Comfortis: monthly flea protection in an oral dose

Tags

ADE reports, advantix, adverse drug experiences, allergies, bad reactions, Center for Veterinary Medicine, comfortis, drug reactions, drugs, elanco, FDA, flea allergies, flea dermatitis, flea preventatives, fleas, frontline, milbemycin oxime, spinosad, trifexis, veterinary medicine

When Bowdu was battling his summer of extreme allergies, I became adamant about the need for continuous flea control. In the past, we’d used monthly topicals with apparent success. It was difficult to see any bugs camping out in Bowdu’s thick fur forest anyway. But in the process of trying to deal with his allergies and improve his skin condition after his hypothyroidism diagnosis, our vet — a new one to us, at the time — recommended that we bathe Bowdu a little more frequently during allergic months, and give him an oral flea preventative to complement that measure. She recommended Comfortis (spinosad), which we’d never tried or heard of before from any of our previous vets. We started using it in October 2010 and have been satisfied with its effectiveness.

There are several disadvantages to spot-on topical flea treatments like Advantix and Frontline. The application process itself isn’t an issue, but I never liked the smell — and if I dislike it, I can only imagine how the lingering scent assaulted Bowdu’s sensitive nose. They leave an unnatural residue, I couldn’t bathe let alone touch the dogs for days after application, and even when instructions were followed to the letter, fleas seemed to return well before a whole month had lapsed… as we found out when we got Bowpi, whose short fur made them easier to detect.

The Bows are active, outdoorsy, and relatively social. If we do nothing, they will pick up fleas, and the last thing we need is an infestation in the house. So it’s critical for me to keep them on some kind of flea preventative — Bowdu in particular, as I fear that a single bite could trigger an itch that would cascade into another summer of dermatitis hell.

So Bowdu gets his flea meds pretty much every month here in the California Bay Area, the land of eternal spring. Fleas never seem to go dormant here, and I’d rather Bowdu be on prevention than deal with the aftereffects. I am more conservative dosing Bowpi for a number of reasons.

For one thing, she really hates the taste. Comfortis claims their product is a “chewable, flavored tablet” that is “readily consumed by dogs.” If it tastes like it smells, it must be rich with the flavor of… medicine. Blechk. We learned just how adept Bowpi can be at spitting out pills because of this drug, which she will NOT ingest unless it’s split up and well hidden in a flavorful, sticky meal. Since you’re supposed to administer this with food, luckily this is not a huge issue.

Secondly, Bowpi’s short fur makes it not only makes it easier to find, but also to eliminate fleas by hand. I’ll often let her go without the drug until I do happen to see a bug. Then I snatch it off her white belly or wherever, she gets medded at next meal, and the problem is quickly resolved. It is startlingly fast and effective; one time, I just happened to find a dead flea on her two hours after dosing her. The package claims that one dose will start killing fleas in 30 minutes, and it remains effective for an entire month. I do not exactly understand the internal mechanism by which the drug spinosad works, but it’s obviously potent!

The main reason I take it easy with Bowpi is because of her weight. She ideally hovers around 20 pounds, give or take half a pound. But the first time my vet sold us the drug, she automatically prescribed the same dosage for Bowpi as 30-pound Bowdu. This makes it easier for us to just buy one box specified for dogs 20.1 ~ 40 pounds that we can give to either dog as necessary, instead of having to purchase two separate boxes.

HOWEVER, I do not give either dogs a full pill. I generally break each tablet into four quarters as evenly as possible, and give Bowpi the equivalent of half a pill while Bowdu gets three-quarters.

I do this for a couple reasons. Elanco’s product label for Comfortis states that the 10.1 ~ 20 pound dosage contains 270 mg of Spinosad per tablet. The 20.1 ~ 40 pound contains 560 mg of Spinosad per tablet, or just a little more than double the amount of drug in the previous weight range.

Recommended minimum dosage for the drug to be effective is 13.5 mg/pound — so each dose actually contains just a little more than this baseline amount for the top end of the weight range to ensure the drug’s effectiveness. Bowpi for example, if at a full 21 pounds, would need at least 283.5 mg (50.6% of a pill) and Bowdu at 30 pounds needs at least 405 mg (72.3%). The drugmakers expect the dogs to be able to tolerate some overage, and indeed, my dogs never seemed to have any problems the two times I gave them the full pill.

Unfortunately, many others do. I first noticed an alarming number of online reports of negative reactions to Comfortis collected in the comments section of an entry by Dr. Patty Khuly dated March 29, 2008 on Fully Vetted, Comfortis, the flea-killing wonder drug, and the general state of flea drug resistance. It was introduced to veterinary use that year, and Dr. Khuly was singing its praises. The comments piling up under that post, however, seemed overwhelmingly negative — now at 139 comments at the time of this post and still accumulating, including the top voted comment about a Shiba Inu’s bad reaction. I have seen no followup on Fully Vetted or on Dr. Khuly’s new blog at VetStreet.

And then I started noticing handfuls of Shiba and Basenji people on my breed-specific forums reporting and asking about bad reactions to Comfortis and its sister drug, Trifexis (which contains both spinosad and milbemycin oxime for heartworm prevention). I got curious and asked about specific weights and dosages, and noticed that everyone who reported issues had pets that weighed in the lower 20-something pounds, but were giving full pills for 20.1 ~ 40 pound dogs. In one case, a Shiba owner followed up with a call to the company hotline, and was told that her specific cluster of symptoms (laying in “contorted positions,” being unresponsive, trembling, having difficulty maintaining balance) had not been reported before.

