Financial Assistance for Veterinary Bills

October 10, 2009 by Lisa  
Filed under Blog

PLEASE CONTACT KARNA’S OWNER, TONY, DIRECTLY IF YOU HAVE ANY INFORMATION THAT MAY HELP HIM AND HIS FAMILY

tony.cerrito@gmail.com

Thank you for the wonderful web site you created dedicated to Canine Liver Disease. I’ve found the information helpful in understanding the disease diagnosis I just received for my 5-year old male German Shepherd, Karna (a rescue).

After treatment in August from my veterinarian for cracking and flaking paws and lethargy proved unsuccessful, she referred me to the North Carolina State University Veterinary School for a diagnosis at their dermatology clinic. I took him last week and was informed that Karna had Phenobarbital induced (he has a history of seizures) Hepatocutaneous Syndrome – also known as necrolytic migratory erythema (NME). This is apparently a new and extremely rare disorder. They want to start a treatment on him quickly that will cost $750-1500 initially, with one or two additional treatments possible and ongoing therapies of injections (administered by yours truly) 3-4 times a day.

Here’s the reason for my email: I am currently unemployed and have been for some time (my profession is tied to the construction industry – hardest hit in this economy, as you probably know). I received my last unemployment insurance check in June and my wife and I are hanging on by a thread. This event with Karna has already put us in debt to the tune of nearly $1200 on top of an additional $700 we spent in February at another specialist (canine neurologist) for treatment of anticonvulsant toxicity he was diagnosed with then. I’m not complaining, I’d do it all over again. We love our boy very much. But we’re facing the reality now of having to make a decision between treatment or euthanasia because we have come to the end of our financial resources. I have asked the NCSU Vet School if we would qualify for financial assistance. The person who makes that decision is out until this Monday when I am scheduled to take Karna in for treatment. So we do not yet know if we will qualify. But we are taking a leap of faith and going ahead with the treatment in the hopes that we will be approved for assistance. However, if we are NOT approved, we will be in financial trouble and likely will be at the tipping point of being able to pay our bills. So I want to ask you if you can direct me to any other organizations that might be able to help my wife and I pay for Karna’s treatments.

Karna is probably the sweetest dog I’ve ever owned. He loves absolutely everyone and doesn’t have a mean bone in his body. He is a frequent hugger, known to wrap his long neck around the legs of those he meets. He deserves a shot at regaining his health. He’s been a brave boy through all of his misery and we want so much to save him. He has many years left in this world if we can do so. The doctor who will be treating him (Dr. Olivery) is optimistic that the treatments will help Karna regain liver function, but admits that only time will tell. Unfortunately, because of the economic downturn, the timing for all of us in this matter couldn’t be worse. I am not one to ask for charity, but I see no other course right now if I wish to try and save my buddy. Any information or help you might be able to provide is very, very much appreciated.

A Touching Memorial Poem

May 27, 2009 by Lisa  
Filed under Blog

This message was posted to one of the Canine Liver Disease Yahoo Groups that I belong to and I really loved the sentiment so I thought I would post it here for everyone to read.

When I was a puppy
I was very much afraid
Then I met you
And I knew I belonged to someone who would always care

When I was a young dog
I did some things to try you
And you would sometimes get angry, but in the end
You never stopped loving me.

When I was a grown up dog
Oh, the fun we had!
I think I loved the hose no, the ball, no, agility class
Well, it all was so wonderful, to spend my happiest and best days with you.

When I was a middle aged dog
You understood when I could not do the things I once could
When I would tire on a walk
How I loved to be carried home safely in your arms

When I became an older dog
I could see my whole life in your eyes.
You were so loving and patient
And I loved nothing more than to just lie quietly with you

When I became a sick dog
Oh the sadness we both felt
But how you cared for me
Oh, that I will never forget

You’d wipe my eyes, and clean me up
And never once got angry
When I would lose control of my body
Your patience and understanding were what let me keep my dignity

When I was a dying dog
You never once left me
Although it was hard for you to watch me as my life came to an end
You did so out of a love stronger than I had ever known before

As I lay in your arms
My whole life flashed before me
And I saw that it was a good life, filled with wonderful memories to last me over the bridge…and beyond

All because you were my person, and I was your dog

In Memory of my golden girl Reiley “Monster” – I miss you still after all these months. I love you!!

