your based swellings again, they're not inflammatory lesions or abscesses apart from a few rare cases.
They are a physical failure of drainage and as a result they do need that physical therapy. So again, systemic anti-inflammatories antibiotics rarely needed. Bacteria involvement is almost certainly secondary if you have got that.
It usually represents overgrowth. And it usually seems to come from a single source, really interesting that, we did a bit of a study and we found that we usually got got bilateral cases with the same bacteria on each side, which is quite interesting. And actually we found that where we did have overgrowth, that staph aureus might be overrepresented.
So if you're seeing inflammatory cells on that, on that smear, then, you know, if. You're not sure what you're treating against, and you're not sure what bacteria you might be seeing, then probably the staff is gonna be an important one to start focusing any antibiotic therapy if you want to do that. But non-surgical management generally appears successful and surgery is, curative, in some of the others who don't respond.
So as wall resections work really nicely. So, that, that's the ears cover. We're now going to talk about drug doss.
And I was asked about those three different doses about what I use. Now people who listen to these webinars probably get very frustrated over the years that I do not like giving out day rates. I don't tend to.
And tonight I'm afraid it's gonna be absolutely no exception at all. But what I'm gonna do tonight is hopefully explain why I don't, and where I get those rates from and what I might do instead, and, where I'm kind of gonna direct you guys to have a look and see what you want to do. So where do these exotic dose rates come from?
Well, in terms of getting numbers, textbooks, formularies, and obviously you get opinion from lectures, from conversations, that kind of stuff. But there are big problems with this, because not all of these do shapes have actually been studied, in fact, very, very, very few of them have been. A few might have been derived and there's technical allometric scaling, so, so we all learned at college at about.
How to adapt to dose rate from from one species to another, one species group to another by using metabolic rate factors and stuff. But those can be quite interesting doses you get from them, they're not always absolutely reliable, and the bigger the gap between the species, the bigger and the differences, and it doesn't account for things like protein binding, and individual species factors. We also don't know from some of those, dose rates have been written down, is how much have they been used?
Did the person who wrote it down, have they used it once? Have they heard it from somebody else? Have they used it 100 times?
We don't know that. And that's an important thing because there are always outriders in every way. Sometimes we have day rates which have been tried and nothing went wrong.
Now, does that show it's safe? Does it show it's efficacious? Again, doesn't.
And efficacy is a real difficult one with a lot of these doses. We have our clinician's mantra of post-docgo propter hock after this, therefore, because of this, I gave this dose, right, the animal got better, drug must have done it. So very often those, those sort of, res reports, miss out the fact there are 6 other drugs given and quite a lot of physical therapy as well.
So they're not always absolutely reliable. And sometimes too, these dose rates are very dated. So even if you get a nice new fresh shiny textbook, there's usually a hell of a gap between it's written down, often 6 months odd, and it's actually published and in somebody's hand to read.
So there may be change in that time, so it's really important to just keep, Aware that even a new formulary might not be the absolutely perfectly up to date material. And the big thing I always heard my favourite quotes about what exotic animal do traits are, they're campfire tales. There's very few scientific derived dead accurate doses there.
So what trusted sources can we use? And these are the two big ones, Carpenters and the BSABA formulary, these are worldwide are the respective sources to go to, get as good as you can get. So why are they trusted?
The reason they trusted both of them reference all their dose rates. Now that may come from peer review, it may come from textbooks, it may come from personal communications. But it does tell you what they are.
And what they do is they represent the current professional opinion. And that's really great because we're all a little bit defensive these days. We all have to sometimes justify what we're doing, and it's really good to know if you use a day straight from there.
This is current opinion. It's not a bad place to be using it. But again, dated.
You know, BSAVA's renewed every, redone every 3 years, that's pretty good. So at least it should be within that last 3 years, but nonetheless that things change. The unreferenced drugs in both those books are still unknown.
You know, they come from personal communication, how accurate, how useful is that dose rate? The big deal for for us using them is that at least we know what. Is known about that drug.
We know how unscientific that data is. So what sort of studies do we get? Most exotic animal studies are pharmacokinetic data, and the reason for that is because they're relatively easy to do.
They're relatively inexpensive to do, and, fortunately there's quite a few things coming from them. There's a lot of good data can be derived from this, and it really can be very useful, but that's why I tend to be. We don't get much in the way of safety data, on many of these drugs.
Negative results tend not to be published, and also because very rarely are we actually getting that kind of proper trial done on, on sort of licencing and everything else, for a drug. Frustratingly, we know for many drugs there will have been laboratory trials, especially here we're talking about rabbits tonight and rabbits for that, and even some who think this LD50 might be helpful with some of these, but it's, it's not bovis or Das are not gonna come out and not be published. We have even fewer efficacy, trials.
They're difficult, they're expensive, they need a lot of of, patients, really hard to, to get going. So efficacy trials are really, really unusual. We'll talk about a couple later on, but they are unusual.
