Human and veterinary insulins are categorized by their onset and duration of action, as well as by the protein source from which they are derived. Short-acting insulins are typically used in the veterinary hospital for intensive blood glucose (BG) control, whereas intermediate-and long-acting insulins are used both in hospital and at home for long-term, daily glycemic control. Based on protein source, insulins are human, human analogue (synthetic insulin that is altered from the natural form but retains biological function), bovine, or porcine. Porcine and canine insulins have an identical amino acid sequence, whereas bovine and feline insulins differ by a single amino acid.

Traditionally, veterinarians have managed diabetes in dogs and cats with a variety of veterinary and human insulins (

). Veterinary insulins include porcine lente and protamine zinc human recombinant insulin (PZI). Human insulins or insulin analogues include neutral protamine Hagedorn (NPH), glargine, detemir, and degludec. Pre-mixed combinations of short-acting lispro or aspart insulin with longer-acting protamine insulin are also available as intermediate-acting insulins.

The overall goals for the treatment of canine diabetes include resolving polyuria and polydipsia, maintaining ideal body weight, preventing diabetic ketoacidosis, decreasing the risk for urinary tract infections, and slowing the development of complications (eg, diabetic cataracts) through excellent glycemic control. Ideally, these goals are accomplished while avoiding clinical hypoglycemia. For dogs, the American Animal Hospital Association recommends the use of porcine lente, PZI, or NPH insulin, plus a complete and balanced diet that lacks simple carbohydrates.

A stable routine for meals, snacks, and exercise is crucial for good glycemic control. Advise pet owners to avoid frequent changes in types and amount of food. Although the ideal diet for diabetic dogs has yet to be determined, recommendations include the following:

High-fiber, restricted-fat diets, which are high in complex carbohydrates (>45%)

Diets with moderate fiber and restricted carbohydrates (< 30% metabolizable energy [ME]), which are higher in fat and protein

High-fiber diets may help delay glucose absorption from the gastrointestinal tract and reduce postprandial hyperglycemia. A number of prescription canine diabetic diets with increased fiber are available, although most have carbohydrate levels less than 45% ME. If used with NPH insulin, these high-fiber diets may exacerbate postprandial hyperglycemia in some dogs because peak gastrointestinal glucose absorption occurs after peak insulin action. High-fiber, moderate-fat diets may cause significant weight loss in some diabetic dogs, and thus are not suitable for most lean or underweight dogs.

A variety of commercially available, nonprescription, grain-free diets are lower in carbohydrates and higher in protein and fat, but they have not yet been used in clinical trials with diabetic dogs. Dietary fat restriction (<30% ME) should be considered for diabetic dogs with concurrent chronic pancreatitis or persistent hypertriglyceridemia. It is generally recommended that insulin be given within 1 hour of a meal and, in most cases, for convenience, the meal and the insulin injection are given at the same time.

The primary goal of treatment in feline diabetes is to obtain remission (ie, maintenance of euglycemia without the need for insulin therapy or other hypoglycemic drugs). Remission is possible in about 80% of cats newly diagnosed with diabetes if normal or near-normal BG concentrations are achieved shortly after diagnosis. The probability of remission is increased when a low-carbohydrate (<15% ME), high-protein diet (Hill’s m/d, Purina DM, or others) is used in combination with a long-acting insulin such as glargine or detemir administered twice daily. Lower remission rates are reported using PZI or porcine lente insulin, or when a moderate-carbohydrate diet is fed. Rapid institution of excellent glycemic control, ideally in conjunction with home monitoring, contributes to remission, while institution of tight control (around 6 months or more) following diagnosis is associated with significantly lower remission rates (84% vs 34%).

Because remission often occurs between 4 and 8 weeks of therapy when cats are managed optimally, weight loss is not a major factor in achieving remission. However, weight management is critically important for maintaining remission. Eating does not need to be coordinated with insulin administration in cats, especially if a low-carbohydrate diet and long-acting insulin are used. The type and amount of food and snacks should be consistent each day; snacks must be low in carbohydrates.

It’s imperative to consider owner-derived clinical information in conjunction with history and physical exam. Monitor the patient’s water intake, urination, body weight, physical activity, and signs of clinical hypoglycemia. Urine glucose and ketone measurements may also be useful, but BG measurements are the most valuable, particularly when performed at home.

Fructosamine concentration can be useful if there is conflicting evidence for glycemic control (eg, the client reports good clinical control but in-clinic measurements indicate poor glycemic control). Fructosamine can also be useful when clinical information is inadequate or unreliable, or if the owner is unable to measure BG at home. Fructosamine concentrations are more useful for adjusting insulin in relatively stable diabetic cats that have been diabetic for months or years and are unlikely to go into remission. This is because insulin dose is adjusted less frequently in these animals, and knowledge of the average BG concentration over 2 to 3 weeks reflected by fructosamine is more relevant in these cats, but it is not useful for day-to-day insulin dose adjustments in newly diagnosed diabetic cats. Fructosamine concentration gives no information on nadir or pre-insulin BG, only mean BG over weeks.

