hand Give em a TICK CONTROL What to watch for Offer less to get more ID ing and treating 3 tick-borne diseases What tick is this?

Transcription

1 With an educational grant provided by: TICK CONTROL Give em a hand Canine tick-borne disease is no picnic, and sometimes it s difficult to feel confident with your patient care protocol. Here s a crash course to get over the hump. p2 April 2017 dvm360.com/toolkit What to watch for Tick-borne disease in cats...6 Offer less to get more Audio tips from an expert:...8 ID ing and treating 3 tick-borne diseases in dogs...10 What tick is this? A tool to help A compelling conversation about ticks in the city.. 13 Talking to ticked-off clients Client handouts > How to check for ticks > Removing ticks...18 > Creating a tick-free backyard...19 Two ideas to talk ticks on social media...20 Go old school use a whiteboard to educate clients...22 ES903763_dvmtoolkit0417_001.pgs :55

2 Canine tick-borne diseases: When to treat a positive patient-side test result Don t feel bad if you re not sure, veterinarians. Tick-borne disease is a pain, says this CVC educator, and nobody really feels like they know what they re doing. Now dive in for his crash course to get over that hump By Sarah Wooten, DVM At a recent session on vector-borne diseases in dogs, CVC educator Adam Birkenheuer, DVM, PhD, DACVIM, leads with this joke: What is the No. 1 presenting complaint of ehrlichiosis in a dog? A wellness exam. First scenario: You just completed a wellness exam on an apparently healthy, 3-year-old Labrador retriever that s bouncing off the wall. Everything looks good until 2 April 2017 dvm360.com/toolkit you check the result on your patient-side, rapid diagnostic test and see a positive result for Ehrlichia canis. What do you do next? Second scenario: A dog presents with fever, thrombocytopenia, proteinuria and painful joints, but the test results are negative. What do you do next? Don t feel bad if you re not sure. In the words of Dr. Birkenheuer, tick-borne disease is kind of a pain and nobody really feels like they know what they re doing. In tick-borne disease, signs are caused by Type 2 and/ or Type 3 immune-mediated hypersensitivities that affect multiple systems in the body, and the same pathogen in the same host can cause completely different signs. Furthermore, tick-borne diseases can be difficult to replicate in laboratory settings, making them difficult to completely understand. However, despite all that, Dr. Birkenheuer has some recommendations that RUNA KAZAKOVA/SHUTTERSTOCK.COM ES903711_dvmtoolkit0417_002.pgs :39

3 may help you communicate to clients, choose appropriate diagnostics and make treatment recommendations for tickborne disease. Positive test results for tickborne infections in apparently healthy animals can occur, but what do they mean? These inhouse tests detect the presence of serum antibodies to tickborne organisms (e.g. Borrelia burgdorferi, Anaplasma phagocytophilum/anaplasma platys, Ehrlichia canis/ehrlichia ewingii/ehrlichia chaffeensis). The detection of antibodies indicates exposure to diseasecausing organisms; the presence of antibodies does not always indicate disease. So keep in mind that these tests should be used to screen for exposure and not to definitively diagnose an active infection or disease. What do you do with a healthy dog that has a positive test result? First, before testing, Dr. Birkenheuer recommends controlling the pet owner s expectations of what the test can detect. Instead of telling your client that you are testing for tick-borne disease, explain that you ll be testing to see whether her dog has been exposed to ticks and some of the infections they carry. Dr. Birkenheuer cautions against fearmongering your clients are less likely to freak out if you tell them that their dogs have been exposed to ticks vs. that their dogs have Lyme disease. In regards to positive test dvm360.com/toolkit April ES903707_dvmtoolkit0417_003.pgs :37

4 to screen for include anemia, thrombocytopenia, hyperglobulinemia and proteinuria. Sometimes the changes are subtle. Dr. Birkenheuer recommends treating any dog with a platelet count lower than 200,000. If the platelets counts don t increase adequately in serial CBCs, then look for another cause of thrombocytopenia. He also recommends re-evaluating the dog once more and performing a fundic examination to look for retinal lesions. Any abnormalities? Treat with tetracyclines Dr. Birkenheuer recommends doxycycline or minocycline (10 mg/kg/day for 28 days). What do you do if the owner won t approve further testing or if further tests don t show abnormalities? At present, there are no clear evidence-based recommendations, Dr. Birkenheuer says, so the decision needs to be made by you and the client you give the information and the client helps make the decision. It helps if your practice partners develop similar styles and education plans for owners to minimize confusion. What would Dr. 4 April 2017 dvm360.com/toolkit RUNA KAZAKOVA/SHUTTERSTOCK.COM ES903710_dvmtoolkit0417_004.pgs :39

5 Sarah Wooten, DVM, divides her professional time between private practice at Sheep Draw Veterinary Hospital in Greeley, Colorado, and writing articles and filming video content for various media outlets. dvm360.com/toolkit April ES903708_dvmtoolkit0417_005.pgs :37

