Veterinary Pharmacy and the Role of the

Justin McDowell RPh, FACVP Pharmacy Manager IVG Veterinary Compounding Pharmacy

Patrick M. Welch, DVM, MBA, DACVO Medical Director, Massachusetts Veterinary Referral Hospital Pharmacy Director, IVG Veterinary Compounding Pharmacy Director of Learning & Development, IVG Hospitals Objectives for Today

• Describe the skills and training needed for to dispense medication to veterinary patients.

• List common concerns for pharmacists who dispense veterinary products.

• Recognize the differences between human products and animal products.

• Become generally familiar with the veterinary industry

• Identify common human medications that pose risks to animals.

• Counsel pet owners on the importance of compliance with medication therapy for their pets. Skills and Training

Curriculum  Current  Future

Drug Information  What resources to use  What to do if veterinary drug information is not available  Reporting adverse reactions Skills and Training

Current Curriculum • Only about 25 schools of pharmacy offer some sort of class involving veterinary pharmacy.

Future Curriculum • Begin in the classroom, residency, and rotations. Skills and Training

Expand all classroom and CE lectures to include  Pharmacotherapy versus medications - Metabolic variation within and across major species - Toxicology - Anatomy - Normal V.S.  Psychosocial aspects of pet ownership  Socioeconomic aspects of pet ownership  Appreciation for versus human practice Aging In Our Pet Population

Large lifespan variability in dogs. • Small breeds 12-16 yrs. • Large breeds, 10-12 yrs. • Giant breeds, 7-8 yrs.

Formula for cats Species Variability • Always contact the prescribing veterinarian with questions or concerns • Do not substitute without checking • Huge species variability Skills and Training Skills and Training

Must be familiar with basic companion animal pharmacology and pharmacokinetics

 Dog (Tramadol dosing 5- 10mg/kg Q6-8H)  Cat (Tramadol 1-2mg/kg Q12H)  Other species (Depending on the location of your pharmacy) Skills and Training

What is the best resource to verify if a drug is approved for veterinary use?

• FDA Green Book

Can you report veterinary ADE’s?

• Call the FDA’s Center for : 1-888-FDA-VETS Skills and Training

“Six Rights” apply

• the right patient • the right drug • the right dose • the right route • the right time • The right labels!!! Veterinary Training

7-8 years for licensure 12 years for specialization and Board Certification General Practice Veterinarian Specialty Veterinarian

Veterinary Rotating Board Undergraduate Residency school Internship Certification

• 3-4 years • 4 years • 1 year • 3 years • Case logs • Pre-vet program • 2 classroom • Optional • Specialty training • Publication • 1 mixed • Rotating services • Progressive • Rigorous exam • 1 clinical responsibility Veterinary Specialization

Diplomate, American College Veterinary Technician of Veterinary (DACV…) Specialty (VTS) in …

• Anesthesia • Preventive Medicine • Dentistry • Behavior • Radiology • Anesthesia • Dentistry • Surgery • Internal Medicine • Dermatology • Sports Medicine • Emergency / Critical Care • Emergency / Critical Care • • Behavior • Internal Medicine • Toxicology • Zoological Medicine • Lab Animal Med • Veterinary Practitioners • Equine • Microbiology • Zoological Medicine • Surgery • Nutrition • Clinical Practice • Ophthalmology • Nutrition • Pathology • Clinical Pathology • Pharmacology • Poultry Medicine Veterinary Team

Veterinary • Veterinarian Team • Technician • Client Care

General Specialist Practitioner Pet Owner Pet Sample Prescriptions

22 pound canine Sample Prescriptions

16 pound canine Acute Canine Glaucoma (pectinate ligament dysplasia) Case Study - Glaucoma

Trans-scleral cyclo-photo coagulation + Medical Management Case Study - Glaucoma

Medical Management of Canine Glaucoma • 1 % Pred Acetate drops: 1 drop OD QID • Dorzolamide: 1 drop OD TID • 0.5% Timolol maleate: 1 drop OU BID • Latanoprost: 1 drop OD SID

• Rimadyl (Carprofen): 50 mg PO BID • Tramadol: 50 mg PO BID Common Concerns

• Ultimate goal of the Pharmacist is to protect all patients.