<

PetsMart Dog Walk

January 26, 2009 by Lisa  
Filed under Blog

Yesterday we did our first local event for The Canine Liver Disease Foundation as we participated in the 1st Annual PetsMart Walk for Charity. We wore our CLDF logo shirts and walked 3 miles around Tempe Town Lake. Braelyn was in heaven as she got to pet the dogs of all shapes and sizes. We hope to be active in more events like these to raise awareness for our group and Canine Liver Disease.

Me, B & Dad before the walk

Me, B & Dad before the walk

Justin, Roxy, Me, B, Chris & Sydney

Justin, Roxy, Me, B, Chris & Sydney

Chris with Sydney

Chris with Sydney

Justin with Roxy

Justin with Roxy

Our tired walker

Our tired walker

Please help us spread the word about Canine Liver Disease!  If there are events in your area that you would like to participate in the name of our foundation, please contact Lisa at:  lisahillerysmith@cox.net

Reiley’s Story

January 12, 2009 by Lisa  
Filed under Blog

Where to begin with Reiley’s story?  I got her as a 9 week old puppy and was by her side as she passed away at 9 years old.  She was my devoted companion before my husband and daughter came along and she was my “furry” baby.  I could not have asked for a more loving and special companion and I was devastated when she died in late October.  I miss her and think about her every day and am so thankful that she was in my life.

In March of 2008, I took Reiley into the vet because her appetite had decreased and she wasn’t eating as much as she previously had.  The vet found she had a high temperature (103.5) and put her on antibiotics.  After 10 days of high fever and even further appetite reduction & vomiting due to the antibiotics, I made the choice to take her off of the antibiotics to see how she responded.  Her fever went away and her appetite returned so…. I thought she had recovered.

Throughout the summer of ’08 there were days when Reiley didn’t eat all of her food, but didn’t have a fever or any other signs of illness.  Needless to say we were shocked when she was diagnosed with cirrhosis of the liver in mid-October.

We received the diagnosis of liver disease during some routine bloodwork for a dental procedure.  Reiley’s appetite had decreased somewhat and she was being a pickier eater than normal, but she was still eating and otherwise acting normal.  When the vet ran her pre-op bloodwork, she had 4 times the normal level of ALT and ALKP and her bile acids were about 3 times the normal levels.

After an ultrasound which definitively name cirrhosis as the offender, we took Reiley to a internal specialist for a consult.  By the time we saw the specialist, Reiley wasn’t eating at all and she had to be hospitalized due to a serious liver infection.  Despite our best intentions and the hard work of the hospital staff, Reiley passed away 2 days after her hospitalization with my husband and I petting her and talking to her, letting her know we loved her and would miss her.

The hardest thing about Reiley’s liver disease is how subtly it worked and how quickly she became ill.  There we only minor symptoms displayed to us; symptoms that could have been attributed to several other things and not something as serious as liver disease.  This is the primary reason I created this website and foundation – to spread the word about this disease and how it affects our beloved pets.  If just one family can save their pet based on the information I have compiled, then it will help me begin to heal from the sadness I feel at losing my best furry friend.

Please feel free to email me at: lisahillerysmith@cox.net to include your success story, tribute, memorial or other story about your dog and liver disease.

Thank you for reading,

Lisa Smith

Founder of The Canine Liver Disease Foundation

In Memory of my Reiley Monster

October 21, 1999 – October 30, 2008

Testing and Diagnosis of Canine Liver Disease

January 4, 2009 by Lisa  
Filed under All Info, Testing and Diagnosis

Comments Off

A thorough approach is needed for a correct diagnosis of any liver problem. An organ like the liver that
is so intimately involved with other important organs will exhibit symptoms that mimic disease in these other organs. Also, what initially might appear as a diseased liver is in reality a disease elsewhere in the
body that is involved with the liver secondarily. This is why it is crucial to follow a thorough and methodical approach called the diagnostic process.

Examination

Specifically noting signs which may indicate liver disease. Periodic ascites, intolerance of a high protein diet, icterus, chronic weight loss, abnormally colored feces or urine, bleeding disorders, chronic illness, and all that has been mentioned above. Sometimes urinary crystals formed from the improperly metabolized proteins and amino acids may indicate liver disease.

Liver disease can occur in pets of any age. If it occurs in young animals we tend to think more of toxicity, a liver shunt or a viral disease like adenovirus in dogs. In older pets we tend to think more of inflammation and cancer as the cause of the liver problem.

