Double Header: Spring Fitness and Human Medications

Double Header : Spring Fitness and Human Medications

I normally wouldn’t do a double-topic like this, but I need to get something off my chest. It’s very very rare that I yell with my white coat on. Today, though? Yes. I’ll be blunt and quick about it:

 

DO NOT GIVE HUMAN MEDICATION OF ANY KIND TO YOUR PET WITHOUT SPEAKING TO YOUR VETERINARIAN FIRST.

Lethal consequences can and do result. Major damage, hospitalization for treatment, and significant costs are also potential outcomes. I don’t know a single veterinarian that charges for phone calls, and at the very least you can be stopped from making a blunder that kills your own pet.

Alright. Deep breaths. With that out of the way, this week’s longer topic was suggested by one of my patients. (Thanks, Ellie!) Springtime is coming in tiny increments, so Ellie is looking forward to longer walks and better weather. She does have some joint trouble, so we talked about how much exercise is the right amount. In contrast to my yelling above, this answer has a lot more variability.

The tipping point between good exercise and bad has to do with the condition a given individual starts in. Young and healthy? Old and arthritic? Heart disease? Injury or surgical recovery? Out of shape or overweight?

Serious consequences can occur from overestimating what your pet can tolerate. Even for healthy dogs, going from zero exercise to a full day of hard activity can be a huge problem. When muscles aren’t used to the level of activity being asked of them, they can easily become overworked and damaged. Damaged muscle releases chemicals that can damage the kidneys. Pets enduring high temperatures can also have this sort of muscle damage, so even light exercise in hot weather can cause muscle damage.

Thankfully, the answers to a lot of these different cases are simple. We’ll tackle them one at a time.

Young healthy pets should take up a fitness program gradually. This means that if there were no walks at all, don’t make the first one hours long, and don’t make it a full-speed run. Somewhere in the neighborhood of activity 10-30 minutes long, in comfortable temperatures should be tolerated fairly well. Just as we would gradually increase the duration or intensity of the workout, you can do so with your pet. If at any point, your pet seems to be lagging behind, or has flat-out stopped, it’s time for a rest! Sometimes, pets are so excited to be playing or walking that they will push themselves far harder than they should. You have to make an assessment of a reasonable duration and intensity of the activity. Always err on the side of caution!

Pets with orthopedic problems such as hip dysplasia, a torn ACL, arthritis, etc. should always stick with low-impact activity. Running or even walking on hard pavement can be enough to make them sore or limp. For dogs, swimming — actually swimming, not running on the beach — is a great way to exercise. Otherwise, slow walks of shorter durations are a good idea. I’d rather have an arthritis patient go for two 10-minute walks than one 20-minute walk if it’s at all possible. Keeping up muscle strength and mobility is critical for arthritis patients. We also have a duty to keep them from hurting. This may mean that some pain medication or an anti-inflammatory are part of the whole care plan. Owners with pets that have advanced arthritis or other bone/joint problems can also look into physical therapy. There are tons of options for PT for pets.

For pets that have more serious conditions such as heart disease or other organ dysfunction, each case has to be very carefully evaluated. It would be irresponsible of me to make any blanket statements or generalizations here beyond the advice that you should ask your vet about your pet specifically. A mistake here could push a heart patient into heart failure, for example. Obviously that’s not a good option.

One last caution for all of you who own pets with short muzzles — the brachycephalic breeds. Exercise can be particularly difficult for brachycephalics. It can also be dangerous. These pets have a heck of a time breathing as it is, and the massive turbulence created when they’re breathing hard can cause life-threatening complications such as welling in the larynx. I’ve seen many bulldogs that come in dying because their throats are swelling shut. It’s particularly dangerous in hot weather. Pugs, bulldogs, Persian cats, ShihTzus — go VERY gently and go in cool temperatures!

In closing, I’ll share two links to other spots on the web with information about exercising with your pets. Thanks again, Ellie! This was a great topic to cover.

ASPCA Exercise Guidelines for Dogs

Hill’s/Science Diet Exercise Tips for Dogs and Cats

Pharmacy Choices

Last week, we ran into a problem at the hospital. It brought right to the forefront a complicated, potentially upsetting dilemma faced by veterinarians and pet owners. I’ve carefully avoided preachy blog posts about the costs involved with pet medications. It’s a topic I can’t cover from an entirely fair position and I’ll admit that up front. I’ll do my best to stay objective.

Online pet pharmacies sell pet medications. They are usually cheaper than at the local vet hospital. Veterinary hospitals can’t purchase medications in enough quantity to be able to offer the prices that online pharmacies do. Some companies offer prices that, if we matched them, would cause the hospital to lose money on the sale. We simply can’t do this and stay in business.

