PRESCRIBING FOR BEHAVIOR: Three Levels: HOW DO YOU DECIDE? 1. Is patient/diagnosis likely to respond to medication? Christopher Pachel, 2. Maintenance/daily vs. Situational/event? DVM, DACVB, CABC Animal Behavior Clinic Portland, Oregon 3. Specific medication options 1 2 1 - Likely to respond to meds? 2 - Treatment focus: (Yes or No) (Maintenance vs. Situational) Diagnoses: Maintenance/daily Fear/Anxiety Triggers are frequent, unpredictable, unavoidable Onset of action from 1-3 to 4-6 weeks Impulsivity/Arousal “Steady state” effect Aggression (motivated by anxiety, impulsivity, etc.) Compulsive disorder Situational/event Urine marking Triggers are predictable, infrequent Adjunctive support Onset of action from 15 min to 1-2 hours In combination with: Rapid adjustment of doses within trial period Safety/management Short duration of action (potential for “scalloped” effect) Behavior modification 3 4 3 – Specific medication options Considerations Patient/Diagnosis likely Treatment focus? Specific options: Medications FDA approved to respond to medication? for use in dogs (NONE in cats) Maintenance Fluoxetine Paroxetine Clomicalm® (clomipramine) – Sertraline Clomipramine Separation anxiety Yes Reconcile ® (fluoxetine) – Situational/Event Trazodone Clonidine Separation anxiety Benzodiazepines (5) Anipryl® (selegiline) – CDS Acepromazine and PDH Other/Adjunctive Gabapentin No Buspirone Sileo® (dexmedotomidine) – Amitriptyline Noise aversion 5 6 1 Neurotransmitters / Intended Impact 3a – Favorite maintenance medications Patient/DiagnosisSSRI likely Treatment focus? Specific options: Amino acids: to respond to medication? Fluoxetine Fluoxetine Glutamate: excitatory Maintenance Paroxetine Paroxetine GABA: inhibitory Sertraline Sertraline Clomipramine Yes Situational/Event Trazodone Biogenic amines: Clonidine TCA Benzodiazepines (5) Serotonin (5HT) Acepromazine Clomipramine Other/Adjunctive Dopamine (DA) Gabapentin Buspirone Norepinephrine (NE) Amitriptyline 7 8 On to cases! Milo (13yr m/n Maine Coon) Primary concern: urination outside of box, spraying, aggression toward other cat (MK) Four cats total in home (two residents - Milo and Max, two new - MK and Murphy) Daily frequency of urine soiling, combination of horizontal and vertical Reliable use of boxes for defecation 9 10 Milo (13yr m/n Maine Coon) Milo (13yr m/n Maine Coon) Previous use of Feliway diffusers, minor impact on Dx: Urine marking (vertical +/- horizontal locations) frequency of soiling Toileting / Inappropriate elimination (horizontal locations) Multi-level home, unstable household routines (owner Intercat aggression travel schedule) Tx: Household mgmt. (separation when unsupervised, journal soiling Medical workup - no significant findings details, enzymatic cleaner, ongoing Feliway use) Increased availability of household resources Use of deterrents (foil, block access, etc.) - no Clicker training for litter box use impact on frequency Zylkene trial (reluctance to use medication initially) Improvement in frequency at 10-12 weeks, but ongoing soiling 11 12 2 Three Levels: “Milo” Fluoxetine 1. Is patient/diagnosis likely to respond to Generic/inexpensive medication? Lots of anecdotal experience within the profession Impulsivity/arousal as focus for treatment, also for fear/anxiety Available research (“dominance aggression”, urine 2. Maintenance/daily vs. Situational/event? marking, separation anxiety – as Reconcile) Negative impact on appetite Pro – resource guarding, competitive aggression, food related arousal 3. Specific medication options Con – anorexia, client perception 13 14 Paroxetine Sertraline Generic/inexpensive Not quite as inexpensive, but generally affordable Generally less of an impact on appetite than Smallest tablet size is 25mg (may require fluoxetine (similar indications) compounding for cats and small dogs) More of an anticholinergic profile than fluoxetine Social anxiety, less impact on arousal/impulsivity Helpful for patients with chronic/situational loose unless at higher end of dose range bowels, urinary incontinence Less likely to cause side effects (sedation, anorexia, Potential for dry mouth and/or constipation constipation, etc.) 15 16 Clomipramine / Clomicalm “Pebbles” (11 mos Chesapeake B.R.) Impact on both serotonin and norepinephrine Primary concern: aggression toward other dog My medication of choice when both (14yr m/n lab mix, Ben) over food impulsivity/arousal and anxiety impact is desired Onset ~6 months old, progressively worsening Significantly more expensive (intensity/frequency, speed of escalation) Generic/compounded, Clomicalm Deferential postures by Ben, lack of appropriate Anticholinergic side effect profile de-escalation by Pebbles Sedation