Final Report 2011

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety

Lead institution: The University of Queensland

Partners: Australian Veterinary Association Chapter of Veterinary Pharmacology Charles Sturt University James Cook University Massey University (NZ) Murdoch University The University of Melbourne The University of Sydney

Authors: Associate Professor Paul Mills Dr Stephen Page Dr Amanda Craig

Website: http://vcpn.moodlesites.com/login/index.php

Support for this project has been provided by the Australian Learning and Teaching Council Limited, an initiative of the Australian Government Department of Education, Employment and Workplace Relations. The views expressed in this report do not necessarily reflect the views of the Australian Learning and Teaching Council Ltd.

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2011

ISBN 978-0-642-78187-1 [PRINT] 978-0-642-78188-8 [PDF] 978-0-642-78189-5 [RTF]

Contents

Abbreviations Used ...... 1 Executive Summary ...... 2 Project Outcomes and Impacts ...... 3 Introduction ...... 3 Rationale ...... 4 Approach and Methodology ...... 5 Resource Builder ...... 6 IT Management sub-committee ...... 6 Outcomes ...... 7 Dissemination ...... 8 (1) Steering committee newsletters...... 8 (2) Attendance at OIE World Veterinary Education conference...... 8 (3) Presentation to Australian Veterinary Dean’s Committee...... 8 (4) Presentation to Australian Veterinary Association annual conference...... 8 (5) Functionality of the VCPN website ...... 8 (6) International collaborators ...... 8 Linkages ...... 9 Evaluation ...... 9 References ...... 12 Appendices ...... 13 Appendix 1: First steering committee meeting – minutes ...... 13 Appendix 2: Newsletter 1 – November 2009 ...... 17 Appendix 3: Newsletter 2 – March 2010 ...... 19 Appendix 5: VeNom coding for term lists ...... 23 Appendix 6: Second steering committee meeting – minutes ...... 25 Appendix 7: Day One Competencies ...... 28 Appendix 8: VCPN Formulary ...... 68 Appendix 9: Case development outline ...... 91 Appendix 10: International symposium ...... 95

Abbreviations Used

ACVSc Australian College of Veterinary Scientists ADE Adverse Drug Events AVDC Australian Veterinary Dean’s Committee AVA Australian Veterinary Association CVP Chapter of Veterinary Pharmacology EQUELLA Digital repository and database LMS Learning Management System Moodle Modular Object-Oriented Dynamic Learning Environment OIE World Organisation for Animal Health RVC Royal Veterinary College SALG Student Assessment of Learning Gain VCPN Veterinary Clinical Pharmacology Network WIMBA Online software package for converting Word to online content

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 1 Executive Summary

Veterinary clinical pharmacology is a dynamic and rapidly changing discipline, with new therapeutic agents and information constantly being produced. The challenge for veterinary science students and, indeed, for graduated veterinary clinicians, is to maintain knowledge and successfully prescribe and apply appropriate agents to a variety of animal species. The aim of the current project was therefore to provide a renewable knowledge base of veterinary clinical pharmacology and utilise a problem-based approach to aid understanding and practical application of therapeutics.

The scope and direction of the project was guided by the requirement for a rapid response to advances in knowledge and specific agents, plus widespread accessibility. Initially, this was directed towards undergraduate veterinary science students, but was intended to be accessible nationally and internationally also to graduates for continuing education and professional development. An online resource was therefore essential and the project moved away from its initial institutional model to a far more versatile and flexible Moodle-based platform. The Veterinary Clinical Pharmacology Network (VCPN) was designed to encompass problem-based learning, supported by a comprehensive formulary (list of therapeutic agents) and guidelines for the use of these agents. Students could therefore apply and test their existing knowledge in realistic scenarios, plus have access to resources to continue their understanding of the discipline. The problems were designed to develop Day One Competencies i.e., to reflect what is expected of a veterinary clinician in terms of being able to prescribe and use therapeutics on graduation.

The release of the trial version of VCPN occurred in November 2010 in conjunction with a major international symposium on veterinary pharmacology. The symposium and the release of VCPN represented a major collaboration between all eight institutions teaching veterinary science in Australasia, plus industry and professional bodies. The trial release of VCPN was deemed successful since it could be readily accessed by national and international collaborators, with strong interest provided for continued development of the online learning resource. This will continue during 2011 for full release towards December, when further evaluation of the learning outcomes will be undertaken. This will also provide an opportunity to liaise with industry to provide continued support for VCPN and thereby provide new drug alerts, adverse drug events and focussed expert drug reviews/webinars and discussion forums.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 2 Project Outcomes and Impacts

Introduction The need for this project arose from the requirement to renew the teaching curriculum for veterinary pharmacology throughout Australia and New Zealand. It was realised that pharmacology, as a discipline, sits at the intersection of many science streams and a renewed curriculum would provide a unique opportunity to be cross disciplinary (involving epidemiologists, infectious disease specialists, parasitologists, microbiologists and clinicians) and cross sectoral (collaborating and interacting with the medical and pharmacy communities).

Further support for renewal of the national veterinary pharmacology teaching curriculum became apparent when the Chapter of Veterinary Pharmacology (CVP) of the Australian College of Veterinary Scientists (ACVSc) was approached to provide assistance in the development of a teaching curriculum in three new veterinary schools. A major problem was perceived in that there were limited numbers of suitably qualified academics to undertake academic teaching role. Furthermore, the rapidly expanding nature of pharmacology provided a significant challenge to maintaining currency in all aspects of the discipline. It was therefore proposed that a national curriculum would be beneficial and this led to the current proposal.

The advantages of a national veterinary pharmacology teaching curriculum were as follows: (i) It would link academics teaching this discipline and maximise the use of available resources by coordination and collaboration; (ii) It would provide an unheralded opportunity to disseminate new information, such as therapeutic breakthroughs or adverse drug reactions, to students quickly; (iii) There was a greater focus on Day One competencies for veterinary science students since graduates entering professional practice were immediately expected to apply their pharmacology knowledge (usually in an unsupervised setting) in the face of a barrage of questions such as: ‘is this the right drug?’, ‘can I give these drugs together?’, ‘can I use this drug in a guinea pig?’ or ‘is this legal to give to an animal before competition?’; (iv) There was (and remains) increasing pressure on veterinary clinicians to respond to the interaction between humans and animals, with particular interest in prudent use of antimicrobial agents and consequences of residues in food products. This pressure emanated from a number of levels, such as food safety, disease control, animal welfare, and from various national and international bodies. For example, The Commonwealth Government response to the report of the “Joint Expert Technical Advisory Committee On Antibiotic Resistance” (JETACAR) strongly encouraged the development of appropriate undergraduate and continuing education curricula (http://www.health.gov.au/internet/main/publishing.nsf/Content/health- pubhlth-strateg-jetacar-index.htm) and The World Health Organisation in their report “Global Principles for the Containment of Antimicrobial Resistance in Animals Intended for Food” (http://whqlibdoc.who.int/hq/2000/WHO_CDS_CSR_APH_2000.4.pdf ) further exhorted the development of educational resources to ensure antimicrobial agent use was judicious.

Further evidence of the need to ensure that veterinary graduates are current in veterinary pharmacology could be provided with just two of many examples: the issue of pain and animal welfare. Pain, as noted by prominent animal welfare experts Kevin Stafford and David Mellor, is a developing issue in veterinary medicine 1. Indeed, pain and animal welfare are behind a radical shift in the wool industry, one of Australia’s most prominent primary producers, with mulesing being

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 3 phased out by 2010 (still not achieved). Veterinarians are the focal point for the control of pain in animals, yet the understanding and pharmacological control of pain is still developing, particularly in large (farm) animals 2. Veterinary graduates cannot afford not to maintain currency with pharmacology from a welfare and social perspective.

What this project sought to achieve was a unique collaboration between all Australasian Veterinary Science Schools/Faculties, Educational Bodies and Industry to create a renewable resource to enhance student learning so that they would graduate with a current understanding of pharmacology knowledge and practice. Veterinary clinicians would therefore be able to quickly respond to major issues (e.g. withdrawn medicines, human-animal microbial resistance). Importantly for the institutions, there would be a valuable resource for student learning to which all participants would contribute. This would open the way towards benchmarking between institutions to further enhance the quality of student learning in a collaborative and student focused approach.

Rationale A process of research-led curriculum renewal in a specific discipline has received little attention in the literature3, but should, ideally, be driven by specialists in the subject area4. Any renewal of a curriculum will obviously build on an existing framework of pedagogy, assessment and linking of outcomes to graduate attributes5,6. A renewal process can therefore focus and better align the curriculum to reflect the needs of the discipline7,8. In many professional disciplines, such as veterinary science, medicine and pharmacy, this translates to effective application of knowledge and provision of specialist (pharmacological) advice to the client (pet owner), colleagues and lay public. Importantly, effective curriculum renewal will introduce learning innovations 9 and facilitate the connection between the existing curriculum, how it is taught and how assessment focuses learning4,10. One advantage of the current proposal is that in addition to cross-disciplinary collaboration between cognate professional schools, there is an excellent opportunity to incorporate suitable methodology on curriculum renewal based on the existing ‘Closing the Gap in Curriculum Leadership’, an ALTC funded project at UQ (D’Agostino and O’Brien, 2006-2009).

New knowledge is expanding the discipline of pharmacology exponentially, creating a significant challenge to the appropriate selection and use of medicines. The consequences of not responding to this challenge are significant with adverse drug events (e.g. Vioxx in human pain relief) and lack of efficacy of existing drugs (e.g. multiple antibiotic resistance in Staphylococcus aureus or Golden Staph) underlining the potential for devastating impacts of medicines and the essential importance of judicious and evidence-based use.

Veterinary pharmacology has similar implications for veterinary practitioners, but has more widespread impact. Not only are the health and welfare of animals essential, but safety of veterinary medicines to the environment and humans associated with animals are paramount. As an example, veterinary medicines that contain organophosphate (recent subject of regulatory review) have the potential to poison humans, as well as animals and the environment, and the veterinary profession plays an important role in providing advice on appropriate use. There are currently 3,371 medicines approved for veterinary use, of which 1,011 are classified as ‘Prescription Animal Remedy’ (S4) and 15 are classified as “controlled drug” (S8), thereby only available through a registered veterinary clinician (http://services.apvma.gov.au/PubcrisWebClient/welcome.do). Veterinarians will be expected to understand and expertly respond to all situations involving the use of approved and extra-label veterinary medicines in animals, including:

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 4 1. Residues of drugs in food animals and related trade and food safety issues with pesticides, antibiotics and other medicines (the advice of veterinarians is relied upon by those industries such as beef cattle production that have significant exports of their products). 2. Antimicrobial resistance selection and the rational use of antimicrobial agents. 3. Zoonoses – how to treat animals with medicines or prevent infection with vaccines and avoid transmission to humans (currently Australian veterinarians are playing a prominent role in supporting the Indonesian government to control rabies in Bali, with appropriate use of vaccination a critical element).

Approach and Methodology Prior to being awarded funding, a workshop was held in October 2008 at The University of Sydney with attendance from all seven current and proposed veterinary institutes, as well as by animal health industry and professional stakeholders. This meeting was sponsored ($5000 p.a. for two years) by CVP. It was generally agreed that most institutes presented basic pharmacology well, but were limited in the instruction of clinical or applied pharmacology. Four key issues were identified that required urgent attention: 1. Students needed an effective curriculum that would enhance the application of pharmacological knowledge; 2. Day One Competencies (i.e. skills and knowledge required when students graduate) must be defined to ensure that veterinary science students are confident, competent and proficient in veterinary clinical pharmacology when they graduate. 3. Pharmacology is constantly and rapidly expanding as a discipline and a curriculum must be able to incorporate new developments as they occur. 4. To be successful, a national curriculum must be readily available to all teaching institutes and stakeholders.

Following the workshop, a working party was formed which surveyed veterinarians attending a Continuing Veterinary Education (CVE) Symposium on Clinical Pharmacology in December 2008. A total of 62 responses provided feedback from graduates of the Australian Veterinary Science institutes with two important outcomes: (i) Clinical or applied pharmacology was frequently poor in new graduates as much of the applied aspects are now taught by clinicians in their individual teaching areas (e.g. cardiologists teach cardiac drugs), without a cross- disciplinary approach that considers drug interactions, species and gender differences and optimisation of the balance of benefits and risks; (ii) Current practitioners would benefit considerably from access to independent and authoritative information on veterinary pharmacology. This supported the ATLC Objective (d): develop effective mechanisms for the identification, development, dissemination and embedding of good individual and institutional practice in learning and teaching in Australian higher education.

The solution to this unmet need is to provide a dynamic and flexible curriculum with authentic resources to ensure that veterinary science students can successfully make the transition to professional clinical practice. The curriculum must be available online so that it is rapidly updatable and available to all institutes, and it must be receptive to input from a number of sources (e.g. industry, academia, international collaborators, etc). This proposal provides three strong advantages:

1. The approach establishes a nexus of academics, students, clinicians, industry and professional bodies within a single forum to focus, evaluate and learn. 2. This will be a highly effective model for other disciplines, particularly professional programs, to provide training to allow graduates to successfully apply knowledge. 3. An important additional benefit is the availability of this resource to graduated

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 5 veterinarians as a source of continuing education, ensuring life-long learning with a familiar tool.

After being awarded funding (2009), an inaugural steering committee meeting was held on the 4th of September 2009 at The University of Sydney campus (see minutes in Appendix 1). The steering committee consisted on the named academic from each institution. An Executive Committee, consisting of Paul Mills, Stephen Page and Amanda Craig, was formed to oversee the project as a whole, and be responsible for day-to-day support. Newsletters (Appendix 2-4) were circulated at regular intervals to update the committees, and their institutions, on progress.

Resource Builder The project was discussed at many levels, with a strong focus on the complexity of the task. It was agreed that simply revising a curriculum was inadequate, since teaching of basic pharmacology was probably already undertaken well in each institution and was guided by a range of excellent texts. What was required was a problem-based approach with online access. This could then be accessed as and when required by academics and, eventually, as a form of continuing education.

The steering committee members were then presented to by Sally Pope from The University of Sydney who had designed problem-based software called Resource Builder. A preliminary case had been developed and this was undertaken to provide information on how this worked. It was initially thought that Resource Builder would be ideal for developing the curriculum (and this was indicated in the original grant proposal). However, this proved incorrect due to institutional restrictions, authentication and access severely limited the value of Resource Building as a multi-institutional tool.

IT Management sub-committee To overcome the problems associated with access to Resource Builder, an IT Management sub-committee was formed, chaired by Amanda Craig, with Scott Edwards, Liz Tudor and Suong Ngo. They investigated various options and engaged with an IT support company called NetSpot. Netspot were able to provide a package based on Moodle (Modular Object-Oriented Dynamic Learning Environment), an open-access Learning Management System (LMS), which was compatible with many institutional learning platforms, including Blackboard and Web-CT. Web- design and management were a major component of the grant funding and NetSpot provided a cost-effective and fully supported website for our purpose, which was called the Veterinary Clinical Pharmacology Network (VCPN).

The advantages of the Moodle site was flexibility, the ability to authenticate large numbers of users (particularly if international access required) and compatibility with a wide range of other technologies. Incorporated into this package was the software program WIMBA, which converted Microsoft Word content into an online format, suitable for problem-based cases. A further software package EQUELLA was also required. EQUELLA is an award-winning Digital Repository that incorporates Learning Objects, Learning Content Management and integrated content authoring. EQUELLA acts as a single repository for Research, Libraries and Learning Objects and is ideal to search, manage and create content online.

In addition to establishing the VCPN website and incorporating license agreements for WIMBA and EQUELLA, NetSpot provided several training sessions for the software packages. In addition, a technician support person, Jo Griffith, was employed by the project to also undertake the training and to facilitate fine-tuning and uploading of case-based problems.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 6 Veterinary Clinical Pharmacology Network (VCPN) The homepage for VCPN was established in February 2010 and access to the steering party was granted to receive feedback on look and functionality. However, before problems could be developed, it was necessary to define the type of cases required, based on expected learning objectives. This was achieved by designing a Formulary (list) of drugs that would be expected to be understood and able to be used clinically by a graduating veterinarian. Stephen Page circulated several iterations of a Formulary through the steering committee for comment and refinement. Problems would therefore be developed to enhance the application and understanding of these drugs. In conjunction with this, Stephen Page developed a list of the active constituents of the more commonly used drugs in veterinary clinical practice, plus a database of essential drug information (what is it used for? Dose rate? Species differences, etc). This was essential information to ensure that the problem-based scenarios were targeted towards what is likely to be encountered when first entering clinical practice.

In conjunction with this drug information database, Amanda Craig investigated term lists to define what method would be most useful to student learning and compatible with other databases nationally and internationally. The most useful system was the VeNom Coding System (http://www.venomcoding.org/home.aspx) developed by The Royal Veterinary College (RVC) in the United Kingdom. The Executive Committee signed a Letter of Agreement with Dr David Brodbelt of the RVC to gain permission to use this coding system in VCPN (Appendix 5).

The VCPN website (http://vcpn.moodlesites.com/login/index.php; Guest login: steering_committee and password VCPNMoodle1) was officially released in November 2010 in conjunction with a major international symposium on veterinary pharmacology (see Dissemination). At this stage, this site contained the Formulary, information on active constituents, ancillary information and three problem-based cases. A second steering committee meeting (see minutes in Appendix 6) was held on Friday 26th November, 2010, immediately prior to this conference and website release. The committee was shown the active website by Jo Griffiths and the discussion focused on feedback on the site and planning further case development. This meeting was also attended by Professor Gabrielle Cooper, the external evaluator, who explained what would be her approach towards the evaluation process and she also offered some valuable suggestions on future develops of VCPN, based on her experience with other educational initiatives. The plan to move forward was to develop sufficient problem-based cases and incorporate VCPN into teaching curricula in 2011.

Outcomes

The major outcome for the project is an active website: VCPN. Preliminary cases have been prepared and checked, which will act as a template for further cases and provide feedback from potential users of the site. Prior to any case development, it was essential to determine a description of the Day One competencies (see Appendix 7) that we would expect a veterinary science graduate to have – this was agreed upon by all eight institutions and guided the way for the problem types that needed to be written. It was also important to have a Formulary (see Appendix 8) of the major drugs and drug classes that we expected students to have knowledge of, within the confines of the Day One competencies. We then devised a list of case- based problems that were required to develop the Day One competencies and required drug classes (Appendix 9). Future cases would be developed following these guidelines, with the intent of continuous case development as more institutions and students access the VCPN resources.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 7

Dissemination

The VCPN and project development has not been completed at the time of writing this report, so some of the planned dissemination activities have not yet taken place. However, there have been a range of dissemination activities that have occurred throughout the project to update and inform stakeholders, plus to facilitate implementation into the teaching curricula once completed.

(1) Steering committee newsletters. A regular newsletter (see Appendix 2-4) was circulated to the steering committee to provide feedback and updates on progress. This was also intended to be circulated to relevant stakeholders at each institution and provide a means of keeping steering committee members involved and active in the project. It was therefore also available for wider dissemination throughout the institution.

(2) Attendance at OIE World Veterinary Education conference. Associate Professor Paul Mills attended the inaugural OIE World Veterinary Education conference on 12-14 October in Paris. Veterinary Deans from many of the world’s veterinary schools and faculties were in attendance and it was a useful forum to disseminate information about VCPN and attract collaborators. Associate Professor Mills was undertaking a short education sabbatical and also visited the Royal Veterinary College (London), University College (Dublin), and several veterinary schools in Italy (Mila, Padua, Perugia, Bologna and Pisa). This was an opportunity to discuss with the pharmacology academics in each institution and these meetings were favourably received.

(3) Presentation to Australian Veterinary Dean’s Committee. Associate Professor Paul Mills and Dr Amanda Craig presented preliminary outcomes to the Australian Veterinary Dean’s Committee (AVDC). The AVDC were gathered for the Australian Veterinary Association (AVA) Annual conference in Brisbane (May 2010). The presentation was received extremely favourably, particularly the potential as a model for other disciplines and for the significant advantages the VCPN site would provide for teachers of pharmacology.

(4) Presentation to Australian Veterinary Association annual conference. The education committee of the AVA invited the Executive Committee to present their findings at the May 17th 2011 AVA national conference in Adelaide. A paper entitled: ‘Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety’ (Mills, PC, Page, S, Craig, A) was presented.

(5) Functionality of the VCPN website An important aspect of the VCPN development was to incorporate, in addition to case-based problems, links to further resources, including the formulary. An active Discussion Board will assist interactive discussion, plus a News and Events section to provide advice about new drug releases and adverse drug events (ADE). These aspects are considered essential for long-term sustainability of the project as they will appeal to industry and be recognised as a mechanism to liaise with future veterinary graduates, albeit on a controlled (by VCPN Executive) and unbiased (all pharmaceutical companies can have equivalent access) approach.

(6) International collaborators The symposium ‘What every practitioner needs to know’ was an international veterinary pharmacology event which attracted over 80 attendees (Appendix

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 8 10). Keynote speakers were: Professor Peter Lees (RVC), Professor Chand Khanna (National Cancer Institute, US) and Dr Ludovic Pelligand (RVC). This not only added excellent presentations on veterinary pharmacology, but facilitated further international collaboration. In addition, Professor Mark Papich (North Carolina, US), Professor Fiona Cunningham (RVC) and several other internationally-recognised veterinary pharmacologists are working with the project to provide further information and dissemination.

Linkages

What became evident to the project team and was indicated by the AVDC was that the current project was an ideal model to generate curriculum change in other disciplines. It was also evident that several disciplines have tried to develop online learning modules and teaching websites, but these have failed due to lack of support and the substantial costs of organizing, hosting and maintaining online sites.

The strong advantage of the current project and the collaboration to date is that all current veterinary faculties and schools across Australia are represented and this has proven attractive to other disciplines within the general field of veterinary science, such as microbiology, parasitology and medicine. The success and continued presence of VCPN therefore will provide this focus and eliminate costly and time-consuming set-up if other disciplines can collaborate and have a presence on this existing tool for online education. It will also provide a ready portal for stakeholders, particularly industry and professional bodies, to maintain contact with graduates. This will be apparent following fine-tuning and expansion of VCPN towards continuing education, a requirement of veterinary professionals in Australia.

Evaluation

The final version of the VCPN site has not been fully released since a sufficient number of cases are still being developed. Following advice from institutional education specialists, it was decided to use the Student Assessment of Learning Gain (SALG) online assessment tool, with specific questions being developed and uploaded by each institution, following consensus. This survey will now be applied towards the end of 2011 when the VCPN website will be fully implemented.

However, a preliminary survey has been developed and the results from various undergraduate students (n=60) was promising and encouraging (Table 1). Students indicated that they were moderately aware of the basic principles of veterinary clinical pharmacology and indicated a need for further resources. They appeared to like the features of VCPN and indicated that not only would it assist learning, but that they would like to access online support in the discipline once graduated. The format and approach, via problem-based learning, certainly appeared to stimulate and support deep learning. A larger trial and survey should verify these preliminary findings.

An external review will be undertaken by Professor Gabrielle Cooper, Associate Dean Clinical Engagement and Head of Discipline of Pharmacy in the Faculty of Health at the University of Canberra. Professor Cooper brings a wealth of knowledge on education and similar projects to the current initiative and has already provided strong guidance on future directions for VCPN.