Unfortunately, the company representative was flat-out wrong. The FDA has actually collected pages and pages of documented Adverse Drug Experiences for both Comfortis and Trifexis — cumulative reports available in .pdf form here (search by drug name, not product name). So make no mistake — it is a controlled substance, and no drug is “perfectly” safe, as the full document made apparent to me.

That said, my own dogs have not had any problems with it, especially not after I began minimizing and fine-tuning the dosage on my own. My own conclusion was not that the drug itself was inherently evil, but that it remains important to monitor my pets for their own, individual sensitivities. Because the Bows have not reacted badly, and for us, the benefits outweigh the [unseen, to us] risks, I do plan to continue using Comfortis. Nevertheless, knowing that my specific breeds (and of course, others) commonly fall in that lower 20-pound danger zone, where they seem most susceptible to the possibility of overdosing, I will continue to suggest splitting up the pills as a precaution. No, the drug is not “guaranteed” to be blended evenly throughout the pill, and it’s not scored for ease of division. But this works for me until Elanco decides to fine tune this particular dosage jump.

Note: a similar problem applies in the difference from 40.1 ~ 60 pounds (810 mg) and 60.1 ~ 120 pounds (1620 mg), but the change is most pronounced in the size upgrade I’ve been discussing.

In summary…

Comfortis PROS:

• Highly effective, fast-acting, consistent
• Leaves no smell or residue
• Lasts a whole month
• Allows pets to be bathed as necessary
• Relatively easy to administer with food, though picky pillers may need some tricks

Comfortis CONS:

• Noxious smell and taste may make it unpalatable to some dogs
• Must be prescribed by your vet
• More expensive than topical treatments (approx. $60/box for spot-ons vs. $90/box for a 6-pack of Comfortis)
• Does not take care of ticks
• Poor customer support from company (based on my own experiences in addition to anecdotal information above)
• Potential for adverse drug effects not fully acknowledged

Finally, if you do find that your pet has experienced an adverse reaction to this or any drug, please ask your vet to help you fill out an Adverse Drug Experience form to send to the FDA. Internet anecdotes and the advice of well-intentioned non-professionals such as myself should always be taken with caution. Ultimately, the relevant regulatory agencies also need to be notified through the appropriate channels.

Adverse Drug Experience form: http://www.fda.gov/AnimalVeterinary/SafetyHealth/ReportaProblem/ucm055305.htm
Comfortis website: https://www.comfortis.com/
Trifexis website: https://www.trifexis.com
Elanco Pet Health (makers of Comfortis and Trifexis): https://www.elanco.com/products-services/pet-health.aspx

Edited to add more relevant links to anecdotal information as I stumble across new info:
Trifexis Toxicity in Dogs: Charlie had a Scare!

The little pill that could: Soloxine

Tags

canine hypothyroidism, drugs, pilling, soloxine, thyrotoxicosis

This post is about our experiences thus far with Soloxine, an inexpensive synthetic hormone currently manufactured and distributed by Virbac. Soloxine is one of the most popular name brands for Levothyroxine Sodium, designated specifically for veterinary (animal) use. Another brand for animals is Thyro-Tabs, which we have no experience with. Brand name L-thyroxine is apparently more effective than generics, and these two were the brands specifically recommended by Dr. Jean Dodds.

When Bowdu had his first thyroid panel done in August 2010, the results came back with his T4 levels below minimum, and his FT4 levels at 1 pmol/L within normal, at the bottom end of the reference range. My vet called it “borderline low,” but based on his concurrent clinical symptoms, I was ready to start him on thyroid supplementation immediately.

Once thyroid supplementation begins, it is usually expected that the dog is to remain on thyroid supplements for the rest of his life. Clinical signs of hypothyroidism, which clearly matched Bowdu’s physical condition, usually indicate that the thyroid has already been mostly destroyed by its own immune system. Long-term hormone replacement would result in the shutdown of any natural hormone production as well, which is why it is important to get an accurate diagnosis with both T4 and Free T4 panels, at the very least.

Meanwhile, we got a second opinion from Hemopet, which confirmed hypothyroidism.

We began with one pill twice a day, at a dose of 0.2 mg based on his weight (at the time) of 33 pounds. Soloxine’s site recommends an initial dose of 0.1 mg per 10 pounds. Hemopet suggests 0.1 mg per 12 – 15 pounds, then adjusting the dosage as necessary according to follow-up bloodwork.

Results were rapidly observable and satisfactory.

I had no hesitation about starting Bowdu on thyroid supplements, as I’d heard anecdotal accounts that they made a huge and immediate difference. I was also less concerned about this medication, given that thyroxine is supposed to be in his system anyway. However, as with all drugs, this one is not completely without side effects, though I think they were of minimal concern and far outweighed by benefits.

