Veterinary Pharmacy An Introduction Jennifer A. Kelleher, PharmD, BCPS, FSVHP Compounding Pharmacist

Transcription

1 Veterinary Pharmacy An Introduction Jennifer A. Kelleher, PharmD, BCPS, FSVHP Compounding Pharmacist IVG Veterinary Compounding Pharmacy Massachusetts Veterinary Referral Hospital - Woburn, MA

2 Disclosure I have nothing to disclose.

3 Objectives List common disease states of companion animals that may result in a prescription to a pharmacy Describe the information needed to identify the appropriateness of a veterinary prescription

4 Objectives Explain why certain dosage forms may be inappropriate to dispense Discuss scenarios when a compounded medication could alleviate stress for both owner and pet

5 What is a Companion Animal? The ASPCA believes that companion animals should be domesticated or domestic-bred animals whose physical, emotional, behavioral and social needs can be readily met as companions in the home, or in close daily relationship with humans.

6 2012 U.S. Pet Ownership

7 2012 U.S. Pet Ownership

8 Veterinarian Client Patient Relationship (VCPR) Established when the veterinarian examines the animal The veterinarian agrees to be available for follow up The client agrees to follow the veterinarian s instructions for treatment A VCPR should exist if you are filling a prescription

9 Metabolism/PK Cats are deficient in the enzyme glucuronyl transferase and therefore do not undergo Phase II metabolic glucuronidation What drugs are metabolized by glucuronidation?

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11 Common Disease States & Treatment

12 Thyroid Disorders Hyperthyroidism in cats Methimazole: mg/cat Available in tablets (5 and 10 mg), compounded in to trans-dermal gel/cream, solutions, capsules or chew treats Hypothyroidism in dogs (10 x human dose!!) Levothyroxine sodium: 20 mcg/kg PO BID Max 800 mcg/kg PO BID Plumb s Veterinary Drug Handbook 8 th Edition

13 Addison s Disease Hypoadrenalcorticism Prednisone (glucocorticoid) Dogs: mg/kg PO SID Available as 1, 2.5, 5, 10, 20, 50 mg tablet Intensol 5 mg/ml contains alcohol 5 mg/5ml solution (be careful!) Fludrocortisone acetate (mineralocorticoid) Dogs: 0.02 mg/kg PO SID or divided BID Available as 0.1 mg tablet Plumb s Veterinary Drug Handbook 8 th Edition

14 Seizure Disorders Phenobarbital (CIV) Initial dose (dogs & cats) mg/kg PO q12h Could cause hepatotoxicity in dogs Potassium Bromide (KBr) Dogs mg/kg per day in divided doses Must be compounded Usually mixed in to food or given with food, diet dependent Do not use in cats! Plumb s Veterinary Drug Handbook 8 th Edition

15 Seizure Disorders Cont. Zonisamide Dogs: 5 10 mg/kg PO q12h Cats: 5 mg/kg PO q12-24h Gabapentin Available as 25, 50 and 100 mg capsules Dogs: mg/kg Q6-8h Cats: 5 10 mg/kg Q8-12h Adjunctive therapy Avoid xylitol-containing suspensions in dogs and for pets with moderate to severe renal impairment Plumb s Veterinary Drug Handbook 8 th Edition

16 Seizure Disorders Cont. Levetiracetam Dogs: 5 10 mg/kg PO q12h Cats: 5 mg/kg PO q12-24h 2nd or 3 rd line Available as 25, 50 and 100 mg capsules Clonazepam, Diazepam & Clorazepate (CIV) Tolerance develops quickly 2nd or 3 rd line Hepatic necrosis in cats with benzodiazepines Diazepam PR Plumb s Veterinary Drug Handbook 8 th Edition

17 Chemotherapy Piroxicam or Meloxicam Carcinomas Prednisone/prednisolone Lymphomas, mast cell tumors, or multiple myeloma Melphalan, Lomustine, Chlorambucil or Cyclophosphamide Lymphomas Plumb s Veterinary Drug Handbook 8 th Edition

