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IDEXX: Contributing to something bigger

On the latest episode of The Vet Blast Podcast, host Adam Christman, DVM, MBA explores the emerging world of electronic prescribing with Elliot Garber, DVM, MPH, MS, DACVPM. They discuss how this can affect workflow and why it has taken so long for this process to make the jump from human to veterinary medicine.

Below is a partial transcript. Listen to the full podcast for more.

: If you're going to be losing those sales anyway, you don't want to then have to pay your staff to sort through both the fax machine and 5 different online portals from different pharmacies to check the medical records [to] make sure...[it] is a valid prescription. Then, go in and approve it or fax it back or get on the phone to the retail pharmacy and try to reach the pharmacist who can actually talk to you to approve a prescription. So, it's kind of a double burn for the veterinary teams, because not only are they losing the sale of that prescription product, but then they have to lose a bunch of their time dealing with that in an inefficient way too.

Podcasts

Electronic prescribing finally comes to veterinary medicine

How e-prescribing can save time and enhance patient safety

, Juan S. Orjuela, DVM, cofounder of the Latinx Veterinary Medical Association, explained why celebrating Hispanic/Latinx Heritage Month within veterinary medicine promotes and gives Hispanic/Latinx veterinary professionals and clients the representation they deserve to get better care for patients. 

The following is a partial transcript of the video.

Hispanic/Latinx professionals are a growing minority in the veterinary industry. It has been estimated that there are over 20 million Latinx pet owners in the United States alone, and this number is steadily growing. So, that kind of just shows you how important it is to have this representation. 

Videos

Juan S. Orjuela, DVM, explains why he thinks it is crucial for veterinary medicine to celebrate Hispanic/Latinx Heritage Month

The importance of representation within veterinary medicine

interview, Philippa Pavia, VMD, head of medical strategy and board-certified veterinary surgeon at Bond Vet—a network of veterinary clinics in New York—spotlights Bond Vet's strategic design promoting a comfortable environment for pet owners, pets, and staff alike while providing practical function.

: [Bond Vet features] a lot of pastel colors. It [has] a lot of soft surfaces, things that are kind of touchable, smellable, anything calming, we want to be very, very different from the sterile surfaces, obviously, everything we have is fully sterilizable. But we want to go away from metal and cold metal tables, uncomfortable chairs, waiting rooms that don't have different levels of seating to allow dogs and cats to not be in line of sight with each other. It's all about being calm, and being very consistent.

In a dvm360® interview, Philippa Pavia, VMD, details the modern elements of Bond Vet

An inside look at Bond Vet's design

I met Buddy early in my career as a rotating intern and learned a lot from him. Buddy was a Havanese puppy brought to the clinic for not acting normally. His presenting clinical signs were acute onset hyporexia and vomiting en route to the hospital. 

Buddy’s initial physical exam was unremarkable, and he appeared to be a happy puppy. His SNAP Parvo Test results were negative, and his radiographs were consistent with a diffuse enteropathy. I prescribed a dose of injectable maropitant citrate (Cerenia), administered subcutaneous fluids, and discharged him. Given Buddy’s presenting physical, I initially was dismissive of his owner’s worry. Three hours later, Buddy returned to the clinic after failing to improve. At this time, he was admitted into the hospital, and hemogram and chemistry panels were submitted.

The hemogram revealed a moderate thrombocytopenia, which I did not confirm with a smear. Chemistry panel revealed a mild elevation in alkaline phosphatase (ALP) and a mild elevation in total bilirubin (0.6 mg/dL; high normal 0.5 mg/dL). Creatinine was elevated at 1.8 mg/dL, which given his vomiting I assumed was prerenal. I went to obtain a cystocentesis urine sample but couldn’t detect his bladder. My second mistake was not being alarmed by the creatinine level. Puppies have low serum creatinine levels; the 1.8 mg/dL was likely a moderate to severe elevation from his normal baseline.