6 Tick-borne disease in cats: What to watch for Things are changing for feline vectorborne disase. If you thought you lived in a state where ticks weren t a problem, you might want to check again they may be advancing into your area soon. Read on for an update on cytauxzoonosis and its effect on cats. By Elizabeth Colleran, DVM, DABVP Cytauxzoon felis is a protozoan blood parasite transmitted via the bite of an infected tick. Bobcats (Lynx rufus) are the reservoir host; infected bobcats are believed to develop shortlived illness followed by clinical recovery and a persistent carrier state. When a tick feeds on an infected bobcat, the tick acquires the pathogen. If that tick then feeds on a domestic cat, infection typically leads to severe illness (cytauxzoonosis) and often death. Amblyomma americanum, the lone star tick, is considered the predominant vector of C. 6 April 2017 dvm360.com/toolkit felis. During feeding, the tick inoculates sporozoites that enter host mononuclear cells and multiply. Infected mononuclear cells distend with organisms known as schizonts. The multinucleated schizonts divide into merozoites. Within days, merozoites rupture from the mononuclear cells and are taken up by red blood cells (RBCs) where they appear as piroplasms. Widespread dissemination of schizonts results in parasitic thrombosis, circulatory impairment, tissue infection and a severe systemic inflammatory response, which can lead to multiorgan dysfunction and failure and death within three weeks of infection. Many cats die within 24 hours of presentation to a veterinary clinic. In cats that survive initial infection, late-stage disease involves erythroparasitemia piroplasm structures within RBCs) that are readily observed in blood smears. Piroplasms persist for months, years or even for life in these cats, although schizonts can no longer be found. Chronic erythroparasitemia is relatively benign. Recovered domestic cats are competent to transmit the pathogen to feeding ticks, but C. felis cannot be transmitted through physical SERGEY SMOLENTSEV/SHUTTERSTOCK.COM ES903776_dvmtoolkit0417_006.pgs :11

7 Cytauxzoonosis in domestic cats Infection with Cytauxzoon felis has been reported in these U.S. states. Source: Merck Veterinary Manual, Dr. Elizabeth Colleran contact between infected cats. Since the first reported case of cytauxzoonosis was recognized in Missouri in 1976, its range has progressively expanded. To date cytauxzoonosis has been confirmed in domestic cats in 17 states (see map). The pathogen has been documented in bobcats in Pennsylvania and North Dakota, where ill domestic cats have not yet been reported. The increase in range is likely due to expansion in the range of the A. americanum population, hypothesized to be linked to an expanding white-tailed deer population. Veterinarians in areas where lone star ticks are found but cytauxzoonosis has not yet been recognized should be vigilant for the disease. In most cats affected by cytauxzoonosis, initial disease signs include fever, anorexia and lethargy. Tachypnea and tachycardia are commonly observed. Within days, clinical signs can progress to severe weakness, icterus, respiratory distress and neurologic dullness. Diagnosis can be made by identification of piroplasms in erythrocytes during microscopic examination of a peripheral blood smear. PCR assays have been developed to confirm the presence of C. felis, but so far they are not useful as a quick diagnostic tool in practice. Still, samples from suspected cats should be submitted to a laboratory to confirm infection. One clinical trial has demonstrated better survival rates (60% versus 26%) with the combination of atovaquone and azithromycin compared with imidocarb in 80 cats with acute disease. 1 Supportive treatment was the same in all cats, suggesting that this antiprotozoal combination plus supportive care is the current approach of choice. In some cats nasoesophageal or esophagostomy tube may be needed to administer drugs and enteral feeding. There is currently no vaccine against C. felis, so prevention is based on living indoors or use of effective tick treatment in cats with outdoor access. Efficacy of an acaricide collar (imidacloprid 10% plus flumethrin 4.5%) for prevention of C. felis reported in domestic cats C. felis reported in bobcats only C. felis transmission has been proven in a controlled prospective clinical trial. 2 In the study two groups of cats were exposed to A. americanum ticks infected with C. felis. No cats with a collar were infected, versus 90% of the cats without a collar. References 1. Cohn LA, Birkenheuer AJ, Brunker JD. Effi cacy of atovaquone and azithromycin or imidocarb dipropionate in cats with acute cytauxzoonosis. J Vet Intern Med 2010; 25: Reichard MV, Thomas JE, Arther RG. Effi cacy of an imidacloprid 10%/fl umethrin 4.5% collar (Seresto, Bayer) for preventing the transmission of Cytauxzoon felis to domestic cats by Amblyomma americanum. Parasitol Res 2013; 112 Suppl 1: Dr. Elizabeth Colleran is the owner of Chico Hospital for Cats in Chico, California, and a frequent speaker at the CVC conferences. dvm360.com/toolkit April ES903775_dvmtoolkit0417_007.pgs :10

8 Offer less to get more Though it may sound counterintuitive, offering fewer choices for fl ea and tick control can lead to more sales and more satisfi ed veterinary clients. CVC educator and veterinary practice consultant Bash Halow, LVT, CVPM, recounts an interesting interaction he witnessed while observing a veterinary hospital one day: A woman walked in at around 5:30 p.m. probably straight from work and asked the client care representative what flea and tick product she should get for her pet. Now, there were probably seven different products offered by this hospital that the person could be sold, and the client care representative launched into a litany of questions to try to determine the best fit for the pet. At the end of the interrogation, the representative said, Well you know, based on what you ve told me, all of these products are really good. So go ahead and pick one. This is a bad approach, Halow says. Most consumers freeze up when they have too many choices. Your job is not to be Walmart you re not an aisle of flea and tick products, he explains. 8 April 2017 dvm360.com/toolkit SARAH2/SHUTTERSTOCK.COM ES903739_dvmtoolkit0417_008.pgs :47