Several canine breeds are prone to getting liver disease:

Bedlington terriers, Skye terriers, Doberman pinschers, and West Highland White terriers get a
problem with excessive copper accumulation that results from failure of normal biliary excretion of copper. Cocker spaniels have an increased incidence of chronic hepatitis

History

Early signs of liver disease are subtle, and might exhibit as some of the symptoms described above. It is important to remember that some pets do not show any symptoms early in the course of the disease. This is another reason for yearly exams, along with blood and urine samples in dogs and cats 8 years of age or more. Even though many cancers do not show up in a blood sample, we can sometimes get indirect evidence there is a problem, leading to additional diagnostic tests that might find cancer.

The recent use of pesticides, insecticides, and drugs might give us a clue. Some Labradors are sensitive to the use of the arthritis medicine Rimadyl. These dogs should have a blood panel analyzed prior to initiating Rimadyl therapy. Every 6 months this panel should be repeated.

A history of poorly controlled diabetes mellitus might also clue us in to liver problems. Pets with
liver shunts might have stunted growth and become depressed right after eating.

Physical Exam

Routine physical exam findings might include:

Distended abdomen due to enlargement of the liver (hepatomegaly) might be found. This can be palpated in some situations, especially in the smaller animals. an enlarged liver from a disease other than liver disease can cause hepatomegaly. This includes heart disease and Cushing’s Disease.

Enlarged lymph nodes due to secondary bacterial infections or spread of a primary or metastatic
liver tumor.

Bruising (hematoma) might be observed under the skin, or when a blood sample is obtained. This is
due to the liver’s affects on the clotting mechanism

Fever- a rectal temperature of greater than 103 degrees F could accompany liver disease when inflammation or infection is present

Skin infections and wounds that do not heal, or recur after antibiotics are stopped

Yellowish discoloration (icterus or jaundice) of the ears, gums, or hairless areas of the skin

Anemia might be observed by checking the mucous membranes for a normal pink color

Extensive Blood Work and Diagnostic Testing

A complete blood count to check for anemia and blood cell abnormalities. A CBC (complete blood
count) and BCP (biochemistry panel) should be run on every pet 8 years of age or more, especially if they have any of the symptoms of liver disease. The CBC might show a decrease in the number of red blood cells (RBC’s). This decrease in RBC’s is called anemia. The white blood cell count (WBC) might be elevated (leukocytosis), normal, or decreased (leukopenia), mostly depending on the cause of the liver problem and how long it has been present. A change in the WBC’s does not necessarily indicate there is a liver problem.

A complete chemistry screen, including ALT, ALP, AST, bilirubin, glucose, urea, electrolyte levels,
albumin, globulin and bile acid levels. The bile acid levels should be checked on an empty stomach and two hours after feeding. All these values, with the exception of the bile acids, usually are included on
a standard Small Animal Data Base Screen.

Important Liver Enzymes

Traditionally the medical practitioner has measured the relative concentration of several enzymes which may indicate alterations in liver health. The following enzymes typically change values in the face of liver failure

Alanine Aminotransferase: ALT – Liver specific. Cell damage will cause elevations of ALT due to leakage. The elevation of the enzyme correlates with the number of cells damaged. Falling levels of ALT may indicate recovery or may indicate a failing number of functional liver cells. Rapid increases in ALT may indicate an acute process, while slow increases may indicate bile duct obstruction.

Normal Test Range: 10-100 U/L*

Aspartate Aminotransferase: AST - an enzyme seen in the liver, heart, kidney, skeletal muscle and brain. The half life of the AST in the blood stream is much shorter than that of ALT, therefore the values of AST tend to drop more rapidly once liver function is resumed. AST elevations and ALT elevations should parallel each other in liver disease

Normal Test Range: 5-55 U/L*

Alkaline Phosphatase: ALKP/ALP – This enzyme is present in many tissues, therefore it not very specific in liver disease, but it appears very early in the progress of liver disease, therefore it is considered quite sensitive. ALP tends to be slightly more specific in the cat, but not quite as sensitive. A similar enzyme or isoenzyme is secreted as a result of high levels of cortisone, therefore an effort must be made to separate Cortisole induced ALP or CALP and normal ALP. Liver ALP is released from the liver when many anticonvulsant drugs are administered to the dog. This must be taken into account when evaluating ALP levels. ALP levels typically are greatly elevated in the young, growing animal and therefore a veterinarian should not mistake any elevations as disease in a young animal.