We do get quite a few case studies, and these can be useful, it can be a good way of getting, a a dose rate out there. You know, I use this, here's a case, I use this dose rate and this has happened. Particularly things like chemotherapies and stuff, that's very often how they're published with exotics.
But of course they're often N equals 1, N equals 2 and how useful those are can be, can be tricky. The question is that two of them are about analgesia, and of course what we really want for that is we have a lot of arthritic patients. We want to use these drugs long term.
But we don't know how how safe they are over the longer term. And even if we do have a safety study, if we do have a PK study, these are often very short term dose rates or short term trials. We'll talk about one longer term one in a moment, which is still only 29 days, but that's a long term one for a for a for a rabbit, in clinical practise.
And very often some of these studies really aren't using very many patients, so larger scale is often quite, quite low, and that again of course affects the accuracy of results you can get through there too. Mention about drug trial data, be really good to have some more of that available, but I suspect we're not going to. The only negative to it, if we had that, of course, most of it's gonna be laboratory animals and laboratory rabbits, and there we're looking at very distinct genetic groups of like young animals, very uniform population.
That's what we don't have in clinical practise with the rabbits we see there. So to some extent we've got to be taking a little bit of a pinch of salt, and we'll talk about where that comes in with sedatives later on. Brief mention of cascade, very few drugs licenced for rabbits.
Now, if you have got those that are reasons not to use them, and valid reasons for an individual case are things like clinical opinion, if you believe a drug will be much better at circumstance, and things like antimicrobial resistance and stuff, which again is a reason to move away from that cascade if you need to. But to do that you need informed consent. To some extent, a blanket informed consent can be useful for for overall exotics practise, but in certain individual cases where you've got particular drugs, you are gonna need to get that on an individual basis.
Should it be signed? Yeah, it's probably gonna have to be these days. But if nothing else, even if you don't have that, especially with things like emergency drugs, you do write down, you've discussed it and that you have .
And you've got that permission to use that drug. You do need, when you do go off Cascade as well, some sort of body of clinical opinion to really back up your reasons why you've left that, especially if you're using clinical opinion to go away from a licenced drug. And of course, don't forget the need now for clinical assessment every time you do use a non-licensed drug.
What clinical assessment is does seem to vary, but you're gonna need to assess each case and when you use those drugs. But the big deal is dose rates change and evolve, and we need to be aware of that. So what do you actually do?
Well, use trusted formulas, obviously. They're a really good place to go to. Use the up to-date textbooks.
If you're gonna use a textbook, make sure it's a current edition. Not 13 decades ago. We all do it.
So try not to. And do review the literature. You know, Google Scholar, Vin, all these different places to go to look at Royal College, library.
All these places are available. Easy to, to just quickly do a search on a dose rate in a species. And you can see.
Anything to be published recently, so do review that. So alongside your formularies, that's a really great place to go. Don't need to do it every single time, but do it regularly enough, you're hopefully keeping up to date there.
Big thing is, don't remember dose rates because that really does cause difficulty. If you remember that dose rate, you almost never forget it. And even when it changes, yours in your head is still that old dose rate.
And also it's a good reason not to look it up each time because you remember it so you don't need to. So it really helps when you're my age and you don't remember a thing, so don't remember those doses. And here's the thing too, very often there are no data.
So do you have to use that drug? If you don't know anything about it, should you use that drug? And can you use alternatives?
So let's look at 3 questions I had tonight. So we're gonna start with paracetamol, and there's people listening from outside of the UK, so acetaminophen is the same thing. Really confusing to go to a state.
Now, look at the BSAV formula. 2 dose rates, no source for either. And there's a pretty wide range in those two dose rates there.
Looking at carpenter, again, 2 stage rates. One is an in water one, which from sheer practicality, I probably would suggest we avoid because for an individual rabbits sick, you know, you can't really control how much you can take with that too. And they also have a toxicity trial included, very unusual.
Well, this is what it is. . So in a small dose of paracetamol and rabbit liver.
And they were giving 150 MB per gig 4 times a day for 2 months. Now looking at dose ranges from the other, references, that's well within limits for what's been suggested for rabbits. 2 months as well is not a long time if you're dealing with an arthritic animal.
And certainly this study showed liver liver toxicity at that dose rate for that time. So we may have a non- benign drug here that we want to be a little bit careful how much we use and probably need some further study. So do we need to use paracetamol?
What else do we have? Well, we've got no licenced products. We've got meloxicam, which does have a lot of PK studies.
It doesn't have much in the way of efficacy studies. It does have a long-term study, 29 days. So it was safe enough to give for 29 days.
And that extends for an 8 year old rabbit who may be on it for 4 years, then hard to say, but we got a 29 day study, which is something at least. We have opiates Really weirdly, there's very few, if any studies on using opiates and dose rates and certain efficacy, within these. We worry might have some gut effects, especially from a pure agonist here, but again, a lot of divided opinion, a lot of lack of knowledge on what it does.