One of the more undesirable side effects that I would ascribe to the thyroid medication (though I don’t know for sure if this is the cause) is exhibited in this video:

Video taken 23 September 2010

About a week after Bowdu started thyroid supplementation and continuing for a couple months, he would exhibit bouts of confusion or just plain weird behavior. In this video, he’s still battling his raging allergies, as he had been all summer, which is why he’s in the cone. These episodes only happened at night, either right before or a few hours after his evening pill. He would get strangely clingy or antsy, and his tail would droop. He’d pant. He’d crawl into corners as if he was looking for something, or try to squeeze himself underneath endtables, or in this case, he’d poke at objects in corners of rooms, like this paper shredder that has always been there. Another time, he jumped up into bed, stepping all over my head in the process (he’s usually more conscious of personal space than that), moved from there to the nightstand, and pawed at the bedside lamp. When I pulled him towards me and held him, I could feel his body trembling.

The trembling was very similar to this video:

Video taken 29 August 2010

The above was taken when Bowdu appeared to be asleep. However, he was awake and very conscious in other episodes of shaking.

My only guess is that these were episodes of short-term thyrotoxicosis, or thyroid drug overdose. According to Soloxine’s drug information insert, the symptoms of thyrotoxicosis include: “polydipsia [increased thirst], polyuria [increased urination], polyphagia [increased appetite], reduced heat tolerance and hyperactivity or personality change.” The last bit seems overly generalized to me, and doesn’t adequately compare to even Wikipedia‘s description: “In excess, [thyroid hormone] both overstimulates metabolism and exacerbates the effect of the sympathetic nervous system, causing ‘speeding up’ of various body systems and symptoms resembling an overdose of epinephrine (adrenaline). These include fast heart beat and symptoms of palpitations, nervous system tremor such as of the hands and anxiety symptoms…”

As I understand it, thyroid hormones are normally secreted as necessary to keep overall levels stable. With synthetic supplementation, artificial “peaks and valleys” are created. While dosing twice a day (BID) as opposed to once every 24 hours (SID) creates more “stable” levels, no doubt the body still responds to the changing level of hormones. If Bowdu’s levels had been low for some time, it would stand to reason that these elevated thyroid levels would feel disorienting, even if they were being maintained at “normal” levels.

So for the sake of minimizing these shocks to his system, I thought it was important to keep Bowdu’s doses as close to 12 hours apart as possible. We’ve developed a pretty good system where he gets his medication first thing in the morning, about an hour before breakfast. Knowing that I have a hard time functioning before coffee, I’ve made things as easy as possible by preparing his marshmallow-wrapped morning dose in advance. A weekly round of morning pills rests conveniently on the nightstand; I don’t even have to be fully awake to pop one out of the case, lean over the edge of the bed to slip it to Bowdu, then hit the snooze bar.

The other half of the daily dose awaits in the kitchen, where it is offered in the evening, about 2-3 hours after dinner.

9 January 2011

Getting Bowdu used to his pills wasn’t hard, though it took a few tricks to turn it into routine. He has a bit of a sweet tooth, so we wrap his pill in a fat-free, but oh-so-sugary mini marshmallow. He also gets more interested if he sees me consuming something first, so at first I made a big show out of eating some marshmallows before offering him one. It also helped to lick the surface of the marshmallow I was offering him, so that it would become a little gooier, thus sticking more to his palate.

Marshmallows are also a great treat for catching in mid-air. Sometimes to liven up the routine of pilling, I’ll grab maybe three or four, one of them stuffed with Soloxine, and gently toss the treats for Bowdu to snap out of the air. When pilling becomes a game, the task is just easier.

About six weeks after he started taking Soloxine, we had a follow-up thyroid panel. Results were within normal range, as expected, so he remained on the same dosage. This will probably change over the years, but for now, we’ll maintain this regimen.

Also, the episodes of oddness depicted in these videos seem to have stopped for now. Something new may arise in the future. As for what came before, I can definitely say we’ve made progress when I compare the archives to his current state.

Photo taken 31 December 2010

He’s not perfect, but at least he’s all right.

As the wind blows

Tags

allergies, canine hypothyroidism, drugs, foot licking, internet pharmacies, Ketoconazole, petmeds, selsun blue, soloxine, yeast infections

As much as I griped about my previous vet not being willing to work with online pharmacies, I know that Internet pharmacies are not above reproach, too. In the interest of equal opportunity bitching, today I will comment on my latest order from 1-800-PetMeds.

So my order, which included a prescription order of Soloxine, was placed last Tuesday. I received notification that it shipped Wednesday, after my vet faxed the prescription to their offices. I took one week, or five business days, to get from Pompano Beach, FL to California. No complaints about the efficiency of the process!

My order consisted of:

• Soloxine 0.2 mg tablets (250 @ $0.09 = $22.50)
• C.E.T. dental chews, size medium (30 count bag, $13.99)
• Diphenhydramine 25 mg, 100 ct. bottle ($7.99)

The dental chews arrived fresh. The generic Diphenhydramine they sent along is called Banophen, distributed by Major Pharmaceuticals (31778 Enterprise Road, Livonia, MI). Good enough.

The main reason for my order, Bowdu’s Soloxine, turned out to be a little disappointing. I ordered 250 as I understood the pills come in either 250-count or 1000-count bottles from the manufacturer. We did not get a sealed bottle from Virbac with the original label and packaging information, as I had hoped would come. Instead, the pills were shipped in PetMed’s own labeled pharmacy bottle, which means I guess they collected the quantity I ordered from loose bottles.

Okay, fine, I can deal with that. But what irked me was that the expiration date was listed as 10/13/2011 — as in exactly one year from when the order was fulfilled. I highly doubt that’s what was written on the bottle(s) from whence these pills came, and so I have no idea how fresh these pills actually are. In that sense, they’re no better than my previous vet, who was giving me pills set to expire in a month.