The preliminary release of VCPN in conjunction with the international symposium was well received by industry stakeholders. The pharmaceutical industry has a vested interest in veterinary science students since the student are future clients and also, potentially, clinical research partners. The ability to have impartial and equitable access to learning resources for undergraduate curriculum is appealing to

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 9 industry, particularly since new drug developments and industry bulletins can rapidly be disseminated via VCPN to all institutions teaching veterinary science. This interest from industry stakeholders will be an important contributor to long-term sustainability of VCPN.

A further advantage of the release of VCPN was the interest expressed by international collaborators. The US, in particular, has been investigating approaches to renew the teaching of veterinary clinical pharmacology, but was faced with many faculties and difficulties arriving at a consensus. The template and collaboration provided by VCPN was timely and is expected to facilitate continued collaboration. This will be particularly useful for benchmarking and further development of resources.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 10 Table 1. Veterinary Clinical Pharmacology Network (VCPN) Student assessment survey

This short survey is designed to indicate impressions and degree of satisfaction with the VCPN site. To undertake this survey, please log onto the site and look through the content, plus attempt some of the case studies. Then complete the survey below. The scales range from 5 (strongly agree), 4 (agree), 3 (uncertain), 2 (disagree) and 1 (strongly disagree). (n=60)

Question 5 4 3 2 1 I am interested in veterinary pharmacology 23 27 5 3 2 I find veterinary pharmacology challenging 36 22 1 1 I feel that I have a good understanding of the various 5 16 14 15 10 classes of drugs I could confidently recommend a suitable antibiotic treatment 3 15 19 16 7 regime based on my understanding of disease and antibiotic agents I could design an effective treatment plan for mild, moderate 5 14 15 20 6 and several pain I am aware of how different physiological states, including 4 13 22 17 4 disease, may affect drug disposition I know where to look for comprehensive information about 16 24 8 9 3 therapeutics agents, their indications, contraindications and species differences I think that an online resource for veterinary clinical 35 17 4 3 1 pharmacology is a useful tool for me The VCPN website contained useful information 29 26 2 3 0 The VCPN website was well set out 24 22 8 4 0 The case studies were easy to understand 25 26 5 3 1 The case studies helped me to learn 28 24 6 2 0 An online problem-based approach is a good way to learning 31 24 2 3 0 veterinary pharmacology I would like to use VCPN and an expanded range of cases to 35 19 4 2 0 continue my learning in veterinary pharmacology The design of the cases with preliminary and ancillary 25 29 3 2 1 information was very helpful to understand why a specific treatment regime may be selected I prefer to learn about veterinary pharmacology from 4 8 25 16 7 textbooks I would like to have access to an online resource, such as 34 22 3 1 0 VCPN, throughout my undergraduate career I would like to have access to VCPN once I graduate 35 21 4 0 0

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 11 References

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Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 12 Appendices

Appendix 1: First steering committee meeting – minutes

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety

INAUGURAL STEERING COMMITTEE MEETING

4 September 2009 10am to 3pm Faculty of Veterinary Science Board Room, The University of Sydney

PARTICIPANTS AND APOLOGIES

CONSTITUENCY REPRESENTATIVE STEERING COMMITTEE Grant holder (UQ) Paul Mills Content consultant Stephen Page Chapter of Pharmacology Stephanie Armstrong The University of Queensland Ian Shiels The University of Sydney Merran Govendir James Cook University Robert Kinobe The University of Melbourne Liz Tudor The University of Adelaide Suong Ngo Murdoch University Tim Hyndman Charles Sturt University Scott Edwards Content consultant Amanda Craig VISITORS The University of Sydney, Sally Pope Faculty of Veterinary Science Sub-Dean for ICT and e- Learning Centre for Veterinary Education Patricia Swift Centre for Veterinary Education Richard Malik APOLOGIES Massey University Paul Chambers

OBJECTIVES 1. To discuss and gain a common understanding of the pharmacology curriculum renewal grant objectives and processes of decision making and implementation 2. To provide an open forum to raise and discuss opportunities, issues and concerns 3. To review current activities 4. To review proposed work plan and agree on key activities

Welcome and Introduction o Paul Mills welcomed the participants and gave the apologies of Paul Chambers. The support of each academic institution along with the Chapter of Pharmacology and the Australian Veterinary Association / Australian Veterinarians in Industry was acknowledged as critical to the success of the grant application. Review of the 2008 unsuccessful application together with ideas and suggestions emerging from the October 2008 Curriculum Meeting and from participants at the CVE Pharmacology Symposium in December 2008 helped refine the application.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 13 o Key elements of the proposal were highlighted for further consideration and discussion:  Rationale  Aims  Approach and methodology  Components of the Veterinary Clinical Pharmacology Network (VCPN)  Flexible delivery and online veterinary pharmacology  Dissemination and embedding  Anticipated deliverables and outcomes  Intellectual property  Evaluation strategies  Budget  Timeline

o A summary of the discussion of the key elements included the following critical points:  The project is ambitious  The timeline is very tight and tasks and actions need to be implemented immediately  Need to look very closely at proposal to ensure that the deliverables are practical and achievable  Surveys of current status need to be developed, finalised and conducted soon  Post implementation surveys, given the short duration of the grant period, may need to be conducted on a selected pilot group of students  Need to finalise consolidated list of day one competencies  Independent evaluator could be selected from within or beyond Australia  Noted that ALTC project led by James Ziogas at the University of Melbourne  The need for a method of assessment of students was accepted as pivotal but the adoption of eportfolios as the vehicle was not widely supported  Online questionnaires (including MCQs) could be developed and provide an effective and simpler solution to assessment  The approach to intellectual property described in the proposal was accepted to the steering committee

o A proposed project organisation structure was presented which included an Executive Committee, Steering Committee and a cluster of working groups. o Membership of the various WGs was sought and Scott Edwards volunteered to join (and lead) the Assessment WG. o Nominations of steering committee members or their associates is encouraged to ensure the work program can start

Website Hosting Opportunity with the Centre for Veterinary Education (CVE) o Patricia Swift from CVE joined the meeting and provided a synopsis of the key activities of CVE. o CVE have an established and working website for use of CVE members and are keen to collaborate with the VCPN o Recommended that VCPN put a detailed specification sheet together for CVE to consider and for collaborative discussion on how CVE may host a web site for VCPN

Elearning: resource builder, ‘virtual pharmacologist’ o Sally Pope presented an outline of resource builder and case builder, using an illustrated clinical case (Antifungal Treatment: Stertorous Cat: nasopharyngeal cryptococcosis) prepared by Richard Malik. o It is proposed that VCPN will contract a postgraduate veterinarian to enter cases

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 14 and to participate in template development o A customised case template (Virtual Pharmacologist) needs to be developed then applied to all cases o A small working group (that could include the early adopters and developers from within the USYD veterinary faculty – Jacqui Norris and Mark Krockenburger) needs to start working on template development o 100 cases are proposed in the grant application. These cases will be selected as exemplars linked to the day one competencies. o Sources of cases can be from within the VCPN and also from academic and practicing clinicians.

Roundtable contributions Robert Kinobe o Having specialists present topics online is considered highly desirable o Content should include pharmacology and toxicology o Sustainability of curriculum very important and will require sources of ongoing funding and technical support.

Tim Hyndman o Eportfolio format not favoured as assessment tool o IP not considered an impediment to submitting materials o Virtual Pharmacologist a superlative idea

Suong Ngo o Toxicology should be included within curriculum o Eportfolio concept a concern o Integration and implementation of proposed curriculum will require involvement of clinicians o Multiple Choice Question banks can be a very effective assessment tool and are well developed and validated within the pharmacy school

Scott Edwards o Favours pooling of content resources (including practical classes) from each participating institution to allow selective adoption and use o First day competencies as drivers of curriculum

Ian Shiels o Chief use of current proposal is to add value to what is already in place o Flexible teaching online is necessary to meet current trends in education

Liz Tudor o Proposed project may more correctly be viewed as a web-based resource than a curriculum o While Resource Builder is a specific in house approach to teaching, there are other more accessible models available that could offer significant teaching and learning benefits

Amanda Craig o Need to consider how new developments will be added to curriculum in a timely and effective manner

Merran Govendir o Need blueprint outlining how proposed curriculum will be developed, starting with day one competencies o Model of underlying pedagogy required o Ideas for learning needed o Quality of programme needs to be assessed and assured

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 15 Richard Malik o There are a multitude of veterinarians in practice who are willing to provide cases for inclusion in the curriculum. CVE could be used as a means of getting messages to the profession and identifying those who would like to assist.

Stephen Page o Day one competencies and the case list (see attachment) o Each participant asked to review the attached list and add any missing competencies. o The proposed 100 cases will be selected to match the full list of day one competencies.

Pharmacology conference 2010 o Proposed to be held at UQ in November 2010 o VCPN initiative supported by Chapter of Pharmacology and Centre for Veterinary Education o CoP has established a Conference Committee to support planning

Summary of Key Actions

DELIVERABLES o Review proposed deliverables and define realistic and achievable interpretation

ASSESSMENTS o Develop pre-implementation survey and survey conduct plan o For ongoing student assessment, explore options including eportfolio and online quizzes, questionnaires, MCQs

WORKING PARTIES o Examine proposed structure and consider nominations for participation

COLLABORATIONS ASCEPT Education SIG o Dr Ngo is a member and volunteered to represent VCPN o Chair contactable at [email protected] o ASCEPT meeting 30 November -2 December and both Dr Ngo and Dr Craig will be attending. Opportunity to discuss the VCPN and possible involvement of.

University of Melbourne ALTC Grant re Medical Pharmacology Curriculum o Arrange to meet James Ziogas to discuss his project and explore opportunities for collaboration

WEBSITE o Prepare specifications for review and discussion with CVE

VIRTUAL PHARMACOLOGIST o Convene WP to prepare draft template for consideration by Steering Committee o Identify a suitable contractor to enter cases and participate in the VP WP

DAY ONE COMPETENCIES o Steering committee members to review attached list of competencies and add and edit as appropriate before returning it to Paul Mills / Stephen Page for finalisation

CURRICULUM CONTENT o the grant proposal focused on Resource Builder as one teaching and learning tool. Steering Committee members should present and describe other tools for discussion and possible inclusion.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 16

Appendix 2: Newsletter 1 – November 2009

To: Steering Committee for Veterinary Clinical Pharmacology Network (VCPN) Date: 26 November 2009

Hi Everyone,

I think that it would be useful to have a regular update to all members of the steering committee, plus the Chapter of Veterinary Pharmacology, of what has been happening and what progress has been made. This can assist with any reporting to your institution and will also elicit feedback from you about issues and concerns.

Technology platform This is the first of more regular updates about the progress of VCPN and what has been happening. I apologise for the delay in this from the last steering committee meeting, but I have been away since October on study leave. However, there has been a lot happening and some great progress made.

We agreed at the last steering committee meeting in Sydney that an executive committee, comprising of Stephen Page, Mandy Craig and I, would be responsible for project direction and day-to-day activities. I hope that everybody is still comfortable with this. We also presented a proposal to investigate the potential of CVE to assist with the website development and determine how this would work with resource builder to achieve our basic aims of a problem-based website. An MOU (I can send this if you wish) was exchanged between the project and The Faculty of veterinary Science at The University of Sydney concerning the use of Resource Builder. This was not a commitment but just an agreement of terms of use for Resource Builder and making sure that the various responsibilities were understood.

In the meantime, Mandy has been very busy looking into the options to allow the created resources to be integrate or be uploaded into the various learning management systems LMS used at the various institutes. Moodle is one of these LMS and is already in use at CVE. Mandy has since been in discussion with Netspot, a commercial company that offer IT consultancy services to the higher education sector in online LMS management including webCT, Blackboard and Moodle as well as training, help desk support and various additional LMS add-ons or plug-ins to allow a wide range of resource functionality. She has formed one of the steering committee sub-groups that we discussed at the meeting. This sub-group is the IT management group and comprises of Mandy, Scott Edwards, Liz Tudor and Stephen Page.

This group had a meeting with Netspot personnel and have formed a plan to use various technologies supported by NetSpot to accomplish many of our aims in developing and hosting the VCPN online curriculum resource and website. Mandy will circulate the minutes of this meeting shortly for comment. Once we decide to go ahead with this approach, we should be well placed to start the online resource and website development and upload it into a usable sharable form quickly.

External evaluator We have approached Professor Gabrielle Cooper, Head of Discipline of Pharmacy in the Faculty of Health at The University of Canberra to act as an external evaluator. This is required by the ALTC in the terms of the project and a stipulated $10 000 was reserved for this purpose, again at the request of the ALTC.

Professor Cooper is already familiar with these sort of projects and is an

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 17 experienced evaluator, plus she has already stated her availability for this project, which is great for us as she can be aware of the project as it develops.

Conference We have been making some progress on a possible veterinary pharmacology conference in 2010. We have been in discussions with CVE to run this conference with them, since they have expertise in conference organisation and implementation. We are still hoping for late November (from the 20th on) in 2010, although this may not be ideal for CVE.

There is a conference committee already working towards this from the Chapter of Veterinary Pharmacology, led by Charmaine Tham. The conference will be a great showcase for veterinary pharmacology, plus a chance to release VCPN officially. The specifics are still under discussion and any input is welcomes. However, we were thinking of a 2 day event, with international speakers (some possibly interacting via lectopia or Skype) to present advances in pharmacology in conjunction with clinical specialists to work through common and complex problems and therapeutic failure. This may work well with two streams, large animal and small animal, to present a useful forum to a wide audience. Please let me know if you have any comments or suggestions about this.

Collaboration agreement The University of Queensland will be sending an ALTC collaboration agreement out shortly to each of your institutions. This is necessary since UQ is responsible for the funding and any reporting to the ALTC. The collaboration agreement is a formal agreement to sign off what you have already agreed to do (detailed in the proposal), but is basically to contribute to the steering committee, provide case material (subject to any IP requirements), to support the project and the renewed curriculum and to assist in the mapping of Day One competencies to specific case-based learning. This does not involve any financial commitments and is what we agreed at the workshop and the steering committee meeting, so hopefully should not cause any concerns, but please let me know if there are any problems and we can address them.

Case development Stephen Page has been working solidly on getting a list of 100 cases mapped to day one competencies. He will circulate this in the next couple of weeks for comment and this will be a great step forward.

International collaboration A component of my study leave was to liaise with a number of veterinary faculties in Europe, including Royal Veterinary College, Dublin, Bologna, Perugia and Milan. All were highly enthusiastic about VCPN and would be very interested in collaborating. This may lead to a truly international project with huge resources. We already have several international collaborators on board, including Mark Papich and Virginia Fajt (USA), Michelle Doucet (Canada) and Fiona Cunningham (UK), which is a great bonus.

I attended the OIE (World Veterinary Education) conference in Paris while on study leave. The theme was ‘Evolving veterinary education for a safer world’ (see attached article) and a number of recommendations were put forward to improve global veterinary education. A number of the recommendations were similar to our project proposal, particularly the ability to continually update the knowledge base and working towards day one competencies.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 18 Appendix 3: Newsletter 2 – March 2010

To: Steering Committee for Veterinary Clinical Pharmacology Network (VCPN) Date: 15 March 2010

Hi Everyone,

The second instalment of this newsletter sees some great progress on both the VCPN website and the symposium in November 2010.

Technology platform It has now been confirmed that we have adopted a Moodle-based approach facilitated by NetSpot (http://www.netspot.com.au/). We are great appreciative of the initial support from Sally Pope at the University of Sydney and Patricia Swift from CVE. They had some excellent ideas based on their successful education approaches to date. However, the advantage of using NetSpot is that they could develop a site that would be independent and capable of expansion. The site would also be capable of managing large numbers of log-ins and various permissions for levels of access.

The credit for investigating NetSpot and reviewing Moodle as a way forward was mainly due to Mandy and the IT Management sub-committee, consisting of Scott, Liz, Stephen and Suong – many thanks.

A preliminary website is up for viewing and comment. Feel free to access via the ‘Guest’ log-in to get a feel for the site. There is obviously minimal content at this stage, but, in addition to the case-based problems, we intend to install lots of ancillary learning material and interesting resources. The site revolves around storage of resources on EQUELLA, which is accessed as required; with various levels of permission (e.g. we could provide guest access to certain components and also control access by students, continuing education candidates, etc). There is also the WIMBA software, which facilitates incorporation of material from Word into a problem-based format. NetSpot will provide training in all these features and these people will disseminate this knowledge to the steering committee once we are up and running. A big advantage of using NetSpot is the excellent support and their experience in setting up similar sites elsewhere.

The IT Management committee would appreciate any feedback to date. We would also like to know if you wish to stay with the name Veterinary Clinical Pharmacology Network (VCPN) or think something else is more suitable.

External evaluator This is just to confirm that Professor Gabrielle Cooper, Head of Discipline of Pharmacy in the Faculty of Health at The University of Canberra, has agreed to act as our external evaluator. Professor Cooper will be invaluable for her expertise and experience with similar projects. We hope that she can provide good formative assessment as we progress and, hopefully, a favourable final report (we are aiming at March 2011 for this report).

Symposium The symposium has been scheduled for November 27th and 28th, 2010, at The University of Queensland. The program (attached below) is looking excellent with a world-class line up of speakers to present the latest developments in pharmacology. The two-day event will consist of cutting-edge pharmacology on day one, with translation of principles to practice on day two by leading veterinary specialists.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 19 I noted in the last newsletter that we have a conference committee led by Charmaine Tham and they have been doing an excellent job with assistance from our executive committee. Charmaine is working with Patricia Swift from CVE to ensure that this conference is memorable and a highlight of the conference calendar for 2010. I would encourage you all to let your colleagues know about this event.

It would be a good chance to have another steering committee meeting before this symposium. Could you please see if you would be available for the afternoon of Friday 26th November to have a pre-symposium meeting and dinner?

Executive news A lot of behind the scenes activity has been going on with the executive committee (Mandy, Stephen and I). In addition to the conference and working on the website development, we have been working on an action plan for the remainder of 2010. This revolved around a 1 month, 6 month and 9 month milestones, initiating from the recent release of the VCPN website by NetSpot.

The one month milestone was to have a working example of a problem-based scenario ready for trial. This is similar to what we did when first evaluating Resource Builder and gives everybody an opportunity to see how it all works.

The six month milestone seeks to expand the problem base, plus add substantial ancillary resource material to assist student learning. Stephen has been looking into this aspect and has some great ideas for resources and items of interest.

The nine month milestone is a fully functioning website coinciding with its launch at the November symposium. VCPN will always be a ‘work in progress’ as more problems and information are added and updated. However, we wish to have a functional and useful tool available by November 2010.

We are also working on the student survey, as indicated in the grant submission. This is a tool to survey students on their pharmacological knowledge before and after release of VCPN. This information would obviously be useful to each of your for institutional reporting and feedback. If people think it appropriate, we could also consider using it as a benchmarking tool, similar to the anatomy and physiology or the equine benchmarking going on at all our institutions currently. Any suggestions or recommendations for questions, format of the survey and what aspects of knowledge and understanding that we are targeting would be most appreciated.

Reporting A six month Progress Report was required by the ALTC by the end of February 2010. I was a little pushed to get this done since we have just moved our entire school, creating much chaos. However, I drafted a report that was circulated to the Executive Committee for approval before sending to the ALTC. I apologise for not circulating to the steering committee for feedback, but will ensure that all future reports are available for comment before submission.

The Progress report was received favourably by the ALTC and both the report and the feedback are attached to this newsletter.

There was a suggestion from Professor Rosanne Taylor that we make a presentation to the Veterinary Dean’s Committee on progress and outcomes. This seemed like a great idea, with upcoming meetings at the AVA/Pan Pac meeting in Brisbane (May) and the November Dean’s Committee meeting appropriate times for this. We will be working on both meetings to present progress. However, I would encourage you all to disseminate this project as widely as possible. We have some keen international interest in the outcomes for this project and it would be good to know that we have similar support at home.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 20

Appendix 4: Newsletter – September 2010

To: Steering Committee for Veterinary Clinical Pharmacology Network (VCPN) Date: 13 September 2010

Hi Everyone,

This is the third newsletter regarding VCPN and further progress has been made on several fronts.

The VCPN website We have a basic website organised (http://vcpn.moodlesites.com/login/index.php) and any feedback is welcome (a generic username and password are: steering_committee and VCPNMoodle1). There has been a lot of activity behind the scenes with training and familiarisation of the software, including training on the use of Wimba and EQUELLA, so we are about ready to start populating the site with case-based problems. Jo Griffith [who has recently been awarded a PhD by the University of Sydney Faculty of Veterinary Science following review of her thesis “Studies into the diagnosis, treatment and management of chlamydiosis in koalas” which included some very interesting pharmacological investigations] has been contracted to manage the incorporation of case material into web-based problems. This will use the Wimba program and will rely on material provided by you and others based on teaching material and interesting cases concerning pharmacology and therapeutics.

Stephen Page has been working very hard on the Day One Competencies expected of a veterinary pharmacologist. This was based on the individual competencies supplied by each of you for your institution. Learning objectives derived will be mapped to day one competencies and a draft list of case studies that illustrate each objective is being prepared. Within the next two weeks the draft assessment will be sent to each of you for comment and feedback before it is finalised. At the same time you will be requested to nominate case studies that you could develop within your institution.

Mandy Craig, chairing the IT Management sub-committee, has devised a template to facilitate devising a case-based problem with the minimum of fuss. She will circulate this following the above draft assessment for comment and, hopefully, some problems from each of you and your colleagues. Jo will then work to prepare case studies in Wimba before uploading onto VCPN. Each problem will be approved before uploading by the executive committee to ensure that content is checked before release.

Symposium I circulated the brochure for the symposium on November 27th and 28th, but have attached it again to remind you to please circulate to colleagues and anybody interested in veterinary pharmacology. It is focused on practical and relevant information, so should appeal to many clinicians. It will also serve as the release date for VCPN. The symposium is being presented in conjunction with Continuing Veterinary Education (CVE) and the Chapter of Veterinary Pharmacology from the Australian College of Veterinary Scientists. This will probably be the last chance to meet Peter Lees before he retires. Professor Lees is one of the most prominent veterinary pharmacologists in the world and a former editor of the Journal of Veterinary Pharmacology and Therapeutics. In addition, Professor Gabrielle Cooper, our external evaluator from the University of Canberra, will be attending, so it would be a good chance for you to meet her also.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 21 As I mentioned previously, we intend to have a final steering committee meeting the Friday before this (i.e., 26th November) to discuss what we have achieved and the sustainability of the project. The project will cover your travel and accommodation (Fri and Sat nights) costs and we will have a dinner that night following the meeting. I sincerely hope that you are able to attend as your views and thoughts are highly valued and can help sculpt the future appearance of veterinary pharmacology. Please let me know if you can attend (I need to book accommodation urgently).

Evaluation and dissemination Two of the executive committee (Paul Mills and Mandy Craig) presented a short update to the Australian Veterinary Dean’s Committee (AVDC) during the recent Pan Pacs/AVA conference in May. This was favourably received and all the deans were supportive of the project and looked forward to the outcomes.

