Even after many years in practice, the dog with immune-mediated hemolytic anemia (IMHA) can still leave us baffled. Should we refer to a specialist, transfer to emergency, or send the dog home on medication? When should we recheck—tomorrow, in a week, in a month? What drugs do we pick? Or should we just run screaming from the building?

IMHA cases usually start out in the emergency room, but sometimes they are caught early during routine bloodwork or the patient presents in general practice with mild early disease. A better understanding of how to manage these cases will help with early diagnosis, catching relapses and even managing them on our own. You don’t need to become an expert to get the ball rolling on a good diagnostic and treatment plan. At a recent Fetch dvm360 conference, Elisa Mazzaferro, MS, DVM, PhD, DACVECC, shared her approach to IMHA cases.

This is the first of two articles on this topic. Here, we discuss the causes and diagnosis of IMHA. The second article will shed light on best practices for short- and long-term therapy as well as monitoring IMHA patients.

IMHA is a disease in which the body attacks its own red blood cells (RBCs). It is among the most common immune-mediated diseases that we see in dogs.

 IMHA has a 30% to 70% mortality rate despite aggressive therapy, Dr. Mazzaferro noted, and relapse rates range from 11% to 15%.

 Upon initial diagnosis, Dr. Mazzaferro said she tells her clients that their hemolyzing pet has roughly a 40% to 50% chance for long-term survival, then she customizes this prognosis based on follow-up diagnostics and response to treatment. Many patients do not make it through the initial hemolytic crisis, but those that do can die later as a result of a thromboembolic disease, renal failure, liver failure, relapse or complications of medical therapy. Dogs with concurrent immune-mediated thrombocytopenia, hypoalbuminemia or very rapid hemolysis can have a significantly worse prognosis.

The median age at presentation is 6 years. Although most cases of IMHA occur in female dogs, males statistically have a worse prognosis. Cocker spaniels, sheepdogs and poodles, among others, are particularly susceptible. IMHA in susceptible breeds is usually far more severe and requires more rapid, aggressive treatment than that in non-predisposed breeds. Pit bull terriers are predisposed to 

Intravascular hemolysis is less common than extravascular hemolysis. The difference between the two—besides the site of RBC destruction—is that with intravascular hemolysis you must be sure to rule out zinc toxicity (and some of the infectious diseases), and you should expect the clinical progression to be more severe, with a higher risk for disseminated intravascular coagulation (DIC). You still treat these patients the same way, but be prepared to be more aggressive, and don’t forget to address the thromboembolic and coagulopathy risks using medication and coagulation testing.

Seventy percent to 80% of canine IMHA cases are idiopathic,

 known as primary IMHA. Secondary IMHA is caused by an immunoglobulin (Ig) M or IgG antibody attack against RBCs in response to infection, neoplasia, an inflammatory condition, drug or toxin, and maybe vaccination. Some toxicities cause direct RBC damage, which can be mistaken for IMHA but is not immune mediated.

Following are potential underlying causes of secondary IMHA:

 Nonsteroidal anti-inflammatory drugs, sulfonamides, cephalosporins

 There is still not substantial evidence that vaccines can cause IMHA, but we suspect that they might, Dr. Mazzaferro said. There is a 2% to 26% incidence of vaccine-implicated IMHA depending on which study you look at,

 she pointed out. It is also not at all clear what the duration from vaccination to onset of IMHA is supposed to be.

 Any malignancy is potentially causal, either directly or indirectly. In patients that are significantly hypoproteinemic, be sure to rule out erythrophagocytic histiocytic sarcoma, Dr. Mazzaferro said.

 Zinc, onions and large amounts of garlic (although these toxicities are not truly immune mediated, they cause Heinz body anemia)

Other infections or inflammatory conditions

 in the body that can overstimulate the immune system (i.e. cholecystitis, pyelonephritis, pancreatitis)

Clinically, patients with IMHA present with lethargy, weakness, vomiting, diarrhea, pale or yellow gums, collapse, discolored urine and petechiae if they have immune destruction of both RBCs and platelets. Alternatively, patients can appear clinically normal with just spherocytes and a mild anemia on routine bloodwork.

They can have a regenerative or non-regenerative anemia. We are encouraged to see regeneration, but it takes the body four to five days to mount a significant regenerative response, so about 30% of cases are nonregenerative on presentation. Spherocytes are present in only 67% to 94% of dogs with IMHA.

