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VETERINARY PHARMACY

OVERVIEW
Wilson Gwin, RPh, DSVHP Elizabeth Young, PharmD, FSVHP
Director of Pharmacy Wasson Veterinary Pharmacy Resident
Purdue Veterinary Teaching Hospital Purdue Veterinary Teaching Hospital
DISCLOSURES
• The presenters, hereby state, that they have
no relevant affiliation or financial relationship
or relationship to products or devices with a
commercial interest related to the content of
this activity to disclose.
OBJECTIVES
• Explain the difference between veterinary and human
pharmacy, including example differences in dosing,
metabolism, and drug interactions.
• Describe common disease states and treatments in animal
patients (e.g., dogs, cats).
• Discuss commonly used and legally acceptable veterinary
compounded preparations.
• List reliable veterinary medicine drug information resources
and training opportunities.
SPECIES DIFFERENCES
ANATOMICAL AND
PHYSIOLOGICAL DIFFERENCES
• Majority of veterinary species
have a horizontal body
orientation instead of vertical
• Gravity does not facilitate
passage of solid dosage forms
to the stomach
• Chase orally administered
solids with at least 5-6 mL of
liquid or with a small amount of
food
Graham JP, Lipman AH, Newell SM, et al. Esophageal transit of capsules in clinically normal cats. Am J Vet Res. 2000;61(6):655-7.
Westfall DS, Twedt DC, Steyn PF, et al. Evaluation of esophageal transit of tablets and capsules in 30 cats. J Vet Intern Med. 2001;15(5):467-70.
Picture: https://3milliondogs.com/dogbook/15-facts-about-the-canine-anatomy-you-probably-didnt-know/
ANATOMICAL AND
PHYSIOLOGICAL DIFFERENCES
• Specific Metabolic Deficiencies
• Dogs:
• Absent acetylation
• Targeted functional groups: Aromatic - NH2
• Cats:
• Limited glucuronidation
• Targeted functional groups: -OH, -COOH, NH2 , =NH, -SH moieties
attached to either phenolic(ring) or alcoholic (straight-chain)
• Limited demethylation
• Targeted functional groups: -SH (purines)

Baggot JD. Principles of Drug Disposition in Domestic Animals: The Basis of Veterinary Clinical Pharmacology. Philadelphia, PA: WB Saunders Company;1977.
ANATOMICAL AND
PHYSIOLOGICAL DIFFERENCES
• Pharmacogenetic pholymorphisms within breeds
• Dogs: mutation of the ABCB1-1Δ allele affects p-glycoprotein
transport mechanisms in herding breeds
• Collies, Australian Shepherds, Whippets, Border Collies,
Shetland Sheepdogs

• Causes failure of the drug efflux pump allowing substrates


to cross the blood brain barrier, leading to severe central
nervous system toxicity

Mealey, Katrina L, and Kathryn M Meurs. "Breed Distribution of the ABCB1-1Delta (multidrug Sensitivity) Polymorphism among Dogs Undergoing ABCB1 Genotyping."
Journal of the American Veterinary Medical Association. 233, no. 6, 921-24.
COMMON TOXICITIES
Drug/Excipient/ Species Toxicity
Food Affected
Avocado Birds Pulmonary congestion, inflammation of the
liver, kidney, pancreas, skin, and proventriculus
Benzoic acid Cats RBC oxidative injury, hemolytic anemia
derivatives
Chocolate Dogs, Birds Cardiovascular and central nervous system
stimulation
Garlic, onions Dogs, Cats Hemolytic anemia
Grapes, Raisins Dogs Renal toxicity
Macadamia nuts Dogs Lethargy, hyperthermia, ataxia, vomiting
Xylitol Dogs, Birds Profound hypoglycemia and hepatocellular
necrosis
-Piscitelli, C.M.; Dunayer, E.K.; Aumann, M. Xylitol toxicity in dogs. -Eubig, P.A.; et.al. Acute renal failure in dogs after the ingestion of grapes or raisins: A
-Hargis, A.M.; Stauber, E.; Casteel, S.; Eitner, D. Avocado (Persea americana) intoxication retrospective evaluation of 43 dogs Gwaltney-Brant, S. Chocolate intoxication
in caged birds. -McKenzie, R.A.; et.al. Macadamia nut poisoning of dogs.
-Bedford, P.G.C.; Clarke, E.G.C. Experimental benzoic acid poisoning in the cat. -Todd, J.M.; Powell, L.L. Xylitol intoxication associated with fulminant hepatic failure in a dog.
1. What excipient prevents the use of human commercially
available medications in dogs?
A. Lactose
B. Xylitol
C. Mannitol
D. Benzoic Acid
COMMON DISEASE STATES OF
CATS AND DOGS SEEN IN
COMMUNITY PHARMACIES
HYPOTHYROIDISM IN DOGS
• Treatment:
• Goal: achieve T4 concentration in the normal range (1.5 – 4.5
mcg/dL)

