Common Questions when Disclosures/Conflict of Interest Caring for Veterinary Patients in Community Pharmacy • Dr. Hogan declares no conflicts of interest, real or apparent, and Melissa Hogan, Pharm.D. no financial interests in any company, product or service mentioned in this program, including grants, employment, gifts, Associate Professor and Chair, stock holdings and honoraria. Department of Clinical and Administrative Sciences Roosevelt University College of Pharmacy Objectives Objectives Pharmacists Pharmacy Technicians At the conclusion of this program, the pharmacist will be able to: At the conclusion of this program, the pharmacy technician will be able to: • Discuss current issues in dispensing medications for pets • Understand current issues in dispensing medications for pets • Describe key points in the pharmacological management of • Recognize medications dispensed for dogs and cats with diabetes diabetes in dogs and cats, including the role of Vetsulin ® • Recognize medications dispensed for dogs and cats with heart • Describe key points in the pharmacological management of heart failure failure in dogs and cats, including the role of pimobendan (Vetmedin ®) • Name the benefits of drug administration aides for dogs and cats • Identify for a client on proper methods of drug administration in their dog or cat Benefits of pets for human health • Physical • Social Introduction • Psychological 5 REFERENCES http://www.cdc.gov/healthypets/health_benefits.htm http://newsinhealth.nih.gov/pdf/NIHNiH%20Feb09.pdf 1 What is new in Veterinary Pharmacy? Pharmacists’ • H.R. 3174 / S. 1200 Fairness to Pet Owners Act of 2015 FAQs • AVMA position about Pet Meds • FTC Letter • What is the problem? • What is the solution? References S. 1200 Fairness to Pet Owners Act. WWW.Govtrack.US Competition in the Pet Medication Industry. FTC Staff report. 8 May, 2015 Most Common Questions Managing Diabetes in • How long should a client use a vial of human insulin on a dog or cat? Dogs and Cats • What kind of dog receives Vetmedin (pimobendan)? • Do OTC pain relievers work for pets? • What are the best ways to administer medication to pets? 10 Diabetes in Dogs Pathophysiology • Prevalence 1 in 400 to 500 • Females (2x more likely than males) • Type 1, insulin-dependent diabetes • Age 8-12 years • Loss of beta cell function • Australian, Fox, Cairn and Yorkshire terriers; Standard and miniature Schnauzers, Miniature and toy poodles, Bichon Frise, Spitz, Samoyed, Lhasa Apso, beagle • Hypoinsulinemia • Impaired transport of serum glucose into cells • Accelerated hepatic gluconeogenesis and glycogenolysis Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3 rd ed. Missouri: Mosby 1998. Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3 rd ed. Missouri: Mosby 1998. 2 Diagnosis Goals of Therapy • Pre-diabetes • Blood glucose between 120 and 200 mg/dl • Maintain BG between 100 – 180 mg/dL • No signs when blood glucose above normal range, but below renal threshold • Normal range: 80-120 mg/dL • Avoid hypoglycemia • Renal threshold: 200 mg/dL • Avoid complications of hyperglycemia • Cataracts, blindness • Clinical diabetes • • UTI, respiratory and skin infections Fasting BG > 200 mg/dL • • Classic presentation (like humans) Chronic pancreatitis • Polyuria, polydipsia, polyphagia, lethargy • Ketoacidosis • If not noticed and treated: • Sudden blindness due to cataracts • Diabetic ketoacidosis Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3 rd ed. Missouri: Mosby 1998. Prognosis Nonpharmacological management • • Weight reduction if needed Client-dependent • Increased quantities of fiber • High mortality in first 6 months • Portion control • • Good survival after 6 months, can live over 5 years after diagnosis Regular exercise • Twice daily walk, recommend 30 minutes after meal Must maintain consistent daily diet and exercise Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Insulin • Intermediate-acting insulin, dosed BID. Other insulins • Start at 0.25 units/kg; average dose 0.5 units/kg. • Administer after meal • U-40 pork lente (Vetsulin) • Most similar to canine insulin • Bovine or Human PZI (protamine zinc insulin) • Duration of action ~ 12 hours • Not formally studied in dogs • Requires U40 syringes • Less expensive • Exp 42 days once open • Human insulin glargine (Lantus) • • Dosed BID in dogs U-100 Humulin N (NPH ) • • Duration of action <12 hr Exp 28 days once open • Exp 31 days once open Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F. Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F. Fracassi, et al. Use of insulin glargine in dogs with diabetes mellitus. Veterinary Record 2012; 170, 52 . Fracassi, et al. Use of insulin glargine in dogs with diabetes mellitus. Veterinary Record 2012; 170, 52. 3 Blood glucose monitoring Clinical Monitoring • Blood glucose • • Every 3 months Weekly for 4 weeks after initiation • • Exam and blood glucose curve Physical and eye exam • Adjust insulin • Blood glucose • Continue until controlled • Fructosamine (control over past 2-4 weeks, not affected by stress hyperglycemia) • Normal: 225-365 mmol/L • Long term home monitoring • Goal (DM): 350-400 mmol/L • Daily for clinical signs, food/water intake, insulin dose • Blood glucose curve if needed • Weekly body weight • Blood glucose two weeks after adjustment, monthly when stable • Every 6 months • Daily home monitoring ideal • Full lab workup: CBC, chem, electrolytes, U/A, urine culture Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215- 224F Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Background Diabetes in Cats • Pathophysiology • Prevalence • Type 2 diabetes mellitus • Cats: 1 in 200 • Insulin resistance with B cell dysfunction • Predominantly neutered males • May be reversible with rapid glycemic control • Age 8 – 13 years • Etiology • More common in Burmese cat • Obesity • Lack of activity • High carbohydrate diet Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA • Corticosteroids 2010; 46:215-224F Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3 rd ed. Missouri: Mosby 1998. Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3 rd ed. Missouri: Mosby 1998. Presentation Diagnosis • Subclinical • Rule out stress hypoglycemia • No clinical signs • Blood glucose 200-250 mg/dL • Glucose between 150 to 250 mg/dL • • No ketones Normal BG 70-150 mg/dL • • May be caused by stress Persists for a few hours to days • Clinical • NO insulin needed • Persistent BG >250 mg/dL • Fructosamine level necessary to rule out DM • Polyuria, polydipsia, polyphagia • Rule out hyperthyroidism • Impaired jumping, abnormal gait • • Cats > 7 years old Fructosamine • • Normal 190-365 umol/L Weight loss • Diagnostic of DM: 350-750 umol/L • Polyphagia Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215- 224F 4 Complications Treatment • Hypoglycemia • Goal • Peripheral neuropathy • Remission! • Plantigrade stance due to hind limb neuropathy • Aggressive dietary and insulin therapy may lead to euglycemia without use of insulin • Ketoacidosis • 17-67% of cats may achieve remission • Pancreatitis • Nonpharmacological • High protein diet, limit carbohydrates • Control portions to control weight • Weight loss not to exceed 1-2% weekly Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Zini E, Hafner M, Osto M, et al. Predictors of clinical remission in cats with diabetes mellitus. J Vet Intern Med 2010;24(6):1314-1321. Nelson RW. Chapter 52. Disorder of the Endocrine Pancreas. In: Couta N. Small Animal Internal Medicine. 3 rd ed. Missouri: Mosby 1998. Insulin Clinical Monitoring • Preferred • Daily • Insulin glargine (Lantus) U100 • Food/water intake • Human protamine zinc insulin (PZI) U40 • Insulin dose, signs of hypoglycemia • • Inadequate response to Vetsulin—not recommended Blood glucose if motivated owner • Weekly • Dosing • BG 6-8 h post insulin dose • In average cat, start at 1 unit/cat q12 hours • Every 2 weeks • Do not exceed 2 units/ cat even if very large or obese • Urine dipstick for glucose and ketones • Monitor for hypoglycemia • If 3 consistent negative urine glucose, possible remission • If BG<150 mg/dL, reduce dose by 0.5 unit • Every 3 months • Return to vet for fructosamine level Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Rucinsky R, Cook A Haley S et al. AAHA Diabetes Management Guidelines for Dogs and Cats. JAAHA 2010; 46:215-224F Client education Client Education for Dogs and Cats with Diabetes • Insulin administration https://www.youtube.com/watch?v=i93tscgFu5I