 They are not pathognomonic to IMHA, but spherocytes are great markers for diagnosing and monitoring this disease. Very few other things cause this.

History is very important. Ask whether the dog is or has:

Eaten something like a penny or other zinc-containing toxin?

The baseline diagnostic workup is more extensive than for most diseases and includes the following:

 Complete blood counts (CBCs) and chemistries, a urinalysis with culture and minimum inhibitory concentration; a pathologist’s review of your CBC is a must.

Packed cell volume/total solids (PCV/TS; in-house).

 Note that the PCV is more accurate than hematocrit because agglutination can interfere with calculated hematocrit.

If both macro- and microagglutination tests are negative, do a Coombs test. If your patient is already auto-agglutinating, a Coombs test will not give you any extra information. (Nobody is going to fault you, though, if you send out a Coombs test because you are unsure of your in-house agglutination test findings. However, there is no good substitute for a slide agglutination test, or for the immediate information that it gives you if it is positive.)

 It should be a smear with a beautiful feathered edge, dried and stained with Diff-Quik. You are looking for reticulocytes, spherocytes, shistocytes and ghost cells in a monolayer near (but not at) the feathered edge—all of which are consistent with IMHA—and using this to do a platelet estimate while you are waiting for the CBC from the lab. 

 for metastatic neoplasia or metallic foreign body ingestion.

to complete your screening for neoplasia.

 send out an infectious disease panel. North Carolina State University’s Vector Borne Disease Lab offers a panel that historically has been the best test, but Idexx offers a similar comprehensive version. The Idexx test does have a polymerase chain reaction (PCR) test for 

 (seen in the Western U.S.) that the NCSU test does not offer. If using Idexx, always test for both antibodies and genetic material (i.e. both PCR and serology).

 This may be of limited availability except at emergency or specialty hospitals. If the lactate level is elevated, your patient may need a transfusion, as elevated lactate can indicate that too little oxygen is getting to the cells (oxygen debt).

For more in-depth information and detailed resources about IMHA diagnosis, the most recent 

ACVIM Consensus Statement on the Diagnosis of Immune-Mediated Hemolytic Anemia in Dogs

Dr. Johnson practices emergency medicine at Berkeley Dog and Cat Hospital in Berkeley, California, and general practice at Cameron Veterinary Hospital in Sunnyvale, California. Her nonveterinary loves are writing, dressage with her Iberian warmblood mare Synergy; watercolor painting on yupo; vinyasa yoga; and running with her dog Tyson. Try as she might, her curly-coated Scottish Fold, Hootie, refuses to go jogging with her.

McCullough S. Immune-mediated hemolytic anemia: understanding the nemesis. 

Piek CJ, van Spil WE, Junius G et al. Lack of evidence of a beneficial effect of azathioprine in dogs treated with prednisolone for idiopathic immune-mediated hemolytic anemia: a retrospective cohort study. 

Weinkle TK, Center SA, Randolph JF, et al. Evaluation of prognostic factors, survival rates, and treatment protocols for immune-mediated hemolytic anemia in dogs: 151 cases (1993-2002). 

Piek C. Immune-mediated hemolytic anemias and other regenerative anemias. In: Ettinger SJ, Feldman EC, Côté E, Eds. 

. 8th ed. St. Louis: Elsevier; 2017:829-837.

Garden OA, Kidd L, Mexas AM, et al: ACVIM consensus statement on the diagnosis of immune‐mediated hemolytic anemia in dogs and cats. 

Day MJ. Immune-mediated anemias in the dog. In: Weiss DJ, Wardrop KJ, Eds. 

. 6th ed. Hoboken: Wiley-Blackwell; 2010;216-225.

Articles

If immune-mediated hemolytic anemia makes you crazy, you are not alone. Here’s the lowdown on diagnosing this confounding disease.

Possible IMHA dog—now what?

If yours is like thousands of veterinary practices, this is the essence of your marketing: “Welcome to ABC Animal Hospital. We are a full-service veterinary facility. We provide preventive care, spay/neuter services, parasite control and more. Give us a call!”

Although these statements are accurate, they actually accomplish very little. This messaging reaches the cortex of your audience’s brain—the logical, linguistic region—but it fails to reach the limbic brain, the part that makes us 

We in the veterinary industry often miss the mark when it comes to marketing: We don’t face communication strategies with the same intellectual rigor as we do our clinical duties.