There's one study of gabapentin showing equivalent plasma concentrations to humans of a dose rate used and a lot of people are proposing using miropotent. As an analgesic and some very conflicting studies out there on using that and certainly very divided opinions such that probably this is a drug that might be useful as an add-on drug, but probably not as a sole agent at the moment until a lot more is known about it. One of the other drugs that has been sold a lot is tramadol.
Tramadol, interesting drug, very weird drug. Here, we actually have a weird thing. We actually do have a PK study.
PK1 is a very exotic type study where they gave 11 mg per kg and found it didn't achieve the plasma levels expect to be therapeutic in people. So the conclusion was the dose needs to be higher than 11 MB per kg. And that's it.
That's where it seems to stop. There are two other, which are efficacy studies, and those do show some, one of them shows definite effect, analgesic effect from the tramadol, and the other one is pretty equivocal, but it used a very, very low dose rate 4 megbake if I remember correctly. So.
There may be some evidence for using tramadol in in rabbits for certainly short term pain relief. So meloxicam, again, the debate is should you use it once a day or twice a day in what dose. Most of the studies indicate that 1 milligramme per kilogramme is needed, but this is far from universal in those studies.
So again, where we've got different effects, and again, we've got evidence for both using both once a day and twice a day. And that might be because we got, we have PK studies, they're not efficacy studies. This might be got breed effects.
There might be husbandry effects, they might be study design effects. So really what we need from meloxicam, we know it, there's some good theory it should work because it's anti-inflammatory. We've got pretty good anecdotal evidence it works pretty well.
We're getting pretty close to having a dose rate of 1 MB per gig as being a good one. And that appears safe enough over 29 days. But we need some efficacy studies showing actually how well it does work.
So, lots of uncertainties, what do you actually do? Because you've got an animal in pain, you've got to give it something. There's not a lot to go on.
So what can you do in those cases? Well, maybe little information's better than none. That can be dangerous as well, but, you know, at least we've got some information on these, got some rationale for using some of these drugs.
Consider predictability, you know, if we've got an inflammatory lesion, an anti-inflammatory should have an effect. If you've got non-inflammatory pain, well, maybe an anti-inflammatory isn't the way to go. We know that rabbits do have opiate receptors and the pathways, so opiates should have some effect.
We've got some evidence for using tramadol. What I would do point out with Tramadol is tramadol has to be converted. It's a prodrug, has been converted to the active form to be effective.
We know that the species that some animals are non-converters and therefore it is absolutely no analgesic effect whatsoever in those. Probably the same happens in rabbits. So we can predict some rabbits won't respond, so we use that.
Evidence for using it, but we do need to watch them quite carefully, make sure they're not a non-converter it does actually do something. We've got toxicity risk, it might be gut, might be liver, gotta keep an eye on those too. And again, we're going to need to be looking at what we do for acute pain versus chronic pain.
So I think that opiates is very much designed for acute pain, long-term use may have other effects, may be a problem. We're looking to be able to assess them. So pain scoring regimes are coming in there.
It's really good. We can do pain scoring ourselves, we can teach owners to assess pain, to do quality of life assessments, that kind of thing to make sure these things are actually doing what we think they should. It can be difficult and we need to educate about that as well.
So things like gabapentin and stuff, really hard to see whether it's having central, just sedative effects or whether it's . Genuinely providing analgesia in this case, it can be difficult. But whatever you do when you're doing these, using these drugs, make a pain relief plan.
So, you know, what are you gonna use when, what the reasons are, and really important in that, have an exit plan as well, because it's very easy to get into this cycle, especially long-term arthritic cases, where you're doing. They're just adding another drug, adding another drug, adding another drug, and you can see some of those rabbits on 4 or 5 different analgesics. It's really hard to know whether you're getting clinical effect, really beneficial effect, or whether even some of the non-go effects are coming from just having so many drugs sort of fighting each other.
In general, we're gonna be using meloxicam because we know most about it. Most of our stuff is gonna be inflammatory. So we use meloxicam plus another drug perhaps.
We might use opium for short term, e.g., post-op, we might use tramadol.
Again, we're gonna watch to make sure it actually does work. We can do other things as well. So we know that most of these drugs are not true analgesics.
They're altering the brain's perception about pain. And we can do that as well by things like environmental enrichment, making life more interesting. We all know that, you know, if you're sat down very bored, whatever it hurts, if you got hurt, it hurts a lot.
If you, your mind's taken off by doing something, you forget about, you don't notice that aching joint or whatever. So environmental enrichment does have an effect. So we can do that.
The things like osteoarthritis, we can change husbandry, you know, we can make ramps very gentle, we can avoid them going up and down steps, we can make the, make sure that the flooring is non-slip. We can stop things getting worse, and we can assist them moving around, and make life just more comfortable, so that can be useful. We also have a, one thing that skirt over so far are things like nutraceuticals.