To PetMed’s credit, they did stick a note onto the pharmacy bottle that indicates the medication is to be taken an hour before or 2 to 3 hours after a meal, which is the correct way to dose Levothyroxine. So they’re at least two steps ahead of my previous vet in terms of price and providing correct instructions.

I’ve e-mailed to ask how I (and other customers) can know for sure that we’re not getting expired drugs, so we’ll see how they respond.

Meanwhile, Bowdu’s skin and feet are no longer swollen and pink thanks to the antibiotic shot and the Ketoconazole, but now his paw pads seem to be cycling through another phase of grodiness. This yeasty overgrowth really is hard to control! We wipe his ears every day with Novalsan Otic, and while there’s considerably less gunk coming out of those orifices, his ears still exude unpleasant odors. We’ve tried shampooing his feet with two brands of pet shampoo so far, but his paw pads get crusty again within days.

I just bought a bottle of Selsun Blue and bathed his feet with it today. There was a noticeable slickness to the texture of his bald skin where the shampoo had soaked for 15 minutes, so I hope that means the selenium sulfide is working.

He has about five days of Ketoconazole left.

The weather is finally turning autumnal.

He’s cone-free at the park again. When he can remain cone-free at home for 24 hours without inflicting any major damage to himself, I’ll finally be able to stop stressing over this… until the next allergy season.

Photo taken 21 October 2010

Edit 24 October 2010: Also, as for this crap?

Screen capture from my e-mail inbox

That’s not my dog, but a generic Shiba Inu picture that’s designed to look like any amateur’s digital snapshot. And it’s creepy when an automated text generator asks me how my dog is doing, by name. It’s even weirder and borderline offensive when your customer service representative asks over the telephone, in her most blase, this-is-my-job-and-I-don’t-really-care tone of voice, So, how’s Bowdu doing? and ends the call with Give Bowdu a hug for us. You really don’t know my dog at all, do you, if you’re suggesting that I give him hugs and kisses on behalf of a total stranger. The very thought — HA! I doubt most shoppers turn to online pharmacies for a “personalized” experience, because any attempts to make it seem so just come across as disingenuous. Please, don’t bother.

Back to comfort with Convenia?

Tags

antibiotics, convenia, drugs, pfizer, vet

Bowdu’s been really good the last few days! He’s even tilted towards spending more time without the cone, including romps at the dog park. I did have to yank him a couple times when he started chewing himself instead of moving along (by which I mean I grab him by his collar and firmly pull him up until he starts walking again), but for the most part, he’s been leaving himself alone since we went to the vet and got him all drugged up.

Aside from the Ketaconazole, which was surely needed, I think the injection of Convenia (cefovecin sodium) really did the trick. I’ve been poking around for information about it. I’ve learned that it’s pretty new, available only since 2008. I wonder if its newness explains why we got the relatively expensive injection for free; I’m guessing that our vet had received free samples from Pfizer, which is currently trying to push the antibiotic.

So here’s what I think, based on what I’ve read and our experience with the drug after the fourth day —

Pros:

• Acts quickly (starts working almost immediately, and “peak plasma level” attained after 6.2 hours in dogs, 2.0 hours in cats). Indeed, Bowdu was able to go cone-free that very evening after his vet appointment (though he’ll still feel irritated and want to itch until he’s all healed back up, so he’s not completely free yet).
• It lasts continuously for about 10-14 days, eliminating the need for repeat pill-popping.
• Great for dogs and cats who are expert pill-spitters
• Pets are less likely to develop bacterial resistance due to proper dosing

Cons:

• If your pet has a bad reaction (which is supposedly rare), you’re screwed, because it’s having its merry way with your pet’s circulatory system.
• It’s a bit expensive. The vet normally would have charged $78.60 for 1.4 mL for my 32 pound dog. This is comparable to a round of Baytril/Enrofloxacin, the toughest and most expensive oral antibiotic my previous vet prescribed at $67.50 for 20 pills. But compared to something like Clavamox ($40.60 for 14 pills) or other oral antibiotics, maybe it’s not as cost efficient.
• Needs to be administered by injection, so if you and your pet are wary of needles…
• It’s new, which means there are no studies yet on long-term use or effects; new is not always better

Things that are inbetween/neutral to me about this particular drug:

• It’s labeled only for “secondary superficial pyoderma [skin infections], abscesses, and wounds” which limits its all-around applicability in a veterinary clinic, but it’s great for my exact concerns with Bowdu’s constant self-inflicted skin infections. Pfizer’s press kit claims the drug is suited for the most common infections needing antibiotic treatment.
• The internet is awash with reports about cats who have suffered fatal reactions from Convenia, despite published findings that insist the drug is as safe as other antibiotics in current use (see the January 1, 2009 issue of the Journal of the American Veterinary Association for more information). While these online anecdotes are definitely disconcerting, problems seem mostly related to cats so far. It’s something to keep an eye on.
• Relatedly, the vet called it a “wimpy” antibiotic, by which she meant that it was supposed to have fewer side effects and therefore would be tolerable given the other drugs and injections he received that day. So maybe it’s good if all he needs is a “wimpy” antibiotic, as opposed to a drug that aims to wipe out every bacteria that it can, to the detriment of the body’s natural balance.