As mentioned on the last newsletter, Professor Gabrielle Cooper, is our external evaluator and will be providing a report on the project to coincide with our final project report in March 2011.

Two other things concerning project evaluation need some input from the steering committee at this stage. Firstly, in the project submission to the ALTC, we indicated that we would undertake a survey of undergraduate veterinary science students to determine their knowledge and understanding of veterinary pharmacology. The aim of the survey is to apply it before and after the release of the VCPN website to determine if it enhanced learning in undergraduates. However, this survey would also be a useful tool to provide some basis for a baseline of understanding of veterinary pharmacology in our students and also as a potential benchmarking tool to compliment the benchmarking initiatives in other disciplines (e.g., anatomy and physiology; equine). At this stage, it would be good to know if you are prepared to have (anonymous) data from your students used for benchmarking or if you wished it restricted to assessing the efficacy of VCPN. I would also appreciate any comments or suggestions for the format and type of questions that you may like included. It should be noted that this survey will complement the survey undertaken by Stephen Page in 2008 from graduate veterinarians who attended the CVE pharmacology workshop.

The second issue to consider is e-portfolios. This was not favoured when last we met as a steering committee and I am happy to let the matter drop if this is still unwelcome. However, there are a lot of new initiatives in e-portfolios and much greater experience from institutional education centres, so it may be worth re-visiting this issue. Please let me know your thoughts on if we should explore this further as a tool to monitor learning in veterinary pharmacology.

Reporting A twelve month report was required by the ALTC by the 2nd of August. Since we were undergoing a period of training and consolidation, including employing Jo Griffith, I put together a short report and briefly circulated to the executive committee. Part of the rush was that I was inundated with supps, specials and the new semester, so my fault for not being a little more organised. I have attached the report and I hope there are no problems with it, but please let me know if you have concerns or find anything you disagree with.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 22 Appendix 5: VeNom coding for term lists

The VeNom Codes: Information for End users

Dave Brodbelt, the VeNom Coding Group (see www.venomcoding.org) and Veterinary Clinical Sciences, Royal Veterinary College Hawkshead Lane, North Mymms, Herts AL9 7TA, [email protected]

The VeNom Codes have been developed in the first opinion and referral hospitals of the Royal Veterinary College (RVC) in collaboration with the University of Glasgow Faculty of Veterinary Medicine (UGFVM) and the PDSA and the codes are now maintained by a multi-institution group, the VeNom Coding Group, consisting of veterinary clinicians and IT experts from the RVC, UGFVM, the PDSA, Cambridge, Bristol and Nottingham Vet schools and Vets Now.

The VeNom codes comprise an extensive, standardised list of terms for recording diagnosis, presenting complaint, breed (dogs currently) and procedure. The diagnoses comprise mainly clinical diagnoses but also includes terms appropriate for administrative transactions (e.g. non prescription diet sales, over the counter items, travel related items) and preventive health visits (vaccination(s), routine parasite control, neutering). Additionally presenting complaints are provided. These can be coded in addition to diagnosis by end-users or instead of a diagnosis. In the event that a clinician seeing an animal feels unable to record a diagnosis for a visit (for example, on a first consultation when only limited diagnostic workup has been possible and a precise diagnosis is not yet available) it is also possible to select one or more presenting complaints (e.g. coughing).

The codes are a long list identified by their unique numeric code and work best with a multi-letter search function: so clinicians type ‘abs’ and get all possible terms with abs as first letters of any of the words in the diagnosis (e.g. ‘anal sac abscess’, ‘abscess – neck (cervical)’ etc). For some terms there are synonyms in brackets behind the main term to allow identification of the correct term if the synonym is searched for. If an item is missing from the list, end-users are requested to inform the VeNom Coding Group and they will make the necessary adjustments as required. The group are currently working on other lists (feline breeds, equine diagnoses etc) and these will be added to the VeNom codes in due course.

1. Diagnoses and presenting complaints The VeNom codes are a long list of conditions (Term name) identified by their unique numeric codes (Data Dictionary Id). There is a label field to identify the type of term (Container and Container ID – e.g. diagnosis, presenting complaint, administrative task etc.). The Top level modelling field includes the parent grouping / body system for each term. There are two versions the ‘Referral active’ version which is elected if the PMS prefers the referral centre version. In this version presenting complaints are stated without a 'presenting complaint - ' prefix and the administrative tasks are excluded. For the first opinion version the ‘Non-referral active’ version includes presenting complaints with the prefix ‘presenting complaint -’ to highlight this is not strictly a diagnosis. The other worksheets include deactivated terms and a list of the recent additions.

2. Breeds The VeNom coding group has developed a set of breeds in collaboration with RxWorks and in consultation with all the available breed group lists. In relation dog breeds, there are two sheets: one has synonyms on the same line (‘input’) and the other ('output'). The Output has synonyms on separate lines being linked behind the scenes. This allows incorporation of linked synonyms into the end- user system without the need for a long single line text string format. For the top 20 breeds the common format is included in addition to the systematic version

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 23 (e.g. German Shepherd Dog versus Shepherd Dog - German).

3. Procedures There are three types of procedures: procedures, diagnostic tests and first-op only procedures. The latter represent primarily first opinion only activities, including vaccinations and other patient managements.

4. Species Species have now also been incorporated and this is likely to be expanded further.

Conditions of Use The main concern is that end-users that adopt the VeNom codes also adopt the rules of the VeNom Coding group: namely that the VeNom Coding group maintains the list. If, for example, a colleague requests a new item, then we request end-users forward the request to us. We then put it to the VeNom Coding group to vote on and if approved it is added to the list, if not it doesn’t go on the list. VeNom Code updates are sent to end-users on a quarterly basis, though we can issue additional updates if end-users require specific terms to be added sooner. We also request that the diagnostic lists used by the PMS’s and other end-users are kept restricted to the standard VeNom terms and that practitioners cannot add their own terms as they go along. Finally we ask that end-users do not distribute the list to third parties without the consent of the group.

For further information please feel free to contact me, Dave Brodbelt, at the address and email above. See also www.venomcoding.org.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 24 Appendix 6: Second steering committee meeting – minutes

VCPN Steering Committee Meeting – Friday 26th November 2010 Minutes from meeting

The meeting commenced at 2 pm and those attending were: Paul Mills (UQ), Stephen Page (Advanced Veterinary Therapeutics), Amanda Craig (Director, Companion Medicine), Paul Chambers (Massey), Robert Kinobe (JCU), Ian Shiels (UQ), Peter White (U Sydney), Scott Edwards (CSU), Liz Tudor (U Melbourne), Suong Ngo (U Adelaide) and Tim Hyndman (Murdoch).

In addition, we had Jo Griffith attending. Jo has been employed as a Technical Officer working with the VCPN site. Also, Professor Gabrielle Cooper (University of Canberra) is a Professor of pharmacy at the University of Canberra and is the external evaluator for the project. It is mandatory to have an external evaluator for these projects and we are very lucky that Gabrielle has agreed to this role and can also bring her expertise to VCPN.

A brief discussion focussed on developments to date. The main feature was that the VCPN website (http://vcpn.moodlesites.com/login/index.php) was now active. This is based on Moodle technology and was produced by NetSpot. In addition, the site can be linked to Equella (which is a digital repository-database to hold information, assist work flow, IP protection, tracking and functions as an e-library) and Stephen Page has already uploaded huge amounts of data and information, which may be useful to teachers and learners of veterinary pharmacology. VCPN also has a license for Wimba, which permits problems that have been developed in Word to be uploaded into the VCPN Equella repository as scorm content and then uploaded into the individual institute learning management systems for problem-based learning.

The licenses for the software were finally signed in October 2010, so a lot of background was undertaken to get this running. In addition, several training courses were run on Wimba and Equella. Many thanks to Mandy Craig and the IT Management sub-committee for this.

Jo Griffith then gave a presentation on the use of VCPN. The emphasis was on Jo understanding and applying the technology, plus eventually teaching others, leaving the problem-development to academics and clinicians. This is streamlined by writing a problem in Word which can then be converted to online using Wimba.

Stephen Page went through the major tasks that he has been doing, which is to bring together day one competencies, based on information provided from some of the steering committee and from the literature. Day One competencies are the things that we would expect a veterinary graduate to know and be able to apply when first entering the clinic or workplace. Stephen discussed his draft formulary and potentially a list of the top 100 (150? More?) drugs that veterinary clinicians should be aware in (in terms of activity, use/indications, toxicity, etc). This led to further detail of essential drug information for each drug (potentially essential drug behaviour?).

Each member of the steering committee then discussed their opinions on the three aspects of problem-development for case-based learning, namely: Day One competencies; Formulary, Essential Drug Information.

Ian Shiels Suggested that drugs required should be broad-based and relate to classes of drug behaviour. This permits understanding of mechanism of action, drug classes, etc. This will assist students to understand how drugs can alter physiology and induce adverse effects (except NSAIDs which are a special case).

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 25

Paul Chambers Agreed with Ian. Already uses a problem-based approach (and had developed an online formulary). This may be great if an i-phone app was thought useful. He used 120 drugs and case-based approach. He has a pdf of all his notes.

Tim Hyndman Day One – must be able to calculate doses. The formulary should include alternative therapies (e.g. silymarin, chondroprotective agents). The essential drug information should be on a ‘per drug’ basis and cover ranges of drugs, dose rates used and potential adverse effects to owners/public. Suggested possibly grouping drugs or incorporating into streams/families.

Scott Edwards Must ensure formulary is current+ drugs are registered in Australia / New Zealand. CSU uses case-based and decision making approaches. Day One competencies are important and incorporated in assessment, especially for final year. The CSU approach includes students ‘developing’ a drug to dispense to a client. A pocket formulary is particularly desired by students. Talked about an APP for a phone.

Suong Ngo Competencies should include pharmaceutical calculations and must consider toxicity, critical thinking and regional differences. The formulary should also include chemotherapeutic agents and opioids.

Mandy Craig There is increased compounding being used. Should consider interdisciplinary interactions. We should incorporate new technologies into the formulary so that graduates are aware of these.

Robert Kinobe Day One competencies should include pharmacogenomics, Pk/Pd, TDM and toxicity. The formulary should include nutrition and nutraceuticals, plus psychoactives. The essential drug information could possibly be divided into core and non-core.

Liz Tudor Pk calculations a good idea, plus should include relevant and practical information, e.g., splitting tablets. Applied kinetics important.

Peter White Suggested 150 drug names needed for the formulary, although could reduce and confine more to drug classes.

Jo Griffith International drugs are useful, particularly if cannot source a suitable drug in Australia or our graduates go overseas. Route of administration is important, plus must incorporate cost ad potential adverse effects into case studies.

Stephen Page Should consider vaccines.

Gabrielle Cooper Students need most to know where to look for information. The Drug Info and Poisons service in each state could be a useful repository of knowledge to tap into. She then gave some overview of the things that she was looking for towards her evaluation. One pertinent comment was to improve our language so that it is clear what we are expecting and achieving. Her evaluations comments are attached.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 26

Survey We need to survey students knowledge of clinical pharmacology. A few options are available and online surveys would be the most convenient. One freely-available survey, the Student Assessment of learning Gain, seemed to have good potential and could be readily modified to incorporate the comments required to evaluate a student’s knowledge and application of veterinary pharmacology. I will look into this further.

The action plan for each member of the steering committee was to assist in the development of case-based problems. A template for writing the problem up in Word will be circulated shortly. These will be aimed at developing each Day One competency and incorporate drugs from the formulary and required essential information for this drug/s. Please note: this is not intended as a burden and can be simplified by getting clinicians and other academics at your institution to assist.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 27

Appendix 7: Day One Competencies

VETERINARY PHARMACOLOGY Day One Competencies NOTES

This document presents a consolidated list of the pharmacology day one competencies identified by five Australasian veterinary schools. In addition key elements of pharmacology curriculum reviews, competencies and learning objectives from recent reviews in the medical, pharmacy and veterinary fields are also provided as background to allow a broad review and enhancement of the current situation in Australasia.

Members of the Steering Committee of the Veterinary Clinical Pharmacology Network are invited to review this document and the accompanying list of veterinary active constituents and prepare their recommendations for updated day one competencies. Subjects of special interest may include:

1. Critical day one competencies 2. Student formulary 3. Essential drug information

AUSTRALASIAN VETERINARY PHARMACOLOGY CONSOLIDATED DAY ONE COMPETENCIES (Contributed by Charles Sturt University, Massey University, The University of Queensland, James Cook University and Murdoch University)

SUBJECT AREAS 1. Addiction 2. Adverse Drug Reactions 3. Adverse interactions 4. Communication skill 5. Decision making 6. Environment 7. Evidence Based Veterinary Medicine (EBVM) 8. Food Safety 9. Formulary 10. Formulations 11. Knowledge acquisition 12. Legal responsibilities, prescribing, dispensing, labelling 13. Off-label use 14. Performance animals, racing and doping 15. PKPD 16. Regulatory system: approval and use of veterinary medicines 17. Residues, Public health 18. Resistance a. Antimicrobial b. Antiparasitic c. Chemotherapeutic 19. Toxins, diagnosis, MOA 20. Antidotes 21. Species differences

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 28 22. Individualisation 23. Vaccines and other immunological products

FORMULARY Allergy & Immunomodulators Anaesthetics, general Anaesthetics, local Analgesics Anticonvulsants Antimicrobials Antiparasitic drugs Blood and blood elements Cancer Chemotherapy Cardiovascular drugs Corticosteroids Dermatological agents Diuretics Endocrine drugs Euthanasia Fluid therapy Gastrointestinal drugs Nervous system drugs (Central and Peripheral Nervous Systems) Non-steroidal antiinflammatory drugs (NSAIDS) Ophthalmic agents Renal System Pharmacology Respiratory Pharmacology Sedatives Vaccines

ESSENTIAL DRUG KNOWLEDGE Examples: Page 7 Jackson and Mangoni (2004) Pages 19-20 Maxwell and Walley (2003) Page 34 Whiting and Holroyd (2002) Pages 36-37 Tobaiqy et al (2007) Pages38 Ross and Loke (2010) Page 52 Pharmaceutical Society of Australia (PSA) (2003)

Orme, M., J. Frolich, et al. (2002). "Towards a core curriculum in clinical pharmacology for undergraduate medical students in Europe." Eur J Clin Pharmacol 58(9): 635-40.

We used a system based on the World Health Organisation concept of an ‘essential drug list’ in order to define a short list of drugs that we would expect medical students in most European countries to know about. After some discussion we had two categories of drugs: firstly, those that we expected medical students to know about in some detail and, secondly, a smaller group of drugs that we would expect students to be aware of and these consisted of third-line agents for some diseases and anticancer drugs. In terms of the first group of drugs, we would expect students to know the details of the mechanism of action of the drug (in broad pharmacological terms), its main indications, its adverse effects and any clinically significant drug interactions. We would not expect them to know the dose of any drug which they would be expected to look up in the appropriate national formulary. The total number of drugs in the first category is just over 120 The second way of trying to establish a core curriculum in CPT was using a disease-based approach. This had first been used in the Medical School at

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 29 Liverpool University, of which one of us (M.O.) was Dean during the development of a new problem-based undergraduate medical curriculum. The concept was to define three types of disease process to help the student know what was important. In the first group were diseases that were common, and which the student must know how to manage which includes the drug treatment of the disease. In the second group were a list of diseases which were less common in the community, but which were thought to be of sufficient importance for the student to be able to diagnose them after which the therapy could largely be looked up in the literature. Finally, there was a third group of diseases which were sufficiently rare for us to feel that the student did not need to know very much about them. They would, however, need to know of the existence of the disease so that appropriate specialist advice could be sought.

Jackson, S. H. D., A. A. Mangoni, et al. (2004). "Optimization of drug prescribing." British Journal of Clinical Pharmacology 57(3): 231-236.

Causes of suboptimal prescribing Nonclinical skills • Failure of grasp of clinical pharmacology and therapeutics • Failure to keep up to date with published work • Prescriber’s opinion outweighing scientific data • Medical ageism • Pressure to cut drug costs Clinical skills • Inadequate clinical assessment leading to incorrect diagnosis • Failure to obtain history/document previous adverse drug reactions • Failure to record current medication including over the counter drugs • Failure to monitor response to treatment • Failure to recognize potentially serious drug interactions • Failure to recognize subtle adverse drug reactions • Failure to review repeat medication • Failure to take account of altered pharmacokinetics and pharmacodynamics • Simple error

Prescription checklist • What are the patient’s views? • What is the diagnosis (or diagnoses) you are treating? • What is the aim of treatment? • What are the treatment possibilities in this patient? • Nonpharmacological • Pharmacological • How is your preferred drug (and its metabolites if relevant) cleared? • Will other disease states affect your choice? • Will physiological states affect your choice? • Could one drug treat more than one problem? • What is the best route and starting dosage? • How will treatment be monitored? • When will you increase the dose? • What will its duration be? • What are the potential adverse effects? • What potential drug interactions are relevant? • Would discontinuing another drug help? • What information should you discuss with the patient?

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 30 Nierenberg, D. W. (1990). "A core curriculum for medical students in clinical pharmacology and therapeutics." Clin. Pharm. Ther. 48(6): 606-610.

CORE INFORMATION (FACTS)

“There is a difference between "clinical pharmacology" and "therapeutics." Core knowledge in clinical pharmacology deals with the facts that are necessary to make rational and optimal therapeutic plans in any area of prescribing, whereas therapeutics denotes optimal treatment for specific diseases or conditions. Clinical pharmacology deals with the principles and process of rational prescribing, whereas therapeutics concerns the application of this rational process to specific problems or diseases. Clinical examples should be used to illustrate basic principles of clinical pharmacology, and case examples can be used to generate general principles.” A consensus on a core curriculum of factual knowledge includes the following topics: 1. Clinical pharmacokinetics. Drug absorption, distribution, redistribution, clearance (biotransformation, excretion), half-life; application to clinical situations. 2. Therapeutic drug monitoring. Scientific basis for how and why to measure plasma drug concentrations; indications; limitations of a target-concentration strategy. 3. Adverse drug reactions. Epidemiology; phannacologic and nonpharmacologic; how to recognize; how to avoid. 4. Drug allergy. Mechanisms; pathophysiology; common examples of four types of allergic responses; common clinical presentations; management. 5. Drug-drug interactions. Epidemiology; mechanisms; how to recognize; how to avoid. 6. Pharmacogenetics. Implications for altered or unusual pharmacokinetics or pharmacodynamics; drug efficacy and toxicity; common clinical examples. 7. Prescribing for elderly patients. Special problems including altered pathophysiology, altered pharmacokinetics, altered pharmacodynamics, special problems with polypharmacy. 8. Prescribing for pediatric patients. Rapidly evolving changes in drug distribution and clearance, altered pharmacokinetics. 9. Prescribing for pregnancy and nursing women. Special concerns for drug toxicity to mother, fetus, and nursing infant; drugs of choice in common disease states. 10. Prescribing for patients with renal disease. Altered pharmacokinetics, especially renal excretion and secretion; altered pharmacodynamics; drugs to be avoided in patients with renal disease; drug-induced nephrotoxicity. 11. Prescribing for patients with hepatic disease. Altered pharmacokinetics, especially biotransformation; altered pharmacodynamics; drugs to be avoided in patients with hepatic disease; drug-induced hepatotoxicity. 12. Substance abuse. Epidemiology; recogniton; management of most commonly abused substances (e.g., alcohol, nicotine, cocaine, opioids). 13. General approach to treatment of the poisoned patient. Stabilization; assessment; decontamination; antidotes; general treatment; procedures to increase drug clearance; recogniton of common presenting syndromes; management of common poisons (e.g., salicylate , acetaminophen). 14. Special rules and regulations affecting prescription. Federal and state regulation; Food and Drug Administration (FDA) regulations; Drug Enforcement Agency (DEA) regulations; experimental therapies; local formularies. 15. Efficacy and toxicity of nonprescription drugs. 16. The process of new drug development and approval. Preclinical development and testing; phase I through III clinical testing; the essential

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 31 elements of a valid clinical trial; informed consent and ethics in clinical research; role of the FDA. 17. Criteria for selecting among drugs in a therapeutic class. Differences in pharmacokinetics; pharmacodynamics; approved indications; drug interactions; cost; toxicity.

CORE SKILLS

1. Clinical pharmacokinetics. Students should be able to solve the most comon pharmacokinetic problems presented by usual and complicated patients; be facile with computing loading doses and maintenance doses for patients with normal and abnormal kinetic parameters; be able to apply their knowledge of half-life to prescribing drugs with optimal dosing intervals; be able to use recent reference sources to locate accurate pharmacokinetic data for commonly used drugs. 2. Therapeutic drug monitoring. Students should become skilled at ordering drug levels at optimal times and for appropriate indications; become skilled at recognizing possibly misleading data; and become skilled at incorporating valid results into revised therapeutic regimens. 3. Adverse drug reactions. Students should develop reasonable skill at analyzing complicated cases in which patients have several diseases, several complaints, and are receiving several drugs; practice and sharpen their skills at distinguishing symptoms and signs caused by disease from those caused by drugs themselves. 4. Drug allergy. Students should become skilled at recognizing and treating the most common presentations of allergic responses to drugs; know the correct approach to managing a patient with an acute anaphylactic reaction; improve their skills in taking a history of drug use, including history of medication allergy or intolerance. 5. Drug interactions. Students should become skilled in recognizing common drug interactions. Equally important, they should be skilled in using common reference materials to ascertain potential drug interactions with the drugs they will be prescribing to avoid unintended and unexpected drug interactions; when interacting drugs must be prescribed, students should be familiar with approaches to rational prescribing to minimize toxic interactions. 6. Pharmacogenetics. Students should develop the ability to use reference sources to find the most commonly described clinically important pharmacogenetic syndromes that produce atypical patient responses to medications. 7. Prescribing for elderly patients. Students should be able to recognize and avoid drugs that pose special problems and risks for elderly patients and should understand characteristics of drugs that indicate a need for dosage modification in elderly patients. 8. Prescribing for pediatric patients. Students should be able to apply dosing strategies on the basis of weight and surface area calculations. 9. Prescribing for pregnant and nursing women. Students should be able to use current reference sources to ascertain drug risk in these populations; be able to prescribe drugs of proven safety and efficacy for commonly encountered illnesses such as urinary tract infections and hypertension. 10. Prescribing for patients with renal disease. Students should be able to calculate an estimated value for creatinine clearance and use this figure to calculate drug clearance and maintenance doses for drugs with predominant renal clearance. 11. Writing prescriptions. Students should be skilled in writing complete, accurate, and unambiguous prescriptions for use in both inpatients and

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 32 outpatients, including drugs with special restrictions such as those requiring a DEA license. 12. Substance abuse. Students should begin to develop their skills in obtaining a history of drug or substance abuse and in recognizing which patients may have such problems. 13. Poisoning and drug overdose. Students should be skilled in the use of common reference sources for rapidly obtaining accurate information about the diagnosis and treatment of toxic emergencies. 14. Learning about new drugs. Students should be familiar with sources of accurate information concerning indications, pharmacokinetics, and appropriate use of new drugs. Students should begin to develop skill in reading and assessing scientific papers describing clinical trials, and develop their skills in distinguishing valid studies from those with serious methodologic flaws or bias. All students should know how to use sources of objective information about current and new drugs. Students should learn how to use available reference texts, library resources, computer data bases (e.g. , Medline) and objective newsletters (e.g. , Medical Letter) to carry out their own programs of continuing education. 15. Communication skills. Students should become skilled in talking with their patients to assess and encourage drug compliance; ascertain previous adverse drug reactions and drug allergies; elicit a complete drug history, including prescription drugs, non-prescription drugs, and topical preparations. Students should know how to use the various written materials that are available as patient inserts. They should have an elementary understanding of the nature of informed consent and how it applies to drug use. 16. Recognition of pressures to prescribe irrationally. Students should develop the ability to recognize in themselves tendencies to irrational prescribing and should recognize the forces encouraging such habits. They should understand the potential for their accepting misleading, incomplete, or biased information when they learn about medications from a variety of sources, including reports of flawed clinical trials, personal experience, advertisements, pharmaceutical representatives, colleagues (word of mouth), patients, or sponsored symposia. They should also begin to appreciate how potential conflicts of interest might affect their ability to prescribe objectively and rationally.