By the end of this article, you will learn how to market your practice in a fundamentally new way. Afterward, your messaging might sound something like this: “She’s there for you when life is hard. She’s there for you when work is stressful. She’s there for you when you need a friend. Now, you get to be there for her. Give us a call, and let’s protect her together.”

Some eighty years ago, literature professor Joseph Campbell began to see a pattern in works of fiction. Publication of his book, 

s, in 1949 forever changed the world of literature and mythology. Campbell discovered that there is a hidden story structure, an archetype, that can be found in virtually all stories we tell. It’s called “the hero’s journey.” You can see it throughout our world today (take 

This hero’s journey is a powerful tool and the secret behind Apple’s and Nike’s success. It’s actually quite simple: There is a well-worn structure that you can begin incorporating right now to create closer and more meaningful bonds with clients, furnish brand advocates and referrals, help more pets, increase your practice revenue and build a more empowered company culture.

There are six primary components to the hero’s journey as it applies to marketing: A 

Almost every company markets the same way: They brag and boast about how amazing their products and services are. You’ll notice that Apple and Nike don’t follow that approach. They tell a story about their customer’s hopes, dreams, fears and aspirations. The No. 1 lesson about the power of storytelling is that you must flip the script. You are not the hero, your customer is.

When Luke Skywalker flew his X-wing skyfighter down those narrow corridors, using the Force to guide his missiles and blow up the Death Star, you probably experienced a significant emotional release. Why? The three layers of the problem had been building up throughout the entire 

The first layer is external, a logistical problem. For Luke, it was the Evil Empire killing his aunt and uncle, and threatening the way of life in the galaxy. The internal layer—Luke’s questioning whether he is good enough to be a Jedi—is far more interesting.

The internal layer is always related to self-doubt and fears of inadequacy. In fact, this is probably why there is one dominant archetype in storytelling. It’s an allegory for our most basic of fears: We all just want to feel good enough, to know that we aren’t inadequate.

The third layer is philosophical. It pertains to how the hero’s struggle relates to morality and justice. In Luke’s journey, the question was whether good would triumph over evil.

You can see evidence of this theme throughout the movie. When Luke shot those missiles, he eviscerated the Evil Empire and proved that he 

good enough to be a Jedi. In the end, good triumphed over evil. The layers of the problem were resolved in an instant, which is why you experienced such a profound emotional reaction while watching.

When a veterinary practice markets itself, it typically speaks to the external layer of a potential client’s problem: I need veterinary care for my pet. But the internal layer of the problem is far more important: Am I doing right by my pet? Do I deserve the intense love they have for me? And the philosophical layer is almost never mentioned: the importance of the bond that humans and animal share. This bond means everything to so many pet owners.

We instinctively look for guides in life—a teacher, parent or coach who encourage us to believe in ourselves. This is what you must become. Helping a hero address their internal problem is a powerful, sacred role. For Luke, that helper was Yoda. For pet owners, it’s you.

In my job running a web design and marketing company, we use the hero’s journey strategy every day. I have learned a few things about how to unearth what makes a particular guide special and how to see the heart and soul of a veterinary practice. My advice to you would be to get your entire team together (founders, veterinarians, technicians, client service representatives … 

), lock the doors for 90 minutes, and come up with answers to these questions:

What, at its core, makes this practice special?

The best answers will demonstrate two qualities: empathy and authority.

The hero must have a clear path to walk. For Luke, that path was Jedi training. For pet owners, it’s forming a relationship with you. Tell them exactly what to expect ahead of time—how the appointment will work, how your team is uniquely equipped to care for them, and what the follow-up care and time between visits will be. And you must call them to action. 

Let’s revisit the example used earlier in the article: “She’s there for you when life is hard. She’s there for you when work is stressful. She’s there for you when you need a friend. Now, you get to be there for her. Give us a call, and let’s protect her together.”

This works well because it’s a powerful call to action for the hero. It speaks to our inner emotional life and lays bare the significance of this relationship.

The world is different to a hero. A hero’s life will never be perfect, but they will feel capable, unburdened by self-doubt and empowered to do what they must. Paint a picture for pet owners that shows how working with you will have a positive impact on their relationship with their pet as well as on their own emotional wellbeing, and make clear other logistical and emotional benefits you can achieve together.

