Claire E Whitehead

Blind Faith? Or sheer stupidity?.?!
Claire E Whitehead BVM&S MS FHEA MRCVS
Diplomate ACVIM (Large Animal)
Camelid Veterinary Services
www.ukalpacavet.com

You?re probably starting off reading this piece wondering what on earth it is going to be about?! Well, if you?ve started reading it, then at least my title has worked in terms of enticing readership. What I actually want to achieve in this article is try to make you more critical of where you acquire your information from for the benefit of your animals. I have now been working with South American Camelids and their owners almost exclusively for 11 years. In that time I have heard all sorts of snippets of advice that people have received and potentially put into practice. Some of these gems are excellent and I would agree with them, while some are complete rubbish and better assigned to the appropriate receptacle? While some of the less successful ?gems? may be pointless, or at best do no harm, sometimes they can have disastrous consequences. So, I would like you as owners and breeders to really critically evaluate the advice that you receive from the various people or places from which you seek it and ask yourself if it can really be right? Don?t just take somebody?s word for it ? ask around to see what others think or if anyone else is doing the same thing. If you?re not sure or something sounds a bit kooky, please always find someone to ask who may be better placed to provide objective advice.
One of the best sources for animal health advice is always your vet. Now I?m well aware that people have varying relationships with their vet and experiences have not always been good. However, when it comes to animal health matters, they are the go-to place of choice for advice. That is for sick animals, chronic problems and herd health issues for example. The number of times I have heard owners say that they?ve asked everyone but their vet for advice and have spent months messing around with all sorts of suggested therapies without bothering to ask the one person that might actually be in a position to help them. On behalf of my colleagues in the veterinary profession, you should realise that none of us (with the exception of some more recent graduates) will have received any formal training on camelids at vet school. What vets have learned about camelids, they have mostly learned since graduating through field experience or from attending further education courses. Having completed a three year residency in large animal internal medicine and having focussed on camelids 95% of the time (by choice), I am definitely the exception rather than the rule! Vets graduate realising that they will continue to learn as they advance through their careers: they also graduate as what is called ?omnicompetent?, meaning that they are competent across the range of commonly-seen domestic animals. So, if they come across a species with which they are unfamiliar, they will work from basic principles and where they find gaps in their knowledge, they will seek to fill them by researching from literature or by consulting with someone like me who specialises in a particular area ? they may also choose to refer a case if they feel completely out of their depth or a case requires further expertise or diagnostic/therapeutic capability that their own practice is unable to offer. This is standard practice: if you don?t feel that your vet is providing the service that you require for your animals, or isn?t prepared to seek advice on your behalf from elsewhere, consider finding an alternative vet. Most of the vets that I consult with are more than happy to ask for advice when they need it ? at the end of the day, they put animal welfare ahead of everything else and have the best interests of their patients and clients at heart. It is rare that you?ll find a vet for whom the bottom line is of more concern.
Evidence-based Medicine
In veterinary medicine ? and human medicine for that matter ? a buzz-phrase that is frequently used now is ?evidence-based medicine?. Evidence based medicine has been defined as ?the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients?.1 There are various levels of evidence. The superior level, or the one with the strongest evidence, requires evidence from multiple research studies of blinded placebo-controlled clinical trials with random treatment allocation (ie treatment not determined by the clinician in order to remove bias). This is obviously more easily achieved where substantial financial backing exists for clinical research in the realm of human medicine, while it is rarely achieved for veterinary species, particularly camelids.