CORE ATTITUDES

Core attitudes are often more difficult to define than core facts or skills. However, in many ways this is at the crux of the concept of the "core" because clinical pharmacology is in essence an approach that should lead to rational or optimal therapeutics. Some of the attitudes that may be viewed as core include the following: The prescription as an experiment. Students should develop the attitude that every prescription is really a carefully designed experiment that can produce efficacy, toxicity, or both. The prescription should be designed to carefully maximize the chances of producing efficacy while minimizing the likelihood of toxicity. The qualitative and quantitative decisions that go into the prescription must be individualized for the specific patient, taking into account the factors unique to the patient and avoiding a "cookbook" approach to therapeutics. The process of rational therapeutics. Students should be accustomed to proceeding through a logical sequence of deliberate steps as they consider instituting any pharmacotherapeutic process. They should attempt to make a firm diagnosis; understand the pathophysiology of the disease they have identified; develop a list of possible therapeutic options; pick the best drug option, qualitatively and quantitatively, given the features of their particular

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 33 patient; establish end points to follow; and communicate adequately with the patient concerning goals, risks, and appropriate follow-up. Developing such a rational therapeutic plan hinges on the ability of the student to accurately assess and estimate the potential risks and benefits of using a drug in a specific patient. The student must begin to develop his skills in quantifying risks and benefits; in some programs, these skills may be extended by developing skills in formal clinical decision analysis. Balanced approach to drug prescribing. Students should strive to avoid the extremes of therapeutic nihilism and over-prescribing. They should be impressed by the power of drugs to help cure and treat disease, but this should be balanced by respect for the power of drugs to cause serious and even fatal adverse reactions. Balanced approach to the introduction of new drugs. Students should not fear the introduction of new drug products, nor should they enthusiastically embrace all new drugs as being the latest and the best. Rather, students should understand that the place of a new drug in the current pharmacopoeia may not be clear initially and that subsequent data may radically change the manner in which the drug is prescribed. Students should be willing to take responsibility for developing their own approach to learning about new drugs as they are approved by the FDA. Importance of the therapeutic contract. Students should understand that at the heart of drug prescribing is a contract or alliance between the physician and the patient. Communication is essential so that the physician can learn enough information to prescribe optimally, and then again to ensure optimal compliance. In addition, the physician must understand that the contract requires him or her to monitor the patient over time to see whether the therapeutic experiment results in beneficial or ill effects. This relationship is a dynamic and changing one; it is philosophically opposite to the approach that a drug prescription terminates a patient encounter and represents the end of a process.

Walley, T. and D. J. Webb (1997). "Core content of a course in clinical pharmacology." Br J Clin Pharmacol 44(2): 171-4.

a) Core knowledge and understanding 1. Basics of pharmacology Students should understand the mechanisms by which drugs produce their pharmacological effects. They should appreciate the links between pharmacological effects at the molecular level, the cellular level, and the tissue/organ level, and how these effects can be disrupted by disease processes and other drugs. Hence they should understand the principles through which therapeutic and adverse effects occur. 2. Clinical pharmacokinetics Students should understand how drugs are absorbed, distributed, and cleared by biotransformation and/or excretion. They should understand the concepts of drug half-life and clearance. (Application to clinical situations should be emphasised and detailed calculations avoided). 3. Monitoring drug therapy 4. Adverse drug reactions 5. Drug interactions 6. Pharmacogenetics 7. Prescribing for paediatric patients 8. Prescribing for the elderly 9. Principles of prescribing for pregnant and breast-feeding women 10. Prescribing for patients with renal disease Students should 11. Prescribing for patients with hepatic disease 12. General approach to the treatment of the poisoned patient 13. Regulations affecting prescribing

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 34 14. The process of new drug development, testing and approval 15. Practical criteria for selecting among drugs in a therapeutic 16. Routes of administration and drug formulations b) Core Skills 1. Clinical pharmacokinetics 2. Adverse drug reactions 3. Drug allergy 4. Drug interactions 5. Seeking information 6. Therapeutic drug monitoring 7. Prescribing for the elderly 8. Prescribing for pregnant and breast-feeding women 9. Routes of administration and drug formulations 10. Writing prescriptions and keeping records 11. Use of evidence 12. Learning about new drugs Communication skills Patient adherence to therapy c) Core Attitudes 1. The process of optimal therapeutics 2. Balanced approach to drug prescribing 3. The prescription as an experiment 4. Learning for the future

Mucklow, J.C. (2002). What knowledge and skills are essential for specialists in clinical pharmacology and therapeutics? Results of a Delphi study. Br. J. Clin. Pharmacol. 53: 341–346.

Statements with which at least two-thirds of panel members agreed (showing level of agreement). A competent specialist in CPT should be able to:

Core of knowledge 1. Explain receptor agonism and antagonism, enzyme inhibition and activation 100 2. Distinguish between competitive and noncompetitive effects 100 3. Explain the implications of competitive and noncompetitive effects for drug action 89.5 4. Explain the meaning of common terms used to describe dose–response relationships, such as efficacy and potency 94.7 5. Explain the concept of a minimum effective and a maximum tolerated dose 100 6. Explain the meaning of common pharmacokinetic terms 100 7. Explain the role of plasma drug concentration measurements as a guide to dose adjustment and the diagnosis of toxicity 100 8. Explain the optimal use of plasma drug concentration measurements as a guide to dose adjustment and the diagnosis of toxicity 100 (e.g. sample timing, interpretation of result) 9. Explain the principles involved in the ethical review of clinical research 100 10. Explain the role and responsibilities of Research Ethics Committees 94.7 11. Explain the selection and use of appropriate statistical analyses 100 12. Explain the principles of clinical trial design and analysis 94.7 13. Explain the principles of Good Clinical Practice 68.4* 14. Explain the strengths and weaknesses of observational data 84.2 15. Explain the principles of pharmacovigilance 100 16. Define pharmaco-epidemiological concepts 73.7* 17. Define pharmaco-economic concepts 73.7* 18. Explain the basis for rational drug selection and use 100 19. List the most reliable sources of information available to guide rational drug use 100 20. Explain the principles of ‘evidence-based medicine’ 100

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 35 21. Explain the application of ‘evidence-based medicine’ 89.5 22. Explain the appropriate constitution, role and context of Drug and Therapeutics Committees 94.7 23. Explain the role of Area Prescribing Committees 73.7* 24. Explain the role of the National Institute for Clinical Excellence 84.2* 25. Explain the criteria used in establishing the diagnosis of an adverse drug reaction 94.7 26. Explain the mechanism of action of common and important poisons 89.5 27. Explain how to investigate suspected cases of poisoning 94.7 28. Explain how to manage common forms of drug poisoning 94.7 29. Explain the factors that cause medication errors 89.5* 30. Explain the mechanisms underlying drug interactions 73.7 31. Explain the place of placebos in clinical research 100* 32. Explain the factors underlying concordance with drug therapy 89.5* 33. Explain the principles embodied by the Declaration of Helsinki 84.2* 34. Explain the importance of pharmacogenetics in determining drug response 68.4 35. Display specialist knowledge of (at least) one area of Therapeutics 84.2

Therapeutic skills 1. Use pharmacokinetic principles to optimize drug administration in man 84.2 2. Use pharmacokinetic principles to optimize the effectiveness and safety of drug treatment 84.2 3. Assess the therapeutic effects of drugs 100 4. Assess the adverse effects of drugs 100 5. Select drugs rationally when planning medical treatment 100 6. Take cost-effectiveness into account when selecting drugs for use in medical treatment 100 7. Adjust therapeutic regimens appropriately to maximize benefit and minimize risk 100 8. Investigate and manage suspected adverse drug reactions 94.7 9. Report suspected adverse drug reactions appropriately to the CSM using a Yellow Card 100 10. Advise on the management of poisoned patients 78.9 11. Write a prescription competently 89.5

Educative skills 1. Evaluate scientific papers 100 2. Devise prescribing policies to govern the choice of medicines by those engaged in patient care 84.2 3. Develop formularies to guide drug selection 100 4. Develop guidelines to facilitate the optimal use of medicines 94.7

Investigative skills 1. Interpret dose–response curves from in vitro and in vivo studies 84.2* 2. Interpret early phase studies of drug action in humans 68.4 3. Write a subject information sheet and a consent form in appropriate lay language 89.5 4. Choose the most appropriate statistical tests in the analysis of experimental data 78.9 5. Perform simple statistical analyses 89.5 6. Design a case-control study 73.7* 7. Investigate a suspected medication error 84.2* 8. Write a medico-legal report on a medication error 68.4*

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 36 Maxwell, S. and T. Walley (2003).

Maxwell, S. and T. Walley (2003b). "Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow's doctors." Br J Clin Pharmacol 55(6): 496-503.

Maxwell, S. and T. Walley (2003a). Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow's doctors. London, UK, Clinical Section Committee of the British Pharmacological Society.

Core knowledge and understanding, skills and attitudes concerning the use of drugs for the medical curriculum These should be key learning outcomes of the curriculum and are required by all graduates, to enable them to prescribe safely and effectively at the point of qualification. These core objectives are generic and applicable to most areas of therapeutics. They should be considered in association with a locally identified list of core drugs and therapeutic problems to which they apply. In each case their relevance to clinical practice should be illustrated with appropriate examples.

Core knowledge and understanding Basic pharmacology • general mechanisms of action of drugs at molecular, cellular, tissue, and organ level; • ways in which these actions produce therapeutic and • adverse effects; • the receptor as a target of drug action and related concepts such as agonism, antagonism, partial agonism, and selectivity; • the development of tolerance to drugs.

Clinical pharmacokinetics • mechanisms of drug absorption, distribution, elimination (metabolism and excretion); • concepts of volume of distribution, clearance, and half-life, and their clinical relevance; • how these factors determine the optimal route, dose, and frequency of drug administration.

Factors that determine interindividual variation in drug response • Pharmaceutical variation; • pharmacokinetic handling of drugs; • pharmacogenetic variation.

Therapeutic drug monitoring • importance of monitoring the impact of drug therapy; • ways in which this can be achieved (measuring clinical outcomes, pharmacodynamic responses, or plasma drug concentrations); • variable relation between plasma drug concentration and drug effect.

Adverse drug reactions • types and mechanisms of adverse drug reactions; • frequency of adverse reactions in primary and secondary care; • recognition of the predisposing factors and how risks can be minimized; • the importance of reporting adverse reactions and the role of the yellow card scheme.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 37 Drug interactions • potential for drugs to interact to cause beneficial and harmful effects; • mechanisms by which drugs interact (pharmacokinetic, pharmacodynamic); • ways in which interactions can be predicted and avoided.

Medication errors • common reasons medication errors occur in practice; • ways in which individual prescribers can reduce the risks of medication errors.

Poisoned patients • principles of treating the poisoned patient; • assessment of poisoned patients; • recognition and treatment of common presentations (e.g. paracetamol); • principles of removing or counteracting the effects of toxic substances after ingestion.

Prescribing for patients with special requirements because of their altered physiology, pharmacokinetic handling, or pharmacodynamic responses, including • elderly patients; • children; • women of child-bearing potential; • pregnant and breast-feeding women; • patients with renal disease; • patients with liver disease.

Legal aspects of prescribing drugs • Categorization of drugs as over-the-counter formulations, prescription- only medicines, and controlled drugs; • prescribing of ‘unlicensed’ medicines or medicines ‘off label’; • the responsibilities associated with prescribing controlled drugs.

Developing new drugs • drug development, including clinical trials (Phase I to Phase IV); • the approval process and major regulatory authorities in UK and Europe; • the requirements of good clinical trial design; • consent, ethics, bias, statistics, dissemination of information.

Medicines management • role of local formularies; • roles of drug and therapeutics committees; • influences that affect individual prescribing choices; • rational assessment of new drugs, based on safety, efficacy and cost- effectiveness.

Ethics of prescribing • informed patient consent and concordance.

Commonly used drugs (locally identified list of commonly used drugs) • mechanism of action, • indications for use,

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 38 • appropriate route of administration • important contraindications and adverse effects

Common therapeutic problems • management of common acute and chronic therapeutic problems

Complementary and alternative medicine • motivations that lead patients to seek complementary and alternative therapies; • some common methods and appraisal of the evidence for their efficacy; • how such therapies can interact with prescription drugs that patients are receiving.

Core skills Taking a drug history • obtaining accurate information about current prescription and non- prescription drugs; • making an assessment of adherence to a medication regimen; • recording current and past adverse drug reactions, including allergies.

Prescription writing • choosing a safe and effective drug and an appropriate dosage regimen; • writing accurate, legible, and legal prescriptions, including controlled drugs; • keeping accurate records of prescriptions and responses; • calculating drug doses; • calculating the strength of an infusion based on the required rate of drug administration; • prescribing oxygen (flow rate, delivery); • prescribing intravenous fluids.

Drug administration • selecting the appropriate route of administration; • giving subcutaneous, intramuscular, and intravenous injections; • preparing drugs for parenteral administration, including mixing and dissolving drugs; • preparing and giving drugs by an infusion pump; • preparing and giving nebulised drugs; • advising patients about special modes of drug delivery, e.g. topical, inhaled, insulin.

Prescribing drugs in special groups • elderly, children, pregnancy, breast-feeding, renal and hepatic failure.

Prescribing drugs to relieve pain and distress • palliation of pain and other distressing symptoms.

Adverse drug reactions and interactions • assessing drugs as possible causes of symptoms and signs; • recognizing the potential for adverse drug interactions; • reporting adverse drug reactions and interactions.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 39 Drug allergy • recognizing allergic drug reactions and taking a history of an allergic reaction; • treating allergic reactions, the emergency treatment of acute anaphylaxis.

Clinical pharmacokinetics • using core knowledge of pharmacokinetics to inform safe prescribing.

Monitoring drug therapy • identifying which therapeutic effect to observe; • using measurements of plasma drug concentrations appropriately (which and when); • acting appropriately on the results.

Analysing new evidence • practising evidence-based prescribing; • assessing the validity of evidence about new drugs or therapies; • reading, assessing, and critically analysing clinical studies; • spotting methodological flaws, including sources of bias; • recognising the difference between true and surrogate end-points.

Obtaining accurate objective information to support safe and effective prescribing • using the British National Formulary; • accessing reliable drug information from medical journals and medical databases; • accessing Poisons Information Services; • discriminating between the reliability of varying sources of evidence and opinion.

Obtaining informed consent to treatment • providing patients with enough information about drugs to allow them to make informed decisions about their treatment; • discussing benefits and risks of drug therapy with patients; • exploring patients’ own views and wishes in relation to drug treatment.

Core attitudes A rational approach to prescribing and therapeutics • identifying the correct diagnosis; • understanding the pathophysiological processes involved; • knowing the drugs that might beneficially influence these processes; • establishing the end-points with which to monitor the therapeutic response; • assessing the potential risks and benefits of treatment; • communicating with the patient in making the decision to treat.

Risk–benefit analysis • recognising that there are risks and benefits associated with all drug treatments; • recognising that these may differ between patients, • depending on a variety of factors;

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 40 • recognising that doctors should monitor the impact of the drugs they prescribe.

Recognizing the responsibilities of a doctor as part of the prescribing community • avoidance of wasteful prescribing and consumption of limited resources; • recognizing the need to report adverse drug reactions for the common good; • controlling the availability of restricted drugs; • adhering to therapeutic guidelines and drug formularies, as appropriate; • avoiding indiscriminate antibiotic prescribing.

Recognizing personal limitations in knowledge • recognising the need to seek further information about drugs when faced with unfamiliar prescribing problems.

Responding to the future • recognising the need to update prescribing practices; • ensuring that patients benefit, when possible, from advances in medical knowledge; • recognising the need to assess the benefits and hazards of new therapies; • knowing the limitations of applying clinical trial data to individual patients.

Core drugs and therapeutic problems: the Student Formulary

Medical students are often overwhelmed by the large number of drugs that they encounter during their clinical attachments. To tackle this, schools should create a list of drugs as the basis for a ‘student formulary’ that helps to prioritize learning. The list should comprise 80–100 commonly used drugs from both primary and secondary care settings, which are used to treat common illnesses and are representative of important drug classes. A newly qualified doctor might be expected to initiate or prescribe these drugs under the direction of a senior doctor.

For each of the drugs or its class, students might be expected to: 1. know its name and class; 2. understand how it works; 3. recognize the appropriate indication for its use; 4. know how to prescribe it – how it is administered, the frequency of administration, the duration of administration; 5. know its important contraindications, potential drug interactions, and major adverse effects; 6. be able to name alternatives when available; 7. know how to monitor the drug’s effects; 8. be able to explain salient features of all of these points to a patient.

Students need not be expected to know exact drug doses, except perhaps for a small number of emergency drugs, but should know where to find the information quickly and easily. The newly qualified prescriber should be expected and encouraged to look up doses before prescribing any drug.

The intention of the student formulary is to provide realistic and attainable learning objectives. A student who achieves these outcomes should be able to cope effectively and safely with most of the prescribing challenges that they

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 41 are likely to face in their early postgraduate years, as well as establishing the key principles of good prescribing for the rest of their careers.

What should I know about this drug?

Medical students regularly have the opportunity to review prescriptions in the context of individual cases during their clinical attachments. They should be prepared to use these as an opportunity for self-directed learning. The following series of questions might help to focus the questions they should tackle. 1. Drug name. Is this the approved or generic name? 2. Drug class. To what class does each drug belong (eg beta blocker, benzodiazepine)? Is this one of the core drugs or drug classes in the ‘student formulary’? If not, is it closely related to other core drugs? 3. Indication. For what reason was the drug prescribed? What problem is the drug meant to correct, or what symptom is to be relieved? 4. Alternatives. What other treatments might have been chosen instead of the drug? Is it a good choice considering its efficacy, safety and cost? 5. Route and dose. By what route, in what dose and at what intervals is the drug being given? What factors about the drug/patient might influence these choices? 6. Monitoring. What observations/measurements can be made to judge whether the aim of treatment has been achieved? When should they be made and by whom? 7. Duration. For how long should treatment continue? What factors will determine when treatment should be stopped? 8. Elimination. How is the drug eliminated? Will the patient’s illness change the usual pattern of distribution and effects of the drug? 9. Adverse effects. What adverse effects may occur form this drug? How will they be apparent? How serious and frequent are they? What is the approximate frequency? 10. Interactions. Are there any other drugs that the patient is receiving that might interact with this drug? If yes, what is the nature of the interaction and should they be avoided? 11. Patient. What does the patient believe about the drug? What have they been told about it and what has he remembered? What additional information is necessary for the patient?

CORE CURRICULUM IN PHARMACOLOGY FOR VETERINARY SCIENCE COURSES. British Pharmacological Society. September 2004

http://www.bps.ac.uk/uploadedfiles/Curricula/corevet.pdf

Aim The aim of a degree in veterinary medicine can broadly be defined as enabling students at the time of graduation at a standard appropriate to a new veterinary graduate to: • understand basic biological principles in relation to normal function and disease of animals • distinguish the pathological from the normal • prevent animal disease and control its transmission to humans • diagnose and treat diseases of animals and alleviate their suffering • demonstrate practical competence in techniques and procedures • advise on animal management and welfare • communicate with the public and with colleagues in their future professional activities

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 42 • demonstrate attitudes that promote professionalism, ethical judgement, enquiry and team work • exercise skills in information technology and data analysis

The principle aim of teaching pharmacology to veterinary students is to provide them with an understanding of the pharmacodynamic and pharmacokinetic principles which determine rational and safe selection of therapeutic agents and their appropriate use in current and future clinical veterinary practice. The basic pharmacological knowledge gained should be applied in the later stages of the veterinary degree courses within the areas of general medicine and/or therapeutics.

It is important to ensure the following are emphasised: • species differences in the ways in which domestic animals metabolise and excrete drugs • species differences in the pharmacodynamics of some drugs which may underpin a lack of efficacy or enhanced susceptibility to toxicity • the importance of the combination of drug pharmacokinetics and toxicity in determining maximum residue limits in meat, milk, eggs and fish.

Core topics  Principles of pharmacodynamics  Principles of pharmacokinetics  Drugs affecting the peripheral nervous system  Drugs affecting the heart and blood vessels  Drugs affecting haemostasis and fibrinolysis  Drugs affecting the respiratory system (excluding anti-inflammatory drugs)  Drugs affecting thyroid gland function  Drugs affecting adrenal gland function  Blood glucose control  Effects of drugs on sodium ion/potassium ion balance  Effects of drugs on acid-base balance  Effects of drugs on mineral balance  Fluid therapy  Gastroprotective drugs and anti-emetics  Drugs affecting intestinal motility and secretion  Ruminant pharmacology  Anti-inflammatory drugs and mediators of inflammation  Pharmacological control of cycles in female domestic animals  Steroids - androgens and oestrogens  Steroids - progestagens  Pharmacology of parturition  Antimicrobial drugs (anti-bacterial, antifungal and anti-viral drugs)  Resistance to antimicrobial drugs  Antineoplastic drugs  Ectoparasiticides  Anti-coccidial drugs  Anthelmintics  Resistance to antiparasitic drugs  Analgesics  Sedatives  Local anaesthetics  General Anaesthetics  Neuromuscular blocking agents  Centrally acting muscle relaxants  CNS stimulants

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 43  Anti-epileptic drugs  Drugs used to modify behaviour  Drug interactions  Drug development and clinical trials  Drug legislation  Safe handling, storage and dispensing of veterinary medicines

Core skills  Ability to retrieve information from drug reference sources  Ability to interpret and analyse pharmacological data  IT skills  Ability to apply basic pharmacological principles to the safe and effective use of drugs to treat diseased animals

Generic skills and attitudes (These skills are developed within the context of the overall objectives of a veterinary degree course as stated above.)  Written and oral communication skills  Deductive reasoning and problem solving skills  Professional responsibility to animal welfare and public health  Communicate with the public and with colleagues in their future professional activities  Demonstrate attitudes that promote professionalism, ethical judgement, enquiry and teamwork

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 44 Quality Assurance Agency for Higher Education (2002). Subject benchmark statements. Academic standards - Veterinary science

Subject knowledge and understanding

The new veterinary graduate should be able to demonstrate knowledge and understanding in the following areas as the basis for the study and practice of clinical veterinary science:

Structure and function of animals from molecules to populations  molecular and ultrastructural basis of cellular function;  macroscopic and microscopic structure of tissues and organs;  physiological and biochemical basis of organ function and homeostasis;  biology of the whole animal individually and in groups.

