Introduction • Psychological

Home , Polyphagia

Common Questions when Disclosures/Conflict of Interest Caring for Veterinary Patients in Community Pharmacy • Dr. Hogan declares no conflicts of interest, real or apparent, and Melissa Hogan, Pharm.D. no financial interests in any company, product or service mentioned in this program, including grants, employment, gifts, Associate Professor and Chair, stock holdings and honoraria. Department of Clinical and Administrative Sciences Roosevelt University College of Pharmacy

Objectives Objectives Pharmacists Pharmacy Technicians

At the conclusion of this program, the pharmacist will be able to: At the conclusion of this program, the pharmacy technician will be able to: • Discuss current issues in dispensing medications for pets • Understand current issues in dispensing medications for pets • Describe key points in the pharmacological management of • Recognize medications dispensed for dogs and cats with diabetes diabetes in dogs and cats, including the role of Vetsulin ® • Recognize medications dispensed for dogs and cats with heart • Describe key points in the pharmacological management of heart failure failure in dogs and cats, including the role of pimobendan (Vetmedin ®) • Name the benefits of drug administration aides for dogs and cats • Identify for a client on proper methods of drug administration in their dog or cat

Benefits of pets for human health

• Physical • Social Introduction • Psychological

5 REFERENCES http://www.cdc.gov/healthypets/health_benefits.htm

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

1 What is new in Veterinary Pharmacy? Pharmacists’

• H.R. 3174 / S. 1200 Fairness to Pet Owners Act of 2015 FAQs • AVMA position about Pet Meds • FTC Letter • What is the problem? • What is the solution?

References S. 1200 Fairness to Pet Owners Act. WWW.Govtrack.US Competition in the Pet Medication Industry. FTC Staff report. 8 May, 2015

Most Common Questions Managing Diabetes in • How long should a client use a vial of human insulin on a dog or cat? Dogs and Cats • What kind of dog receives Vetmedin (pimobendan)?

• Do OTC pain relievers work for pets?

• What are the best ways to administer medication to pets?

Diabetes in Dogs Pathophysiology • Prevalence 1 in 400 to 500 • Females (2x more likely than males) • Type 1, insulin-dependent diabetes • Age 8-12 years • Loss of beta cell function • Australian, Fox, Cairn and Yorkshire terriers; Standard and miniature Schnauzers, Miniature and toy poodles, Bichon Frise, Spitz, Samoyed, Lhasa Apso, beagle • 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. 3 rd ed. Missouri: Mosby 1998. Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3 rd ed. Missouri: Mosby 1998.

2 Diagnosis Goals of Therapy • Pre-diabetes • Blood glucose between 120 and 200 mg/dl • Maintain BG between 100 – 180 mg/dL • No signs when blood glucose above normal range, but below renal threshold • Normal range: 80-120 mg/dL • Avoid hypoglycemia • Renal threshold: 200 mg/dL • Avoid complications of hyperglycemia • Cataracts, blindness • Clinical diabetes • • UTI, respiratory and skin infections Fasting BG > 200 mg/dL • • Classic presentation (like humans) Chronic pancreatitis • Polyuria, polydipsia, polyphagia, lethargy • Ketoacidosis • If not noticed and treated: • Sudden blindness due to cataracts • Diabetic ketoacidosis

Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3 rd ed. Missouri: Mosby 1998.

Prognosis Nonpharmacological management • • Weight reduction if needed Client-dependent • Increased quantities of fiber • High mortality in first 6 months • Portion control • • Good survival after 6 months, can live over 5 years after diagnosis Regular exercise • Twice daily walk, recommend 30 minutes after meal

Must maintain consistent daily diet and exercise

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

Insulin

• Intermediate-acting insulin, dosed BID. Other insulins • 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 • Bovine or Human PZI (protamine zinc insulin) • Duration of action ~ 12 hours • Not formally studied in dogs • Requires U40 syringes • Less expensive • Exp 42 days once open • Human insulin glargine (Lantus) • • Dosed BID in dogs U-100 Humulin N (NPH ) • • Duration of action <12 hr Exp 28 days once open • Exp 31 days once open

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

3 Blood glucose monitoring Clinical Monitoring

• Blood glucose • • Every 3 months Weekly for 4 weeks after initiation • • Exam and blood glucose curve Physical and eye exam • Adjust insulin • Blood glucose • Continue until controlled • Fructosamine (control over past 2-4 weeks, not affected by stress hyperglycemia) • Normal: 225-365 mmol/L • Long term home monitoring • Goal (DM): 350-400 mmol/L • Daily for clinical signs, food/water intake, insulin dose • Blood glucose curve if needed • Weekly body weight • Blood glucose two weeks after adjustment, monthly when stable • Every 6 months • Daily home monitoring ideal • Full lab workup: CBC, chem, electrolytes, U/A, urine culture