Prior to leaving for the evening, I checked on Buddy and noted that he had not urinated, so I increased his intravenous fluid rate. When I arrived the next morning, I noted that Buddy looked significantly more lethargic and that no urine was noted overnight. A serial chemistry panel revealed a progressive hyperbilirubinemia to 1.8 mg/dL. The creatinine had doubled to 3.3 mg/dL. Both his phosphorus and ALP levels were worse. The most concerning finding was a hyperkalemia of 7.1 mmol/L, which can be an indicator of oliguria or anuria.

Abdominal ultrasound was then performed and revealed mild bilateral renomegaly consistent with an acute kidney injury. Given Buddy’s young age, azotemia, and hyperbilirubinemia, I prioritized leptospirosis. At this point, the team escalated Buddy’s care by placing a central line and urinary catheter. The team administered a fluid bolus and dose of furosemide with no resultant urine production. Given the oliguria and anuria, at this point dialysis was recommended and elected by the client. Unfortunately, because of his small size, Buddy was not a candidate for hemodialysis. Peritoneal dialysis was elected, but Buddy died 18 hours after therapy was initiated.

If I could go back in time, I would have taken the client’s initial complaint more seriously and been more diligent in interpreting the initial chemistry panel. I also should have reattempted to obtain urine. A persistently small bladder may have triggered a concern for oliguria sooner than the serial chemistry panel.

Leptospirosis is a multisystemic disease that primarily affects the kidneys and liver. It is a tubular disease, and when there is a glomerular component, clinicians will see mild to moderate elevated urine protein to creatinine (UPC) ratios. Severe elevations in UPC should raise concern for other glomerulonephropathies. Glucosuria also may be present, which can be indicative of proximal tubular injury. Prognosis is typically fair to good if caught early and managed appropriately.

In the end, my time with Buddy made me a better doctor and, ultimately, a better internist. I learned to take in all the information at hand before jumping to conclusions, which can have a large impact in complicated medical cases.

, received his veterinary degree from St George’s University and completed clinical rotations at Cornell University. He then completed an intensive small animal rotating internship in medicine and surgery with VCA in Norwalk, Connecticut, before returning to Cornell University for a 3-year residency in internal medicine. His professional interests include nephrology, gastroenterology, and immune-mediated disease.

Articles

Tinkering with tubules in an acute kidney case

High creatinine levels, low urine output lead to leptospirosis diagnosis

This article was updated September 27, 2022. 

Many individuals are using medication for their mental health. However, our dogs and cats sometimes get into our pharmaceutical supply and suffer the consequences. In fact, over 30% of calls received by the helpline involve exposures to human medications and supplements, many of them psychotropic, according to Renee D. Schmid, DVM, DABT, DABVT, senior toxicologist at Pet Poison Helpline and SafetyCall International.

Dogs corner the market on pharmaceutical poisonings, at about 65% of cases, she added, while presenting a lecture at the 2022 Fetch dvm360® Conference in Kansas City, Missouri. Although felines claim only one-third of this total, Schmid warned attendees that they are not to be counted out. “Cats really love the taste of these medications,” she said.

Be it cat or dog, decontamination is rule number one in a toxic situation. For ridding most toxins, however, emesis is only effective within an hour of ingestion.

Safety should be kept in mind, Schmid noted. “It’s instinctive for us, when an animal has ingested something, to try to get it back out. But when that animal is lateral recumbent, or when it’s bouncing off the walls, it is not a candidate for inducing vomiting,” she said.

Furthermore, consider that each class of psychiatric medication has its very own toxic stamp and specific recommended fix.

Medications used to treat attention deficit hyperactivity disorder (ADHD) are ubiquitous in American households. According to the CDC, over 60% of children ages 2 to 17 years who are diagnosed with ADHD are using medication to treat it.

ADHD drugs fall into a few different categories: stimulants, alpha-2 adrenergic agonists, and selective norepinephrine reuptake inhibitors (sNRIs).

Prescription stimulants are used in children and adults to address ADHD, narcolepsy and, occasionally, obesity. These include amphetamines and methylphenidate preparations.