Health and husbandry of domestic animals  principles of animal behaviour;  scientific foundations of animal nutrition and its practical application;  physiology and endocrinology of animal reproduction; maximising reproductive efficiency in commercial populations;  the molecular basis of animal genetics and its practical application;  husbandry and housing of domestic animals;  biological and management strategies in limiting animal disease.

Understanding animal disease  pathogenesis - the processes by which disease may develop;  the biochemical and cellular basis of immune and inflammatory responses;  principles of oncogenesis and tumour biology;  macroscopic and microscopic changes in pathological processes as a basis for recognising and managing clinical disease;  the epidemiology of animal diseases.

Disease agents  structure and function of prions, viruses, bacteria, fungi and other parasites;  biology, population dynamics, transmission and pathogenicity;  agents causing diseases in animals; those which may also cause disease in man.

The principles of pharmacology and toxicology  structure, mode of action and pharmacokinetics of active compounds;  scientific basis of safe and efficient use of veterinary drugs;  ethical, environmental and human health implications of veterinary drug usage.

Legal, environmental and ethical considerations  the economic, environmental and public health consequences (beneficial and otherwise) of keeping animals;  medicine legislation and the guidelines on the responsible use of medicines;  the law and ethical codes relating to animals and to food hygiene;  statutory requirements for animal transport, slaughter houses, cutting plants and the storage of meat products;  the importance of research for the extension of the knowledge base in veterinary science;  the relationship between veterinary science, medical science and other biosciences;

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 45  sourcing and synthesis of information; the principles of biological statistics and their correct application

Emergency Medicine Pharmacological Knowledge Kilroy, D. A. and J. S. Mooney (2007). "Determination of required pharmacological knowledge for clinical practice in emergency medicine using a modified Delphi technique." Emerg Med J 24(9): 645-7.

Development of questionnaire content It was made clear to respondents that ‘‘required knowledge’’ of a given item was taken to be an appreciation of its indications, actions at the tissue level, contraindications, side effects and common interactions.

DISCUSSION

A pharmacology curriculum is of necessity a dynamic one. Having established a core postgraduate curriculum, we are mindful of the need for regular review. Having the document as a web-based tool allows us to review its content easily. Where new agents appear to the market, the Basic Sciences Research Group weighs the need to subject the agent to immediate scrutiny for inclusion. The broader strategy for maintaining currency of content, however, is to re-administer the Delphi on a 3 yearly basis based on abbreviated content of those new agents which have appeared in the time since the original study.

Future work We have demonstrated the utility of a consensus methodology involving a large respondent panel to determine national curricular policy. During 2007 we are examining ways in which the core pharmacology curriculum can be administered in a more interactive web format,11 mapped to learning outcomes as part of workplace-based assessment, in order to allow trainees to both acquire and demonstrate knowledge acquisition in daily practice.

THE COLLEGE OF EMERGENCY MEDICINE. Common Competences For Emergency Medicine, June 2010

COMMON COMPETENCIES CC1 History taking CC2 Clinical examination CC3 Therapeutics and safe prescribing CC4 Time management and decision making CC5 Decision making and clinical reasoning CC6 The patient as central focus of care CC7 Prioritisation of patient safety in clinical practice CC8 Team working and patient safety CC9 Principles of quality and safety improvement CC10 Infection control CC11 Managing long term conditions and promoting patient self-care CC12 Relationships with patients and communication within a consultation CC13 Breaking bad news CC14 Complaints and medical error CC15 Communication with colleagues and cooperation CC16 Health promotion and public health CC17 Principles of medical ethics and confidentiality CC18 Valid consent CC19 Legal framework for practice CC20 Ethical research

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 46 CC21 Evidence and guidelines CC22 Audit CC23 Teaching and training CC24 Personal behaviour CC25 Management and NHS structure

Assessment Method Glossary AA Audit Assessment ACAT Acute Care Assessment Tool C Case Based Discussion (CBD) D Direct observation of procedural skills (DOPS) E Examination L Life support course Mi A Mini-clinical evaluation exercise or anaesthesia clinical evaluation exercise (Mini-CEX or Anaes-CEX) M Multi-source feedback (MSF) PS Patient Survey S Simulation TO Teaching Observation W Web based, ENLIGHTENme Hub and Knowledge Bank http://www.enlightenme.org/

Good Medical Practice (GMP) domain headings GMP 1 Knowledge, skills and performance GMP 2 Safety and quality GMP 3 Communication, partnership and teamwork GMP 4 Maintaining trust

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 47

THE COLLEGE OF EMERGENCY MEDICINE Curriculum and Assessment Systems For Core Specialty Training ACCS CT1-3 & Higher Specialty Training ST4-6 Training Programmes. June 2010

CMP2 Cardio-Respiratory Arrest Outline indication and safe delivery of drugs used as per ALS and APLS algorithms Be able to diagnose and treat peri-arrest arrhythmias and know the indication, contraindications and side effects of the drugs used

CMP4 Septic Patient Knowledge of the pharmacology and rationale for the use of: Vasoactive drugs used in sepsis Adjunctive drugs used in sepsis

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 48

CMP5 Shocked Patient Demonstrate a knowledge of the different fluids and drugs e.g. inotropes used in the treatment of shock

CAP6 Breathlessness Demonstrate knowledge of the indications, contraindications and adverse effects of the drugs used to treat the causes of breathlessness

CAP8 Confusion, Acute/Delirium Describe the indications, contraindications and side effects of drugs used in acute psychosis including, but not limited to: haloperidol, benzodiazepines, clonidine

CAP9 Cough Identify risk factors relevant to each aetiology including precipitating drugs Know when to use drugs for dizziness and vertigo and understand their limitations and side effects

CAP16 Haematemesis and Melaena Safely prescribe drugs indicated in event of an established upper GI bleed using the current evidence base

CAP22 Oliguric patient Understand the principal causes of a low urine output in the critically ill patient, and be able to identify the principal sub-causes (pre-renal, renal and post-renal), including but not limited to: hypotension and inadequate renal perfusion, renal tract obstruction, nephrotoxic drugs and contrast media Outline immediate management options including but not limited to: fluid resuscitation, increased cardiovascular monitoring, administration of vasoactive drugs and inotropes, the role of diuretics

Be able to safely prescribe for patients in renal failure CAP23 Pain Management The trainee will be able to use analgesic drugs safely and appropriately in the acutely ill patient.

Identifies appropriate analgesic regimes including types of drugs and doses

Understands the pharmacology of commonly used analgesics including but not limited to: Indications and contraindications, Side effects, Safety profile, Drug interactions

CAP25 Palpitations Recall common arrhythmogenic factors including drugs

Recall the indications, contraindications and side effects of the commonly used anti- arrhythmic medications and indications for pacing

CAP27 Poisoning Recall indications for activated charcoal and whole bowel irrigation

Know the pharmacology and management of poisoning of the following (but not limited to): paracetamol, salicylate, beta blockers, opiates, alcohol, anticoagulants, benzodiazepines, carbon monoxide, antidepressants, SSRIs, amphetamine, cocaine

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 49 Understand the role of antidotes and demonstrates knowledge of specific therapies in poisoning including but not limited to: ♦ activated charcoal ♦ acetyl-cysteine ♦ bicarbonate ♦ hyperbaric oxygen

CAP28 Rash Recall risk factors, particularly drugs, infectious agents and allergens

Recognise the importance of a detailed drug history

3.3.4 Anaesthetic Competences CT1&2 Discusses how to manage drug therapy for coexisting disease in the peri-operative period including, but not exclusively: obesity, diabetic treatment, steroids, anti- coagulants, cardiovascular medication, epilepsy

Knows about the complications of anaesthetic drugs [including anaphylaxis, suxamethonium apnoea and malignant hyperpyrexia] and how to predict patients who are at increased risk of these complications A2 Premedication Lists basic indications for prescription of premedicant drugs Explains how to select appropriate sedative or anxiolytic agents Discusses the applied pharmacology of these drugs Recalls/describes the applied pharmacology of pro-kinetic and antacids including simple alkalis, H2 and proton pump antagonists

A3 Induction of general anaesthesia The ability to recognise and treat immediate complications of induction, including tracheal tube misplacement and adverse drug reactions

In respect of the drugs used for the induction of anaesthesia: recalls/summarises the pharmacology and pharmacokinetics, including doses, interactions and significant side effects of: induction agents, muscle relaxants, analgesics, inhalational agents including side effects, interactions and doses. Identifies the factors that contribute to drug errors in anaesthesia and the systems to reduce them Identifies appropriate post-operative analgesic regimes including types of drugs and doses Explains how to manage ‘rescue analgesia’ for the patient with severe pain Lists the complications of analgesic drugs Recalls/describes the basic pharmacology of anti-emetic drugs

C Critical Incidents Adverse drug reactions Local anaesthetic toxicity

D Paediatric anaesthetic competences listed for ACCS Explains the importance of modification of drug dosages

O3 Procedural Sedation To understand that conscious sedation is: “A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation”

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 50 To be able to safely deliver pharmacological sedation to appropriate patients

Describes the pharmacology of drugs commonly used to produce sedation

ICM Competency: Describes Safe Use of Drugs to Facilitate Mechanical Ventilation Demonstrate knowledge of drugs which can be used to induce anaesthesia and facilitate tracheal intubation

Demonstrate knowledge of drugs which can be used to sedate patients during mechanical ventilation, and the advantages and disadvantages of these drugs Demonstrate an understanding of how using combinations of sedative agents may be preferable to use of single agents.

Outlines rationale for use of neuromuscular blocking drugs during mechanical ventilation and appropriate pharmacology

ICM Competency: Prescribes safe use of vasoactive drugs and electrolytes The trainee will understand the use of electrolyte-containing solutions and vasopressors in the critically ill patient, and be able to prescribe such agents safely

Azer, S. A. and A. G. Frauman (2008). "Seeing the wood for the trees: approaches to teaching and assessing clinical pharmacology and therapeutics in a problem-based learning course." Ann Acad Med Singapore 37(3): 204-9.

The six steps in the decision-making process for competency in clinical pharmacology and therapeutics.

Whiting, B., N. H. Holford, et al. (2002). "Clinical pharmacology: principles and practice of drug therapy in medical education." Br J Clin Pharmacol 54(1): 1-2.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 51 ‘What do I need to know about this drug?’

The same question should always be asked when any clinical scenario is being considered. The quality and maturity of the answer will depend on a thorough knowledge of underlying principles established earlier in the course, and this should be in the hands of an effective Advocate who can oversee the progression of the subject as time advances. We suggest that the important principles should reflect the issues accompanying any potential drug administration and that Clinical Pharmacology and Therapeutics breaks down into (a) fundamental principles and (b) the practicalities of prescribing in many different clinical situations.

Four guidelines suggest themselves:

(i) Don’t interfere if not warranted: don’t give drugs just for the sake of it. (ii) Always be mindful of the balance between beneficial and adverse toxic side-effects. (iii) Start with a low dose and increase the dose gradually if necessary. (iv) Bear in mind target concentration intervention

Students on clinical attachments should be able to answer the question posed above – ‘What do I need to know about this drug?’. In order to answer this question it may be helpful to consider the following questionnaire:

1 Is there an accurate diagnosis? 2 Is drug therapy really necessary? 3 Has the most appropriate drug been chosen? 4 Is the drug being used correctly? 5 Has account been taken of the influence of any disease or genetic factors? 6 Has the age of the patient been considered? 7 Is the patient pregnant or lactating? 8 Has the influence of food been considered? 9 Is drug dependence likely? 10 Have the objectives of drug therapy been defined carefully? 11 Is there a plan to monitor the effects of the drug? 12 Is there a plan to monitor the concentrations of the drug? 13 What are the potential side-effects? 14 Are there any potential drug interactions? 15 Is the route of administration correct? 16 Has a clear, concise, correct, legible prescription been written? 17 Is there a plan to review all drug therapy periodically? 18 Has the drug therapy been explained clearly to the patient? 19 Has a complete drug history been taken, including over-the- counter drugs? 20 Is there any evidence of drug allergy?

This list covers all the important issues in drug therapy; it could be printed on a small card as an aide-memoire. We suggest that such a questionnaire should become integral to all good and safe prescribing.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 52 Ross, S. and Y. K. Loke (2010). "Development of learning outcomes for an undergraduate prescribing curriculum (British Pharmacological Society prescribing initiative)." British Journal of Clinical Pharmacology 70(4): 604-608.

“Overall, a consensus on 50 learning outcomes that should be included in the BPS Core Curriculum for Prescribing has been reached. We believe that this list of outcomes accurately reflects the recent emphasis on teamwork and communication, as well as the need to minimize polypharmacy and medication errors. We plan to use these outcomes in developing teaching and assessment material that will be disseminated widely across a broader spectrum of trainee prescribers. This should enable us to evolve and refine further the prescribing curriculum in the drive to improve patient safety, with the hope that certification of practical prescribing competency will become a reality, not just for junior doctors but for nonmedical prescribers as well.”

OUTCOMES INCLUDED IN THE CURRICULUM Write an unambiguous, legible, complete and legal prescription, on hospital prescription forms including supplementary charts 5.00 (0.00) Complete a discharge prescription 5.00 (0.00) Know their own limits and ask for help when needed 5.00 (0.00) Elicit and record an accurate medication history, including current and recent medicines 5.00 (0.00) Recognize situations where their prescribing skills are not sufficient, and seek advice before proceeding* 5.00 (0.00) Check for contraindications 4.92 (0.27) Check for special circumstances (e.g. renal or hepatic impairment, pregnancy, breast feeding) 4.92 (0.27) Define problem(s) to be treated 4.92 (0.27) Document the rationale for new prescribing decisions in patient notes 4.92 (0.27) Recognize the expression of drug doses and apply appropriate mathematical techniques to calculate drug doses correctly 4.88 (0.33) Interpret the medication history, noting specifics such as previous allergies and ADRs 4.88 (0.43) Follow clinical guidelines/protocols where appropriate 4.88 (0.43) In doing so, consider possible contraindications, drug–drug interactions, previous ADRs, any special circumstances, age, gender and patient affordability 4.88 (0.43) Check for drug–drug interactions 4.88 (0.33) Consider risks and benefits of specific drug therapies 4.88 (0.33) Check the suitability of a drug for a specific patient 4.85 (0.46) Take appropriate action in contraindications, interactions and special circumstances 4.85 (0.37) Define the therapeutic objective(s) for new therapy 4.85 (0.37) The prescriber has appropriate knowledge of drugs 4.85 (0.37) The prescriber has appropriate knowledge of the principles of ADRs, interactions and medication errors 4.85 (0.37) Knowledge of the principles of managing patients in special groups 4.85 (0.37) Communicate treatment plan to other members of staff, both verbally and in the patient records, discharge prescriptions and letter to GP 4.85 (0.37) Manage toxicity and overdose 4.81 (0.49) Ensure over-the-counter, complementary medicines and the pill are specifically included 4.81 (0.40) Review medication at appropriate intervals 4.81 (0.40) An appropriate working diagnosis has been made 4.81 (0.40) Ensure that adequate knowledge of the patient’s medical and drug history has been obtained before prescribing* 4.81 (0.51)

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 53 Check appropriate parameters before prescribing a drug 4.77 (0.51) Understand the limits of information sources and compensate for them 4.77 (0.43) Communicate treatment plan and instructions to patient, at a suitable level of information 4.77 (0.43) Choose appropriate formulation, dose, route, frequency and duration of the drug 4.77 (0.59) Recognize the potential for medication errors and take steps to reduce the risks* 4.76 (0.54) Interact with the multidisciplinary team, and the pharmacist in particular, with regard to prescribing 4.73 (0.45) Gain information from a variety of sources (including transcription from GP letter) 4.73 (0.45) Write a prescription on supplementary prescription forms such as anticoagulation, insulin or infusion charts* 4.72 (0.58) Write an unambiguous, legible, complete and legal prescription, on general practice prescription forms 4.69 (0.62) Identify for each drug the original indication, formulation, dose, route, duration and effects 4.69 (0.55) Consider whether drug treatment is needed for each indication 4.69 (0.55) Recognize drugs with narrow benefit:harm profile or high potential for serious adverse effects/interactions, and take appropriate precautions when prescribing* 4.67 (0.66) Use nondrug therapy where appropriate 4.65 (0.69) The prescriber can assess evidence of safety and efficacy 4.65 (0.56) Monitor treatment outcomes appropriately 4.65 (0.56) Initiate appropriate treatment/management of patients suffering from ADR (including stopping drug) 4.65 (0.48) Calculate appropriate doses for individual patients by weight/body surface area/nomogram 4.62 (0.64) Avoid abbreviations when writing a prescription 4.62 (0.57) Select appropriate doses for patients in special groups (or other changes as needed) 4.62 (0.64) Adapt therapy based on therapeutic drug monitoring or results of other investigations 4.54 (0.65) Use therapeutic drug monitoring where needed, and interpret it 4.50 (0.71) Stop drug where patient receiving no benefit from drug 4.50 (0.65) Use appropriate reference materials to gather information on drugs 4.50 (0.51)

EXCLUDED OUTCOMES Encourage shared decision making 4.42 (0.58) Select appropriate end-points to assess efficacy 4.38 (0.75) Select an appropriate drug for the condition based on evaluation of the evidence for its safety, efficacy and cost 4.29 (0.78) Minimize waste in prescribing 4.27 (0.60) Identify when there is a pharmacological prophylaxis should be given with the main drug being prescribed* 4.25 (0.86) Administer medicines parenterally (s.c., i.m., i.v.) 4.19 (0.75) Complete a yellow ‘card’ for a suspected ADR 4.19 (0.63) Encourage patient compliance* 4.10 (0.79) Participate in audit of prescribing* 4.05 (0.80) Use capital letters when writing a prescription 4.00 (0.89) Prepare parenteral medications 3.88 (0.91) Assess cost–benefit for specific therapies in specific patients* 3.57 (0.50)

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 54

PHARMACOLOGY TEACHING WEBSITES

INTERACTIVE CLINICAL PHARMACOLOGY http://www.icp.org.nz/index.html

TEACHING RESOURCE CENTRE PHARMACOLOGY http://coo.lumc.nl/TRC/redirect.aspx?lessonid=30

Naritoku, D. K. and C. L. Faingold (2009). "Development of a Therapeutics Curriculum to Enhance Knowledge of Fourth-Year Medical Students About Clinical Uses and Adverse Effects of Drugs." Teaching and Learning in Medicine: An International Journal 21(2): 148 - 152.

ABCs of pharmacology - Mental algorithm for rational drug use

A. Pharmacodynamics 1. What drugs are available that exert pharmacological effects needed to correct the pathophysiology problem? 2. What are the mechanisms of action of this drug?

B. Pharmacokinetics 1. What factors alter target cell responsiveness over time for this drug? (e.g., tolerance, adaptation, desensitization, dependence, age) 2. What metabolism-related factors (including pharmacogenomics, age, or other drugs) can alter the patient’s responsiveness to this drug?

C. Pharmacovigilance 1. What is the risk/benefit ratio of therapy (therapeutic index) of this drug? 2. What are the contraindications (absolute/relative) of this drug? 3. What adverse (side) effects are caused by this drug? 4. What drug-related disease-like symptoms (including those due to drug abuse), can be mistaken for additional disease symptoms? 5. What alterations of clinical laboratory tests can be caused by this drug?

Royal College of Veterinary Surgeons Essential Competences Required of the Veterinary Surgeon (2006)

Introduction

1. There are many definitions of ‘competence’ and many views on how it can be developed and assessed. In general terms, however, competence is a concept that integrates knowledge, skills and attitudes, the application of which enables the professional to perform effectively, and to respond to contingencies, change, and the unexpected.

This document takes a broad definition of competence as being “the ability to perform the roles and tasks required by one’s job to the expected standard” 1 (Eraut & Boulay, 2000 ). The advantage of this definition is that it recognises that requirements and expectations change depending on job role and context. It also recognises that competence develops, and that an individual may work ‘competently’ at many different levels, either at different stages of their career, or indeed from one day to the next depending on the nature of their work.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 55 The essential competences have been broken down into three main areas, and these are reflected in both the “day one” and the “year one” requirements. They are:

A. General professional competences and attributes describing the distinguishing characteristics of a veterinary surgeon B. Underpinning knowledge and understanding describing in general terms the breadth of knowledge and understanding needed for a career as a veterinary surgeon, and for subsequent professional development in whatever sphere of veterinary science the individual wishes to pursue C. Practically-based veterinary competences describing the basic practical competences that are expected a) at the point of graduation, and b) following an extended period of further professional training in practice. The ten guiding principles of the RCVS Guide to Professional Conduct should be seen as overarching requirements for registration (and by implication, continued registration) with the College. The Guide states that:

Your clients are entitled to expect that you will: 1. make animal welfare your first consideration in seeking to provide the most appropriate attention for animals committed to your care 2. ensure that all animals under your care are treated humanely and with respect 3. maintain and continue to develop your professional knowledge and skills 4. foster and maintain a good relationship with your clients, earning their trust, respecting their views and protecting client confidentiality 5. uphold the good reputation of the veterinary profession 6. ensure the integrity of veterinary certification 7. foster and endeavour to maintain good relationships with your professional colleagues 8. understand and comply with your legal obligations in relation to the prescription, safe-keeping and supply of veterinary medicinal products 9. familiarise yourself with and observe the relevant legislation in relation to veterinary surgeons as individual members of the profession, employers, employees and business owners 10. respond promptly, fully and courteously to complaints and criticism.

