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Drug Monitoring

Dr. Elizabeth Feltes has shared how she empowers owners so they can be an integral part of drug monitoring in their animals.

As a veterinarian who sees a full-time behavior case load, obtaining client updates on medications is a huge part of my follow-up care. Drug monitoring can be one of the best ways to ensure continuation of care and to aid client compliance. But how do you do that if you often feel lunch is a thing of the distant past? With The Behavior Clinic’s approach, I feel any practitioner can educate their client to become a helpful part of the medical team.
First, education is key. That’s how, as clinicians, we know if drugs are working or not. Pass that education on to your client! Handouts can provide a great deal of security in what clients can monitor at home. Drug information sheets inform your clients of common side effects and guide them on what to watch for. But watching for side effects is very different than assessing how well a drug is working in a particular individual, especially if it’s the first time the drug is employed. We use a Drug Trial Handout for each short-acting medication used to help our clients prepare and execute each drug trial effectively. The handout is customizable for the drug, dose and duration of the trial. There are three separate sections that guide the owner through the information we want to obtain:

(1) How long until an effect is seen ? By knowing how long the trial should last, the client knows to continue looking for any effect throughout the time frame.
(2) What effects are noted ? Clients are instructed that any non-typical behavior (shorter duration of patient display, ataxia, etc.) should be recorded as a possible effect.
(3) How long do these effects last in duration? By the time a drug trial is over, the client can relay to the clinic what effects were seen during the trial, when they kicked in and how long they lasted. This allows for succinct communication in our busy day and an easy way to repeat a trial at a different dose.

Let’s look at a recent example from my clinic. “Toby” was a dog with an extreme fear of the vet clinic. He was being loaded on fluoxetine in an 8-week titration. However, he needed to have his rabies vaccine updated within the next three weeks. During a 3-hour consultation with his owners, we decided – based on his medical history and co-morbid diagnoses – to start with clonidine trials. Toby’s owners were instructed to use their customized Clonidine Trial handout to evaluate a 0.01 mg/kg dose over 6 hours when they would be home with him. They were to watch for latency to effect, log the effects and monitor their duration. The handout was to be emailed or faxed or the results called into our reception specialist in 2 days. We discussed that the effect we were looking for was less conflict signaling (a body language discussion was done 30 minutes prior to this) during touching of Toby (as that was his typical response to this situation) and a low level display of the problem behavior we were trying to change in a veterinary clinic.
When those results arrived, I determined not enough effect was noted as he still showed conflict signaling during petting. Another trial with a ½-tablet increase was performed and a new drug trial handout was emailed (there are three lines to enter on our end and three sections of log lines for the client to complete). More relaxation was noted when the next results were obtained and no conflict signaling was observed, so I asked that the client trial this dose 2 hours and 15 minutes (because that was Toby’s found latency to effect) before a scheduled Happy Visit at their referring clinic. Toby was able to be touched in a friendly manner by the RVT and DVM as well as eat (he was previously anorexic there) and be weighed. Toby went back for 2 subsequent Happy Visits on this dose, and it was determined he needed a higher dose prior to attempting an injection because conflict signaling (paw lift, head turns away) and a growl was elicited with the touch of a capped needle. A repeat of the above steps at another ½-tablet increase revealed that the increased dosage had a shorter latency to effect (1 hour 45 minutes) so an appropriately scheduled Happy Visit later, Toby was vaccinated without an aggressive display!
Drug trials with specifically mined information allowed for a successful outcome, likely at a faster pace. Toby’s mom was thrilled and stated that she felt comfortable with the trials because she felt like she had a lot of control of the situation, knowing  exactly what to watch for and how to get that information to me.

Clients are also often afraid of the side effects that they read about on the internet  or heard about at a dinner party. How do you combat information overload? An Adverse Event Log can help put side effects based on your trends into perspective. Medicine is an art, after all, and the way I prescribe fluoxetine may not be the same as another clinician. Monitoring side effects within my clinic walls provides a valuable perspective. After about 100 patient trials, I personally feel comfortable telling clients that I have a fair amount of experience with a particular medication in that I see a trend in side effects.
At the end of the day, it feels wonderful to have empowered my clients to become educated medical team members in the pursuit of a better day for their pets.

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