• Levothyroxine – gold standard


• Initial dosing: 0.022 – 0.04 mg/kg every 24 hours or more commonly
as a divided dose every 12 hours
What is the initial Why such a large dose
Why twice daily?
human dose? compared to humans?
~1.6 •Low bioavailability Short elimination
mcg/kg/day •Higher GFR half-life
Plumb’s Veterinary Drugs. Levothyroxine. Available at: https://www.plumbsveterinarydrugs.com/#!/monograph/CEWcOGBgRE/ . Accessed March 17, 2018
HYPERTHYROIDISM IN CATS
• Treatment:
• Thyroidectomy
• Radioactive iodine ablation
• Lifelong medical management
• Methimazole
• Initial dose: 2.5 mg every 12 hours for 3 weeks, titrate to
effect
• Compound into an oral liquid or transdermal gel

Daminet S. Best practices for the pharmacological management of hyperthyroid cats with antithyroid drugs. J Small An Pract. 2014; 54(12):667-71.
Lécuyer M, Prini S, Dunn ME, et al. Clinical efficacy and safety of transdermal methimazole in the treatment of feline hyperthyroidism. Can Vet J. 2006;47(2):131-5.
Carney, Hazel C, Cynthia R Ward, Steven J Bailey, David Bruyette, Sonnya Dennis, Duncan Ferguson, Amy Hinc, and A Renee Rucinsky. "2016 AAFP Guidelines for the
Management of Feline Hyperthyroidism." Journal of Feline Medicine and Surgery. 18, no. 5, 400-16.
CANINE DIABETES MELLITUS
• Types of Insulins
• Rapid Acting: Not used often in dogs
• Regular Insulin: Used more as an in house insulin with monitoring
• Intermediate Insulin:
• Neutral Protamine Hagedorn (NPH)
• Porcine Insulin Zinc Suspension (lente insulin)
• Long-Acting Insulin:
• Detemir
• Protamine Zinc
• Glargine – used only in poorly controlled diabetes and who
failed NPH and lente insulin
Behrend, E., Holford, A., Lathan, P., et.al. 2018 AAHA Diabetes Management Guidelines for Dogs and Cats, 2018. J Am Anim Hosp Assoc 2018; 54:1-21.
CANINE DIABETES MELLITUS
• Porcine Insulin Zinc Suspension
• 40 unit/mL
• Intermediate Acting
• Initial Dosing: 0.5 units/kg SQ once daily (can be given twice daily at a 25% lower
dose)
• **SHAKE WELL**
• Protamine Zinc Insulin
• 40 units/mL
• Long Acting
• Initial Dosing: 0.5 units/kg SQ every 12 hours (can be decreased to once daily
depending on effect)

Behrend, E., Holford, A., Lathan, P., et.al. 2018 AAHA Diabetes Management Guidelines for Dogs and Cats, 2018. J Am Anim Hosp Assoc 2018; 54:1-21.
FELINE DIABETES MELLITUS
• Treatment Options:
• Oral antidiabetic agents are often not effective in cats, so
insulin is the mainstay of treatment
• Protamine zinc insulin
• Insulin glargine
• Porcine insulin zinc suspension

• The duration of action of Neutral Protamine Hagedorn


(NPH) insulin is too short to be useful in most cats (<12 hours)

