Benzos in animals..

[Chrish]

Gettings,

Pharmacist here. We have an owner who gets Xanax 2 mg # 30 tabs approximately every 45 days for anxiety for her dog.

I have a concern about legitimacy of this prescription, especially it being relatively high dose of Xanax. My question is, can this kind of dose be justified in rare circumstances? How often if ever do you guys prescribe benzos in your practice?

Thanks

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[Minnerbelle]

Gettings,

Pharmacist here. We have an owner who gets Xanax 2 mg # 30 tabs approximately every 45 days for anxiety for her dog.

I have a concern about legitimacy of this prescription, especially it being relatively high dose of Xanax. My question is, can this kind of dose be justified in rare circumstances? How often if ever do you guys prescribe benzos in your practice?

Thanks

Why don’t you call the prescriber and ask? That’s the easiest way to get to the bottom of it. They’ll either say yes that is what I prescribed the patient for situational anxiety or whatever, or they’ll tell you it’s fishy.

If you’re asking if the veterinarian is off base, I suggest you get a veterinary formulary for your pharmacy. It’s pretty cheap to get the plumbs app or a physical copy (do they still have those?).

 

[battie]

Also can't really give an answer without the weight of the patient or frequency of dosing 🤷🏼‍♀️ There are certainly veterinarians that would be prescribing Xanax with regularity if they're behavior specialists. Just not enough info in your post to give even general information.

 

[VIN-Foundation]

Our patient size can very by a 2 orders of magnitude; and that's just for dogs. Add in horses and cattle and it's even more. So veterinarians almost always dose by patient weight. 2 mg alprazolam would be well within a typical dose range for a larger dog. And veterinarians often write for benzos, depending on specific scope of practice.

But the only and the best way to know for sure is to communicate directly with the prescriber, it possible.

 

[Chrish]

Our patient size can very by a 2 orders of magnitude; and that's just for dogs. Add in horses and cattle and it's even more. So veterinarians almost always dose by patient weight. 2 mg alprazolam would be well within a typical dose range for a larger dog. And veterinarians often write for benzos, depending on specific scope of practice.

But the only and the best way to know for sure is to communicate directly with the prescriber, it possible.

That answers my question. Thanks.

Not necessarily vets, but we often call dr offices for clarification on such matters but don’t necessarily get detailed information. And I have even encountered scenarios where doctor was writing high dose control prescriptions for someone who works in the office.

So, I was just curious if such dose is rare or common practice.

 

[JaynaAli]

That answers my question. Thanks.

Not necessarily vets, but we often call dr offices for clarification on such matters but don’t necessarily get detailed information. And I have even encountered scenarios where doctor was writing high dose control prescriptions for someone who works in the office.

So, I was just curious if such dose is rare or common practice.

I’m not trying to beat a dead horse after your question has been answered, but a common sentiment I see in vet groups and forums is “I wish the pharmacist would have just called and talked to me about it”. So seriously, if you’re ever wondering about a vet prescription, just call the vet. There are things that are dosed very different than in humans or used for other purposes if you’re not familiar with veterinary prescriptions. Like literally every vet I know would happily take a minute to accept a phone call from a pharmacist and explain their reasoning and ask you to fill as requested/educate you or thank you for catching a true mistake.



Also vets don’t have NPI numbers and even though many commercial systems want you to use a DEA number to look up the provider if we don’t have an NPI, some of us don’t even have a DEA license and we don’t have to provide a DEA for non-controlled substances anyway.

 

[Chrish]

I’m not trying to beat a dead horse after your question has been answered, but a common sentiment I see in vet groups and forums is “I wish the pharmacist would have just called and talked to me about it”. So seriously, if you’re ever wondering about a vet prescription, just call the vet. There are things that are dosed very different than in humans or used for other purposes if you’re not familiar with veterinary prescriptions. Like literally every vet I know would happily take a minute to accept a phone call from a pharmacist and explain their reasoning and ask you to fill as requested/educate you or thank you for catching a true mistake.



Also vets don’t have NPI numbers and even though many commercial systems want you to use a DEA number to look up the provider if we don’t have an NPI, some of us don’t even have a DEA license and we don’t have to provide a DEA for non-controlled substances anyway.

True that you don’t have to provide DEA number for non-controlled prescriptions but the way at least our system is set up (large retail chain), we don’t have any other way of entering the provider in our system without NPI/ DEA.

We have no choice but to turn away some prescriptions because vet office didn’t want to provide us with DEA info.

 

[JaynaAli]

True that you don’t have to provide DEA number for non-controlled prescriptions but the way at least our system is set up (large retail chain), we don’t have any other way of entering the provider in our system without NPI/ DEA.

We have no choice but to turn away some prescriptions because vet office didn’t want to provide us with DEA info.