ESSENTIAL COMPETENCES REQUIRED OF THE NEW VETERINARY GRADUATE “DAY ONE SKILLS” A1 - GENERAL PROFESSIONAL SKILLS AND ATTRIBUTES The new veterinary graduate should be able to:

B1 - UNDERPINNING KNOWLEDGE AND UNDERSTANDING The new veterinary graduate will need to have acquired a thorough knowledge and understanding of the following:

. B1.1 The sciences on which the activities of veterinary surgeons are based . B1.2 Research methods and the contribution of basic and applied research to all aspects of veterinary science . B1.3 How to evaluate evidence . B1.4 The structure and functions of healthy animals, and all aspects of their husbandry . B1.5 The aetiology, pathogenesis, clinical signs, diagnosis and treatment of the common diseases and disorders that occur in the common domestic species in the UK. . B1.6 Legislation relating to the welfare (including transport) of animals and notifiable diseases . B1.7 Medicines legislation and guidelines on responsible use of medicines

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 56 . B1.8 The principles of disease prevention and the promotion of health and welfare . B1.9 Veterinary public health issues including zoonoses

C1 - PRACTICAL COMPETENCES The new veterinary graduate should be able to undertake the following:

Royal Veterinary College Bachelor of Veterinary Medicine Day One Skills

http://www.live.ac.uk/documents/DOS_handbook.pdf

1. Underlying Principles 2. Professional Practice 3. Evaluation of Animals and their Care 4. Clinical Decision Making 5. Care and Treatment of Animals

4. Clinical Decision Making E Reaching Diagnosis and Formulating Treatment Plan Have a clear, logical and appropriate diagnostic and therapeutic approach to the common clinical signs that occur in practice Formulate a rational approach to further investigation taking into account owner preferences and any financial contraints Formulate a treatment plan that takes account of the inter-relationship of animal specific, financial and any other significant factors Make appropriate referrals supported by evidence 5. Care and Treatment B Drug and Fluid Administration Administer medication by appropriate route Oral Topical Subcutaneous Intramuscular Intravenous Intraperitoneal Select and prescribe drugs according to need of individual case (using data sources if necessary) Select appropriate dosage, timing, frequency and route Prescribe drugs in compliance with legislative requirements Write prescription in compliance with current legislative requirements Obtain informed consent when prescribing off-label drugs Make up and draw up drug solutions and instruct others in these procedures

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 57 Ensure safe and legal handling and management of drugs Manage risk to self or others associated with particular substances Store drugs in accordance with special requirements Calculate drug dosages - using technology as necessary Dispense medications in accordance with legal requirements and cascade Dispose of drugs in line with legislative guidelines C Anaesthesia Prepare for anaesthesia Perform a pre-anaesthetic evaluation Prepare patient Select and prepare drugs Check and prepare anaesthetic machine Select and prepare breathing system / circuit / pollution control Select and prepare monitoring equipment Perform anaesthesia Administer premedication Administer induction agent Perform endotracheal intubation Administer inhalation agents Calculate and administer fresh gas flow rates Perform manual intermittent positive pressure ventilation (IPPV) Maintain and monitor the patient during anaesthetic process Measure temperature, check heart rate, central and peripheral pulse, respiratory rate and depth (including oesophageal stethoscope) Evaluate findings from pulse oximetry, ECG, respiratory monitors Assess depth of anaesthesia Complete anaesthetic monitoring records Ensure general health and well-being of the anaesthetised and recovering patient Perform local anaesthesia Local infiltration Topical application Nerve blocks for dehorning and castration in farm animals Nerve blocks for local surgery in horses Recognise and manage pain during the anaesthetic process Respond to complications and emergencies during the anaesthetic process E Euthanasia

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 58

Bell, C. E., R. H. Ellaway, et al. (2009). "Getting started with curriculum mapping in a veterinary degree program." J Vet Med Educ 36(1): 100-6.

Aims of curriculum mapping project

• facilitating curriculum review, • improving integration across the curriculum • providing a clear and transparent means of demonstrating outcomes for QA purposes, including accreditation visitations, and • providing clarity in an increasingly integrated curriculum.

Examples of the information that stakeholders may require from the Curriculum Map (table 2)

Current Vet School students Where do I learn about topic X ? How do I learn about topic X ? How will I be assessed on topic X ? How does topic X link in with what I will learn later in the course ? How will learning about topic X be relevant to me as a vet?

Vet School staff When are students taught about topic X ? What will students have already learned about topic X before coming to my class ? Do I need to include topic X in my classes or is it covered elsewhere ? How do I ensure that I achieve constructive alignment between my teaching and assessment of topic X ?

Quality-assurance and accreditation bodies Where is topic X provided in the curriculum? How is topic X provided in the curriculum? Where is topic X assessed in the curriculum? How is topic X assessed in the curriculum?

Prospective students What would they teach me on the vet course? How would they teach me on the vet course? What would I learn in the first year of the vet course? How is this course different from those at other veterinary schools?

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 59 Chapter of Pharmacology (2010). Veterinary Pharmacology Study Course (VPSC). Learning Objectives

MODULE 1 DRUG DISPOSITION AND ACTION The following learning objectives are presented to provide focus as you review the included reading materials. At the end of this module, you should be able to:

1. Define and Describe  Pharmacokinetics  Absorption  Distribution (including factors influencing distribution)  Metabolism (all sites)  Phase I  Phase II  Excretion (all routes)  Zero order processes  First order processes  AUC (area under the curve)  Tmax  Cmax  Clearance  Plasma clearance (Total Clearance)  Renal clearance – glomerular filtration, active secretion, reabsoprtion  Hepatic clearance – first pass effect, cytochrome P450, conjugation  Enterohepatic circulation  Extraction ratio  Volume of distribution  Half life  Protein binding  Tissue binding  pKa  Ionisation and pH partition hypothesis  Bioavailability (F)  Bioequivalence  Pharmacodynamics  Adverse drug reaction  ED50  LD50  Therapeutic ratio  Therapeutic window  Partial antagonist  Agonist-antagonist  Pharmacokinetic/pharmacodynamic integration (+/- physiologically based)  Population pharmacokinetics  Pharmacogenetics  Transport mechanisms  Induction and inhibition

1. Describe the relationship between clearance, volume of distribution and half life of a drug. 2. Describe how dosage regimens are designed, considering dose rate, dosing interval and the need for a loading dose and duration of dosing 3. Describe, supported diagrammatically, the relationship between dosage form, pharmacokinetics and pharmacodynamics. 4. Describe supported diagrammatically and discuss the principal factors affecting the concentration of a drug at its site of action 5. List and explain the physicochemical and other relevant factors of a formulation that may affect the absorption of a drug after non-IV routes of administration –

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 60 intramuscular, subcutaneous, oral, topical, inhalational, intra-osseous, intra- articular etc 6. Discuss advantages and disadvantages of using each of the above routes of administration. 7. List the physicochemical factors of a drug that may affect its distribution to various tissues including fat, bone, skin, eye, CNS, lung. 8. Discuss how the species of an animal can affect the pharmacokinetics and pharmacodynamics of a drug: For example: i) sheep versus goat with respect to anthelmintics ii) horse versus cattle with respect to alpha2 agonists iii) ruminant versus monogastric with respect to absorption and distribution of drugs iv) dog versus cat with respect to paracetamol 9. Describe examples of how changes to clearance or volume of distribution can affect the appropriate dose of a drug to be administered. 10. Predict what would happen to drug clearance, volume of distribution and half life in the following pathological or physiological conditions i) renal disease ii) pregnancy iii) lactation iv) fever v) hepatic diseases vi) obesity vii) neonatal patient viii) severe heart disease ix) geriatric patient 11. In the examples above, describe how and why you would (not) need to alter your dose regimen (amount, frequency, duration) of drugs if the physiological or pathological condition of the animal was known? 12. Provide examples of drugs or drug classes that are: i) cleared only by renal mechanisms ii) cleared only by hepatic mechanisms iii) cleared both by the kidneys and the liver iv) distributed only to plasma v) distributed throughout the body vi) not absorbed after oral administration vii) poorly absorbed when co-administered with food viii) better absorbed when food is administered and provide reasons why these drugs have these characteristics. 13. Give veterinary clinical examples of drug interactions in which the interaction was due to changes in i) protein binding ii) liver metabolism iii) renal secretion iv) competitive antagonism of effect v) non-competitive antagonism of effect vi) potentiation of effect 14. Discuss, giving relevant veterinary drug examples, the following statement: ‘When a drug binds to a receptor, it initiates a sequence of events that culminates in the drug effect’ in terms of i) cell membrane receptors and intracellular receptors ii) types of receptors (channels, enzymes etc) iii) second messengers.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 61 15. Draw a log concentration (x-axis) – effect (y-axis) curve for a fictitious drug and use it to discuss i) potency ii) antagonism iii) ‘ceiling’ effect

MODULE 2 CHEMOTHERAPEUTICS Principal Objectives • To have a broad understanding of the basic principles and practical applications of chemotherapy and the factors influencing the balance of benefits and adverse consequences. • To understand the factors and situations promoting the selection of resistance, how resistance selection can be minimised, how resistance can be managed, and the various impacts of resistance on animal and human health

Learning Objectives At the end of this module, you should be able to discuss:

‘Chemotherapeutic agents exploit differences in essential processes between bacteria / viruses / parasites / cancer cells and hosts so that selective toxicity can be achieved’

‘Without the prudent selection and use of chemotherapeutic agents the long term usefulness of these valuable tools will be lost’

CHEMOTHERAPY OF BACTERIAL DISEASES

1. Define and Describe  Minimum inhibitory concentration  Minimum bactericidal concentration  Constitutive resistance  Acquired resistance  Cross resistance  Co-resistance  Horizontal gene transfer  R-factors  Plasmids  Post-antibiotic effect  Post-antibiotic leukocyte enhancement  Super-infection  Nosocomial infection 2. List and justify essential points in a Code of Practice for the Use of Antimicrobials in Veterinary Practice (food and non-food producing animal species) that you may use in practice. 3. Discuss the classification of antibacterials based on spectrum of activity narrow versus broad spectrum mechanism of action resistance characteristics animal species in which common drugs are used 4. Given likely pathogens / diseases in each domestic species, predict the best choice of antibacterials and the management of cases. Be able to support your answer using basic principles.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 62 5. Discuss penetration of antibacterials to their site of action with particular emphasis on:  Penetration into extracellular fluid / cells / inflammatory fluid  Physiological barriers to penetration  Barriers to penetration as a result of infection 6. Give examples of  antibacterials that demonstrate concentration –dependent killing  antibacterials that demonstrate time-dependent killing  how the mode of killing influences dosing strategies 7. Discuss the role of supportive therapy (in addition / instead of antibacterial therapy) in the prevention and treatment of bacterial infections. 8. Give examples of in vivo synergism and antagonism between antibacterials and how these properties may affect the clinical use of such drugs 9. Discuss the concepts behind the purported link between the use of antimicrobials in animals and the development of antimicrobial resistance in human patients. 10. Give clinical examples which support the following statement ‘Organisms that are variably sensitive to antimicrobials present more of a problem to the clinician than those that are predictably not sensitive’. 11. List means by which a veterinary practitioner can improve client compliance. 12. Give examples of appropriate antiseptics and disinfectants used in clinical settings (and rationale for use) including  Non-heat sterilisation of surgical instruments  Pre surgical preparation of a dog’s abdomen  Disinfection of a kennel area after a parvovirus outbreak  Cleaning of an ICU after a nosocomial Klebsiella spp. infection where Klebsiella bacteria were isolated from air duct vents and drains  Mastitis control in a large dairy herd  Cleaning of a rhinolaryngoscope (with plastic / perishable parts) 13. Describe the decision making process in the selection of antibacterials and other therapies for the treatment of acute mastitis in cattle 14. Discuss the role of intramammary preparations in the prevention and treatment of mastitis. 15. Discuss the use of antibiotics for growth promotion in animals in terms of  Major antibacterials / groups registered for this purpose  Mechanisms of action to promote growth  Advantages and disadvantages of use for this purpose 16. Discuss antibacterial resistance in terms of  Constitutive and acquired resistance (what are some of the means by which bacteria are inherently resistant or develop resistance ?)  Role of antibacterial use pattern in development of resistance  Transfer from food-producing animals to humans 17. Discuss contemporary issues regarding residues arising from antibacterial use in food-producing animals and means by which residues can be avoided. 18. Discuss the key features of the history of antibacterial development and usage since the 1930s; and outline the limitations to the continued development of antibacterials in the 21st century. 19. Describe the basic modes of action of anti-viral, anti-fungal and antiprotozoal agents. 20. Discuss appropriate use of anti-viral, anti-fungal and anti-protozoal drugs that are currently registered for use in domestic animal species.

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CHEMOTHERAPY OF NEOPLASTIC DISEASE

1. Outline the impact of tumour biology on chemotherapy. 2. List the categories of chemotherapeutic drugs used in veterinary oncology, describing their basic mechanism of action, and giving examples of each category. 3. Describe multi-drug resistance in cancer. 4. Outline a program for the safe handling and use of chemotherapeutic drugs in a veterinary practice. 5. Discuss expected side-effects of common chemotherapeutic drugs and means by which these can be avoided, minimised or treated.

CHEMOTHERAPY OF PARASITIC DISEASES

1. Define  Ectoparasiticide  Endoparasiticide  Endectocide 2. Categorise and describe anti-parasiticides based on  Mechanism of action  Groups of parasites affected 3. Given likely parasites / diseases in each domestic species, describe how one may make the best choice of antiparasitic drugs to be used in the prevention and management of parasitic infections. Be able to support your answer using basic principles. 4. Discuss approaches for avoidance and management of anthelmintic resistance. 5. Discuss the potential environmental impact of anthelmintic drugs.

MODULE 3 SYSTEMS PHARMACOLOGY

LEARNING OBJECTIVES 1. Discuss drugs used in the control, prevention and treatment of the following. You should be able to support your discussion with an understanding of how these drugs affect the pathophysiology of the disease or signs of disease. Candidates should have a working knowledge of the major drugs used in all species, however, particular focus and depth can be retained for examples of major drugs in specific species. i) pain ii) inflammation iii) dehydration iv) shock v) congestive heart failure vi) cardiac arrhthymias vii) oedema viii) asthma and inflammatory conditions of the lung ix) seizures x) behavioural changes xi) bladder dysfunction xii) renal failure xiii) vomiting xiv) diarrhoea xv) GI ulcers xvi) inflammatory conditions of the intestine xvii) diabetes mellitus and insipidus

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 64 xviii) hyper- and hypothyroidism xix) hyper- and hypoadrenocorticism 2. Describe the pharmacology of the general classes of drugs used in a) anaesthesia b) ophthalmology c) dermatology d) animal reproduction.

3. The following drug classes require special attention as they impact on numerous systems and diseases : a) corticosteroids b) non-steroidal anti-inflammatory drugs c) adrenergic agonists and antagonists d) parasympathetic agonists and antagonists e) opioid agonists and antagonists f) drugs used for sedation and tranquillisation.

For each drug class, select at least one drug and describe a) mode of action b) general pharmacokinetic principles c) indications d) contraindications e) precautions f) adverse reactions g) overdosage h) dosage and administration

MODULE 4 VACCINES AND IMMUNOLOGY Principal objectives

• To acquire a broad knowledge of the principles of immunology, particularly as they relate to the clinical application of vaccines • To understand the benefits and limitations of vaccination and other forms of immunotherapy and immunoprophylaxis.

The candidate should be able to: 1. List the types of constituents that may be present in a vaccine, giving examples of each type. 2. Distinguish between humoral and cell mediated immune responses 3. Describe how adjuvants promote an immune response to vaccine antigens. 4. Discuss the arguments for and against the use of the various types of vaccines: especially subunit, inactivated and living vaccines. 5. Discuss risks and benefits of emerging vaccine technologies eg. DNA and recombinant technologies. 6. Describe the principal considerations in choice amongst the various routes of administration of vaccines. 7. Discuss methods by which the success of vaccination can be measured. 8. Discuss the concept of population (herd) immunity. 9. Discuss potential risks with importation of live or inactivated vaccines into Australia or New Zealand. 10. List the diseases that are prevented or treated by vaccination in the major domestic animal species in Australia or New Zealand. 11. Describe the spectrum of possible adverse reactions to vaccines and how they may be minimised. 12. Identify reasons for true or suspected vaccination failure and how they can be distinguished.

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 65 13. Discuss the challenges presented by public perception of increased vaccine- related adverse events and the resultant pressure to vaccinate less often and with alternative adjuvants. 14. Define the following terms :  antibody  sub-unit  antigen  immunogen  recombinant  idiotype  epitope  antibody titre  vaccination  immunisation  immunological memory  anamnestic response  adjuvant  inactivation  potentiation  attenuation  adventitious agent  modified live virus vaccine  vector  peptide vaccine  nucleic acid vaccine  protective immunity  humoral immunity  cell mediated immunity  mucosal immunity  passive immunity  immunosupression  immunotherapy  colostral transfer of immunity

MODULE 5 PRINCIPLES OF TOXICOLOGY

Learning Objectives The student should have a broad understanding of the: 1. Principles of toxic drug action, selective toxicity, safety testing of drugs, including husbandry and use of experimental animals for the following groups: a) common plant poisons, b) organic poisons including therapeutic drugs, c) inorganic compounds such as metals, d) pesticides including rodenticides, herbicides and wood preservatives, and e) toxins of animal origin. 2. Investigation of suspected poisoning cases, use of emetics and antidotes and relevance of toxin and drug residues in carcasses and the environment. 3. Specific toxicants. Be able to describe the aetiology, clinical presentation, diagnosis and management of common poisonings seen in companion animal and large animal practices. Be familiar with the pharmacology of antidotes available for use in the treatment of poisonings in veterinary practice, including:  4-amino pyridine  N-acetyl-L-cysteine  Ammonium molybdate and ammonium tetrathiomolybdate  Anti-digoxin fab antibodies  Antivenenes (tick, spider and snake)

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 66  Atipamezole  Atropine  Copper (as glycinate, disodium edetate or sulfate)  Desferrioxamine  Dimercaprol (bal)  Edetate calcium disodium (EDTA)  Ethanol  Flumazenil  Fomepizole  Glucagon  Hydroxycobalamin  Leucovorin  Methocarbamol  Methylene blue  Naloxone  Pamidronate disodium (aminohydroxy-propylidene biphosphate)  Penicillamine  Physostigmine  Potassium iodide  Pralidoxime (2-PAM)  Protamine  Pyridoxine  Prussian blue  Sodium nitrite  Sodium thiosulfate  Succimer (dimercaptosuccinic acid)  Thiamine  Tolazoline  Trientine (triethylenetetramine)  Vitamin k (phytomenadione)  Yohimbine  Zinc acetate 4. Discuss dosage and other factors that influence toxicity. 5. Discuss the principles of diagnosis and management of the poisoned patient. Be able to describe supportive care, toxicological decontamination techniques, and initial treatment techniques for acutely and chronically poisoned patients. 6. Discuss the principles of toxic drug action, selective toxicity, dosage response relationships and safety testing of drugs. 7. Be able to describe what an adverse drug reaction is, and how these events may be investigated and managed. 8. Describe the relationship between drug concentration in meat, meat withholding period and public health risk. Discuss the relationship between a NOEL ( No Observable Effect Level ) and ADI ( Acceptable Daily Intake ) and a MRL ( Maximum Residue Level ). Describe how microbiological safety is being considered in the determination of drug residue safety in food animals. 9. Describe the significance of drug residues in food producing animals and the principles of minimisation or avoidance in foodstuffs.

MODULE 6 DRUG DEVELOPMENT AND MANUFACTURE Learning Objectives The student should have an understanding of: a) the fundamentals of drug screening b) dose rate determination and selection c) routes of administration

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 67 d) formulation/stability/manufacture of test substances e) design/analysis/interpretation of clinical studies f) safety/efficacy/residue study evaluation g) how quality is built into each step of drug development and manufacture

Specifically the student should understand the key components of and be able to discuss: • GLP – good laboratory practice • GMP – good manufacturing practice • GCP – good clinical practice • How to set up a clinical trial for product registration purposes

MODULE 7 REGULATORY AFFAIRS AND REGISTRATION

Learning objectives Candidates need to have a good general knowledge of the Registration Requirements of either Australia or New Zealand. Candidates should develop and very good understanding of registration data requirements for metabolism and kinetics, residues, efficacy and safety, trade requirements, product quality assessment with a broad understanding of the other requirements (for example public health, environmental safety, and occupational health and safety). In particular candidates should be able to: (Suggested website resources in brackets) 1. Describe the types of chemicals that require registration (http://www.apvma.gob.au/registration/registering.shtml) 2. Explain how and why drugs and poisons are scheduled, particularly the relevant controls placed on Prescription Animal Remedies, Poisons, Dangerous Poisons and Controlled Substances (in the Australian context, or relevant considerations in the New Zealand context); begin with (http://www.tga.gov.au/ndpsc/scheduling-revised.htm and see also http://www.apvma.gov.au use search) 3. Discuss the veterinarian’s “right to prescribe” and off-label use; (http://www.ava.com.au/) 4. Discuss restrictions/controls pertaining to veterinarians under Veterinary Surgeons Acts and Poisons Acts (or similar restrictions in New Zealand); (http://www.ava.com.au) 5. Describe essential details of labeling of veterinary chemical products, and restraint statements (http://www.apvma.gov.au/publications/labelling_code.shtml) 6. Discuss licensing of Veterinary Manufacturers and veterinarian’s right to make up products extemporaneously (http://www.apvma.gov.au/qa/mls.shtml) 7. Describe important aspects of tissue residues in food animal production (http://www.apvma.gov.au use search) 8. Define NOEL, ADI, MRL, WHPs (and their relationships), Dietary Exposure Evaluation, Codex Committee on Veterinary Drugs in Food, and Export Slaughter Intervals (use www.google.com.au to search for definitions) 9. Discuss the concepts behind National Residue Surveys 10. (go to http://www.affa.gov.au and search for NRS) and other residue testing programs e.g. Australian Total Diet Survey (Market Basket Survey) (www.anzfa.gov.au) 11. Explain the principles of an Adverse Experience Reporting Program (http://www.apvma.gov.au/qa/hgp.shtml) 12. Discuss regulatory requirements with respect to antibiotic resistance data for new antibiotics [see also Module 3] (www.health.gov.au/pubhlt/strateg/jetacar/index.htm) 13. Discuss regulatory controls over hormonal growth promotants

Veterinary pharmacology curriculum renewal to improve graduate outcomes and public safety 68 (http://www.apvma.gov.au/qa/hgp.shtml) 14. Discuss issues related to the horse as a food producing animal and relevant WHPs (www.apvma.gov.au/publications/labelling_code.shtml) 15. Discuss control of the use ( as distinct from the supply ) of veterinary medicinal products (in Australia, under State legislation) (begin with http://www.apvma.gov.au/about_us/legislat.shtml) 16. Discuss issues related to pesticide residues in wool [see also Module 7] 17. Have general understanding of the issues behind recent or current reviews by regulatory authorities (http://www.apvma.gov.au/chemrev/chemrev.shtml) 18. Describe the general categories of risk that regulatory authorities consider and the general types of studies required for each e.g. efficacy, safety, human toxicology etc.