We have information, we have data in some species that things like, you know, glucosamine, cucumin might be effective in certain cases. We don't really have that in rabbits, but we might be able to transfer that, and we might be able to use those if nothing else, just a dose sparing effect occasionally. But again, if you're gonna use something like that, get in get informed consent, tell people what you're doing, make sure you're observing and seeing how well those work.
Now the other drug I asked about was ondansetron and. Sometimes, very often actually, with these talks, is that, I end up doing an awful lot of CPD around this and it's really great cause it really gets me thinking. I really did have to look at what this drug was and and see what it is.
So, here we go. First things first, I've never used it. So I had to really check what it does.
So what does it do for people who may not be, maybe as badly informed as I am? It's an antiemetics, anti-nausea. It's especially as a chemotherapy because it's a really strong agent for this.
It has both, because it has both central and peripheral effects. So while using a rabbit, well, anti rabbits don't vomit, so anti-emeis isn't needed. But they do have nausea centres, so anti-nausea, I think is no bad thing to be looking at a rabbits, and actually can be often a lot worse than actually vomiting.
And it does definitely have studies showing that it's a pro kinetic on the ilium. So Are there doses for rabbits? No.
Not in forms, not on Google Scholar, not, not anywhere I could find it as a peer-reviewed, text. There are studies in lab rabbits, showing it's doing something to the gut or whatever else there. Those obviously have dose rates in there.
Are they safe for clinical dosing? Hard to say, really. You need a lot more data, you need to read the whole papers, make sure no losses, make sure no particular side effects, because they're really only looking to see does it affect the gut.
So just be a little bit careful when you do those use those lab studies for potentially using it. So could we use allometric scaling for this? Yes, you could.
Again, if you've got a dose rate in another species, in humans or in dogs, you could allometrically scale that to rabbits, and you could produce produce a dose rate. But what you've got to bear in mind, if you choose to use that drug, is you're kind of using it off your own bat. There's no real body of experience.
There's no real, information out there to say, is this a good idea? What's it gonna do? And is it a safe thing to do?
If you do have a lot of data showing that it's been pretty safe and effective and you've done this, that and everything with it, please publish it because we all need to know that. So back to our other question with it, if you've got very little data to use, do we actually need to use it? Are there any other alternatives?
So we're looking at things like anti-nausea and prokinetic, well, we're usually thinking about small intestinal stasis, . And so what other drugs do we have? Well, one drug is being used more and more now, it's more potent.
Definitely anti-nausea. There's some materials being suggested it might be prokinetic, but I think that's certainly far from proven at the moment. But definitely an anti-nausea agent, and there are quite a few small scale studies being produced of Neropotent in rabbits.
Interestingly enough, the dose rate is rising, and this is a really good example of keep reading my literature, because the dose rates from rabbits get higher and higher and higher. When I started using it, I was using 1 mg per gig, the dose rate's about 5 MB per gig out there. It really, it's got a wide therapeutic index, thank goodness, but it's finding higher doses are needing to be used.
So again, really watch out and see what the latest one is. Efficacy studies again, really hard to tell. It's think about nausea, you kind of need that to be able to speak to you to tell you how it feels with that one.
You can try and look for signs of it not being nauseous anymore, but very hard to do. So efficacy studies are a little bit hard to come by, and it's not a proven efficacious drug, but it has some theoretical reasons why it might be useful and it's pretty safe. And the other drug widely used, of course, metoclopramide.
There is a PK study published of metoclopramide in rabbits, worth having a look there. Again, we know we have known anti-nausea effects. The prokinetic efficacy, the studies are pretty contradictory on that, so we don't totally know what it does.
But it may have some prokinetic effect to it. But here's the big deal is that for a lot of these medical gut stasis cases, we don't need prokinetics anyway. So we've got to look after that fuses coli.
And so that's why most of the cases, really we can treat pretty effectively with fluids, analgesia, with feeding. I'll add in an anti-stress agent like midazolam into that as well, . And just generally reduce the stress that that that rabbit.
And those actually work pretty effectively in a large number of cases, really. So you may not even need to use a prokinetic within those, and certainly not one where there's very, very little information about what to do with it. I'm really looking forward to a question answer at the end of it because I'm really hoping somebody's gonna stand up and say, oh, you should see this this study, cos it's, it's, it's showing all this, all these good effects, and this is the dose rate.
So, you know, let's see what we can find. So big deal with a drug like that. Do, do watch literature because there may well be that that that that dose rate emerging, and see when it does come out.
And it's gonna come in the literature before it hits the formularies. So, moving on, very similar about using sedative anaesthetic protocols. Because again this is drug doses and stuff, and again, I'm not particularly gonna go into a particular magic dose dose rate to use.
