Episode 22: The GP Update You'll Actually Use on Monday

From nutrition and renal cysts to phantom pregnancies, ear cytology and a new three-month OA antibody: the practical points we're taking back into first-opinion practice.

EPISODE PARTNERS Purina Institute sponsored this episode, in which we explore its 2026 well-pet nutrition handbook. We have also partnered with Vet Shadow, who are offering Chatty Vets listeners a discount on their clinical support service. Thank you to both partners for helping us keep making practical content for GP veterinary teams.

One shift. Seven decisions. Very GP.

If you've ever opened a Friday-afternoon biochemistry result and felt your pulse climb with the creatinine...

If you've ever admitted a bitch for a routine spay, found a suspiciously watery mammary secretion and wondered whether you were being sensible or simply wrecking the ops list...

If you've ever looked down the microscope at a blizzard of Malassezia 'snowmen' and wished the treatment could match what was actually on the slide...

This episode is for you.

Episode 22 is a proper general-practice pinball machine: nutrition, kidneys, spay timing, ultrasound, preventive medicine, otitis, osteoarthritis and the awkward business of asking for help. That sounds unruly. It is also exactly what a Tuesday in GP looks like.

So here are the bits we're taking with us: what is useful, where the context matters and what might genuinely change the next consult.

1. Nutrition is medicine, not the bit after medicine

We got properly excited about the Purina Institute's 2026 Handbook of Canine and Feline Well-Pet Nutrition, which is the sponsored centrepiece of this episode. It is much more than a tour of macronutrients. It connects nutrition with life stage, body condition, cognition, musculoskeletal health and common disease risks, in a format a busy team might actually open between consults.

A couple of extra details are worth carrying into the consult.

One of the figures we loved was the roughly 15% survival difference associated with lean feeding. The original lifetime study paired Labrador retrievers and fed one dog in each pair 25% less than its littermate. The leaner-fed dogs had a median lifespan about 1.8 years longer and developed several chronic diseases later. It is a brilliant way into a body-condition conversation, provided we explain where the number came from rather than turning it into a promise for every dog or cat.

The MCT and epilepsy section is another genuinely useful one. MCT-enriched diets have helped reduce seizure frequency in some dogs with idiopathic epilepsy when used alongside their usual management, including in a randomised crossover trial. The mechanism may be broader than simply making more ketones, because MCT-derived fatty acids may have antiseizure effects of their own. For us, the practical point is that nutrition can be a meaningful adjunct while the diagnostic work-up and indicated antiseizure medication remain firmly in place.

And the gut-kidney axis? Fascinating, and a good reminder that renal nutrition is about more than protein and phosphate. Altered microbial metabolism and uraemic toxins may contribute to CKD progression, although the best way to turn that science into dependable patient-level choices is still developing. For now, it sits alongside the familiar CKD jobs: diagnose carefully, stage a stable patient, control phosphate, address proteinuria and hypertension, maintain nutrition and hydration, and monitor the individual in front of us.

MONDAY-MORNING MOVE Bring in one nutrition question into your general consult. Whether its a skin allergy dog and you suggest increasing fish oils or oily fish into the diet or find out if a routine cat appointment brings up furballs every two weeks, which would a good reason to start making some dietary changes.

2. Azotaemia is a finding. It is not yet a diagnosis.

Brendan's older small-breed dog moved from a creatinine of 234 micromol/l on Friday to 144 micromol/l on Monday after improving at home. That pattern can fit a reversible pre-renal component, but it also reminds us how little one number can say about hydration, filtration, chronicity or concurrent renal disease.

When feasible, get urine before fluids. A urine specific gravity interpreted alongside hydration, sediment, glucose, protein and the rest of the case can preserve valuable diagnostic information. When it is not feasible or the patient needs immediate stabilisation, treat the patient and document the limitation. No single sample is worth delaying necessary care.

The same discipline applies to staging. IRIS CKD staging is for a stable, hydrated patient with CKD, not an acutely unwell or potentially volume-depleted animal on first presentation. Repeat renal values, blood pressure and urine protein assessment belong in the plan once the patient is stable enough for the label to mean something.

Those 'Swiss-cheese' kidneys: what else could they be?

