Common Questions when Caring for Veterinary Patients in ... - vet pharm slides ipha... · Caring...

Common Questions when Caring for Veterinary Patients

in Community PharmacyMelissa Hogan, Pharm.D.

Associate Professor and Chair,

Department of Clinical and Administrative SciencesRoosevelt University College of Pharmacy

ObjectivesPharmacists

• Discuss current issues in dispensing medications for pets

• Describe key points in the pharmacological management of diabetes in dogs and cats, including the role of Vetsulin®

• Describe key points in the pharmacological management of heart failure in dogs and cats, including the role of pimobendan(Vetmedin®)

• Identify for a client on proper methods of drug administration in their dog or cat

At the conclusion of this program, the pharmacist will be able to:

ObjectivesPharmacy Technicians

• 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 failure

• Name the benefits of drug administration aides for dogs and cats

At the conclusion of this program, the pharmacy technician will be able to:

Introduction

5

Benefits of pets for human health

• Physical

• Social

• Psychological

REFERENCEShttp://www.cdc.gov/healthypets/health_benefits.htm

http://newsinhealth.nih.gov/pdf/NIHNiH%20Feb09.pdf

What is new in Veterinary Pharmacy?

• H.R. 3174 / S. 1200 Fairness to Pet Owners Act of 2015

• AVMA position

• FTC Letter

• What is the problem?

• What is the solution?

ReferencesS. 1200 Fairness to Pet Owners Act. WWW.Govtrack.USCompetition in the Pet Medication Industry. FTC Staff report. May, 2015

Pharmacists’ FAQs

about Pet Meds

8

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?

Managing Diabetes in Dogs and Cats

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

Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3rd ed. Missouri: Mosby 1998.

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.

Diagnosis• 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

• Clinical diabetes

• Fasting BG > 200 mg/dL

• Classic presentation (like humans)

• Polyuria, polydipsia, polyphagia, lethargy

• If not noticed and treated:

• Sudden blindness due to cataracts

• Diabetic ketoacidosis


Goals of Therapy

• Maintain BG between 100 – 180 mg/dL

• Avoid hypoglycemia

• Avoid complications of hyperglycemia

• Cataracts, blindness

• UTI, respiratory and skin infections

• Chronic pancreatitis

• Ketoacidosis

Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F

Prognosis

• Client-dependent

• High mortality in first 6 months

• Good survival after 6 months, can live over 5 years after diagnosis


Nonpharmacological management

• 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


Insulin

• Intermediate-acting insulin, dosed BID.

• Start at 0.25 units/kg; average dose 0.5 units/kg.

• Administer after meal

• U-40 pork lente (Vetsulin)

• Most similar to canine insulin

• Duration of action ~ 12 hours

• Requires U40 syringes

• Less expensive

• Exp 42 days once open

• U-100 Humulin N (NPH)

• Duration of action <12 hr


Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F.

Fracassi, et al. Use of insulin glargine in dogs with diabetes mellitus. Veterinary Record 2012; 170, 52.

Other insulins

• Bovine or Human PZI (protamine zinc insulin)

• Not formally studied in dogs

• Human insulin glargine (Lantus)

• Dosed BID in dogs


Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F. Fracassi, et al. Use of insulin glargine in dogs with diabetes mellitus. Veterinary Record 2012; 170, 52.

Blood glucose monitoring

• Blood glucose

• Weekly for 4 weeks after initiation

• Exam and blood glucose curve

• Adjust insulin

• Continue until controlled

• Long term home monitoring

• Daily for clinical signs, food/water intake, insulin dose

• Weekly body weight

• Blood glucose two weeks after adjustment, monthly when stable

• Daily home monitoring ideal


Clinical Monitoring

• Every 3 months

• Physical and eye exam

• Blood glucose

• Fructosamine (control over past 2-4 weeks, not affected by stress hyperglycemia)

