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Dr. Matt Gurney: How Librela has Changed the Way European Vets Manage OA Pain in Dogs
494 Plays11 months ago
In our last episode, we introduced a new class of drugs that have recently hit the veterinary market for treating pain associated with osteoarthritis: nerve growth factor monoclonal antibody therapy. Just over one year ago, Librela (bedinvetmab) entered the North American veterinary market, shaking up our traditional pharmaceutical approach to osteoarthritis pain management in dogs. However, Librela has been available in the United Kingdom and Europe for years Zoetis, the pharmaceutical manufacturer and distributor of Librela, reports that millions of doses of Librela have been administered to dogs since its introduction in 2021, with veterinarians rating their overall satisfaction with the product at about an 8 out of 10.
What can veterinarians in America learn from the experience of European vets about effectively incorporating this novel drug into an overall pain management plan for dogs with osteoarthritis?
Host Dr. Bonnie Gatson chats with UK veterinary anesthesiologist and internationally recognized expert on companion animal pain management, Dr. Matt Gurney. Dr. Gurney is past president of the European College of Veterinary Anesthesia & Analgesia and now works as an anesthesiologist and pain management expert at Eastcott Referrals in the UK. He is also co-founder of Zero Pain Philosophy, an educational resource for veterinary professionals around the globe with a mission to help achieve excellence in veterinary pain management. Together, they discuss how Librela has changed the way European vets manage osteoarthritis pain in dogs, clinical pearls on using Librela in practice, and side effects observed by European vets compared to anecdotal adverse events that have been reported out of the United States.
Resources mentioned in this episode:
The Canine Brief Pain Inventory for dogs
The European and American data sheets on Librela (bedinvetmab)
A comprehensive review of nerve growth factor antibody therapy for the treatment of osteoarthritis pain in humans by Dr. Schmelz
If a patient experiences an adverse event associated with use of Librela, please contact product support at Zoetis at 1-888-963-8471.
Learn more about achieving analgesic excellence at your clinic with Dr. Gurney’s Zero Pain Philosophy. You can check out Zero Pain Philosophy Podcast, wherever you get your podcasts.
Become a member of NAVAS for access to more anesthesia and analgesia educational and RACE-approved CE content.
Our mission: Reduce mortality and morbidity in veterinary patients undergoing sedation, anesthesia, and analgesia through high-quality, peer-reviewed education.
Thank you to our sponsor, Dechra - learn more about the pharmaceutical products Dechra has to offer veterinary professionals, such as Zenalpha.
All opinions stated by the host and their guests are theirs alone and do not represent the thoughts or opinions of any corporation, university, or other business or governmental entity.
Special thanks to Chris Webster, Saul Jimenez, and producer Maria Bridges for making this podcast a reality.
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Transcript
Introduction to the Podcast and NAVAS
00:00:06
Speaker
Hello, gas pastors, and welcome back to another episode of the North American Veterinary Anesthesia Society podcast, sponsored by DECRA.
00:00:15
Speaker
I am your host and proud fellow gas passer, Dr. Bonnie Gatson. For our first bit of housekeeping, thank you to all that attended the NAVAS virtual spring symposium last month. We hope that it was a beneficial educational experience for you. And if you missed out, fear not.
Annual Meeting Announcement
00:00:33
Speaker
You can find tons of ongoing continual education opportunities at the NAVAS website, www.mynavas.org.
00:00:43
Speaker
Also, the American College of Veterinary Anesthesia and Analgesia will be hosting its first ever solo annual meeting in Denver from September 25th to 27th later this year. NAVAS members get a small discount on registration and I will be there and I hope to see some of you there too. Learn more about the upcoming annual meeting at acva.org.
Podcast Mission
00:01:07
Speaker
As I always state at the beginning of each episode, our mission with this podcast is to bring you, our listeners, the most up-to-date information on veterinary anesthesia and pain management to improve your ability to provide top-notch quality care to your patients.
Monoclonal Antibodies for Pain Relief
00:01:24
Speaker
And speaking of current updates in veterinary anesthesia and analgesia, there is a new class of medications sweeping the market promising to provide pain relief to animals suffering from the debilitating discomfort of osteoarthritis.
00:01:39
Speaker
Through a single monthly injection, these medications work as monoclonal antibodies against nerve growth factor, one of the many inflammatory mediators involved in the upregulation of pain sensitization that occurs from chronic degenerative joint disease.
00:01:55
Speaker
In our last episode, we featured one of these medications, Salencia, that has been on the market in the US for a little over two years at this point, that is licensed to combat pain associated with osteoarthritis in cats. In this episode, we are gonna focus on osteoarthritis management in dogs.
00:02:14
Speaker
librella or bedded vetmab was approved by the FDA and released about one year ago and with its introduction has revolutionized the way veterinarians can manage pain associated with degenerative joint disease in dogs. That being said, given how new and innovative this drug is, librella doesn't come without its controversies.
00:02:38
Speaker
Although Librella may be new in North America, it has been available to veterinarians in the UK and Europe for several years now. And lucky for us Americans, there is a lot we can learn from the experiences of vets across the pond using Librella for osteoarthritis pain management.
Guest Introduction: Dr. Matt Gurney
00:02:56
Speaker
and lucky for us here on the NavS podcast, we will be speaking to an individual who is incredibly knowledgeable and equally passionate about pain management, who hails from the UK and has integrated librella into his pain management practice over the past several years.
00:03:13
Speaker
In this episode all about librella we will be speaking with dr. Matt gurney. Dr. gurney is an internationally respected british anesthesiologist who is past president of the european college of veterinary anesthesia and analgesia
00:03:28
Speaker
and now works at Eastcott Referrals in the UK. He is also co-founder of Zero Pain Philosophy, which is a wonderful educational resource for veterinary professionals around the globe to help achieve excellence in veterinary pain management.
Zero Pain Philosophy Resource
00:03:42
Speaker
To find out more about Dr. Gurney and Zero Pain Philosophy, including access to podcasts, webinars, and even nerve block videos, we recommend you check out zeropainphilosophy.com.
00:03:56
Speaker
But not before you tune into this incredibly informative conversation all about Librella, where we talk about how Dr. Gurney has integrated this drug into his pain management practice over the past several years, side effects that he's seen with this drug and how he's managed those side effects.
00:04:15
Speaker
which types of patients he chooses to use Librella as part of an integrative pain management approach to osteoarthritis, and any general advice he has for vets here in America that are just now getting to know this drug.