Monitoring BG at home is invaluable for maximizing the probability of remission. Home BG measurements are typically more accurate because they avoid the spurious effects of patient stress.

 At-home monitoring for feline patients also provides more data on which to base insulin dose adjustments, enables accurate assessments for cats that are responding as expected, and is convenient for the owner.

Interest in measurement of hemoglobin A1c (HbA1c) has seemingly been renewed, possibly given the significance of type 2 diabetes in humans and much commercial advertising of new pharmaceuticals intended to lower the HbA1c of people with diabetes.

 Glycosylated hemoglobin is a hemoglobin product with a glucose molecule attached to its N-terminal amino acid valine. Glycosylation is irreversible and concentration of HbA1c within the circulation is approximately 2 to 3 months (the lifespan of a red blood cell). A dried blood spot test is currently offered (Baycom Diagnostics), yet published data on its performance remain unavailable.

As for cats, single sporadic BG measurements in dogs provide little useful clinical information for monitoring glycemic control. Instead, serial BG concentration curves that follow the same protocol as those obtained in hospital are required. Results must be related to the dog’s clinical signs; interpretation requires an understanding of the complex interactions involved in glucose homeostasis in diabetic dogs.

There is considerable day-to-day variability in BG measurements in diabetic dogs,

 and home-generated serial BG curves are as reliable as hospital-generated curves and have many of the same limitations.

For both dogs and cats, a practical approach incorporates knowledge of clinical signs to guide the timing of home-generated BG curves. If clinical signs are consistent with hypoglycemia occurrence at home, owners must be accustomed to measuring their dog’s BG concentration. This can confirm whether hypoglycemia is present and whether timely treatment is needed.

Samples can be obtained from the marginal vein of the lateral pinna, by collection of capillary blood, or by direct venipuncture. Once the owner becomes familiar with the technique, they usually require considerable practice collecting samples at home before they develop sufficient skill to generate a serial BG curve.

Selecting an appropriate glucose monitor and obtaining reliable glucose readings are essential. Some monitors read whole blood concentration as opposed to serum or plasma values. This causes an “under-reading” effect, in which a true serum concentration of 65 mg/dl will be read out as 50 mg/dl.

 In addition, the distribution of glucose between red cells and plasma is different for cats and humans,

 so human-calibrated plasma monitors may be misleading. Owners should be encouraged to purchase a veterinary-specific BG meter. I recommend the AlphaTRAK (Merck), as this has been well validated.

David Bruyette, DVM, DACVIM, was medical director at VCA West Los Angeles Animal Hospital and is currently chief medical officer at Anivive Lifesciences. He is also CEO of Veterinary Diagnostic Investigation and Consultation, and editor of the just-released 

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 2003;44(7):298-305. doi:10.1111/j.1748-5827.2003.tb00158.x

8. Van de Maele I, Rogier N, Daminet S. Retrospective study of owners' perception on home monitoring of blood glucose in diabetic dogs and cats. 

9. Alt N, Kley S, Haessig M, et al. Day-to-day variability of blood glucose concentration curves generated at home in cats with diabetes mellitus. 

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2019;31(3):408-414. doi:10.1177/1040638719832071

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Articles

Nearly all veterinary patients with diabetes are managed with a combination of insulin therapy, diet, and weight management. Here’s the latest.

Treating diabetes mellitus in cats and dogs: What are your goals?

We said goodbye to the last of their 2 Dachshunds today. I felt their tears as the black one fell asleep for the last time. Nearly a year of poor health was ending, and with it came the tender memories that would be too sensitive to touch for a while. Some people would say it was just a dog, but I beg to differ, and so would they. Those of us who are younger may be wise to see how the sunshine years hold a tribute to weenie dogs.

The dogs gave them something to care for—a living creature that still needed them for guidance and the basics of life. Yet bigger than that, it gave them meaning that carried over from years of raising children and grandchildren. You cannot just turn those emotions off as time changes its definition of wisdom and usefulness.

The dogs gave them stories to share with one another as the retirement years set in. Adventures hung in the air for hours and those short legs carried a long back into the mischievousness of puppyhood. Each new trick was story material for the next phone call with family. Lap time was special, with not a bump or change in skin texture going unnoticed.