Like many psychiatric medications, these generally come in immediate- (IR) and extended-release (ER) versions.

 To ease administration, particularly in children, formulations other than the standard swallowed tablet are available. These include patches, as well as tasty chews, solutions, powders, and beads. The flavorings, which may incorporate xylitol, render them appealing to pets.

In dogs and cats, amphetamines are generally toxic at 1 mg/kg (0.8 mg/kg for ER formulations). Methylphenidates are toxic at 0.5 mg/kg.

Clinical signs of stimulant intoxication stem from central nervous system (CNS) excitement and sympathomimetic agonism: agitation, hyperactivity, vocalization, tachycardia, hypertension, head bobbing, tremors, seizures, mydriasis, and hyperthermia.

A pet that has ingested an IR formulation can experience clinical signs within 20-30 minutes that may persist for 12-24 hours.

 “If the animal is asymptomatic after 3-4 hours, it probably did not actually get into the medications,” said Schmid.

For ER formulations and ingested patches, onset of signs may be delayed by 4-6 hours, and clinical effects can last a day or two.

The first step in treating these pets is decontamination. If the animal is neurologically appropriate, emesis should be induced. Chewable and oral disintegrating products are absorbed very quickly, leaving little time to induce emesis. If a dog or cat has ingested an IR product and lives far away, the owner should induce vomiting prior to transporting the pet to the hospital.

For ER products, metabolism is slower, and decontamination can be performed with slightly less urgency. So, if an animal with ER drugs on board lives near the clinic, emesis usually can be delayed until the animal arrives. “Time is on our side,” she said.

If a patient is neurologically intact, attempts to scavenge any remaining drug can be made by feeding activated charcoal. But once clinical signs have set in, most of the drug has been absorbed, and activated charcoal will not be very effective.

Schmid also addressed the hazards of drug patches. “Dogs do like to ingest patches,” she said.

The majority of drug is still active long after patches are discarded. A dog that swallowed one may exhibit significant clinical signs that endure until the patch is completely gone.

Patch removal can be achieved via endoscopy, or by feeding multiple meals until the patch has been expelled. Activated charcoal can then be used to bind any free-floating drug that has leached from the patch.

Extended hospitalization is generally required for pets that have ingested patches and other ER products having slow drug absorption.

Emesis and catharsis should be followed by sedation. “Acepromazine is your friend in just about any toxin case that shows signs of agitation,” Schmid said.

She recommended a dose of 0.02 mg/kg to 0.04 mg/kg IV, IM, SQ (0.05 mg/kg to 0.1 mg/kg if already manifesting signs). Butorphanol (0.2-0.4 mg/kg IV, IM, SQ), for its cardiac-sparing properties, is safer for some heart disease and geriatric patients. Benzodiazepines should be avoided, as they can cause dysphoria and other CNS effects.

If a patient is experiencing serotonin syndrome, characterized by CNS, autonomic and neurobehavioral signs like dysphoria, vocalizing and muscle rigidity,

 cyproheptadine (dogs, 1.1 mg/kg; cats 2-4 mg/kg/cat) can be given by mouth or as a slurry per rectum to ease signs. Methocarbamol (55-220mg/kg IV) is useful for animals experiencing tremors, and anticonvulsants like phenobarbital or levetiracetam can address seizures.

Guanfacine and clonidine are alpha-2 adrenergic agonists that act centrally to modulate the symptoms of ADHD in children and adults.

 Clonidine is also used for autism, Tourette syndrome and insomnia in people, and to treat behavioral issues like phobias and separation anxiety in dogs.

These drugs have a narrow margin of safety in pets,

 and clinical signs—which include depression, sedation, ataxia, vomiting, bradycardia, hypotension, tremors and seizures in dogs—can develop in doses as low as 0.01 mg/kg to 0.02 mg/kg. Onset occurs within four hours after ingestion, and effects can persist for 24 to 72 hours.