• Normal: 225-365 mmol/L

• Goal (DM): 350-400 mmol/L

• Blood glucose curve if needed

• Every 6 months

• Full lab workup: CBC, chem, electrolytes, U/A, urine culture


Diabetes in Cats

• Prevalence

• Cats: 1 in 200

• Predominantly neutered males

• Age 8 – 13 years

• More common in Burmese cat



Background

• Pathophysiology

• Type 2 diabetes mellitus

• Insulin resistance with B cell dysfunction

• May be reversible with rapid glycemic control

• Etiology

• Obesity

• Lack of activity

• High carbohydrate diet

• Corticosteroids


Presentation

• Subclinical

• No clinical signs

• Glucose between 150 to 250 mg/dL

• Normal BG 70-150 mg/dL

• May be caused by stress

• Clinical

• Persistent BG >250 mg/dL

• Polyuria, polydipsia, polyphagia

• Impaired jumping, abnormal gait

• Fructosamine

• Normal 190-365 umol/L

• Diagnostic of DM: 350-750 umol/L


Diagnosis

• Rule out stress hypoglycemia

• Blood glucose 200-250 mg/dL

• No ketones

• Persists for a few hours to days

• NO insulin needed

• Fructosamine level necessary to rule out DM

• Rule out hyperthyroidism

• Cats > 7 years old

• Weight loss

• Polyphagia


Complications

• Hypoglycemia

• Peripheral neuropathy

• Plantigrade stance due to hind limb neuropathy

• Ketoacidosis

• Pancreatitis


Treatment

• Goal

• Remission!

• Aggressive dietary and insulin therapy may lead to euglycemia without use of insulin

• 17-67% of cats may achieve remission

• Nonpharmacological

• 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.

Insulin

• Preferred

• Insulin glargine (Lantus) U100

• Human protamine zinc insulin (PZI) U40

• Inadequate response to Vetsulin—not recommended

• Dosing

• In average cat, start at 1 unit/cat q12 hours

• Do not exceed 2 units/ cat even if very large or obese

• Monitor for hypoglycemia

• If BG<150 mg/dL, reduce dose by 0.5 unit


Clinical Monitoring

• Daily

• Food/water intake

• Insulin dose, signs of hypoglycemia

• Blood glucose if motivated owner

• Weekly

• BG 6-8 h post insulin dose

• Every 2 weeks

• Urine dipstick for glucose and ketones

• If 3 consistent negative urine glucose, possible remission

• Every 3 months

• Return to vet for fructosamine level


Client Education for Dogs and Cats with Diabetes

29

Client education

• Insulin administration

https://www.youtube.com/watch?v=i93tscgFu5I

• Blood glucose monitoring

• Ear, inner lip, elbow callus

https://www.youtube.com/watch?v=N-HoadHq4CM

https://www.youtube.com/watch?v=i93tscgFu5I

https://www.youtube.com/watch?v=N-HoadHq4CM

Key Counseling Points

• Disease is manageable; do not need to euthanize pet

• Encourage consistent diet and exercise

• Modify diet if needed

• Portion control is necessary; have client measure food

• Avoid excessive treats


• Greatest risk of death in dogs and cats is due to hypoglycemia

• Difficult to assess

• Should see low level of glucose in urine or test BG

• May reduce/hold insulin if low glucose

• DO NOT increase insulin without DVM advice

• Stress hyperglycemia should NOT be treated with increased insulin dose

• Administer insulin AFTER pet eats meal

• If hypoglycemic

• Rub honey/karo syrup/maple syrup on gums or apply to paw

• Provide meal when pet can eat

• Bring to DVM immediately if loss of consciousness


• Be sure client gets correct syringes for insulin

• U40 for Vetsulin; U100 for Humulin, Lantus

• Use standard ½ inch , 29 gauge needles

• How long can clients use vial of insulin?

• As long as vet says they should OR

• As long as continue to get adequate control OR

• Until gone

Why might this approach be ok??

Questions about Diabetes?

Pimobendan• Vetmedin (U.S.--veterinary); Acardi (Japan—human)

• Mechanism of Action

• Phosphodiesterase III inhibitor

• Positive inotrope—calcium sensitizer

• Peripheral vasodilation, decreased afterload

• Indications

• Canine chronic valvular heart disease and dilated cardiomyopathy

• NOT for use in asymptomatic heart disease or hypertrophic cardiomyopathy in dogs

Sonya G. Gordon, Matthew W. Miller, and Ashley B. Saunders (206) Pimobendan in Heart Failure Therapy – A Silver Bullet? Journal of the American

Animal Hospital Association: March/April 2006, Vol. 42, No. 2, pp. 90-93.

