Veterinary Vertex
Veterinary Vertex is a weekly podcast that takes you behind the scenes of the clinical and research discoveries published in the Journal of the American Veterinary Medical Association (JAVMA) and the American Journal of Veterinary Research (AJVR). Tune in to learn about cutting-edge veterinary research and gain in-depth insights you won’t find anywhere else. Come away with knowledge you can put to use in your own practice – along with a healthy dose of inspiration to remind you what you love about veterinary medicine.
Veterinary Vertex
Exploring the One Health Approach to Acid Suppressant Use in Veterinary Medicine
Discover a One Health approach to acid suppressant use in veterinary medicine with Drs. Katie Tolbert and Emily Gould. Discover their groundbreaking research featured in JAVMA and AJVR, as they share invaluable insights on the One Health approach driving the current and future applications of these medications. Learn why evidence-based usage, treatment monitoring, and considering broader impacts on the immune system are crucial for every veterinarian. Katie and Emily guide you through the often-overlooked pH-independent effects of acid suppressants and the importance of staying open-minded to the multifaceted influences these drugs can have on animal health. Together, they highlight the interconnectedness of immunity, infectious disorders, and oncology, painting an exciting picture of where veterinary research is headed. Don't miss this insightful episode packed with expertise, innovation, and a glimpse into the future of veterinary medicine!
JAVMA open access article: https://doi.org/10.2460/javma.24.07.0434
AJVR open access article: https://doi.org/10.2460/ajvr.24.07.0194
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You're listening to Veterinary Vertex, a podcast at the AVMA Journals. In this episode we chat about acid suppressant use in veterinary medicine with our guests Katie Tolbert and Emily Gould.
Speaker 2:Welcome to Veterinary Vertex. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Today we have Katie and Emily joining us. Katie and Emily, thank you so much for taking time out of your busy schedules to be with us here today. Yeah, thanks for having us.
Speaker 3:Thanks so much, sarah, and Lisa Been looking forward to it.
Speaker 1:So, katie and Emily, thank you so much for contributing your current One Health articles to JAVMA and AJBR. As we said, we're super excited to talk with you about this today, so we'll start with your JAVMA article. So this one discusses a One Health approach and how that guides current and future acid suppressant use in veterinary medicine. Please share with our listeners the background on this article.
Speaker 4:Yeah, so this was an article that was really driven by Dr Kylie Grady, who's a third year medicine resident at NC State and has a lot of interest in this particular subject. But over the last I don't know 10 years we've done a lot of research into better understanding the rationale for, and the efficacy of, acid suppressants in veterinary medicine. At least, it wasn't that long ago that I went to veterinary school and pretty much used proton pump inhibitors or histamine 2 receptor antagonists for almost anything that came into the ICU, and we're really trying to fight that and really have a more thoughtful approach to when acid suppressants are indicated and, when they are indicated, how to best use them, and it differs a little bit between dogs and cats. So that's really what the article is about.
Speaker 1:And what are some of the important take-home messages from the JAVMA article?
Speaker 4:The biggest thing from the JAVMA article really would be, before you use acid suppressants, consider whether or not you have an appropriate indication. And then, if you feel like you have an appropriate indication, such as you suspect that there might be GI bleeding because you have maybe a non-regenerative anemia, maybe a microcytosis, something that really indicates, yeah, your patient could have GI bleeding, then you want to have measures with which to monitor a response to treatment. So you want to say, okay, if this, then that. So in the next four to six weeks, I'm going to monitor things like the packed cell volume. I'm going to, you know, monitor things such as, you know, the BUN or something like this, to tell you that there is a real improvement in what you're treating. And if you don't see that improvement, then you need to kind of come back to the original thought and say is this still GI bleeding? And if so, is it because my drugs aren't working or could there be some other reason why my patient has a non-regenerative anemia?
Speaker 1:Always good to have an evidence-based approach. We definitely stress that too on the podcast. Absolutely so. On the other hand, your HABR article discusses the pH-independent effects of acid suppressants in dogs and cats. Please share with our listeners the background on this article.
Speaker 3:So Katie's just being super modest. She and I have worked together for I guess almost 10 years now, and I was lucky enough to do my graduate training with her and I think she initially, years and years ago, before I started my PhD you know, kind of stumbled in the literature across. Wow, there are some other things that these drugs are doing beyond what we think they're doing. So, as Katie already alluded to, we use them, you know, predominantly just in kind of the GI realm right now, but there's actually quite a bit of literature in, you know the rodent in vitro and then human literature that they're having all these other kind of interactions and effects with the immune system and in some cases might even be cytotoxic to certain cells. And so really I think, dovetailing with the JAVMA article, the AJVR article is looking at what are the future research directions, what are the future uses for these drugs, and not just in a research sense, but what else is happening in the patient's body when we're giving these drugs.