First of all, there are licenced drugs in rabbits for anaesthesia, and we've got alfaxolone as an induction agent, and we have isoflurane as a gaseous maintenance agent. So we have those. So Cascade says this is what we probably ought to be doing in using alfaxolone and again using isoflurane afterwards.
But do we have to? Well, we can say clinical experiences it's not always what we want to use. I might also want to spare the doses.
Our facts alone that some of the doses has been shown to have potential cardiac effects, some of the higher dose rates, so I want to be a little bit careful. So you really want to try and bring that dose rate down a little bit. And so, you know, what you might want to use non-licensed drugs to pre-med and do that.
And you might want a little bit more, analgesia than that combination might actually provide. So yes, there's plenty of reasons to go away from that particular combination. It can be a very good combination, but you might want to move away from it, and you're gonna need informed consent to do that.
Are there studies on these different combinations, different sedative combination stuff, yes, there are. And yes, they produce many different results, but there's certainly evidence out for many of them, quality varying. If you're gonna look at through our studies, look at the recent ones, and do note.
As opposed to Meropotent, these dose rates fall. So if you look at a textbook from say 20 years ago and look at, say, the alpha 2, ketamine, opiate combinations there, they'll be much higher than they are in a textbook now. And these tend to fall, probably because they start in laboratory rabbits, these young, uniform rabbits, and they start being used more and more in the pet rabbits which is very different.
So again, use a formulary, use a literature search and try and find the data rates from there with some evidence behind what sort of regime you're going to use. So what about my recommendations? I was asked about doing this for neutering and radiography.
What I used when I was doing this regularly in practise, I tend to use Sivoflurane as my main maintenance agent, for neutus, I pre-med with midazolam, buprenorphine, and I would induceivoflurane and maintain with that. So why did I do that? Got really fast recoveries.
They ate really quickly afterwards, they went home very quickly afterwards, which relieve the stress a lot from that too. We also had really low levels of adverse events, which is great. And stress reduction was my big things with these, and the dasams are a really important part of that.
Was it ideal? No. It really wasn't an ideal anaesthetic contamination.
It was effective, but I think we can do a lot better than that. So do I recommend it? Not necessarily.
If I have a really high risk patient, a gas only anaesthetic can be really useful for that to get some quick imaging done, which I really need to get the animal stabilised and I need that information very fast. Often you can stabilise first of all, but sometimes you can't. So as gas only can be useful for that.
But there's a price to pay. You get a bigger drop in blood pressure and that can be a problem. You do get apnea.
Withbo, much less than you do with isofluorinne, but you still get an apnea, you still get a negative effect on the animal's stress levels from that. It's also got virtually no analgesia in there. Now if you pre-med with, with, with an opiate, yes, you're gonna improve that analgesia, but again it could be improved still further.
We do potentially have staff safety effects from using anaesthetic gases. We found very little from that, and we certainly didn't get get monitors triggered. But it's got to be a factor and you've got to take a lot of measures to prevent that.
And of course these days we do worry more about the environmental effects. Again, Cray's been shown to have less than isofluorine, but if we can reduce the amount of gas we're chucking around there, that might be quite a useful thing to do. So that's what I, I used to do.
It's got certainly some some good parts to it, but it's not necessarily the best way forward for all of these. We could adapt that and and and add a few more drugs in and we can actually probably make that a more mixed, balanced anaesthetic combination. So what do you do when you do, when you do have an anaesthetic regime?
This is what we should all be doing. So it is useful to have familiarity. You don't want to be constantly chopping and changing and changing out the regime because that makes it very difficult to review and that's gonna have a safety aspect of saying right.
You wanna review regularly about what it's doing, how well it's working. Are you getting what, what you need from that? Clinical audit here is really, really important, and especially if you actually change your combination, make sure you're, but you know what, you know, your adverse events were before.
Have those improved after you've changed? Or have they got worse or are they exactly the same, which is other things may be there. I'd always consider individual needs.
There will be some outriders, you know, if you're gonna use a regular or triple combination. Are you really gonna use that in a young neuter the same dose rate or the same way as you'd use that in an 11 year old sick rabbit? And sometimes bad things do happen.
Well they do review. Reflect on it, see if you got reasons why it happened. Was it due to underlying illness, that's the most common reason for anaesthetic mortality events.
You need to find out what happened, and when do you need to respond, when do you need to change? Very often had lots of emails and phone calls from vets, we were really worried. They had one or two deaths in the last month.
They hadn't had any for 56 years before that, so they were reasonably happy with then this happened should they change? Well, If you don't know the reason why it happened, hopefully you can work it out. If you can't do that.
Just watch, keep auditing, keep checking because. It may just be averages. That we know one in so many is going to have a problem because there's underlying disease.
It may just be the two happened close together. It may be That they hadn't happened in the previous time, they don't always come spread out. So even if you have a couple of bad events close to each other, there may be reasons for that and may need to change.