Finally, the promised “convenience” of not having to administer oral medication isn’t a huge incentive for me, as I’m extremely reliable and Bowdu accepts his marshmallow-encased pills with no resistance. I’m most impressed by how quickly Convenia seems to act. And since he’s got plenty of other pills and marshmallows to swallow in the meantime, we may as well eliminate the need for another, lest he return to his pre-Soloxine Staypuff figure.

[This list compiled with help from Dogster Vet Blog posts dated 9 August 2008 and 9 January 2009, MyPetsDoctor.com post dated 21 April 2009, and Pfizer Animal Health’s online product information]

Finally refilled

Tags

canine hypothyroidism, drugs, levothyroxine, pet internet pharmacies, petmeds, pharmacies, soloxine, thyroids, vca, vet, walgreens

So after all my running around trying to get thyroid meds for Bowdu, we finally got the prescription filled at…

Drumroll, please…

My original VCA.

Yeah, that’s how it worked out.

On Monday, I finally picked out a new vet. I went in and scheduled a follow-up blood draw for Bowdu’s thyroid panel, to be done in a couple weeks. Bowpi’s also going in for a tech appointment, during which they’ll evaluate her teeth and offer an estimate for dental work. Then I showed them the written prescription from my old vet, and asked if they said they would be able to fill it. The vet tech was sympathetic to my explanation, but after consulting with the doctors, had to tell me that legally, they could not fill my prescription because they had not yet seen Bowdu. I’m not sure if they were following AVMA guidelines, state law, or some other policies, but since I was already mentally prepared for rejection, it came as no shock.

They suggested I try a human pharmacy. So I went to Walgreen’s. Surprisingly, they presented the least resistance, and were all set to send me out the door with sixty pills of Levothyroxine until I realized they were going to sell me a generic brand for $32.99 (or, I could sign up for their pharmacy savers program for $20, then the price would be $10.99). I had been advised not to get the generic version, as dogs don’t seem to absorb it very well. As I soon realized, Soloxine is a brand name manufactured by Virbac that is specifically formulated for animal absorption. That is what is written on my prescription, and even though it wasn’t coming up in Walgreen’s database of drugs, the pharmacist just took my word that Levothyroxine was the same drug.

So even a human pharmacy was no use. Today, we trekked back up to the old VCA one last time. I had no intention of entering the clinic again after I “broke up” with them, but the Doggy Daddy was willing to oblige. Meanwhile, I took the dogs around the block for their daytime walk. Bowdu remembered the neighborhood, as he was moving cagily the entire time and pooped within a block, which he does when he’s anxious. He CHARGED the car when the Doggy Daddy came back and I gave the cue to pack up and go home.

The Doggy Daddy said that the VCA receptionist was surprised that the prescription was so hard to fill. Har, har, har. If they had just faxed the prescription to PetMeds in the first place (a Vet-VIPPS approved online pharmacy), NONE OF THIS WOULD’VE BEEN HARD AT ALL! PetMeds cannot legally accept faxed copies from private customers, only veterinary clinics, so I would have had to mail the paper prescription in. By the time I realized that every clinic in town was going to refuse to fill my prescription, we were down to four days worth of meds. Four days (including Sunday) to get a piece of paper across the country, an order processed, and shipped from whatever originating warehouse to my dog who needed his daily thyroid medication. The funny thing is that even if we had requested next day air shipping, the total cost would have been less than the $24.70 that the VCA charged us again.

And this time, they weren’t even good enough to put an expiration date on the bottle. It just says **/** where a date should be. I wonder if this batch is coming from the same bottle that is set to expire 10/10 like the batch they gave us last month, and so they just “conveniently” forgot to enter the expiration date on the label. I wouldn’t put it past them.

Photo taken 21 August 2010

Inventory of despair

Tags

allergies, aloe vera, anxiety, cone of pride and triumph, cone of shame, cortisones, drugs, fish oil, flaxseed oil, foot licking, furminator, lidocaine, neosporin, skin, sulfodene, yucca, zoom groom

The fur on Bowdu’s body is looking great. Black skin on pits slowly fading and receding.

However, there has been a renewed bout of foot-licking and chewing, in spite of the cone.

I swear, it’s not from lack of effort.

Here’s another tally of everything we’ve tried:

• Baby wipes (after dusty dog park excursions)
• Fish oil
• Flaxseed oil
• Yucca extract (just received this in the mail, started using it yesterday)
• Sulfodene (not used often, because he reacts strongly to the smell, though he might be more tolerant with counterconditioning)
• Septiderm Skin Care Bath (haven’t used this in a while; see my review)
• Allercaine lidocaine spray
• Biocaine lidocaine topical
• Excel hydrocortisone lotion (not using this very much lately, trying to stay away from cortisone products)
• A spray bottle of hydrocortisone liquid, forgot what brand (put it in another bottle because the original pump broke; also not using this very much, mainly because it feels greasy)
• Spray bottle of lavendar oil diluted in water (as a natural flea repellent)
• Neosporin wound cleaner for kids (foams instantly, supposedly doesn’t sting)
• Benadryl allergy tablets
• Zoom Groom (to promote circulation of natural skin oils and help him remove the loose fur that he can’t groom himself
• Furminator (used less often than the Zoom Groom these days)
• Aloe vera spray (applied mainly to his tummy and his pits)
• Lots of drugs (five pharmacy vials are in this photo, though not all are visible)
• Nolvasan Otic ear cleanser (to help maintain gunk-free ears since he’s not able to clean or aerate them in the cone)
• HomeoPet anxiety relief drops (administered in an attempt to keep him calm while topicals are applied and at night, so he’s perhaps less inclined to gnaw on his feet while the humans are trying to fall asleep)
• Not pictured: giant bag of Epsom salt for foot soaks
• Not pictured: bags and bags of highest quality raw food and fish-based kibble
• Not pictured, but always on: Kong XL cone
• Not pictured: Advantage flea killer, to drive away any remaining itch factors
• Not pictured: can filled with pennies which I rattle mainly when he goes for his feet before and after meals, during which we remove his cone (the Doggy Daddy refuses to participate in this activity and has pleaded with me not to do it in the early morning or late evenings, which is when he gets most obsessed with licking)
• Not pictured: more stuff which is yet to come…