Speaker 1:Yeah, super important too. So what are some of the important take-home messages from the AJVR article?
Speaker 3:Yeah, I think the biggest take-home would be, in a simplistic sense, have your eyes open, because these medications are doing a lot more than we think, probably at the doses that we're giving them. I think that you know, as clinicians prescribing medications, and then also just thinking about ourselves in the human realm, as patients ourselves. We are not not everyone is created equally right so we're taking all sorts of different medications, our patients are taking different medications, they're eating different diets, they're not in the same environment and so really kind of thinking about the whole patient picture, have your eyes open to that and I think just being aware of you know things where we can think outside the box and kind of doing this review article and working on it made me think a lot about those kind of those aha moments where you're like wow, what else is happening that we're not aware of? But, yeah, just keeping an open mind.
Speaker 2:You know my next question perfectly, emily. Sarah asked you what some of the most important take-home messages are, the key ones, and you just said you had some aha moments. What were the most surprising findings, or one finding, from your AJVR article?
Speaker 3:Yeah, I think the biggest surprising finding for me was just how much evidence there is in other realms of you know, the scientific field and the publications that are out there that are not even veterinary medicine specific. So I think, going back to the whole one health approach to we tend to, you know, think about kind of large animal or production animal being more one health but truly companion animal medicine is also a huge part of that. And so I think for me, just looking at kind of what's out there and how much work we still have to do to look at what these drugs are doing, it's important, as you said in human medicine, to be your own advocate.
Speaker 2:You know it's commonplace for all medical health professionals you give one drug, you see a side effect, you give another drug for that side effect and oftentimes you don't back up and figure out the biochemistry and the pharmacokinetics behind them. It's a lifelong learning for sure. Yeah, katie, what do you think your most surprising finding was in your Jabma article?
Speaker 4:Yeah, surprising finding is tough for me because I feel like we've done a lot of the the research in our own lab, um, so I don't know that there was too much that was entirely surprising from that article itself. I think you know, in terms of thinking about the articles together, one of the things we often talk about as a lab is the adverse effects that we might see in veterinary medicine, meaning that they occur, we should see them, but maybe actually we don't pick up on it because we don't have really large population-based studies. It was funny. I was talking to someone the other day who was saying that they were in the middle of a study and they were really disappointed to see that somebody else had already published the results of their study in veterinary medicine. And I said, well, see that somebody else had already published the results of their study in veterinary medicine. And I said, well, how big was the study? And they said there's 12 dogs. I was thinking to myself. There's, like you know, meta-analyses with studies that are each 10,000 people strong. So I think one of the things that you know, emily and I have talked a lot about and that Emily is working on is being better at the detection of some of these adverse effects.
Speaker 4:So in people, one of the things that is reported although it's just an association, not a causation yet is maybe a link between proton pump inhibitor use and kidney injury, whether that be acute kidney injury or chronic kidney disease.
Speaker 4:And it's really common, unfortunately, that these acid suppressant drugs are used for dogs and cats with kidney disease. And the question is, could there be certain animals not all of them, but if the right things kind of come together where environment plus genetics plus something else plus PPI equals exacerbation of the kidney disease, you might not pick up on it. You might not pick up on it. So I think that's the biggest thing and I agree with what Emily is saying we need to be better clinician scientists, better detectives and sort of sleuthing out what's going on with some of these adverse effects of acid suppressants and, again, being very careful and being mindful of yeah, when there's an appropriate indication you should absolutely use these drugs, but if there's not an indication, then you shouldn't add it on top of the therapy, because not only could you have consequences such as poor compliance with other medications that are really important, but you could also potentially cause some adverse effects that you might not pick up on.
Speaker 3:Regarding some of these other you know, ph independent or anti-inflammatory effects, I think that it's really popular for people to ask about antimeoplastic effects, which we talk about in the article, or ways in which you know these medications can work in conjunction with chemotherapeutics to improve the outcome for patients, but there's actually just a ton it's doing with the immune system, separate from cancer. So I think, whereas cancer is super important and it's attractive to talk about, we treat a lot of patients with these drugs that could have, and do have immune conditions or have infections that we just don't know how that's. You know how the proton pump inhibitors might be impacting the immune system and it could be a pro or a con. So really thinking about doing our diligence as clinicians and, you know, doing no harm that we always talk about that in the veterinarian's oath, I think thinking about that as well.
