http://respond poorly.
Journal of Small Animal Practice (2020), 1–9
DOI: 10.1111/jsap.13214

前田塾2020.12.26 おざき動物病院

入江Accepted: 30 July 2020

INTRODUCTION
Feline chronic enteropathy (CE) describes a spectrum of diseases
resulting in chronic gastrointestinal (GI) signs, with unknown
aetiology (Willard 1999). However, the pathogenesis is hypothesised to involve the variable interplay of four key components;
genetic susceptibility, environmental risk factors, intestinal dysbiosis and altered GI mucosal immune response (Jergens 2012).
Definitive diagnosis of CE requires ruling out all known causesof chronic GI signs with extensive laboratory and faecal testing,trans-abdominal ultrasound and GI histopathology. Treatment
often requires a sequential or combination approach with diet,antibiotics and immunosuppressive medication depending on
the severity of the disease (Jergens 2012). However, the numberof cats in primary practice that are treated empirically for CE,
without extensive diagnostic tests, due to financial or logisticalconstraints or contraindications to general anaesthesia for collection of GI biopsies is suspected to be high.

Journal of Small Animal Practice • © 2020 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf ofBritish Small Animal Veterinary AssociationIntroduction
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,1

provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
▶猫の慢性腸症(CE)は、慢性胃腸疾患となる広範囲の疾患を指している(Willard1999)。
▶CEの確定診断には、慢性胃腸疾患で考えられるあらゆる疾患の除外が必要である。

▶治療は、食餌、抗生物質、免疫抑制剤の継続的または併用したアプローチが必要になる(Jergens 2012)。
※しかし、一次診療では、様々な理由から試験的に治療されている猫も多いと考えられる。

▶CE罹患猫に対する加水分解食の効果の報告は１つしかない(Mandigers et al. 2010)。
▶目的：①慢性嘔吐・下痢を呈す猫の加水分解食に対する反応を調査。
②加水分解食を使用する前または使用と同時に薬物療法を行うことが、治療反応と関連があるかを調査。

Material and Method▶コホート研究▶症例：2016年にVetCompass Programmeに参加した一次診療施設で治療を受けた全ての猫(512,213頭)から加水分解食を使用した症例を絞り込み、組み入れ基準、除外基準に照らし合わせる(図1)。→977頭が合致。
▶poor responseと6項目(表1)の関連を単変量解析・多変量解析により調査。

※poor responseの定義：加水分解食の処方後のAB またはGCの追加処方があった。または、フォローアップ期間中に胃腸症状により死亡した。

Results(表2)▶性別、毛色、品種はpoor responseとの関連はなかった。
▶最初に加水分解食を処方された年齢が>6歳の方が 6歳に比べ有意にpoor responseであった(P < 0.001)。

▶pre-treatment：ABまたはGCが処方されていた猫は処方されていなかった猫と比べpoor responseの割合が高かった(ABのみ: P = 0.005、GCのみ: P<0.001、両方: P<0.001)。
▶treatment：ABまたはGCが処方されていた猫は処方されていなかった猫と比べpoor responseの割合が高かった(P<0.001)。

Discussion▶年齢とpoor responseとの関連は犬での報告(Allenspach et al. 2007)や過去の報告(Gianella et al. 2017)と類似。
※診断されていない消化管腫瘍などの疾患も含んでる可能性→高齢だと反応に乏しい理由となる。
▶poor responseとなった理由として、以下の理由が考えられる。
-胃腸症状の重症度-獣医師による差-腸内細菌への影響(Manchester et al. 2019)や粘膜の免疫機能への影響(Coutinho & Chapman 2011)▶Limitation-皮膚症状で加水分解食が処方されている猫は除外されている。
-下痢や嘔吐症状がなく、体重減少や食欲不振の猫は除外されている。

Conclusion▶本研究は、一次診療において病因が確定できなかった慢性嘔吐/下痢の猫の市販の加水分解食への反応を記述した初めての研究である。
▶ABやGCを使用していると加水分解食の反応が乏しくなる確率が高い。

→今後は、これらの投薬と予後についてのランダム化比較試験が必要である。

批評▶本研究では、コントロール群がないため、実際に加水分解食の有効性は示されていない。
▶猫の慢性腸症では、食物反応性腸症、IBDの２つに分けられている(Textbook of Veterinary Internal Medicine
8th)→一次診療においてはできる限り疾患の除外をした上で、加水分解食を使用する意義はあるのでは?