Large retailers are now offering, and heavily advertising, pet medications as well. These prices are also lower than at most veterinary hospitals. Prices, again, may be due to buying in high volume, or a strategy to serve as a loss leader. We simply don’t know.

Lastly, some medications are human meds that we use in veterinary patients. Those are also sold by any human pharmacy. Sometimes those prices are lower than what we can offer. The reasons are the same as above.

At this point, it certainly seems like veterinarians and vet hospitals are crying over a loss of revenue. To some degree, that’s true. We’re having to find new ways to serve our clients fairly and well with the loss of revenue from some medications. I think that everyone understands our need to pay and educate our staff well, to have good equipment and supplies, and so on. All professions, all private businesses, all corporations, set out to make a living from their work.

So what’s the catch? There are several. I’m going to use heartworm prevention as an example. The manufacturers of heartworm prevention products generally sell their products directly to vets or through a licensed/approved distributor. The manufacturers tell us that they only sell this way, and that they don’t sell to online pharmacies or retail outlets. Somehow, the products end up at other retailers, though. There are only two plausible reasons: vets buy tons of product and sell it to other retailers, or the manufacturers are selling to retail outlets.

If the products are purchased by vets and sold to other retailers, that’s called diversion, or “gray market” sales. The manufacturer’s can’t safely say that their products were handled properly, stored in the proper conditions, or are free from tampering. As a result, the manufacturers won’t guarantee those products. You’ll have to deal with the retail outlet. And, of course, I’d hope that your veterinarian can help out. The trouble is, if your heartworm prevention doesn’t work the way it’s supposed to, your pet could be the one that suffers. Nobody wants that, not the vet, not the retail outlet, not the owner.

The situation that prompted this post occurred with one of our clients. They requested a written prescription for heartworm prevention for their cat. They took it to a local human pharmacy that was offering pet medications. The store didn’t have what we’d scripted in stock, and told the owner to see if the dog version would work just as well. Thankfully, the owner called and asked rather than just taking the medication home. It wouldn’t have harmed the cat, but the medication was different from the cat version — including an additional ingredient not in the cat product.

As far as I’m aware, human pharmacists and pharmacy staff do not often have any official training on veterinary medications. I’m hopeful that the retail chains offering pet medications will provide education and training for the staff there. If they haven’t, or they don’t, it’s far from an ideal situation. I’m not trying to say that pharmacists are bad people or that they don’t care. They’re probably just as uncomfortable with the situation as we are.

So what’s our take on the situation? We feel that the health and safety of your pet should be in the hands of properly trained professionals. Vets, vet techs, and even our reception staff have been trained to know which medications are the appropriate choices. They’re familiar with the products we carry. The manufacturers guarantee their products’ safety and effectiveness when you purchase through a vet hospital.

While I firmly believe that everyone involved in the practice of vet med and pharmacy has a desire to help keep pets healthy, the simple fact remains that your vet hospital is the best educated advocate for your pet’s well-being. I want all of our clients — and all pet owners — to make an informed choice.

Iverhart Plus Recall

Iverhart plus is a monthly heartworm prevention tablet made by Virbac. It’s roughly equivalent to Heartgard Plus and TriHeart plus in terms of the medications in the tablets.

There was also a recall in 2009 for the same problem with Iverhart Plus. In 2012, there was a recall on a related product (Iverhart Max).

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Six lots of Iverhart Plus Flavored Chewables, a heartworm preventive, have been recalled because of a stability issue involving the medication’s active ingredient ivermectin, the American Veterinary Medical Association reported this week.

Iverhart Plus Chewable tablets are packaged in a foil-backed blister card.
The manufacturer, Virbac Animal Health of Fort Worth, Texas, did not issue a public recall notice. A spokesperson could not be reached to comment.

A selected amount of Iverhart was recalled:

• Large dogs (51 to 100 pounds): lots 120076, 120086 and 120856.

• Medium dogs (26 to 50 pounds): lot 120202.

• Small dogs (up to 25 pounds): lots 120196 and 120844.

Iverhart Plus, a generic equivalent to Merial Ltd.’s Heartgard Plus, is formulated for the prevention of heartworm disease and for the treatment and control of roundworms and hookworms.

Stability concerns led Virbac to recall a single lot of Iverhart Max Chewable Tablets in April 2012. A lack of stability can reduce a medication’s efficacy.

Veterinarians or pet owners who have questions may contact Virbac Technical Services at 800-338-3659, ext. 3052.