Open up a journal or a Word document and begin writing down the major themes of your practice’s “hero journey.” Then include it on your website’s home page, in your social media strategies, in your print marketing and everywhere else. Once you do, your marketing will reach the limbic brain of potential customers instead of merely the cortex. 

You might not attract every pet owner in the world, but you will attract the right ones

After all, your customers are the heroes. You’ll just help them care for their pets like one.

Robert Sanchez is the founder and CEO of Digital Empathy, an award-winning web design and marketing firm for veterinary practices. He frequently lectures at national conferences, leads a team of wonderful employees, sits on the board of VetPartners, and shares his home with two very spoiled dogs—Cole and Lula.

To reel in new veterinary clients—and turn them into loyal customers—you must appeal to their hidden “hero.” 

What Luke Skywalker has to do with veterinary practice marketing

Part of being a good leader is allowing and encouraging your team to have fun. At our monthly meetings, which are usually well attended—we have free lunch, go figure—we discuss client service, hospital events, hospital policies and procedures, and we also make time for fun team-building exercises.

One week we did a photo scavenger hunt with two teams and two cell phone cameras. We ran around the hospital performing silly tasks and taking photos. Everyone had a great time.

When team members are having fun, they're less stressed. People that are stressed make more mistakes, take more sick days and have poorer communication than those who are less stressed. Fun reduces stress.

When team members have fun, they are more engaged in the business. Engaged employees provide better customer service to clients and pay more attention to details.

Productivity also increases when people have fun. Some fun or relaxation time refreshes us and allows us to feel energized, engaged and motivated, allowing us to get more done.

When work is fun, the business has lower turnover. When workers know that their employer has their back and that they are allowed to have fun, they're less likely to look for another job.

 Watch your employees to observe when they have a good attitude or are having fun. When you notice, tell them you love to see them happy and having fun at work. Participate in the merriment if you can and reward them for their great attitude.

 When you're the leader, you're expected to do better and act better. Do you enjoy your work? If it's not obvious, you need to share your feelings more openly with your team. If you have fun, your team will join you.

 It's difficult as a leader to see people who are on the time clock not working, but team members need a little space to chat, joke and eat together. One time I bought my team donuts we all took a minute to eat donuts together. This gave them time away from their work. Once they ate, they were much happier and were able to get back to work and serve clients.

 This is my favorite step when it comes to fun for my team. I love to create games and fun things for us to do at work: scavenger hunts, shopping trips, movies, puzzles, auctions. In an ongoing game at our hospital right now, we dress a Barbie doll in a lab coat and move it around the hospital. When a team member finds her, that team member must write a compliment about another team member and post it in the lunchroom on the board “Barbie says.” Then the team member has to hide her again for the next person to find. 

 mutually exclusive. We can create a more successful work environment by simply creating and allowing a little more fun. Lead well and have some fun while you’re at it!

Dr. Julie Cappel owns Warren Woods Veterinary Hospital in Warren, Michigan. She served as president of the Michigan Veterinary Medical Association in 2015.

Lead better by having more fun with your veterinary team

The need for social distancing has many veterinary professionals pondering newer and safer ways to care for patients, 

. How are appointments scheduled? What services can be offered? Should there be a charge?

To help address these concerns, the Viticus Group (formerly Western Veterinary Conference) recently hosted a Facebook Live discussion with telehealth experts Aaron Smiley, DVM, and Jessica Vogelsang, DVM. One of the key takeaways? Telemedicine is not limited to real-time video chats.

“Everyone assumes that telemedicine means a live video appointment, and that is not true,” said Dr. Vogelsang, owner of 

Dr. Smiley, who is chief of staff at both Devonshire Veterinary Clinic and Geist Station Animal Hospital in Indiana, wholeheartedly agreed, adding that what makes veterinary telemedicine so brilliant is that it functions perfectly while remaining asynchronous. “That means [sending] text messages, videos and pictures, which is so much more efficient for the client and the doctor,” he said. “From a 20-second video, I can get an amazing amount of perspective and the owner can do it on her time. That is key.”

Dr. Smiley advised veterinarians to establish 

 they can sustain long term. “Someday the pandemic is going to be gone, and when that day comes, if veterinary medicine is only doing synchronous telemedicine it is going to be very difficult to maintain because doctors are really busy,” he said.

Without a doubt, the best types of clients to offer telehealth services to are those with whom you have an established veterinarian-client-patient relationship, Dr. Smiley said. As for which services to offer through telemedicine, he suggested virtual medical rechecks as a hospital’s first foray. Many times it is the ideal, convenient option for both the veterinarian and the pet owner.

