Use knowledge, not fear, to make pet drug decisions

My sister-in-law is a pharmacist – not the kind who hands out your prescriptions at the drug store, but an expert in drug interactions, side effects and the use of medications in the elderly and chronically ill.



A few years ago, we were discussing the use of pain medications in patients with kidney disease. "You know," she said, her head tipped to the side, "you know more about drugs than any non-pharmacist I've ever met."



I had to laugh. "You can say that until we start talking about some drug that's not used in dogs and cats."



So if you want to know my thoughts on, say, cholesterol-lowering drugs, I got nothin'. But if you want to know what I think about how, when, and with what we drug our pets, that's a different story.



Fear and lack of information are the greatest enemies of effectively and safely treating our pets' illnesses, injuries, and pain. We're afraid of drugs, and don't know how to get the information that would allow us to put that fear in context. Just as with human medicine, the influence of drug companies and their sales reps has eroded the trust we might otherwise have in our doctors and veterinarians, and so we turn to other pet owners and the Internet for advice.



But those sources are suspect, too. Much of the health "information" on the Web is nothing but scare tactics, and it's often tainted by commercial interests itself. There are many people fear-mongering about prescription drugs who are selling herbal alternatives that purport to do the exact same thing. And while sometimes alternative therapies are effective and safe, it's actually harder to evaluate most of them than the drugs with which they're competing because there has been less research done into them.



Even among those who have nothing to sell you, agendas you can't know about -- or sometimes even imagine -- are compromising the information you're getting. People become such passionate believers in certain philosophies and ways of life that it colors everything they think, say, and advocate. It's like some of my fellow raw/homemade diet feeders; everything is caused and cured by diet. They don't want to hear about anything else – and don't, usually by putting their hands over their ears and going "la la la, I can't hear you."



Big Pharma on the left, snake oil on the right. You're paralyzed with indecision and mistrust, but your dog has arthritis or your cat has kidney disease. You don't have the luxury of doing nothing. So what exactly do you do?



The answer is to educate yourself. It would be nice to be able to sit back, knowing the experts have done all the work for you and you can just be a passive consumer of health care, but that's no more reality in veterinary medicine than it is in human medicine. If you want the best for your pets, you have to work at it. Here are a few of my tips on how to do that:



Expect more of your pet's veterinarian. When you fill a prescription for yourself at a pharmacy, you're given the package insert and label information, as well as a consultation with the pharmacist, who will go over the instructions and answer your questions.



When your pet's veterinarian dispenses drugs to you for your dog or cat, that's exactly what should happen, but it rarely does. In fact, I've seen many vets respond to questions about side effects with a dismissive, "I've never seen any problems."



That's not an acceptable answer, even if it's true. The side effects of prescription medications are known. They're listed in books like Plumb's Veterinary Drug Handbook, and on the labels and inserts of the drugs themselves. The wording of those warnings are mandated by law, and you are entitled to that information. You need to politely and consistently ask about side effects, drug interactions, and contraindications.



And veterinarians need to realize that this isn't a threat to their authority but its best and most potent expression. It's ironic given how many vets are fighting to keep their drug dispensing in-house but still fail to use the one thing they have that no human, chain, big-box, or Internet pet pharmacy can offer: their expertise as veterinarians, and their knowledge and experience with veterinary drugs



It's all about risk vs. benefit. The words "safe" and "unsafe" get thrown around a lot, but the truth is, those aren't absolute terms. Virtually everything has the potential for some risk and some benefit, and where on the spectrum a given substance or therapy falls is going to vary by the individual and the situation.



You also have to consider the risk and benefit of doing nothing. Take urinary incontinence, a problem that affects as many as 20 percent of all spayed female dogs. Not treating it will protect your dog from the dangers of synthetic hormone therapy (DES) or a banned human decongestant (PPA), but it will also expose her to chronic skin irritation and a potentially increased risk of urinary tract infections.



And having a dog who constantly leaks urine can also be fatal, if it results in a frustrated owner taking her to the shelter. That has to be part of the "risk vs. benefit" math, too.



So if you're considering a medication for your pet, be sure you examine all the alternatives, including doing nothing, and ask not only about risk but benefit. That process generally does make the right answer pretty clear.



Are there safer alternatives? For all I get annoyed at the baseless claims of many "natural" products, there are several alternative treatments that are very safe, very effective, and very well-studied – and often, very unknown to your pet's veterinarian. Resources like the "Physician's Desk Reference of Herbal Medicine" or the excellent reference book "Herbs for Pets" can help you make informed decisions about them, and might spare your pet some unnecessary side effects. (You can also find my SFGate.com column about some of my favorites here.)



For example, the standard prescription for symptoms of inflammatory bowel disease or irritable bowel syndrome in dogs is the drug Flagyl (metronidazole). This drug has some pretty severe possible side effects, and while it can help control the symtoms of IBD and IBS in dogs, there's no reason it should be the first line of treatment. Dietary therapy -- including homemade diets -- and the use of proven, safe herbs like peppermint have given thousands upon thousands of dogs as much or greater symptomatic relief with absolutely no side effects at all.



The same is true of painkillers. Why are non-steroidal anti-inflammatory drugs (NSAIDs) like Rimadyl, with their known risks including ulcers, kidney damage, and even death, almost always the first treatment offered for dogs with arthritis, when the human generic drug tramadol has far fewer and less serious side effects?