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

Background Diabetes in Cats

• Pathophysiology • Prevalence • Type 2 diabetes mellitus • Cats: 1 in 200 • Insulin resistance with B cell dysfunction • Predominantly neutered males • May be reversible with rapid glycemic control • Age 8 – 13 years • Etiology • More common in Burmese cat • Obesity • Lack of activity • High carbohydrate diet

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

Presentation Diagnosis • Subclinical • Rule out stress hypoglycemia • No clinical signs • Blood glucose 200-250 mg/dL • Glucose between 150 to 250 mg/dL • • No ketones Normal BG 70-150 mg/dL • • May be caused by stress Persists for a few hours to days • Clinical • NO insulin needed • Persistent BG >250 mg/dL • Fructosamine level necessary to rule out DM • Polyuria, polydipsia, polyphagia • Rule out hyperthyroidism • Impaired jumping, abnormal gait • • Cats > 7 years old Fructosamine • • Normal 190-365 umol/L Weight loss • Diagnostic of DM: 350-750 umol/L • Polyphagia

4 Complications Treatment • Hypoglycemia • Goal • Peripheral neuropathy • Remission! • Plantigrade stance due to hind limb neuropathy • Aggressive dietary and insulin therapy may lead to euglycemia without use of insulin • Ketoacidosis • 17-67% of cats may achieve remission • Pancreatitis

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

Insulin Clinical Monitoring • Preferred • Daily • Insulin glargine (Lantus) U100 • Food/water intake • Human protamine zinc insulin (PZI) U40 • Insulin dose, signs of hypoglycemia • • Inadequate response to Vetsulin—not recommended Blood glucose if motivated owner • Weekly • Dosing • BG 6-8 h post insulin dose • In average cat, start at 1 unit/cat q12 hours • Every 2 weeks • Do not exceed 2 units/ cat even if very large or obese • Urine dipstick for glucose and ketones • Monitor for hypoglycemia • If 3 consistent negative urine glucose, possible remission • If BG<150 mg/dL, reduce dose by 0.5 unit • Every 3 months • Return to vet for fructosamine level

Client education Client Education for Dogs and Cats with Diabetes • 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

5 Key Counseling Points Key Counseling Points

• Greatest risk of death in dogs and cats is due to hypoglycemia • • Disease is manageable; do not need to euthanize pet Difficult to assess • Should see low level of glucose in urine or test BG • Encourage consistent diet and exercise • May reduce/hold insulin if low glucose • Modify diet if needed • DO NOT increase insulin without DVM advice • Portion control is necessary; have client measure food • Stress hyperglycemia should NOT be treated with increased insulin dose • Avoid excessive treats • 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

Key Counseling Points • Be sure client gets correct syringes for insulin Questions about Diabetes? • 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??

Pimobendan • Most Common Questions Vetmedin (U.S.--veterinary); Acardi (Japan—human ) • Mechanism of Action • Phosphodiesterase III inhibitor • How long should a client use a vial of human insulin on a dog or cat? • Positive inotrope—calcium sensitizer • Peripheral vasodilation, decreased afterload • What kind of dog receives Vetmedin (pimobendan)? • Indications

• Do OTC pain relievers work for pets? • Canine chronic valvular heart disease and dilated cardiomyopathy • • NOT for use in asymptomatic heart disease or hypertrophic cardiomyopathy in What are the best ways to administer medication to pets? 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

6 Mitral Valve Dysplasia Mitral Valve Dysplasia--Treatment • Pathophysiology • Murmur on exam • ACE inhibitors • Left-sided heart failure: pulmonary congestion (dogs), effusion (cats) • AE: Diarrhea • May progress to right-sided heart failure • Start low, go slow on dosing • Presentation • Enalapril 0.5mg/kg PO bid – approved for dogs • Murmur on exam • If not tolerated, try a different ACEI • Pulmonary congestion ‰cough • Lisinopril, benazepril, captopril • If progresses to right-sided heart failure ‰ascites • Diuretics • • Breed predilection Furosemide or HCTZ and/or spironolactone Cavalier King Charles Spaniel, Schnauzer, Poodle • Use lowest effective dose and titrate to response

Heart Disease and Heart Failure In: The Merck Veterinary Manual Heart Disease and Heart Failure In: The Merck Veterinary Manual