Focus on Librella
00:04:28
Speaker
So let's learn all about Librella right here on the NavAss Podcast.
00:04:37
Speaker
Thank you so much for being our guest today on the NavAss Podcast. Can you start by introducing yourself and briefly describing your past training and your current role? Yeah. Hi, everyone. Thanks for the invitation. It's great to be here. My name is Dr. Matt Gurney. I'm a veterinary specialist in anesthesia and pain management.
00:04:59
Speaker
And I currently work in a hospital in the UK called Eastcott that referrals and I run zero pain philosophy, which is an educational resource for that professionals. Can you tell me a little bit about what drew you into
Conclusion and Closing Remarks
00:05:14
Speaker
studying anesthesia in the first place?
00:05:16
Speaker
When I first started working as a vet, I went into mixed practice and I spent two and a half years enjoying everything that mixed practice had to throw at me. So in the morning I'd be consulting, dealing with cats and dogs, and then going out and seeing farm animals and horses, being on call, all of the usual stuff that comes with that.
00:05:38
Speaker
I really enjoyed the mixed element of my role, but I found it really difficult to be good at everything and you can't be good at everything. And I thought, right, okay, I want to retain that mixed element. How do I do that? And I thought, well, anesthesia, ophthalmology, maybe cardiology. A role came available. A residency was advertised at the University of Liverpool, which is where I graduated from. And I applied for the residency and I got the residency. So that's kind
00:06:07
Speaker
kind of how it happened. It was quite fortuitous how it happened. And I went back to Liverpool loving equine work and loving equine anesthesia. And my residency was 50% equine, 50% small animal. And then by the end of the three years, I was really interested in pain management and particularly small animal pain management. And that's where I am nearly 20 years later. So here we are.
00:06:32
Speaker
So you mentioned that you were mostly drawn to pain management aspect of the anesthesia slash analgesia portion of your residency, and you currently are a founder of zero pain philosophy. So what drew you to having an interest in pain management?
00:06:52
Speaker
I think like a lot of us, you get inspired by certain people that you work with, and I was really inspired by somebody I worked with during my residency called Izzy If. Izzy works at the University of Bern now. Izzy ran the pain clinic at Liverpool, and she runs a pain clinic in Bern.
00:07:10
Speaker
And that just kind of piques my interest. And Izzy had been to the IS conference, the International Association for the Study of Pain, came back from that conference really enthused and got the group of residents together. And we had a series of seminars where we talked about pain and pain physiology. And I just found it so interesting. And I think what still fascinates me about pain and pain research is
00:07:39
Speaker
It's really interesting. There's so much out there. You never quite feel like you know everything. From a lifelong learning point of view, I'm definitely still learning about pain management. Yeah, there's always something to learn about pain management. That's what's really cool about the topic. I think that is amazing. I did my residency at the University of Florida and at the time there wasn't a pain management clinic there.
00:08:04
Speaker
And luckily we had really wonderful mentors like Sheila Robertson, who is, I would say almost like the, I don't know, like the grandmother of pain and cats. She's really has done some incredible research on that front. And that's really just jump-started a lot of knowledge that has come forward recently about
00:08:25
Speaker
managing pain and understanding pain in cats. So I can totally understand when you're saying you get inspired by the people that you are around. So that's really wonderful that that is now translated to something that has become an educational resource for veterinarians in pain management.
00:08:41
Speaker
We're going to jump now to our main topic of conversation today, which is going to be about Librella, which is a drug that has been around in the United States for about a year now. But I was very interested in speaking with you because Librella has now been around in Europe for several years now.
00:09:00
Speaker
And with it being a new drug, there's a lot of questions and even maybe some controversy about it. So we're going to jump into everything about this drug that we can possibly manage in a 60 minute episode. We're going to start with understanding Librella as far as the European perspective is concerned. Do you know when this drug was introduced into European markets?
00:09:22
Speaker
Yeah, we first heard about Labralla in February 2020, and I first had access to the product around about April, May 2020. I remember that because the first patient I treated, we took a photo of that patient, and I have pictures of us wearing gloves, masks, gowns, because we were right at the start of COVID. Nobody knew what they were doing.
00:09:45
Speaker
from a COVID perspective. And all of a sudden, we have this new products and these patients that were coming to us once a month for their monthly injections of Librella. Yes. Yeah. So we've had it approximately four years. There was a bit of a blip. Once the product was released, there was a manufacturing issue. So we didn't have access to the product for new patients for a couple of months, but the blip went away and we were in full force with using it now.
00:10:13
Speaker
So in the US, the Federal Drug Administration is responsible for ensuring that clinical drug safety trials are conducted prior to release of a medication to ensure that the drug is labeled correctly, essentially. Is there an equivalent European administration that inspects newly developed pharmaceutical agents to ensure their safety prior to release?
00:10:37
Speaker
In the UK and Europe, we have the European Medicines Agency, and despite the fact that the UK has left the European Union now, that agency still applies. I don't know what will happen with future politics, but who knows? The European Medicines Agency is our equivalent of the FDA.
00:10:57
Speaker
Interestingly, Liberale got its license through the European Medicines Agency, and then the FDA requires some further studies. If you look at the licensing papers, there's a study from Corral et al, which I think was published in 2021.
00:11:17
Speaker
And then there's a further study in 2023 based on the further questions that the FDA demanded. So sometimes that works both ways. So a drug will be approved in Europe, but then the FDA will want more information. And vice versa, a drug will be approved in the States by the FDA and then the European's Medicines Agency will want more information. And I think that's where. So if you look at the galley print label,
00:11:43
Speaker
the labeling indication is different between the states and between Europe because of those demands from the regulatory agencies. Yeah. Yeah. I always find that to be super interesting how the labeling for a single, like a same drug can be so different in like various different countries. In the US, liberal is labeled for the control of pain associated with osteoarthritis in dogs.
00:12:08
Speaker
Is there a similar labeling for European or UK markets or is there a different label for you guys?
00:12:15
Speaker
Yeah, that is the label in the UK. The pain associated with arthritis, I think, are the exact words. Again, you can see a variation with different products. So again, using the example of Galliprant, in Europe, the label says for mild to moderate pain, because in the licensing studies, there were no dogs in the severe pain category.
00:12:38
Speaker
The librela license doesn't say mild, moderate or severe, but when you talk to zoetis, and when you indeed look at the papers and look at the patients recruited into that study, they did fall into those different categories, so mild, moderate and severe, with their arthritis certainly in the European study. And I'm sure that's the same with Michael's paper from the US.