And what about the exercise? The black dog was paralyzed in the hindquarters for almost 11 months. Improvement was slow, but it was coming. The surgery had been a success, and a good prognosis depended on much physical therapy at home. Imagine that—11 months of walking and exercising and moving those legs and swimming that critter in the bathtub and carrying it outside and tucking it into bed. It makes you wonder who got the most exercise. It also makes you wonder whether you would have exercised at all.

No disappointment. This love is unconditional. So what if you go to bed at 8:30 PM? These dogs will be more than happy to stay right beside the bed until 5:00 am when you start the next day. So what if you keep the house at 88 °F year-round? They’ve never known any different. So what if you drive 25 miles per hour on the interstate? They just love going for rides. So what if you tell the same story over and over? They love it as much the last time as they did the first.

Inside of me is a huge tribute to weenie dogs. I’ve seen their effect. I’ve laughed at those stories. I’ve helped you notice every bump and change in skin texture. I’ve monitored that exercise program. And I’ve seen that love in your eyes as you held a precious friend in your lap.

If the world has collapsed and there is no love at all, there would still be the love of a dog. They just don’t know how to do otherwise.

The love of a dog is endless, even when it’s their time to go. After nearly a year of suffering, a couple says goodbye to their sweet Dachshund.

A tribute to weenie dogs

I am originally from the South (OK, Texas, but still…), and I grew up knowing that people with integrity put the safety of women and children first. For example, when a woman boards a full bus, a man likely gets up and offers his seat. If it’s raining, my husband drops me off at the restaurant door and then goes to park the car.

This practice applies not just in uncomfortable situations but unsafe circumstances as well. If the lawn mower is on its last legs and the blade may to break into smithereens and come flying out in all directions, then mom is certainly not allowed to mow the lawn. Dad cuts the grass until the mower is repaired or a new one purchased.

Now, let’s escalate these hypothetical situations further. If a shooter enters a room, some men will instinctively push any women and children behind them. But what if the man enters the room not with a gun but coughing, sniffling, and clearly suffering from a severe respiratory illness? There may be no bullets but, in 2020, this man is likely perceived as a clear and present threat to others.

The topic is currently being discussed around supper tables across the globe. What if a vaccine for SARS-CoV-2, the virus that causes coronavirus-19 disease (COVID-19)—a proverbial bullet-proof vest—becomes available? Who gets to be at the front of the line?

The idea of women and children first is believed to have been coined in 1852 when the British troop shipHMS Birkenhead sank off the coast of South Africa. Of the more than 634 men, women, and children on board, only 193 survived the disaster, including all of the women and children.

 This logic doesn’t really translate well to pandemics, emerging pathogens, and vaccine protocols, does it? The question remains: Who gets the vaccine first when it becomes available, and who gets it if the supply is limited? And who decides who is at the front of the line?

Unfortunately—or fortunately depending on your perspective—only 50% of Americans intend to get vaccinated for SARS-CoV-2 once a vaccine is available.

 Public misperception surrounding the need for and safety of vaccination is a real problem globally. In 2019, well before COVID-19 came along, the World Health Organization (WHO) listed vaccine hesitancy as 1 of the top 10 major global health threats.

 With a COVID-19 vaccine being developed and brought to market at “warp speed,” the unknowns about adverse effects and overall longevity of efficacy are likely to be a huge stumbling block to vaccine administration to the masses. So, the line may not be as long as some think, yet the public is still concerned with who gets to go first.

In 1964, the Advisory Committee on Immunization Practices (ACIP) was chartered to provide expert advice and recommendations for vaccine use in the civilian American population to the secretary of US Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC).

 Today, the ACIP remains a globally respected gold standard for guidance on childhood immunization schedules, efficacy monitoring (think rabies titers) and, of course, pandemic priority populations for vaccination.

The secretary of HHS appoints 15 voting members of the ACIP following an application process. According to the CDC, 14 of the members have expertise in vaccinology, immunology, pediatrics, internal medicine, nursing, family medicine, virology, public health, infectious diseases, and/or preventive medicine. One member is a consumer representative who provides perspectives on the social and community aspects of vaccination.

 All 15 serve as volunteers and are joined by 8 ex-officio committee members representing federal agencies with immunization program responsibilities as well as 30 more nonvoting members who act as liaisons from external organizations with immunization expertise, such as the American Medical Association and the American Academy of Pediatrics.

According to ACIP, when developing recommendations, the members use an explicit evidence-based method based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

 In April 2020, amid the expanding pandemic, the ACIP formed a 41-member COVID-19 working group charged with preparing for the introduction of safe and effective COVID-19 vaccines, reducing disease transmission and associated morbidity and mortality, helping to minimize disruptions to society and the economy, including health care capacity, and ensuring equity in vaccine allocation and distribution.

However, a second group has been appointed by the National Academy of Medicine at the direction of top US health officials to develop a framework to determine priority for vaccination.

