1/8/23

What's new in IBD treatment?

Inflammatory Bowel Disease (IBD) is a significant health concern in companion animals, characterized by chronic inflammation of the gastrointestinal tract. The etiology is multi-factorial, involving genetic predisposition, immune dysregulation, environmental triggers, and alterations in the intestinal microbiome. Treatment therefore is also multi-factorial, attempting to address the disease from multiple angles. Response to therapy is variable and it’s important to closely monitor for subtle improvements in clinical signs to determine if a given treatment is effective. This guide offers an in-depth view of the current therapeutic strategies for IBD in dogs and cats. Some treatments are species specific. In addition, therapies should not be started without the consent of a veterinarian, and medications must be prescribed by a veterinarian with a valid patient relationship, Links provided in this guide are affiliate links that help support this website but feel free to research products or price shop on your own.

Treatment Strategies

1. Dietary Management

• Hypoallergenic or Limited Ingredient Diet: Identifying and eliminating dietary allergens can significantly reduce GI inflammation.

• Highly Digestible Food: Facilitates nutrient absorption and minimizes intestinal workload.

• Fiber Modification: Depending on the individual response, both soluble and insoluble fibers can be beneficial. Soluble fibers (e.g., psyllium) aid in stool formation and gut flora balance, whereas insoluble fibers help with intestinal motility or act as bulking agents.

• Diet trial: A diet trial is a common diagnostic tool used in the evaluation of dogs and cats with suspected IBD. The goal of a diet trial is to determine if dietary changes can improve the dog's symptoms. About 50% of dogs will respond to a diet trial, and therefore their disease would be considered a "food responsive enteropathy". Other animals with IBD may improve with a change in their diet but their signs may not resolve completely. Here is how a diet trial typically works:

• Change to a novel (new) protein source: Your veterinarian may recommend switching your pet to a diet that contains a protein source that your animal has not previously been exposed to, such as duck or fish. This helps eliminate any potential food sensitivities or allergies that may be contributing to symptoms. There are also hydrolyzed diets which take the protein source and process them into smaller sections so that the body can no longer recognize them as the original protein. A dismantled engine cannot be identified from a single screw.

• Avoid treats and table scraps: During the diet trial, it is important to strictly avoid giving your dog any treats or table scraps. Any deviations from the prescribed diet can compromise the results of the trial. Even a small lick of another pet's kibble, or a scrap of food from the street can begin the cycle of inflammation within the intestinal tract and negate the results of the diet trial. In addition, feeding a new protein at the same time as a food your dog is allergic to can induce an allergy to the new protein.

• Monitor for improvement: Over the course of the trial, which typically lasts 2-4 weeks, your veterinarian will closely monitor your dog for improvement in symptoms. If there is significant improvement, this may support a diagnosis of IBD.

2. Pharmacological Interventions

• Corticosteroids: Steroids are commonly used for anti-inflammatory and immunosuppressive properties. Long-term use necessitates monitoring for side effects. This medication should not be stopped suddenly unless directed by a veterinarian.  Side effects can include increased thirst and urination, as well as gastrointestinal ulcers (vomiting blood, black tarry stools).  Long term side effects include weight gain, a distended abdomen, skin changes, hair loss, weakness, and exercise intolerance. It occasionally causes diabetes or puts strain on the heart. In larger dogs it can also cause ligament weakness that can lead to ligament tears. Steroids can cause an enlarged liver and elevated liver enzymes, but generally not irreversible damage to the liver.  Steroids do suppress the immune system and decrease healing, therefore, any infection or wound needs to be treated promptly and aggressively. Steroids also have serious interactions with non-steroidal anti-inflammatory drugs like Rimadyl (carprofen), Metacam, Previcox, etc, leading to intestinal ulcers. Examples of steroids include prednisone, prednisolone, and budesonide. Prednisolone is used more often in cats because they have a decreased ability metabolizing prednisolone to the active prednisone component. Budesonide is a steroid that theoretically is metabolized more quickly in the liver, and therefore may have fewer systemic side effects seen than prednisone. It has been less well studied in comparison to prednisone but is effective in many animals that cannot tolerate the side effects caused by prednisone/prednisolone.