I think we have the largest size cone on him already. If we were to make the cone any bigger, he’d be unable to drink. No need to suggest a donut collar — it’s already on the list of things to try, though I am doubtful.

I’m losing sleep over this, especially as he gets into these awful, lip-smacking licking sessions early in the morning, before breakfast. I snap awake when I hear him grunting with effort as he forces access to those back paws, or nyup-nyup-nyupping against the plastic cone, obsessively licking that screen in place of the front paws he can’t quite reach.

Some days I get more upset about the seemingly incurable nature of this condition. This is one of those days.

Veterinary pharmacies: the saga continues

Tags

american veterinary medical association, drugs, internet pharmacies, pet internet pharmacies, vca, vet

This afternoon, I grabbed Bowdu’s scrip for Soloxine and set off on a doggy drug run. Unfortunately, this whole affair has taken so long that he’s down to four days worth of meds — which means he needs a refill to keep his thyroid supplemented until his next blood draw, which I have not yet scheduled because we’re inbetween vets. Had things gone smoothly when I first placed my order, we would have received the drugs by mail in plenty of time. Had I anticipated the obstacles I have so far encountered, this would’ve been taken care of weeks ago.

But there’s some rule that things in the American health care system are never supposed to proceed as smoothly as we’d like, right?

So after verifying on the phone that I could get what I wanted from the low-cost clinic and supply store across town, I drove over to pick up the pills. Turns out that they misunderstood our phone conversation. Both Bowdu and Bowpi have been seen there once for other issues, when it was a matter of getting more Temaril-P for Bowdu’s allergies and to get a general checkup and dental evaluation on Bowpi. It was a $15 visitation fee for both of them. Medications were sold at less than 70% of what the VCA charged me. And when we renewed the prescription with another online pharmacy, the low-cost clinic did fax the order their way with no complaint.

I thought I made it clear that the thyroid issue was a recent diagnosis, verified by another vet. They would not, however, fill a prescription for a problem that they did not diagnose. I had Bowdu’s entire stack of paperwork with me, including labwork from two places, the entire book of records from the VCA, and the original, unfilled prescription in hand. They could not give me the medications.

“But you guys can’t diagnose hypothyroidism anyway,” I pointed out. “It requires a blood draw and testing with specific equipment that most vets don’t have on site. Why do you even have thyroid medication on hand if you can’t dispense it?”

The only response I got was a shrug and “I don’t know.” As it turns out, the thyroid medication they stocked wasn’t even the brand I wanted anyway. So I asked for some assistance in finding another pharmacy, and they directed me to the vet down the road.

I made my second stop at a big, fancy hospital with the largest waiting area I’ve ever seen at a vet. Strangely enough, it was completely empty on a Saturday afternoon (which I imagine should be a pretty busy time for many active practices). I explained my situation, presented my paperwork, but again, they wouldn’t fill my prescription unless I was already an established client. They, too, had no recommendations as to where to go. I explained that I had originally tried to get the order filled with an internet pharmacy, and the woman behind the counter revealed just the hint of a scowl before saying, “Yeah, we don’t deal with those. Most vets around here require the patient to have been seen within the last year before they give you any drugs.” This is what they call a veterinarian-client-patient relationship. But despite how generally it’s defined by the AVMA, there’s still an unwritten sense of propriety that determines how the relationship is executed.

My final resort was the pet emergency service and referral center in town, though I was almost certain they would not have the drug on hand. The ladies there were so nice and so calm about everything, despite the palpable waves of stress coursing back and forth across the cramped little waiting room. No, they didn’t have any Soloxine on hand to offer me, but I should check with VCA — which was still open for the evening.

As in, my ex-VCA.

With the wryest grin on my face, I told her, “I don’t want them to fill my prescription.”

Apparently my facial expression was sufficient for her to understand there was more to the story than needed to be explained. She recommended checking with another VCA, which was in the direction of the low-cost clinic which had been my first stop, about an hour and a half ago.

At that point, I gave up for the day. I was near tears, I was hungry, and I had other things that had to be done by yesterday. With bitter irony, I wondered, What thrill is there in supposedly “outsmarting” the system when the system is so DUMB?! Why does the AVMA make it a point to state that doctors should allow their prescriptions to be filled elsewhere, as a matter of ethics, but at the same time, the doctors that control these pharmacies WON’T fill prescriptions they did not issue? Given these circumstances, why wouldn’t a client prefer an internet pharmacy?