 While the appointment of 2 prestigious expert panels to assess vaccination priorities could prove problematic, it is good to remember that both entities serve only to make recommendations and to advise the HHS secretary. The task of true decision and execution, once a vaccine is available, rests with the Secretary alone.

Despite potential confusion over disparate recommendations, the ACIP working group recently made public early prioritization populations for SARS-CoV-2 vaccination. As reported, “…the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.”

 This ranking of priority populations is much more sophisticated than women and children. It is based largely on likelihood of exposure, severity of illness, and the transmissibility characteristics of the virus itself.

It is prudent to remember that a vaccine is not yet available. Just as researchers are working at “warp speed” to develop a safe, effective vaccine, the virus itself continues to spread through community transmission with many recovering from the disease with immunity. It remains to be seen when the vaccine will be available and how many people in priority populations remain without naturally developed antibodies.

If all this sounds a little familiar, it should. The ACIP also determined priority vaccination populations during the (H1N1) 2009 pandemic. The CDC has extensive information available to the public related to pandemic influenza response and vaccine allocation. The CDC doesn’t play favorites with emerging pathogens, but influenza surely receives a large amount of respect and attention from public health officials, especially when compared with emerging coronaviruses. Mutagenicity, morbidity and mortality rates, transmissibility, and other factors combine to demand more attention for influenza than coronavirus. However, we can rest assured that once a SARS-CoV-2 vaccine is available, 50% of Americans will line up,

 according to population groups determined by unelected, appointed experts, for a dose of protection from COVID-19 while only about 38% of the population will get a seasonal flu shot that may provide cross-protective immunity to novel influenzas.

 How encouraging! Estimates indicate that for community immunity to SARS-CoV-2 to be reached, about 70% of the population must be immune, whether through vaccination or natural disease recovery.

 With approximately 5.5 million cases at the time of writing,

 the United States is about 324 million cases short of the 70% immunity target. Until the majority of us 

 trust in science and data, keep calm and mask on.

Jenifer Chatfield, DVM, DACZM, DACVPM, is board certified in zoological medicine and preventive medicine. She has been a practice owner, worked in zoos, and completed international fieldwork. Her peer-reviewed publications include pharmacokinetics, wild animal behavior, infectious disease, and assisted reproduction in endangered species. Chatfield loves French bulldogs, Himalayan cats, the dirtiest of vodka martinis, and basking in the sun on any Caribbean beach. Find more about her exploits and adventures at 

1. Johnson B. “Women and children first!” Historic UK. Accessed October 18, 2020. 

https://www.historic-uk.com/CultureUK/Women-Children-First/

2. Cornwall W. Just 50% of Americans plan to get a COVID-10 vaccine. Here’s how to win over the rest. American Association for the Advancement of Science.June 30, 2020. Accessed September 11, 2020. 

https://www.sciencemag.org/news/2020/06/just-50-americans-plan-get-covid-19-vaccine-here-s-how-win-over-rest

3. Ten threats to global health in 2019. World Health Organization. Accessed September 11, 2020. 

https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

4. Smith JC, Hinman AR, Pickering LK. History and evolution of the advisory committee on immunization practices—United States, 1964-2014. 

5. About GRADE. Centers for Disease Control and Prevention. October 23, 2018. Accessed September 11, 2020. 

https://www.cdc.gov/vaccines/acip/recs/grade/about-grade.html

6. Coronavirus remains front and center at June ACIP meeting. The American Academy of Family Physicians. July 1, 2020.Accessed September 11, 2020. 

https://www.aafp.org/news/health-of-the-public/20200701acipjunemtg.html

7. Splete H. ACIP plans priority groups in advance of COVID-19 vaccine. MD Edge Hematology and Oncology. June 29, 2020. Accessed October 18, 2020. 

https://www.mdedge.com/hematology-oncology/article/224632/coronavirus-updates/acip-plans-priority-groups-advance-covid-19

8. Branswell H. Confusion spreads over system to determine priority access to Covid-19 vaccines. STAT. July 22, 2020. Accessed September 11, 2020.

https://www.statnews.com/2020/07/22/confusion-spreads-over-system-to-determine-priority-access-to-covid-19-vaccines/

9. Estimates of influenza vaccination coverage among adults—United States, 2017–18 flu season. Centers for Disease Control and Prevention. November 5, 2018. Accessed September 11, 2020. 

https://www.cdc.gov/flu/fluvaxview/coverage-1718estimates.htm

10. Herd immunity and COVID-19 (coronavirus): what you need to know.Mayo Clinic. June 6, 2020. Accessed September 11, 2020. 

https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808

11. United States COVID-19 cases and deaths by state

Centers for Disease Control and Prevention. October 18, 2020. Accessed September 11, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

A One Health expert outlines the many factors involved in determining who will receive a vaccine and urges us—for the time being—to keep calm and mask on.

