top 10 things you should know before filling veterinary ... · •desktop, smartphone, tablet...
TRANSCRIPT
The Top 10 Things You Should Know Before Filling Veterinary Prescriptions
Gigi Davidson, BSPharm, Dipl.ICVP
NC State University College of Veterinary Medicine
Disclosure
• Gigi Davidson declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.
Objectives
Identify information resources most useful to community pharmacists when filling prescriptions for animal patientsIdentify
Recognize the overarching principles of veterinary drug laws and regulationsRecognize
Describe the impact of species-specific vital signs, metabolic capacity, gastrointestinal physiology, and dietary habit on drug disposition in animalsDescribe
Review the most common veterinary-only drugsReview
List most common dispensing errors for veterinary prescriptionsList
#1 Veterinary Information Resources
One Stop Veterinary Drug Information
Plumb’s Veterinary Drugs (electronic)www.plumbsveterinarydrugs.com
• Desktop, smartphone, tablet versions available
• Veterinary Medication Guides (client education)
Plumb’s Veterinary Drug Handbook (print)Donald C. PlumbWiley-BlackwellJanuary 2015 (8th edition)
• Desk-size and pocket-size formats available
• 9th Ed. 2018
Veterinary PDR Equivalent
Compendium of Veterinary Products
• https://bayerall.naccvp.com/?u=bayer&p=dvm
• Free with online registration
• US and Canadian versions
• Over 6010 product package inserts
• Charts
• Anthelmintics and Parasiticides
• Biologicals (vaccines)
• Withdrawal times
Phone app “CVP Vet”
Disease State Management
The Merck Veterinary Manual (print)Merck & Co., Inc.July 2016 (11th edition)
The Merck Veterinary Manual (electronic)www.merckvetmanual.com
• Free
• Updated continuously
Today’s Veterinary Practice
Today’s Veterinary Practice (electronic)
• http://todaysveterinarypractice.navc.com/
• Free with registration
• Current topics
• Clinical resources
• Disease state management
Today’s Veterinary Practice (print)
#2 Understand Veterinary Abbreviations
What Does This Mean??
What is the dose?
Veterinary dosing is commonly allometric
and not empiric
mg/kg
mg/lb
mg/m2
Species Specific formulas
Chemotherapy
Do not misinterpret empiric dosing as allometric dosing
amlodipine: 0.625 mg/CAT not 0.625mg/kg
atenolol 6.25 mg/CAT not 6.25mg/kg
Check in: Translate the
Script
#3 Understand Veterinary Drug Law
Overarching Principle: Animals are food for humans.
“Intended Use”
In the US, the only species that cannot be consumed as food are:
• Humans
• Endangered list species
• Horses (intermittently)
Human dietary preferences determine if an animal or their byproducts are “food”
• Cattle, chickens
• Meat, milk, eggs
• Buffalo, ostrich
• Meat, milk, eggs
• Rattlesnakes
Food animal or pet? Always assume food!
Which are most likely food animals?
Humans Eat Animals: Consequence #1: Withdrawal Times
WDT: the length of time after the last dose during which an animal or its byproducts may not be consumed as food
• Must be supplied by veterinarian on prescription
• Examples:
• Do not sell for slaughter for 5 days after last dose.
• Discard milk for 36 hours after last dose.
• Discard eggs for 14 days after last dose.
Humans eat animals:Consequence #2:
OTCs must be used as labeled
FDA approves veterinary OTC’s:
• For target species
• For approved indication(s)
• At approved dose
• By approved route
• For approved duration
Extralabel use of veterinary OTC must be directed by veterinarian
• Pharmacists may NOT recommend use of human OTCs in animals
• Scenario
Law Continued: Understanding Veterinary Credentials
Can a physician write a prescription for his dog?