9 Instead, Halow says your message should be: I don t need to offer you a wall of products. I know all about that wall. This is the best product for your pet. Buy this one. If they refuse your recommendation, you can send them to your online store to check out additional options. Halow s approach has scientific backing. According to the 2006 Harvard Business Review article, More isn t always better, research has shown that when consumers have too many choices they are less likely to buy anything. And even if they do end up buying something, they are less likely to be satisfied with their choice. So instead of picking your clients brains with a bunch of questions, pick a flea and tick preventive and be ready to explain why you, the expert, know it s the best. CONFIDENT COMMUNICATION This should go without saying, but we re going to say it anyway, just in case: Don t send your clients to a big box store to buy flea and tick preventives! Making the case for why pet owners should buy from you is simple. According to Halow, you should say, Because I am your pet s healthcare provider, I want to be able to oversee all aspects of its care, including preventives. We offer preventives at the clinic both for your convenience and to ensure quality. DON T GET YOURSELF IN A JAM Listen to the clip below to hear Halow s advice in his own words, or check out dvm360.com/ ticktoolkit for more. The Harvard Business Review article cites a 2000 study from psychologists Sheena Iyengar and Mark Lepper in which shoppers at an upscale grocery store were presented with display table of 24 jams one day and only six jams on another. Shoppers who sampled the jams were given a $1 off coupon to use on any jam. Though the larger display attracted more interest, those who visited it were only one-tenth as likely to purchase a jam as those who visited the smaller one. dvm360.com/toolkit April ES903740_dvmtoolkit0417_009.pgs :47

10 3 tick-borne Identifying and treating diseases in dogs Diagnosis of canine tick-related disease has been occurring with greater frequency, making knowledge of all tick-borne diseases increasingly important. This detailed overview of anaplasmosis, ehrlichiosis and Rocky Mountain spotted fever will help you be prepared when these diseases make an appearance in your veterinary clinic. By Mary Bowles, DVM, DACVIM 10 April 2017 dvm360.com/toolkit NANIANNETTE/SHUTTERSTOCK.COM ES903788_dvmtoolkit0417_010.pgs :15

11 Anaplasmosis, ehrlichiosis and Rocky Mountain spotted fever (RMSF) are three tick-borne diseases commonly diagnosed in dogs. Ehrlichia canis, Ehrlichia chaffeensis and Ehrlichia ewingii cause ehrlichiosis. These organisms belong to the family Anaplasmataceae along with Anaplasma platys and Anaplasma phagocytophilum, which cause anaplasmosis. RMSF is caused by the organism Rickettsia rickettsii (Table 1). With any of these diseases, co-infections with more than one type of tick-borne organism is possible, potentially altering the signs of illness in the affected patient. It is also possible for patients to be infected with any of these tick-borne diseases but have a predominance of signs related to co-existing non-tickborne disease. Geographic distribution The organisms causing ehrlichiosis and RMSF have been reported in various parts of the United States. These organisms and related diseases are commonly reported in dogs from southeastern (E. canis, E. chaffeensis, E. ewingii, R. rickettsii), south-central (E. chaffeensis, E. ewingii, R. rickettsii), southwestern (E. canis), south Atlantic (R. rickettsii), and mid-atlantic (E. chaffeensis) states. 1 Th e fact that E. canis may produce a subclinical chronic disease phase can alter the typical geographic distribution since an infection may not be diagnosed until the animal manifests TABLE 1 Canine tick-borne diseases and associated vectors clinical signs after being transported to a nonendemic area. A. phagocytophilum has an increased geographic presence on the west coast and in the northeast and upper midwest of the United States. Although the intermediate hosts and tick vectors of A. platys have not been fully confirmed, the organism could potentially have a widespread distribution in the United States in association with the suspected tick vectors. The prevalence of tick-borne disease in any particular region is dependent upon multiple factors, including the presence of associated intermediate hosts and tick vectors as well as elements such as weather conditions. Diagnosis of ehrlichiosis, anaplasmosis and RMSF in the United States Disease Organism Classic host cell infected Tick vector Anaplasmosis Anaplasma phagocytophilum Granulocyte Ixodes species Anaplasmosis Anaplasma platys Platelet Rhipicephalus sanguineus,* Dermacentor species* Ehrlichiosis Ehrlichia canis Mononuclear Rhipicephalus sanguineus, Dermacentor variabilis* Ehrlichiosis Ehrlichia chaffeensis Mononuclear Amblyomma americanum, Dermacentor variabilis* Ehrlichiosis Ehrlichia ewingii Granulocyte Amblyomma americanum Rocky Mountain spotted fever Rickettsia rickettsii Endothelial Dermacentor species *Suspected tick vector dvm360.com/toolkit April ES903786_dvmtoolkit0417_011.pgs :16

12 ID ticks with this tool Ticks are second only to mosquitoes in the number of diseases they transmit, which is why it s so critical to prevent ticks from attaching to and feeding on pets and people in the fi rst place. Size up pesky ticks with this tool. Understanding the tick life cycle and the behavior of these pesky parasites can help keep them in check, so we developed this handy tick identification chart for you, your team and your clients. This chart, inspired by a similar chart from the Centers of Disease Control and Prevention, shows what three common ticks the blacklegged tick, the lone star tick and the American dog tick look like at different phases in their life cycle. It s all drawn to scale to help your clients see how tiny these little bloodsuckers can be. Scan the code to download the tool now, or visit dvm360.com/ticktoolkit. has increased over the last several years. It is possible that the rise in diagnosis of these tick-borne diseases could be the result of an increase in the overall population of the associated tick vectors and/ or spread of tick vectors into previously nonendemic areas. However, elevated awareness of these tick-borne diseases and improved diagnostic methods could also contribute to the increase in the number of positive canine cases. To more accurately determine the prevalence of canine ehrlichiosis and anaplasmosis down to the county level of individual states, veterinarians can consult the Companion Animal Parasite Council website (capcvet.org), which provides user-friendly parasite prevalence maps as well as other up-to-date information about tick-borne diseases. Signalment Anaplasmosis and RMSF do not appear to have an age, breed or sex predisposition. However, E. canis seems to have a predilection for infecting German shepherds. History and clinical signs Dogs with anaplasmosis, ehrlichiosis or RMSF often have a history of tick exposure. Petechiae or ecchymoses may be observed in patients with these diseases. Rocky Mountain spotted fever and ehrlichiosis. Other historical signs frequently reported with RMSF and ehrlichiosis are lethargy, hyporexia or anorexia, weight loss, lameness with neurologic abnormalities, tissue swelling, epistaxis, ocular and nasal discharge, and dyspnea. Physical examination of patients with ehrlichiosis or RMSF can reveal evidence of the historical signs listed above as well as fever; muscle, neck, or joint pain; generalized lymphadenopathy; splenomegaly; icterus; and pale mucous membranes. The tissue swelling mentioned as a potential historical finding may be identified on physical 12 April 2017 dvm360.com/toolkit ES903785_dvmtoolkit0417_012.pgs :14