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Appendix 8: VCPN Formulary

# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 1 4-Amino pyridine 479 Etamiphylline camsylate 957 Oxybenzylphosphinic acid sodium salt 2 6-Phytase 480 Ethacrynic acid 958 Oxybutinin chloride 3 Abalone 481 Ethambutol 959 Oxyclozanide 4 Abamectin 482 Ethanol 960 Oxycodone 5 Acarbose 483 Ethanolamine 961 Oxycontin 6 Acebutalol 484 Ethanolamine derivatives 962 OXYGEN 7 Acemannan 485 Ether 963 Oxyglobin 8 Acepromazine 486 Etheylenediamine derivatives 964 Oxymorphone (acetylpromazine) 9 Acetaminophen see 487 ETHINYLOESTRENOL 965 Oxytetracycline Paracetamol 10 Acetazolamide 488 Ethion 966 Oxytocin 11 Acetic acid 489 Ethopabate 967 Paclitaxel 12 Acetohydroxamic acid 490 Ethyl lactate 968 Palonosetron 13 Acetonide 491 Ethylene oxide 969 Pamidronate disodium 14 Acetyl salicylic acid see 492 Ethylenediamine 970 Pancrelipase Aspirin dihydroiodide (eddi) 15 Acetylcholine (ACh) 493 Ethyloestrenol 971 Pancuronium bromide 16 Acetylcysteine 494 Etidronate disodium 972 Pantoprazole 17 Aciclovir 495 Etiproston as etiproston 973 Paracetamol (acetaminophen) tromethamide 18 Acid citrate dextrose 496 Etodolac 974 Paraffin liquid 19 Acitretin 497 Etomidate 975 Parapox ovis virus immunomodulator 20 Acriflavine 498 Etoposide 976 Parbendazole 21 Actinomycin D 499 Etorphine 977 Paregoric (dactinomycin)

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 22 Activated charcoal 500 Eucalyptus oil 978 Paromomycin 23 Acyclovir 502 Exocrine pancreatic enzyme 979 Paroxetine replacements 24 Adenosine (incl 5- 503 Extract ginger 980 Parvaquone monophosphate / triphosphate ) 25 Adrenaline see Epinephrine 504 Extract liquorice 981 Pectinase 26 Adriamycin see 505 Extract squill 982 Penciclovir Doxorubicin 27 Aglepristone 506 Famciclovir 983 Penethamate hydriodide 28 Alandronate 507 Famotidine 984 Penicillamine 29 Alanine 508 Famphur 985 Penicillin G (Benzylpenicillin) 30 Albaconazole 509 Fatty acids, essential, omega 986 Penicillin V (Phenoxymethyl- penicillin) 31 Albendazole 510 Febantel 987 Pentamethonium 32 Albendazole oxide 511 Felbamate 988 Pentamidine isetionate 33 Albuterol (salbutamol) 512 Feliway 989 Pentastarch sulfate 34 Alcohol ethoxylate teric 12a 513 Fenbendazole 990 Pentazocine 23 35 ALDOSTERONE 514 Fenoldopam 991 Pentobarbital (Pentobarbitone) 36 Alendronate sodium 515 Fenoxycarb 992 Pentolinium 37 Alfacalcidol 516 Fentanyl / fentanyl patches 993 Pentosan polysulfate 38 Alfentanil 517 Fenthion 994 Pentosanases - beta glucanase 39 Aliphatic alcohol 518 Fenvalerate 995 Pentoxifylline propoxylate ethoxylate polyether 40 Alkylbenzene sulphonic 519 Ferrous sulfate 996 Peppermint oil acid 41 Allantoin 520 Fexofenadine 997 Pergolide mesylate 42 Allergenic extract 521 Filgrastim 998 Perindopril

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 43 Allopurinol 522 Finasteride 999 Permethrin (incl 25:75::cis:trans / 40:60::cis:trans / 80:20::cis:trans) 44 Aloe vera extracts 523 Fipronil 1000 Pethidine (meperidine) 45 Alpha-cypermethrin 524 Firocoxib 1001 Phenamidine 46 Alphaxalone 525 Flavophospholipol 1002 Phencyclidine 47 Alprazolam 526 Flavoxate 1003 Phenethicillin 48 Alprenolol 527 Flecainide 1004 PHENIRAMINE 49 Altrenogest 528 Florfenicol 1005 Phenobarbital (Phenobarbitone) 50 Aluminium acetate 529 Fluanisone 1006 Phenolphthalein 51 Aluminum hydroxide (& 530 Fluazuron 1007 Phenothrin aluminium carbonate) 52 Amandatine HCl 531 Flubendazole 1008 Phenoxybenzamine 53 Amber oil 532 Flucloxacillin 1009 Phenoxyethanol 54 Ambroxol hydrochloride 533 Fluconazole 1010 Phentolamine 55 Amfetamine 534 Flucytosine 1011 Phenyl mercuric nitrate 56 Amikacin 535 Fludrocortisone acetate 1012 Phenylalanine 57 Amiloride 536 FLUDROMETHASONE 1013 Phenylbutazone 58 Aminacrine hydrochloride 537 Flugestone acetate 1014 Phenylephrine 59 Aminocaproic acid (EACA) 538 Flumazenil 1015 Phenylpropanolamine 60 Aminopentamide hydrogen 539 Flumethasone 1016 Phenytoin sulfate 61 Aminophylline 540 Flumethrin 1017 Pheromones 62 Amiodarone 541 Flunixin meglumine 1018 Phosphate, parenteral 63 Amitraz 542 Fluocinolone acetonide 1019 Phospholine iodide 64 Amitriptyline 543 Fluoride present as sodium 1020 Phosphoric acid fluoride 65 Amlodipine 544 Fluorouracil (5-fluorouracil) 1021 Phosphorus (incl dicalcium phosphate / tricalcium

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT phosphate / magnesium hypophosphite / monopotassium phosphate / sodium tripolyphosphate) 66 Ammonia (incl carbonate / 545 Fluoxetine 1022 Phthalic acid dibutyl ester chloride / ferric citrate / molybdate / sulfate) 67 Ammonium chloride 546 Fluphenazine decanoate 1023 Phthalylsulfathiazole 68 Ammonium molybdate 547 Flurazepam 1024 Physalaemin 69 Ammonium 548 Flurbiprofen 1025 Physostigmine salicylate tetrathiomolybdate 70 Amoxicillin 549 Flurithromycin 1026 Phytomenadione see Vitamin K1 71 Amoxicillin-clavulanate 550 Flutamide 1027 Phytonadione 72 Amphotericin B 551 Fluticasone propionate 1028 Phytosphingosine 73 Ampicillin 552 Fluvoxamine 1029 Pilocarpine 74 Ampicillin-sulbactam 553 Folic acid 1030 Pimecrolimus 75 Amprolium 554 Follicle-stimulating hormone 1031 Pimobendan (FSH) (ovine, porcine) 76 Amrinone 555 Fomepizole 1032 Pindolol 77 Amylase (incl alpha 556 Formalin (formaldehyde) 1033 Pine oil amylase) 78 Anidulafungin 557 Formestane 1034 Pioglitazone 79 Aniseed oil 558 Formoterol 1035 Pipecuronium 80 Anthracycline 559 Foscarnet 1036 Piperacillin 81 Apomorphine 560 Fosinopril 1037 Piperacillin + tazobactam 82 Apraclonidine 561 Fotemustine 1038 Piperazine (incl anhydrous / citrate / dihydrochloride) 83 Apramycin sulphate 562 Framycetin sulfate 1039 Piperonyl butoxide 84 Aprepitant 563 Frusemide (furosemide) 1040 Piperoxan 85 Arginine-l hydrochloride 564 Furazolidone 1041 Pirlimycin HCl

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 86 Ascorbic acid 565 Furosemide 1042 Piroxicam 87 Asparaginase (L- 566 Fusidic acid 1043 PLASMA FRESH FROZEN asparaginase) 88 Aspergillus (incl niger 567 Gabapentin 1044 Plicamycin fermentation extract / oryzae fermentation extract) 89 Aspirin 568 Gallamine 1045 p-menthane-3,8-diol (PMD) 90 Astemizole 569 Gamma-oryzanol 1046 PMSG (eCH) 91 Atenolol 570 Ganciclovir 1047 Poly glycanohydrolase 92 Atipamezole 571 Garlic 1048 Poly(hexamethylene biguanide) hydrochloride 93 Atovaquone 572 Gatifloxacin 1049 Polyandroalbumin 94 Atracurium besylate 573 Gefitinib 1050 Polyethylene glycol 3350 (PEG) 95 Atropine 574 GELATIN SOLUTIONS 1051 Polymyxin B 96 Auranofin 575 Gemcitabine 1052 Polypropylene glycol ethoxylate 97 Aurothioglucose 576 Gemfibrozil 1053 Polysulfated glycosaminoglycan 98 Avilamycin 577 Gentamicin 1054 Ponazuril 99 Avoparcin 578 Gentian root powder 1055 Porcine somatotropin = PST 100 AZAPENTINE 579 Glimepiride 1056 Posaconazole 101 Azaperone 580 Glipizide 1057 Potassium (incl acetate / aspartate / chloride / citrate / gluconate / glycerophosphate / nitrate / phosphate monobasic / sorbate / sulfate) 102 Azathioprine 581 Glucagon 1058 Potassium bromide 103 Azithromycin 582 Glucanase (incl endo 1,3(4) 1059 Potassium chloride b-d glucanase / endo-1,3(4)- b-glucanase (I.U.B. No. 3.2.1.6))

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 104 Azlocillin 583 Glucosamine 1060 Potassium citrate 105 Aztreonam 584 Glucose 1061 Potassium gluconate 106 Bacillus licheniformis+B843 585 Glutamic acid-l sodium salt 1062 Potassium iodide 107 Bacillus subtilis (incl 586 Glutamine-l 1063 Potassium phosphate fermentation extract) 108 Bacitracin 587 Glutaraldehyde 1064 Povidone iodine 109 Baclofen 588 Glyburide 1065 Pradofloxacin 110 Ball clay r 589 Glycerin 1066 Pralidoxime (2-PAM) 111 Balsam peru 590 Glycerophosphate 1067 Pramoxine 112 Baquiloprim 591 Glyceryl trinitrate (GTN) 1068 Praziquantel 113 Bay oil 592 Glycine 1069 Prazosin 114 BCNU 333 593 Glycopyrrolate 1070 Prednisolone (incl acetate / sodium succinate) 115 Bear berry leaves 594 GNRF - protein conjugate 1071 Prednisone 116 Benazepril 595 Gold (sodium thiomalate) 1072 Prilocaine 117 Bendiocarb 596 Gonadorelin (hydrochloride, 1073 Prilocaine hydrochloride diacetate tetrahydrate) = LH = gonadotrophin 118 Bentonite 597 Gonadotrophin-chorionic 1074 Primaquine phosphate 119 Benzalkonium chloride 598 Gonadotrophin-serum 1075 Primidone 120 Benzathine penicillin 599 Gonadotropin, chorionic (see 1076 Probenecid hCG) 121 Benzethonium chloride 600 Gonadotropin-releasing 1077 Probiotics e.g lactobacilli in hormone (GnRH) yogurt 122 Benznidazole 601 Gramicidin 1078 Procainamide 123 Benzocaine 602 Granisetron 1079 Procaine hydrochloride 124 Benzoic acid 603 Granulocyte colony- 1080 Procaine penicillin stimulating factor (G-CSF) 125 Benzoyl peroxide 604 Green lipped mussel (incl 1081 Procarbazine stabilised green-lipped mussel powder)

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 126 Benzyl alcohol 605 Griseofulvin 1082 Prochlorperazine 127 Benzyl benzoate 606 Growth hormone (see 1083 Proflavine hemisulfate somatostatin) 128 Betacyfluthrin 607 Guaiacol 1084 Progesterone (incl inert silicone elastomer) 129 Betametasone 608 Guaifenisin 1085 Proligestone 130 Betaxolol 609 Guanethidine 1086 Promazine 131 Bethanechol 610 Haemoglobin glutamer-200 1087 Promethazine (bovine) 132 Bicarbonate 611 Halofuginone base as the 1088 Pronethalol lactate 133 Bifidobacterium (incl 612 Haloperidol 1089 Propanidid bifidum / longum / thermophilum) 134 Bimatoprost 613 Halothane 1090 Propantheline 135 Biotin 614 hCG (chorionic 1091 Proparacaine gonadotropin) 136 Bisacodyl 615 Hemicellulase 1092 Propentofylline 137 Bismuth subnitrate 616 Hemicholinium 1093 Propetamphos 138 Bismuth subsalicylate 617 Heparin (Low molecular 1094 Propionibacterium acnes weight heparin (LMWH) / injection Unfractionated heparin) 139 Black cohosh 618 Heptaminol hydrochloride 1095 Propionibacterium freudenreichii 140 Bleomycin 619 Hesperidin 1096 Propionic acid 141 BLOOD 620 Hetacillin 1097 Propiopromazine 142 Boldenone undecylenate 621 Hexachlorophene 1098 Propofol 143 Boric acid 622 Hexamethonium 1099 Propoxur 144 Boron 623 Hexamine (syn 1100 Propoxyphene methenamine) 145 Botulinum toxin A 624 Hexetidine 1101 Propranolol

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 146 Bretylium 625 Histamine 1102 Propylene glycol 147 Brimonidine 626 Histidine-l hydrochloride 1103 Propylthiouracil monohydrate 148 Brinzolamide 627 Homatropine 1104 Prostaglandin F2α 149 BRODIFACOUM 628 Hyaluronic acid (HA) 1105 Protamine sulfate 150 Bromfenac 629 Hydralazine 1106 Protease (incl fungal (FCC iii)) 151 Bromhexine hydrochloride 630 Hydrochlorothiazide 1107 Pseudoephidrine HCl 152 Bromide 631 Hydrocodone 1108 Psyllium 153 Bromocriptine 632 Hydrocortisone / 1109 Pyraclofos Hydrocortisone sodium succinate (HSS) / Hydrocortisone aceponate 154 Bromosulphan 633 Hydrogen peroxide 1110 Pyrantel (pamoate, tartrate) 155 Budesonide 634 Hydromorphine 1111 Pyrethrin (incl pyrethrins / pyrethrum) 156 Bumetanide 635 Hydroxy progesterone (incl 1112 Pyridostigmine bromide caproate / hexanoate) 157 Bunamidine hydrochloride 636 Hydroxyamphetamine 1113 Pyridoxine HCl (vitamine B6) 158 Bupivacaine 637 Hydroxycarbamide 1114 Pyrilamine maleate (hydroxyurea) 159 Buprenorphine 638 Hydroxyl daunorubicin see 1115 Pyrimethamine Doxorubicin 160 Buserelin acetate 639 Hydroxymorphone 1116 Pyriprole 161 Buspirone 640 Hydroxyprogesterone 1117 Pyriproxyfen hexanoate 162 Busulfan 641 Hydroxyproline 1118 Quinacrine hydrochloride 163 Butaphosphan 642 Hydroxyurea 1119 Quinalbarbitone sodium 164 Butorphanol 643 Hydroxyzine 1120 Quinidine 165 Butoxamine 644 Hyoscine 1121 Quinine (incl hydrochloride / sulfate) 166 Butylscopolamine (N- 645 Hyoscyamine 1122 QUINUPRISTIN/DALFOPRISTI

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT butylscopolamine, N- N butylscopolammonium) 167 C12-C+B75615 alcohol 646 Ibafloxacin 1123 Rabeprazole ethoxylate 168 Cabergoline 647 Ibuprofen 1124 Racemethionine 169 Caffeine 648 Icaridin 1125 Ractopamine hydrochloride 170 Cajuput oil 649 Ichthammol 1126 Rafoxanide 171 Calciferol 650 Idarubicin and epirubicin 1127 Raltitrexed 172 Calcitonin 651 Idoxuridine 1128 Ramifenazone 173 Calcitriol 652 Ifosfamide 1129 Ramipril 174 Calcium (incl carbonate / 653 Iloprost 1130 Ranitidine glubionate / glucoheptonate / glycerophosphate / hypophosphinate / iodate / lactobionate / pantothenate / phosphate / propionate / sulfate) 175 Calcium acetate 654 Imatinib 1131 Recombinant GP70 sub-type A 176 Calcium carbonate 655 Imidacloprid 1132 Recombinant omega interferon of feline origin 177 Calcium chloride 656 Imidapril hydrochloride 1133 RegressinV 178 Calcium citrate 657 Imidazole carboxamide 1134 Remifentanil 179 Calcium gluconate, calcium 658 Imidocarb 1135 Reserpine borogluconate 180 Calcium lactate 659 Imipenem 1136 Resmethrin 181 Calcium pentosan 660 Imipenem-cilastin 1137 Resorcinal polysulfate 182 Camphor (incl camphor oil) 661 Imipramine 1138 Ribavirin 183 CANDESARTAN 662 Imiquimod 1139 Ricobendazole 184 Canine erythrocytes 663 Inamrinone 1140 Rifampicin (rifampin) 185 Canine plasma 664 Inamrinone lactate 1141 Rimandtadine

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 186 Capsicum oleoresin 665 Indometacin 1142 Ringer’s solution 187 Captopril 666 Inositol 1143 Risperidone 188 Carbamazepine 667 Insulin (glargine / isophane / 1144 Robenacoxib lente / protamine zinc / ultralente) 189 Carbaryl 668 Interferon / Interferon-ω / 1145 Robenidine Interferon-a 190 Carbenicillin 669 Interleukin-2 1146 Rocuronium 191 Carbimazole 670 Intravenous immunoglobulins 1147 Romifidine 192 Carbohydrase 671 Iodine 1148 Ronidazole 193 Carbon dioxide 672 Ipecac syrup 1149 Ropivacaine 194 Carbon monoxide 673 Ipodate 1150 Rosemary extract 195 Carboplatin 674 Ipratropium 1151 Rosiglitazone 196 Carfentanil 675 Irbesartan 1152 Rotenone 197 Carmustine (BCNU) 676 Iron (incl ferric chloride / 1153 Roxarsone (3-nitro-4- ferric citrate / ferric hydroxide hydroxyphenylarsonic acid) sucrose compound / ferric oxide / ferric pyrophosphate / ferric saccharate / ferric subsulphate / ferrous fumarate / ferrous gluconate / ferrous sulfate / gleptoferron / iron amino acid chelate / iron carbonyl / iron polymaltose) 198 Carnidazole 677 Iron dextran 1154 Roxithromycin 199 Carnitine 678 Isoeugenol 1155 Rutin 200 Carprofen 679 Isoflupredone acetate 1156 Saccharomyces boulardii 201 Carteolol 680 Isoflurane 1157 Saccharomyces cerevisiae 202 Carvedilol 681 Isoleucine - l 1158 S-adenosyl methionine (SAMe) 203 Cascara sagrada 682 Isoniazid 1159 Salbutamol (albuterol) sulfate

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 204 Caspofungin 683 Isoprenaline (isoproterenol) 1160 Salicylic acid 205 Castor oil 684 Isopropamide 1161 Salinomycin sodium 206 Catechu = catechu black = 685 ISOPYRIN 1162 Salmeterol cachou 207 CCNU (lomustine) 686 Isosorbide 1163 Sarafloxacin mononitrate/dinitrate 208 Cefaclor 687 Isotretinoin 1164 Saralasin 209 Cefadroxil 688 Isoxsuprine HCl 1165 Sassafras oil 210 Cefalonium 689 Itraconazole 1166 Scopolamine 211 Cefalothin 690 Ivermectin 1167 Selamectin 212 Cefamandole 691 Kanamycin 1168 Selegiline 213 Cefazolin 692 Kaolin and pectin 1169 Selenium (incl amino acid chelate / elemental / selenate / selenite / selenium yeast / sulfide) 214 Cefdinir 693 Ketamine 1170 Selenium sulfide 215 Cefepime 694 Ketanserin tartrate 1171 Semduramicin sodium 216 Cefixime 695 Ketoconazole 1172 Senna 217 Cefodoxime 696 Ketoprofen 1173 Serratia marcescens 218 Cefoperazone 697 Ketorolac 1174 Sertraline 219 Cefotaxime 698 Kitasamycin 1175 Sevelamer 220 Cefotetan 699 Labetalol 1176 Sevoflurane 221 Cefovecin 700 Lactated Ringer’s solution 1177 Shark cartilage 222 Cefoxitin 701 Lactic acid 1178 Sildenafil 223 Cefpodoxime proxetil 702 Lactic acid bacteria (incl 1179 Silver sulfdiazine lactobacillus acidophilus - strain 45 / lactobacillus acidophilus - strain 51 / lactobacillus delbrueckii subspecies bulgaricus /

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT lactobacillus plantarum / lactobacillus reuteri strain / lactobacillus rhamnosus) 224 Ceftazidime 703 Lactose 1180 Silymarin 225 Ceftiofur (hydrochloride, 704 Lactulose 1181 Sirolimus sodium, free acid) 226 Ceftriaxone 705 Lamivudine 1182 Sisomicin 227 Cefuroxime 706 Lansoprazole 1183 S-methoprene 228 Celecoxib 707 Lapatinib 1184 Sodium arsanilate 229 Cellulase 708 Lasalocid sodium 1185 Sodium bentonite 230 Cephalexin 709 L-asparaginase 1186 Sodium bicarbonate 231 Cephalonium dihydrate 710 Latamoxef 1187 Sodium borate 232 Cephapirin 711 Latanoprost 1188 Sodium cacodylate 233 Cephradine 712 Lauryl pyridinium chloride 1189 Sodium calcium edetate 234 Cetirizine 713 Lavender oil 1190 Sodium chloride (0.9%, 7.2%) 235 Cetrimide 714 L-cysteine 1191 Sodium cromoglycate 236 Charcoal activated 715 L-deprenyl see Selegiline 1192 Sodium dodecahydrate 237 Chloral hydrate 716 Lead acetate 1193 Sodium hyaluronate 238 Chlorambucil 717 Lecithin 1194 Sodium iodide 239 Chloramine 718 Leflunomide 1195 Sodium lauryl sulfate 240 Chloramphenicol 719 Lepirudin 1196 Sodium pentosan polysulfate 241 Chlordiazepoxide 720 Letrozole 1197 Sodium phosphate enemas 242 Chlorfenvinphos 721 Leucine-l 1198 Sodium polystyrene sulfonate 243 Chlorhexidine 722 Leucovorin 1199 Sodium propionate 244 Chloride (sodium, 723 Leuprolide (leuprorelin) 1200 Sodium salicylate potassium, ammonium) 245 Chlorophene 724 Levamisole 1201 Sodium salt of linear alkylbenzene sulonate 246 Chlorothiazide 725 Levetiracetam 1202 Sodium stibogluconate

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT (antimony sodium gluconate) 247 Chloroxylenol 726 Levobunolol 1203 Sodium sulfate 248 Chlorpheniramine 727 Levobupivacaine 1204 Sodium thiosulfate 249 Chlorpromazine 728 Levodopa 1205 Somatostatin 250 Chlorpropamide 729 Levofloxacin 1206 Somatotropin 251 Chlorpyrifos 730 Levothyroxine 1207 Sorbitol 252 Chlortetracycline 731 Lidocaine (lignocaine) 1208 Sotalol 253 Chlorthiazide 732 Lime sulfur 1209 Soybean oil 254 Cholecalciferol 733 Linalool oil 1210 Spectinomycin 255 Choline 734 Lincomycin 1211 Spinosad 256 Chondroitin sulfate (incl 735 Linezolid 1212 Spiramycin sodium chondroitin sulfate) 257 Chromium 736 Linoleic acid 1213 Spironolactone 258 Ciclosporin 737 Linolenic acid 1214 Stanozolol 259 Cidofovir 738 Liothyronine 1215 Staphage lysate (Staphylococcal phage lysate) 260 Cimetidine 739 Lipase (incl lipase AP6 / 1216 Staphoid AB fungal (FCC iii) 261 Cinchocaine hydrochloride 740 Liquorice 1217 Sterculia 262 Cinchophen 741 Lisinopril 1218 Stilboestrol 263 Ciprofloxacin 742 Lithium 1219 Stockholm tar 264 Cisapride 743 Lobaplatin 1220 Streptococcus salivarius subspecies thermophilus 265 Cisplatin 744 Lodoxamine 1221 Streptokinase 266 Citalopram 745 Lomustine (CCNU) 1222 Streptomycin 267 Citrate salts 746 Loperamide 1223 Streptozocin 268 Citrate-phosphate- 747 Loratadine 1224 Succimer dextrose-adenine 269 Citric acid 748 Lorazepam 1225 Succinylcholine

