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PEER REVIEWED On YOur Best BehaviOr

The Use of Medications in Q & A:Canine Behavior Therapy Ilana Reisner, DVM, PhD, Diplomate ACVB Reisner Veterinary Behavior & Consulting Services, Media, Pennsylvania

our longtime client, Mrs. Jones, presents Addressing Client Buttercup, the Papillon, with “a behavior Reluctance Y problem”: For several months, Buttercup has if behavioral medication been biting houseguests. Through questioning and is indicated, but the client is reluctant, discuss- ing specific concerns educates the client about the observation, you determine that Buttercup is anxious. benefits of medication. Common concerns include: She was “shy” as a puppy, exhibits fearful postures 1. My pet’s much-loved personality will change. when unfamiliar people try to pet her, and—as a this is not the goal. the only personality charac- teristics targeted for change with therapy are home video of her behavior reveals—runs away from those associated with anxiety and reactivity, or guests trying to interact with her. such problems as repetitive (compulsive) behavior. Because psychopharmacology can have unexpect- ed effects—for example, one client reported that The presentation of behavior problems during routine her dog seemed less inclined to play with toys after appointments is one of the inevitabilities of today’s vet- administration of a drug—it is also important to erinary practice. Behavioral can help manage reassure the client that his or her pet’s response will these problems—but not all drugs are equally useful, be monitored, and the medication effects can be and their use is not always indicated. The plot thickens reversed or limited by reducing the dose or switch- when some clients demand medication, while others re- ing to a different drug. fuse to use it despite veterinary recommendations (see 2. Drugs are unhealthy or unsafe. Addressing Client Reluctance). there are many behavioral drugs, and most are quite safe to use—even with chronic administra- WhY use BehaviOral tion—in healthy patients. Medication is prescribed only after a physical examination and, if the medica- MeDiCatiOn? tion will be administered for a long period of time, Augmentation of Behavior Modification screening blood analysis should be performed. The treatment goal of any behavior problem is modi- this testing, including CBC, serum biochemistry fication of that behavior. However, the term behavior profile, and urinalysis, is recommended: modification is vague and depends upon the individu- • annually for patients receiving behavior drugs for al patient and behavior being addressed. over 1 year Q1. Management of any problem behavior requires • semiannually for patients over 8 years of age that recognizing and avoiding the stimuli that trigger the are receiving behavior drugs, or more frequently if behavior in question. there are concurrent medical issues of concern. 2. The dog needs to learn to behave differently in 3. My pet will be sleepy all the time. response to the stimulus. The term differently is unless sedation is the goal, such as during thun- intentionally nonspecific because it is tailored to the derstorms for phobic dogs, nonsedating drugs individual animal and context in which the problem are used, so sleepiness should not be an issue. if behavior occurs. unexpected sedation is a of behavioral Behavior modification might include anything from medication, the drug dose can be reduced or a dif- counter-conditioning a fearful dog; actively training an ferent medication can be prescribed. While it is not appropriate, alternative behavior to a cue; or desensitiz- uncommon for behavioral drugs to cause transient ing a separation–distress dog to its owner’s leaving the sedation initially, it can often be avoided by starting room. Thus, behavior modification can play an impor- with a lower dosage, then increasing it over several tant role in management of a problem behavior. weeks to the desired dose.

