Compounding of Veterinary Drugs for Equine Practitioners.

Equine practitioners should follow these recommendations when using compounded medications: (1) the decision must be veterinary driven, based on a valid veterinarian-client-patient relationship and on evidence-based medicine; (2) compliance with the Animal Medicinal Drug Use Clarification Act of 1994; and (3) use limited to (a) horses for which no other method or route of drug delivery is practical; (b) those drugs for which safety, efficacy, and stability have been demonstrated; or (c) disease conditions for which a quantifiable response to therapy or drug concentration can be monitored.

Use of Enrofloxacin and Hydrotherapy in the Management of Fibrodysplasia Ossificans Progressiva (FOP) in a Savannah Cat.

FOP is a rare genetic condition, described mainly in man and cats, characterized by progressive, painful debilitation and shortened lifespan. A 10-month-old neutered male Savannah cat was referred for progressive gait abnormalities and multifocal firm masses within the soft-tissues that were unresponsive to previous treatment. Diagnosis of FOP was based on histopathological evaluation of intralesional biopsies, which revealed osteo-cartilaginous metaplasia and fibrocellular proliferation with intralesional chondrogenesis and endochondral ossification. The cat was managed with 5 mg/kg BID enrofloxacin and hydrotherapy for 3 years until acute death. During that three-year period, the cat displayed consistent improvement in endurance, quality of life, and range of motion. Postmortem histopathology further confirmed the diagnosis of FOP via identification of intramuscular and intra-fascial ossification with lymphoplasmacytic infiltration, degeneration, and regeneration of adjacent myocytes. To the authors' knowledge, this is the first report of long-term enrofloxacin treatment and hydrotherapy for the management of FOP in a cat, leading to improved mobility and survival time, and the first report of FOP in an exotic breed cat.

Stability and uniformity of extemporaneous preparations of voriconazole in two liquid suspension vehicles at two storage temperatures.

OBJECTIVE: To determine the stability and distribution of voriconazole in 2 extemporaneously prepared (compounded) suspensions stored for 30 days at 2 temperatures. SAMPLE POPULATION: Voriconazole suspensions (40 mg/mL) compounded from commercially available 200-mg tablets suspended in 1 of 2 vehicles. One vehicle contained a commercially available suspending agent and a sweetening syrup in a 1:1 mixture (SASS). The other vehicle contained the suspending agent with deionized water in a 3:1 mixture (SADI). PROCEDURES: Voriconazole suspensions (40 mg/mL in 40-mL volumes) were compounded on day 0 and stored at room temperature (approx 21 degrees C) or refrigerated (approx 5 degrees C). To evaluate distribution, room-temperature aliquots of voriconazole were measured immediately after preparation. Refrigerated aliquots were measured after 3 hours of refrigeration. To evaluate stability, aliquots from each suspension were measured at approximately 7-day intervals for up to 30 days. Voriconazole concentration, color, odor, opacity, and pH were measured, and aerobic and anaerobic bacterial cultures were performed at various points. RESULTS: Drug distribution was uniform (coefficient of variation, < 5%) in both suspensions. On day 0, 87.8% to 93.0% of voriconazole was recovered; percentage recovery increased to between 95.1% and 100.8% by day 7. On subsequent days, up to day 30, percentage recovery was stable (> 90%) for all suspensions. The pH of each suspension did not differ significantly throughout the 30-day period. Storage temperature did not affect drug concentrations at any time, nor was bacterial growth obtained. CONCLUSIONS AND CLINICAL RELEVANCE: Extemporaneously prepared voriconazole in SASS and SADI resulted in suspensions that remained stable for at least 30 days. Refrigerated versus room-temperature storage of the suspensions had no effect on drug stability.

Improving patient access to medical services: preventing the patient from being lost in translation.

The Medical Access to Service project was initiated to broadly engage participants in the health system to collectively improve service integration and patient access to primary care and specialist medical services. The Conference Model (the Axelrod Group, Willmette, IL) was used as a change vehicle. The ideal design was translated into the creation of central access and triage (CAT) processes across medical specialties, development of prioritization tools and implementation of access and efficiency through Alberta AIM (access improvement measures) collaboratives for process re-engineering. The ultimate goal for all Albertans who need care is one point-of-access--one standardized process to ensure equal access for all regardless of where they live.

Moving forward to improve migraine management in Canada.