[EDIT 19 September 2010: I find this post and discussion from Dogster, originally dated 22 June 2008, to be interesting.]

Internet pharmacies

Tags

american veterinary medical association, drugs, new media, online pharmacies, pet internet pharmacies, pharmacies, prescriptions, vet, VIPPS

I went to scout out a new vet today. While surveying the waiting room, I picked up a pamphlet entitled “Pet Internet Pharmacies — what you need to know…” It was brief and informative. All the text is basically the same as this brochure available online through another vet (with which I have no affiliation). From this brochure, I learned of the Verified Internet Pharmacy Practice Sites (Vet-VIPPS) approval system, which authorizes “reputable” online pharmacies. Glad to know such an entity exists, though I don’t think I was ever in danger of buying drugs from an uncertified dispensary. The store my previous vet refused to work with is up to standards, according to Vet-VIPPS. Thus, their blanket refusal to work with online pharmacies appears more like an attempt to preserve their own corporate interests. The pamphlet sheds some light on the underlying rationale:

“Our pharmacy is a vital and integral part of our practice. It provides our clients and their pets with the latest technology, convenience, and the right medications — all at a competitive price. Revenue from our pharmacy allows us to purchase the latest equipment and pay for our caring, dedicated staff of professonals.”

This is reasonable and fairly straightforward. If you’re pleased with your vet, by all means you want them to make money and develop their work. I just think that in the case of my previous vet, prices were absolutely not competitive, and since I questioned the efficacy of their work, I wanted to go elsewhere.

Anyway, I dug around a little more online and found the American Veterinary Medical Association’s official policy on internet pharmacies. It sounds reasonable enough to me. My annoyance is with point #2:

Drugs may be dispensed or prescribed. Veterinarians should honor client requests to prescribe rather than dispense a drug (AVMA Principles of Veterinary Medical Ethics). The client has the option of filling a prescription at any pharmacy.

However, if an option is not made known to a client, it isn’t really an option at all, is it? I don’t see anything in the AVMA guidelines that suggest that clinics display a sign reminding clients that they’re free to get prescriptions filled elsewhere, as I’ve heard some vets do. I’ve not had much need or experience with prescription medications for myself (knock on wood), so I am admittedly a bit ignorant about these things, but I would never have known this was an option unless other people told me.

Which leads me to my final gripe (for now) about parts of this material. I find the tone on some of these FAQs directed at pet owners to be downright patronizing. For example:

Q: A friend told me about an Internet site that sells drugs for pets, and it’s cheaper than I pay at my veterinarian. Why shouldn’t I order my pet’s drugs over the Internet?
A: Finding a “deal” makes you feel great…like you’ve outsmarted the system. But it’s only a great “deal” if you’re also receiving a quality product. Without quality, lower prices can prove to be a false savings. And sometimes the prices are not lower.

Why is the detail of “a friend told me” in this question even relevant, unless they mean to subtly discredit the very real function of anecdotes shared amongst pet owners (in contrast to information that comes straight from the vet)? When I found my “deals” online, I didn’t think I had outsmarted the system… I was actually thinking Yay capitalism! Yay free market! Yay for THE SYSTEM.

More generally, I marvel at the ways that Internet business changes the practices of so many “established” industries, and thus reminds me of just how new all these industries actually are. One of my favorite local video stores recently closed down, blaming Netflix for their demise (which is only part of the story, in my opinion). But video rental stores have only been significant for a few generations, taken for granted only amongst the nostalgic. Major music corporations frequently decry the proliferation of digital bootlegs, yet a large number of independent musicians embrace the mp3, YouTube, and so forth as viable and empowering supplements, if not subversions, to staid distribution practices. But even the idea of a being a rock star (or any kind of “star”) is fairly new in the history of modern culture, attendant on developments in mass media, economic standards of living, and globalization…

So I say, let the Internet pharmacies do their thing. They certainly won’t dismantle the solid veterinary practices, but they might inspire some long term changes to veterinary medicine as a whole, if both sides can get over their turf wars and eventually arrive at a system that works, particularly for legitimate clients… until the next wave of “radical” new ideas.

Vet frustrations make me want to chew *my* paws off, too

Tags

canine hypothyroidism, drugs, grooming, soloxine, thyroids, vca, vet

Due to my schedule this semester, I thought I would be too exhausted most Wednesdays to make any significant posts. However, I’ve just spent a good chunk of my evening fuming with anger after I received a voicemail message from my soon-to-be ex-vet. Apparently, I deleted it in frustration so I can’t transcribe it here. Basically, they called to tell me —

1. They “don’t deal directly” with 1-800-PETMEDS, with whom I just placed an order for a mere 60 more pills of Soloxine (0.2 mg). My vet could hand me the prescription and I could fax it in myself, but their policy is not to deal with these online pharmacies.

2. Their price on Soloxine is actually “pretty good,” they said. In fact, they could sell us 250 pills of what I want — the whole bottle — for about $24.XX. So this is something I might want to consider.

The second part is what set me off. I call bull. It’s absolutely ridiculous that they sold me 60 pills of Soloxine last time for $24.70, and they turn around and tell me they can offer me the whole bottle for that price only after I decide to go elsewhere to get the prescription filled, as is entirely within my rights by law. They’re probably going to tell me that it’s a different price for loose pills versus the entire bottle, but I still find it absurd that they would charge over eight times more per pill than the cheapest place I was able to find it online (which, for the record, was not 1-800-PETMEDS, but I had some other things I wanted to buy and they price match, which is why I chose them). Oh, by the way, the pills that the vet sold me the first time were set to expire in a month, according to the label.