Behrend, E., Holford, A., Lathan, P., et.al. 2018 AAHA Diabetes Management Guidelines for Dogs and Cats, 2018. J Am Anim Hosp Assoc 2018; 54:1-21.
CANINE MITRAL VALVULAR DISEASE
• Pimobendan
• Positive inotrope unique to veterinary medicine
• Has been shown to increase the time before therapy was
intensified and resulted in smaller heart size and less retention of
free water.
• Initial Dosing: 0.25 – 0.3 mg/kg PO every 12 hours

Häggström J, Boswood A, O'Grady M, et al. Longitudinal analysis of quality of Llife, clinical, radiographic, echocardiographic, and laboratory variables in dogs with
myxomatous mitral valve disease receiving pimobendan or benazepril: the QUEST study. J Vet Intern Med. 2013;27(6):1441-51
Atkins, C., J. Bonagura, S. Ettinger, P. Fox, R. Gordon, B. Haggstrom, V. Hamlin, Keene, Luis-Fuentes, and Stepien. "Guidelines for the Diagnosis and Treatment of
Canine Chronic Valvular Heart Disease." Journal of Veterinary Internal Medicine. 23, no. 6, 1142-150.
FELINE HYPERTROPHIC
• Clinical signs vary widely CARDIOMYOPATHY
• Many are asymptomatic until they experience sudden death
• When signs are present they include:
• Dyspnea and open mouthed-breathing
• Exercise intolerance
• Anorexia
• Tachypnea (>30 breaths/min)
• Vomiting
• Collapse
• Posterior paralysis and dragging hind limbs
• Due to saddle thrombus at the bifurcation of the aorta down the
rear legs
Luis Fuentes, Virginia, and Lois J Wilkie. "Asymptomatic Hypertrophic Cardiomyopathy: Diagnosis and Therapy." The Veterinary Clinics of North America. 47, no. 5, 1041-054.
Picture: https://www.cat-world.com.au/saddle-thrombosis-in-cats.html
FELINE HYPERTROPHIC
CARDIOMYOPATHY
• Treatment:
• Goals: enhance ventricular filling, relieve congestion, control
arrhythmias, minimize ischemia, and prevent thromboembolism
• Medications used:
• ACE Inhibitors, diuretics, antithrombotics, antiarrhythmic agents,
inotropes

Luis Fuentes, Virginia, and Lois J Wilkie. "Asymptomatic Hypertrophic Cardiomyopathy: Diagnosis and Therapy." The Veterinary Clinics of North America. 47, no. 5, 1041-054.
FELINE ASTHMA
• Treatment
• Goal: symptomatic relief

• Remove known or potential triggers


• pollen, perfumes, cigarette smoke, dusty cat litter
• Use of anti-inflammatory agents and bronchodilators

Reinero CR, Decile KC, Byerly JR, et al. Effects of drug treatment on inflammation and hyperreactivity of airways and on immune variables in cats with experimentally
induced asthma. Am J Vet Res. 2005;66(7):1121–7.
Cohn LA, DeClue AE, Cohen RL, et al. Dose effects of fluticasone propionate in an experimental model of feline asthma. In: 2008 American College of Veterinary
Internal Medicine Forum Proceedings; June 4-7, 2008; San Antonio, TX.
Scherk M. Bronchopulmonary disease in cats—is it really asthma? In: Proceedings of the 2010 Wild West Veterinary Conference; October 13-17, 2010; Reno, NV.
FELINE ASTHMA
• Anti-Inflammatory Agents
• Prednisolone
• **NOT PREDNISONE**
• Initiated at 1-2 mg/kg every 12 hours for 5 to 7 days, tapered
gradually to effect
• Fluticasone
• Considered therapy of choice for feline asthma because
of the relatively low incidence of systemic adverse effects
• Cyclosporine
Reinero CR, Decile KC, Byerly JR, et al. Effects of drug treatment on inflammation and hyperreactivity of airways and on immune variables in cats with experimentally
induced asthma. Am J Vet Res. 2005;66(7):1121–7.
Cohn LA, DeClue AE, Cohen RL, et al. Dose effects of fluticasone propionate in an experimental model of feline asthma. In: 2008 American College of Veterinary
Internal Medicine Forum Proceedings; June 4-7, 2008; San Antonio, TX.
Scherk M. Bronchopulmonary disease in cats—is it really asthma? In: Proceedings of the 2010 Wild West Veterinary Conference; October 13-17, 2010; Reno, NV.
FELINE ASTHMA
• Anti-Inflammatory Agents
• Fluticasone
• Considered therapy of choice for
feline asthma because of the
relatively low incidence of
systemic adverse effects
• Many vets initiate therapy with the
44 mcg inhaler as 1 to 2
actuations every 12 hours