“Inevitably, I wasn’t able to get my clients in for rechecks but I wanted to see how my therapy worked out,” he said. “I had always assumed no news was good news, but that is not always the case.” At his practice, Dr. Smiley bills the client for the recheck while they are at the office for the initial visit and requests that the pet owner send a video of the patient at a determined future date for the staff to assess.

Telemedicine is not a substitute for in-office appointments across the board, Dr. Smiley emphasized. “As the doctor, you are the expert,” he said. “You know when a dog needs to be physically touched.”

Hospitals that offers telemedicine must communicate to clients that it is still a specialized service and will be billed accordingly. “Sometimes veterinarians fail to value themselves as professionals,” Dr. Smiley admitted. This can result in misinterpreting a consultation or recheck as simply offering advice to a client, when in fact the veterinarian is providing a highly skilled service.

Dr. Smiley added that hospitals can—and should—continue to offer free telehealth services through its veterinary technicians and nurses. “Mrs. Jones can still call for a prescription refill or general advice, but if there is something that needs to be diagnosed, prognosed or prescribed, we’re going to roll the doctor in,” he explained.

Dr. Vogelsang added that in recent weeks, several veterinary professionals have told her they’re feeling overwhelmed [about telemedicine], but she reassures them that active measures are being taken by various groups to provide guidance for new adopters. She encourages first-time telemedicine users to rely on the experience and resources of the 

“Don’t rush into anything if you’re not comfortable, and ask your colleagues for help,” she advised. “We have your back.”

With so many practices turning to telemedicine during the COVID-19 pandemic, experts share what it really means—and some key benefits of incorporating telehealth into veterinary practice.

Telemedicine: more than just video chats

As veterinary hospitals try to return to business as usual in the wake of nationwide shutdowns related to the novel coronavirus pandemic, they do so in the face of a global recession, continued COVID-19 outbreaks, employees unwilling to return to work and lingering fears about disease transmission. Here are four challenges that you and your team can expect to confront in the months ahead, with suggestions for mitigating their impact on your business and your staff.

Most economists agree that we’re not just headed for a recession; we’re already in one. The question is how long will it last? To mitigate the crisis, Congress has greased the paddles of a ginormous economic defibrillator with nearly three trillion dollars as a way to get the heart of American business beating again.

But it’s not just the U.S. that’s in danger of flatlining; the rest of the world’s economy is also a worrisome blue. Improved consumer confidence, intact supply chains, and some way for the service industry to recover or transform is required 

Prepare your business as best you can for a recession:

Hold on to as much cash as possible. Request forbearance from your creditors as needed.

Reduce your inventory, and use any existing down time to review and implement inventory management best practices.

 for which your business may be eligible.

Review your exit strategy. Practice owners interested in selling should talk with potential buyers now.

Devise ways to improve the efficiency of your new workflow and lower costs.

COVID-19 infections may continue to crop up regionally, dampening economic activity and in some cases instigating new community-wide lockdowns. Consumers may also choose to sit tight for another month or two at home because of lingering fears of infection.

Keep in mind that one of your team members may test positive for the virus, forcing all practice employees to self-quarantine and your business to close. Expect a dizzying array of what-should-I-do scenarios as team members exhibit mild symptoms of allergies or illness that you and your coworkers fret may be signs of COVID-19.

Revisit your sick leave policy in the wake of COVID-19. Decide how you will handle employees’ potential exposure to COVID-19, when it’s okay for COVID-19–positive employees to return to work and how you will manage employees’ varying levels of fear about infection. The 

Centers for Disease Control and Prevention

 are a great place to start when considering plans.

 your practice will operate post COVID-19. Many practice teams have determined that some of their pandemic protocols will be more efficient and client-friendly than their former protocols, and will become part of normal practice.

If you haven’t already, explore telemedicine providers. Use this time to get acquainted with the technology and start thinking about how to use it to best service your clients while continuing to generate revenue.

Challenge 3: Cash-strapped clients and cautious spenders

Thus far, about 75% of American workers have emerged from the COVID-19 shakeup relatively unscathed, but for many service workers, farmers, the travel industry and the poor, the pandemic has created crippling hardship. 

and what kind of industries are in your area, you may find that your clients don’t have the money they once had for pet care, even if it’s urgent care.