Pandemics: Beyond “women and children first”

If you’ve been in clinical practice for more than a few weeks, you’ve probably worked with at least 1 retail pharmacy. Sometimes providing a script to an outside pharmacy is a necessity when your practice does not have the medication in stock. Other times, a client requests a prescription because the medication likely costs less at a retail pharmacy. According to the American Veterinary Medical Association (AVMA), veterinarians should honor all client requests for a written prescription.

Many clients are unaware of the headaches associated with these prescriptions, or the errors that may occur when a prescription is filled by a retail pharmacy. In 2012, the Oregon Veterinary Medical Association released the results of a survey investigating outcomes when veterinarians scripted medications to both online and brick-and-mortar retail pharmacies. Of the veterinarians surveyed, 35% had experienced an instance in which a retail or online pharmacy changed a prescribed dose or changed the medication itself without contacting the prescribing veterinarian, with 16.5% reporting that these changes led to adverse effects for the patient.

 Understanding why these problems arise and building relationships with pharmacists in your community can help to improve outcomes for your patients.

Why conflicts arise between veterinarians and pharmacists

Just as veterinarians are bound by ethical and legal obligations that govern the practice of veterinary medicine, pharmacists have professional requirements to which they must adhere. Pharmacists are legally required to verify the accuracy and validity of each prescription they fill, and to advise clients about potential side effects and drug interactions. For medications intended for people, this is simple to do because pharmacists have the knowledge and resources to fulfill these requirements. Unfortunately, pharmacists do not receive training in veterinary pharmacology as part of their core curriculum. This opens the door for error because for some drugs large differences exist between humans and animals with regard to in dosing and side effects.

Although it is easy to say that pharmacists should receive more education and have access to veterinary pharmacology resources, making this a reality is not so simple. The AVMA and National Association of Boards of Pharmacy (NABP) have worked together to increase awareness of the problems for both veterinarians and pharmacists and encourage the addition of veterinary pharmacology education to pharmacy school curricula.

The NABP has also modified its model practice act to add a requirement that a veterinary drug reference be available in any pharmacy where veterinary medications are dispensed.

 To date, only a handful of states have implemented this recommendation. If you are in a state that does not currently require a veterinary drug reference to be on hand in pharmacies filling pet medication prescriptions, consider reaching out to your state veterinary medical association. Encourage them to start a conversation with the state pharmacy board and advocate for this change.

Tips for building working relationships with community pharmacists

The AVMA’s Pharmacy and Prescription Resource Center offers detailed information about reducing prescription errors, writing prescriptions, compounding, pharmacy complaints, e-prescribing, clients education and more. Visit 

avma.org/resources-tools/animal-health-and-welfare/animal-health/pharmacy

To report a pharmacy error to the AVMA, visit 

avma.org/sites/default/files/resources/complaint_form.pdf

A recent survey of veterinarians and pharmacists in Ohio found that members of both professions felt that interprofessional collaboration was important to optimizing outcomes for veterinary patients.

 Sometimes, veterinarians become overwhelmed when working with pharmacies, developing a negative outlook on collaboration because of previous experiences. Here are several ways you can establish productive working relationships with pharmacists in your area:

Open the lines of communication with local pharmacies by visiting them or sending a letter (the AVMA has a sample letter available at 

). Introduce yourself and express your desire to work with the pharmacy for the best possible veterinary patient outcomes. Encourage the pharmacy team to contact you with any questions regarding pet prescriptions.

Donate an old copy of your favorite veterinary drug reference to your local pharmacy. Doing so may decrease the number of phone calls you receive from pharmacists.

Provide handouts for pharmacists that can serve as a quick reference guide on common toxins (eg, xylitol, acetaminophen) and prescription concerns (eg, changes in insulin type, thyroid medication doses).

Maintain patience when pharmacists do call with questions. Use these conversations as a chance to educate pharmacists and encourage them to continue calling.

Educate pharmacies about identification numbers. Many pharmacies will call asking for a national provider identifier (NPI) or Drug Enforcement Agency (DEA) number to fill a prescription. (The NPI is an identification number used for Medicaid patients.) Instead of saying “I don’t have an NPI number, and I won’t provide a DEA number for noncontrolled substances,” consider letting the pharmacist know 

 you don’t have an NPI and that the DEA opposes the use of a DEA number for identification purposes.

Always provide clear prescriptions. Written prescriptions are the best way to reduce miscommunication. Typed prescriptions are preferred, but legible, hand-written prescriptions are acceptable. Write out the entire prescription and avoid using abbreviations such as SID (once daily), which are not used in human medicine. Specify “no substitutions” when applicable, and write “must not contain xylitol” when prescribing suspensions, orally disintegrating tablets, and human chewable tablets.