Thursday News

Treating infections is one of the most widely known aspects of medical practice. Humans and other animals are in a constant and highly variable relationship with the microscopic world inside and outside our bodies. Bacteria help us digest and use our food, but they can also cause life-threatening infections. Dealing with the bad bugs often requires an antibiotic, a chemical that kills the bacteria. Finding new antibiotics that can be brought to the market as a safe, effective treatment is a long, expensive, arduous process. As a result, we don’t see too many new antibiotics.

Scientists have discovered a small molecule in the bloodstream of the giant panda that has antibacterial properties. The pandas make this small chain of amino acids (a peptide) naturally and it circulates in their body. Interestingly, it kills bacteria very quickly — more quickly than the drugs and molecules we already know about. The hope, of course, is that we can find a way to make this available to help humans and other animals. Scientists are working on making this peptide in the lab so that wild pandas can be protected.

This is another example of why research into the natural world is far, far more important than it might at first seem. Nature has a great deal to share with us about elegant solutions.

Here’s the link to the article. (It’s pretty short.)

A Little Drop of Poison

The majority of the time that we spend talking about toxicities, we’re assuming that a patient has ingested a large amount of something bad. While that’s the more common way for things to happen, we’ve had to deal with a fair number of low-quantity toxicities. Some medications/toxins are dangerous at small doses, infrequent doses, or a single dose.

By far, the most frequent issue we deal with is an NSAID. NSAIDs are “non-steroidal anti-inflammatory drugs.” This class includes aspirin, ibuprofen, naproxen, ketoprofen, and many others. Many of these medications are available over the counter for humans to use. They’re indicated for pain most commonly. A quick peek at Wikipedia cites a source with this frightening information: NSAID-associated upper gastrointestinal adverse events are estimated to result in 103,000 hospitalizations and 16,500 deaths per year in the United States, and represent 43% of drug-related emergency visits. Clearly, these medications are not to be taken lightly.

We do use NSAIDs in veterinary practice. Thankfully, we have a variety of options that have been specifically developed for pets. While all NSAIDS (veterinary and human both) have potentially dangerous side effects, when they are given properly they’re considered safe. Monitoring is necessary to ensure that side effects are not occurring.

The crux of the post today is that human NSAIDS can be extremely toxic to pets. I’ve seen cases where a single Aleve (naproxen) or just 2 doses of ibuprofen have seriously and permanently damaged a dog’s kidneys. I’ve seen stomach ulcers caused by aspirin.

In many of these cases, owners were giving the medication with the best of intentions, to help their pets not be in pain. I can understand the desire to ease pain. What I can’t understand very well at all is the assumption that if it’s OK for people it must be OK for pets. This simply isn’t true!! Dogs and cats have some unique aspects to their physiology that make medications behave differently than they do in the human body. Sometimes this means we have to give more of a certain medication; others, far less nor none at all. Supplements are considered medications as far as I’m concerned. Anything holistic, naturopathic, herbal, traditional medicine, etc. should be considered with the same weight as a “drug.”

I wholeheartedly believe that we can, and should, consider our pets as family members. They’re children, albeit shaggier than their human siblings. What we can not and should not do is treat them as if they’re tiny humans. If we are going to adhere to the idea that we will do what’s best for our pets, giving them any medications/supplements/treatments at all without consulting a qualified veterinary professional is a bad idea. It may be a fatal mistake.

Very few things are as crushing to an owner as finding out that something that was done with the best of intentions is responsible for the death or severe illness of their pet.

I strongly encourage you to call us (or your regular vet!) if you are considering ANY product for your pet. I realize that resources are sometimes limited, so you may not always be able to come in for a consultation or appointment, but at the very least we can help you avoid a terrible mistake. It’s always best to call BEFORE starting a medication or supplement. There may not be much I can do if someone calls and says, “I’ve been giving Product X for the last week and Fluffy isn’t eating, now…”

My last comment from the soapbox today is to mention that even products “made for pets” can be dangerous. I’ve seen flea and tick prevention for dogs and cats cause serious toxicities even when used as directed. I’ve cruised the aisles at pet supply stores and seen huge bottles of aspirin for dogs on the shelf. I’ve seen supplements that contain things that I don’t think are beneficial at best (and dangerous at worst). The point here is that finding something in a pet store doesn’t mean it’s the right choice for your pet!

Thanks for reading! Up next on Thursday is a guest column written by one of our techs. She volunteered to do a post on “Whoops, my dog’s pregnant. Now what?” (Bonus points if you recognize the little face. A flashback from when I was far younger…)

ProHeart 6

This week I’m going to tackle a controversial type of heartworm prevention. The hospital is considering the 6-month heartworm prevention injection for regular use again (ProHeart 6). This product was temporarily pulled from the market in 2004 due to concerns about safety. I’m going to spend some time today going over the history on ProHeart 6 and sharing some research data that examines the weight of any concerns about adverse reactions to the product.