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Reduction of Stress In some cases, there are limits to how far behavior mod- Case Application: Buttercup ification alone can go. Extreme situational stress or fear in Buttercup’s case, the first step—avoid- can interfere with learning and decision making. ing the stimuli that trigger the behavior—might When dogs are overtly reactive—or, in the language simply mean keeping her in a separate area or of dog training, over threshold—they are physiologi- gated part of the house while Mrs. Jones en- cally aroused, which involves both the autonomic (fight tertains guests. or flight instinct) and endocrine (hypothalamic–pitu- the second step—learning to behave differ- itary–adrenal axis up-regulation) systems. In these cases, ently in response to these stimuli—can include: there is rarely any middle ground—the dog will move • Feeding Buttercup a high-value food while a rapidly from a lack of reaction to extreme avoidance, ag- guest is seated and in view (counter-conditioning) gression, or panic. • asking her to lie down on a previously speci- Temperamental or inherited generalized anxiety can fied mat while the owner is entertaining (alter- also interfere with learning. Generalized anxiety, similar native behavior). to situational anxiety, is more pervasive and challenging to overcome through training alone. In these patients, the addition of behavioral drug learned tasks, successful desensitization, and/or therapy can significantly improve response to treatment. counter-conditioning, drug therapy may allow the When underlying anxiety is reduced, the dog is more owner to move further toward treatment goals. receptive to learning and its behavior can change more reliably in the long-term. As one owner of a fearfully aggressive dog reported after 2 months of ad- hOW shOulD MeDiCatiOn Be ministration, “I feel like it’s opened a door to her brain.” PresCriBeD? Anxiety is an underlying component of many canine be- Sedation, If Needed havior problems (Table 1). Reducing this anxiety often Although, on a day-to-day basis, sedation is not a desir- improves the problem behavior directly or decreases able drug effect, it may be necessary to eliminate distress stress, raising the threshold for reactivity, fear respons- spikes in specific situations, most frequently: es, and other behaviors. • Separation anxiety (administered at point of the Before starting drug therapy in any animal, regardless of owner’s departure) Q age, physical health, or category of drug, a medical history • Thunderstorm or fireworks fear (administered just (including current medications) and physical examination before the event) are indicated, along with analysis of blood and urine. • Car or airplane travel (administered 30 minutes before travel; then repeated as needed during travel). Rather than administration on a daily or standing taBle 1. Canine Behavior Problems basis, sedative medication can be given on an as-needed associated with underlying anxiety basis, often in combination with a daily medication. • aggression between household dogs • Compulsive disorder When shOulD BehaviOral • Fear-related aggression • Fears/phobias MeDiCatiOn Be PresCriBeD? • inappropriate attention-seeking behavior There is some flexibility with regard to prescribing medi- • leash reactivity cation relative to the behavior modification plan. • resource guarding • If drug therapy is unequivocally indicated (eg, • separation anxiety severe separation anxiety or severe fear, including fear-aggressive behavior), ideally prescribe it during Qthe same appointment as the behavior assessment, Duration of Therapy which incorporates it into the entire behavior man- Duration of treatment with behavior medication agement plan. ranges from: • If the plan includes significant management • Relatively short-term (eg, 6 months for patients in changes that do not require medication and/or which anxiety must be reduced to allow learning to the pet is not impaired by stress (ie, pet has rea- occur) to sonably good quality of life at time of presentation), • Longer-term therapy (eg, years for animals whose consider delaying medication implementation until a behavior is not adequately responsive to behavior follow-up visit. In some cases, behavioral drugs may modification alone). be unnecessary. Other considerations include: • If a pet undergoing behavior modification has • Length of time for medication to take effect: reached a plateau with little advancement in Some medications (eg, ) require 1 to 2

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months for full effect, while others, such as benzodi- azepines and other sedatives, act more immediately. • Loading period: The initial loading period of taBle 2. Common Medications used for Ca- some drugs should be considered when planning nine Behavioral Problems therapy and duration of treatment. (alpha Order by Class) Once it’s been determined that the patient’s response POTENTIAL to medication is adequate, a reasonable duration of ini- DRUG DOSE ADVERSE tial therapy would be at least 6 months, which allows EFFECTS a generous period of time for behavior modification Azapirone (learning). 1–2 mg/kg PO Q • aggression 8–24 h disinhibition Discontinuation (anecdotal) Abrupt discontinuation of medication may cause re- • increased bound anxiety or exacerbate behavior problems. Any anxiety medication should be tapered gradually (weeks to months, depending on duration of therapy); a good guideline is a 25% reduction every 1 to 2 weeks. Slow discontinuation 0.02–0.1 mg/kg • agitation also allows the owner to report any reappearance of the PO Q 8 h or Prn • ataxia behavior problem, in which case a lower, but effective, 0.5–2.2 mg/kg • Polyphagia dose can be continued or the original dose resumed. PO Q 8 h or Prn • sedation Q & a: the in use BehaviOr theraPY OF MeDiCatiOns 0.5–2.2 mg/kg PO Q 8 h or Prn The Importance of Informed Consent Monoamine Oxidase Inhibitor Many drugs used in veterinary behavioral 0.5–1 mg/kg PO • agitation medicine fall into the following 2 categories: Q 24 h • Disorientation 1. Human psychiatric agents not licensed by • vomiting/ the Food and Drug administration (FDa) for use in companion animals Antagonist- 2. FDA-approved drugs for use in dogs with specific behavior problems, such as fluoxetine 3–5 mg/kg PO Q • increased (veterinary product no longer available) and 8–24 h or Prn anxiety for separation anxiety and sele- • sedation giline for cognitive dysfunction syndrome; how- Selective Serotonin-Reuptake Inhibitor ever, administration for other behaviors, such Fluoxetine 0.5–2 mg/kg PO • agitation/ as anxiety-based aggression, is extra-label. Q 24 h increased When recommending these drugs, inform anxiety clients that the use is off- or extra-label. it 1 mg/kg PO Q 24 h • inappetence* may be advisable to have the owner sign a • lowered sei- release form that lists the risks, limitations, 1–3 mg/kg PO Q zure threshold and potential adverse effects of the drug 24 h • sedation being prescribed. • tremors 1–4 mg/kg PO Q • Constipation What MeDiCatiOn shOulD 12 h • Decreased Clomipramine 1–3 mg/kg PO Q appetite Be useD? 12 h • Dry mouth/dry Antidepressants eyes The most commonly used agents are: • increased • Selective serotonin-reuptake inhibitors (SSRIs), anxiety such as fluoxetine (Prozac, lilly.com), sertraline • lowered sei- (Zoloft; pfizer.com), or paroxetine (Paxil, gsk.com) zure threshold • Tricyclic antidepressants (TCAs), such as clomip- • sedation Q • tachycardia/ ramine (Clomicalm, novartis.us) and amitriptyline. • Selegiline (Anipryl, zoetisus.com), a monoamine tachyarrhyth- oxidase inhibitor (MAOI) approved for treatment mia • urine retention of canine cognitive dysfunction syndrome or senile dementia. * less likely with paroxetine and sertraline Fluoxetine (no longer available as a veterinary