• Consider owner/caregivers medications/allergies.  IE: Dog needs a sulfonamide and owner is allergic.

• Protect all members of the household.  Some animal products are toxic, proper disposal of pesticides, chemotherapy, and other hazardous drugs.  Chloramphenicol. Exposure, even a trace amount one time has been reported to cause irreversible aplastic anemia in humans. Common Concerns

• Pharmacists should be competent in educating the client on proper methods of dosing animals. (Dog, cat, guinea pig).

• How to handle an animal that spits out or “cheeks” a dose or vomits it up.

• Pharmacists should be a patient advocate…..for all patients and a partner with the veterinarian.  Monthly heartworm and flea/tick products can be lifesavers. • Medication storage conditions. What about DEA and NPI?

• All have a DEA number  Use as identification number can be confusing.  Veterinarians are exempt from Mass PMP reporting.  Veterinarians are not eligible for NPI number. Extralabel Drug Use

• Valid Veterinarian – Client – Patient relationship • Medical need • Labeling & record keeping requirements • Common for both Human and Veterinary drugs • Creates a need for compounding Quick Quiz

1)Flea and tick products used for a 10 lb. Chihuahua and a 10 lb. cat are the same. TRUE / FALSE

2) Prednisone and Prednisolone are equivalent in cats and dogs. TRUE / FALSE Prescription Errors

Oregon – VMA survey of 525 clinics.

• 35 percent reported the pharmacy changed the prescribed dosage or medication without their authorization.

• 17 percent reported adverse events as a result of these changes.

• Types of errors: incorrect substitution (Dog with immune- mediated disease was dispensed azithromycin but prescribed azathioprine)

• Types of errors: Dosage change (Dog with epilepsy prescribed 15mg of phenobarbital BID but the RPh recommended half dosages. Problem discovered, but euthanasia was outcome. Prescription Errors

Some reasons why errors occur:

1. Unclear abbreviations (SID=QD not QID or BID) 2. EOD = Every other day 3. Unfamiliarity with veterinary dosing/medications 4. U = Units not 0 (zero) 5. IU = International Units – not IV (intravenous) 6. mcg or µg = microgram – not mg 7. TIW = three times weekly – not TID (three times daily) 8. QHS = at bedtime – not every hour Products: Human vs. Veterinary

Prescription items made for humans. • Diastat, APAP, Enalapril, atenolol, most ophthalmics

Prescription items made for animals. • Recuvyra (fentanyl), Clavamox, Rimadyl (carprofen), Baytril (enrofloxacin), Salix (furosemide) Products: Human vs. Veterinary

• Keep a separate inventory

• Have species specific counting trays and tablet cutters

• Veterinary generics are on the rise.

• State imposed fees. (Taxes) Case Study – Feline Conjunctivitis

FHV- (Feline Herpes Virus) • Ubiquitous in feline population – 80% become latently infected • Direct viral cytopathic effects on conjunctival and corneal epithelium • Recrudescence / Shedding due to several factors: • Stress • CORTICOSTEROIDS Case Study – Feline Conjunctivitis Medical Management • Topical • Trifluradine • Commercial option • Idoxuradine • Compounded • Cidofovir • Decreased frequency of admin • Erythromycin • Broad spectrum antibiotic • Why not TAB ointment? • Oral • Famciclovir • L-lysine • Interferon-α Quick Quiz

1)Which of the following is safe to use as a treat for a dog?  Grapes  Carrots  Onions 2) Sugar free chewing gum is toxic to pets. TRUE / FALSE Toxic Human Medications

NSAIDs • NSAIDs like ibuprofen or naproxen are the most common cause of pet poisoning in small animals. • Cats are particularly sensitive, and can cause serious problems even in minimal doses. • GI ulceration and perforation, renal damage most common. • Risk of chewable pills for veterinary forms. Toxic Human Medications

Acetaminophen • Cats are especially sensitive to acetaminophen, which can damage red blood cells and interfere with their ability to transport oxygen. In dogs, it can cause liver damage and, at higher doses, red blood cell damage • Watch for combination products

Pseudoephedrine • Pseudoephedrine acts like a stimulant if accidentally ingested by pets. In cats and dogs, it causes elevated heart rates, blood pressure and body temperature as well as seizures Human Foods to Avoid Feeding Your Pets