00:13:01
Speaker
Since LaBrola is a drug that's developed for the treatment of canine osteoarthritis, let's start just by talking about degenerative joint disease in dogs. What is the physiologic process that occurs to create pain associated with osteoarthritis?
00:13:17
Speaker
I think the easiest way to explain it is thinking about tissue damage that you have associated with osteoarthritis. So we have osteophyte formation, we have cartilage damage, you have exposure of subchondral bone, and remembering that
00:13:36
Speaker
The cartilage is typically anural, but abnormal cartilage can develop new neuronal growth. So you have that difference between cartilage being a shock absorber to damage cartilage actually playing a role in pain sensation.
00:13:55
Speaker
We've also got a thickening of that subchondral bone. We've got decreased in quality of the joint fluid. There are a whole host of pathological changes, all of which are triggering inflammatory mediators. It's the inflammatory mediators that are activating the nociceptors or sensitizing the nociceptors and kicking them into action, essentially.
00:14:19
Speaker
We're really familiar with the prostaglandins because we know so much about non-steroidals. They've been around for ages. We understand the pathophysiology by which the pathophysiology they work on. So we're familiar with the concept of inflammatory mediators, sensitizing those receptors.
00:14:36
Speaker
with the inflammatory mediator's nerve growth factor, and that release an activation of nerve growth factor sensitizes the nociceptor. Of course, we're also seeing that activation of prostaglandins as well.
00:14:54
Speaker
You may have heard people refer to the term, a soup of inflammatory mediators, axing on the nociceptors. Prostaglandins is just one of those inflammatory mediators. Nerve growth factors is another one of those inflammatory mediators. There are a whole host of other inflammatory mediators. Essentially, the common outcome there is they are activating or sensitizing those nociceptors.
00:15:17
Speaker
So we're going to get back a little bit into how the umbrella works essentially, which you've already hinted at. But before we get to that, do we know what portion of the canine population is suffering from osteoarthritis?
00:15:32
Speaker
That's a really interesting question. I think one that has advanced in recent years, if we look back at typical references, I think a lot of us are familiar with the number of 20%. And I think more recently, that number has been re-estimated at between 40 to 50% of the population.
00:15:55
Speaker
And that's thinking about the general population overall. There's been some more work recently looking at osteoarthritis in younger dogs. And we typically think of this as a disease of old dogs. Okay, I know we recognize hip dysplasia, we recognize elbow dysplasia. Those are developmental conditions that will at some point lead to osteoarthritis.
00:16:18
Speaker
There's some interesting work from North Carolina State University a couple of years back that looked at dogs between eight months of age and four years of age and they showed that approximately 23% of those dogs have both radiographic and clinical evidence of pain.
00:16:35
Speaker
which i think is quite a surprising number i'm sure if you haven't heard that number yet i think people listening to this will think well 23% of young dogs that's a really high number and you can therefore understand why in the general population when you add in all those older dogs it probably is 40 to 50% in the general population so more than definitely more than we think.
00:16:57
Speaker
Has there been any studies looking at weight or breed as a factor of whether or not certain breeds or certain sized dogs, essentially, are more prone to osteoarthritis, or has that not been done before? The one study that springs to mind is a study in laboratory. I think they were Labrador Retrievers.
00:17:18
Speaker
and they looked at weight control in those dogs, and they had two groups. One group that was fed a restricted ration, and one group that was fed ad libitum, and the dogs that were fed ad libitum, of course, their body weight increased, their body condition score increased, and those dogs were more likely to be suffering from osteoarthritis. So, yes, weight management is key. Is it a coincidence that there's a Labrador Retriever? I'm not quite sure.
00:17:48
Speaker
Of course, if you wanted a study where you had to feed dogs ad libitum, you would put labs in there.
00:17:59
Speaker
I think that if you were to think about like a general poster child for a dog with osteoarthritis, you would think of like an older, slightly overweight lab. So I was wondering if there are any studies looking at, I mean, we know, as you mentioned, there's a study looking at young dogs where there's about a 20% prevalence of osteoarthritis in the younger dog population. Is that influenced at all by breeds of dogs?
00:18:26
Speaker
In that study, there were approximately, I'm going to say approximately a hundred dogs in that study, and they were all sorts of different breeds. They were staff pets from people that worked at North Carolina State. So they were a mix of breeds. I can't remember off the top of my head exactly what that mix was. I think that's really powerful though, because it really shows that there was an interesting study that was done not too long ago about
00:18:56
Speaker
veterinarian's perspective on pain associated with the breed of dog. And I think it's really important to try to realize that any breed can really experience osteoarthritis and so to be more cognizant about really looking for signs of osteoarthritis in a wide variety of different breeds as opposed to focusing on this like large breed dog, older dog type of mentality when you're screening dogs for osteoarthritis.
00:19:25
Speaker
It's a really interesting reflection, isn't it? I think about the pain clinic population. Like you said, you do think of it as a typical labrador. We see lots of labradors in the hospital for stifle surgery, for elbow arthroscopy, spring espanol. Certainly in the UK, spring espanol have dreadful elbows. They have humeral intercondylar fissures.
00:19:48
Speaker
I've seen elbow arthritis in a lot of Springer Spaniels in the pain clinic. We see arthritis in a fair number of the, I'm going to say the doodles and you'd think, well, hang on, they're a hybrid breed. What's going on with the hybrid vigor there? Are we not supposed to be protective against osteoarthritis? I think they are properly illustrating that, yes, we should be suspicious of osteoarthritis in any breed of dog and maybe take the breed out of it.
00:20:16
Speaker
Before Labrella was introduced in European markets, what was the gold standard for treating osteoarthritis in dogs? That's quite an interesting question, I think. We don't honestly know that one size fits all for every dog. I always say this to my clients, and I say this when I'm teaching vets that drugs are only one part of the picture with OA management. And I've seen plenty of patients where
00:20:43
Speaker
A little bit of drug therapy in conjunction with weight management, exercise control, physiotherapy, some of the other things we do, like laser treatment, can make a huge difference to those patients. I think that probably does influence the progression of their osteoarthritis. I think it's quite hard. When you've got a disease,
00:21:07
Speaker
that has so many different ways that we should be treating it, it's really hard to say that this is what we would term gold standard. Yeah, really difficult one. Yeah. I hear what you're saying about the gold standard. I guess a better way of asking that would be in your perspective, what do you see that vets were reaching for first? In the US, I would say for Librella, and even really now, I would say the gold standard treatment is long-term NSAID therapy.
