12 minute read
What if the worst were to happen?
by VetScript
MAS Senior Advisor Dane Boswell knows all too well the terrible consequences of underinsuring your life and income-earning potential. Phil Belcher, MAS Life and Disability Product Manager, shares Dane’s story.
WHEN DANE WAS 20 years old, his mother died in an accident on the family property in Kerikeri. Unfortunately his parents had cancelled their life insurance just six weeks earlier, because they felt they were in a position to manage on their own – they had a successful business and were feeling secure with their income.
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Dropping down to one income put Dane’s father under huge financial pressure, and meant that he had to work until he died in his late 70s. Because of this, Dane is passionate about helping MAS members to make informed decisions on protecting themselves and their families, often using his own painful personal experience as an example of a worst-case scenario.
“I want to make sure others don’t go through what my family has been through. I’ve lost both my parents and I’m only in my mid-30s. My dad had a really tough last few years of life because no-one spoke to him about insurance with enough conviction to ensure he and Mum had enough cover in place.
“It’s definitely a sad position to be in, especially for my kids – they can’t get to know my side of the family at all. It really drives home that New Zealanders need to do away with the ‘she’ll be right’ attitude. It’s my job to make sure members don’t end up in the same situation and are protected in case the worst happens.”
Life insurance pays a cash lump sum if you pass away or are diagnosed as terminally ill. It’s usually used by your loved ones to repay the mortgage or for childcare and education. Income protection insurance pays a regular amount of up to 75% of your usual earnings if you can’t work due to an illness or injury. It also continues to top up your income to 75% of your previous earnings as you return to full-time work. The Accident Compensation Corporation only covers you if the injury is caused by an accident and there’s a cap on how much of your income will be covered.
KIWIS ARE UNDERINSURED
Research commissioned by the Financial Services Council has revealed that a lot of Kiwis are underinsuring their lives despite being aware of the importance of insurance. Only nine percent of Kiwis are adequately insured for critical illness, 11% have enough income protection/ mortgage repayment insurance, and 29% have adequate life insurance (Financial Services Council, 2020).
Dane believes that a person’s underinsurance comes down to a
combination of their being uninformed and an attitude that ‘it won’t happen to me’.
“People aren’t really willing to delve into ‘what if?’ scenarios. A lot of our members generate really good incomes. But some fail to realise that their ability to earn good incomes is their biggest asset and it needs to be adequately protected,” he says.
DON’T SET AND FORGET
Dane sees members making mistakes that are easily avoided. His advice is to ensure you keep your advisor in the loop if your circumstances change, have your policies reviewed frequently and, if you haven’t had this sort of insurance before, make time for an in-depth conversation with your advisor to understand your best options.
“The most prevalent mistake I see is people taking out policies and not reviewing them when their situations change. I often see policies that have been in place for 10–15 years without anyone looking at them, and they’re no longer applicable to those people’s situations,” he says. “You could get married or divorced, have a child, buy a house, take on other dependants like elderly parents, change job roles or have an income increase. All these life events should trigger a review of your life insurance and might change the advice an advisor will give.
“Quite often I see people with life cover amounts that may not actually be required. In some situations a better option is to put some premium into recovery or income security benefits instead.”
TAKE ACTION NOW
If you’d like to discuss income protection insurance, you can book a free appointment with a MAS advisor. They don’t receive a commission, so you can rest assured they have your best interests at heart.
REFERENCE:
Financial Services Council. Gambling on life: The problem of underinsurance. www.fsc.org.nz/ site/fsc1/Gambling%20on%20Life%20-%20 The%20Problem%20of%20Underinsurance%20 -%20Financial%20Services%20Council%20-%20 January%202020.pdf (accessed 20 August 2020 Auckland, New Zealand, 2020
This article is of a general nature and is not a substitute for professional and individually tailored financial, business or legal advice.© Medical Assurance Society New Zealand Limited 2020.
MAS has been busy doing good lately. We’ve established a foundation to fund health initiatives in our communities, we’ve been awarded Consumer NZ People’s Choice for house, contents, car and life insurance for four years running, and we’ve continued to deliver outstanding service to Members, like Kristine and Kris, especially at claims time.
Choose the insurer that invests in the health of Kiwis. Find out more at mas.co.nz
WHENcan I check for…?
Sandra Forsyth, Clinical Pathologist for SVS Laboratories, offers some recommendations on when you should take samples in relation to medications.
A QUESTION THAT veterinarians commonly ask staff at diagnostic laboratories is, “When do I take a sample in relation to a particular medication?” The following are recommendations for some of the more common situations.
MONITORING THYROID FUNCTION
Hyperthyroid cats In cats on antithyroid treatments (including prescription diets), serum T 4 is usually assessed 10–20 days after starting therapy or adjusting the dosage, then at three- to six-month intervals once the cats are stable.