A lesser level of evidence would be achieved by studies that include statistical evaluation of data from clinical cases and some of these are available for camelids. Also at the bottom end of the evidence scale would be expert opinion and case reports (published in peer-reviewed journals). There is also plenty of this available for camelids, and new information is becoming available all the time, so it?s not sensible to assume that something that used to be correct advice is always going to remain so. From a practical perspective, no drugs are licensed for use in South American Camelids in the UK: therefore, when I want to decide on a particular drug to use, I will look for evidence of pharmacokinetics studies showing that a particular drug is absorbed effectively at the dosage and route listed and that it should reach therapeutic concentrations in camelids. Some groups of drugs, such as non-steroidal anti-inflammatory drugs (or NSAIDs ? eg Finadyne) vary massively from species to species in terms of efficacy, including route of administration used, and also in terms of potential adverse side-effects. For example, we know that flunixin (a common trade name for which is Finadyne) should be dosed similarly to the dose for horses and half that for cattle, and that is should be given only by non-oral means or it will be uneffective. Phenylbutazone (?Bute?), which is commonly used for horses with arthritis and many other problems, is useless given to camelids as it has a very short half-life: it is also banned in food-producing animals because residues remain in the meat for a very long time ? which is one of the reasons people have been concerned about unauthorised horsemeat entering the food chain lately?
One of the most annoying things from my perspective is a ?works-for-me!? attitude for something for which you can?t easily visualise an actual response. For example, using an antibiotic for a particular complaint which might have actually got better by itself. A classic example of this is the use of trimethoprim sulpha granules (eg Duphatrim or Equitrim in the UK) in alpacas for treatment of infections: there are actually four studies that show the oral TMP-S is not absorbed in alpacas and all that you are likely achieve is disruption of the normal gut flora. If cases improve on this therapy alone, it is likely that they would have improved anyway. Another example would be administration of oral plasma to newborn crias ?to prevent failure of passive transfer?. Crias have the first 24 hours of life to absorb antibodies from the colostrum to protect them from bugs present in their environment: the colostrum is extremely rich in antibodies while plasma is massively diluted. Therefore, by administering plasma orally to crias and taking up space in their stomachs, you are actually reducing their ability to achieve sufficient antibody intake ? a typical feed volume will be 60-90ml every 2 hours during the first 24 hours of life. You are therefore better off ensuring adequate intake of actual fresh colostrum (nursing) during the first 24 hours and if colostrum isn?t available for whatever reason, or intake is insufficient, addressing that failure of passive transfer by administering your plasma intravenously ? it will have taken reasonable expense to collect and process it, you might as well ensure that its use is worthwhile!
If you (or your vet) are going to extrapolate treatment plans from other species, and that is a viable approach because there is not always going to be a recommended treatment plan for every situation, then the first thing to do is look at the potential that a particular drug might be harmful. If the data sheet for a particular drug says that it is toxic in some species, there is a good chance that that drug is not the ideal choice in camelids where no data for its use exists. Therefore pick a safer alternative. Then advice from other clinicians working more frequently with camelids could be sought. For example, your vet might call someone like me, or potentially ask a question from the various email discussion groups available for vets. Lama_med is one such group, based in the US but with global participation, and is quite active among both practitioners and academicians. The British Veterinary Camelid Society also runs its own discussion group for members. In many cases, someone somewhere will have tried something and may be able to offer advice, even if it?s not been written up in a journal article or textbook.
Parasite Control Strategies
One question that I get asked frequently from owners is ?What should I use for worming alpacas?? I think that very often they think that there is an answer that can be fitted into two or three lines of email. Of course this is just not the case. Underpinning the answer to this question lie the basics of camelid husbandry skills. Every worming programme should be tailored specifically to the individual farm: no one policy is going to be appropriate for every situation. Many new owners fall into the trap of taking someone else?s worming strategy and just using it as their own which is not necessarily going to be appropriate. They can be used as a guide, and that is how the breeders probably want them viewed (as long as they include monitoring), but blindly following parasite control programmes without proper monitoring and based on another farm?s protocol may lull the owner into a false sense of security. You may find yourself using a drug to which the parasites are resistant (you wouldn?t know because you?re not dosing animals with known burdens and retesting to check on efficacy), using a drug that is not effective against the particular parasite you have in your animals, or even worming for no reason when you actually don?t need to dose in any case! It should be remembered that the costs associated with treating moribund animals or the death of a prize alpaca are far higher than the costs of a good monitoring program. This includes faecal testing. Faecal testing should not be the area you try to save money?