Reach out to local pharmacy groups or schools and offer to provide a lecture on veterinary prescriptions.

Even with relationship building and improved education, errors may still occur. In these cases, it is important to reach out to the pharmacy to advise them of the error and discuss how to avoid the same error in the future. Additionally, errors can be reported to both the AVMA and the state pharmacy board.

Ultimately, it will take both veterinarians and pharmacists working together to improve the situation and prevent errors. Problems with pharmacies are common and frustrating for veterinary teams, but we encourage veterinarians to take the first step toward bettering working relationships. Neither the veterinarian nor the pharmacist wants to see a patient harmed, but it is only by working together that we can reduce conflict and maximize patient safety.

Kate Boatright, VMD, a 2013 graduate of the University of Pennsylvania, is an associate veterinarian and freelance speaker and author in western Pennsylvania. She is actively involved in organized veterinary medicine at the local, state, and national levels and is a former national officer of the Veterinary Business Management Association.

Lauren Forsythe, PharmD, DICVP, is a licensed pharmacist who is board certified in veterinary pharmacy. She has worked in retail pharmacy and currently supervises the pharmacy at the Veterinary Teaching Hospital at the University of Illinois.

1. Principles of veterinary medical ethics of the AVMA. American Veterinary Medical Association. August 2019. Accessed October 3, 2020. https://www.avma.org/resources-tools/avma-policies/principles-veterinary-medical-ethics-avma

2. Kolb G. Veterinary prescriptions & retail pharmacies summary of membership survey

 Oregon Veterinary Medical Association. September 2012. Accessed October 3, 2020. https://www.ftc.gov/sites/default/files/documents/public_comments/request-comments-and-announcement-workshop-pet-medications-issues-project-no.p121201-560891-00569/560891-00569-84588.pdf.

3. Regulators and stakeholders explore means to support safe dispensing of pet medications by community pharmacies. 

 2013;42(7):145-147.https://nabp.pharmacy/wp-content/uploads/2016/08/August_2013_NABP_Newsletter.pdf

4. Updated Model Act Available; Amended Language Addresses Timely Pharmacy Practice Topics. Newsletter NABP 44(8):157-158.

5. Fredrickson ME, Terlizzi H, Horne RL, Dannemiller S. The role of the community pharmacist in veterinary patient care: a cross-sectional study of pharmacist and veterinarian viewpoints. 

https://doi.org/10.18549/PharmPract.2020.3.1928

6.Inappropriate requests for Drug Enforcement Agency (DEA) registration numbers. American Veterinary Medical Association. Accessed October 3, 2020. 

https://www.avma.org/resources-tools/avma-policies/inappropriate-requests-drug-enforcement-administration-dea-registration-numbers

Veterinarians are keenly aware of the errors and frustrations that can occur when working with a retail pharmacy. Building relationships with pharmacists can help improve patient outcomes.

Why—and how—to build relationships with community pharmacists

How many of us have heard owners talk about their dog “slowing down”? “He’s just getting older,” they often say. Yet, according to Amber Ihrke, DVM, CCRT, CVA, CVSMT, CAC, CVPP, owner and medical director of Integrative Pet Care of Homer Glen in Homer Glen, Illinois, age alone does not cause pets to slow down. Instead, slowing down is a manifestation of underlying disease, and it is important to find the true cause and address it.

Commonly, the underlying cause is osteoarthritis (OA). OA affects 1 in 5 adult dogs and is the leading cause of chronic canine pain.

 It can lead to decreased quality of life, reduced performance and activity and, in some cases, eventual euthanasia. Ihrke told attendees at the American Veterinary Medical Association Virtual Convention that it is important to intervene before end-stage joint degeneration—preferably as soon as a patient’s activity level starts to decrease.

Ihrke first reviewed a bit about the pathophysiology and progression of OA.

 First, pathologic changes occur in the articular tissues, commonly manifested by thickened joint capsules. The synovial membrane then becomes inflamed, and the synovial fluid less viscous. Pain begins at this stage as a result of synovial inflammation, and it is during these early stages that intervening offers the most benefit. The next phase is cartilage deterioration. Finally, osteophytes develop and bone remodeling occurs. This mechanical failure of articular cartilage is the defining element of OA and is irreversible.

 No risk factors, patient is clinically normal

 At-risk dogs; clinical signs are difficult to detect, but physiologic factors of OA are present

 Mild OA; clinical signs are intermittent and include obvious impairment of the ability to perform certain daily activities, consistent alterations in body carriage, and muscle loss

 Moderate OA; patient has constant impairment of form and a diminished capacity to engage in activities of daily living

 Severe disease; mobility is impaired, and the patient’s ability to move or jump is decreased compared with previous normal activity

Clinical disease caused by these pathophysiologic changes can be quantified using the Canine OsteoArthritis Staging Tool (COAST), which categorizes OA into 5 stages (see 

 Owners typically start noticing reduced activity in their pets during stage 2, and patients are presented for evaluation most commonly during stage 2 or 3.

