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Veterinary Transdermals Veterinary Pharmacy and the Role of the Pharmacist 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 pharmacists 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 veterinarian 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 Veterinary Medicine: 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 • Theriogenology • 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 Veterinarians 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
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