00:21:35
Speaker
or, honestly, gabapentin, a lot of people reach for now, combined with weight management and possibly surgery would probably be the gold standard treatment that I see. I don't know if that's something that you're seeing that was similar over across the pond.
00:21:53
Speaker
If I asked a room full of vets to put their hand up and say, which non-steroidal do you use for treating osteoarthritis? I know the vast majority would be saying meloxicam. Meloxicam is the market leader, probably definitely in the UK, probably across the whole of Europe. It does tend to be people's go to non-steroidal. I think it's really easy to administer and dose. It is very easy for clients.
00:22:20
Speaker
So, yeah, Meloxicam was definitely the market leader from a non-steroidal point of view. I think we'd like to hope that weight management, but I think clients are just less good at abiding by the rules as far as weight management goes. I send the clients to the physiotherapist and tell them they're going to read them the right act about the dog's weight. That works. That's so interesting. I would say probably the number one and said, if I had to pick in the US that's being used, I would say Carprofen. Okay.
00:22:48
Speaker
Yeah, Remedil, I think is probably really popular. Galloprant has also become very popular as a choice, which I know this conversation is not about Galloprant, but I think a lot of vets in the US are very interested in Galloprant because
00:23:03
Speaker
it tends to have potentially less of an insult on the kidneys. And when we're talking about using this as an older population of animals, I think a lot of vets are interested in trying to transition away from long-term NSAID use and switch to a non-traditional NSAID like gallop rant just because of the side effects. So I don't know if you're seeing that either.
00:23:25
Speaker
I think what's really interesting, I was part of a key opinion leader panel looking at non-steroidals across Europe. When the market research people go out and they talk to vets about what influences your prescribing considerations, those vary hugely between different European countries.
00:23:43
Speaker
So, in the UK, we're interested in compliance. Can the owner get the product into the pet? In other countries, they're really interested in the COX1-COX2 ratio. We don't find that a massive issue in the UK. And I think we always hear from the US that people are really worried about the renal adverse effects of any drug really.
00:24:06
Speaker
I think we've got three, what I would call first-line classes of drug for treating OA. We've got the nonsteroidals. I put Galliprant, Grappie friend in a separate class. It's a pitprant. It reduces prostaglandins. I personally think it is slightly different from nonsteroidals as far as class of drugs go, but some people do consider it a nonsteroidal. I guess it is a nonsteroidal and it is not a steroid and it has an anti-inflammatory affair.
00:24:34
Speaker
and then there are the anti-NGF drugs, bed-in-bed mapping dogs, and free-to-bed mapping cats. I think from a galley problem versus non-steroid, it would be really nice to have the data that suggests that said one was superior from a renal protective point of view, but I don't think we have that information at the moment.
00:24:56
Speaker
I would agree with you on that one. There's a lot of things I would love to know about Galloprant, since just as you mentioned, it's not a traditional NSAID, like what we think of a traditional NSAID, like a Lambscam or Carproven. There's so many questions about it that I wish we had more information. But in any case, we're not going to talk about Galloprant. We're supposed to talk about Librella.
00:25:18
Speaker
Yeah, so I'll pull us back into Librella for a moment. So as you mentioned about the inflammatory soup, our classic NSAIDs are going to be combating prostaglandins, which are just one portion of that inflammatory soup. Librella is going to be combating against another inflammatory mediator, which is nerve growth factor. Can you just talk a little bit about how Librella actually combats against nerve growth factor?
00:25:47
Speaker
When we have inflammation, nerve growth factor is one of those inflammatory mediators. Nerve growth factor binds to the track A receptor, the trapamycin kinase receptor A on the nociceptor. And that's how it activates the pain transmission signal. When you get that nerve growth factor track A complex, that complex is transported up to the dorsal rear ganglion, which is the cell body of that primary efferent.
00:26:16
Speaker
you then at that level, you get upregulation of a variety of genes associated with pain transmission. And then what happens with that complex is it goes both ways. It goes from the dorsal root ganglion up to the dorsal horn of the spinal cord. And also you have this retrograde effects as well, whereby you get the formation of more trache receptors in the periphery.
00:26:45
Speaker
And that is referred to as neurogenic inflammation, and so it causes more peripheral sensitization. So our prostaglandins in the periphery causing peripheral sensitization, our nerve growth factors causing peripheral sensitization. That's causing more transmission in the nociceptor, more activity at the dorsal root ganglion, then more activity, so more pain transmission at the dorsal horn of the spinal cord.
00:27:10
Speaker
our main neurotransmitter at that level is glutamate. If we get an excess of pain transmission at the dorsal end of the spinal cord or very long-term pain transmission, that's when the risk is central sensitization. So our central nervous system becomes more receptive to any pain signal coming from the periphery. We get greater perception of pain in our patient.
00:27:36
Speaker
So how does librela work to essentially decrease nerve growth factor sensitization?
00:27:44
Speaker
So, Librella as a monoclonal antibody target is specifically against nerve growth factor. I think the easiest way to think about it is when you have that inflammatory soup with nerve growth factor in it, the Librella bed in Batman is scavenging excess nerve growth factor, so it's reducing the nerve growth factor levels. It's not taking those levels completely down to zero, so what we see is a reduction in nerve growth factor, so a reduction in activation of nerve growth factor on the nociceptors.
00:28:14
Speaker
the other aspects that you see. Nerve growth factor binds to track A receptors on mast cells. So it's a second mechanism. And by activating mast cells, you then trigger further inflammation. So actually, we talked about prostaglandins. By scavenging nerve growth factor and reducing nerve growth factor, you reduce other inflammatory mediators.
00:28:42
Speaker
Does librella stop the development of osteoarthritis in dogs?
00:28:46
Speaker
I don't think we have the data yet to be able to say that anything stops the development of osteoarthritis. When I'm talking to pet owners in the pain clinic, I say that this is a progressive disease. It's something we're going to manage. We like to think that if we have great control of every single aspect of osteoarthritis, we could slow the progression, but we don't have any evidence to support that at the moment, sadly.
00:29:14
Speaker
So let's move to clinical application of Librella in your pain clinic. So, Librella is administered as a sub-q injection once a month. In your experience, when you're using Librella, do dogs typically respond after a single injection? Do they need multiple injections for you to see a response? What has been your clinical experience with that?
00:29:40
Speaker
My experience is that you should see a response by seven days, and in the study for the European licensing, they were able to document an effect after seven days. The primary outcome measure in that study was reduction in cane and reef pain inventory scores at day 28, but they did see reduction by day seven.
