In House Prescription Monitoring.... discussing the many different meds (Rimadyl, Etogesic, Enacard, Phenobarbital, etc) that should have diligent monitoring, how to achieve this in a clinical setting, and how this betters patient care and increases clinic profitability"
Host: Lori Martindale, BS
May 12, 2002

***** Logging started: 5/12/2002 7:01:14 PM

Kristine: I am very interested to learn about the different medications used in the hospital. I have heard the names but am not familiar with their uses yet.

Lori: I'm a technician manager at a small animal clinic in Des Moines, Iowa.. tell me about yourself

Kristine: I just started working part-time at a local vet and am a Client Liaison -- learning vet tech things as well

Lori: what do you do as a Client liaison?

Kristine: I have a BS in Psychology and am extremely interested in animal behavior and animal psychology. As a client liaison, I am expected to act as the liaison between the clients and the vet. I am also being trained as a vet tech so I can help out wherever needed.

Lori: excellent! So getting to know the different meds, their usages and contraindications is important!

Nanette: I am an RVT and CVT, VT program instructor and working on my masters in vocational education, but I'm not currently in a practice.

Lori: I'm going to go ahead and get started. Please feel free to jump in with questons and comments at any time! If I am unclear about anything, please jump in! There are many medications that veterinarians prescribe daily that will be used on a long-term basis. Can you name any?

Kristine: Amytryptoline, barbitrol (spelling??)
Dawn: it would be good to know about drug interactions

Lori: Yes! Rimadyl and Etogesic, Lasix, Enacard, Digoxin, Levothyroxin, Tapazole, Prednisone, and others. Many of these drugs can cause serious side-effects alone and have important drug interactions or cautions. The implementation of an in-clinic monitoring program for long-term medication is key in ensuring that the medication you prescribe today doesn't cause the problems you will be seeing tomorrow.

Dawn: most don't think of that they just try to give correct doses

Lori: Do either of you currently have a drug monitoring protocol at your hospital?

Kristine: I believe we do along with anesthesia monitoring books
Dawn: we monitor controlled drugs and expirary dates im not sure about anything else... i'm pretty new at my work. We have a drug book that gets filled out as to what we use for pre anesthesia and for induction as well

Lori: well, we'll see if you can't take back some vital information for your clinic from tonight's chat!

Kristine: I greatly appreciate this opportunity, Lori.

Lori: One way to do this is by asking staff members to make a list of the most commonly prescribed medications. Then, take this list and discuss the medications individually over many staff meetings. Discuss the primary usage for the drugs, interactions and cautions that the drugs have, as well as conditions to watch for once a patient is on the medication.

If you don't have veterinarians that are "teachers", you can make this a homework assignment for staff members. Through researching the drug, you get a better understanding the hows and whys of it. Soon your staff members will be walking pharmacology books! This will allow them to easily answer questions that your clients have about the medications that are being given to their pets.

Once your staff is up-to-speed on medications, a monitoring schedule needs to be made. If a patient in going to be on a medication for more than four weeks, a blood panel, complete blood count, and electrolytes should be checked to make sure the patient does not have any pre-existing conditions that would make the medication contraindicated. Once the patient has been on the medication, a blood panel specific to the medication should be run every six to twelve months, to insure that we are not causing harm to our patient. The important thing is to create a clinic monitoring protocol and stick to it. Does this sound like something you could implement in your clinic if you're not already doing so?

Dawn: i think it could be brought up
Kristine: Sounds like something that is extremely important to have and follow by

Lori: Very true, Kristine... and, unfortunately, something that is all too often forgotten. Informing the client is key to keeping your monitoring program running smoothly. Owners want to do what is right for their pets.

Kristine: The tough part may be getting it started and training the staff, but something that in the long run would be extremely beneficial.
Dawn: yes and we want what's best for the pets too

Lori: If regular blood testing is necessary to keep their pet healthy, most clients will be willing to do so. Drug interactions and side-effects need to be explained to the clients, so they fully understand the importance of the blood work for their pets. It is also helpful to put a blood test reminder directly on the pet's prescription vial.

Dawn: that's a good idea that i never thought of before

Lori: Right now, who explains the medications to your clients?

Dawn: i think the veterinarians do and the receptionists
Kristine: The vet tech and/or the vet -- both most of the time to ensure that the client understands

Lori: Perfect! And do they give warnings with medications?

Kristine: Yes - we give each client a report card which provides a bullet for each item discussed and warning signs are included

Lori: That's awesome! Do you have clients that will ask about the warnings?