Look for the balance between "tried and true" and "new and improved." When new human drugs come out, Big Pharma gets into gear with a massive marketing campaign aimed at you, and another one aimed at your physician. The same thing happens with veterinary products, albeit with a smaller budget.



Many veterinarians quite rightly resist making their patients test subjects for a new drug, and prefer to give a new medication some time to prove itself. Others, again quite rightly, feel that it's not fair to let their patients suffer through their learning curve, and stick with procedures and therapies that are familiar to them instead of adopting new methods of anesthesia, pain control, or disease treatment.



But sometimes there really is a revolution in efficacy or safety, and clinging to an outmoded therapy can put your pet at risk. When new veterinary NSAIDs came on the market, many vets continued to give steroids, not because they were safer – they can be, but usually aren't – but because they mistrusted the new drugs. Others kept prescribing aspirin because they were familiar with it, without explaining or perhaps even understanding that aspirin, too, is a NSAID, and shares the same risks.



To be fair, many dog owners are probably glad their vets took their time here, because the side effects of NSAIDs in dogs weren't well-explained or publicized in the early days. But despite those side effects, which can include death, there are many dogs who are happily and safely on NSAIDs for years, who experience relief of pain and improved quality of life without any side effects at all – particularly those dogs whose veterinarians follow the monitoring protocols recommended by the FDA for long-term NSAID use.



The point is that you want to find the right balance for your pet and his particular situation; your vet shouldn't reject or accept a new treatment simply because it's new.



Sometimes less actually is less… less effective and less safe. It's easy to believe that giving fewer drugs will reduce the risk of drug side effects, but there are many times when the opposite is true. For instance, gas anesthetic drugs are safer when used in combination with other drugs known as "induction agents," which reduce the side effects of the gas and also allow less gas to be used.



When giving pain medications, it's often safest and most effective to use two or more drugs that attack the pain in different ways. Combining tramadol with NSAIDs, for instance, may allow you to use the NSAID only for "breakthrough" pain, or at a lower dose. And combining a GI protectant drug like misoprostol with NSAIDs will reduce the risk of one of the worst and most common of their side effects: ulcers.



The bottom line is this: don't let fear of the treatment leave your pet suffering. Yes, there are often safer alternatives to what your veterinarian is prescribing. No, you can't just blindly trust someone else to figure this all out for you – including me. Your pets can't do this research for themselves, so you're going to have to do it for them.

Comments

[Susan]

I am always eager to do such research, but less than eager to fix what's not broken. For example, my bulldog was on rimadyl for many years -- followed by my vet's blood tests, etc. Yet over and over again, people SWORE to me that rimadyl was a "killer" drug and that they "personally knew" dozens of dogs which died as a result. Oh, bushwah. Only if they "personally" shoved a rimadyl overdose down those dogs' throats. Researchers have to learn to read with a discerning eye and sort between the crap and the truth. This not-without-its-risks medication helped my dog. Responsibly used, I'm sure it will help many others in future.

[Original Lori]

Thank you for this! I'm actually going to print this out and keep it in Kasey's med file to remind me.

[Heather]

Excellent article Christie. The only thing I'd quibble with is that most people have no idea the side effects - or even the name - of a drug they're taking themselves. While I know what drugs my dogs are taking, usually both the generic and trade names, and what I might watch for as side effects - most of my coworkers never would consider asking their physician for the name of the antibiotic their child is taking. (They're on "medicine" or "antibiotics" and asking which one draws a blank stare.) They may have the insert, but they don't look at it. And in my experience, my doctor is far less forthcoming than my vet - the doctor assumes it's over my head and the vet knows it's not. I wonder if more physicians were better at this, people would come to expect it from their vets as well.

[Christie Keith]

Good point, Chris, but even the human drugs are in Plumb's.... with contraindications, known interactions, and side effects for dogs, cats, and usually other animal species, too.

[Chris]

Great job with this article, Christie.



I've often wondered why drug inserts and/or info on side-effects isn't required to be distributed with prescriptions filled at veterinary offices—and my wife is a vet. Presumably it's a matter of what's required by the various state licensing boards.



One point to keep in mind, though, is that while information on drug side-effects is widely available, that info is not necessarily available for every species a vet might have to treat, and side-effects that are experienced by one species won't necessarily be experienced by another. Also many vets use human medications because a veterinary analogue doesn't exist. Enough might be known about a human drug to suggest that it can fill a gap in the veterinary armamentarium, but the full range of side-effects likely isn't known. In such cases, a vet's "I've never had any problems with this" might be the best reassurance available.



Still, few human drugs achieve widespread use in vet med without some understanding of the risks and benefits, which vets should be explaining to clients. It's all about informed consent!

[Scott Moore]

Thanks for articulating a concern of mine. It actually started when moving from Vet to Vet and problems in care,treatment or attitude became apparent.

I haven't actually had the wherewithal to cause a Vet to change treatment but instead have spoken to other Vets until finding one with a better sounding plan.

The hardest thing about researching on the web is the overwhelming BS, especially those that promise miracles when only a miracle will do. Thanks again for your clarity and wide ranging interests.

[Christie Keith]

I agree we make many of the same mistakes for our own drugs as for our pets, LOL, but when I fill a prescription for myself, I'm offered a consult with the pharmacist and they give me the inserts and warnings. If I choose not to avail myself of those, it's on me. But it's still the norm, unlike in vet med.

[Jan]

I've learned a lot here, thanks Christie. You make the understanding of these types of things so much clearer.