Before we can develop a treatment protocol, Ihrke said, we need to confirm the diagnosis. A thorough and systematic patient evaluation is important and should not be overlooked. This includes signalment (to help guide the differential diagnosis), a thorough history, gait assessment, physical examination, and diagnostic tests. The history should include detailed questions about the pet’s ability to perform various daily activities (eg, getting into and out of their bed, going up or downstairs, walking around the yard).

“It’s important to compare the pet’s current and past activity levels,” Ihrke said. “Knowing that a patient can walk 1 mile at the time of evaluation is a seemingly good sign, but it can be misleading if a couple months earlier the pet was able to walk 2 or 3 miles.” Additionally, be sure to establish whether the patient is a pet versus a performance animal.

When evaluating gait, do so in several situations, and from multiple directions, Ihrke advised. Assess the patient as they walk casually around the exam room and when moving on a leash at both a walk and a trot. Transitions from 1 position to another (eg, rising from lying down) can be telling, but these actions must be voluntary and without manual interference. Ihrke recommends using video recordings where possible and said use of a lameness scale is essential. “Many scales are available and will help objectively compare findings from 1 visit to the next, or assess accurately when evaluations are done by more than 1 associate,” she said. Importantly, the owner can conceptualize improvement more easily when they can see progress on a quantified scale.

The physical examination is clearly essential. The crepitus, range of motion, effusion, pain, instability (CREPI) system for joint evaluation provides a systematic approach.

 Palpate both sides of the patient, starting with the presumed unaffected areas. Assess muscle atrophy, joint swelling, asymmetry, muscle tenderness, and heat. The goal of the examination is to confirm the area of lameness and lead you toward a diagnostic plan. Much like a scoring system for gait is essential, a pain score is similarly important. The diagnostic plan would then include case-appropriate modalities, such as orthogonal radiographs and joint taps.

Ihrke presented a list of 5 management goals for dogs with OA:

These goals are best accomplished, she said, using a multimodal and comprehensive approach.

One of the starting points of treatment is nonsteroidal anti-inflammatory drugs. Adjunctive therapies such as amantadine, amitriptyline, or gabapentin (or combinations thereof) may also be used. Disease-modifying agents such as polysulfated glycosaminoglycans may also be beneficial and are commonly used. Omega-3 fatty acid supplements, chondroprotective supplements, and diets rich in eicosapentaenoic acid are also beneficial.

Ihrke sais this term is often better received by owners than “weight loss” or “diet,” and can have a great impact. Weight loss of 6.10% has been associated with a subjective decrease in lameness, and improvement on kinetic gait analysis can be seen with a weight loss of 8.85%.

 As such, her goal for patients is a standard 10% reduction in body weight, as weight optimization alone may help reduce clinical signs of OA.

Rehabilitation is part of the multimodal approach, but in itself is also multimodal. Environmental modifications to improve traction in the home (eg, carpet, yoga mats, booties) is 1 component. There are also many therapeutic aids, in addition to manual therapy. Thermotherapy employs a combination of cold packs (to reduce acute-phase inflammation) on affected joints, with hot packs (to increase blood flow, improve connective tissue extensibility, and promote muscle relaxation) on soft tissues in the surrounding regions. Other therapies include transcutaneous electrical nerve stimulation, which provides pain relief and can be used at home; photobiomodulation (therapeutic laser); hydrotherapy, which can reduce the load on hip joints by 60% when water is at hip level; therapeutic ultrasound; pulsed electromagnetic field therapy; and extracorporeal shockwave therapy. All of these modalities are used to reduce pain and inflammation or improve muscle relaxation and mobility. As such, some may be targeted to the affected joint and others on the adjacent muscle groups.

Manual therapy remains the most essential aspect of rehabilitation. “Above all other rehabilitation tools, manual therapy is always a component—and the cornerstone—of the treatment protocol,” Ihrke said. Manual therapy includes releasing trigger points, improving joint range of motion, and decreasing pain through massage.

The second most important aspect of the rehabilitation protocol is a therapeutic exercise program. “Fitness in dogs is not achieved via self-directed activities,” Ihrke said. “Walking around the yard is not the same as an intentional plan to target a specific group of muscles or a specific movement.”

Much like rehabilitation aids can be used to improve a patient’s pain control or function, intraarticular injections (eg, hyaluronic acid or corticosteroids) may do the same. These are administered on a case-by-case basis and are always prescribed alongside a corresponding rehabilitation plan. Further, intra-articular injections of platelet-rich plasma or stem cells may have a role in the future, particularly in early OA.