In hyperthyroid cats there is no significant relationship between T 4 and dosing interval or post-pill times in a 24-hour period. Consequently, the timing of a blood test is not important if the cat is consistently receiving medication. T 4 can return to pre-treatment values within 48 hours of stopping medication.
T4 is not the only parameter that should be monitored in cats on antithyroid medication. Adverse reactions occur in about 20% of cats receiving methimazole/ carbimazole, and are usually seen in the first three months of treatment. Mild changes in the complete blood count may be seen and a small proportion of cats (less than 5%) may develop severe leukopenia or thrombocytopenia.
Recommendations for monitoring T 4 levels in cats after radioactive iodine (I-131) are usually offered by the treatment providers, but in general levels are monitored at one, three, six and 12 months post-treatment and then every six to 12 months thereafter.
The glomerular filtration rate falls during treatment for hyperthyroidism and this can unmask renal dysfunction, with about 30% of cats developing chronic kidney disease as their hyperthyroidism is controlled. Baseline urine-specific gravity of less than 1.035 was found to be the most sensitive (90.9%) marker for predicting post-treatment I-131 azotaemia, whereas baseline creatine (>140umol/L) was most specific (DeMonaco et al., 2020). It is probably similar for cats on oral medications.
Moderate to severe non-thyroidal illness can suppress total T 4 concentration in normal, hyperthyroid and treated cats, and this should be kept in mind when interpreting results.
Hypothyroid dogs The best method for monitoring thyroid hormone replacement therapy in hypothyroid dogs is uncertain. There are considerable day-to-day variations in peak (four- to six-hour post-pill) serum T 4 concentration, and altering a patient’s thyroid medication based on a single result should be done carefully and in conjunction with the clinical response to the medication.
Therapeutic monitoring is usually carried out two to three weeks after starting or adjusting the thyroid medication, and then at six- to 12- monthly intervals. A serum sample for T 4 is taken four to six hours after starting or adjusting medication.
THE EFFECT OF GLUCOCORTICOIDS ON TOTAL T 4
Glucocorticoids can reduce serum T 4 concentration. A single dose of shortacting glucocorticoid produces no significant change in T 4 concentration. However, long-term treatment can have a significant effect and glucocorticoid should be stopped for at least four weeks, and preferably six to eight weeks, before testing thyroid function. Similarly, dogs with hyperadrenocorticism frequently show suppressed T 4 concentrations.
MONITORING ADRENAL FUNCTION
Hyperadrenocorticoid dogs When trilostane was first introduced, adrenocorticotropic hormone (ACTH) stimulation became the default test for monitoring the treatment response as a hangover from mitotane monitoring. However, the use of ACTH stimulation for monitoring trilostane efficacy has not been supported by studies, which show that clinical control is only loosely related to cortisol concentration following adrenal stimulation. One study found that pre-trilostane cortisol concentrations deliver as good an estimate of adrenal control, providing that the dog was clinically well controlled and was not showing signs of illness or hypoadrenocorticism at the time of testing (Macfarlane et al., 2016).
A serum sample taken zero to one hour before the next trilostane dose provided evidence of good control when the cortisol concentration was 40–138nmol/L (variations in analysis methods mean that reference intervals will differ between laboratories). Stressed and excited dogs may show higher cortisol concentrations (Boretti et al., 2018). ACTH stimulation remains the test of choice in dogs who show poor control or signs of illness.
After starting trilostane, it is recommended that the patient be checked at two weeks to confirm overdosage hasn’t occurred. In many dogs the serum
cortisol concentration continues to fall over the ensuing weeks without an increase in dose. Cortisol is rechecked in another two to four weeks then at threemonthly intervals.
Hypoadrenocorticoid dogs While not fitting with the ‘when do I test?’ theme, the difficulty in obtaining ACTH (Synacthen) raises the question of alternative tests for the diagnosis of a suspect hypoadrenocorticoid dog. The urinary cortisol-creatinine ratio (UCCR) has been found to have a high sensitivity and specificity to detect hypoadrenocorticism when the UCCR is less than three (Rowland et al., 2018). However, other authors have found UCCR may be less than three in urine samples collected at home, but generally not in samples collected at the clinic (Citron et al., 2020).
THE EFFECT OF GLUCOCORTICOIDS ON SKIN BIOPSIES
Glucocorticoids should be stopped at least two and preferably four weeks before biopsying skin lesions.
WITHDRAWAL TIMES IN ANIMALS ON ANTIBIOTICS
Ears When culturing ear swabs, a three-day withdrawal from topical medications is usually sufficient, although if bacteria are seen on cytology despite treatment, culturing could be done immediately. Skin If there is no response to antibiotic therapy, immediate culture would theoretically be acceptable. However, 48 hours without medication prior to culturing is recommended.