It may be there is a need to change, that's why it's really important to review and see what's going on. So do keep a check on things, and we all do this thing, don't we? We just think, oh, it's all right, it's doing whatever.
I don't think we have a problem. It's only when you actually write it down your scenarios, you've got more than you thought you had, or less than you thought you had sometimes. And of course this is just drugs, there's more than anaesthesia in drugs, but on average, no such thing as safe anaesthetic to a safe anaesthetist is really true.
Look at stress reduction, look at the nursing, look at the housing, those rabbits are really important. And above all, when the rabbit comes in for anaesthetic, make it's day better. So permit it with its companions.
Have quite dedicated waiting hospitalisation areas. That it come with its own food, have some fresh food for it, handling in a nice gentle, considerate manner. Lots of hiding places for it to go, lots of bedding for it to hide in and and and and and whatever else there and can make it comfortable.
And consider things like so these rabbit appeasing pheromones, they're really useful, they do seem to have a generally beneficial effect for these these animals. Anything you can just to get those stress levels down, because adrenaline floating about the system really doesn't help any agent, whatever you're using. And of course we worry about gut stasis, our post-op, big post-op negative event.
Look after that fuss coli, back to what we're talking about just now. Analgesia, don't forget the pain score, make sure we're actually using enough analgesia. Fluids, stress reduction, feeding those those animals post-anesthetic, return to normal as quick as possible.
And again, do we need prokinetics around anaesthetic time? Probably not. We can look after that if uses coline much more effectively by doing all those simple basic things.
So that leads on to one of the things they come in for for the day, the things they begant for is for the the spa. So ovarectomy versus ovarian hysterectomy, it's a great question. Because there's lots of things we should be asking about this, and we ask this in other species too, and I think it's a great question there.
I couldn't find, again, please have a chat, tell me if I'm wrong on this, and you've got something I'd love to know. I can't find any studies as yet comparing the outcomes from these two. Both techniques are done.
Both will sterilise, both auto behaviour. The one thing I point out in rabbits is we tend to stay to prevent uterine adenocarcinoma. In theory, this hormone linked, an ovarectomy should be effective.
But long-term studies and observations are probably ongoing, but they haven't been done for long enough to really give an outcome from that to say that it really will prevent it. And the same with ovarian hysterectomy will. So what would I do?
I would do very hysterectomy. And the reason is very simple. I'm doing this because I'm telling people I want to prevent tumours.
I'm promising tumour prevention. I can't do that unless I get the whole uterus out, as well as adenocarcinoma, there are other uterine tumours. Now many of those are benign, but none unless they are uterine tumours.
And some of those are not necessarily hormone driven. So they may occur even if I remove the ovaries. And it's very difficult to say when you've got a symptomatic rabbit with a benign uterine tumour.
And say, well, OK, fine, I prevented that tumour but not that one, so if I'm doing it for a reason, I want everything out, so I know I can say to the owner, yep, I've done my best to prevent this. Where I would probably change the advice is if laparoscopic surgery really came in for rabbits. It has been used, there are techniques written up, and some people do use this and do ovarectomy with that, which is great.
There have been some problems with it, that, that, that rabbit gut, which is so big, does cause problems and some laparoscopic surgeons don't like doing this rabbits so much there. So, and again, because the wound sizes, because the size of the animal, there's less a difference between laparoscopic wounds and your, your surgical wound. Which reduces some of that pain relief from there.
So it's not quite the same advantage doing laparoscopic in rabbits as it is in dogs and cats. But again, techniques change, so that advice may be revisiting. And if there is a clear advantage to laparoscopic ovarectomy, no obvious, .
Change in prevention of uterine adenocarcinoma, that advice about doing OVH and AVE may need to be revisited and changed. So watch that literature, watch what's coming out there. There will be a study at some stage, and it will be really, really interesting to see what, what's concluded from that.
So summary, thank you very much for these brilliant questions tonight. Got some great themes which I think really show what we don't know. And the important thing with that is, don't guess.
Research literature and relates to publications whenever you get a chance to do so and whenever you need to. And always when you're looking for treatment options, don't just think about the drug and the dose rate. Look at all the treatment options that are non drug based options out there as well.
And very importantly, look at that whole rabbit, not just the bit that's being treated. So take a really holistic view of, of your case. Thank you.
John, as always, that was amazing. So, thank you for that. I just wanna say before we go across to, Peter, and our sponsors, we've had a lot of questions coming through about, can you go back on the slides and that sort of thing.
Folks, I should have probably mentioned in the beginning, I do apologise, but we are recording the webinar and it will be up on, the Webinar vet website within the next 24 or 36 hours. The other thing to remember is that a lot of the questions that we've got coming through have already been answered by John in previous webinars that he's done. And those recordings also are on the webinar vet website.
So, do yourselves a favour. If you want to learn from, a real expert about bunnies, go and have a look at John Chitti's, recordings on the webinar vet website. So, thanks, John.