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product) and clomipramine were approved by the FDA for The dose range tends to be wide; owners can use a start- use in canine separation anxiety; either agent can be ben- ing dose while they are home to observe, and increase the eficial for other anxiety-related problems. dose on subsequent days with veterinary guidance. The Anxiolytic antidepressants should be given daily on a regular goal should be relaxation and mild sedation. basis. Adverse effects may include agitation, increased anxiety, Drugs in this class may vary significantly in their clinical undesirable sedation, inappetence (fluoxetine), and lowered effect for individual patients. seizure threshold. Side effects may be dose-dependent; initiat- • Alprazolam is relatively short-acting and, therefore, ing treatment with a lower dose may help. may be useful for separation anxiety (because af- Table 2 (page 65) lists the behavioral medications for fected dogs are typically distressed just after owner use in dogs discussed in this section, along with doses departure). and side effects. • Clorazepate is longer-acting and perhaps more useful overnight or when a thunderstorm is predicted several hours after administration. Case Application: Buttercup Buttercup tends to be distressed during Mrs. Jones’ Buspirone book club meetings and dinner parties, and is now Buspirone, a nonsedating anxiolytic, can be useful for gen- often restricted to the back bedroom during these eralized anxiety. Because it has been anecdotally associated times. Administration of a sedative and a special, with aggression disinhibition, it may be best limited to treat- long-lasting, food-filled toy could help Buttercup ment of anxiety with no history of aggression to humans relax and be less worried in these situations. or to other dogs. However, it is important to keep in mind that any psychotropic drug may cause increased agitation or aggression. & Trazodone In cases when sedation or an extra boost of anxiolysis Combination Therapy would be helpful, shorter-acting drugs can be given on Combination therapy can be helpful for some individual an as-needed (PRN) basis; examples are benzodiazepines patients, and may include a: (eg, alprazolam) or trazodone. Benzodiazepines are anx- • Standing antidepressant + benzodiazepine iolytic drugs and, used longer-term, can elicit anxiolysis • Standing antidepressant + trazodone (with caution) without sedation. • Standing antidepressant + benzodiazepine + trazodone. Trazodone can be dosed either regularly or PRN; an However, monotherapy with an antidepressant (or the example of the latter would be its use in fearful dogs PRN benzodiazepine) is recommended initially so that side during thunderstorms. However, if used in combination effects can be identified and linked to the drug being ad- with SSRIs, TCAs, or MAOIs, it should be used with caution ministered. due to the potential for serotonin syndrome (see Beware of Serotonin Syndrome). Other Agents Benzodiazepines are often useful for PRN sedation in To further effect anxiolysis or other behavior change, nonphar- cases, such as separation anxiety or thunderstorm fear, when maceutical agents can also be added to therapy (Table 3). a focused need for anxiolysis is needed. Side effects include polyphagia, aggression disinhibition, and paradoxical agi- tation and ataxia without adequate anxiolysis, and may be Table 3. Complementary Nonpharmaceu- dose dependent. tical Agents for Behavioral Therapy NONPHARMACEUTICAL EXAMPLES AGENT Beware of Serotonin l-theanine • Anxitane, Syndrome virbacvet.com Because trazodone, SSRIs, • Composure, TCAs, and MAOIs boost vetriscience.com serotonin levels, their use in combination (any 2 Pheromone diffusers, • Adaptil, ceva.us of these drugs together) may potentially trigger collars, or sprays • Feliway, ceva.us serotonin toxicity, or serotonin syndrome, a Prescription diets • Veterinary Diet Calm, potentially fatal reaction. Tell owners to watch for royalcanin.us early signs of serotonin syndrome, which can be • Hills b/d, hillspet.com ambiguous, but include agitation, tremors, and seizures. At the doses typically used in veterinary S-adenosylmethionine • NOVIFIT (NoviSAMe), behavioral medicine such reactions are rare, but (SAMe) virbacvet.com the potential for them indicates monitoring the Vitamins & natural • Senilife, ceva.us dog’s response. compounds