Then maybe if y’all are going to be filling vet prescriptions y’all pharmacists should advocate to management to change that. I’m pretty sure the DEA even states that the DEA numbers aren’t really supposed to be used for identification anyway. I know it’s not something you can change yourself but it’s a major headache for many vets, and I imagine for y’all as well.

 

[battie]

Then maybe if y’all are going to be filling vet prescriptions y’all pharmacists should advocate to management to change that. I’m pretty sure the DEA even states that the DEA numbers aren’t really supposed to be used for identification anyway. I know it’s not something you can change yourself but it’s a major headache for many vets, and I imagine for y’all as well.

You are absolutely correct the DEA specifically states the number shouldn't be for identity since it's based on location, not the person. So I can't use my DEA for drugs for patients I see at location A when it's linked to location B. Instead a separate doctor's DEA is used for that hospital.

Honestly, any pharmacy (large chain vs private vs other) that is going to fill veterinary prescriptions should be required to have staff CE include veterinary pharmacology and how our part of the medical world works.

 

[Minnerbelle]

I’m not trying to beat a dead horse after your question has been answered, but a common sentiment I see in vet groups and forums is “I wish the pharmacist would have just called and talked to me about it”. So seriously, if you’re ever wondering about a vet prescription, just call the vet. There are things that are dosed very different than in humans or used for other purposes if you’re not familiar with veterinary prescriptions. Like literally every vet I know would happily take a minute to accept a phone call from a pharmacist and explain their reasoning and ask you to fill as requested/educate you or thank you for catching a true mistake.

.

Yup this is more or less what I was getting at. Please please please do not ever change the rx, deny an rx, or advise a pet owner without talking to the prescribing veterinarian first. You may think you’re being helpful with excellent intent, but causes a lot of harm. I regularly need to warn clients that the pharmacist is going to tell them x, y, or z about particular drugs but to not to accept those things and to have the pharmacist call me if they have any issues.

Maybe you don’t, but these are issues vets gripe about all the time when dealing with human pharmacists.

 

[DVMDream]

I know it has been stated already, but definitely call the veterinarian and verify. I would really appreciate a call from a pharmacist to discuss a medication, dose, route, quantity, etc than for them to ask a random internet forum. Could that be the dose they prescribed and be fine? Yes. Could the owner have a drug problem and be utilizing the dog for that problem? Also yes. You can't know without opening that line of communication. I will happily get on the phone with any pharmacist with a question.

Medications in dogs and cats are quite different and can have significantly different doses. I had a canine patient once with severe, severe separation anxiety. I was seeing him after he had caused himself minor injuries due to his severe separation anxiety. I prescribed him two common behavioral medications to be used concurrently for his separation anxiety. I prescribed typical doses. The pharmacist didn't change the doses, but made a comment to the owner along the lines of "I don't know why she prescribed such high doses and both of these drugs together, this doesn't seem safe." So the owner proceeds to not give one of the medications and gives a reduced dose of the other. I see the dog again about 6 weeks later due to severe injuries. The dog had become so anxious it chewed its way through a garage door, into the garage, tore through things in the garage, cutting itself on the door, drywall and other items. The dog had severe lacerations totaling nearly $1k in surgical repairs. I had to explain to the owner why I picked those medications together and those doses. Once the owner started to follow my recommended treatment, the dog did much better and stopped injuring itself from severe separation anxiety.

Just please reach out to us.

 

[DVMDream]

Examples of how medications vary between dogs, cats, humans.

A good example is levothyroxine. Levothyroxine in humans is dosed in micrograms, in dogs it is dosed in milligrams. Large dogs can easily take up to 0.8-1.0mg of levothyroxine twice a day. Dogs can tolerate really large doses of levothyroxine and need higher doses for treatment and management of hypothyroidism.

Another example is acetaminophen. Humans can tolerate some fairly decent doses compared to dogs and definitely compared to cats. Dogs can tolerate small doses of acetaminophen, but it is generally not a recommended pain control for dogs. Cats can't tolerate any amounts of acetaminophen. Acetaminophen is metabolized in multiple different ways, one of which is glucuronidation. Glucuronidation creates a non-toxic metabolite, cats have significant lack of the enzyme that does glucuronidation. While cats can metabolize the acetaminophen via the sulfation pathway (to non-toxic metabolites), they also have a reduced amount of this pathway and once this pathway is saturated, the acetaminophen is then broken down into the toxic NAPQI metabolite by cytochrome p-450. Cat's red blood cells are really susceptible to the effects of NAPQI and cats very easily develop methemoglobinemia when given acetaminophen.