Cohn LA, DeClue AE, Cohen RL, et al. Dose effects of fluticasone propionate in an experimental model of feline asthma. In: 2008 American College of Veterinary Internal
Medicine Forum Proceedings; June 4-7, 2008; San Antonio, TX.
Picture: http://vhc.missouri.edu/small-animal-hospital/small-animal-internal-medicine/diseases-and-treatments/understanding-feline-asthma/
2. True or False: Feline patients should always
receive a prescription for prednisolone,
instead of prednisone because cats cannot
metabolize the medication to the active
drug.
3. Which insulin needs to be shaken instead of
gently rolled prior to administration?
a) Insulin glargine 100 units/mL
b) Protamine Zinc Insulin 40 units/mL
c) Porcine Insulin Zinc Suspension 40 units/mL
d) Neutral Protamine Hagedorn (NPH) 100 units/mL
COMPOUNDED VETERINARY
DOSAGE FORMS
• Non-Sterile Compounds
• Oral Suspensions
• Oral Pastes
• Oral Capsules
• Chewable Treats
• Transdermal Gels
• Suppositories
• Ear Drops
• Sterile Compounds
• Eye Drops
• TPN’s
Davidson, Gigi. "Veterinary Compounding: Regulation, Challenges, and Resources." Pharmaceutics. 9, no. 1, Pharmaceutics. , 2017, Vol.9(1).
Picture: https://shop.fagron.us/en-us/connectionerror.aspx
COMMON COMPOUNDS
• Gabapentin Suspension
• Brand name contains xylitol
• Cisapride capsules and suspensions
• No longer commercially available
• Methimazole transdermal
• Only commercially available as tablets
• Prednisolone 10 mg/mL
• Commercially available as a 1 mg/ml or a 3 mg/ml

Davidson, Gigi. "Veterinary Compounding: Regulation, Challenges, and Resources." Pharmaceutics. 9, no. 1, Pharmaceutics. , 2017, Vol.9(1).
FLAVOR PREFERENCES BY SPECIES
Species Preference
Cat Meat, organ meat, fish
Dog Meat, salty, sweet
Horse Sweet, fruit, herbs/grasses
Ferret Meat, fish, sweet
• Birds flavor preferences are dietary dependent:
• Herbivorous and omnivorous birds, such as caged birds and
poultry, often prefer color and movement over flavor and
texture. For example, chickens usually prefer a colorful, wiggly
medicated gummy worm offered by hand over a flavored,
colorless, oral suspension delivered from an oral syringe.
Thombre AG. Oral felivery of medications to companion animals; palatability considerations. Adv Drug Deliv Rev. 2004;56(10):1399-1413.
Koppel K. Sensory analysis of pet foods. J Sci Food Agric. 2014; 94(11):2148-2153.
4. What is the reason for compounding a cisapride
suspension?
a) To make a different strength that is not commercially
available
b) To prevent xylitol toxicity in dogs
c) It is not currently commercially available
d) a & b
CONTINUING EDUCATION
OPPORTUNITIES
• Power-PAK C.E.
• Pharmacist Certificate Program in Veterinary Pharmacy
• 10 CE courses for a total of 22 credit hours
• $59.00

• https://www.powerpak.com/vet/
5. True or False: Merck Veterinary Manual is a good resource
for reviewing anatomic systems and the specific conditions
that are located in that system.
VETERINARY PHARMACY
OVERVIEW
Wilson Gwin, RPh, DSVHP Elizabeth Young, PharmD, FSVHP
Director of Pharmacy Wasson Veterinary Pharmacy Resident
Purdue Veterinary Teaching Hospital Purdue Veterinary Teaching Hospital