Multiple rounded anechoic spaces in both kidneys are hard to miss, and calling them polycystic kidney disease is an understandable first thought. The context helps us decide how confident to be. In cats, PKD is strongly associated with Persian and related ancestry and can be supported by characteristic bilateral cysts plus breed or genetic context. In dogs, inherited cystic diseases are much less common and breed associations differ. Depending on the case, acquired cysts, hydronephrosis, abscessation, haematoma and cystic or necrotic neoplasia may also sit on the list.

Our practical approach would be to describe exactly what we can see, correlate it with renal function and urine findings, compare both kidneys, and ask a diagnostic imager or pursue further testing when the pattern, breed or clinical course feels unusual. The scan has already done something valuable: it has given us a better question to answer.

POCUS and a complete abdominal scan are different jobs

We love AFAST and TFAST because they are focused, repeatable examinations that can answer urgent questions such as whether free fluid is present or whether thoracic findings are changing. They also throw up useful surprises. The helpful boundary is remembering that they do not assess every organ or exclude every injury. When a focused scan finds more than expected, it has usually pointed us towards the next test.

3. Phantom pregnancy: the spay can wait

A little watery secretion from several mammary glands is exactly the kind of finding that turns a routine admission into a judgement call. Charlotte's explanation gives us the reason to pause: removing luteal progesterone during active pseudopregnancy can increase prolactin drive and prolong or intensify clinical signs. That is why standard reproductive guidance favours performing an elective ovariectomy or ovariohysterectomy during anoestrus, after pseudopregnancy signs have resolved.

The decision should use the whole picture: timing of the last season, mammary development or secretion, nesting or mothering behaviour, appetite and demeanour, vulval changes, and the possibility of a silent or poorly observed season. If active pseudopregnancy is plausible and surgery is elective, postponing is usually the cleanest choice.

Cabergoline can shorten clinical signs when treatment is warranted, subject to the product information and the individual patient. We would still separate that treatment decision from the timing of elective surgery: help the patient through the pseudopregnancy, then reschedule once the hormonal picture has settled.

ADMISSION PROMPT Before an elective bitch spay, ask about the last observed season, nesting or toy-mothering, mammary enlargement or discharge, and any recent vulval swelling or discharge. Record the answer before premedication.

4. Sedation for ultrasound: decide what question you are asking

Sedation can transform a tense, panting, deep-chested dog into a much more diagnostic abdominal study. It may improve contact, reduce motion and stress, and make the cranial abdomen less of a wrestling match. Equally, an unstable patient, a patient with a high anaesthetic risk or a genuinely focused yes-or-no scan may not need it.

A useful sequence is:

• Define the question: focused triage, first-opinion full abdominal scan, or a procedure requiring stillness?

• Assess stability, pain, airway and aspiration risk, cardiovascular reserve and concurrent medication.

• Choose handling, positioning and anxiolysis or sedation for this patient, not for an imaginary average dog.

• Set expectations with the owner: ultrasound does not always require sedation, but some patients will get a calmer and more complete examination with it.

The aim is not sedation for prettier pictures. It is the least stressful, safest route to images good enough to answer the clinical question.

5. Ear cytology gets to earn its keep

DuOtic 10 mg/1 mg ear gel for dogs prompted one of our favourite practical points in the episode. It combines terbinafine, an antifungal, with betamethasone acetate, a glucocorticoid, without adding an antibacterial. It is licensed for canine otitis externa associated with Malassezia pachydermatis, so when cytology shows inflammation and abundant Malassezia without bacteria, we can choose an option that more closely matches what is on the slide.

The NOAH particulars specify one tube per affected ear, repeated after seven days, with maximum clinical response potentially taking until day 28. The ears should be cleaned and dried before the first application; in the clinical trials, saline was used for that initial clean and the ears were not cleaned again during the 45-day study period.

Before applying it, we still need a thorough ear examination and an intact tympanum. The product is not for dogs with generalised demodicosis, pregnancy or lactation, or breeding animals; safety has not been established below two months of age or 1.4 kg. The particulars also advise avoiding use in cats and recommend administration by a veterinary surgeon or under close veterinary supervision because accidental ocular exposure can occur when the dog shakes its head.