Speaker 2:I like what you said, emily. Like, not all side effects are bad side effects. Yeah, yeah, some of them are advantageous. Katie, you said a little bit ago maybe partially already answered this question. Obviously you wouldn't say it, but you're a key opinion leader in the world in this area and your lab has done most of the research. What do you see as the next step for research in this topic?
Speaker 4:I think we need to do a better job of focusing on cats, my lab in particular. We haven't done a good enough job about, you know, doing studies in terms of the efficacy of acid suppressants. So when we side-by-side compare some of the studies that we've done in dogs to cats, we see that cats have maybe a weaker response to acid suppression at the same doses, and the question is is that okay? Like is they do? They just have a weaker response, but actually they don't need as much acid suppression for the treatment of their ulcerative disease and we haven't done enough studies to really investigate that. And so that is really. The next step for me is really being a little bit more serious about investigating some of the feline diseases that we see and seeing if acid suppressants are dosed appropriately or not.
Speaker 3:And, I think, kind of dovetailing on that.
Speaker 3:Yeah, I would love to do more feline research, I think, in general, in regard to investigating some of these other effects, I have my first PhD student right now, which is really exciting, and she is currently looking at kind of taking a step further of what I looked at in my PhD, which was mainly focusing on in vitro or cell culture based, you know, investigation of looking at these drugs on in vitro healthy and neoplastic mast cells.
Speaker 3:So she's actually looking at them in the healthy dog. So we think of, you know, in vitro and then you look at ex vivo and in vivo and she's kind of doing step one which is saying, all right, so when we either take these immune cells from healthy dogs and treat them with the drugs, or treat the dogs with the drugs and then take the cells from the dog, what differences and similarities do we see? So we're really excited about that. We're looking at cytokines, kind of pro and antioxidant effects, and then effects on innate immune cell function, so neutrophils and then some of the other innate immune cells. So I'm really excited to see how that turns out and it'll be a good kind of platform springboard, I think, for starting to look at these and the patients that we treat in real life with these medications.
Speaker 2:Congratulations on your PhD student. That's a transformative step in a professorial line to really get your own lab up and cooking.
Speaker 3:Yeah, scary but exciting.
Speaker 2:Yeah, big responsibility. And also I hear lots more AJVR and Java manuscripts coming our way from what you and Katie are saying, so we'll look forward to reading those as well. Hopefully we see artificial intelligence, large language models, everywhere. Do you see a role for LLM or AI in this area of research?
Speaker 3:I can go first and then we'll see what Katie's brain is kind of thinking about this. I'm not sure. To be honest, you know, hearing that question for the first time, my initial instinct is, hmm, I'm not sure. But then I think, thinking about it a little bit more. In at least our AJBR article we cover a lot of what is known about the impact of these drugs on certain white blood cell cell counts. So you know, separate from thinking about pro or con adverse effects, just what they're doing with the immune system, and when we think about some of the other kind of naturally occurring diseases that we see in veterinary medicine, like Addison's, that are already being looked at for AI, I do think maybe there might be a role, depending on what we find in future research. So, say, if these acid suppressants impact cell counts at all, maybe trying to use AI as a way to, you know, predict how this patient might respond, whether it's positive or negative in regard to immunosuppressants or chemotherapeutics and those sorts of things.
Speaker 1:That's super cool, Katie. What are your thoughts?
Speaker 4:Yeah, I feel like I'm just a little infant when it comes to AI and figuring out the power of it. I do think, kind of going back to what we're saying and some of the large scale studies that have been done, sometimes the problem is in terms of association versus causation. There's so much noise that you can't really figure out if, like, yeah, x is leading to Y or X and Y are just occurring at the same time. So I think having something like AI that can maybe help you to ignore the noise and see some of the patterns that are going on, to look for things like adverse effects, probably will be best done in the human first, and then we'll learn a lot about what they discover and then we can apply it to our veterinary species, just because, again, we're really saddled by not having big enough studies to be able to look for some of these problems definitely something to keep an eye out for the future.
Speaker 1:It's super cool. I know, emily, we're chatting before we jumped on the podcast about how it's a really fascinating question when you think about veterinary research, like what is the role, potentially, of AI in the future. So we'll be on the lookout. So, katie, what sparked your research interest in acid suppressants?
