Disclosures/Conflict of Interest
Common Questions when Caring for Veterinary Patients in Community Pharmacy
• Dr. Hogan declares no conflicts of interest, real or apparent, and
no financial interests in any company, product or service mentioned in this program, including grants, employment, gifts, stock holdings and honoraria.
Melissa Hogan, Pharm.D. Associate Professor and Chair, Department of Clinical and Administrative Sciences Roosevelt University College of Pharmacy
Objectives Pharmacists
Objectives Pharmacy Technicians At the conclusion of this program, the pharmacy technician will be able to:
At the conclusion of this program, the pharmacist will be able to:
• Discuss current issues in dispensing medications for pets • Describe key points in the pharmacological management of
• Understand current issues in dispensing medications for pets • Recognize medications dispensed for dogs and cats with diabetes • Recognize medications dispensed for dogs and cats with heart
diabetes in dogs and cats, including the role of Vetsulin®
• Describe key points in the pharmacological management of heart
failure
failure in dogs and cats, including the role of pimobendan (Vetmedin®)
• Name the benefits of drug administration aides for dogs and cats
• Identify for a client on proper methods of drug administration in their dog or cat
Benefits of pets for human health • Physical • Social • Psychological
Introduction
5 REFERENCES http://www.cdc.gov/healthypets/health_benefits.htm http://newsinhealth.nih.gov/pdf/NIHNiH%20Feb09.pdf
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What is new in Veterinary Pharmacy?
Pharmacists’ FAQs about Pet Meds
• H.R. 3174 / S. 1200 Fairness to Pet Owners Act of 2015 • •
AVMA position FTC Letter
• •
What is the problem? What is the solution?
References S. 1200 Fairness to Pet Owners Act. WWW.Govtrack.US Competition in the Pet Medication Industry. FTC Staff report. May, 2015
Most Common Questions • How long should a client use a vial of human insulin on a dog or cat?
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Managing Diabetes in Dogs and Cats
• What kind of dog receives Vetmedin (pimobendan)? •
Do OTC pain relievers work for pets?
• What are the best ways to administer medication to pets? 10
Diabetes in Dogs • Prevalence 1 in 400 to 500 • Females (2x more likely than males) • Age 8-12 years •
Australian, Fox, Cairn and Yorkshire terriers; Standard and miniature Schnauzers, Miniature and toy poodles, Bichon Frise, Spitz, Samoyed, Lhasa Apso, beagle
Pathophysiology
• Type 1, insulin-dependent diabetes • Loss of beta cell function • Hypoinsulinemia • Impaired transport of serum glucose into cells • Accelerated hepatic gluconeogenesis and glycogenolysis Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3rd ed. Missouri: Mosby 1998.
Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3rd ed. Missouri: Mosby 1998.
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Diagnosis
Goals of Therapy
• Pre-diabetes • •
Blood glucose between 120 and 200 mg/dl No signs when blood glucose above normal range, but below renal threshold
• •
Normal range:
80-120 mg/dL
Renal threshold: 200 mg/dL
• Maintain BG between 100 – 180 mg/dL • Avoid hypoglycemia • Avoid complications of hyperglycemia • • • •
• Clinical diabetes • • • •
Fasting BG > 200 mg/dL Classic presentation (like humans) Polyuria, polydipsia, polyphagia, lethargy
Cataracts, blindness UTI, respiratory and skin infections Chronic pancreatitis Ketoacidosis
If not noticed and treated:
• •
Sudden blindness due to cataracts Diabetic ketoacidosis Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F
Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3rd ed. Missouri: Mosby 1998.
Nonpharmacological management
Prognosis • Client-dependent • High mortality in first 6 months • Good survival after 6 months, can live over 5 years after diagnosis
• Weight reduction if needed • •
Increased quantities of fiber Portion control
• Regular exercise •
Twice daily walk, recommend 30 minutes after meal
Must maintain consistent daily diet and exercise
Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F
Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F
Insulin Other insulins
• Intermediate-acting insulin, dosed BID. • •
Start at 0.25 units/kg; average dose 0.5 units/kg.
•
U-40 pork lente (Vetsulin)
Administer after meal
• • • • •
•
• Bovine or Human PZI (protamine zinc insulin)
Most similar to canine insulin Duration of action ~ 12 hours
•
Requires U40 syringes
• Human insulin glargine (Lantus)
Exp 42 days once open
• •
U-100 Humulin N (NPH)
• •
Not formally studied in dogs
Less expensive
Duration of action 250 mg/dL Polyuria, polydipsia, polyphagia Impaired jumping, abnormal gait
Fructosamine
• •
•
Blood glucose 200-250 mg/dL
• • •
Persists for a few hours to days
•
Normal BG 70-150 mg/dL
Clinical
• • •
•
• Rule out stress hypoglycemia
No clinical signs
Normal 190-365 umol/L Diagnostic of DM: 350-750 umol/L
No ketones
NO insulin needed Fructosamine level necessary to rule out DM
• Rule out hyperthyroidism • • •
Cats > 7 years old Weight loss Polyphagia Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F
Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215224F
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Complications
Treatment
• Hypoglycemia • Peripheral neuropathy • • •
• Goal •
Remission! Aggressive dietary and insulin therapy may lead to euglycemia without use of insulin 17-67% of cats may achieve remission
•
Nonpharmacological
• •
Plantigrade stance due to hind limb neuropathy Ketoacidosis Pancreatitis
• • •
High protein diet, limit carbohydrates Control portions to control weight Weight loss not to exceed 1-2% weekly Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Zini E, Hafner M, Osto M, et al. Predictors of clinical remission in cats with diabetes mellitus. J Vet Intern Med 2010;24(6):1314-1321.
Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3rd ed. Missouri: Mosby 1998.
Insulin
Clinical Monitoring
• Preferred • •
•
Insulin glargine (Lantus) U100
• • •
Human protamine zinc insulin (PZI) U40
• Inadequate response to Vetsulin—not recommended • Dosing • •
Do not exceed 2 units/ cat even if very large or obese
Blood glucose if motivated owner
•
Every 2 weeks
• •
If BG 180 mmHg Often secondary to renal dysfunction Amlodipine • Dogs 0.3 mg/kg/day, titrate q 2-3 days up to 1 mg/kg/day • Cats 0.625 mg/day titrate to max of 1.25 mg bid • Side effects • Hypotension—avoid with slow titration • Gingival hyperplasia in dogs—d/c if occurs Heart Disease and Heart Failure In: The Merck Veterinary Manual
Questions about Heart Failure?
Most Common Questions • How long should a client use a vial of human insulin on a dog or cat? • What kind of dog receives Vetmedin (pimobendan)? •
Do OTC pain relievers work for pets?
• What are the best ways to administer medication to pets?
Can we recommend any OTC analgesics for Pets? •
Short term use only! • Dogs
• •
• YES! • The vets want to hear from you to check on any concerns or questions. • Vets aren’t all aware of your services • Contact vets near your store to inform them of products you carry or can
Acetaminophen 10-15 mg/kg BID - TID Aspirin 10 mg/kg po BID - TID
•
•
Buffered, NOT enteric-coated
Cats
• •
Should we call the vet when we substitute generic Rimadyl?
NO acetaminophen—TOXIC
order
Aspirin 10 mg/kg every 2 days
• Refer to DVM for chronic pain management D Plumb. Veterinary Drug Handbook
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What about those jerky treats?
• From 2007 to 2014, FDA received > 5000 complaints of illness from
What is the third most common companion animal, after dogs and cats?
jerky-type treats imported from China
• •
3 human illnesses, 1000 canine deaths Necropsies in 72 dogs
• • •
54% clearly died from causes unrelated to jerky treats Could not rule in or out treats as cause in remaining dogs Fanconi syndrome in 5
• FDA found link between some complaints and jerky treats • •
• BIRDS! • Birds often require compounded medications • Birds need concentrated liquid dosage forms • Usually prefer fruit flavors
Avoid jerky treats or any dog treats from China Always wash hands after handling dog food/treats http://www.fda.gov/AnimalVeterinary/NewsEvents/CVMUpdates/ucm434865.htm
Most Common Questions
What is the best way to administer medications to dogs and cats?
• How long should a client use a vial of human insulin on a dog or cat? • What kind of dog receives Vetmedin (pimobendan)? •
Do OTC pain relievers work for pets?
• What are the best ways to administer medication to pets?
Recommendations Drug administration • Dosage forms • • • •
Oral solid (e.g., capsules in smaller strength) Oral liquid (e.g., metronidazle suspension) Topical (e.g., PLO for cats) Injectable (e.g., insulin)
• Safety concerns • •
Aggressive or untrained pets Immunocompromised owner
• •
• Trim cat claws • Wrap cat if necessary • Enlist an assistant • Change dosage form • Hide medication • •
Food like peanut butter or cheese OTC products: Flavor Doh, Pill Pockets
Elderly HIV/AIDs, cancer
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Recommendations
Solid oral dosage form --DOGS • Place dog in “sit-stay” • Approach dog from the side • Place non-dominant hand over muzzle with thumb and fingers on opposite
• Train dog to sit-stay • Handle pets to accustom them to medical care. • Be gentle but firm and confident • ALWAYS praise pet after medication is administered • Use food rewards only if compatible with medication
sides
• Apply pressure with thumb and fingers to cause dog to open mouth • Holding pill in other hand, place medication as far back in throat as possible • Close dog’s mouth and stroke throat until medication is swallowed • Observe dog to ensure medication is retained and swallowed
Solid oral dosage form-- CATS • Position cat for administration • •
If cooperative, cat can be held in lap or placed on table If uncooperative, firmly wrap cat in blanket or towel so that only head is showing
• Follow same steps as for dog
Liquid oral dosage form • Place dog in a sit-stay, or place cat on table or lap • Insert syringe into side of mouth, aiming toward the back of pet’s mouth • Tip head back and depress plunger slowly • Allow time to swallow
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Post-test
Any questions? 1.
The FTC and veterinary organizations have expressed concerns regarding pharmacists’ increased role in dispensing medications for animals. The main focus of these concerns is:
a. b.
Pharmacies have misled clients on the price of the veterinary medications
c.
Pharmacists are not knowledgeable about veterinary medications
Post-test 2. Which of the following best describes the type of diabetes that dogs and cats usually acquire?
a. b. c. d.
Dogs and cats get Type 1 diabetes Dogs and cats get Type 2 diabetes Dogs get Type 1 diabetes and cats get Type 2 diabetes
Pharmacies are not acquiring the additional licensing to dispense veterinary medications
Post-test
2. Pimobendan is a positive inotrope which is approved for use in a. b. c.
Dogs with symptomatic dilated cardiomyopathy Cats with hypertrophic cardiomyopathy Dogs with valvular heart disease
Dogs get Type 2 diabetes and cats get Type 1 diabetes
Post-test 4. A client comes to your pharmacy. She recently filled a prescription for prednisone for her German Shepherd. She admits she has not gotten any of the medication into her dog. He has refused it and now snarls and snaps at her when she comes near him with it. How should you advise her to administer the medication?
a. b. c.
Crush the tablet and sprinkle it on the dog’s food Place the tablet on the tip of the dog’s tongue Hide the tablet in FlavorDoh or a pill pocket and offer it to the dog as a treat
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