Now, it's my pleasure to hand over to Peter from Burges. Peter, do you want to, share your screen and take it away for us? Thanks Bruce and thanks John, another great webinar.
If I let you into a little secret, when we talk about subjects, I know that the Q and A's are one of John's favourite, favourite webinars to do so I'm, I'm glad it's gone well, and hopefully everyone found that really useful. I won't take up too much time cos I know there are some questions, but I just want to cover a few things and update, on what's been going on at Burgess, just so you're abreast of, some of the news that we've got. Firstly, I'd just like to thank everybody that that came to see us at London Veter .
When we go to these events and and and people come and talk to us about our products and and and the work that we're doing, it's always hugely, you know, reaffirming that we are doing the right things, and it makes us feel as a business, really proud that we're able to support the veterinary profession. So thank you for, for those that came and visited at the stand. We did use the London Vet Show as a, an opportunity to showcase some new products and I'll, I'll briefly touch on them.
mature guinea pig nuggets and also, we have some new treats, some forage and feast mini bales. I know it's a rabbit webinar, but if you please excuse me, a minute just to talk about the mature rabbit food. It's specifically formulated for the needs of guinea pigs for and over.
And you know, other mature guinea pig foods are out there or senior guinea pig foods are out there, but what I would ask is just, just have a look at what people are, are doing, what they're putting in their food to make them specific to the needs of mature guinea pigs, and I think this is. I don't think it is, you know, our most advanced formulation yet. There's some specific ingredients that we put in there.
We have marigold, that's a source of loots and can help support eye health. And from other work that we've seen done, we know that eye problems are the main reason that guinea pigs go into into practise. Joint support, John touched on glucosamine for mature, mature rabbits and arthritis in rabbits.
I was surprised at London Vet show to, to hear about how many people are actually treating guinea pigs for arthritis, so that glucosamine's in there to help support the joints. We have some specific mono dye and triglycerides which have been shown to. Help support brain function, maintain cognitive function.
The work was in in dogs, but as has been pointed out to, to me, the brain chemistry is the same in guinea pigs as it is in dogs. And, and really, a new innovation we've been adding. Prebiotics to to our diets for a long time to help support digestive health.
And in the guinea pig we actually have, postbiotics, and, and some really good interesting work that shows how they can improve, vitality. In, in animals, and we need to know more and more about how gut health actually impacts. On all areas, supporting the immune system, and into, to vitality, and mental health, so that that's really exciting, it's a product we're really proud of.
We pivot back onto on onto rabbits. We also have our new forage and feastinbales. These are really great way to add some enrichment and a bit of a boredom breaker, for the, for the small animals, and you can see here on the right, this is Nelly.
This is the rabbit of one of our staff at Burgess, tucking into one of the May bales. They're almost like a little bit of a puzzle feeder for for the rabbits and guinea pigs, you know, they try and eat them and then they roll off, so. They're a really really great product.
3 variants, one with marigold, with rosy, and the final one with, with corn flour, and effectively it's hay, wrapped into a little bundle, with the, with the toppings on. So there's nothing in there that's gonna cause any problems to these animals, diet. And it is a great way to, to help encourage hay intake as well, cos effectively it's, it's, mostly, mostly Timothy hay.
So there's a couple of new products, . Whilst we're just talking about treats, again, John touched on this a little bit in the, in the webinar about er enrichment and husbandry. The range of treats you here, you see here, they're all grass based, which means they're all high in fibre, there's no added sugar, and they, they cover all uses.
Whether it's the hay bales that we've talked about as a boredom breaker, we have forage mixes which you can sprinkle around around the housing or into the hair to encourage that natural, foraging behaviour. And we also have the range of baked treats which again have, you know, they're grass based. Not full of, full of honey and, and sweet corn and things stuck onto a stick.
And they're a great way to for people to interact with their animals and, and for me, you know, if you give your, your, your rabbits a treat every day and they come running to you, that, that interaction's important both for the human and for the animal. But also from a, from a husbandry and and welfare point of view, observing how that animal behaves, you know, if they don't come running to you when they do normally, for me that's one of the first indications that there could be something wrong. So I, I think they have a really useful role in just helping people observe the overall health of their pets.
Just in some other news. Burgess is now available in, in Germany. We have a dedicated website and dedicated to products available to the German market.
I know we have a huge international reach with these webinars, so if there is anybody, watching from Germany and you want to know more about the products or talk to us about how we can support you in practise, if you contact us on the email address there, vet support at Burgess petcare.co.uk, we'd love to talk to you.
So please reach out to us. And then just the, the other news that we had, is a recent announcements of the 2024 XL Bet Awards. Thanks to John, who's one of the judges, and thank you to everybody who nominated, people to, to receive these awards.