18 Pain Acetaminophen Aspirin Dogs: mg/kg PO q12h Do not give to cats! Dogs: 10 mg/kg PO Q12h with food (short term) Cats: 10 mg/kg PO Q48-72h with food Never recommend OTC NSAIDs! Plumb s Veterinary Drug Handbook 8 th Edition

19 Pain - NSAIDs in Dogs Meloxicam Etodolac Only for post-op pain in cats Ketoprofen May be given to cats Plumb s Veterinary Drug Handbook 8 th Edition

20 Pain - Opioids Buprenorphine Available as a compounded solution, absorbed transmucosally Tramadol Chronic pain Codeine Can be combined with acetaminophen in dogs Fentanyl Patch Post op pain management or palliative care Plumb s Veterinary Drug Handbook 8 th Edition

21 Pain - Other Gabapentin Chronic pain, incisional pain, arthritis Do not use xylitol-containing suspension in dogs Plumb s Veterinary Drug Handbook 8 th Edition

22 Anxiety Disorders Separation Anxiety SSRIs Fluoxetine and Paroxetine TCAs Clomipramine and Amitriptyline BZDs Alprazolam, diazepam, and clorazepate Buspirone Do you think cats or dogs have more separation anxiety? Plumb s Veterinary Drug Handbook 8 th Edition

23 Anxiety Disorders Generalized Anxiety Disorder - Cats SSRIs Fluoxetine and Paroxetine TCAs Clomipramine and Amitriptyline BZDs Alprazolam, diazepam, clonazepam, lorazepam, oxazepam, clorazepate, chlordiazepoxide Plumb s Veterinary Drug Handbook 8 th Edition

24 Clinical Pearls Toxicities/Adverse Effects - Cats Acetaminophen As little as 40 mg can cause fatal methemoglobinemia NSAIDs Can cause serious renal toxicity Doxycycline can cause serious esophageal strictures or erosions if not given with food and water Permethrin can be toxic to cats 2015 Plumb s Veterinary Medications Guide

25 Clinical Pearls Toxicities/Adverse Effects - Dogs Over-the-counter NSAIDs (e.g. ibuprofen, naproxen, aspirin): Relatively low dosages can cause serious GI bleeding and/or renal toxicity Xylitol (common sweetener, sugar alcohol) can cause life-threatening hypoglycemia and acute hepatic failure Phenobarbital can cause hepatotoxicity 2015 Plumb s Veterinary Medications Guide

26 Clinical Pearls Like in humans, sulfamethoxazole/trimethoprim is dosed on TMP component. Confirm TMP dose with Veterinarian. Cats can not metabolize prednisone into prednisolone. Always question a prescription for prednisone for a cat. Birds may receive medications per nare/per nostril.

27 Clinical Pearls Many antibiotics come in reconstitutable oral suspensions in flavors that human children or people who can not swallow pills may prefer Raspberry doxycycline, cherry clindamycin, or chocolate mint diazoxide Do you think you dog or cat would like those flavors?

28 Clinical Pearls Pill pockets can disguise pills or capsules The human amoxicillin:clavulanate ratio may not be an appropriate for dogs or cats Clavamox 50mg/12.5mg versus Augmentin 400mg/57mg

29 Is a Prescription Appropriate? What Information Do You Need? Species (& breed if available) Sex Age Current Weight (convert to kg if pounds) +/- Diagnosis

30 Is This Prescription Appropriate? Q: Where do I look up the appropriate dose? A: Plumbs Veterinary Drug Handbook - Eighth Edition When in doubt Call the Veterinarian!

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32 Compounded Medications Commonly Available Dosage Forms Capsules Tablets Suspensions (flavored or unflavored) Transdermal creams/gels Medicated chews Solutions Suppositories Ointments

33 Compounded Medications Ideal volume for liquid suspension/solution doses: Large dogs: 1 3 ml Small dogs ml Cats ml Pocket pets, reptiles & birds ml

34 Benefits of Compounded Medications Formulations can be adapted for pets with food sensitivities, allergies or flavor preferences Availability of weight-specific doses of medications that are not commercially available Customized delivery systems to alleviate owner stress associated with giving prescribed medications Continued access to discontinued or short-supply medications