Kristine: We certainly do - wanting to know what the signs are if their pet has an allergic reaction and what to expect regarding behavior and such

Lori: Okay, let's identify appropriate blood monitoring protocols:

Carprofen (Rimadyl) is used for arthritis and pain relief.

Drug interactions and cautions include aspirin, medrol, prednisone, tylenol, phenobarbital, enalapril, and phenylpropanolamine.
Conditions to watch for include renal failure, hepatic failure and diabetes mellitus.
Baseline blood work should include ALKP, ALT, BUN, CREA, GLU, and TP.
Blood work rechecks should be at fourteen days and then every six months thereafter, consisting of ALT, ALKP, AST, BUN, and CREA.

Kristine: What is renal failure?

Lori: that is kidney failure.... there can be problems with both the kidneys and the liver associated with this drug. Because of this, blood monitoring of liver and kidney values are important

Kristine: So if one of these were to happen, what would be the timeframe?

Lori: Damage to those organs can sneak up on you. But, if you are vigilant in monitoring, you can catch it early. I have seen changes in ALKP and ALT (liver enzymes) at the first blood recheck.

Enalapril (Enacard) is used for heart disease.

Drug interactions and cautions: It may lower furosemide requirements; Rimadyl or Etogesic may cause increased dosage. Conditions to watch for include low blood pressure, elevated serum potassium and kidney damage.
Baseline blood work should consist of a full blood panel, including CBC and electrolytes
Monitoring should occur at thirty days, and then every six months, and should include ALT, ALKP, BUN, CREA, and electrolytes.

Nanette: Because kidney damage is one of the side effects, do you inform the client of anything concerning water intake (i.e. water available at all times)

Lori: Elderly dogs are often the ones that are medication for heart disease. Combine this with medication for arthritis, and you have double the problems to watch for! We always advise water available at all times, and recommend that the intake be observed for any changes as well as any changes in urine output

Kristine: So an outward symptom of kidney disease is increased water intake?

Lori: increased water intake can be an early warning sign, as well as increased urinary output

Nanette: It's all part of those physical exam things that you can find out before your DVM, that may get the client thinking before the DVM comes in :)

Lori: It's good to know... that way if the owner says "fluffy's drinking fine... and peeing up a storm" you should have bells going off!

Kristine: Is the increased urinary output due to the kidney overworking?
NanetteL: Hello all, this is my first time joining vspn and chat.

Lori: Increased urinary output is due to the kidney's decreased capacity to work. The water is then not reabsorbed into the body, which is why your renal failure patients are often dehydrated... ...Think really old emaciated kitty.... Their kidneys just aren't doing their job getting that fluid back into the body where it belongs

Kristine: I understand - it all makes sense

Etodolac (Etogesic) is used for arthritis and pain relief.

Drug interactions include aspirin, medrol, prednisone, tylenol, pheylpropanolamine, and enalapril.
Conditions to watch for include potentially fatal bleeding ulcers in the stomach and intestine, diabetes mellitus and hepatic failure. These are much the same signs that Rimadyl has, however, Etogesic seems to be less hepatotoxic.
Baseline blood work should include ALKP, ALT, BUN, CREA, GLU, and TP.
Monitoring should occur at thirty days, and then every six months thereafter, and should consist of ALT, ALKP, BUN, and CREA.

Furosemide (Lasix, Salix) is used in treating heart disease.

Drug interactions include altering effects of or be affected by theophylline, prednisone, Medrol, rimadyl, etogesic, enalapril, and digoxin.
Conditions to watch for include increased thirst and urination, dehydration, electrolyte imbalances, GI upset, anemia, restlessness and weakness.
Baseline blood work should consist of a full blood panel, including CBC and electrolytes.
Monitoring at thirty days and then every six months thereafter, with ALT, ALKP, BUN, CREA, CBC, and electrolytes.

Levothyroxine (Soloxine) is used to treat hypothyroidism.

Drug interactions may include altering insulin and digoxin requirements.
Baseline blood work should consist of ALKP, ALT, BUN, CREA, GLU, TP and Total T4.
Monitoring of the Total T4 should be done at thirty days and then every six months thereafter. Blood should be taken 4 - 6 hours after administration.

Nanette: How about T3 measurements? And....special handling? (sorry, been awhile since I've sent bloodwork in )

Lori: At my clinic, we will often do a full thyroid panel if the total T4 is borderline normal, however, for monitoring of the levothyroxine, total T4 is all that is necessary. As to special handling, the blood needs to be in a PLAIN (not serum separator) tube. Serum Separators may give you falsely elevated readings

Methimazole (Tapazole) is used to treat hyperthyroidism.

