Veterinary Pharmacy: Pearls for the Community Pharmacy 9/23/2016. Disclosures and Conflicts of Interest. Learning Objectives

Transcription

1 Veterinary Pharmacy: Pearls for the Community Pharmacy SHELBY DENNEY, DOCTOR OF PHARMACY CANDIDATE 2017 WASHINGTON STATE UNIVERSITY Disclosures and Conflicts of Interest I consult as a Drug Information Specialist for Plumb s Veterinary Handbook I did not receive any compensation for providing this lecture today Learning Objectives At the completion of this presentation, the pharmacist should be able to: 1. List reliable references relevant to veterinary pharmacy 2. Identify substances toxic to pets 3. Compare and contrast drug dosing/counseling/indication for animal vs. human patients 4. Identify species specific and breed specific differences that affect drug therapy 5. Identify laws and regulations relevant to dispensing veterinary prescriptions 1

2 Learning Objectives At the completion of this presentation, the technician should be able to: 1. List reliable references relevant to veterinary pharmacy 2. Recognize red flags when inputting a prescription for an animal patient 3. Identify laws and regulations relevant to dispensing veterinary prescriptions Importance of Veterinary Education 28,29 NABP Veterinary Pharmacy Education (Resolution ) Encourage development and availability of veterinary pharmacology education at COP s with CVM collaboration Pharmacists dispensing medications for veterinary patients possess the competence and have access to resources necessary to appropriately dispense and provide care. NABP Model Act Requires pharmacies that dispense to pets/animals to have a vet drug reference (like Plumb s) Legal and Regulatory WHAT NOT TO DO 2

3 Brief Overview of Laws AMDUCA and Extra Label Drug Use (ELDU) Food Animals GFI #230 Resources WHERE TO FIND WHAT YOU DON T KNOW Plumb s Veterinary Handbook The Micromedex of the vet drug world! Cost: $85/year for RPh & free for students Medium: Text, web, phone app 3

4 Compendium of Veterinary Products (CVP) Nearly 6000 monographs for Rx and OTC drugs Vaccine info Cost: Free (must create a login) Website: Click resources then Compendium of Vet Products Merck Veterinary Manual Disease state information and Prevention Drug Therapy Cost: Free Website: ASPCA Animal Poison Control Center (APCC) Poison Control/Toxicology plants, foods, meds, etc. Drug Therapy Cost: Free Website: care/animal poison control 4

5 PetPlace.com *great resource for owners* Disease state information/ prevention/ treatment Articles written by veterinarians and vet specialists Cost: Free Website: PetEducation *great resource for owners* Patient Drug Info Sheets Medication Administration Cost: Free Website: Patient Info Sheets: Local Pet Emergency Clinic Know your local emergency clinic! Spokane: Pet Emergency Clinic and Referral Center 21 E. Mission Ave (Corner of Division & Mission) open nights, weekends and holidays 5

6 Legal and Regulatory Resources FARAD: AMDUCA: AVMA s FAQ: and AMDUCA FAQs.aspx Green Book: GFI #230: uidanceforindustry/ucm pdf Toxicology WHAT NOT TO GIVE YOUR PETS Human Foods 2,5,16,21,22,27 FATAL Chocolate Grapes and Raisins Xylitol (found in SF candy/gums) Alcohol Onion, Garlic, Chives AVOID/LIMIT Milk Dairy Citrus Fruits Nuts Large amounts of salt 6

7 Medications 2,16,21,22,27 DOGS APAP, ASA, NSAIDs Sulfa ABX and Sulfonylureas Estrogens CATS APAP, ASA, NSAIDs (including carprofen) Benzoic Acids Opioids Some Benzos (Diazepam) Prednisone Common Pet Prescriptions WHAT PHARMACISTS NEED TO KNOW Hypothyroidism in Dogs 13,16 Dogs >> Cats Signs and Symptoms: Dry skin & excessive hair loss Weight gain (no change in appetite) Lethargic, tires easily Obesity/weight gain Aggression??? 7