ACVIM Consensus Statement J Vet Intern Med 2009;23:1142–1150

Mitral Valve Dysplasia

• Pathophysiology

• Murmur on exam

• Left-sided heart failure: pulmonary congestion (dogs), effusion (cats)

• May progress to right-sided heart failure

• Presentation

• Murmur on exam

• Pulmonary congestion cough

• If progresses to right-sided heart failure ascites

• Breed predilection

Cavalier King Charles Spaniel, Schnauzer, Poodle

Heart Disease and Heart Failure In: The Merck Veterinary Manual

Mitral Valve Dysplasia--Treatment

• ACE inhibitors

• AE: Diarrhea

• Start low, go slow on dosing

• Enalapril 0.5mg/kg PO bid – approved for dogs

• If not tolerated, try a different ACEI

• Lisinopril, benazepril, captopril

• Diuretics

• Furosemide or HCTZ and/or spironolactone

• Use lowest effective dose and titrate to response


Mitral Valve Dysplasia -- Treatment

• Positive inotrope

• Digoxin—cheaper! Must monitor levels to get therapeutic

• Pimobendan (Vetmedin)

•Dosing: 0.2-0.3 mg/kg po bid

•Adverse effects

• Vomiting and loose stools

• Rare, self-limiting

Sonya G. Gordon, Matthew W. Miller, and Ashley B. Saunders (206) Pimobendan in Heart Failure Therapy – A Silver Bullet? Journal of the American Animal Hospital Association: March/April 2006, Vol. 42, No. 2, pp. 90-93.ACVIM Consensus Statement J Vet Intern Med 2009;23:1142–1150

Dilated Cardiomyopathy

• Pathophysiology

• Cardiac muscle stretches, develop arrhythmia

• Genetic disorder common in Boxers, Dobermans, Great Danes, Basset hounds

• Presentation: syncope, weight loss, sudden death

• Treatment

• Antiarrhythmics as needed to manage clinical signs

• Pimobendan—early treatment MAY prolong life

• Taurine supplementation

• American Cocker Spaniel


CHF in Cats

• Hypertrophic cardiomyopathy

• Genetic predisposition in feral and mixed breed cats—effectively eliminated from purebred cats

• Severe disease occurs early in life; milder forms take longer to progress

• Typically present with clot or sudden death


Hypertrophic Cardiomyopathy in Cats

• Treatment• Atenolol 6.25 – 12.5 mg q 12-24 hr

• May not improve survival

• Diltiazem 7.5 mg q 8-12 hrs

• Furosemide 0.5 -1 mg/kg/day

• Enalapril 0.5 -5 mg/kg/day

• Monitor for electrolyte imbalances, renal function

• Manage systolic dysfunction with pimobendan NOT digoxin

• Use of pimobendan in cats is unapproved but has shown promise

• 0. 25 mg/kg bid


Considerations in managing Dogs and Cats with CHF

• Compliance with medications improves survival

• When possible, select medications the owner is taking

• If one ACE inhibitor causes side effects, try another

Systemic Hypertension in Dogs and Cats

• Diagnosis

• Systolic BP > 180 mmHg

• Pathophysiology

• Often secondary to renal dysfunction

• Treatment

• 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


Questions about Heart Failure?

Can we recommend any OTC analgesics for Pets?

• Short term use only!

• Dogs

• Acetaminophen 10-15 mg/kg BID - TID

• Aspirin 10 mg/kg po BID - TID

• Buffered, NOT enteric-coated

• Cats

• NO acetaminophen—TOXIC

• Aspirin 10 mg/kg every 2 days

• Refer to DVM for chronic pain management

D Plumb. Veterinary Drug Handbook

Should we call the vet when we substitute generic Rimadyl?

• 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 order

What about those jerky treats?

• From 2007 to 2014, FDA received > 5000 complaints of illness from 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

• 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

What is the third most common companion animal, after dogs and cats?

• BIRDS!

• Birds often require compounded medications

• Birds need concentrated liquid dosage forms

• Usually prefer fruit flavors

What is the best way to administer medications to dogs and cats?

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

• Elderly

• HIV/AIDs, cancer

Recommendations

• 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

Recommendations

• 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

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 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

Any questions?

Post-test

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. Pharmacies have misled clients on the price of the veterinary medications

b. Pharmacies are not acquiring the additional licensing to dispense 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. Dogs and cats get Type 1 diabetes

b. Dogs and cats get Type 2 diabetes

c. Dogs get Type 1 diabetes and cats get Type 2 diabetes

d. Dogs get Type 2 diabetes and cats get Type 1 diabetes

Post-test

2. Pimobendan is a positive inotrope which is approved for use in

a. Dogs with symptomatic dilated cardiomyopathy

b. Cats with hypertrophic cardiomyopathy

c. Dogs with valvular heart disease

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. Crush the tablet and sprinkle it on the dog’s food

b. Place the tablet on the tip of the dog’s tongue

c. Hide the tablet in FlavorDoh or a pill pocket and offer it to the dog as a treat

Common Questions when Caring for Veterinary Patients in ... - vet pharm slides ipha... · Caring...

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