13 examination as joint swelling or edema of the face, limbs, ventral body, scrotum or prepuce. Erythematous skin lesions or necrotic lesions involving the distal extremities, ear margins or nasal planum may be found in some of these patients, especially in RMSF cases. A variety of ocular lesions can be present, including serous to mucopurulent discharge, conjunctivitis, anterior uveitis and evidence of a primary hemostatic defect in the form of hyphema or conjunctival, scleral or retinal petechiation or hemorrhage. Neurologic abnormalities such as vestibular or cerebellar signs (e.g. head tilt, ataxia, nystagmus, tremors, paresis, stupor, seizures, hyperesthesia and various cranial nerve deficits) can be observed. Anaplasmosis. Patients infected with A. phagocytophilum most commonly have lethargy associated with fever and musculoskeletal pain. Patients infected with A. platys typically do not show any systemic signs of illness but occasionally may have mild fever, uveitis, petechiae or ecchymoses. Seasonality Patients with ehrlichiosis, anaplasmosis and RMSF most frequently present from the A compelling conversation Are you thinking, Do I really need to have this conversation one more time with pet owners? The quick answer: Yep. Absolutely. Early and often. The good news: There s plenty to say to keep this conversation compelling. Have your team consider this sample script. (You might even try role-playing it at your next staff meeting.) I live in the city. Do I really have to worry about ticks and my pets? Team member: I m sure you don t see ticks very often in the city, but that doesn t mean they aren t around. While it s true ticks are more common in wooded or grassy areas, they can actually be found anywhere even in the city. The truth is that any pet may be exposed to ticks. You could even carry ticks into your home, where they can jump onto your indoor-only pets. Of course, pets are more likely to be exposed to ticks when they re outdoors. So we recommend avoiding tall grasses and checking your pets frequently for ticks. Ticks are known to carry pathogens that can cause serious illnesses, such as Rocky Mountain spotted fever, Lyme disease, ehrlichiosis and more. The longer a tick is attached to your pet, the more likely the tick can transmit disease. And an attached tick can cause skin irritation and even infection in your pet. The most important thing you can do is to keep ticks from affecting your pet in the first place. This is why it s so important to use tick prevention all year round. I m happy to go over some of the products our veterinarian recommends. For more ideas, go to dvm360.com/ticktoolkit. dvm360.com/toolkit April ES903783_dvmtoolkit0417_013.pgs :15

14 TABLE 2 Antimicrobial dosages for treating canine ehrlichiosis, anaplasmosis and Rocky Mountain spotted fever Drug Anaplasmosis Ehrlichiosis RMSF Doxycycline Tetracycline Oxytetracycline Minocycline Chloramphenicol Enrofloxacin Imidocarb dipropionatee 5-10 mg/kg orally b.i.d. for 10 days 22 mg/kg orally t.i.d. for days 25 mg/kg orally or intravenously t.i.d. for days b 10 mg/kg orally or intravenously b.i.d. for 10 days b mg/kg orally, intravenously, or subcutaneously t.i.d. for 14 days d 3-5 mg/kg orally or subcutaneously b.i.d. for days b Not recommended 5-10 mg/kg orally or intravenously once a day or b.i.d. for days a 10 mg/kg orally or intravenously once a day or b.i.d. for 7-14 days 22 mg/kg orally t.i.d. for days a 22 mg/kg orally or intravenously t.i.d. for 7-14 days 25 mg/kg orally or intravenously t.i.d. for 28 days c 10 mg/kg orally or intravenously b.i.d. for days a mg/kg orally, intravenously, or subcutaneously t.i.d. for days a Not recommended 5 mg/kg intramuscularly or subcutaneously given once, then repeated after a two-week interval f Not recommended Not recommended mg/kg orally, intravenously, or subcutaneously t.i.d. for 7-14 days 3-5 mg/kg orally or subcutaneously b.i.d. for 7-14 days Not recommended a Recommended minimum duration of treatment for Ehrlichia canis infection is 28 days. b Recommended for the treatment of Anaplasma platys only. c Recommended for the treatment of Ehrlichia canis and Ehrlichia chaffeensis only. d Recommended for the treatment of Anaplasma phagocytophilum only. e Pretreat with atropine or glycopyrrolate intramuscularly or subcutaneously 20 minutes before giving imidocarb to prevent cholinergic signs. f Recommended for the treatment of Ehrlichia canis only; variable efficacy. spring through early fall in association with the activity of the tick vectors. However, tick season can extend into late fall or even last year-round in some areas, depending on the climate. Patients that have been infected with E. canis may be admitted for clinical signs 14 April 2017 dvm360.com/toolkit throughout the year because of the various clinical phases (acute, subclinical, chronic) of E. canis. Treatment Treating ehrlichiosis, anaplasmosis and RMSF centers around appropriate antimicrobial administration and adjunctive or supportive care. Doxycycline is the mainstay of antimicrobial treatment. Table 2 lists suggested dosages for doxycycline and alternative antimicrobial drugs recommended for therapy. ES903787_dvmtoolkit0417_014.pgs :13