8 Levothyroxine 16 Kinetics: Low bioavailability + short half life (12 16 hours) Dosing (Dogs): Initial: 0.02 mg / kg (= 20 mcg / kg) Q12h Do not initiate at more than 0.8 mg Q12h Give on an empty stomach (food decreases bioavailability) Signs of overdose: pan ng, thirst, nervousness, excitability, HR Other considera ons: hypothyroid dogs have CrCl Hyperthyroidism in Cats 6,16,23 Cats >> Dogs Signs and Symptoms: Weight loss (despite increased appetite) Increased activity, restless, irritable Decreased grooming Seeking cool places Diagnosis: TT 4 Treatment: Methimazole + beta blocker Methimazole 16 Dosing (Cats): 2.5 mg po Q12h Titrate by 2.5 mg after 3 weeks Max: 20 mg (10 mg BID) Very bitter transdermal gel Not safe in pregnancy or lactation ADR s: Vomiting, lethargy, itching, jaundice Serious ADR s: renal or liver failure Other formulations: transdermal gel 8

9 Tramadol 16 Pearls: Use IR formulation Do not use APAP formulation in cats Dosing Dogs: 4 10 mg/kg po TID Cats: 1 2 mg /kg po BID *recommended dosing no standard dosing available* Up to 2 weeks for full effect ADR s: sedation, agitation, GI disturbances, increase seizure risk Cats may avoid due to taste Give with or without food Interactions: Avoid with SSRI s Carprofen (Rimadyl ) 16 MOA: NSAID inhibits COX 1 and COX 2 Indications: arthritis and surgical pain Pearls: Do not use oral form in cats ADR s: vomiting, diarrhea, GI ulcers, bleeding, pancreatitis Fluoxetine 1,16 Reconcile flavored, chewable tablet Indication: separation anxiety, anxiety, aggression, OC behavior, marking/spraying (cats) Dosing: Dogs: 1 2 mg/kg po daily Cats: mg /kg po daily 9

10 Fluoxetine weeks to see changes and 4 8 weeks for full benefit ADR s: lethargy, anxiety, aggression, decreased appetite Interactions: NSAIDs, tramadol, flea collars/dips Taper needed if treated > 8 weeks Pearls: Caution in pets with diabetes affects BG and insulin requirements Half life Humans: 2 3 days for fluoxetine & 7 9 days for norfluoxetine Dogs: 6 hours for fluoxetine & ~2 days for norfluoxetine Often compounded as a transdermal gel for cats Amitriptyline 1,16 Indication: separation anxiety, anxiety, aggression, OC behavior, marking/spraying (cats), neuropathic pain and itching, UTI s (cats), feather plucking (birds) Dosing: Dogs: 1 4 mg/kg Q12h Cats: mg QD or mg BID ADR s: fatigue, dry mouth, constipation ensure access to water Interactions: flea collars Pearls: Clomipramine (Clomicalm) is FDA approved in dogs Transdermal absorption in cats is poor Cats more sensitive to TCA s than dogs Monitoring: CBC and EKGs Recognizing a Seizure 14,15,20,23,25 Signs/Symptoms: Pre Seizure: anxious, stressed, scared, clingy, vocalization During a Seizure: urinate/ defecate, stiffen, twitching, faint or collapse, biting Post Seizure: disoriented, tired, hyperthermia Keep pet cool post seizure Stay away from head/mouth during a seizure Important to time length of seizure Get pet away from furniture, stairs, etc. 10

11 Phenobarbital 16,19,23 Dosing: Dogs: mg/kg po q12h Cats: 1 3 mg/kg po q12h Monitoring: serum phenobarbital levels, CBC, LFT s (dogs), bilirubin Give at same times everyday Give with or without food ADRs at ini a on: fa gue, thirst/appe te, urination KBr or NaBr Likely compounded 16,23 Added if phenobarbital alone does not work Limit salt intake VERY long half live (1 month to reach therapeutic levels) MUST GIVE LOADING DOSE Monitoring: serum phenobarbital levels, CBC, LFT s (dogs), bilirubin ADRs at ini a on: fa gue, thirst/appe te, urination Prednisone/Prednisolone 16,19 ADRs: thirst/hunger/urina on, pan ng, ulcers (dogs) Allergy skin testing: D/C at least 14 days prior Tapering necessary! Give with food Pearls Cats do not convert prednisone prednisolone 11