We had more entries than ever and ever since we've launched the number of people entering and the number of nominations has gone up and up. I don't know if any of the winners are, are on the webinar tonight listening in live, but just a big, you know, well done, and thank you for promoting the, you know, small animal and rabbit and guinea pig, you know, welfare, and and really making a difference. So if Catherine, Josie, anybody from Watkins and Tasker or Highcroft.
Lucy, Joe or anybody from Towerwood here, thank you. And what I would do is for the rest of you, please keep an eye out towards the end of this year, when the awards will be running again. And we'd like to see those entries go up more and more and, and really celebrate the people and make a difference in practise.
So coming up, we, we will be at BSAVA, the 20th to 22nd of March, so please come along and see us. We will be handing out our usual support literature, lots of posters, whether it's about our products or whether it's about, helping owners look after their, their animals better. So pop along with, you know, we handed out thousands of posters in London vets show.
I'm sure we'll do the same in Manchester at the SAVA. We also have a, you know, there's lots of support literature available. If you need anything, just contact us on the email address, which is the same one as I read out earlier.
And also we will be announcing the theme for raw 2025, in the next few, maybe in a couple of months, . In the meantime, if you've scan that QR code that will enable you to receive reminders. So you will get an announcement around the theme when it's launched, all the dates and links through to to download the packs, so please er just scan that.
And you get those reminders, and that is me finished. I'll shut up and hopefully there's still some time for some questions, sir. Back to Bruce and John.
Thank you. Peter, thank you very much. If you'll just leave that screen up for us, please, so people have got time to scan that QR code and thank you for your presentation.
Huge congratulations to all the . Burgess Xcel winners. It really is lovely to see people engaging and, our colleagues being recognised for the fantastic work that they are doing.
And I must say a big thank you to Burgess, not only for sponsoring tonight, but also for the work that they have put into the awareness and the growing awareness, of, bunnies and guinea pigs and those. So, Yeah, not only do you guys have fantastic products, but your, your creative juices when it comes to creating awareness are amazing. So Peter, thank you to you and to the whole team at Burgers.
Folks, just to, reiterate what I said before, we do have a lot of questions asking for, go back to the slide and do this and do that. These are recorded and Dawn has popped in the cha the chat box, a link to all of John's webinars kindly sponsored by Burgess, so you can see it there on the webinar vet. Burges Excel link.
And most of the questions that we got tonight will be answered by those. We've had a lot coming through, John as well about, yes, but what about this drug and what about that and that. I think I just want to repeat what John has already said, and if you go back and listen to the webinar, don't try and remember, look it up, research it, go to your exotic formulary and your BSAVA manual and the up to-date ones, not the ones that were their first publication that they ever did.
So, we're not going to be able to get into individual drugs further than what John already has tonight. But go back and listen to that recording and follow his great advice. John, one question, we are running out of time.
One question that I would like to ask. Balta asked, when you were doing the, the ear lumps and bunnies. She said, wouldn't it be better to stay in the cytology with H&E as you do in dog's ear smears?
Yeah, it would be. Definitely, I use a standard sort of be like, rapy, ra rapidiff type, trichrome stains. They're the ones you normally use in practise because they're really easy to keep, they're really easy to get repeatability on them.
So for practise use, they are absolutely brilliant. H&E is a fantastic stain. Probably much better, for, for doing those cytologies, but for general practise lab where if you got, not the most massive 3 put, they're it's probably a little bit more difficult to use.
I know H&E fans will say, probably not so bad there, but I use a standard trichrome and got on absolutely fine with it. So yeah, I mean, like all these things is use what you're familiar with, use what you enjoy, . What you do find if you do change stain, everything looks so completely different.
It really weirds you out for a while. So if you do change from trichrome to HD or vice versa, then do double up for a bit just to make sure you've got your reference point to, to take twice the smears and double up and make sure your reference point to go back to while you relearn a stain made it look very, very different indeed. But yeah, HD's great, absolutely fantastic.
And what I've got a chance on this one is I thank you for thanking Excel. I can. Completely forgot to thank Burgess for sponsoring this webinar, and I'm just feeling so ungrateful.
So thank you again, Burgess. They, they know you and I'm sorry. Yeah, you guys are a great combination.
John and Burgess, that's a recipe for success when it comes to bunnies and exotics. So that's fantastic. Guys, we have run out of time.
I saw there were a whole lot of questions for Burgess as well. We just don't have time. But if you do write to them, there's an email address there, you can get a hold of them and they are really, really responsive.
It's a great company, and they will get back to you and answer your questions and help you, and support you in the great work that they do for all of our bunny friends. That's it for tonight. Once again, thank you to Peter and Burgess.
Thank you to John for an amazing webinar. Thanks to Dawn, my controller, for making everything run smoothly in the background. And most of all, a big thank you to all of you for attending tonight.
I hope you've enjoyed it as much as I have, and, we look forward to seeing you at the next webinar. From myself, Bruce Stevenson, it's goodnight.