[EDIT 16 September 2010: Their answer as to why there’s such a large difference in price — one is an “introductory price” for a first- or one-time dose. The second, where they offered me the whole bottle, is a “chronic med price”. I find this explanation inadequate. My response was that the first dose is basically a chronic dose, since you’re expected to keep the dog on thyroid medication once you start. Hormone supplementation will result in his own thyroids shutting down, if they weren’t already mostly non-functional to begin with. If they had actually considered the medication they were offering as more than something to look up on a price chart and ring into the register, they would’ve known that and have been able to deal with his case in a reasonable, rather than mechanical (dare I say corporate and anonymous?) manner.]

The thing is, we don’t know that we even need 250 pills yet. The standard procedure, as I understand it from Hemopet, from chatting with other hypothyroid dog owners, and as I’ve read in the veterinary literature, is for the dog to go on a 6-8 week therapeutic trial and then return for another blood draw to make sure that the dosage is correct. After the initial dose, thyroids can be retested after 2 weeks, and should be retested after no more than eight weeks at most, as about half of all dogs require a dosage adjustment. One article I read specifically said that dogs with “borderline” levels (as our vet proclaimed them to be) would be fine waiting 6-8 weeks before retest [citation forthcoming]. Given all this, the four weeks that our vet initially gave us seemed conservative, like they were in a hurry to get us back (as if our monthly visits since the month of May weren’t enough!).

However, you might recall that Bowdu was extremely stressed out by the previous blood draw. When I asked specifically what we could do to ease his anxiety before the next visit, if they had any mild relaxants that wouldn’t interfere with the heavier sedatives they’d most certainly have to give him, they professed to have nothing to offer.

It was disappointing to hear them say that they had no suggestions to help either us or themselves. I’m at a loss as to what to do in this situation. The only thing I can think of is to hang out with the vet and a behaviorist in the weeks leading up to the dreaded blood draw. Obviously this is not practical for anyone involved. Bowdu is unfortunately a high maintenance Shiba who does not like being handled by strangers, and every subsequent visit has just escalated into greater anxiety. The next visit is not going to make things any easier, nor help his impression of vets in general.

So we want to push the next visit back as far as possible, and we need more thyroid drugs in the meantime. That’s why I ordered from an online source. I sure as hell didn’t want to get gouged for another vial of drugs that he’s likely going to be on for the rest of his life.

But this vet is not going to make it easy for me to get my prescription filled where I want. Just like they didn’t make it easy for me to get his blood tested where I want. If it’s their policy not to deal with labs or pharmacies outside of their own VCA network, fine. I’m not asking them to bend any rules for us. We’ll just have to find a vet with different policies.

Searching for a good vet is tiring. This is not a personal judgment against the receptionists and vets, as they all seemed genuinely friendly and our interactions were always professional. As far as facilities go, they have some of the nicest I’ve seen (it feels rather unclinical, not like a hospital). Every DVM on staff graduated from top veterinary schools, and there are a couple reputable surgeons among the group. But I don’t need a surgeon. I need someone who knows thyroids and maybe a little bit about my relatively “rare” breeds. I want policies that permit client input. I want a vet with whom I see eye-to-eye on some core principles, like the value of holistic and natural treatments, and is willing to dole out such advice without prodding (fish oil, Epsom salt baths, over-the-counter Benadryl, apple cider vinegar, kelp supplements, baby wipes — not a word of these were ever mentioned by my vets). And I am hoping for a team of more creative diagnosticians, vets who can look outside their tunnel vision (i.e., regarding Bowdu’s problems as merely dermatological the entire time) and stay abreast of the constantly changing field of veterinary medicine.

This is what I’m prepared to tell them tomorrow in my “break up speech” when I get Bowdu’s prescription so we can get it filled elsewhere.

For old time’s sake, here’s a video of what Bowdu used to be like when he was permitted to lick himself freely:

Video taken 15 August 2008

Bottoms up! (again)

Tags

canine hypothyroidism, chewing, drugs, enrofloxacin, fur, hair loss, licking

For reference —

Left, taken 27 August 2010; Right, taken 5 September 2010

The waft of stench emanating from Bowdu’s pink and gray tummy is gone. Hair is quickly growing back on that stripe down the middle of his belly.

These and the following photos all from 5 September 2010

His armpits are still really black, but the previously bald spots right at the crux between his leg and his chest now have fine, downy chick fur. And you can see that the fur on his legs is a little more even now (this is part of his natural fur shedding cycle and our regular grooming). The fur around his neck is really tamped down and stiff, due to the cone. I try to take it off and brush the fur loose whenever I can…

But without his cone, he still scratches and chews.

That front left dewclaw is still a bother.

If I block him with my own hand, he’ll lick me instead of himself. It almost seems like the urge is more psychological than physical, since he doesn’t act upset when this privilege is restricted by the cone. He’s quite content to lick my hand for the sake of satisfying some oral fixation. But I can’t always be there as a human pacifier, so back in the cone he goes.

Really hoping to see him out of the cone by the end of the month. His antibiotics (Enrofloxacin) run out in two days, so we’ve got to be absolutely vigilant about not setting him back with renewed infections.