A parasite control strategy should be based on a number of factors:
1. The number of alpacas kept as well as their relative ages (certain age groups are more susceptible to parasite infestations)
2. Stocking density (how many alpacas are kept on how many acres of pasture)
3. The type of pasture available
4. What the weather is doing? (the horribly wet summer of 2012 resulted in very bad Haemonchus infestations on many farms, and earlier in the year than we would typically see it in alpacas)
5. What worm eggs are present in faecal screening tests (using appropriate tests ? preferably the Modified Stolls test or the VLA?s modified McMasters test)
6. Results of regular (ie monthly) body condition scoring
7. Whether the pasture is cleaned regularly (at least every 2-3 days)
8. Quarantine of new (or relocated) stock.
If you need help developing a parasite control strategy, chat to your regular vet first. I am also very happy to help in developing parasite control strategies appropriate to your own farm and offer the Modified Stolls faecal testing (please refer to my website at www.ukalpacavet.com).
Skin Problems
One of the most frequent complaints among alpaca owners is skin problems. Unfortunately many different ideas exist for how to treat the various skin problems that alpacas get, the most frequent of which is mange. Skin scrapes to determine the particular mite that is involved are useful in directing appropriate therapy: they are not always helpful though and that can put people off performing them. However, if you do see the mites, it helps enormously in choosing the correct treatment plan, and what the implications might be for the rest of the herd. Sarcoptes mites produce a mange that tends to be more aggressive and contagious, while the mites do not survive a long time on pasture: Chorioptes mites produce a more chronic (long-term) skin condition that worsens progressively and these mites may survive for up to 90 days off the host resulting in almost continual pasture contamination unless it is rested.
Unfortunately the often-used injection course of avermectin drugs (eg ivermectin, doramectin), although easy, is rarely the solution to mange. It is very helpful in sarcoptic mange, but ineffective in chorioptic mange ? the more common type - and does absolutely nothing to address the skin problem! For this, aggressive topical treatment is required, using regular bathing (usually 3 times a week) and mite-killing treatment. The bathing is the key part of treatment and the part that requires the most effort: depending on the particular shampoo used, this not only addresses the crusting, scaling and hypersensitivity of the skin leading to an improvement in overall appearance, but it will be soothing for the affected animal. Not too long ago a vet contacted me for advice about a case of apparently chorioptic mange that the owners had been trying to sort out for over five years. I passed on my treatment protocol and he was happy to report to me a couple of months later that the owner was having good success with the plan and was seeing significant improvement for the first time.
Other various ointments and ?salves? have been quoted to me by others over the years, but these are generally not curative. ?Witches? Brew? is an oft-quoted potion? Please do not go off searching for it. It comprises mineral oil, ivermectin, DMSO and gentamicin: it?s mixed up and smeared all over the affected areas. I have a BIG problem with this potion and I?ll tell you why. DMSO is a substance that apparently helps things cross the skin and potentially has some analgesic effects (maybe it stops some of the itching): however, it is pretty toxic stuff. The most commonly reported side effects include headaches and itching of the skin but also severe allergic reactions have been reported including death in humans. It is also neurotoxic. Probably not the sort of thing you want smearing over the skin of your alpacas? Gentamicin is an antibiotic that is very specific for Gram negative bacteria: it is potentially of value in treating sepsis, usually in combination with penicillin which potentiates its effects ? I use it commonly in crias with failure of passive transfer and subsequent sepsis, in which Gram negative bugs are often involved. The skin is covered in mostly Gram positive bacteria, so I see no indication for its use here. All it may achieve is an overgrowth of other bacteria and potentially yeasts or fungi, and smearing it over the skin is a massively irresponsible use of an antibiotic for a non-bacterial infection. We need to be seriously concerned about the misuse of antibiotics because of the potential for development of resistant strains of bacteria. Only the other day, the Chief Medical Officer for England warned that in 20 years time, people may die from routine operations in hospital because of the development of antibiotic resistant bacteria.2
Vitamin D Supplementation
Most keepers of camelids are aware of the susceptibility of camelids to vitamin D deficiency. This is largely a consequence of removing animals from an area of the world where they are adapted to receiving large doses of ultraviolet radiation at equatorial latitudes and high altitude and taking them to sea level and non-equatorial latitudes, in our case from 50 degrees North. In these areas, it is not possible for them to make enough vitamin D in the skin due to the action of UV light, and rickets is the clinical result in growing crias. Adults may also be affected from low vitamin D concentrations in the form of immunosuppression mostly. Vitamin D supplementation through the winter months protects crias from development of rickets and also supports the immune system: in adults it may help the immune system too, but also in females can improve lactational performance and foetal growth for example.