Dilated Cardiomyopathy Mitral Valve Dysplasia -- Treatment • Pathophysiology • Positive inotrope • Cardiac muscle stretches, develop arrhythmia • Digoxin—cheaper! Must monitor levels to get therapeutic • Genetic disorder common in Boxers, Dobermans, Great Danes, Basset hounds • Pimobendan (Vetmedin ) • Presentation: syncope, weight loss, sudden death • Dosing: 0.2-0.3 mg/kg po bid • Treatment • Adverse effects • Antiarrhythmics as needed to manage clinical signs • Vomiting and loose stools • Pimobendan—early treatment MAY prolong life • Rare, self-limiting • Taurine supplementation • American Cocker Spaniel

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 Heart Disease and Heart Failure In: The Merck Veterinary Manual Association: March/April 2006, Vol. 42, No. 2, pp. 90-93. ACVIM Consensus Statement J Vet Intern Med 2009;23:1142–1150

CHF in Cats Hypertrophic Cardiomyopathy in Cats • • Treatment Hypertrophic cardiomyopathy • Atenolol 6.25 – 12.5 mg q 12-24 hr • Genetic predisposition in feral and mixed breed cats—effectively eliminated • May not improve survival from purebred cats • Diltiazem 7.5 mg q 8-12 hrs • • Severe disease occurs early in life; milder forms take longer to progress Furosemide 0.5 -1 mg/kg/day • • Enalapril 0.5 -5 mg/kg/day Typically present with clot or sudden death • 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

Heart Disease and Heart Failure In: The Merck Veterinary Manual Heart Disease and Heart Failure In: The Merck Veterinary Manual

7 Systemic Hypertension in Dogs and Cats Considerations in managing Dogs and Cats with CHF • Diagnosis • Systolic BP > 180 mmHg • Compliance with medications improves survival • Pathophysiology • • Often secondary to renal dysfunction When possible, select medications the owner is taking • • Treatment If one ACE inhibitor causes side effects, try another • 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

Heart Disease and Heart Failure In: The Merck Veterinary Manual

Questions about Heart Failure? 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?

Can we recommend any OTC analgesics for Pets? Should we call the vet when we substitute

• Short term use only! generic Rimadyl? • Dogs • • YES! Acetaminophen 10-15 mg/kg BID -TID • • Aspirin 10 mg/kg po BID -TID The vets want to hear from you to check on any concerns or questions. • Buffered, NOT enteric-coated • Vets aren’t all aware of your services • Cats • Contact vets near your store to inform them of products you carry or can • NO acetaminophen—TOXIC order • Aspirin 10 mg/kg every 2 days

• Refer to DVM for chronic pain management

D Plumb. Veterinary Drug Handbook

8 What about those jerky treats? What is the third most common companion animal, after dogs and cats? • From 2007 to 2014, FDA received > 5000 complaints of illness from jerky-type treats imported from China • 3 human illnesses, 1000 canine deaths • • BIRDS! Necropsies in 72 dogs • • 54% clearly died from causes unrelated to jerky treats Birds often require compounded medications • Could not rule in or out treats as cause in remaining dogs • Birds need concentrated liquid dosage forms • Fanconi syndrome in 5 • Usually prefer fruit flavors • 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 best way to administer medications to Most Common Questions dogs and cats?

• 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?

Recommendations Drug administration • Dosage forms • • Trim cat claws Oral solid (e.g., capsules in smaller strength) • • Oral liquid (e.g., metronidazle suspension) Wrap cat if necessary • Topical (e.g., PLO for cats) • Enlist an assistant • Injectable (e.g., insulin) • Change dosage form • Hide medication • Safety concerns • • Food like peanut butter or cheese Aggressive or untrained pets • • Immunocompromised owner OTC products: Flavor Doh, Pill Pockets • Elderly • HIV/AIDs, cancer

9 Recommendations Solid oral dosage form --DOGS

• • Train dog to sit-stay Place dog in “sit-stay” • • Handle pets to accustom them to medical care. Approach dog from the side • • Be gentle but firm and confident Place non-dominant hand over muzzle with thumb and fingers on opposite sides • ALWAYS praise pet after medication is administered • Apply pressure with thumb and fingers to cause dog to open mouth • Use food rewards only if compatible with medication • 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

10 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 Post-test

2. Which of the following best describes the type of diabetes that dogs and cats usually acquire? 2. Pimobendan is a positive inotrope which is approved for use in a. Dogs and cats get Type 1 diabetes a. Dogs with symptomatic dilated cardiomyopathy b. Dogs and cats get Type 2 diabetes b. Cats with hypertrophic cardiomyopathy c. Dogs get Type 1 diabetes and cats get Type 2 diabetes c. Dogs with valvular heart disease d. Dogs get Type 2 diabetes and cats get Type 1 diabetes

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