not uncommon especially as getting started Superficial injuries to Ben (significant stress/fear) with treatment 17 18 3 “Pebbles” (11 mos Chesapeake B.R.) “Pebbles” (11 mos Chesapeake B.R.) No history of aggression at dog park or daycare Lack of response to interventions (walk away, call away, sweet talk, reprimand) Generally "inflexible", “Police Officer Pebbles" Solid obedience/manners training, moderately structured household 19 20 “Pebbles” (11 mos Chesapeake B.R.) Three Levels: “Pebbles” Dx: 1. Is patient/diagnosis likely to respond to Resource guarding / competitive aggression (relationship specific) medication? Generalized anxiety (mild, underlying influence on behavior) Tx: Leadership program 2. Maintenance/daily vs. Situational/event? Basket muzzle training "Feeling outnumbered" strategies (incl. “belle of the ball”) Proactive mgmt/avoidance of triggers, intervention strategies Body language awareness 3. Specific medication options Physical exercise 21 22 “Silas” (3yr m/n GSD) “Silas” (3yr m/n GSD) Primary concerns: fearful of people, objects, trees, Hypervigilant in public cars; aggressive toward some dogs Refuses food when overly aroused/stressed 18 months in home (10th home / 2 years) Defecates 4x/day, softer stools with daily stress Onset within 6 weeks of adoption (also with prior Attempts at "desensitization" border on "flooding“ owners) Walked 1-3 hours/day, 6 mile runs with owner Variable reaction to other dogs (n/r to "ballistic") 23 24 4 “Silas” (3yr m/n GSD) “Silas” (3yr m/n GSD) Dx: Fear based behaviors (worse on leash, neophobia) Generalized anxiety (hypervigilance, startle reactions) Territorial/protective behavior (minor, opportunity based) Breed specific patterns (GSD), Insufficient socialization (presumed) Tx: Shift in training style (limit of obedience/suppression) Behavior modification (relaxation, movement cues, DSCC to triggers) Proactive avoidance / recovery strategies / no rehearsal Body language awareness (threshold!) Phase out use of e-collar (as skill set improves) 25 26 Three Levels: “Silas” SSRI/TCA 1. Is patient/diagnosis likely to respond to Dosages (oral administration): medication? Canine Feline Fluoxetine (Prozac®) 1-2 mg/kg q24hr 0.5-1.0 mg/kg q24hr 2. Maintenance/daily vs. Situational/event? Paroxetine (Paxil®) 1-2 mg/kg q24hr 0.5-1.0 mg/kg q24hr (q12hr instead?) Sertraline (Zoloft®) 1-3 mg/kg q24hr 0.5 mg/kg q24hr (q12hr instead?) Clomipramine (Clomicalm®) 1-3 mg/kg q12hr 0.3-0.5 mg/kg q24hr 3. Specific medication options 27 28 “Mabel” (4yr female French bulldog) “Mabel” (4yr female French bulldog) Primary concerns: separation anxiety (from Steve), Able to be kenneled when home alone, no self fear of strangers, aggression toward owner (Ron) injury or environmental destruction Recently adopted, breeder from puppy mill Limited training (attempted classes, unable to make More likely to aggress toward Ron when resting on progress in class or at home) couch with Steve, otherwise fearful/avoidant of Ron Occasional soiling when at home with Ron (unable Snapping >>> biting (one bite with contact, no to get her outside vs. anxiety) injury) “Back injury” – no evidence of pain/discomfort 29 30 5 “Mabel” (4yr female French bulldog) Three Levels: “Mabel” Dx: 1. Is patient/diagnosis likely to respond to Fear based behaviors (impact of undersocialization) medication? Separation anxiety Resource guarding Tx: BMod (clicker training, sit, eye contact, hand targeting) 2. Maintenance/daily vs. Situational/event? Relationship building (awareness of body language, mark/reward engagement) Calm departures/greetings (Steve) Zylkene trial (reluctant to use medication) Insufficient response to treatment at 10-12 weeks 3. Specific medication options 31 32 "Riley" (5yr f/s Springer spaniel mix) "Riley" (5yr f/s Springer spaniel mix) Primary concerns: target of aggression by other Owners have limited training experience, slow to dog, unable to confine elsewhere in home, unable to acquire training skills train due to stress level Able to manage both dogs during normal daily Recently acquired by family, one other dog in home, routine, support needed for household gatherings Riley is target of competitive aggression (2-3 per year) Infrequent visitors to home, noises from household Short trial of fluoxetine, "zoned out", discontinued activity more likely to trigger arousal/barking than Previous use of alprazolam/acepromazine, is separation/isolation inconsistent response to combination 33 34 "Riley" (5yr f/s Springer spaniel mix) Three Levels: “Riley” Dx: 1. Is patient/diagnosis likely to respond to Separation anxiety (separation affects tolerance for other stressors) medication? Social/situational anxiety (affects response to training