First, review local and national economic forecasts as a way to understand your community’s progress through the recession. Then, keep the following points in mind:

Pet owners will look to online sources for answers. Write (and share on your website and via social media) material that not only helps pet owners find those answers, but also introduces them to the affordable care that your practice provides.

Consider using telemedicine platforms to offer generalized tele-advice as a way to meet new clients and introduce them to your practice. These platforms can build on clients’ newfound affinity for managing their lives, and the lives of their pets, online.

Do not resort to knee-jerk instincts to lower prices or give away services unless doing so is part of a larger structured strategy to grow overall revenue.

Younger pet owners are more likely than older pet owners to adapt quickly to the post–COVID-19 economy. These young people approach health care more holistically and may be looking for alternatives to the traditional allopathic model. Pivot your focus of annual visits away from vaccines to more competitive services like 

, especially inhouse ones like those offered by 

 that have the benefits of being low cost and timely.

Weigh the optics of offering payment plans. Companies like 

 have low default rates and a line of financial products that many veterinary hospitals find extremely helpful.

Keep lines of communication to the shelters open for more information on how the economic downfall is affecting a broader sampling of your pet-owning community. Review your policy on pet relinquishment and convenience euthanasia, and be sure to provide your team members with sensitivity training on the topic.

Challenge 4: Persistent callouts and HR issues

Regardless of whether you are permitted to return to normal business activity, regional outbreaks may cause local school and business shutdowns that will force your parent-workers to stay home with children. 

Some employees may fear returning to work 

and will resign. Some furloughed employees may qualify for both unemployment and additional CARES Act funds, and find that in its haste to rescue workers from economic catastrophe the federal government has given them

Other employees will exceed the maximum number of paid hours they have left for the year, even exhausting the additional time allowed for by the CARES Act. Expect a significant portion of your and your practice manager’s time to be consumed with addressing unemployment claims, CARES Act–related Payroll Protection Plan issues and applications to other aid packages as they become available.

Review your state laws regarding full-time and and part-time layoffs, being mindful of the internal and external optics of layoffs. Handle such discussions with delicacy and respect.

Stay transparent with your team regarding your financial needs as a business owner, but don’t use your predicament to reproach your staff for what you may regard as their insensitivity to your plight.

There will likely be an uptick in the number of people looking for employment. Revisit the way you hire employees, and try to take as much of it online as you can.

COVID-19 has put pressure on all of us. Don’t underestimate the ability of stress to ruin your professional and personal relationships, negatively color your decision-making and take a toll  on your health. Take control of your wellbeing through the many available veterinary resources, including dvm360.com and the 

Despite the bleak forecast, change can be as much an opportunity as a liability. If you push yourself to see the world as a source of positives instead of negatives, your decisions are more likely to propel you toward a positive outcome.

Strong leadership, on every level, is how we’ll navigate our way forward successfully as a nation and world. The same is true for your business. It’s okay to be human, but try to be the best human you can be. It will make your job easier, garner loyalty from your team, and help you recognize your best attributes and to evolve as a person.

Bash Halow, CVPM, LVT, is a graduate of the College of William and Mary and of the Veterinary Management Institute series at Purdue University. During his 20 years as a veterinary professional, Bash has served as a practice manager, regional manager position and hospital administrator before opening his practice management consulting business, 

. Bash is also a regular Fetch dvm360 speaker.


As shelter-in-place restrictions are lifted throughout the country, the full impact of the pandemic shutdown will come into clearer focus. Here are four major challenges veterinary practices can expect—and how to handle them. 


 What will ‘normal’ look like after COVID-19?

Spring and summer usher in a host of undesirable visitors that pester pets and people alike. As veterinarians, we cannot help but associate warm weather and mosquitoes with heartworm disease (HWD). For dogs, the evolution of macrocyclic lactone preventives has made available new products, such as ProHeart 12 (moxidectin) and Simparica Trio (sarolaner + moxidectin/pyrantel),

 both from Zoetis, to prevent canine HWD, but where does that leave cats?

Despite the availability of monthly heartworm preventives for cats, feline HWD remains a less common conversation in the exam room. With the high success of feline heartworm prevention in both experimental and field trials,

 veterinary teams should be more excited to share with clients our trust in these products to prevent the nightmare of managing a heartworm-positive cat.