Cytology does a lot of useful work in a very small space. It helps us distinguish cocci, rods, yeast and inflammatory cells, gives us a baseline for response and supports antimicrobial stewardship. Recurrent or non-responsive disease, rods, suspected otitis media, severe proliferative change, a foreign body or an uncertain tympanum may then point us towards culture, imaging or a different treatment plan.

Treat what is on the slide, but keep asking why it is there: allergy, conformation, moisture, keratinisation disorders, endocrinopathy, parasites, foreign material and treatment technique all deserve their turn.

6. Preventive medicine when the internet is loud

The L2-versus-L4 conversation and online reports about parasite products can be difficult because a temporal association feels very much like causation to a worried owner. We do not need to dismiss that experience or accept every link as established. We can acknowledge what happened, explain what is and is not known, and compare the product risk with the disease risk for this particular patient.

Leptospirosis vaccination

We use current UK product information and local epidemiology, then make the risk discussion as specific to the dog as we can. Exposure is not limited to the cartoon dog cheerfully swimming in a canal; wildlife and environmental contamination make the picture broader than that. Vaccination reduces risk without making leptospirosis impossible, so vaccination status adjusts the differential rather than deleting it.

Isoxazolines and neurological adverse events

This was a useful bit of nuance for us. Regulators and product labels warn that tremor, ataxia and seizures have been reported with isoxazoline flea and tick products, including in animals without a previous neurological history. In a patient with epilepsy or another seizure disorder, we would slow down, read the label for the individual product and have a deliberate risk-benefit conversation rather than treating the whole drug class as an automatic yes or no.

When a suspected adverse event occurs, stabilise the patient, record timing and competing explanations, check the current Summary of Product Characteristics, and report through the VMD's pharmacovigilance route. Signal detection improves when reports are detailed, even when causality is uncertain.

7. OA watch: a new three-month option

The new arrival we mentioned is Lenivia (izenivetmab). Vet Times reported on 29 May 2026 that the VMD had approved it for alleviation of pain associated with osteoarthritis in dogs, with administration once every three months. Zoetis describes it as the first long-acting canine anti-nerve growth factor monoclonal antibody with that interval. That is genuinely interesting for adherence and continuity of care.

The report also says that a field study showed improved mobility and reduced pain from the first injection, although those details are attributed to Zoetis. It is tempting to think of Lenivia as 'three-month Librela', but izenivetmab and bedinvetmab are distinct monoclonal antibodies. We will want the full SPC and study details as they become available, then watch the real-world experience develop alongside them.

Whatever the product, OA care remains multimodal: confirm the pain generator, measure function as well as pain, manage body weight, use appropriate exercise and environmental modification, involve rehabilitation where useful, and agree what success or deterioration will look like. A three-month injection must not become a three-month gap in assessment.

Start the ageing conversation before 'just slowing down'

The BSAVA PetSavers Canine Ageing Toolkit is a useful owner-facing bridge. Use the questionnaire before the dog is obviously struggling. Difficulty rising, altered stair use, hesitation on slippery floors, disrupted sleep, reduced interaction and new panting can all justify a closer look, but none is specific for OA on its own. The job is to turn an observation into an examination, not an automatic diagnosis.

8. Clinical back-up is a system, not a confession

We finished by talking about support. Vet Shadow offers practices rapid access to experienced clinicians by message, voice note and image sharing, and our partnership with them includes a listener discount. What resonated with us is the importance of time-to-help, especially for sole-charge and out-of-hours work.

Used alongside a practice's own clinical protocols and referral pathways, Vet Shadow gives the attending vet another experienced brain to draw on while they stay in control of the case. For us, the appeal is simple: timely, accessible advice and a little more thinking space when a shift is busy or you're working sole charge.

Brendan's potassium example is a good one: 8 mmol/l deserves immediate attention. We would check whether haemolysis, sampling error or species-specific artefact could be contributing while treating severe hyperkalaemia as potentially life-threatening and assessing ECG changes and the underlying cause. A screenshot to a colleague can help in the moment; a reliable critical-results process helps the whole team every time.

Take-home points

• A good diet history is a clinical test, not lifestyle small talk.

• The Labrador lifespan study gives us a memorable lean-feeding conversation, as long as we explain the population behind the 15% figure.

• Stage CKD only when the patient is stable and hydrated; collect urine before fluids when feasible, never at the cost of urgent care.