signs at a subsequent visit without receiving antibiotic or gluco- for vomiting/diarrhoea at subsequent visits at least 3 months
corticoidfor their vomiting/diarrhoea, 76 were prescribed anti- after first receiving the hydrolysed diet and concurrent gluco図１：症例の絞り込み(組み入れ基準、除外基準)
biotic for vomiting/diarrhoea at a subsequent
visit; 1 of which corticoid; 18 of which ultimately died or were euthanased for
母集団：512,213頭
was ultimately euthanased for GI signs and 159 were prescribed GI signs. Of these 100 cats, 8 also received other non-glucoglucocorticoid with or without antibiotic for vomiting/diarrhoea
corticoid anti-inflammatory or immunosuppressive medication検索
at subsequent visits, of which 38 of these ultimately died or were at subsequent visits for vomiting/diarrhoea. Two cats received「zd,z/d,HA,
hypoallergenic,anallergenic,allergy」chlorambucil and 1 cat both cyclosporine
euthanased
for GI
signs.
Of these
240 cats with a poor
response,cyclosporine,
5 cats18 also received other non-glucocorticoid anti-inflammatory or and chlorambucil. Of these 8 cats, 4 were euthanased for GI
5,569頭immunosuppressive medication at subsequent visits for vomit- signs at a subsequent visit.
ing/diarrhoea. Two cats received
sulfasalazine, 5 cats cyclospoランダムに5,000頭を選択
rine, 8 cats chlorambucil, 2 cats chlorambucil and cyclosporine Univariable and multivariable analysis of poorand 1 cat chlorambucil and sulfasalazine. Of these 18 cats, 6 died response for all catsor were euthanased for GI signs at a subsequent
visit.
There were four variables that were liberally significant in uni組み入れ基準
variable analysis and were promoted for multivariable analysis:(1) 少なくとも2週間続く嘔吐and/or下痢に対して初めて加水分解食が処方されている。
Cats
first prescribed the diet with concurrent
the age of the cat when the hydrolysed diet was first prescribed,(2) 加水分解食を処方されるような他の疾患がない(ex.
皮膚疾患)。
(3) 1ヶ月以内に食事の返品や中断がされていない。
antibiotic(without glucocorticoid)sex and neuter status, pre-treatment subcategory and treatment(4) the
症例の胃腸症状についての記録照会が可能。
Of
127 cats (13% of total) first prescribed the diet with con- subcategory (Table 3). After accounting for the other factors,(5) 症状悪化により死亡または安楽死にならない限り、少なくとも6ヶ月は同じ施設でフォローアップしている。
current
antibiotic (without glucocorticoid), 56 (44%) did not the final multivariable model showed that cats aged over 6 years(6) 検査で、慢性炎症性腸炎以外の病因が明らかにできなかった。
have a poor response for a median follow-up time of 946 days when first prescribed the diet had increased odds of a poor
(range 186-3599) (Table 2). Of the remaining
71 cats (56%) response compared to cats that were 6 years of age and younger
除外基準(1) 記録以前に嘔吐and/or下痢に対して加水分解食が処方されており、記録が照会できない。
that
had a poor response, 34 were prescribed further antibi- (OR 1.81, 95% CI: 1.37-2.40, P < 0.001) (Table 4). For the pre(2) 加水分解食を処方されて1週間以内に胃腸症状以外の症状に対してグルココルチコイドが開始される。
otic
for vomiting/diarrhoea at a subsequent visit; 3 of which treatment subcategory, cats that were prescribed antibiotic andwere ultimately euthanased for GI signs and 37 were prescribed cats that were prescribed glucocorticoids before the hydrolysed
glucocorticoid with or without antibiotic for vomiting/diar- diet had increased odds of a poor response compared to thoserhoea at subsequent visits, of which 8 ultimately
died or were cats that received no antibiotic or glucocorticoid before the diet977頭
euthanased for GI signs. Of these 71 cats, 5 also received other (OR 1.55, 95% CI: 1.14-2.11, P = 0.005 and OR 4.11, 95% CI:
表１：
non-glucocorticoid
anti-inflammatory or immunosuppressive 2.00-8.43, P < 0.001, respectively) (Table 4). Cats that were premedication at subsequent visits評価項目
for vomiting/diarrhoea. One scribed both antibiotic and glucocorticoid before the hydrolysed
cat received cyclosporine, 3 cats chlorambucil and 1 cat sul- diet had 2.42 times the odds (95% CI: 1.51-3.86, P < 0.001) of(1) 加水分解食を処方された年齢：中央値6歳以上
or 以下 for GI signs at afasalazine.
Of these 5 cats, 1 was euthanased
a poor response compared to those cats that received no antibisubsequent
visit.
otic or glucocorticoid before the diet. In relation to the treat(2) 毛色
ment subcategory, cats that were first prescribed the diet with(3) 性別と避妊・去勢の有無
Cats
first prescribed the diet with concurrent
concurrent antibiotic or glucocorticoid had increased odds of a
glucocorticoid(with or without antibiotic)
poor response compared to those cats that received no antibiotic(4) 品種In the 153 cats (16% of total) that were first prescribed the diet or glucocorticoid when the diet was first prescribed (OR 2.08,(5) Pre-treatment(加水分解食を処方される前に行われた治療)
withconcurrent glucocorticoid (with or without antibiotic), 95% CI: 1.38-3.11, P < 0.001 and OR 2.66 95% CI: 1.76-4.00,
53-抗生剤なし、グルココルチコイドなし
cats (35%) did not have a poor response for a median fol- P < 0.001, respectively) (Table 4). Sex and neuter status, coat-抗生剤あり、グルココルチコイドなし
low-uptime of 1082 days (range 213-3888) (Table 2). Of the colour and breed were not associated with the odds of a poor
-抗生剤なし、グルココルチコイドあり
remaining
100 cats (65%) that had a poor response, 16 were response. Pairwise interaction showed no significant associations-抗生剤あり、グルココルチコイドあり
euthanased or died due to vomiting/diarrhoea at a subsequent between the three variables in the final model. The Hosmervisit
within 3 months of first receiving the hydrolysed diet and Lemeshow test indicated good model fit (P = 0.812), and the(6) Treatment(加水分解食の処方と同時に行われた治療)
concurrent
glucocorticoid. Eighty-four cats continued to receive area under ROC curve (0.679) indicated moderate predictive-抗生剤なし、グルココルチコイドなし
glucocorticoid
or were prescribed antibiotic or glucocorticoid ability.
-抗生剤あり、グルココルチコイドなし-抗生剤なし or あり、グルココルチコイドあり