NSAIDs are another great example. Human medicine has great NSAIDs: ibuprofen, naproxen, diclofenac, celecoxib, indomethacin, etc. Dogs and cats generally can't tolerate human NSAIDs and they can develop GI ulceration and acute kidney injury. We do have some veterinary specific NSAIDs for dogs and a couple of ones for cats. Cats in general are very sensitive to the effects of NSAIDs, even the veterinary specific ones we monitor blood work closely in cats and dogs taking NSAIDs chronically.

Another thing we worry about in dogs especially that isn't worried about in humans are any products containing xylitol. Human medications can sometimes contain xylitol, so we have to be wary of that as well. Xylitol will cause hypoglycemia and potentially liver failure in dogs.

Never hesitate to reach out to a veterinarian if you have a question. Dogs and cats are much different than humans and different from each other. We use some things in humans that should never be given to a dog or cat, and there are some things we use in dogs and cats that aren't and shouldn't be used in humans.

 

[Chrish]

Examples of how medications vary between dogs, cats, humans.

A good example is levothyroxine. Levothyroxine in humans is dosed in micrograms, in dogs it is dosed in milligrams. Large dogs can easily take up to 0.8-1.0mg of levothyroxine twice a day. Dogs can tolerate really large doses of levothyroxine and need higher doses for treatment and management of hypothyroidism.

Another example is acetaminophen. Humans can tolerate some fairly decent doses compared to dogs and definitely compared to cats. Dogs can tolerate small doses of acetaminophen, but it is generally not a recommended pain control for dogs. Cats can't tolerate any amounts of acetaminophen. Acetaminophen is metabolized in multiple different ways, one of which is glucuronidation. Glucuronidation creates a non-toxic metabolite, cats have significant lack of the enzyme that does glucuronidation. While cats can metabolize the acetaminophen via the sulfation pathway (to non-toxic metabolites), they also have a reduced amount of this pathway and once this pathway is saturated, the acetaminophen is then broken down into the toxic NAPQI metabolite by cytochrome p-450. Cat's red blood cells are really susceptible to the effects of NAPQI and cats very easily develop methemoglobinemia when given acetaminophen.

NSAIDs are another great example. Human medicine has great NSAIDs: ibuprofen, naproxen, diclofenac, celecoxib, indomethacin, etc. Dogs and cats generally can't tolerate human NSAIDs and they can develop GI ulceration and acute kidney injury. We do have some veterinary specific NSAIDs for dogs and a couple of ones for cats. Cats in general are very sensitive to the effects of NSAIDs, even the veterinary specific ones we monitor blood work closely in cats and dogs taking NSAIDs chronically.

Another thing we worry about in dogs especially that isn't worried about in humans are any products containing xylitol. Human medications can sometimes contain xylitol, so we have to be wary of that as well. Xylitol will cause hypoglycemia and potentially liver failure in dogs.

Never hesitate to reach out to a veterinarian if you have a question. Dogs and cats are much different than humans and different from each other. We use some things in humans that should never be given to a dog or cat, and there are some things we use in dogs and cats that aren't and shouldn't be used in humans.

Appreciate you taking time to write these posts. I never tell owners to make any changes to vet regimens because I don’t have any access to pet’s info (weight, age, symptoms etc.). All I personally care about is potential abuse by the owner of meds prescribed for the pet. Anytime I see an rx of benzos, I have very hard time believing that owner is NOT using it personally. You can say years of working in pharmacy has made me quite a cynic.

Xylitol was a big deal recently. Our chain discontinued liquid gabapentin solution containing Xylitol for dog prescriptions and had us ordered the one without it.

 

[Chrish]

PS rx in OP has been getting filled for about 8 months at my pharmacy. Owner is requesting it every 1.5 - 2 months. It was verified by other pharmacist at one point (though there is no other detail).

That was the reason for creating this thread. Are benzos used in animals for chronic use instead of situational anxiety like thunderstorms?

 

[battie]

That was the reason for creating this thread. Are benzos used in animals for chronic use instead of situational anxiety like thunderstorms?

They can be depending on the patient and their clinical state. As DVMD said, there's the possibility the client is or isn't abusing the meds. So calling the clinician would give you that relevant info to make that distinction.

 

[DVMDream]

PS rx in OP has been getting filled for about 8 months at my pharmacy. Owner is requesting it every 1.5 - 2 months. It was verified by other pharmacist at one point (though there is no other detail).

That was the reason for creating this thread. Are benzos used in animals for chronic use instead of situational anxiety like thunderstorms?

I get it, as vets we have to take the same DEA opioid/controlled drug abuse CE. We're responsible for watching for drug abuse as well. Which is why I strongly recommend you reach out to the prescribing vet just to be sure everything matches with what they've prescribed. It will be the only way to know for sure if it is legitimate or if there's something else going on.