Urine When culturing urine, about five elimination half-lives of the drug should pass before a sample is taken. This is about three to five days when the antibiotic is administered two or three times per day, and five to seven days for once-a-day medication.
REFERENCES: Boretti F, Musella C, Burkhardt W, KuemmerleFraune C, Riond B, Reusch C, Siber-Ruckstuhl N.
Comparison of two prepill cortisol concentrations in dogs with hypercortisolism treated with trilostane. Veterinary Research 14(1), 417, doi: 10.1186/s12917- 018-1750-3, 2018
Citron LE, Weinstein NM, Littman MP, Foster
JD. Urinary cortisol-creatinine and protein-creatinine ratios in urine samples from healthy dogs collected at home and in hospital. Journal of Veterinary Internal Medicine 34(2), 777–82, 2020
DeMonaco SM, Panciera DL, Morre W, Conway T,
Were S. Symmetric dimethylarginine in hyperthyroid cats before and after treatment with radioactive iodine. Journal of Feline Medicine and Surgery 22(6), 531–8, 2020
Macfarlane PL, Parkin T, Ramsey I. Pretrilostane and three-hour post-trilostane cortisol to monitor trilostane therapy in dogs. Veterinary Record 179(23), 597 doi:10.1136/vr.103744, 2016
Rowland A, Birkenheuer AJ, Mamo L, Lunn
KF. Comparison of urine cortisol:creatinine ratio and basal cortisol for the diagnosis of canine hypoadrenocorticism. Proceedings from the American College of Veterinary Internal Medicine Conference 2018 (Abstract EN13)
Liver enzymes and bile acids – what do
they tell us?
Graham Swinney, Medical Affairs Veterinarian for IDEXX Laboratories and internal medicine consultant, considers the most effective ways to get information on liver function.
IN-HOUSE LIVER-ENZYME
MEASUREMENT is routine practice for clinical veterinarians, whether it’s needed as part of a pre-anaesthetic screen, an evaluation of an unwell patient or a preventive care strategy.
A number of liver enzymes provide clues to the nature of liver changes such as hepatocellular damage or cholestasis. For example: » alanine aminotransferase and aspartate aminotransferase are indicators of hepatocellular damage, although the latter is less specific given that it is also a marker of muscle damage » alkaline phosphatase is produced in the hepatocytes in response to cholestasis, but can also be sourced from bone (osteoblastic activity) » an alkaline phosphatase isoenzyme can be induced in dogs through a glucocorticoid effect » gamma glutamyl transferase comes from biliary epithelium, and also increases in response to cholestasis. However, liver enzymes do not provide us with any specific information about hepatic function. Reduced levels of indirect markers of hepatic function (such as urea, glucose, cholesterol and albumin) may suggest hepatic dysfunction, but they may all be low for other reasons. Conversely, the absence of reduced levels of these markers does not exclude the possibility of hepatic dysfunction.
To gain specific information on liver function, it is useful to consider ammonia tests (including the ammonia tolerance test) and bile acids. The former, while useful, have technical challenges; bile acids are more straightforward to measure.
Bile acids are produced in the liver from cholesterol and stored in the gall bladder. The ingestion of food stimulates gall bladder contraction – a process where the bile acids aid in fat absorption by micellising the fat, and are primarily resorbed in the ileum. Once in the portal circulation, the bile acids are extracted by hepatocytes in a very efficient process. This means fasted bile acids are relatively low, whereas a two-hour postprandial sample challenges the system.
The reasons for elevated bile acids include: hepatocellular loss or failure; portovascular anomalies (portosystemic shunts or microvascular dysplasia/portal atresia), which allow the portal blood to bypass the liver; and cholestasis.
Signs that it might be appropriate to measure bile acids include: » changes in biochemical profile, such as increased liver enzymes in an unwell patient » hypoalbuminaemia » hypoglycaemia » hypocholesterolaemia » low blood urea. You might also need to measure bile acids when assessing a patient for hepatic dysfunction, as the signs can be vague and affect other body systems such as the nervous system, gastrointestinal tract and urinary tract. Signs may include unexplained seizures, other central nervous system signs such as disorientation, poor growth, weight loss, ammonium biurate urolithiasis or crystalluria, microhepatica, and increased liver enzymes for patients on phenobarbitone. Note there is little value in measuring bile acids in patients with hyperbilirubinaemia.
The Catalyst Dx Chemistry Analyzer now has the ability to test bile acids and measure them in real time. This offers great benefits for veterinarians assessing patients for liver dysfunction, when patients have elevated liver enzymes on pre-anaesthetic testing or there are concerns about their hepatic function.