All of these aspects of evaluation and treatment circle back to setting goals for the patient. The goals set by a clinician must take into account the goals of the owner and the role of the patient (whether it is a pet, working dog, or performance dog). If the owner’s goals are unrealistic, have a discussion to reach a reasonable consensus. Ihrke advised setting SMART goals with clients: specific, measurable, attainable, relevant, and time-based. An example of a SMART goal is to improve weight-bearing of the right pelvic limb by 15% (relevant, measurable, and specific) in 4 weeks (time-based and attainable).”

Ihrke’s comprehensive patient evaluation plan includes signalment, a thorough patient history, gait evaluation, physical examination, and diagnostic testing. A multimodal treatment protocol, including medications, weight optimization, supplements, and rehabilitation, is best implemented in the earliest stages of joint progression when possible. In this way, we can provide the most benefit to dogs suffering from OA that need our help to maintain a favorable quality of life.

Rebecca A. Packer, DVM, MS, DACVIM (Neurology/Neurosurgery), is an associate professor at Colorado State University College of Veterinary Medicine and Biomedical Sciences in Fort Collins. She is active in clinical and didactic training of veterinary students and residents and has developed a comparative neuro-oncology research program at Colorado State University.

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4. Roe SC. Diagnosis and conservative management of joint disease. Paper presented at: 32nd Congress of the World Small Animal Veterinary Association Proceedings; August 19-23, 2007; Sydney, Australia. Accessed October 14, 2020. 

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Early recognition of degenerative joint disease combined with a multimodal treatment approach that includes a comprehensive rehabilitation plan can improve patient outcomes.

Rehabilitation and canine osteoarthritis: a multimodal approach

The serious nature of spleen removal surgery is often overlooked. Perhaps the fact that dogs can function well without the organ is partly to blame. Or maybe, as posited by Harry W. Boothe, DVM, MS, DACVS, professor emeritus of soft-tissue surgery at Auburn University College of Veterinary Medicine, it’s because for many years it wasn’t unusual for veterinary schools to use the procedure in junior surgical laboratory settings as an exercise in knot tying and ligation placement.

Years of experience have taught Boothe to see the surgery a little differently. He says that while splenectomies are often straightforward and predictable, he has been a part of many surgeries that haven’t fit that neat and tidy mold— both peri- and postoperatively. “There are a lot of things we don’t understand about the spleen,” Boothe explained during a session at the Fetch dvm360® virtual conference in August, “not the least of which is the 

cause of cardiac arrhythmias being associated with splenic masses, splenic enlargement, and splenectomies.”

Boothe began with a quick refresher on splenic anatomy. The spleen, he said, is suspended by the greater omentum and attached to the greater curvature of the stomach by the gastrosplenic ligament. The splenic artery arises from the celiac artery, which is the first branch of the abdominal aorta and divides into multiple smaller hilar branches before entering the spleen.

“In addition to supplying the spleen, the splenic artery supplies the left pancreatic limb," Boothe said. That pancreatic limb that lies caudal and parallel to the stomach is a lot closer to the spleen than I think we often realize—or at least the blood supply is. And I think part of
my concern with some of the minimal ligation techniques is that, particularly with splenic hilar disease, we could be a lot closer to embarrassing blood supply to the left pancreatic limb then we realize.”

Boothe added that it is important to remember that although the splenic veins parallel the splenic artery, they enter the portal vein, not the caudal vena cava. “We can use them to access the portal venous system and to evaluate portal venous pressures,” he explained.

There are several reasons for removing a patient’s spleen, including lesions and trauma. Boothe focused first on splenic torsion, explaining that the condition occurs when the spleen rotates around its vascular pedicle, resulting in venous obstruction and subsequent splenomegaly.

True to the textbooks, Boothe has seen splenic torsion consistently in large- and giant-breed dogs with deep-chested conformations. “In my experience, it’s usually an isolated event, meaning it’s not necessarily associated with trauma or other situations." But, he said, “we always look for splenic torsion in association with gastric-dilatation volvulus.”

Boothe explained that there are 2 possible presentations for dogs with splenic torsion: acute and chronic. Abdominal pain and collapse are common acute presentations, while vomiting, anorexia, intermittent abdominal pain, abdominal distension, polyuria, and polydipsia characterize chronic cases. “I can recall a case with chronic presentation that did very poorly following splenectomy,” said Boothe. “I think time is some- what of the essence in dealing with presumed or documented splenic torsion.”

Sometimes, splenectomies are straightforward and predictable. Other times, not so much. A veterinary surgeon shares tips for getting better outcomes in splenic torsion cases.