15 Need clues on diagnosis? Don t miss the article on page 2 and see Dr. Bowles guidance on what other tests can help you pinpoint infection from one of these tick-borne bothers at dvm360.com/ticktoolkit. But let s head straight to treatment Adjunctive or supportive therapy can vary widely, depending on the organ systems affected and associated clinical signs. Patients that exhibit neurologic signs, hemolytic anemia, severe thrombocytopenia, edema, joint swelling or muscle pain frequently require high anti-inflammatory or immunosuppressive doses of corticosteroids initially (prednisone/prednisolone at 1 to 2.2 mg/kg/day orally; dexamethasone sodium phosphate at 0.15 to 0.35 mg/ kg every 48 hours intravenously until oral prednisone can be given) in combination with an appropriate antimicrobial drug to achieve timely resolution of these more critical or uncomfortable aspects of infection. After the patient receiving corticosteroids starts to show clinical signs of improvement, the corticosteroid dose can be rapidly tapered while monitoring for any signs of relapse. In severely affected patients, nutritional and fluid support may be needed. Patients with severe anemia may require a blood transfusion. Treatment response The prognosis for most affected dogs is good if treatment is initiated early in the disease course. Clinical improvement for the tick-borne diseases discussed here often occurs within a few days to weeks of initiating appropriate therapy. Hyperglobulinemia may take several months to normalize. Severe glomerulopathy and bone marrow suppression may improve slowly but may never improve in some cases. Patients with suspected RMSF that have clinical signs persisting for longer than two weeks after initiating therapy should be reassessed for a different disease. Resolution of clinical signs does not always mean that the infection has been eradicated. Decreasing antibody titers would reinforce the likelihood that treatment could be discontinued. However, antibody titers for most of the Anaplasmataceae and RMSF organisms, especially E. canis, often remain high for several months in spite of successful treatment of the associated disease. A negative PCR assay result on a specimen obtained at least two weeks after discontinuing antibiotic therapy would be a good indication that the organism had been successfully eradicated. Reinfection Rechecking patients periodically after apparent successful treatment, including performing pertinent diagnostic tests such as a platelet count, is an important method of not only detecting a relapse but also monitoring for reinfection. Resolving an episode of tick-borne infection does not confer immunity to reinfection (with the possible exception of dogs that have recovered from RMSF). Owners should be instructed to watch for recurrence of clinical signs and to practice diligent tick prevention. Periodic antimicrobial treatment of dogs in areas highly endemic for organisms causing ehrlichiosis or anaplasmosis may be considered, especially for hunting dogs that are at greater risk for ongoing tick exposure. You can also consider low-dose daily therapy with doxycycline (3 mg/kg orally once a day) during tick season. Reference 1. Sykes JE: Ehrlichia, anaplasmosis, Rocky mountain spotted fever, and Neorickettsia infection. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 7th ed. Philadelphia: Saunders Elsevier, 2010; Mary Bowles, DVM, DACVIM, emeritus associate professor, recently retired after a 40-year career as a clinician in the Department of Veterinary Clinical Sciences, Center for Veterinary Health Sciences, Oklahoma State University in Stillwater, Oklahoma. dvm360.com/toolkit April ES903784_dvmtoolkit0417_015.pgs :13

16 Talking to ticked off clients Let s be real here: giving clients the tick talk gets repetitive. Here are a few suggestions to overcome common objections. From the rebel client saying, I ve never seen a tick in this area! to the penny-pincher telling you she can get much cheaper parasite preventive at Walmart, you ve got a lot on your plate when it comes to talking ticks with your clients. This conversation tree will steer you down a more stable path, especially when fronted with clients like the skeptic telling you, You re just trying to sell me more stuff. Mr. Rebel: I ve never seen a tick in this area. You: Have you ever seen a bird, squirrel or rabbit in your yard? There are areas where ticks are more prevalent, but there are reported cases of tick-borne diseases in every state. Mr. Rebel: Well, I ve never seen a tick on my dog, so... Scan this code to download a free printable version of this conversation tree and (hint, hint) make it the subject of your next team meeting. Go to dvm360.com/ticktoolkit for more. If you really want to creep out your clients, give them an image they ll never forget: the tick hotel. Take a specimen cup and fill it with alcohol, then collect all of the ticks you pull off of your patients. When clients start to argue about ticks in the area, show them your little hotel. You can even decorate it with a no vacancy sign. 16 April 2017 dvm360.com/toolkit ES903768_dvmtoolkit0417_016.pgs :01

17 Mrs. Pennypincher: I can get much cheaper stuff at Walmart. Ms. Skeptic: You re just trying to sell me more stuff. You: Many generics have neither the research nor the efficacy of major frontrunners, though they claim to have the same active ingredients as leading brands. Some of these companies are actually comparing themselves to the antiquated version of the brand names which used to kill adult fleas but not their eggs or larvae. The trusted topical brands have improved formulas that contain a pesticide and an insect growth regulator, and that their patented inactive ingredient spreads throughout the body in the oil glands of the skin. You: It takes a good, solid freeze to kill off parasites. If you live in a warm climate or experience a mild winter, the pest population doesn t have the chance to die off as it should and can potentially double or triple. A quick web search provides plenty of pictures and horrible accounts of pet owners whose animals were harmed by generics. Keep a file or book of photos on hand to show what could happen with the wrong product and your clients may never go back to their old ways. Providing a free sample of a trusted prevention product proves you aren t just trying to make a sale. If clients won t budge, sending them home with product in their hands can be a reminder that you re on their side. dvm360.com/toolkit April ES903767_dvmtoolkit0417_017.pgs :00