00:30:04
Speaker
and the quality of life improvement that they documented also started from day seven. You would expect those pain scores to decrease progressively up to that, I'm going to say two to three month time point because we do see progressive increase in comfort over that period of time.
00:30:25
Speaker
I expect to use that injection at day zero to see the client again at day 28 and for an effect to be documented. I then expect the dog to continue to improve up to the point of the second and maybe the third injection. And then probably that's where we're getting our, where we're saying, right, okay, this is the optimal effects that we can expect.
00:30:50
Speaker
So when you are using Librella, are you having clients and yourself fill out like a canine brief pain inventory score and then re-scoring that dog again in 28 days?
00:31:02
Speaker
In the pain clinic, I use a combination of the K&M Brief Pain Inventory. I really like it because it's simple. It's 10 questions. I really like it because it's quick and easy. I also, in my history taking, when I'm talking to the client, I'm gathering some of the client reported outcome measures. They're asking them about, I term them pain behaviors for the clients. What are the behaviors that your dog does that tells you that they're in pain? What are the things that they've stopped doing since they've been in pain?
00:31:30
Speaker
And I try to get at least three paying behaviors, and I'm then going to ask them about those paying behaviors at that second visit. So I tend to start with the paying behaviors. I like doing the Canadian Brief Pay Inventory as a baseline. I won't always repeat it. If at day 28, the client's telling me that all those paying behaviors are much better, I'm probably not going to go through the process of doing the CBPI again. It really does depend on the case. But I find most of those clients are reporting
00:31:56
Speaker
positive benefits and differences in those pain behaviors. And they'll often mention things that you hadn't even talked about in that first consultation. Oh, I've noticed that she started doing this. Oh, she feels like she's part of the family again now. That's maybe not something that they mentioned to me at that first consultation. So it's definitely worth using those things that you talk about the first and second consultation in your history as outcome measures.
00:32:24
Speaker
Do you ever see tolerance, meaning the dogs are maybe responding after three months, but then the effects start to wane after some time? I think that's a really good question. It's really interesting. Obviously, Librella is a monoclonal antibody, and it has been documented that you can get anti-drug antibodies forming to monoclonal antibodies full stop, not just Librella. There are a number of monoclonals on the market.
00:32:53
Speaker
And obviously the concern with anti-drug antibodies is that they form and then they decrease the effects of the product. When I say there isn't any evidence to say that does happen with Lebrela, it may happen. And I think I have seen cases where I've certainly heard clients say, oh, my friend's dog had Lebrela for how long and I didn't think it was working that much anymore.
00:33:19
Speaker
I'd be a bit cautious with how I interpret that because I've had clients say that with a number of drugs and is it because the disease is just, the underlying disease is progressing and it's time for us to add something else in. And then you have that question, well, actually, do I stop the drug? And you can have that discussion with the client and say, right, okay, we've been treating with X drug. We don't think it's working anymore. Let's stop it.
00:33:41
Speaker
But we need to monitor that dog because if that drug was doing something and now your dog is a lot worse, it just proves the point that the drug was doing something. So it's a really difficult one. And I think we've got to just take it with a pinch of salt when a client says that about any drug and just be careful that by backing off that drug, we don't make that dog more painful again.
00:34:07
Speaker
That is a really good point to make about that. So I'm really glad you brought that up. Just about if you hear a client saying that they don't think a drug is working, you really need to dig a little deeper into that conversation. Yeah. I think that's really where it's useful, having those pain behaviors because, okay, what do they mean by not working anymore? Is it because they've been talked to their friends and that happened to their friend's dog and there was another reason behind it. Okay.
00:34:33
Speaker
What are the pain behaviors telling you today? The things we talked about in our first consultation, where are we up to? Let's make an assessment because if the arthritis is getting worse, then we need more analgesia or we need to focus on our weight management or exercise control. It's easy to blame the drug, isn't it? When actually the kids keep walking the dog at the weekend five miles and that needs to stop.
00:34:58
Speaker
Yes, as an anesthesiologist, I often hear people blaming the drugs for everything. We've got to look at the whole picture every time.
00:35:07
Speaker
Yeah, exactly. Do you ever inject librella more often than once a month or spread it out a little bit, depending on the response of the animal? Obviously this is an off-label approach, but I've heard of some people thinking that animals need librella maybe every three weeks because of the pain behaviors that are being experienced or trying to back off on how often you're injecting it because the animal's still comfortable at that like 28 day mark. So have you ever done that clinically?
00:35:37
Speaker
When the umbrella was launched in the UK, I think it was about four, five or six months in that I heard people saying, oh, it's not lasting as long as the four weeks we're using every three weeks. That's quite an expensive way to go. You're increasing the frequency for the client, aren't you? So over time they're going to pay more.
00:35:54
Speaker
When you look at the dose range, the dose range is half to one milligram per kilo. From the bottom to the top, you've got double the dose. Like you see, as an anesthetist, we deal with drugs all the time. A drug with a range that doubles from top to bottom, that's quite unusual.
00:36:15
Speaker
And when you look at the dose chart that comes in the packet, some of those dogs will be on that lower end of the dose range. So what I would do, first of all, is if you have a dog and you don't think the librela has lasted in the four weeks, go back and just double check the dose. My first response is to increase the dose closer to one megapig.
00:36:36
Speaker
And in my experience, that closes that gap from the three to four week gap that people talk about. Other things to think about there, have we got everything else right with our management of our osteoarthritis? Because that suggests we've got some breakthrough pain and breakthrough pain isn't just drug related, it's compliance, it's exercise levels, it's progression of the underlying disease.
00:37:04
Speaker
Going back to the previous point, I have heard some people say, well, can I stretch it from four weeks to six weeks? And I think you do have some of those clients that say, oh, I just forgot to make the appointment. And I think they're just trying to spread things out from a cost perspective.
00:37:19
Speaker
In the licensing studies, the only data that we have available to us is Librela used every month, so there wasn't any work looking at a lower frequency of injection. For the cat products, it was one of the early studies where they said the benefits lasted for six weeks in cats.
00:37:40
Speaker
I'm not saying that you should be spreading salencia around six weeks in cats. I think what's useful for us as vets to know is that the product was tested on a monthly basis and nobody's looked at any different frequency of injection so far. So we talked a little bit earlier about our quote unquote gold standard for treating osteoarthritis prior to the release of Librella. So now that Librella has been on the market for a few years in Europe and in the UK,
00:38:09
Speaker
How often do you think vets are reaching for libroa as opposed to like a long-term NSAID therapy? I would say, again, based on shows of hands in the room when I'm talking to vets, I think it's probably 60-40. I think people are still bonded to their non-steroidals as a first line, I guess.