Suspicion of feline HWD should be based on a combination of history, environment, clinical examination and diagnostic findings. Clinical findings may include acute or chronic respiratory distress (hemoptysis, dyspnea, orthopnea, cough); sudden death may also occur.

Orthogonal thoracic radiographs may reveal dilated peripheral pulmonary arteries, a bronchointerstitial lung pattern and/or an enlarged cardiac silhouette.

 Less common radiographic findings reported by the American Heartworm Society include chylothorax, pneumothorax and ascites.

The most trust in diagnosing feline HWD should be placed in serology: heartworm antigen and antibody testing. We must recall our epidemiology roots established in veterinary school to explain the limitations, and often frustrations, of these diagnostics to our clients. Specifically, a false-negative heartworm antigen test can occur with a same-sex male infection, a low worm burden, an early infection or operator error.

 However, an antigen-positive test is considered 100% specific in confirming HWD.

 Alternatively, a positive antibody test could suggest current infection or previous exposure to 

 larvae, but overall this is less sensitive than antigen testing.

 Experts recommend that we explain to clients that paired serology—both antigen and antibody testing—is better than a single test when screening for feline HWD.

Our options for managing feline HWD are limited. The use of corticosteroids, surgical extraction of adult worms and benign neglect all offer much lower than the 99% success rate in eliminating adult heartworms with the melarsomine three-injection protocol used in dogs.

 (The melarsomine protocol is not an option for cats due to its reported toxicity in the species.

There has been some success with retrieving adult worms via cardiac catheterization; however, these were considered salvage surgeries.

 Both clients and veterinarians should understand and agree that prevention is a much better option than treatment when it comes to HWD in cats.

HWD can be scary for both clients and veterinarians. It is important to emphasize our trust in monthly chemoprophylaxis, given its great success in preventing HWD and its high margin of safety. Selamectin + sarolaner (Revolution Plus—Zoetis) and imidacloprid + moxidectin (Advantage Multi—Bayer) are the powerhouse macrocyclic lactones for preventing feline HWD. Both products offer 100% prevention of developing adult heartworms following exposure to 

 cats were injected with L3 larvae and treated with monthly Revolution Plus for one to three consecutive months. Four to six months following treatment, 100% of the cats had no adult worms on necropsy.

 investigated the opposite pattern: application of Advantage Multi prior to inoculation with L3 larvae. All cats received four consecutive monthly applications of Advantage Multi, after which they were exposed to heartworm larvae every seven days for about one month. At the end of seven months, all cats were reportedly antigen- and antibody-negative.

Your clients don’t need to understand the nuances of these studies, but they should understand three simple words conveyed by your veterinary team: “These products work.” If the curious client would like to be pointed in the direction of these studies and product labels, we can confidently provide them with these resources.

One way we can connect to our clients is by being transparent about the unpredictability of feline HWD during annual wellness visits. For example, “Mrs. Dyer, unlike Chloe’s chronic kidney disease, which is manageable, treating heartworm disease in cats can be difficult. Let’s discuss ways to keep Chloe protected with a topical monthly preventive to avoid this.” This statement explains the difficulty in treating heartworm disease, provides a personal parallel to the patient and provides the client with a solution.

We can also rely on the feline HWD guidelines provided by the American Heartworm Society when talking with clients. In one small study on heartworm disease in the U.S., for example, a reported 25% of strictly “indoor cats” tested positive for HWD.

 This is a great opportunity to discuss why all domestic cats—even those that do not go outside—should be on year-round monthly parasite prevention. If the owner is unwilling to commit to this, share the AHS recommendation that heartworm prevention can be started one month before the onset of warm weather and continued three months after the warm season ends to accommodate the molting of larvae to adults.

 This conversation can be initiated by the nursing staff collecting information on indoor/outdoor status that the veterinarian can reference later during the examination.

At the end of day, we want to provide our clients with power. There are many ways to celebrate their decision to apply monthly feline HWD prevention. This includes educating them about rebate programs available through Zoetis for clients purchasing six to 12 months of Revolution Plus, hanging a wall display of the names of feline patients that are on monthly prevention or encouraging clients to post photos of “protected cats” on the practice’s social media platform, with a prize offered to one of those clients selected randomly. Whatever celebration your practice creates to motivate clients to purchase feline heartworm prevention, have comfort that there will be one fewer case of feline HWD to worry about!