• Other immunosuppressive Drugs: For dogs and cats not responding to steroids, or to reduce steroid dependence, medications like chlorambucil or cyclosporine can be used. Chlorambucil is a chemotherapy medication and is the treatment of choice for patients with small cell intestinal lymphoma but can also be used for refractory IBD cases.The main side effect of this medication is intestinal upset, bone marrow suppression, liver damage, and pancreatitis. Bloodwork needs to be monitored periodically while on this medication.

• Antibiotics: Metronidazole or Tylosin are frequently prescribed for their anti-inflammatory and antimicrobial effects. It may be beneficial in some animals that have concurrent small intestinal bacterial overgrowth. However, recent studies have shown that administration of antibiotics like metronidazole can have long-term effects on the microflora of dogs and therefore this medication is being prescribed more selectively than it has in the past. Secondary or deep-seated tissue infections are also possible but generally this can only be determined with tissue biopsy samples from endoscopy or surgery.

3. Probiotics and Prebiotics

• Imagine your dog's gut as a bustling city. There are good citizens (beneficial bacteria) and bad apples (harmful bacteria) living there. Ideally, the good guys keep the bad guys in check, maintaining a healthy balance. But sometimes, the bad guys can take over, causing inflammation and digestive issues like those seen in IBD.

• Probiotics are like reinforcements for the good bacteria in your dog's gut. They're live microorganisms, usually bacteria or yeast, that are similar to the good bacteria already present. By adding more good guys to the mix, probiotics can help restore the balance and potentially alleviate IBD symptoms. Products containing specific strains of Lactobacilli or Bifidobacteria are commonly used. There are many probiotics on the market, such as Visbiome, Proviable, and Fortiflora. It is unclear if any probiotic is more effective than any other, and it may take multiple trials of different probiotics to find one that works for any given patient.

  • Visbiome: https://amzn.to/3vuc1Gv

  • Proviable: https://amzn.to/3tU31tD

• Prebiotics are like the fertilizer for your gut garden. They're a type of dietary fiber that your body can't digest, but the good bacteria in your gut just love them. These beneficial bacteria munch on prebiotics and produce short-chain fatty acids (SCFAs), which have a whole range of health benefits for your body. Many products contain mixtures of both prebiotics and probiotics.

• It's important to note that antibiotics and probiotics should not be given at the exact same time, and 1-2 hours or more seperation is recommended between administration.

4. Symptomatic and Supportive Treatments

• Antiemetics (Anti-nausea): Medications such as maropitant (Cerenia) or ondansetron are often used for controlling vomiting. Some studies have shown that maropitant may not be as effective for nausea but either medication can be trialed. Side effects are fairly rare with these medications but care should be taken in patients with concurrent diseases, such as heart arrhythmias.

• Anti-diarrheal Agents: Loperamide (imodium) or diphenoxylate/atropine (Lomotil) may occasionally be used for diarrhea control. They work by slowing down the movement of the intestines, allowing more time for fluids and electrolytes to be absorbed back into the body, resulting in firmer stools and fewer bowel movements. These medications are not as commonly used as they are only providing symptomatic care as opposed to treating the underlying cause of the intestinal issues, but can be helpful in some cases.

• Promotility Agents: In contrast, some animals have decreased motility of their gastrointestinal tract. Promotility drugs are a group of medications used to help stimulate the movement of food and fluids through a dog's digestive system. In dogs with GI disease, where digestion gets sluggish or stalled, promotility drugs can be a valuable tool to alleviate symptoms and improve overall health. Some examples include metoclopramide and cisapride.

• B12 (cobalamin) Supplementation: Many dogs and cats with IBD have concurrent cobalamin deficiency and require regular vitamin B12 injections or oral supplementation. Sometimes treatment of the underlying disease (such as with diet or medications) can lead to resolution of the B12 deficiency. Luckily B12 is a water soluble vitamin so oversupplemented cobalmin will be excreted in the urine. There are veterinary specific B12 supplements (Cobalequin) but it can also be found at human pharmacies and health food stores. Just make sure there are no dangerous additives. 