Normal Test Range: 23-212 U/L*

Gamma Glutamyltransferase: GGT – This enzyme is has its highest concentration in the kidneys and pancreas, but it is also found in the liver and other organs. The major proportion of GGT in the serum seems to come from the liver. Elevations of GGT in disease seem to stem from new synthesis rather than leakage, therefore the changes seen due to disease are not spectacular. Large elevations of GGT are more commonly associated with pancreatitis and bile duct obstruction.

Bile Acids

These series of organic acids circulate almost entirely in the localized blood flow between the intestines
and the liver (a.k.a. the Portal system). The flow is typically from the liver, into the bile duct system, then excretion into the intestines to aid digestion after a meal, to be re- absorbed into the portal system and recycled by the liver. Very little of the bile acids escape from the portal circulation system into the rest of the body. Leakage is considered abnormal and is a sure sign of a liver abnormality. This is one of the most sensitive tests available to diagnose liver disease. While the liver does actually manufacture this product, it has tremendous reserve capacity and can easily meet the bodies demand for bile acids despite severe disease. As a result of this reserve, the bile acid levels do not typically drop due to liver disease.

Normal Test Range: Pre = Less than 7.0 umol/L, Post = Less than 15.0umol/L*

A complete urine analysis

Check urobilinogen levels, bilirubin levels, glucose levels, protein levels. Again all this is usually on a standard urinalysis panel.

Radiograph the abdomen

X rays can show increased liver size, decreased liver size liver abscesses, abnormal mineralization , and circulatory abnormalities (using special dyes).

Ultrasound the liver

Perfect technique for visualizing the circulation of the liver, the bile duct system, the density of the liver tissue, the size of the liver. Ultrasound is highly beneficial in the diagnosis of liver disease. We recommend ultrasounding a liver when the liver enzymes tests are elevated over time, or the bile acids test is abnormal. The internal structure (called parenchyma) can be analyzed, and post-hepatic liver disease can be differentiated from hepatic liver disease. This can be very important because disease in the liver can often be diagnosed with a biopsy during the ultrasound. Post-hepatic liver disease cannot easily be diagnosed in this matter. Instead it is diagnosed and treated with an exploratory surgery (called a laparotomy).

Biopsy of the liver

While this is a surgical technique, it is the ultimate for diagnosis, since it allows us to directly examine and test liver tissue, give an absolute diagnosis and hopefully a final treatment regime. Biopsies can be taken by full laparotomy, where the surgeon actually looks at the liver and removes a small piece, or they can be done by a biopsy needle guided by ultrasound through the body wall. The liver will regenerate any piece that has been removed, therefore liver biopsy is usually a low risk procedure in capable hands.

*The ranges for the test results listed above are dependent on the lab, the testing done and are relative. Some specialist allow for a much larger range before they diagnose “true” Liver Disease. After receiving your test results, please consult with an internal specialist and have them explain the results to you.

Treatment Options for Canine Liver Disease

January 3, 2009 by Lisa  
Filed under All Info, Treatments

Comments Off

The course of treatment required in a case of canine liver disease will depend upon the cause of the condition. For example, if trauma was the trigger, hospitalization while the dog recovers from the impact of the trauma may be all that is required. On the other hand, antibiotics may be needed if a bacterial infection is at the root of the disease. Furthermore, when liver disease is caused by another medical condition such as cancer or anemia, these additional medical circumstances will need to be taken into account.

In addition to certain medications, dietary adjustments and supplements can be very useful when attempting to treat canine liver disease. Dietary changes can include adjusting the amounts of proteins, vitamins, carbohydrates, fats, and minerals that a dog ingests. This will then ensure that the canine patient is receiving the nutrition it needs and will also help to decrease the stress and workload of the liver.  Furthermore, vitamin K can be helpful with respect to controlling bleeding disorders while vitamin E, as an antioxidant, helps to remove free radicals and to prevent continued oxidative damaged to the canine’s liver.

Certain homeopathic remedies can also be very helpful when treating canine liver disease. Natural herbs and substances such as burdock and greater celandine have properties that assist with the purification of blood, the stimulation of digestive enzymes, and the protection of the liver from toxic substances. Also, some such substances have anti-inflammatory and antibacterial properties.

Milk thistle is another natural ingredient that is known to be very effective in cases of canine liver disease. This natural substance acts as an antioxidant like vitamin E, stimulates production of new liver
cells, and helps to prevent certain toxins from attaching to the liver.