Dr. Santos practices at Brick Town veterinary Hospital in Brick Township, New Jersey. She is a 2019 graduate of Purdue University College of Veterinary Medicine. Her interests include physical rehabilitation/pain management, endocrinology and client communication.

1. McTier TL, Kryda K, Wachowski M, et al. ProHeart® 12, a moxidectin extended-release injectable formulation for prevention of heartworm (Dirofilaria immitis) disease in dogs in the USA for 12 months. 

2. FDA approves new combination parasite preventive. dvm360.com website: 

dvm360.com/view/fda-approves-new-combination-parasite-preventive

. Published February 28, 2020. Accessed May 10, 2020.

3. McTier TL, Pullins A, Chaplin S, et al. The efficacy of a novel topical formulation of selamectin plus sarolaner (Revolution® Plus/Stronghold® Plus) in preventing the development of Dirofilaria immitis in cats

4. Little SE, Hostetler JA, Thomas JE, et al. Moxidectin steady state prior to inoculation protects cats from subsequent, repeated infection with Dirofilaria immitis. 

5. American Heartworm Society. Current feline guidelines for the prevention, diagnosis, and management of heartworm (

) infection in cats. Wilmington, DE: AHS; 2020. Available at: 

heartwormsociety.org/veterinary-resources/american-heartworm-society-guidelines

6. American Heartworm Society. Current feline guidelines for the prevention, diagnosis, and management of heartworm (

) infection in dogs. Wilmington, DE: AHS; 2018. Available at 

heartwormsociety.org/images/pdf/2018-AHS-Canine-Guidelines.pdf

7. Small MT, Atkins CE, Gordon SG, et al. (2008). Use of a nitinol gooseneck snare catheter for removal of adult Dirofilaria immitis in two cats. 

8. Atkins CE, DeFranceso TC, Coats JR, et. al. Heartworm infection in cats: 50 cases (1985-1997). 


Summer is just about here, and so are the mosquitoes. Here’s why—and how—to talk to your clients about heartworm disease prevention in cats.


Matters of the heart: Educating clients about feline heartworm disease prevention

If you take the time to look, there’s usually little mystery about why some staff members at veterinary clinics are “checked out.” Many of the reasons for employee apathy stem from hospital mismanagement. Here’s a look at some of the top factors and a few solutions to combat them.

For some team members, the reason why they don’t care is that they truly don’t care. Specifically, they don’t care about the work you do or the job they have. For some, their job in a veterinary practice is equivalent to a retail job at Target or a lifeguard post at the local pool. Hiring folks who don’t have a sincere desire to work in animal health is like trying to staff The Ritz-Carlton with a crew from Motel 6. After dozens of interviews with America’s best companies, one hiring strategy is common to all: Don’t suffer the fools. Terminate them.

That’s right. The reason your employees don’t care is because they don’t think you do. High-functioning people want their hard work and success acknowledged. I understand that you’re busy being a full-time veterinarian, but don’t forget to acknowledge your employees’ contributions and growth. Appreciation and approbation are powerful tools when wielded with sincerity.

I once visited a practice where the owner complained that his team was “brainless.” Upon closer inspection, I discovered that he was right; they weren’t the brightest bulbs in the box! What was interesting to me was that he hired the very people he was complaining about. His dictatorial management style and his insistence that only 

 could make decisions regarding service, care, client issues, and the like naturally eliminated all employees eager to think for themselves. It’s in your best interest to hire people who think like owners, but here’s the trick: Let them try to act like owners, too.

One quick way to suck the life out of your veterinary team is by allowing—or being part of—an unhealthy work environment where people backstab, gossip, gripe, snipe and bicker incessantly. And even worse, if you, yourself, are the perpetrator of such antics. Sure signs of a toxic workplace environment include chronic callouts, high turnover, employee isolation and sluggish productivity. These are all hints that your employees are disengaged. It’s never too late to turn around a negative workplace, but it requires honestly and open communication among the entire team.

At one practice, a nurse noticed that she had missed a boarder’s treatment. She planned on telling the pet owner about the oversight but was coached by the practice owner to stay quiet because no harm had been done. Perhaps this should have been the mission statement for this practice: “We have the best service around … provided you’re gullible enough to believe it!” If you want to create a team of enthusiastic employees, create an ethical and moral system that they’ll want to engage in—not one that only counts when someone’s looking.

A veterinary practice manager and consultant shares from personal experience why some team members are disengaged—and what to do about it. 

Vetted June 2020

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