12 Congestive Heart Failure 23,26 Signs/Symptoms: Cough (dogs), tachypnea, lethargy, exercise intolerance Treatment 1. Loop Diuretic (Furosemide) preload, pulmonary edema 2. Positive Inotrope cardiac contrac lity 3. ACE Inhibitor (enalapril or benazepril) vasodilator Pearls: Approved vet formulation of Lasix (Salix) Pimobendan (Vetmedin) approved positive inotrope of choice for dogs Enalapril (Enacard) approved ACE I for dogs and cats Furosemide 16 Dosing: mg/kg po QD or BID (dogs and cats) Counseling ADRs: urina on (do not limit water), ototoxicity (cats) Monitor: weight, Pearls: For human injectable solution do not use if contains yellow coloring Diazepam 16 Dosing Dogs: mg/kg po Counseling ADRs: sleepiness, excitability, aggression, appe te (cats) Pearls Do not use in cats Tolerance can occur when used for seizure 12

13 Diabetes 3,4,8 12,17 Dogs Type 1 DM (99%) Oral agents not used Normal: mg/dl Cats Type 1 DM (~30%) Type 2 DM (~70%) Oral agents may be used in T2DM Serum Fructosamine: 1 2 week indicator for diabetes control Diabetes Resources Diabetes in Dogs: conditions of dogs/hormones bodychemistry/diabetes in dogs a guide to understanding and treating your dog Guide to a Diabetic Cat: conditions of cats/hormones bodychemistry/guide to a diabetic cat what you need to know to effectively care foryour cat Home Monitoring: conditions of dogs/hormones bodychemistry/home monitoring of the diabetic dog with a glucometer Multidrug Sensitivity in Dogs 13

14 MDR1 Testing at WSU 24 Breeds: Herding dogs Drugs: Ivermectin, Milbemycin, moxidectin, selamectin Loperamide Acepromazine Butorphanol Many chemo agents Frequency of MDR1 Mutations 24 Breed Frequency Breed Frequency Australian Shepherd 50 % Old English Sheepdog 5 % Mini Australian Shepherd 50 % Shetland Sheepdog 15 % Border Collie < 5 % English Shepherd 15 % Collie 70 % German Shepherd 10 % *Adapted from Washington State University s College of Veterinary Medicine Veterinary Clinical Pharmacology Lab Considerations THINGS TO KEEP IN MIND 14

15 Considerations for New Prescriptions 16 SID used instead of QD SID (semel in die) = once a day QD (quaque die) = each day Veterinarians do not have NPI numbers Biological Considerations 16,31 Different CYPs = Different Drug Metabolism Dogs have much greater blood/kg than human Dogs have faster GFR Cats have little to no ability to undergo several metabolic pathways Humans are vertical. Dogs and cats are horizontal! More Biological Considerations 16,30,31 Brachycephalic breeds vs dolichocephalic breeds Dogs have much more acidic stomach Variation in GI transit times Different normal for vitals 15

16 Ingredients to Avoid 7,16,18,27 Dogs Sweeteners/Flavors/Colors: xylitol, aromatic amines Preservatives: ethanol, thimerosal, ethoxyquin Surfactants: polysorbate 20 & 80, polyethoxylated castor oil Cats: Colors: azo dyes Benz Essential Oils (peppermint oil) Ethanol, propylene glycol QUESTIONS? HAPPY HOWL OWEEN Resources 1. Amitraz Toxicity in Dogs and Cats. Amitraz Toxicity in Dogs and Cats, 2. Animal Poison Control. ASPCA, care/animal poison control. Accessed Sept. 22, Diabetes Mellitus in Dogs. VCA Animal Hospitals, healthinformation/article/animal health/diabetes mellitus in dogs/ Diabetes Mellitus in Dogs. VCA Animal Hospitals, healthinformation/article/animal health/diabetes mellitus in dogs/ Foods You Should Not Feed Your Cat. Foods You Should Not Feed Your Cat, 6. Johnny D. Hoskins DVM PhD DACVIM. Hyperthyroidism: Cats Can Live a Normal Life. dvm360.com, 16 July 2014, cats can live normal life. Accessed Sept. 22, Peterson ME. Topics in Companion Animal Medicine. Xylitol. 28:1 (2013). 8. PetPlace.com. Diabetes in Cats. Diabetes in Cats, 1 July 2015, conditions of cats/hormones body chemistry/diabetes incats. 16