Contraindications include: It is not for patients with liver disease or clotting disorders Side effects include anorexia, GI upset, bleeding, low white blood cell count and platelet counts. Baseline blood work should include a full body profile, including CBC, and electrolytes, and a Total T4.
Blood work should be rechecked at fourteen days and then every three to six months thereafter, including Total T4, ALKP, ALT, BUN, CREA, and CBC.
** It's always important to keep current with your laboratory's protocol for medication monitoring purposes ie, drawing times post-pill, specific tube requirements, etc

Phenobarbital is used for epilepsy and seizures.

Conditions to watch for include lethargy or depression, anxiety or agitation, increased thirst, appetite and urination.
Baseline blood work should include a full body panel, including CBC and electrolytes.
Monitoring: A phenobarbital level should be checked at fourteen days until stable and then every six months. ALT, ALKP, BUN, and CREA should be checked at thirty days and then every six months.

Prednisone, Prednisolone, and Medrol are used for treating allergies and other corticosteroid-responsive conditions.

Drug interactions may include: Rimadyl, Etogesic, aspirin, or tylenol
Conditions to watch for include: Side effects include increased appetite, thirst and urination; Cushing's disease; GI ulcers; increased appetite and weight gain; activation or worsening of diabetes mellitus, hypothyroidism, pancreatitis, muscle wasting, and behavioral changes.
Baseline blood work should include ALKP, ALT, BUN, CREA, GLU, and TP.
Monitoring should occur at thirty days, and then every six months thereafter, consisting of ALT, ALKP, BUN, and CREA.

Selegilene (Anipryl) is used for Cognitive Dysfunction Syndrome and Cushing's Disease.

Drug interactions include Amitraz (mitaban, preventic collar), amitriptyline, Prozac, and ephedrine.
Conditions to watch for include: Side effects include restlessness or agitation, vomiting, disorientation, anorexia, and anemia.
Baseline blood work should include a full body panel including CBC and electrolytes, and a Total T4.
Monitoring, consisting of ALT, ALKP, BUN, and CREA, should occur at thirty days and then every six months thereafter.

Lori: So, as you can see, many of these drugs can and are prescribed concurrently. Knowing the side-effects, as well as drug interactions, is key to keeping our patients happy and healthy.

A table of commonly prescribed long-term medications is available through IDEXX (1-800-355-2896). They also have excellent pamphlets on Monitoring Your Pet's Medication, which explain the importance of regular blood testing.

In-clinic medication monitoring must be a team approach. With good guidelines, information, and communication comes a smoothly running pharmacy, healthier patients, and a boost to the bottom line.

Anyone have any questions or comments?

Kristine: The more information we can have, the more information we can give. Pamphlets are a great idea because most clients don't remember what they were told after they leave.

Nanette: What is the real deal with Sucralfate.....when do you give...since it coats? Great info for the handouts! Thanks! I love the idea of pamphlets and such.....That would be a great thing to be able to point out to a client, maybe highlight specific points

Lori: With sucralfate you have to wait at least 30 minutes between giving it and reglan or cimetidine... patients on these meds can be a real handful!

Nanette: which first?

Lori: We had to put a sign in our pharmacy stating give cimetidine at least 30 minutes prior to sucralfate, because we got sick of looking it up!

Nanette: what about if it's longer than a half hour?

Lori: It has to be AT LEAST 30 minutes... longer is better

Give Carafate at least 30 min before Cimetidine (Carafate needs an acidic environment to work in).
Give Reglan at least 30 minutes after Cimetidine (Reglan may change the rate of absorption of it)

Nanette: okay good to know. Great information!

Lori: My key to remembering it is that cimetidine has to have acid in the stomach in order to work... and sucralfate would partially block that through coating action. I apply the same rule to cimet. and pepto, although I don't know if it's true or not

Kristine: What type of reference books due you recommend? Is their a "Pill Book" for animals as there is for humans?

Lori: We use and love Plumb's (aka the little red book) and have added to it through photocopies of OTC medication dosages, offlabel usages, etc. There is even an Herbal book out now!

We taped the photocopies in the back between the extra pages. For offlabel usages, we either write it with the drug, or put it on those extra pages... especially if it's something we use often but can't remember!

Kristine: What due you mean by "offlabel usages"?
Nanette: good idea

Lori: offlabel usages would be using the drug for things other than it is specifically labeld for ie, using ivermectin as a mite medication

Kristine: Well, this has been very helpful and I will most definitely look into our monitoring procedures. Thank you, Lori!!
NanetteL: Thank you for all the good info.

Lori: Thank you all for coming! Good luck in rounding-out your monitoring programs!

***** Logging stopped: 5/12/2002 8:08:23 PM

Participants: Nanette, Dawn, Kristine, NanetteL