Emetics (within 30 minutes of ingestion) and activated charcoal can be administered to asymptomatic patients. If symptomatic, the alpha-2 adrenergic antagonist atipamezole (50 mcg/kg IM, redosed PRN) can be used to reverse signs of poisoning. (Anticonvulsants are indicated in the rare case of seizures.) Intravenous fluids should be given to maintain blood pressure, perfusion, and hydration. Vital signs, particularly heart rate, must be monitored frequently.

Selective norepinephrine reuptake inhibitors

Atomoxetine, a nonstimulant sNRI used as a second line treatment for ADHD,

 can cause sedation/agitation and anorexia at low doses in dogs and cats; and hypertension, tachycardia, and tremors at higher doses.

Treatment is with emesis induction for recent ingestion, followed by a single dose of activated charcoal. Further support may include sedation for agitation, antiemetics for nausea/vomiting, beta blockers for persistent tachycardia, methocarbamol for tremors, and intravenous fluids for cardiovascular support.

Some 25 million American adults have experienced a major depressive episode in the last few years, according to the CDC. The population most afflicted—at a rate of 21%—are those aged 18-29 years.

This is important, said Schmid, because “a lot of times, (this age group) may not store medications in their original packaging or may leave medications lying around, increasing the ability of their pets to get to them.”

Selective serotonin reuptake inhibitors (SSRIs)

Used in both people and pets to address anxiety-based behaviors, SSRIs bathe the CNS with “feel-good” seratonin by blocking its reuptake in the presynaptic membrane.

 Common SSRIs include fluoxetine, citalopram, escitalopram, paroxetine and sertraline. Trazodone, though not a true SSRI, also blocks serotonin reuptake to produce a calming effect.

The toxicity profile for SSRIs varies by species, with cats being more sensitive than dogs.

 Small overdoses of 2 to 3 times the therapeutic dose result in sedation or agitation, hypersalivation, vomiting, mydriasis, tremors, and hyperthermia. Larger overdoses can cause ataxia, dysphoria, aggressive behavior, nystagmus, and seizures. Even greater amounts may produce serotonin syndrome.

Treatment is generally supportive, and involves routine decontamination, intravenous fluids, tranquilizers, methocarbamol, cyproheptadine in the case of seratonin syndrome, benzodiazepines for seizures absent seratonin syndrome, and phenobarbital or levetiracetam for seizures associated with higher ingested doses and/or serotonin syndrome.

Like SSRIs, TCAs can combat depression and anxiety in both humans and animals.

 Common TCAs include amitriptyline, clomipramine, nortriptyline and doxepin.

TCAs differ from SSRIs in their narrow margin of safety.

 Overdoses produce anticholinergic effects:constipation, urine retention, mydriasis, hypertension, tachycardia, and disorientation.Vomiting, seizures, and serotonin syndrome may also result.

Toxicities involving bicyclic antidepressants, like venlafaxine and serotonin and norepinephrine reuptake inhibitors (SNRIs) duloxetine , cause sympathomimetic effects, similar to those seen with SSRI intoxication. Toxicities associated with TCAs, bicyclics and SNRIs are treated similarly to SSRI overdoses; for TCA overdoses, careful cardiovascular monitoring is also advised.

Benzodiazepines and nonbenzodiazepine sleep aids

Benzodiazepines are effective anxiolytics, anticonvulsants, muscle relaxants and sedatives;

 nonbenzodiazepine hypnotics produce sleep in those whose brains fight it.

 Both operate through the inhibitory neurotransmitter gamma-amino butyric acid (GABA).

Benzodiazepines used in humans and veterinary medicine include alprazolam, diazepam, midazolam, and clonazepam.

 think zolpidem, eszopiclone, and zaleplon. Of these, clonazepam and zolpidem account for the most Pet Poison Helpline calls.

With their wide safety margins, benzodiazepines and nonbenzodiazepine poisonings rarely cause fatality in animals.