Speaker 4:Well, like everything for me, I feel like it's always the mentor that really shapes my career, like when I went to vet school I thought I was going to be an epidemiologist and was going to go to the CDC and evaluate zoonotic diseases and then I met a few people that you know Cindy Ward at Georgia, katie Creevey at Georgia who really sort of opened my world to internal medicine.
Speaker 4:And then I went on to do medicine and at the time I did it under Sally Bissett, who was an internist at NC State, and she was the first one actually to bring the pH monitoring technology that we use now in our research into the first study that I did, actually as a resident, and I really loved it and I was really excited by that line of work. And so after I finished my PhD I carried it on. But it was really Sally Bissett's idea that she let me kind of carry with me, which is really, I think, the role ofissett's idea that she let me kind of carry with me, which is really, I think, the role of a mentor right Is that they sort of help you develop an idea that you're really passionate about and then they sort of gift it to you and say okay, it's yours now, take it. So she did that for me and I'm forever thankful.
Speaker 2:There you go, Emily. That's a good mentor's do right there. Let the graduate student develop it within their confines, but within the grant. You still have to fulfill the grant, but and that's how you grow. It's really cool. That's a great answer, Katie.
Speaker 3:Yeah, yeah, and I think that answer also kind of speaks to when I was going back to talking about aha moments or, you know, giving kind of room to breathe, to having those light bulb moments and then really connecting with what. What am I passionate about about this research? And I think it goes both ways right, like I think that mentors are inspired by their mentees, I think mentees are inspired by their mentors and kind of that that flow with it. And yeah, I mean, I think, similar to what Katie's saying, just about all of her, her acid suppressant research and just kind of making a lot of headway in a field that we talked a lot about it but didn't have evidence for it.
Speaker 3:I, going way back to vet school, I did not want to specialize, I did not want to stay in academia.
Speaker 3:I was like I'm going to go out, I'm going to be a general practitioner, which there's a great need for, but that's what I thought I wanted to do.
Speaker 3:And then at the end of vet school, I was like, oh shoot, I really like internal medicine. And then it was like, oh shoot, I really like this research when I was in my master's and kind of one thing leads to the next, and for me, I've always been really interested in immunity, you know, not only in the context of immune mediated diseases, but also infectious disorders and then oncologic disorders. So I'm an internist but all of these things are interconnected right and I think that's a really cool thing about this facet of acid suppressants and it also just makes you think about all these other medications too. Right Like now I feel like, oh, I'm developing this pharmacology interest that I didn't know I had, and just one thing leading to the next, and so it's really powerful to think about when you kind of stop fighting your plans or your vision for your life. I always joke that I have the short-term, long-term plan, now the acute, chronic plan of what I want to do, because it's there's just so many amazing, you know directions that you could go.
Speaker 1:Yeah, this field is truly fabulous. I was actually just helping out a high school student writing an essay on why she wants to be a veterinarian. We were kind of talking through all the different career paths and personally I was on like the three-step program, like internship, specialty internship, residency, and after a specialty internship, jumped to publications because I really liked writing and reviewing, et cetera. So a lot you can do. And for those of you just joining us, we're discussing acid suppressant use in veterinary medicine with our guests Emily Gould and Katie Tolbert. So this next set of questions, katie and Emily, is going to be really important for our listeners. And the first one centers around the veterinarian. So what is one piece of information the veterinarian should know about acid suppressant use in veterinary medicine?
Speaker 4:I would say they can be really effective when used appropriately for the right patient.
Speaker 1:So then, on the other side of the relationship, what's one thing clients should consider around acid suppressant use in veterinary medicine.
Speaker 3:Yeah, I love this question because, especially in veterinary medicine I always joke it's kind of like pediatrics, right, Like pediatrics for geriatrics, at least in internal medicine too, because you have that client there. You know it's not just another veterinarian you're talking to, or this in the JAVMA article, we talk about this in the AJVR article, but again, each patient is not in the same environment. Each patient is its own. You know dog or cat or horse or whatever we're talking about. And so really, as a client, you do know your animal best.
Speaker 3:I think that you know, as veterinarians we are trained to educate and make these decisions. But we definitely have clients like just, for example, in the context of acid suppressants, that will come in and say I am convinced my animal is doing better. You know, on the histamine 2 receptor antagonist when used in conjunction with these other things, and I think part of that comes back to these anti-inflammatory effects and these drugs doing things that we don't know they're doing in the body. So whether it's a positive effect or a negative effect, you know, listen to your veterinarian. They're educated, they have a lot of years of education, but there's a lot of things that we don't know, and that's how science progresses, and that's how we make discoveries. So yeah, listen to your furry friend.