A study out of Australia showed that a dose of 1000 IU vitamin D per kg bodyweight (Duphafral ADE Forte, Fort Dodge, subcutaneous administration) maintained vitamin D concentrations of crias at adequate concentrations >50nmol/L for about 7 weeks while a dose of 2000 IU/kg lasted between 7 and 11 weeks.3 In adult female alpacas, the same doses were shown to increase vitamin D concentrations significantly above untreated females for 16 weeks. Therefore treatment recommendations of 1000-2000 IU/kg of vitamin D given every 2 months for growing animals, and perhaps once or twice to adults during the winter should be appropriate. Darker-fleeced adults may require dosing every 3 months during the winter since pigmentation of the skin makes these alpacas more susceptible to vitamin D deficiency. [In the same study mentioned above, the vitamin D concentrations of the darker adult females had dropped below 50nmol/L at 16 weeks, but were still fine at 11 weeks.3]
Lately I have heard about massive doses of vitamin D being recommended by owners for prevention of rickets. Elizabeth Paul was advocating doses of between 7,500-18,000 IU/kg for adults in a recent issue of Alpaca World Magazine (Autumn 2012) which she ?scaled down a bit for crias?. She justified these doses on the basis that dairy cows receive doses up to 20,000 IU/kg just prior to calving ? although this is actually to prevent milk fever (not rickets) and the practice was discontinued since doses used were found to be very close to the doses causing irreversible soft tissue mineralisation in cattle and they had to be given at precisely the right time to have the right effect. These doses are entirely unnecessary based on the properly conducted research that has been carried out and published in peer reviewed literature, as described above. During my Masters study, I supplemented adult female alpacas with vitamin D at 2000 IU/kg prior to parturition and, when they gave birth between 3-13 weeks later during the summer, their vitamin D concentrations were a mean of over 500 nmol/L: when I repeated the study in winter, their mean vitamin D concentrations were over 150 nmol/L at 1-2 months after dosing. In humans, concentrations of <25 nmol/L are considered deficient. Clinical signs of rickets are typical in crias with vitamin D concentrations of <15 nmol/L. Therefore, concentrations induced by vitamin D supplementation at 2000 IU/kg are perfectly adequate for alpacas: dosing above this is completely unnecessary and potentially harmful.
Vitamin D toxicity has been documented in alpacas. The only reported cases so far in the literature were crias that were administered 3750 IU/kg/day for 7 days and nearly 13000 IU/kg/day for 5 days. This resulted in widespread soft tissue mineralisation due to excessive calcium ? the main clinical problem was irreversible kidney failure as a result. Both crias died despite considerable efforts on the part of the hospital clinicians that admitted them, including peritoneal dialysis in one. The actual safe upper limit for dosing with vitamin D is unknown, and in these two cases, it is believed that it was a combination of the high total dose and repeated dosing that was critical for development of toxicity. They suggested that accumulation of time may be important.