00:38:31
Speaker
UK compared to the US, if we're less concerned about the renal adverse effects or the GI adverse effects of nonsteroidals, that's probably why that could be quite a unique UK picture. I guess you may find in the States that that could be the opposite where people are reaching for the umbrella over something like a nonsteroidal because of the differences in the adverse effect profile.
00:38:55
Speaker
When you're picking a client or a patient to use Librella on, do you tend to consider whether or not that patient does have concurrent renal or gastrointestinal disease? I would say some of these cases come in my direction from other services in the hospital, particularly the medicine service.
00:39:15
Speaker
So if you've got a patient that's got renal disease, hepatic disease, GI disease, they're on steroids for another reason. Personally, I think those are perfect as candida for librella and that is my recommendation to my fellow clinicians when they present me with those cases.
00:39:36
Speaker
So when you are thinking of choosing Librella as part of your pain management for a dog with osteoarthritis, is there a certain patient population you're looking for when you're recommending Librella for a dog owner? I've used Librella in a whole range of cases from mild arthritis across to really severe arthritis.
00:40:01
Speaker
I've got a younger dog and I guess an important thing to touch on is the license indication is for patients over 12 months of age. And that comes back to the fact that certainly for people up until our late teens, early twenties, we do need nerve growth factor. But beyond that, you don't need nerve growth factor. I'm not really sure where the 12 months came in as an arbitrary line in the sand, if you like, for you can use it beyond 12 months, but not less than 12 months.
00:40:31
Speaker
Somebody must have decided that at a kind of laboratory level. I have used liberality in younger dogs with hip dysplasia, hip osteoarthritis and hip pain to good effect.
00:40:44
Speaker
I think it's useful in those cases where you probably don't want to start an 18-month-old dog, a two-year-old dog on a non-steroidal. I know I would struggle to back that up with science, with saying just because the dog is on non-steroidals for a long period of time, it doesn't mean it's going to get liver or kidney damage, but I
00:41:05
Speaker
I guess there is a possibility there. Clients often don't want their dogs on medication long-term, and I guess, okay, Librella is still a long-term medication. But it's not a daily medication, you know? Yeah, I think that's maybe a difference, because let's remember, there is a caregiver burden associated with giving a medication every day to your dog, and maybe clients don't see that when it's a monthly injection, and it's easier for them.
00:41:34
Speaker
So I have used the Brella and young dogs right up to older dogs as well, particularly those really old dogs. You see those really old dogs, you think, how did your arthritis get this bad? It's so severe. You really need a multimodal approach right from day one, or they've been on non-steroidals for many, many years and they just haven't been rechecked. Nothing's ever been added. The owners just think, oh, arthritis, it's just my dog slowing down. It's just age.
00:42:03
Speaker
And then you examine those dogs and they're just so painful. I think, actually, you're really, really painful. I think Librella is going to be really helpful to you.
00:42:12
Speaker
So when I spoke to a Zoetis rep about Librella, I asked them about combining therapies with Librella. So for example, using Librella along with an NSAID or an injectable glycosaminoglycan like Atiquan or something like that. They mentioned to me that many dogs wind up not even needing multimodal therapy. Many dogs can just be weaned off their, if they're on chronic NSAID therapy, they can be weaned off entirely while taking Librella.
00:42:42
Speaker
Is that your experience with with Librella personally?
00:42:47
Speaker
I would say my experience and my recommendation is if you've got a dog, let's say you've got a dog on non-steroidals and you decide that their pain has got to the stage where they need something else, Librella is a good option to use in that circumstance. Or you might have an owner that says, I'm aware this product is available. I don't want my dog to have non-steroidals for whatever reason. Or let's say you've run an SDMA and it's high and you think, right, we need to ditch the non-steroidals and switch.
00:43:14
Speaker
My recommendation for those ones that are on non-steroidals is that you inject the labrella and then transition them off the non-steroidals. I did that over two weeks based on one of the lab studies associated with the licensing that demonstrated it is safe to do that. That was a healthy population of lab dogs.
00:43:35
Speaker
I think we're continuing to learn about this. I think ideally, you would just have that dog on a umbrella. The concern there is in people, with people that
00:43:46
Speaker
received an anti-nerve growth factor product and carry on taking their non-steroidals. They are more likely to develop a condition called rapidly progressing osteoarthritis. Now, when the umbrella was licensed, there was no evidence that this happens in dogs. However, I think that there is some growing concern that this could happen and people maybe are seeing this in dogs.
00:44:07
Speaker
So I'd probably be more cautious now saying you should withdraw the non-steroidal. I don't think you should use non-steroidal alongside Librella because that could be contributing to this picture. I think it's very early days, but I think based on the recommendations of people, it's probably sensible to avoid using non-steroidal and Librella at the same time.
00:44:29
Speaker
Okay, we will have dogs treated with labrilla. The arthritis progresses. We need to add something else in. I think I would be thinking something, an NMDA antagonist, like a man sitting or a man team would be my choice. What we have seen is people treating dogs with vets, treating dogs with a labrilla.
00:44:47
Speaker
The arthritis progresses and they add back in the nonsteroidals because it's a really easy thing to do because the owners are familiar with it. They were given their dog nonsteroidal before. If somebody asked me that question tomorrow, I would say I would go for a different class of drugs rather than nonsteroidals. I don't think we know enough yet about that combination.
00:45:05
Speaker
Yeah, that's really interesting. And I think it's a great segue from moving on to side effects associated with Librella. I think this is probably the area, at least the United States, that has been having the most controversy with this particular drug.
00:45:21
Speaker
So can you just summarize beyond the rapidly progressing osteoarthritis, can you summarize some of the most common side effects that you have personally seen with Librella and also how often are you seeing those types of side effects in the patient population that you were seeing?
00:45:40
Speaker
From an adverse effect profile, when the product was launched, what we understood from the data sheet was that the most common side effects were swelling at the injection site. And I've seen that in one dog. It's one dog that we injected fairly early on. And that's the only time I've seen swelling at the injection site.
00:46:03
Speaker
This wasn't on the datasheet originally. I believe it is on the European datasheet now. It's polyurea polydipsia. It's something that was reported between six months and 12 months after the product's being released in the UK.