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What Other FaCtOrs shOulD in the management of a variety of problems. The ac- cessibility of information about their use, and growing Be COnsiDereD? choices of the medications themselves, increase their Management Changes convenience. Most important, they can facilitate a posi- It is sometimes too easy to think that a medication or tive outcome in otherwise complicated behavior cases. combination of medications will do most of the work, Medications are now a conventional option for manage- when in fact management changes, safety practices, and ment of behavioral problems rather than a “last resort.” re-learning are needed for a successful outcome. Unfor- Qtunately, administration of a behavior drug often pushes FDa = Food and Drug administration; Prn = as need- these efforts to the back of the line. ed; ssri = selective serotonin-reuptake inhibitor; tCa = ; MaOi = monoamine oxi- Follow-Up dase inhibitor Follow-up is critical in management of behavior cases, not only for dose adjustment and changes in choice of drug, but also for feedback on modification, implemen- The Special Case of Aggression tation, and progress. human-directed aggression is the most common canine behavior complaint; fear or self-defense is Client Expectations the most frequent reason for aggression. although Behavioral drug use in pets is common enough that clients clients may naturally assume that anti-anxiety Q & a: the in use BehaviOr theraPY OF MeDiCatiOns may ask specifically for medication (“puppy Prozac”) for a medication can resolve this problem, remind variety of problems. Before accommodating that request, them—ideally in a written document—that there is however, consider these recommendations: no reliable “cure” for aggressive behavior, and no • Remember that behavioral medication use is deter- drug will prevent biting. mined by the veterinarian per the Animal Medicinal More important than any medication is the need Drug Use Clarification Act (avma.org/KB/Resources/ Reference/Pages/AMDUCA.aspx) for clients to understand safety recommendations, • Review the indications and mechanisms of action avoidance of triggers of aggression, and the • Be familiar with potential contraindications and application of behavior modification, including adverse effects both classical and operant conditioning. it should • Address any confounding or comorbid medical prob- be emphasized that punishment or other harsh lems associated with the behavior problem, includ- training methods, including shock collars and ing pain, sensory decline, or hypersensitivity. outdated “dominance” exercises, can backfire The client should also be forewarned that patience by increasing defensiveness and the likelihood of will be needed, especially while waiting for the drug to further biting. “load” over the course of 1 to 2 months. in any animal with a history of biting, the risk If the medication is being administered at the correct for future bites can never be entirely elimi- therapeutic doses, and there still is no measurable nated. Owners may not want to change—decreased frequency or intensity of the problem face the prospect of permanent behavior—it may be necessary to taper and discontinue caution, but nevertheless it is that medication; then important to emphasize safety begin a new one and and preventive measures. Case Application: start the wait again. read Dog Bites: Protecting Buttercup This lag period can Your Staff & Clients (november/ Buttercup’s lunging be helped by use of a and snapping behavior December 2011) for further informa- more immediately ef- tion, available at tvpjournal.com. significantly decreased fective anxiolytic, such after 2 months of: as trazodone, but con- 1. treatment with fluox- sider educating clients etine that the beginning Ilana Reisner, DVM, PhD, Diplomate 2. Consistent effort by of drug administra- ACVB, is a veterinary behaviorist and the owner to counter- tion can mimic a long consultant in Media, Pennsylvania. She condition her to visi- ride on a slow-motion has served as the director of the Vet- tors (seated a “safe” roller coaster. erinary Behavior Clinic at University of distance away) Pennsylvania Veterinary Hospital and as- 3. Creation of a separate sistant professor of behavioral medicine “safe haven,” where in suMMarY at Penn’s School of Veterinary Medicine. she could indulge in Behavioral medi- She is past president of the American Veterinary Society of Animal Behavior. She received her DVM from Oregon feeder toys. cations can make a significant difference State University and her PhD from Cornell University.

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