18 Get your hands on more videos, tips & tools at: dvm360.com/ticktoolkit FOR CLIENTS: How to do a tick check on your pet (and what to do if you find one) Educate your clients on the task of checking their pets for ticks from home, and make sure they know exactly what to do if they fi nd one. Dealing with ticks is a tricky business, especially if you know little to nothing about them. Luckily, your clients don t necessarily have to come into the clinic every time they re worried there could be a tick on their pet. This client handout can be the perfect tool to teach them how to check for ticks themselves, and tell them what to do if they find any, all from the comfort of their home. Scan to download now Removing ticks at home Give brave pet owners this handout for tackling ticks on their pets at home. For those veterinary clients who want to remove their pets ticks at home, ta-da here s a handout to give them (well, a downloadable PDF). It s got all the greatest hits for tick-tackling tips: don t try to torch them with matches... don t pop them before you get them out... and, most important, put removed ticks in a bottle of alcohol in case they need a tick-borne disease test for themselves or their pet after all. Now go forth and share the joy! Scan to download now 18 April 2017 dvm360.com/toolkit ES903709_dvmtoolkit0417_018.pgs :38

19 Help clients create a tick-free backyard Help your clients keep their backyards inhospitable by sharing these tips. Ticks are carriers of nasty diseases that can infect your patients and and their owners. Help them create a tick-unfriendly zone in their yard using these tips from the University of Rhode Island s Tick Encounter Resource Center to keep pets free from these pests. Scan this code to download the free client handouts below or find more information at client-handout-creating-tick-freezone-backyard dvm360.com/toolkit April ES903703_dvmtoolkit0417_019.pgs :35

20 Two ideas for talking about ticks WE RE BURSTING WITH IDEAS! on social media Looking for new ways to bring up tick preventives on your veterinary practice s Facebook account? We ve got posts for that. Tick season is year-round, so we can t blame you for feeling fatigued when it comes to encouraging clients to use preventives on social media. We ve taken some of the pain out of the process with these two Facebook post ideas. Follow the simple instructions, and ta-da you re done with the posts, that is. Ideally, these posts will initiate conversations between your practice and your clients, so get everyone on your team ready to talk ticks! 20 April 2017 dvm360.com/toolkit ES903728_dvmtoolkit0417_020.pgs :41

21 IDEA #1 IDEA #2 Attention-grabbing adorableness 1. Buy or borrow a few pet costumes (or maybe you can just raid your closet). 2. Ask a couple of clients who ve brought their pets in for routine exams if you can take pictures of their pets wearing the disguises. Tell the clients what you plan to do with the photos and get permission to use them (Psst! Get a printable photo release form at dvm360.com/photorelease) Engaging education 1. Go to dvm360.com/twoideas and drag and drop the image of the handout below to your computer s desktop. Drag and drop this image to your computer s desktop. Agnes is here to look cute and serve as inspiration. (Photo courtesy of dvm360 associate content specialist Sarah Mouton Dowdy) 3. Pick your favorite pictures and then post them to Facebook along with the following text, modifying it according to the costume and the pet: This isn t really a strawberry it s Agnes in disguise! Gotcha! Tick-borne diseases are similarly hard to recognize in both pets and people. The best way to protect yourself and your pets is with year-round prevention. Call us or stop by to get tick preventives for your pet! 2. Post the image on your practice s Facebook page along with the following text: It typically takes less than 48 hours for a tick to transmit disease to your pet. That s why it s so important to use preventives year-round and to regularly check your dog or cat for ticks even if you live in an urban area. Click on the link to download a handy handout on tick prevention and scanning for ticks at home, and then reach out if you have any questions! Don t forget to pay attention. Once you post, your job s not done. Monitor the comments and answer any questions that pet owners might have. Be their trusted partners and a valuable resource for important information for their pets. dvm360.com/toolkit April ES903727_dvmtoolkit0417_021.pgs :40

22 How to use an old-school whiteboard to educate clients about ticks Data on ticks, intestinal parasites and heartworms can provide a public service to your veterinary clients and help protect your patients. A simple dry erase whiteboard can change the conversation about parasite prevention from selling product to protecting patients. A 2015 study by the Companion Animal Parasite Council (CAPC) has shown that 90 percent of pet owners want their veterinarian to provide them with information on parasites. Posting local, timely parasite prevalence numbers in your waiting area can help stimulate conversation with your clients and provide a public service. STEP Buy a whiteboard at an office supply store. STEP Visit capcvet. org and click on Parasite Prevalence Maps. STEP Identify the disease you want to highlight (such as Lyme disease or heartworm infection) and find the prevalence data for your state and county. STEP STEP STEP Want to learn more? Check out this video from CAPC by scanning the QR code or visiting dvm360.com/ticktoolkit. Write the number of cases in your county on the whiteboard and set it or hang it near where clients check in and out. Educate clients about parasites and related diseases when they ask about the numbers on the board. Change the statistics you highlight on the board according to changing seasonal risks. 22 April 2017 dvm360.com/toolkit ES903735_dvmtoolkit0417_022.pgs :42