Speaker 2:Awesome. Thank you guys so much. I learned a lot reading both of your articles and this has really been truly fantastic to be here with you today. As we wind down a little bit, we like to ask some of a little bit more of a fun question. So, katie, we'll start with you. When you put together a puzzle, we can kind of guess what the answer is, but sometimes we're surprised. When you put together a puzzle, do you start with the exterior, the border pieces, or do you do the interior pieces, like by color or style or something like that? How do you do a puzzle?
Speaker 4:I wish I could be cool and just go straight for the middle of the puzzle, but I have to do the outside and do the frame of the puzzle first. And my son, my son's six we did a puzzle this morning because he's home from school sick, and so I was like teaching him like no, no, don't go to the outside first, we're going to do that first. But yeah, so unfortunately, maybe that's how I am I have to have the framework before.
Speaker 2:I jump in. That's interesting. We might have to add to the list of what we commonly see is surgeons do the outside. Oh, interesting, any internal medicine person typically does inside, by either color or like. Oh, I'm going to put the trees together first, but maybe, maybe a structured researcher does the border too yeah, well, she could do a poll.
Speaker 3:That'd be a fun study yeah, didn't wait, katie, didn't you also? Weren't you split between surgery and medicine? Didn't you share that at some point? Your face?
Speaker 4:look at the grimace, the grimace surgery three times during vet school because I couldn't decide orthopedic surgery three times and soft tissue surgery twice because I was very torn, but okay well, that explains it.
Speaker 2:Then you're a true border girl.
Speaker 4:But I will have to do that study because I don't know if you've seen, some journals have really like around Christmas time they have kind of fun studies that they'll publish. So it's a fun one to do a poll for all different specialties and see if, yeah, we could hypothesize maybe, like surgeons are more likely to do the outside that would be really cool.
Speaker 3:Yeah, I mean I know that was Katie's question, but I do a combination of the both of those things, Lisa, that you had said. So I do the same way as her. I do border first, but then I do grouped by color, or you know, I chunk it out then and then I pick the chunk that's like I'm most interested in or looks the most fun first.
Speaker 2:Yeah, leave the mosaic part for later.
Speaker 1:Yeah, yeah.
Speaker 2:Emily, for you, your question is what's the oldest or the most interesting item on your desk or in your desk drawer?
Speaker 3:Yeah, so I love that question because it's just I think so, or can be so personal.
Speaker 3:So the object I'm going to share I actually just re-gifted it a couple of weeks ago, but prior to that I'd had it for, I guess, nine years, so almost a decade. So one of our licensed veterinary social workers from Tennessee, where I did my master's and medicine residency, and that's where I met Katie she had given me this. Like you know, they're almost like wishing stones, like a little stone that said like authentic on it, and the idea is that you pass this along to someone when they have done something that you think they are staying true to themselves, so whether it's a decision or an action, and then you're supposed to hold on to it until you feel it's the right time to pass it on. So I actually had this stone for a really long time. Part of it was probably got shuffled around in the multiple moves somewhere, but anywho, I just passed it along a couple weeks ago. So even though it, you know, newly departed my desk, I wanted to share that.
Speaker 1:That's super cool. I had not heard of that before.
Speaker 3:Yeah, so I think it's something that's really fun to do, so maybe people listening to this will want to do it also.
Speaker 2:Maybe it'll show up in a future podcast when we have somebody else with the most interesting item on their desk.
Speaker 3:Yeah, yeah, and it can be anything too. You know like you can do that with anything. It doesn't have to have a word on it, but just you know the meaning behind it.
Speaker 1:Yeah, that'd be full circle. That'd be pretty cool. So we'll see. We'll let you know if it shows up again.
Speaker 3:Yeah, no pressure, listeners no pressure.
Speaker 1:Very cool. Well, just thank you again, katie and Emily. We really appreciate you both taking time out of your busy schedules to be here today, and also for sharing your articles, too, with Javma and AJVR.
Speaker 4:Yeah, thanks for having us and thanks for providing a space for us to publish articles. We really appreciate it.
Speaker 3:Thank you guys so much. It was great. It's always nice chatting with kind of new faces and then about a topic you're passionate about.
Speaker 1:And to our listeners. You can read Katie and Emily's current someone health articles and print Javma or online using your favorite search engine. I'm Sarah Wright with Lisa Fortier. We want to thank each of you for joining us on this episode of the Veterinary Vertex podcast. We love sharing cutting edge veterinary research with you and we want to hear from you. Be sure to leave us a rating and review on Apple podcasts or whatever platform you listen to.