Chocolate, Coffee, Caffeine • These products all contain substances called methylxanthines. • When ingested by animals, methylxanthines can cause vomiting and diarrhea, panting, excessive thirst and urination, hyperactivity, abnormal heart rhythm, tremors, seizures and even death. • Darker chocolate is more dangerous than milk chocolate. White chocolate has the lowest level of methylxanthines, while baking chocolate contains the highest. Human Foods to Avoid Feeding Your Pets

Avocado • The leaves, fruit, seeds and bark of avocados contain Persin (a fungicidal toxin), which can cause vomiting and diarrhea in dogs. • Birds and rodents are especially sensitive to avocado poisoning, and can develop congestion, difficulty breathing and fluid accumulation around the heart. Some ingestions may even be fatal

Alcohol • Alcoholic beverages and food products containing alcohol can cause vomiting, diarrhea, decreased coordination, central nervous system depression, difficulty breathing, tremors, abnormal blood acidity, coma and even death People Foods to Avoid Feeding Your Pets

Macadamia Nuts • Macadamia nuts are commonly used in many cookies and candies. However, they can cause problems for dogs. • These nuts have caused weakness, depression, vomiting, tremors and hyperthermia in dogs. Signs usually appear within 12 hours of ingestion and last approximately 12 to 48 hours.

Grapes & Raisins • Although the toxic substance within grapes and raisins is unknown, these fruits can cause kidney failure. • In pets who already have certain health problems, signs may be more dramatic. • Acute renal failure can occur after ingesting 3gms/kg of raisins or dry matter of grapes Human Foods to Avoid Feeding Your Pets

Xylitol • Xylitol is used as a sweetener in many products, including medications, gum and candy. Causes insulin release in most species, which can lead to liver failure. The increase in insulin leads to hypoglycemia. • Initial signs of toxicosis include vomiting, lethargy and loss of coordination. • Liver failure can occur within a few days

Onions & Garlic • All close members of the onion family (shallots, onions, garlic, scallions, etc.) contain compounds that can damage dogs’ red blood cells if ingested in sufficient quantities. • Affected dogs may seem weak or reluctant to move, or they may appear to tire easily after mild exercise. Their urine may be orange-tinged to dark red in color. Poison Control

ASPCA Animal Poison Control Center 1-888-426-4435 www.apcc.aspca.org A consultation fee may be applied to a credit card. Pet Poison HELPLINE 1- 800-213-6680 www.petpoisonhelpline.com A consultation fee may be applied to a credit card. Angell Poison Control Hotline 1-877-2ANGELL A consultation fee may be applied to a credit card Owner counseling • It is just as important to counsel pet owners on medication compliance as it is our human patients.

• Parasiticides (Frontline, K9 Advantx, Heartguard, etc….)  Controlled by EPA not FDA (if your company sells these products consider placing on a refill reminder.  Probably one of the most important things you can do to directly improve a pets health and well-being. Owner Counseling Owner Counseling Some people get really creative! Questions?

Please feel free to contact us!

Justin McDowell [email protected]

Patrick Welch [email protected] References

• The Role and Education of the Veterinary Pharmacist Am J Pharm Educ. 2009 February 19; 73(1): • www.aspca.org/pet-care/poison-control/people-foods.aspx • www.fda.gov/animalveterinary/safetyhealth/reportaproblem/ucm055305.htm • Plumb, D. (2013). Plumb’s Veterinary Drug Handbook, Online Edition. • Papich, M.G., Riviere, J.E. (2009) Veterinary Pharmacology & Therapeutics, Ninth Edition, Wiley • Wanamaker, B. P., Lockett Massey, K. (2009) Applied Pharmacology for Veterinary Technicians, Fourth Edition, Saunders – Elsevier • Allen Jr, L., (2012) The Art, Science, and Technology of Pharmaceutical Compounding, Fourth Edition, APhA • Krauss, H. (2003) Zoonoses: Infectious Diseases Transmissible from Animals to Humans, Amer Society for Microbiology • Kolb, G., Oregon Veterinary Medical Association. (2012). Veterinary Prescriptions & Retail Pharmacies Summary – Membership Survey • Trissel, L. (2012). Trissel’s Stability of Compounded Formulations, Fifth Edition, APhA