• Multiple renal cysts deserve context and differentials before the label 'polycystic kidney disease'.

• Postpone an elective spay when active pseudopregnancy is plausible, and operate once signs have resolved.

• Sedation for ultrasound is a patient-and-question decision, not a badge of scanning ability.

• Ear cytology should change what you prescribe, while the underlying cause still needs a plan.

• With vaccines, parasite products and new OA therapies, compare labelled risk, disease risk and patient context; keep reporting suspected adverse events.

• Clinical support works best when it is timely, governed and easy to use before the shift gets away from you.

The last word

We do not leave this episode with one immaculate protocol. We leave with something more recognisable: a collection of those moments just before the decision, when the result is awkward, the scan is surprising, the owner has read something alarming and the next patient is already waiting.

That is where good GP medicine lives. We name the uncertainty, ask one better question, use the evidence we have and get another pair of eyes when we need them. Then we make the best decision for this patient, in this practice, today.

Listen to Episode 22 of The Chatty Vets Podcast, then tell us: which apparently tiny GP decision causes the biggest debate in your team?

Useful links from this episode

Did we inspire you to check out Purina Institute's Canine and Feline Well-Pet Nutrition Handbook? Download the free handbook.

Interested in finding out more about VetShadow's services for your veterinary practice? Explore VetShadow and use code CHATTY5 for a 5% discount.

Help owners spot age-related changes earlier with the BSAVA PetSavers Canine Ageing Toolkit.

Source notes

Kealy RD et al. Effects of diet restriction on life span and age-related changes in dogs. Journal of the American Veterinary Medical Association, 2002. Lifetime paired-Labrador study; 25% dietary restriction was associated with a 1.8-year increase in median lifespan. Abstract / DOI (paywalled full text)

Law TH et al. A randomised trial of a medium-chain TAG diet as treatment for dogs with idiopathic epilepsy. British Journal of Nutrition, 2015. Adjunctive MCT-enriched diet reduced seizure frequency in some dogs during the trial period. Free abstract; article access varies

International Renal Interest Society (IRIS): CKD staging and treatment recommendations. Current staging principles and management recommendations for stable canine and feline CKD, including blood pressure and proteinuria substaging. Free access

International Cat Care: Polycystic kidney disease. Owner-facing overview of inherited feline PKD, breed association, screening and clinical course. Free access

Merck Veterinary Manual: Pseudopregnancy in small animals. Clinical overview, prolactin biology, treatment and timing of elective ovariohysterectomy outside active pseudopregnancy. Free access

WSAVA Vaccination Guidelines Group: 2024 guidelines for the vaccination of dogs and cats. Risk-based vaccination principles and leptospirosis guidance; use alongside current UK product information and local epidemiology. Free access

US Food and Drug Administration: Isoxazoline adverse-event fact sheet. Regulatory summary of reported neurological adverse reactions and the need for patient-level discussion in animals with seizure histories. UK clinicians should also check the VMD SPC for the individual product. Free access

Vet Times: 'Milestone' as VMD approves Zoetis' Lenivia for OA. News report dated 29 May 2026 confirming VMD approval of izenivetmab for OA-associated pain in dogs and reporting the three-month interval. Efficacy descriptions in the article are attributed to Zoetis. Free access

Veterinary Medicines Directorate: Product Information Database. Live UK source for authorised indications, dosing intervals, warnings and pharmacovigilance information for Lenivia, isoxazolines and otic products. Free access

BSAVA: PROTECT ME. Practice resources supporting responsible antibacterial use and antimicrobial stewardship. Free access

NOAH Compendium: DuOtic 10 mg/1 mg ear gel for dogs. Official product particulars for terbinafine and betamethasone acetate ear gel, including the indication, administration schedule, contraindications, precautions and adverse events. Product information supplied as a NOAH printout dated 2 August 2026. Free access

BSAVA PetSavers: Canine Ageing Toolkit citizen-science project. Owner and practice resources for recognising and discussing age-related changes in dogs. Free access

Purina Institute: Handbook of Canine and Feline Well-Pet Nutrition. Sponsored resource discussed in the episode, linked through the supplied Chatty Vets campaign landing page for the 2026 edition. Free access; commercial source