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 270 Citronella oil 749 Lorcainide 1226 Sucralfate 271 Cladribine 750 L-ornithine alpha- 1227 Sucrose ketoglutarate 272 Clarithromycin 751 Lorsartan 1228 Sufentanil 273 Clavulanic acid 752 Loteprednol etabonate 1229 Sulbactam 274 Clemastine fumarate 753 L-thyroxine 1230 Sulfabromomethazine 275 Clenbuterol 754 L-tri-iodothyronine 1231 Sulfacetamide sodium 276 Clindamycin 755 L-tryptophan 1232 Sulfachlorpyridazine sodium 277 Clofazimine 756 Lufenuron 1233 Sulfadiazine 278 Clomifene acetate 757 Luteinizing hormone 1234 Sulfadimethoxine 279 Clomipramine 758 Luxabendazole 1235 Sulfadimidine (sulfamethazine) 280 Clonazepam 759 Lysine 1236 Sulfadoxine 281 Clonidine 760 Maduramicin ammonium 1237 Sulfamerazine 282 Clopidogrel 761 Mafenide hydrochloride 1238 Sulfamethoxazole 283 Clopidol 762 Magnesium (incl magnesium 1239 Sulfaquinoxaline alloy / aspartate / carbonate / chloride / gluconate / glycerophosphate / hydrolysed protein chelate / hydroxide / hypophosphite / oxide) 284 Cloprostenol 763 Magnesium (parenteral) 1240 Sulfasalazine 285 Clorazepate 764 Magnesium / aluminium 1241 Sulfate (incl magnesium / antacids sodium / thiosulfate) 286 Clorsulon 765 Magnesium citrate 1242 Sulfathiazole 287 Closantel 766 Magnesium fluorosilicate 1243 Sulfatroxazole 288 Clotrimazole 767 Magnesium hydroxide 1244 Sulfonylureas 289 Clove oil 768 Magnesium sulphate 1245 Sulfur (incl sublimed, precipitated) 290 Cloxacillin 769 Malachite green 1246 Suprofen

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 291 Clozapine 770 Maldison 1247 Suxamethonium 292 Coal tar see TAR 771 Malic acid 1248 Synthetic analogue of f3 fraction feline facial pheromone 293 Cobalt [incl disodium 772 Maltase 700 1249 Synthetic porcine GHRH chelate / carbonate / encoding plasmid chloride / gluconate / oxide / sulfate] 294 Cocaine 773 Manganese (incl chloride / 1250 Tacrolimus EDTA / gluconate / glycerophosphate / oxide / sulphate)+A640 295 Cod liver oil 774 Mannitol 1251 Tamoxifen acetate 296 Codeine 775 Marbofloxacin 1252 Tannic acid 297 Colchicine 776 Maropitant 1253 Tar (incl coal / pine / acids / tar BP88) 298 Colloidal oatmeal 777 Mebendazole 1254 Taurine 299 Colony stimulating factor 778 Mecamylamine 1255 Tazobactam, piperacillin 300 Copper (incl calcium 779 Mechlorethamine 1256 Tea tree oil copper edetate / carbonate / chloride dihydrate / cupric oxide needles / cupric salicylate / gluconate / glycinate / nitrate trihydrate / oxide / sulphate 301 Copper indometacin 780 Meclizine HCl 1257 Tegaserod 302 Corticotropin (ACTH) 781 Meclofenamic acid 1258 Teicoplanin 303 Cortisone acetate 782 Medetomidine 1259 Telmisartan 304 Cosyntropin 783 Medium chain triglycerides 1260 Temephos (MCT) 305 Cresol 784 Medroxyprogesterone 1261 Teniposide acetate 306 Cresylic acid 785 Megestrol acetate 1262 Tepoxalin

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 307 Cromolyn sodium 786 Meglumine antimonate 1263 Terbinafine 308 Crospovidone 787 Melaleuca oil 1264 Terbutaline 309 Crotamiton 788 Melarsomine hydrochloride 1265 Terfenadine 310 Curare 789 Melatonin 1266 Testosterone (incl cypionate / decanoate / enanthate / hexahydrobenzoate / isocaproate / phenylpropionate / propionate) 311 Cyanocobalamin 790 Melengestrol acetate (MGA) 1267 Tetracaine 312 Cyclopentolate 791 Meloxicam 1268 Tetrachlorvinphos 313 Cyclophosphamide 792 Melphalan 1269 Tetracycline 314 Cycloserine 793 Menthol 1270 Thenium closylate 315 Cyclosporin see ciclosporin 794 Meperidine (pethidine) 1271 Theobromine 316 Cypermethrin 795 Mepivacaine 1272 Theophylline and aminophylline 317 Cyproheptadine 796 Mercaptopurine 1273 Thiacetarsamide sodium 318 Cyromazine 797 Meropenem 1274 Thiamazole 319 Cysteine 798 Mesalamine 1275 Thiamine (see vitamin B1) 320 Cythioate 799 Metacresolsulfonic acid- 1276 Thiamphenicol formaldehyde 321 Cytosine arabinoside 800 Metaflumizone 1277 Thiamylal (cytarabine) 322 Dacarbazine 801 Metaprolol 1278 Thiazide 323 Dactinomycin (see 802 Metaproterenol 1279 Thioctic acid Actinomycin D) 324 Dalteparin 803 Metaraminol 1280 Thioguanine 325 Danazol 804 Metergoline 1281 Thiomersal 326 Danofloxacin 805 Metformin 1282 Thiopental (Thiopentone) 327 Dantrolene 806 Methacholine 1283 Thiophanate 328 Dapsone 807 Methadone 1284 Thioridazine

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 329 Darbepoetin alfa 808 Methandriol dipropionate 1285 Thiostrepton 330 Dasatinib 809 Methantheline 1286 Thiotepa 331 Daunorubicin 810 Methazolamide 1287 Thiouracil 332 Decamethonium 811 Methenamine mandelate 1288 Thiourea 333 Decoquinate 812 Methicillin 1289 Threonine-l 334 Deferoxamine mesylate 813 Methimazole 1290 Thymol 335 Delmadinone acetate 814 Methionine (incl n-acetyl-dl- 1291 Thyroid extract methionine) 336 Deltamethrin 815 Methocarbamol 1292 Thyroid hormone 337 Dembrexine hydrochloride 816 Methohexital sodium 1293 Thyroid releasing hormone monohydrate 338 Demecarium 817 Methoprene (incl (S)- 1294 Thyrotropin methoprene) 339 Denatonium benzoate 818 Methotrexate 1295 Thyroxine (oroxine) 340 Deoxycortisosterone 819 Methoxamine 1296 Tiabendazole (thiabendazole) pivalate (DOCP) 341 Deoxycortone (incl acetate 820 Methoxyflurane 1297 Tiamulin / pivalate) 342 Deracoxib 821 Methscopolamine 1298 Ticarcillin 343 Desethylamiodarone 822 Methyl benzoquate 1299 Ticarcillin-clavulanate 344 Desflurane 823 Methyl salicylate 1300 Ticlopidine 345 Desipramine 824 Methyl sulfonyl methane 1301 Tigecycline 346 Desipramine 825 Methylated spirits 1302 Tiletamine 347 Desloratidine 826 Methylatropine 1303 Tilmicosin 348 Deslorelin 827 Methylene blue 1304 Tiludronate 349 Desmopressin acetate 828 Methylergometrine 1305 Timolol 350 Desoxycorticosterone 829 Methylnaltrexone 1306 Tincture gentian pivalate 351 Detomidine 830 Methylphenidate 1307 Tincture ginger 352 Dexametasone 831 Methylprednisolone 1308 Tincture squill

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT (dexamethasone) 353 Dexamfetamine 832 Methylsergide 1309 Tinidazole 354 Dexchlorpheniramine 833 Methyltestosterone 1310 Tiopronin 355 Dexmetomidine 834 Meticillin 1311 Tirofiban 356 Dexpantherol 835 Metipranolol 1312 Tobramycin 357 Dexrazoxane 836 Metoclopramide 1313 Tocainide 358 Dextran 70 837 Metocurine 1314 Toceranib 359 Dextromethorphan 838 Metomidate 1315 Tolazoline 360 Dextrose 839 Metoprolol 1316 Tolfenamic acid 361 Dextrose solution 840 Metronidazole 1317 Toltrazuril 362 Diamphenethide 841 Metyrapone 1318 Toluene 363 Diaveridine 842 Mexiletine 1319 Tolvaptan 364 Diazepam 843 Mezlocillin 1320 Topiramate 365 Diazinon 844 MGK 264 (N-Octyl 1321 Torsemide bicycloheptene dicarboximide) 366 Diazoxide 845 MGK 326 (Di-N- 1322 Tramadol propylisocinchomeronate) 367 Dibekacin 846 Mibolerone 1323 Trandolapril 368 Dibenamine 847 Micafungin 1324 Tranexamic acid 369 Dibozane 848 Miconazole 1325 Trans-4-((3,5-dibromo-2- hydroxybenzyl)-amino) cyclohexanol hydrochloride see Dembrexine 370 Dibutyl phthalate 849 Midazolam 1326 Travaprost 371 Dichlorobenzene 850 Mifepristone 1327 Trazadone 372 Dichloroisoproterenol 851 Milbemycin oxime 1328 Trenbolone acetate 373 Dichlorophen 852 Milrinone and amrinone 1329 Treprostinil 374 Dichlorphenamide 853 Mineral oil 1330 Tretinoin

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 375 Dichlorvos 854 Minocycline 1331 Triamcinolone acetonide 376 Diclazuril 855 Mirtazapine 1332 Triamterene 377 Diclofenac 856 Misoprostol 1333 Triazolam 378 Dicloxacillin 857 Mithramycin see Plicamycin 1334 Tricaine methane sulfonate (MS-222) 379 Dicoumarol 858 Mitomycin C 1335 Trichlorfon 380 Dicyclanil 859 Mitotane 1336 Trichlormethiazide 381 Diethylcarbamazine citrate 860 Mivacurium 1337 Triclabendazole 382 Diethylstilbestrol (DES) 861 Mixelitine 1338 Triclosan 383 Diethyltoluamide (DEET) 862 Mixoxantrone (mitozantrone) 1339 Trientine 384 Difloxacin 863 Molybdenum 1340 Triflumuron 385 Diflubenzuron 864 Mometasone furoate 1341 Trifluoperazine monohydrate 386 Digestive enzymes (with 865 Monensin sodium 1342 Triflupromazine lipase, protease & amylase) 387 Digitalis 866 Monepantel 1343 Trifluridine 388 Digitoxin 867 Monosulfiram 1344 Trifluridine 389 Digoxin 868 Montelukast 1345 Tri-iodothyronine 390 Dihydrocodeine tartrate 869 Montmorillonite 1346 Trilostane 391 Dihydrostreptomycin 870 Morantel 1347 Trimeprazine tartrate 392 Dihydrotachysterol 871 Morphine 1348 Trimethidium 393 Di-isopropylamine 872 Mosapride 1349 Trimethobenzamide dichloroacetate 394 Diltiazem 873 Moxidectin 1350 Trimethoprim (+ sulfadiazine, + sulfamethoxazole) 395 Dimenhydrinate 874 Moxifloxacin 1351 Trimetrexate 396 Dimercaprol 875 Mupirocin 1352 Tripelennamine HCl 397 Dimethyl sulfoxide 876 Muscarine 1353 Tris = trometamol = tromethamine 398 Dimethyl sulphone 877 Mycobacterium cell wall 1354 TRIS-EDTA SOLUTION (TBE

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT (Methylsulfonylmethane fraction OR TAE?) (MSM)) 399 Dimethylglycine 878 Mycophenolate mofetil 1355 Troglitazone hydrochloride 400 Dimetridazole 879 Myo-inositol-hexaphosphate 1356 Tropicamide phosphohydrolase 401 Diminazene 880 Nalbuphine 1357 Tropisetron 402 Dinitolmide (3,5-dinitro-o- 881 Nalmefene 1358 Trypan blue toluamide) 403 Dinoprost tromethamine 882 Nalorphine 1359 Trypsin 404 Di-N- 883 Naloxone 1360 Tryptophan propylisocinchomeronate see MGK 326 405 Diphenhydramine 884 Naltrexone 1361 Tulathromycin 406 Diphenoxylate 885 Nandrolone (incl cypionate / 1362 Turpentine oil decanoate / laurate / phenylpropionate) 407 Diphenylhydantoin 886 Naphthalene 1363 Tylosin (incl tartrate / phosphate) 408 Diphenylmethane 887 Naphthalophos 1364 Undecenoic acid 409 Diprenorphine 888 Naproxen 1365 Urea 410 Dipyridamole 889 Narasin 1366 Urea glycerine chitosanide 411 Dipyrone 890 Natamycin 1367 Ureidopenicillin 412 Dirithromycin 891 N-butyl chloride 1368 Uridine triphosphate 413 Dirlotapide 892 Neatsfoot oil 1369 Urofollitropin 414 Disophenol 893 Nefazodone 1370 Urogastrone epidermal growth factor (uro-EGF) 415 Disopyramide 894 Nemadectin 1371 Ursodeoxycholic acid (ursodiol) 416 Dithiazanine 895 Neomycin 1372 Valacyclovir 417 D-limonene 896 Neostigmine 1373 Valine – l 418 Dobutamine 897 Nepafenac 1374 Valproic acid

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 419 Docetaxel 898 Netilmicin 1375 Valsartan 420 Docosahexaenoic acid 899 Niacinamide 1376 Vanadium 421 Docusate sodium (dioctyl 900 Niaddk-ofsh-17 standard 1377 Vancomycin sodium sulfosuccinate) 422 Dolasetron 901 Nicarbazin 1378 Vasopressin 423 Domperidone 902 Nicergoline 1379 Vecuronium bromide 424 Dopamine 903 Niclosamide 1380 Vedaprofen 425 Doramectin 904 Nicotine 1381 Verapamil 426 Dorzolamide 905 Nicotinic acid 1382 Vidarabine 427 Doxapram 906 Nifedipine 1383 Vinblastine 428 Doxepin 907 Nifurtimox 1384 Vincristine 429 Doxorubicin 908 Nikkomycin Z 1385 Vinorelbine 430 Doxycycline 909 Nitazoxanide 1386 Virginiamycin 431 Dozolamide 910 Nitenpyram 1387 VIRKON 432 Dronabinol 911 Nitrofurantoin 1388 Vitamin A 433 Droperidol 912 Nitrofurazone 1389 Vitamin A (retinyl acetate) 434 Drotrecogin alfa 913 Nitroglycerin 1390 Vitamin B1 = thiamine 435 D-tubocurarine 914 Nitroprusside 1391 Vitamin B12 = cyanocobalamin 436 eCG (equine chorionic 915 Nitroscanate 1392 Vitamin B15 (pangamic acid) gonadotropin) (PMSG) 437 Echothiophate iodide 916 Nitrous oxide 1393 Vitamin B2 (riboflavin) 438 Econazole 917 Nitroxynil as eglumine 1394 Vitamin B3 = nicotinamide 439 Edatrexate 918 Nizatidine 1395 Vitamin B5 = pantothenic acid- d 440 Edetate disodium see 919 N-Octyl bicycloheptene 1396 Vitamin B6 (pyridoxine EDTA dicarboximide see MGK 264 hydrochloride) 441 Edrophonium chloride 920 Nonivamide 1397 Vitamin C = ascorbic acid 442 EDTA 921 Nonoxynol-9 1398 Vitamin D 443 Eicosapentaenoic acid 922 Norandrostenolone laurate 1399 Vitamin D3 = cholecalciferol

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT 444 Eledoisin 923 Norepinephrine 1400 Vitamin E (incl dl-alpha (noradrenaline) tocopheryl acetate) 445 Eltenac 924 Norethandrolone 1401 Vitamin K1 = phytomenadione 446 Embutramide 925 Norfloxacin 1402 Vitamin K3 = menadione 447 Emodepside 926 Norgestomet 1403 Vitamin M = folic acid = PGA 448 Enalapril 927 Nortriptyline 1404 Voriconazole 449 Encainide 928 Novobiocin 1405 Warfarin 450 Enflurane 929 Nystatin 1406 White soft paraffin 451 Enilconazole 930 Ocreotide 1407 Witch hazel 452 Enoxaparin 931 Octyl methoxycinnamate 1408 Wood oil 453 Enrofloxacin 932 Oestradiol (incl oestradiol 17 1409 Wormwood oil beta / benzoate / cypionate / dipropionate / valerate) 454 Enterococcus faecium (incl 933 Oestriol 1410 Xenon live culutre / fermentation product) 455 Ephedrine 934 OESTROGEN 1411 Xylanase (incl from T. longibrachiatum + T. koningii / endo-1,4-b-xylanase (IUB no. 3.2.1.8)) 456 Epinephrine (adrenaline) 935 Ofloxacin 1412 Xylazine 457 Epipodophyllotoxins 936 Olaquindox 1413 Yohimbine 458 Epirubicin 937 Oleandomycin 1414 Yucca extract 459 Eplerenone 938 Olmesartan 1415 Zafirlukast 460 Epoitin alfa 939 Olopatadine 1416 Zaleplon 461 Epoprostenol 940 Olsalazine sodium 1417 Zeolite 462 Eprinomectin 941 Omeprazole 1418 Zeranol 463 Eprosartan 942 Ondansetron 1419 Zeta-cypermethrin 464 Epsiprantel 943 Orbifloxacin 1420 Zidovudine (AZT) 465 Eptifibatide 944 Orciprenaline 1421 Zileuton

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# ACTIVE CONSTITUENT # ACTIVE CONSTITUENT # ACTIVE CONSTITUENT (metaproterenol) 466 Ergocalciferol 945 Ormetoprim 1422 Zinc (incl zinc disodium edetate (sulfadimethoxine) chelate / methionine oxide / pyrithione / sulfate) 467 Ergotamine 946 Orthophenylphenol 1423 Zolazepam 468 Erlotinib 947 Oseltamivir phosphate 1424 Zolpidem 469 Ertapenem 948 Oxacillin 1425 Zonisamide 470 Erythromycin 949 Oxaliplatin 471 Erythropoietin 950 Oxantel 472 Escitalopram 951 Oxazepam 473 Esmolol 952 Oxfendazole 474 Esomrpramazole 953 Oxibendazole 475 Essential fatty acids 954 Oxpentifylline 476 Esterified starches 955 Oxtriphylline (hetastarch, hydroxyethyl starch, pentastarch) 477 Eszopiclone 956 Oxybenzone 478 ETAMIPHYLLINE

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Appendix 9: Case development outline

VETERINARY CLINICAL PHARMACOLOGY NETWORK CASE STUDY PROGRAMME

SUBJECT AREA CASE STUDY CASE STUDY DESCRIPTION 1 DESCRIPTION 2 (target species, learning (target species, objective) learning objective) Select one or multiple Select one or multiple categories categories Section A. Principles of Pharmacology Veterinary Pharmacology: An Introduction to the Discipline Pharmacokinetics Absorption, Distribution, Metabolism, and Elimination Mechanisms of Drug Action and Pharmacokinetics/Pharmacodynamics Integration in Dosage Regimen Optimization for Veterinary Medicine Section B. Drugs Acting on the Autonomic Nervous System. Introduction to Neurohumoral Transmission and the Autonomic Nervous System Adrenergic Agonists and Antagonists Cholinergic Pharmacology: Autonomic Drugs Section C. Anaesthetics and Analgesics Introduction to Drugs Acting on the Central Nervous System and Principles of Anaesthesiology Neuromuscular Blocking Agents Inhalation Anaesthetics Injectable Anaesthetic Agents Opioid Analgesic Drugs Sedative Agents: Tranquilizers, Alpha-2 Agonists, & Related Agents Local Anaesthetics Euthanasia Agents Section D. Autacoids and Antiinflamatory Drugs

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SUBJECT AREA CASE STUDY CASE STUDY DESCRIPTION 1 DESCRIPTION 2 (target species, learning (target species, objective) learning objective) Select one or multiple Select one or multiple categories categories Histamine, Serotonin, and Their Antagonists Peptides: Angiotensin and Kinins Prostaglandins, Related Factors, and Cytokines NSAIDs Analgesic, Antiinflammatory, Antipyretic Drugs Select Anticonvulsant Drugs Drugs Affecting Animal Behavior Section E. Drugs Acting on the Cardiovascular System Digitalis, Positive Inotropes, and Vasodilators Antiarrhythmic Agents Section F. Drugs Affecting Renal Function and Fluid-Electrolyte Balance Principles of Acid-Base Balance: Fluid and Electrolyte Therapy Diuretics Section G. Drugs Acting on Blood and Blood Elements Hemostatic and Anticoagulant Drugs Section I. Endocrine Pharmacology Hypothalamic and Pituitary Hormones Hormones Affecting Reproduction Thyroid Hormones and Antithyroid Drugs Glucocorticoids, Mineralocorticoids, and Adrenolytic Drugs Drugs Influencing Glucose Metabolism Section I. Chemotherapy of Microbial Diseases Mastitis, dairy cattle. Considerations in selection of a treatment of mastitis Antiseptics and Disinfectants

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SUBJECT AREA CASE STUDY CASE STUDY DESCRIPTION 1 DESCRIPTION 2 (target species, learning (target species, objective) learning objective) Select one or multiple Select one or multiple categories categories Sulfonamides and Potentiated Sulfonamides

β-Lactam Antibiotics: Penicillins, Cephalosporins, and Select Related Drugs Tetracycline Antibiotics Select Aminoglycoside Antibiotics Select Chloramphenicol and Derivatives, Macrolides, Select Lincosamides, and Miscellaneous Antimicrobials Fluoroquinolone Antimicrobial Drugs Select Antifungal and Antiviral Drugs Section J. Chemotherapy of Parasitic Diseases Gastrointestinal nematodosis, sheep: Considerations in selection of a treatment for sheep Antinematodal Drugs Select Anticestodal and Antitrematodal Drugs Select Macrocyclic Lactones: Endectocide Compounds Select Antiprotozoan Drugs Ectoparasiticides Section K. Speciality Areas of Pharmacology Chemotherapy of Neoplastic Diseases Immunosuppressive Drugs and Cyclosporine Drugs Affecting Gastrointestinal Function Dermatopharmacology: Drugs Acting Locally on the Skin Drugs that Affect the Respiratory System Pharmacogenomics Therapeutic Drug Monitoring Considerations for Treating Minor Food-Producing

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SUBJECT AREA CASE STUDY CASE STUDY DESCRIPTION 1 DESCRIPTION 2 (target species, learning (target species, objective) learning objective) Select one or multiple Select one or multiple categories categories Animals with Veterinary Pharmaceuticals Zoological Pharmacology Section L. Regulatory Considerations. Legal Control of Veterinary Drugs Drug Approval Process Compounding / Veterinary Pharmacy Regulation of Drug and Medication Use in Performance Animals Adverse Drug Reactions Dosage Forms Evidence-Based Veterinary Medicine Chemical Residues in Tissues of Food Animals (meat, offal, milk, eggs, honey) Section M. Toxicology Pesticides Heavy metals Natural toxins (phytotoxins, phycotoxins, mycotoxins etc) Antidotes OTHER SUGGESTED TOPICS Section N. Vaccines

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Appendix 10: International symposium

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