Thus, many natural substances and remedies can be very beneficial for dogs suffering from liver disease. However, it is always important to carry out any form of treatment under the supervision of a qualified veterinary doctor.

SPECIFIC TREATMENTS AND PROGNOSES

Portal Vascular Abnormalities

Fluids and Electrolytes – This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. Pets
that are severely ill from PSS should not be given anything orally initially.

Cleansing Enemas – Enema’s will decrease the bacterial count of the intestines, leading to less ammonia absorption.

Lactulose – Lactulose works in the large intestine to minimize the production of ammonia by bacteria. It does this by changing the pH and converting ammonia to a form that is not readily absorbed into the bloodstream. It also stimulates normal colon bacteria to absorb ammonia, which is then passed in the feces. Finally, it stimulates the intestines so that ammonia passes through faster, which means there is less time for absorption.

Antibiotics – These drugs are also administered, especially if mental depression is present. They minimize the bacteria count in the colon, thus reducing the amount of ammonia that is absorbed
from the intestines into the bloodstream. They work well with lactulose to decrease the ammonia level.

Dietary Modification – A diet that is restricted in protein may be beneficial because less ammonia is produced as a by-product of metabolism. This protein needs to be of high biological value, such as eggs and dairy products. Meat based proteins should be avoided since they can increase the chance of HE. Most of the caloric needs of a pet with PSS should be supplied with carbohydrates like rice and pasta. Higher fiber diets might also be helpful, as long as the dog or cat is not undernourished. They can act to minimize ammonia production and absorption in a manner that is similar to lactulose

Surgical – For many PSS cases surgery is the treatment of choice. The abnormal vessel that is shunting blood around the liver is identified and closed (ligated) to minimize blood flowing through it. When the abnormal blood vessel is ligated blood will now flow through the liver instead of around it. This is readily accomplished for solitary extrahepatic shunts. Intrahepatic shunts can be more difficult
to identify and ligate. Post surgical monitoring is important. If the pressure within the liver becomes too high due to the increased blood flow through the liver then the ligation on the shunting vessel(s) must be reduced or removed.

In some cases medical management must also be utilized to affect a cure. The final outcome of treatment depends on what age the PSS started, how long it has been present, and whether it is intrahepatic (worse prognosis) or extrahepatic in nature.

Long Term Monitoring – Pets on long term medical care need to be monitored carefully. Body weight, albumin, and total protein are watched to ensure adequate protein in the diet. Initially, these tests should be performed monthly, then every 3 months. In addition to the above tests, bile acids are monitored monthly, then every three months to assess the vitality of the liver. Blood ammonia levels are monitored monthly to assess effectiveness of treatment. When stable, ammonia levels can be monitored every 3 months.

Prognosis – Many pets with isolated extrahepatic shunts return to a normal life after surgery. There is no guarantee that surgery will correct the problem, especially those pets that develop the disease very early in life. Some of them will need medical management simultaneously. The prognosis for pets that are treated only medically varies.

Chronic Active Hepatitis

Fluids and Electrolytes – This corrects the dehydration that occurs with a poor appetite and supplies needed sodium, potassium, and chloride. This fluid is usually given intravenously (IV) at first. It can be given subcutaneously (SQ) at home after the initial dehydration is corrected. B-Complex vitamins are routinely added to the fluid bag. Care must be taken not to give excessive amounts of fluids, especially if they contain sodium, in pets with fluid buildup in the abdomen (ascites).

Treating the Cause (when known) – Antibiotics are used to control bacterial infections and drugs that are suspected of causing this disease are stopped. We tend to use antibiotics that have minimal need for liver metabolism in order to minimize their toxic effects.

Rest – The liver has ability to heal itself if the disease is not too advanced. Rest can be a big aid, along with proper nutrition.

Ascites Reduction – Sodium restriction helps minimize fluid buildup (ascites) in the abdomen. This can be accomplished using Hills K/D Prescription Diet. Diuretics like Lasix are also used to help pull this fluid out of the abdomen.

Dietary Modification – Using a diet that is restricted in protein may be beneficial because less ammonia is produced as a by-product of metabolism. This protein needs to be of high biological value, such as eggs and dairy products. Meat based proteins should be avoided since they can increase the chance of HE. Higher fiber diets might also be helpful, as long as the dog or cat is not undernourished. This is the same basic diets as for pets with PSS (see above).

A diseased liver needs calories, which sometimes need to be supplied with a feeding tube.