23 (sarolaner) Chewables FOR ORAL USE IN DOGS ONLY CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Description: SIMPARICA is a flavored, chewable tablet for administration to dogs over 6 months of age according to their weight. Each tablet is formulated to provide a minimum sarolaner dosage of 0.91 mg/lb (2 mg/kg) body weight. Sarolaner is a member of the isoxazoline class of parasiticides and the chemical name is 1-(5 -((5S)-5-(3,5-Dichloro-4-fluorophenyl)-5-(trifluoromethyl)-4,5-dihydroisoxazol-3-yl)-3 - H-spiro(azetidine-3,1 -(2)benzofuran)-1-yl)-2-(methylsulfonyl)ethanone. SIMPARICA contains the S-enantiomer of sarolaner. The chemical structure of the S-enantiomer of sarolaner is: CI F F F F CI O N Indications: SIMPARICA kills adult fleas, and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis), and the treatment and control of tick infestations [Amblyomma americanum (lone star tick), Amblyomma maculatum (Gulf Coast tick), Dermacentor variabilis (American dog tick), Ixodes scapularis (black-legged tick), and Rhipicephalus sanguineus (brown dog tick)] for one month in dogs 6 months of age or older and weighing 2.8 pounds or greater. Dosage and Administration: SIMPARICA is given orally once a month at the recommended minimum dosage of 0.91 mg/lb (2 mg/kg). Dosage Schedule: Body Weight SAROLANER per Tablet (mg) Number of Tablets Administered 2.8 to 5.5 lbs 5 One 5.6 to 11.0 lbs 10 One 11.1 to 22.0 lbs 20 One 22.1 to 44.0 lbs 40 One 44.1 to 88.0 lbs 80 One 88.1 to lbs 120 One >132.1 lbs Administer the appropriate combination of tablets SIMPARICA can be offered by hand, in the food, or administered like other tablet medications. Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes to ensure that part of the dose is not lost or refused. If a dose is missed, administer SIMPARICA and resume a monthly dosing schedule. SIMPARICA should be administered at monthly intervals. Flea Treatment and Prevention: Treatment with SIMPARICA may begin at any time of the year. In areas where fleas are common year-round, monthly treatment with SIMPARICA can continue the entire year without interruption. To minimize the likelihood of flea re-infestation, it is important to treat all dogs and cats within a household with an approved flea control product. Tick Treatment and Control: Treatment with SIMPARICA can begin at any time of the year (see Effectiveness). Contraindications: There are no known contraindications for the use of SIMPARICA. Warnings: Not for use in humans. Keep this and all drugs out of reach of children and pets. For use in dogs only. Do not use SIMPARICA in cats. SIMPARICA should not be used in dogs less than 6 months of age (see Animal Safety). Precautions: SIMPARICA may cause abnormal neurologic signs such as tremors, decreased conscious proprioception, ataxia, decreased or absent menace, and/or seizures (see Animal Safety). The safe use of SIMPARICA has not been evaluated in breeding, pregnant, or lactating dogs. Adverse Reactions: SIMPARICA was administered in a well-controlled US field study, which included a total of 479 dogs (315 dogs treated with SIMPARICA and 164 dogs treated with active control once monthly for three treatments). Over the 90-day study period, all observations of potential adverse reactions were recorded. Table 1. Dogs with adverse reactions Adverse reaction sarolaner sarolaner active control active control N % (n = 315) N % (n =164) Vomiting % % Diarrhea % % Lethargy % % O N TM O O S O Additionally, one female dog aged 8.6 years exhibited lethargy, ataxia while posturing to eliminate, elevated third eyelids, and inappetence one day after receiving SIMPARICA concurrently with a heartworm preventative (ivermectin/pyrantel pamoate). The signs resolved one day later. After the day 14 visit, the owner elected to withdraw the dog from the study. For a copy of the Safety Data Sheet (SDS) or to report adverse reactions call Zoetis Inc. at Additional information can be found at For additional information about adverse drug experience reporting for animal drugs, contact FDA at FDA-VETS or Clinical Pharmacology: Sarolaner is rapidly and well absorbed following oral administration of SIMPARICA. In a study of 12 Beagle dogs the mean maximum plasma concentration (C max ) was 1100 ng/ml and the mean time to maximum concentration (T max ) occurred at 3 hours following a single oral dose of 2 mg/kg to fasted animals. The mean oral bioavailability was 86% and 107% in fasted and fed dogs, respectively. The mean oral T 1/2 values for fasted and fed animals was 10 and 12 days respectively. Sarolaner is distributed widely; the mean volume of distribution (Vdss) was 2.81 L/kg bodyweight following a 2 mg/kg intravenous dose of sarolaner. Sarolaner is highly bound ( 99.9%) to plasma proteins. The metabolism of sarolaner appears to be minimal in the dog. The primary route of sarolaner elimination from dogs is biliary excretion with elimination via the feces. Following repeat administration of SIMPARICA once every 28 days for 10 doses to Beagle dogs at 1X, 3X, and 5X the maximum intended clinical dose of 4 mg/kg, steady-state plasma concentrations were reached after the 6th dose. Following treatment at 1X, 3X, and 5X the maximum intended clinical dose of 4 mg/kg, sarolaner systemic exposure was dose proportional over the range 1X to 5X. Mode of Action: The active substance of SIMPARICA, sarolaner, is an acaricide and insecticide belonging to the isoxazoline group. Sarolaner inhibits the function of the neurotransmitter gamma aminobutyric acid (GABA) receptor and glutamate receptor, and works at the neuromuscular junction in insects. This results in uncontrolled neuromuscular activity leading to death in insects or acarines. Effectiveness: In a well-controlled laboratory study, SIMPARICA began to kill fleas 3 hours after initial administration and reduced the number of live fleas by 96.2% within 8 hours after flea infestation through Day 35. In a separate well-controlled laboratory study, SIMPARICA demonstrated 100% effectiveness against adult fleas within 24 hours following treatment and maintained 100% effectiveness against weekly re-infestations for 35 days. In a study to explore flea egg production and viability, SIMPARICA killed fleas before they could lay eggs for 35 days. In a study to simulate a flea-infested home environment, with flea infestations established prior to the start of treatment and re-infestations on Days 7, 37 and 67, SIMPARICA administered monthly for three months demonstrated >95.6% reduction in adult fleas within 14 days after treatment and reached 100% on Day 60. In well-controlled laboratory studies, SIMPARICA demonstrated 99% effectiveness against an initial infestation of Amblyomma americanum, Amblyomma maculatum, Dermacentor variabilis, Ixodes scapularis, and Rhipicephalus sanguineus 48 hours post-administration and maintained >96% effectiveness 48 hours post re-infestation for 30 days. In a well-controlled 90-day US field study conducted in households with existing flea infestations of varying severity, the effectiveness of SIMPARICA against fleas on Day 30, 60 and 90 visits compared to baseline was 99.4%, 99.8%, and 100%, respectively. Dogs with signs of flea allergy dermatitis showed improvement in erythema, papules, scaling, alopecia, dermatitis/pyodermatitis and pruritus as a direct result of eliminating fleas. Animal Safety: In a margin of safety study, SIMPARICA was administered orally to 8-week-old Beagle puppies at doses of 0, 1X, 3X, and 5X the maximum recommended dose (4 mg/kg) at 28-day intervals for 10 doses (8 dogs per group). The control group received placebo tablets. No neurologic signs were observed in the 1X group. In the 3X group, one male dog exhibited tremors and ataxia post-dose on Day 0; one female dog exhibited tremors on Days 1, 2, 3, and 5; and one female dog exhibited tremors on Day 1. In the 5X group, one female dog had a seizure on Day 61 (5 days after third dose); one female dog had tremors post-dose on Day 0 and abnormal head coordination after dosing on Day 140; and one female dog exhibited seizures associated with the second and fourth doses and tremors associated with the second and third doses. All dogs recovered without treatment. Except for the observation of abnormal head coordination in one dog in the 5X group two hours after dosing on Day 140 (dose 6). There were no treatment-related neurological signs observed once the dogs reached the age of 6 months. In a separate exploratory pharmacokinetic study, one female dog dosed at 12 mg/kg (3X the maximum recommended dose) exhibited lethargy, anorexia, and multiple neurological signs including ataxia, tremors, disorientation, hypersalivation, diminished proprioception, and absent menace, approximately 2 days after a third monthly dose. The dog was not treated, and was ultimately euthanized. The first two doses resulted in plasma concentrations that were consistent with those of the other dogs in the treatment group. Starting at 7 hours after the third dose, there was a rapid 2.5 fold increase in plasma concentrations within 41 hours, resulting in a C max more than 7-fold higher than the mean C max at the maximum recommended use dose. No cause for the sudden increase in sarolaner plasma concentrations was identified. Storage Information: Store at or below 30 C (86 F) with excursions permitted up to 40 C (104 F). How Supplied: SIMPARICA (sarolaner) Chewables are available in six flavored tablet sizes: 5, 10, 20, 40, 80, and 120 mg. Each tablet size is available in color-coded packages of one, three, or six tablets. NADA # , Approved by FDA Distributed by: Zoetis Inc. Kalamazoo, MI Inappetence 0 0% % Made in Switzerland Revised: July A&P black ES904830_DVMTOOLKIT0417_023_FP.pgs :10