Law: Prescription Verification• Veterinarians are NOT eligible for NPI
numbers:• CMS identifier
• DEA strongly opposes use of DEA number for non-controlled substances
• NCPDS recommends use of prescriber state license ID number to verify
NOTE: Some non-controlled substances are reportable in the Virginia PMP (e.g. gabapentin and naloxone) and require the prescriber’s DEA number for reporting.
Law: Generic Substitution
• Veterinarians are unaware of CMS requirements to dispense generics
• Veterinarians are unaware of the Dispense As Written signature line
• Call veterinarian to verify if Brand is required or if generic substitution is permitted
Elements of a Veterinary Prescription Label*
• Pharmacy name, address, and phone number
• Prescription number
• Date of initial dispensing
• Name and species of the animal patient Note: VA requires name of animal owner and species of patient for CII PMP reporting
• Directions for use
• Name and strength of the drug product (or active ingredients in a compounded prescription)
• Quantity or volume of drug product dispensed
• Name of the prescribing veterinarian
• Any withdrawal times stated for food-producing animals
• Name of the dispensing pharmacist
• Expiration or beyond-use date
• Number of refills
*American Veterinary Medical Association-https://www.avma.org/KB/Policies/Pages/Guidelines-for-Veterinary-Prescription-Drugs.aspx
#4 Be Aware of The Most Common Dispensing Errors
Veterinarians’ Perceptions NCSU Survey March
2015 (Sorah E, Davidson G. Royal
K. Dispensing Errors for Non-Human Patients in the
Community Pharmacy Setting:
A Survey of Pharmacists and
Veterinarians. Poster. SVHP
Portland, ME, June 2015.)
Insulin substitutions
Levothyroxine dosage changes
RPh recommended human OTC
Inappropriate counseling
Wrong drug salt dispensed
AVMA Survey September 2014
(Cima, Greg. Substitution errors. JAVMA (2014): 462-
465.
Insulin substitutions
Levothyroxine dosage changes
RPh recommended human OTC NSAID instead of prescribed NSAID
Other Potential Errors
Drugs withdrawn for human safety are commonly used in animals
• Cisapride
• Bromides
• Phenylpropanolamine
• Diethylstilbestrol
Metabolic capacity of a species may result in completely different drug disposition compared to humans
• Levothyroxine
• Digoxin
• Diazepam
#5 Understand the Patient’s Metabolic Capacity
Feline Metabolic Limitations
Glucuronide conjugation (deficient)
• Targeted Functional Groups: -OH, -COOH, NH2, =NH, -SH moieties attached to either phenolic (ring) or alcoholic (straight-chain)
• Targeted Drugs: Acetaminophen, Azo Dyes, Benzodiazepines, Benzyl alcohol, Benzoic acid derivatives, Carprofen, Chloramphenicol, Codeine, Morphine, Lamotrigene, Phenazopyridine, Phenols, Propofol, Salicylates, Zidovudine
Methylation (deficient in thiopurine methyltransferase)
• Targeted Functional Groups: --SH (purines)
• Targeted Drugs: Azathioprine, 6-mercaptopurine
Canine Metabolic Limitations
Acetylation (absent)
• Targeted Functional Groups: Aromatic—NH2
• Targeted Drugs: Dapsone, Hydralazine, Isoniazid, Procainamide, Sulfonamides
Metabolic Capacities: Canine Genetic Anomalies-ABCB1-Δ and BBB
Affected Dog BreedsBreed Approximate Frequency
of Mutation (%)Australian Shepherd (standard and mini)
50
Border Collie <5Collie 70English Shepherd 15German Shepherd 10Herding Breed Crosses 10Long-Haired Whippet 65McNab 30Mixed breeds 5Old English Sheepdog 5Shetland Sheepdog 15Silken Windhound 30
Targeted Drugs• Acepromazine
• Butorphanol
• Chemotherapy agents• Doxorubicin• Paclitaxel• Vinblastine• Vincristine
• Loperamide
• Macrocyclic lactones• Ivermectin• Milbemycin• Moxidectin (used in doses higher than labeled for
heartworm prevention)• Selamectin
#6 Understand the Patient’s Gastrointestinal Physiology/Diet
Effects of Dietary Habit
Carnivores
• More acidic gastrointestinal pH
• Low pH kills raw diet pathogens
• Shorter, faster gastrointestinal tract
Omnivores Herbivores
• More alkaline gastrointestinal pH
• Volatile fatty acids from carbohydrate digestion
• Longer, slower gastrointestinal tract
Effect of Gastric pH on Drug Disposition
• Weak acids are more bioavailable in dogs and cats due to lower GI pH (lower dose compared to
humans.)