00:46:21
Speaker
I guess, bearing in mind at that point, the clinical trials, there were 287 dogs in that first clinical trial. Half of those got labrella, half of them in the placebo group, so actually not many dogs there in that study population. Of course, you roll a product or a drug out to a wider population and you're more likely to start to see a whole variety of adverse effects.
00:46:45
Speaker
because those dogs are a normal population of dogs. They're not laboratory dogs. And we started to hear polyureopolyadipsia reported as an adverse effect. Now, in some of those dogs, if you stop the drug, then the symptoms resolve. I have had some clients that say, yes, I know my dog drinks more, my dog pees more, but they're so much more comfortable than their previous treatment, so I'm happy to keep them on that medication.
00:47:13
Speaker
So it's occurring often enough that we should warn owners about it. I would have to look at the European data sheet to look at the classification of the incidence of that because I haven't got that at the front of my brain. We can post a link to that data sheet for people to peruse in the show notes for this podcast episode if people are interested in that. As far as
00:47:39
Speaker
The experience of veterinarians with Librella in the United States, I think that there has been some reports of some fairly devastating side effects that have been associated with injection of Librella. And this has been coming out of veterinarians in North America. And those side effects include things like urinary incontinence, a sudden onset of very intense pruritus,
00:48:08
Speaker
And some fairly serious neurological effects, which include dogs that maybe a week after the injection have become tetraplegic or even paraplegic. These are dogs that go down about a week or so after the injection. And this has been causing some veterinarians in the United States to be very hesitant about using Librella because
00:48:34
Speaker
they are fairly devastating side effects. And the controversy really comes from, because this is a monoclonal antibody against nerve growth factor, are we potentially causing some kind of neurologic pathology from its use? Or are these dogs maybe have
00:48:55
Speaker
underlying IVDD, we give them a drug that is going to make them essentially feel better and they overdo it. They're running around and all of a sudden, boom, they have release of disc material to a greater extent. And there is a lot of back and forth conversation amongst veterinarians about what is actually going on with this drug.
00:49:20
Speaker
So these side effects are not, I mean, they have been definitely reported out there so I don't want to dismiss them at all. Do you have any idea of like why maybe some of this is occurring and are you seeing these types of side effects or have heard of these types of side effects happening in Europe or in the UK?
00:49:39
Speaker
Let's start with the urinary incontinence one. I'll tell you what, my rationalization for that one. Okay, we know you get polyurea polydips, yeah. So these dogs are thirsty, they're drinking more. I wonder, I think what people are thinking is urinary incontinence, thinking about the older population of dogs, maybe they do have a degree of urinary strength to mechanism incompetence, you fill their bladders up and they leak.
00:50:09
Speaker
The other thing, if we think about those arthritic dogs, they're uncomfortable, they're moving around all the time, they're getting up, they're getting down, you analges them and they sleep and therefore they don't get up to go for a pee and they overflow. That's how I'm adding those things up in my brain. The difficult question there is why does it cause polydipsia? Because bed in bed, it's a big molecule, it doesn't cross the blood-brain barrier.
00:50:35
Speaker
So, where is the interaction with the normal physiology? That kind of taxes my brain. I haven't heard anybody come up with a pathophysiological mechanism for why exactly the polydips happens, but it happens definitely. So, like I say, we need to warn clients about that.
00:50:55
Speaker
I wonder from a management point of view, we need to say to clients, this could happen and ask them the question, is your dog sleeping more? Do you think it's associated with the fact that they are comfortable with sleeping more? Therefore, we just need to make sure the dog has an opportunity to urinate more frequently. The second one, the pruritus.
00:51:11
Speaker
I haven't heard of pritus in dogs, but it is on the day the European data sheet in cats. So what was described was a focal dermatological lesion. Now, I would call that a hotspot in the ones I've seen is kind of the size of an irritable inflamed area, the size of your fingernail.
00:51:32
Speaker
I saw that in... I've heard vets talk about it. I've seen it in a cat from one of our nurses at work. We started her on salencia originally because she had iris stage two kidney disease, arthritic, 15-year-old cat, treated with meloxicam for a number of years. The kidney disease wasn't progressing, but when you have a product that doesn't have any impact on the kidneys, why not use that as opposed to nonsteroidal?
00:51:56
Speaker
Anyway, a couple of injections later, she developed this skin reaction and it isn't at the site of injection. I don't think I've ever seen one at the site of injection, so it's not associated with the physical injection. This was on the medial thigh in this cat. We stopped the salencia and those signs resolved. However, she got more painful and we resumed salencia in that cat and she didn't develop that reaction again.
00:52:24
Speaker
In people, when you go back through the papers, and again, this is probably one to put in the show notes, the authors schmelt, if you just PubMed nerve growth factor schmelt, you'll come up with that paper, pruritus does happen in people, again, unsure of the mechanism.
00:52:42
Speaker
I think if you're a cat and you're itchy, what do you do? You lick it or you gnaw it, and that's how you develop a hotspot. So that's my, again, my rationalisation, knowing feline behaviour. But I haven't heard about it in dogs. But obviously, if you can get it in people and you can get it in cats, then I don't see any reason why it can't happen in dogs. I guess, again, mechanism, we don't know why.
00:53:03
Speaker
I think based on my experience in that camp I would stop the injection okay you're gonna have to provide something else in way of analgesia in the meantime but I would stop for the umbrella until that lesion has resolved. Is it a lesion or is it just peritis, not just peritis? Are there lesions people reporting?
00:53:24
Speaker
That's a good question and I don't know the answer to that question. I've just heard about pruritus, but I'm not sure about specific lesions. I personally have not had experience with that. This is just things I've heard floating around in the veterinary community. I think the last one around the dogs that develop drastic neurological issues,
00:53:53
Speaker
I guess when the product was launched, the understanding was that it reduces nerve growth factor levels. We don't need nerve growth factor levels as adults. Therefore, reducing our nerve growth factor levels should just have an analgesic benefit. It shouldn't have any other detrimental effect.
00:54:13
Speaker
There was a concern from a neurological point of view, oh, are we taking away something that our patients need? So there's German shepherds with degenerative myelopathy, can I use librarians in those cases? And I have used librarians in those cases because a lot of them have concurrent arthritis. I don't think it makes their degenerative myelopathy any worse.
00:54:32
Speaker
But I understand that some people are concerned that maybe the nerve growth factor is doing something and is needed. It's really difficult when you don't have any evidence either way to confirm or refute those concerns. The rationale could fit together. You've got a dog and you've analgesed them and they're moving around a lot more and nobody knew that their disc was on the edge and they've got a prolapse.