17 Resources 9. PetPlace.com. Diabetes in Dogs A Guide to Understanding and Treating Your Dog. Diabetes in Dogs A Guide to Understanding and Treating Your Dog, 28 Sept. 2015, conditionsof dogs/hormones body chemistry/diabetes in dogs a guide to understanding and treating your dog. Accessed Sept. 22, PetPlace.com. Diabetes Mellitus in Dogs. Diabetes in Dogs, 26 Aug. 2015, conditions of dogs/hormones body chemistry/diabetes in dogs. 11. PetPlace.com. Home Monitoring of Diabetic Dogs. Home Monitoring of Diabetic Dogs, 10 Sept. 2015, aid for dogs/nursing care for sick dogs/home monitoring of diabeticdogs. 12. PetPlace.com. Home Monitoring of the Diabetic Dog with a Glucometer. Home Monitoring of the Diabetic Dog with a Glucometer, 10 Sept. 2015, conditions of dogs/hormonesbody chemistry/home monitoring of the diabetic dog with a glucometer. 13. PetPlace.com. Hypothyroidism It Makes Buster a Dull Dog. Hypothyroidism It Makes Buster a Dull Dog, 27 Sept. 2015, conditions of dogs/features/hypothyroidism %e2%80%93 itmakes buster a dull dog. 14. PetPlace.com. Seizure Disorders in Cats. Seizure Disorders in Cats, 3 Aug. 2015, conditions of cats/symptoms/seizure disorders in cats. Accessed Sept. 22, Resources 15. PetPlace.com. Seizure Disorders in Dogs. Seizure Disorders, 22 July 2015, conditions of dogs/symptoms/seizure disorders in dogs. 16. Plumb's Veterinary Drugs. Plumb's Veterinary Drugs, Accessed Sept. 22, Thompson A, Lathan P, Fleeman L. Dovepress. Update on insulin treatment for dogs and cats: insulin dosing, pens and more. 6(2015) Weiszhar Z et al. European Journal of Pharmaceutical Sciences. Complement activation by polyethoxylated pharmaceutical surfactants: Cremophor EL, Tween 80 and Tween :4 (2012) Riviere, J. Edmond, and Mark G. Papich. Veterinary Pharmacology and Therapeutics. Ames, IA, Wiley Blackwell, Seizures in Cats (Feline Epilepsy). Seizures in Cats (Feline Epilepsy), Sharon Gwaltney Brant DVM PhD DABVT DABT Irina Meadows DVM DABT. Toxicology Brief: The 10 Most Common Toxicoses in Dogs. dvm360.com, 29 Oct. 2014, 10 most common toxicoses dogs?id=&sk=&date=&%0a%09%09%09&pageid=5. Accessed Sept. 22, Resources 22. Sharon Gwaltney Brant DVM PhD DABVT DABT Irina Meadows DVM DABT. Toxicology Brief: The 10 Most Common Toxicoses in Dogs. dvm360.com, 29 Oct. 2014, brief 10 most common toxicosesdogs?id=&sk=&date=&%0a%09%09%09&pageid= Tilley, Larry P. et al. Blackwell's Five Minute Veterinary Consult: Canine and Feline, 6th Edition. John Wiley &Amp; Sons, Veterinary Clinical Pharmacology Lab. Washington State University VCPL, Weiss Roessler, By Josh. How to Recognize and Handle Dog Seizures. Cesar's Way, 25 Feb. 2016, and care issues/how to recognize and handle dog seizures. 26. Elaine Blythe. Veterinary Therapeutics. University of Florida. January PCCA. Veterinary Compounding. Principles of Toxicology. PCCA. September NABP. Veterinary Pharmacy Education (Resolution ). pharmacy education resolution May NABP. Model Act. act. August PCCA. Veterinary Compounding. Anatomical and physiological considerations for drug therapy in non human species. PCCA. September Tibbitts J. Toxicologic Pathology. Issues related to the use of canines in toxicologic pathology issues with pharmacokinetics and metabolism. 31(2003) DOI: /