Vitamin D supplementation actually suppresses the normal hormonal control of calcium and phosphorus by suppressing conversion of vitamin D to active vitamin D in the kidneys: in cattle, that can actually result in rebound milk fever following calving because it takes a while for the normal stimulation of active vitamin D to reboot once the supplemented vitamin D has been cleared. It might therefore be suggested that oversupplementation at a level that is not actually toxic can result in apparent dependency on vitamin D. In the absence of hard evidence about the actual safe upper limit of vitamin D supplementation by injectable products, it seems foolhardy to dose at levels massively above those that have been shown to be effective at increasing vitamin D concentrations to adequate levels. I have heard comments coming out of Australia that suggest that some of the products that they are now using are ?less effective?. One of the products used in Australia is Hipravit ADE Forte (Hipra). Since Hipravit is not available legally in the UK, and Duphafral ADE Forte is (via your vet), it would seem that we still have a product here in the UK that actually does work? Hideject (Bomac Laboratories, NZ) is another product that I recently came across in Norway: I am unaware as to whether it is circulating in the UK. This product contains 500,000 IU/ml of vitamin D (compared with 50,000 IU/ml in Duphafral ADE). I consider this a dangerous product since dosing correctly is very difficult: an adult weighing 75kg would require a dose of only 0.3ml using even the higher dose of 2000 IU/kg. A cria weighing 10kg, would need only 0.04ml which is quite difficult to dose accurately.
It would be appropriate at this point to point out that it is illegal to import drugs into the UK without a license from the Veterinary Medicines Directorate. This covers injectable vitamin ADE products (oral ADE pastes are not covered). It is also illegal to sell these products unless you are a vet or licensed wholesaler (who sell to vets) ? the legislation exists because the unregulated purchase and use of potentially harmful drugs can be dangerous. New legislation is set to come into force later this year which will allow the VMD to prosecute not only those selling drugs illegally but also those benefitting from their sale. I am aware of owners using multiple avenues for purchase of injectable vitamin D. Therefore, if you are unaware of this legislation, please take note. You can obtain Duphafral ADE Forte via your vet in the UK: the license has expired in the UK (and will not be renewed) so they have to fill out a Special Import Certificate (this is free) and then purchase either small quantities (<10 bottles) from veterinary wholesalers in the UK, or larger quantities can be purchased from suppliers in Ireland.
Indiscriminate use of Antibiotics
A last area of concern governs inappropriate use of antibiotics. I have already written about this topic in a previous issue of Alpaca World Magazine. However, I feel that this is a topic that requires repeated airing. I still hear from vets about alpacas that have been owner-treated prior to calling out the vet: they may have been given one dose of one antibiotic, then another, with no apparent success, and it?s only when the drug options in the cupboard run out that the vet is called. Some of these bottles may have been used for a previous case and long past the 28 day ?open bottle? period that it is recommended to use them within. Firstly, single doses of antibiotic are unlikely to be useful and it generally takes 48 hours of use at appropriate doses and intervals to see a visible improvement in white cell count and to assess clinical response properly. Secondly, antibiotics should only be given when there is a clinical suspicion of a bacterial infection ? your vet is trained to determine this, while owners are (generally) not. You could be wasting time treating the alpaca for something that it doesn?t have while failing to diagnose a clinical problem that it does have: this time wasting may mean the difference between survival and non-survival. If you wait until the alpaca is practically dead to call the vet, you can?t expect the vet to work miracles on your behalf. Thirdly, and perhaps most importantly, inappropriate use of antibiotics leads to the development of microbial resistance to antibiotics. This will result in fewer drugs being available that may be effective, for both animals and humans. Furthermore, the legislators may decide that people are not to be trusted using antibiotics in animals and ban more and more drugs from use in animals leaving us with few treatment options, not to mention a decidedly depressing veterinary career! This has already happened in some Scandinavian countries.
Summary
Within this article, I hoped to stimulate some thought in terms of the accuracy of various sources of information and to address some of the more common areas of misinformation that I have come across within the camelid industry over a number of years. It?s possible that I am preaching to the converted here, but if you have found yourself using some of the treatments mentioned and may now think twice about your own practices, then I hope that my comments have been helpful.
References
1. Sackett DL et al. Evidence based medicine: what it is and what it isn?t. BMJ 1996;312:71-2.
2. BBC News website, 11/3/13. Antibiotics resistance ?as big a risk as terrorism? ? medical chief.
3. Judson GJ and Feakes A. Vitamin D doses for alpacas (Lama pacos). Aust Vet J 1999;77:310-315.
4. Goff JP. The monitoring, prevention, and treatment of milk fever and subclinical hypocalcemia in dairy cows. The Veterinary Journal 2008;176:50-57.