  • Cobalequin for small dogs and cats: https://amzn.to/3NW3jqG

  • Cobalequin for large dogs: https://amzn.to/41RMWkN

• Fiber supplementation: Fiber can be added to the diet in addition to what is present in specialized diets.Psyllium fiber, the fiber found in Metamucil, is commonly used and has both soluble and insoluble properties. Psyllium fiber power or husks can be found over the counter at many grocery stores, pharmacies, and health supplement stores. Find a source that doesn’t have any additives such as sugar, as some additives like xylitol can be dangerous for dogs and cats. 

  • An example of the psyllium fiber powder, NOW brand: https://amzn.to/3tLuWvS

5. Emerging Therapies

• Fecal Microbiota Transplantation (FMT): Fecal microbiota transplantation (FMT) is an emerging treatment modality in veterinary medicine for animals with chronic diarrhea, particularly when linked to dysbiosis (imbalance in the gut microbiome). This procedure involves the transplantation of fecal material from a healthy donor into the gastrointestinal tract of an affected animal. The aim is to restore a healthy balance of gut flora, which can be disrupted by conditions like inflammatory bowel disease, antibiotic use, or dietary indiscretions. FMT has shown promising results in correcting microbial imbalances and alleviating symptoms of chronic diarrhea in animals, although it is still in the somewhat experimental stage of treatment. The procedure can be performed via various methods, such as enemas, oral capsules, or direct endoscopic placement. While generally considered safe, there are risks of transmitting infectious agents, so careful donor screening is crucial. FMT is gaining recognition for its potential to offer a natural and effective treatment option for managing gastrointestinal disorders in animals but more research is necessary to determine when this treatment can and should be performed. 

• Octreotide: Octreotide, a synthetic somatostatin analog, is gaining interest in veterinary medicine as a potential treatment for dogs with Protein-Losing Enteropathy (PLE), though its use is not yet standard. PLE, characterized by the loss of proteins like albumin into the gastrointestinal tract, which can result in severe symptoms like abdominal fluid build-up. Octreotide works by reducing gastrointestinal secretions and blood flow, which could theoretically decrease protein leakage in PLE. Its application in veterinary cases is primarily extrapolated from human medicine, with limited direct research on dogs. The use of octreotide in canine PLE is still in the preliminary stages, and considerations include its cost, availability, undocumented side effects in dogs, and the absence of established veterinary dosing guidelines, underscoring the need for careful, case-by-case evaluation.

• Cholestyramine: Cholestyramine is a bile acid sequestrant used in veterinary medicine for the treatment of bile acid diarrhea in dogs. This condition involves the improper reabsorption of bile acids from the intestines, leading to chronic diarrhea. Cholestyramine works by binding to bile acids in the intestine, preventing their reabsorption and subsequent irritation of the intestinal lining, which helps alleviate diarrhea. While it's effective in managing symptoms, cholestyramine does not treat the underlying cause of bile acid malabsorption. It's important to monitor dogs on cholestyramine for potential side effects, such as constipation or nutrient malabsorption, and adjust the treatment as necessary. Additionally, cholestyramine may interfere with the absorption of other medications, so careful consideration of drug interactions is essential. 

Monitoring and Long-Term Management

Ongoing monitoring of clinical signs, body weight, and appetite is crucial. Keeping track of the frequency and severity of intestinal issues can be helpful to assess improvement, as not all animals will have symptoms completely resolve. Adjustments to the treatment plan should be made based on the animal’s response and any adverse effects of medications. It is most helpful to start treatments in succession and to give each some time to determine if they are an effective treatment.

Conclusion

The management of IBD requires a multifaceted approach, tailored to each individual dog or cat. It encompasses dietary modifications, pharmacological therapy, and regular monitoring. Close communication and regular check-ins with your veterinarian is important in improving the chances of therapeutic success. Although not all animals can become symptom free, most patients show an improvement in symptoms along with an increase in quality of life.