Ulcer Treatment – This will make pets more comfortable, more inclined to eat, and prevent bleeding in the stomach.

Liver Specific Drugs:

Corticosteroids – Cortisone is used if there is evidence that the immune system is implicated as a cause
of the liver problem.

Ursodiol – This drug replaces toxic bile acids with a type of bile that is less toxic.

Zinc Supplementation – Might help reduce the effects of copper toxicity.

Long Term Monitoring – CCHID monitoring is similar to PSS (see above). In addition, repeating a liver biopsy 6 months after initiating therapy used.

Infectious Canine Hepatitis

Like most viral diseases therapy is directed towards symptoms. When symptoms are severe enough, intravenous fluids are administered. Since clotting factors can be disrupted particular attention needs to be paid to bleeding problems. If bleeding problems are severe enough, a whole blood transfusion must be administered. Dogs that are comatose may need intravenous glucose.

Copper Toxicosis (Copper Storage Disease)

Treatment has two goals – Enhance excretion of excess copper, and minimize further absorption of copper from the intestines.

Chelating agents – Drugs like penicillamine bind with copper to allow easier excretion.

Zinc – Zinc will help minimize further copper absorption from the intestines.

Supportive Care – Similar to other liver diseases previously described.

Long Term Monitoring – Serum, enzymes, and bilirubin should be monitored at least every 6 months.

Cancer

Primary hepatic neoplasms are treated by removal of the affected liver lobe when possible. If multiple lobes are involved then surgery is usually not performed. Secondary hepatic neoplasms are treated with chemotherapy. The results vary, and depend on the duration, location, and degree of malignancy of the neoplasia.

The prognosis is poor for long term survival.

Supportive care that is similar to other liver diseases is also used in neoplasia.

**Information from this section was compiled from the following sources:

http://www.lbah.com/liver.htm

Preventative Maintenance

January 2, 2009 by Lisa  
Filed under All Info, Yearly Prevention

Comments Off

1. LISTEN TO YOUR INSTINCTS. You know your dog better than any vet or specialist. If there is something “not quite right”, encourage blood tests to see what is going on. The symptoms of canine liver disease are so subtle and can be mistaken for so many other things, ask for a liver panel test to rule it out.

2. Educate yourself about the signs/symptoms of canine liver disease so that you are able to recognize them if any are present in your dog.

3. Feed your dog a high-quality balanced diet with easily digestible protein (beef and fish are harder for dogs to digest), no animal by-products, fillers or allergens.

4. Know your dog’s normal body temperature and take it regularly and if/when they show behavior changes. Temperatures above 103F may be linked to internal infection and may be affecting the liver.

5. Know your dog’s eating and bathroom habits. If there are even slight changes that extend over a period of a week or so, seek out the advice of your veterinarian.

6. Do not allow dogs to roam freely where they can encounter animals or insects, standing water or poisonous plants.

7. Routinely vaccinate dogs for infectious canine hepatitis and leptospirosis.

8. Take your dog in for a yearly exam that should include blood, stool and urine samples in dogs 8 years of age or more. (Veterinarians will do these tests on dogs under the age of 8 as well.)

9. If tests are abnormal or presenting high range numbers, seek out the advice of an Small Animal Internal Medicine Specialist – your vet should be able to refer you to someone in your area.

10. Practice good dental hygiene for your dog. Brushing your dog’s teeth helps rid the gums and mouth of harmful bacteria that, if left unchecked, can spread to the heart, liver and other vital organs.

11. Avoid medications such as Cortisone, Rimadyl and Phenobarbital if at all possible. Also try to minimize exposure to flea and tick products, heartworm medication, anti-fungals, etc.

* If Rimadyl cannot be avoided:

A blood panel should be taken and analyzed prior to initiating Rimadyl therapy.
Every 6 months this panel should be repeated.

* If Phenobarbital cannot be avoided:

Have a chemistry panel with the liver enzymes ALT, GGT and alkaline phosphate
done every 3 to 4 months.

If all three liver enzymes are severely elevated (more than just a few points
above normal) then you should do a urine bile acid test or a pre- and post-meal
bile acid test to see what kind of damage has been actually done to the liver so you
can change the diet to the liver cleansing diet and/or reduce the Phenobarbital.

Monitor Phenobarbital levels every 6 months, more frequently if you do not have
seizure control or if there are any signs of toxicity like ataxia, wobbliness, and hind end
weakness (not after a seizure).