• Weak acids are less bioavailable in horses due to higher GI pH. (higher dose compared to humans)
• Sustained-release or extended-release dosage forms designed for the human GI tract are unlikely
to have the same release profile in non-human patients. Drug contents may be released
prematurely or not at all, depending on pH and GI tract length.
#7 Know Likely Toxins for Each Species
Toxic Excipients and Foods in Dogs, Cats, and BirdsDrug/Excipient/Food Species Affected Toxicity
Alcohols Dogs, cats, birds Central nervous system toxicity
Avocado Birds Pulmonary congestion, nonsuppurative inflammation of the liver, kidney, pancreas, skin, and proventriculus
Benzocaine, benzoic acid derivatives Cats Red blood cell oxidative injury, hemolytic anemia
Chocolate Dogs, birds Cardiovascular and central nervous system stimulation
Cremophor Dogs Histamine release, anaphylaxis
Fat, fatty foods Dogs Increased risk of pancreatitis
Garlic, onions Dogs, cats Hemolytic anemiaGrapes, raisins Dogs Renal toxicityMacadamia nuts Dogs Lethargy, hyperthermia, ataxia, vomiting
Pennyroyal Cats HepatotoxicityPolysorbate 80 Dogs Histamine release, anaphylaxis
Raw yeast dough Dogs Alcohol poisoning, gastrointestinal dilatation and volvulus
Xylitol Dogs, birds Profound hypoglycemia and hepatocellular necrosis
#8 Know Species Vital Sign Thresholds
Fever Thresholds in Various Species
Pulse and Respiratory Rate Ranges
Gestational Periods by Species
#9 Be Familiar With Veterinary-Only Drugs
Veterinary Fluoroquinolones
Enrofloxacin (Baytril®)
Marbofloxacin (Zinequin®)
Pradofloxacin (Veraflox®)
Danofloxacin (Advocin®)
Orbifloxacin (Orbax®)
Veterinary NSAIDs
Carprofen (Rimadyl®)
Deracoxib (Deramaxx®)
Firocoxib (Previcox®)
Robenacoxib (Onsior®)
Grapiprant (Galliprant®)
Flunixin (Banamine®)
Phenylbutazone (Butazolidin®)
Veterinary Endocrine Agents
Trilostane (Vetoryl®)
Pergolide (Prascend®)
Estriol (Incurin®)
Diethylstilbestrol (DES®)
Domperidone (Equidone®)
#10 Know Where to Report a Veterinary ADE
Adverse Drug Events
FDA Form 1932a “Veterinary
Adverse Experience, Lack of Effectiveness
or Product Defect Report”
https://www.fda.gov/AnimalVeterinary/SafetyHealth/ReportaProblem/ucm055305.htm#Drugs_and_Devices
May be reported by veterinarian, pet owner or pharmacist
VeterinarianCan determine if truly an ADE or if related to disease
May choose to report to FDA using form 1932a
Report Errors to?
For immediate discontinuation of therapy or other resolutionPet owner
For needed monitoring or additional therapyVeterinarian
To broaden database for dispensing errorsBoard of
Pharmacy
Pharmacy Dispensing Complaint Form AVMA
Summary
Keep these 10 tools sharp and readily retrievableKeep
Call veterinarians for questionsCall
Report any adverse events or errors to veterinarianReport
Learn as much as you can about non-human patientsLearn
Questions?