24 NOT ALL FLEA AND TICK CHEWS ARE CREATED EQUAL Flea and tick protection that goes on and on and on...all month long Introducing Simparica Monthly chewables for dogs that offer persistent *,)..#)(,)'r-(.#%-} Simparica acts fast #.-.,.-%#&&#(!r-1#."#( v")/,-(.#%-1#."#({")/,- 1 (%*-!)#(! strong for 35 days 2 without losing effectiveness at the end of the month. IMPORTANT SAFETY INFORMATION: #'*,##- ),/-)(&3#()!-~y')(."-)!()&,} #'*,#'3/-(),'&(/,)&)!#-#!(--/"-.,'),-~,-)(-#)/-*,)*,#)*.#)(~.2#~,-),-(.'(~( ),-#4/,-}#'*,#"-().(0&/.#()!-.".,*,!((.~,#(!),&..#(!}#'*,#"-(- &3/-#()!-.,.1#.")'')(&3 *,-,#0#(-~*,-#.##-().",'#.#)(-}"')-.,+/(.&3,*),.0,-,.#)(-1,0)'#.#(!(#,,"} /&&,-,##(! ( ),'.#)()(."%)."#-*! and at Fetch more information about Simparica,)').#-½/-.)',,0# ZOETIS-1 or } References: 1. #2~/,(~½,.,~.&}0&/.#)()."-*) %#&&) -,)&(, #'*,#!#(-.#(/#( -..#)(-).",-*#-).#%- '&3)'''/&./'~ 2)--*/&,#-~ 2)-,##(/- )()!-}Vet Parasitol.usty uuuvz wu}2.#2~0,..~)/(!~.&} q3) ()0& ),& ),'/&.#)() -,)&(, #'*,#!#(-.q0)'')(.#%-*#-#( -.#(!)!-#(."(#...-}Vet Parasitol.usty uuuu{ vu} &&.,',%-,."*,)*,.3) ).#-,0#-½),,&.)'*(3),&#(-),/(&--).",1#-().} usty).#-,0#-½} &&,#!".-,-,0}.),usty} sssw{ ES904831_DVMTOOLKIT0417_024_FP.pgs :10