 Clinical signs of acute toxicity, occurring within 30-60 minutes after ingestion, are vomiting, ataxia, disorientation, and either sedation or paradoxical CNS stimulation. In cats, chronic oral use of diazepam can lead to hepatic failure, though acute exposures do not carry the same risk.

Treatment for these overexposures is much the same as for the other psychotropics: decontamination and supportive care. If paradoxical agitation occurs, sedation can be achieved with acepromazine or butorphanol. In rare cases of severe CNS or respiratory depression, the antidote flumazenil (0.01 mg/kg IV, PRN to effect) can reverse signs.

The dietary supplement 5-hydroxytryptophan (5-HTP) has become popular for inducing sleep, enhancing mood, and promoting a sense of wellbeing. As an over-the-counter medication, Schmid explained, “Owners think it’s safer and won’t be a problem for pets.”

Nonetheless, she warned of this serotonin precursor’s narrow margin of safety in dogs and cats: at just 3 mg/kg—a single 100 mg capsule in a medium-sized dog—agitation, tachycardia, hypertension, vomiting, diarrhea, and transient blindness can occur within 2 to 4 hours of consumption. Treatment is by decontamination, intravenous fluids, sedation, cyproheptadine, methocarbamol and cerenia.

Toxic ingestions of human psychiatric drugs can cause clinical signs in pets that range from sympathomimetic to anticholinergic. 

Psychotropic medications are posing dangers to pets

Vets Pets, a network of veterinary hospitals in North Carolina, has begun construction of a state-of-the-art facility in Wilson, North Carolina.

the Points East Veterinary Specialty Hospital (Points East) will be a 17,000-square-foot facility that will replace an existing smaller facility under a mile away. The project officially launched on September 26, 2022, featuring a ceremonial groundbreaking at the new facility's Grover Lane location.

Vets Pets medical director Paige Harrington, DVM, anticipates that the new Points East Veterinary Specialty Hospital will offer more convenience, comfort, and medical capabilities to pet owners within the area. "We'll have more of everything here—exceptionally knowledgeable, skilled, compassionate, board-certified personnel plus the region's most advanced emergency, surgical, critical-care, diagnostic, and therapeutic technologies," Harrington stated.

The original Points East, at the time known as Eastern Carolina Veterinary Emergency Treatment Services (ECVETS), debuted in 2006, started by Frank Batten, DVM, in a 2,500-square-foot industrial complex. The next year, Batten and his son-in-law Steve Thomas, Vets Pets CEO, founded Vets Pets by coupling ECVETS with another veterinary practice.

In 2010, Vets Pets bought and renovated a vacant 5,100-square-foot restaurant at 4935 Raleigh Road Parkway West as the home of ECVETS, which has been it ever since. That facility underwent renovation in 2015 and specialty surgery services were added, bringing Points East to fruition.

The facility was renovated again in 2019, and 24/7/365 emergency and critical-care services were then available. This along with the additional offered services were rebranded under the Points East name. Its Wilson location near the intersection of I-95 and U.S. Hwy. 264 located it in amid a vast, largely underserved region stretching eastward from Raleigh's Triangle Area to the Carolina coast.

"At its inception, ECVETS was the only veterinary hospital of its kind in the region, and with a consistent focus on growth and advancement, Points East remains so today," expressed Thomas, in the release.

Harrington added that moving to the larger facility was a plan that had been in the works for some time.

"We knew we were going to need a larger place if we were to keep pace with the surging demand for our services and to be able to continue accepting the growing variety of cases being brought to us," she shared. "The new, much larger, and better-equipped facility will help us do both."

Vets Pets breaks ground in Wilson, N.C., to build new home for Points East Veterinary Specialty Hospital. News release. Vets Pets. September 27, 2022. Accessed September 27, 2022. https://www.prnewswire.com/news-releases/vets-pets-breaks-ground-in-wilson-nc-to-build-new-home-for-points-east-veterinary-specialty-hospital-301632402

New clinic to provide better convenience, comfort, and medical capabilities to pet parents within the Wilson, North Carolina area

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