00:54:58
Speaker
I was just curious if that is an experience or if that's something that has been controversial in the UK or in Europe at all, if you've had any experience with people saying very similar things on kind of your end of the point.
00:55:14
Speaker
I think what is really important is we have seen dogs where you give them a umbrella and they are a completely different dog. We then have in the conversation with the owners and say, you've got to control their exercise. I have not given you a three-year-old dog back. You still have a 10-year-old, 11-year-old dog. They cannot run around the controlled exercise. We still need to abide by the rules as far as controlled exercise goes. I think you can see how these dogs
00:55:43
Speaker
could potentially damage those arthritic joints because we haven't made the arthritis any better. We've just taken the pain away. And if they put excessive forces on those joints, they are going to cause damage. And I guess the same could be true from a disc point of view.
00:56:00
Speaker
And I think the more we use the product, I think it's really good that we've got people that are focused on looking at different areas. Because perhaps we've had a blanket approach so far, we've taken a product that has had a license visit, let's use it in everything because it's great. And now people are saying, well, hang on, what about these cases? What about these cases?
00:56:19
Speaker
I think we'll learn, of course, when you release new products, what are we four years in and only a year in in the States? I think we're going to learn a lot more by people examining these things a bit more closely and that will bring us a better understanding of which patients we can and can't use these products in. Yeah, and I would also suggest to people who have had adverse effects
00:56:43
Speaker
in their patients when they've used Librella to please report that to Zoetis because the more information we have, now that we have this new drug, the better we can really target what patients are going to benefit the most from this particular product. Yeah, absolutely. It's really hard. We know from
00:57:01
Speaker
There was a study a few years ago in the UK on adverse effects of non-steroidals, and the quality of the data is there, but the quality is not great, and we know these things are under-reported. So if after 30 years of using non-steroidals, we're saying the data quality is rubbish, how can we improve it? We've got to be really, really detailed when we provide those adverse event reports.
00:57:23
Speaker
So in general, how would you advise veterinarians to incorporate Lobrella into their current treatment plan for dogs with osteoarthritis? I consider Lobrella to be a first-line treatment just as Montserratas or Grapoprent are first-line treatments for osteoarthritis.
00:57:43
Speaker
The really important thing is that we have an understanding of the pain and we can track that pain through monitoring, whether that's the Canadian brief pain inventory, whether that's the Helsinki chronic pain index, however you score your pain, incorporate those client reported outcome measures so we can track whether the products we're using is making a difference. Talk to owners about those potential adverse effects.
00:58:07
Speaker
We can definitely mention the swelling injection sites, polyurea, polydips. We definitely know those are happening. I think the other adverse effects, we will learn more about those as they're reported. I guess right now, I wouldn't let any of those get in the way of my prescription of Librella, but I've been monitoring that patient very closely.
00:58:30
Speaker
the conversation about exercise needs to happen in that first consultation as well. Because if that dog does become a lot more comfortable, the client needs to understand that they still have those horrible arthritic joints and the joint isn't actually going to get any worse. So I think those are probably my basics for starting there. And like I say, I would withdraw the non-steroidal. If you've got a patient that's already on a non-steroidal, I don't think we should be using the umbrella alongside non-steroidals. We need a bit more information before we do that.
00:59:00
Speaker
And as someone who has used Librella for several years, do you have any advice for vets in North America who are learning how to use this drug to its full potential? I think my first piece of advice would be go with the dose between half and one make per cake that it says on the summary product characteristics. And I was asked the owner when they're coming back for that second injection and that third injection, how long do they think it lasted?
00:59:30
Speaker
that means we're going to capture those ones that maybe it doesn't work for four weeks, and then we can optimize the dose and make sure that the dog is receiving the correct dose for that patient. A lot of questions come around this, okay, fine, the vet should see the pet for the first injection, but when do you get them to come back and just see a tech rather than seeing the vet every time? I think it takes those, definitely, I would be making the assessment out of that third injection,
00:59:59
Speaker
So, you could argue that you see the patient for the first injection, then you ask your tech to do the second injection, but collect that data, the canary brief pain inventory, the client reports the outcome measures of the second injection, and then the vet to see them for the third injection and make a decision whether we're saying, right, okay, they're fine for another six months to carry on with tech appointments, and then come back and see the vet. That's definitely a question that has come up quite a lot.
01:00:27
Speaker
I guess that's down to the individual practice and how you choose to manage that within your practice. Well, Dr. Gurney, I appreciate your time. This has been an incredibly informative discussion. I learned a lot. And I just want to thank you so much for your time. So thank you for coming on the Navitas podcast, talking to me all about Librella. It's been a pleasure. It's really good to talk to people across the globe.
01:00:57
Speaker
If you like what you heard today, I encourage you to check out NavAss and consider becoming a member. As a member of the North American Veterinary Anesthesia Society, you get tons of benefits, including access to CE events, focusing on anesthesia and pain management, blog posts, fireside chats with bored and anesthesiologists, as well as specialty technicians, and just so much more.
01:01:20
Speaker
visit www.mynavas.org to advance your anesthesia journey today. If you have been enjoying the content of this podcast, I would sincerely appreciate it if you could give us a like or subscribe to our podcast, write a review, or simply spread the word about this podcast to your friends and coworkers.
01:01:40
Speaker
We appreciate any and all listener support. If you have any questions about this week's episode or the NavAss podcast in general, or if you want to suggest topics you would like for us to discuss in future episodes, please reach out to us at education at mynavass.org. We would love to hear from all of you.
01:01:59
Speaker
Also, a huge thank you to our sponsor, Decra, without whom this podcast would not be possible. Visit their website, www.decra-us.com to learn more about their line of veterinary anesthesia products. This podcast was produced by Maria Bridges, edited by Chris Webster of Chris Webster Productions, and technical support was provided by Saul Jimenez.
01:02:23
Speaker
I want to thank our guest, Dr. Matt Gurney, for this incredibly insightful discussion on Librella. To learn more about him and zero-pain philosophy, visit zeropainvelocity.com. And lastly, a huge thank you to all the gas pastors out there who choose to spend their time with me today on the Navas Podcast. Becoming a skilled anesthetist is a lifelong journey of learning and self-discovery, so I hope you consider listening in the future.
01:02:50
Speaker
I'm your host, Dr. Bonnie Gatson, and thank you for listening. See you next month with another episode of the North American Veterinary Anesthesia Society podcast.