Table 4. Multivariable logistic regression analyses results for associations with the odds of a poor response in cats that wereprescribed a hydrolysed diet with or without
concurrent antibiotic and/or glucocorticoid for chronic vomiting and/or diarrhoea
表2：多変量解析によるpoorresponseとの関連
Variable

6 years of age andyounger
Pre-treatment
subcategory

Treatment
subcategory

Yes
No
No AB or GC
AB but no GC
GC but no AB
AB and GC
No concurrent AB or GC
Concurrent AB (without GC)
Concurrent GC (with or without AB)

Poor response N (%)

Good response N (%)

Odds ratio (95%confidence interval)

P-value

153 (16.6%)
227 (24.7%)
139 (14.2%)
168 (17.2%)
30 (3.1%)
74 (7.6%)240 (24.6%)
71 (7.3%)
100 (10.2%)292 (31.7%)
248 (27.0%)
296 (30.0%)210 (21.5%)
13 (1.3%)
47 (4.8%)457 (46.8%)
56 (5.7%)
53 (5.4%)–1.81 (1.37–2.40)–
1.55 (1.14–2.11)
4.11 (2.00–8.43)
2.42 (1.51–3.86)–
2.08 (1.38–3.11)
2.66 (1.76–4.00)–<0.001–
0.005<0.001<0.001–<0.001<0.001

6参考：胃腸症状に対して行われた検査
Journal of Small Animal Practice • © 2020 The Authors. Journal of Small Animal Practice published by John Wiley & Sons Ltd on behalf ofFIV/FeLV

127頭(13%)

血液・生化学検査

704頭(72%)

血清チロキシン濃度

292頭(30%)

糞便検査(寄生虫、 便培養、 ジアルジア by ELISA、 トリコモナス by PCR)

424頭(43%)

胃腸症状に対して試験的な駆虫457頭(47%)

血清ビタミンB12と葉酸325頭(33%)

膵リパーゼ免疫活性(PLI)

347頭(36%)

トリプシン様免疫活性(TLI)

218頭(22%)

腹部超音波検査349頭(36%)

小腸の病理組織学的検査

123頭(13%)

British Small Animal Veterinary Association