ProHeart 6 is a specialized medication that allows the slow release of its active ingredient from the injection site over 6 months. The active ingredient is moxidectin. That same medication is found in Advantage Multi (made by Bayer Pharmaceuticals). The product was initially introduced by Fort Dodge in 2001. Fort Dodge had gone through all of the required FDA studies to have the product licensed for use in the US. Proheart 6 didn’t show any significant adverse effects, so it was put on the market. Veterinarians began using it extensively within a very short time. Millions of doses were administered all over the US. Many other countries also used ProHeart 6, including those in Europe, Asia, and Australia. In some places, ProHeart was licensed for 12-month protection (the dosing was different in those places).

Any time a new medication is released, a far larger number of patients receive it than during the safety and efficacy studies. Inevitably, this wide range of patients is a different population than in the safety studies. Dogs that may have had other illnesses, dogs of various ages, a wider range of breeds, use of the drug when vaccines are administered, other concurrent medications, etc. are all factors that contribute to differences ‘in the field’ as opposed to in the lab.

Concerns began to show up that ProHeart 6 was causing severe and serious reactions. These reactions included liver damage, autoimmune anemia, vomiting, anaphylactic reactions, and in some cases, deaths. The internet exploded with web pages (many of which are still up if you search) discussing the thought that “Proheart 6 is killing dogs.” At that time, no one was sure whether there was merit to this association or not. Bear in mind that there’s a difference between association and causation.

Fort Dodge voluntarily pulled ProHeart 6 off the market in the US in 2004. The equivalent oversight boards in most other countries did NOT recommend a recall of the product. Only South Korea took it off the market. Canada did NOT take it off the market. Four million doses were given in Australia. Europe had 3 million, and Japan 2 million.

A study published in 2005 used data from the Banfield vet hospital chain to examine whether ProHeart was associated with any increased risks, more reactions, or was causing deaths. The study used data from 1.93 million dogs, which is a very large sample size. It compared reactions from 2 oral heartworm preventions, ProHeart 6, and vaccinations.

This study led to a LOT of interesting comparative results. Overall, though, ProHeart was not implicated as a reason for increased rises in illness or disease or major reactions. The death rate per 10,000 encounters was NOT higher with ProHeart 6 patients, with or without concurrent vaccines. Concurrent drug use (NSAIDs, steroids) were associated with increased risk. There was an increase in some one type of cancer with dogs that received ProHeart 6 (mast cell tumor). The highest increase in problems came from pets receiving vaccinations. That may not surprise you if you slogged through the immunology posts with me! 🙂

The FDA allowed ProHeart 6 to come back on the market in 2008. As far as I’m aware, no change was made to the formula. Some very specific rules were placed that limited the types of patients that could have ProHeart 6. Pets had to be under 7 years old to get the product. Bloodwork had to be done BEFORE getting ProHeart 6. It had to be given on a separate visit from vaccines. Caution was advised for any dog with other types of allergies. Any animal with a history of weight loss could not get ProHeart 6. Vets had to have a 1-hour training session online and pass a small test to be allowed to order ProHeart 6 for use. We briefly used it at Pet Authority at that time, but clients were not very interested in jumping through all of the hoops, so we stopped offering it.

At no time did we see severe reactions to ProHeart 6 (even before it was recalled). We had no deaths that we can attribute to ProHeart 6.

Recently, Pfizer bought Ford Dodge. Pfizer now owns and manufactures ProHeart 6. The conditions I described above no longer HAVE to be followed, though Pfizer is, of course, recommending that veterinarians carefully choose which pets get ProHeart 6. We don’t routinely vaccinate animals that are sick or debilitated, so ProHeart 6 won’t be given to patients who shouldn’t be getting it, either.

We’re very likely to start stocking and offering ProHeart 6 again at Pet Authority. We feel the product is safe, and it’s a tremendous asset for some clients and patients. Only about 46% of clients remember to give their dogs heartworm prevention every month, so ProHeart 6 gives us an opportunity to make sure those dogs aren’t at risk. We’ll discuss the risks and benefits with all clients, the same way that we do for any other medications we give.

If you’re interested in that study that used the Banfield records, click here.

If you’d like to see the 2008 “Risk Minimization Action Plan” by Fort Dodge for the reintroduction of ProHeart 6, click here.

If you’d like to see the ProHeart 6 web page, click here.