The goal of the Canadian Migraine Forum was to work towards improving the lives of Canadians with migraine by reducing their migraine-related disability. Migraine has been ranked 19th by the World Health Organization among causes of years of life lived with disability. To improve management of migraine in Canada, the participants in the forum identified several important needs and strategies. There is a need for more leaders in the field of migraine to work with other stakeholders to obtain funding and develop treatment programs across Canada. Leadership is also required to address the under use of both migraine specific symptomatic medications and prophylactic medications in Canada. More non-physician health professionals are required to work with physicians in migraine treatment teams. This could assist with a shortage of physician resources, and could also help to better meet the needs of the migraine patient. Individuals with migraine need to be identified who could work with health care professionals to help meet the needs of the migraine patients in our communities. Application of the chronic disease management model for migraine treatment was also seen as an important factor for the management of migraine. Programs are needed to promote earlier diagnosis, long-term follow-up, comprehensive patient education, and the use of multidisciplinary treatment teams where appropriate. Also considered important was the need to increase knowledge about migraine through public awareness campaigns, websites, medical education, and appropriate reading material for patients. The public needs to be aware that migraine is a biological disorder that can cause significant disability and suffering. Lastly, there is a pressing need to promote more migraine research, including careful outcome assessments for treatment programs that involve non-pharmacological treatments and a team based approach to migraine management. There are many challenges that must be overcome if we are to be successful in reducing migraine related disability in Canada. Success will depend upon the joint efforts of physicians, other healthcare professionals, individuals with migraine, and the public at large.

Drug distribution and stability in extemporaneous preparations of meloxicam and carprofen after dilution and suspension at two storage temperatures.

OBJECTIVE: To determine dispersion uniformity and stability of meloxicam and carprofen in extemporaneous preparations stored for 28 days. DESIGN: Prospective study. SAMPLE POPULATION: Meloxicam and carprofen (commercial formulations) were compounded (day 0) with deionized water (DW), 1% methylcellulose gel (MCG), MCG and simple syrup (SS; 1:1 mixture), or a suspending and flavoring vehicle combination (SFVC; 1:1 mixture) to nominal drug concentrations of 0.25, 0.5, or 1.0 mg/mL and 1.25, 2.5, or 5.0 mg/mL, respectively. PROCEDURES: Preparations were stored at approximately 4 degrees C (39.2 degrees F) or 22 degrees C (71.6 degrees F). For each preparation, drug concentrations were determined and drug stability was evaluated at intervals during storage; on days 0 and 28, pH values were measured and bacterial cultures were initiated. RESULTS: In meloxicam-DW, meloxicam-MCG (0.25 mg/mL), and meloxicam-MCG (0.5 mg/mL) preparations, drug distribution was uniform (coefficient of variation < 10%); > 90% of the original drug concentration was maintained for 28 days. Despite uniform drug distribution of the carprofen-SFVC preparations, most retained > or = 90% of the original drug concentration for only 21 days. Use of the MCG-SS combination resulted in foamy preparations of unacceptable variability. After 28 days, pH decreased slightly in meloxicam-DW and meloxicam-MCG preparations (0.17 +/- 0.04 and 0.21 +/- 0.04, respectively). Carprofen-SFVC (2.5 mg/mL) and carprofen-MCG-SS (5.0 mg/mL) preparations stored at 22 degrees C for 28 days yielded bacterial growth. CONCLUSIONS AND CLINICAL RELEVANCE: DW, MCG, and the SFVC can be used successfully for extemporaneous preparation of meloxicam and carprofen for administration to small exotic animals. Refrigeration is recommended for preparations of meloxicam-DW and carprofen-SFVC.

Pharmacists in veterinary education: bridging the gap.

Veterinary patients stand to benefit greatly from the collaboration of pharmacy and veterinary medicine, and there are many ways pharmacy and veterinary medicine can work in concert. The best efforts to revise and remodel veterinary and pharmacy education to fit an evolving world of clinical practice are grounded in an understanding of each profession. Veterinary education should impart to its students and residents the skills necessary to critically evaluate drug therapy, select therapies based on facts from drug information sources, and operate a veterinary practice that abides by the legal, regulatory, and operational requirements necessary to maintain and dispense drugs. The academic training environment of each profession must include information on the other, in order to better prepare professionals for a realistic practice environment. When armed with an understanding of what pharmacists can provide their patients, veterinarians can demand these skills where appropriate. With the ultimate goal of producing an optimal learning environment, veterinary curricula should allow both pharmacy and veterinary medicine to work together to build a path to quality patient care and educational superiority.

Therapy of systemic fungal infections: a pharmacologic perspective.

An increase in the incidence of severe, invasive, systemic fungal infections has been noted over the last decade in human and veterinary medicine. Reports of drug resistance and therapeutic failure to currently available antifungal agents have also been on the rise. Many factors are likely to be involved in these trends, including immune suppression and the use of broad-spectrum antibiotics. The use of fungistatic drugs, suboptimal doses, compounded drugs, poorly absorbed drug formulations, and inadequate tissue penetrations of antifungals also contribute to the development of acquired resistance. Because of the unique chemical complexities of the antifungal agents, drug/drug and drug/food interactions may also play a significant role in poor therapeutic outcome. This review summarizes the pharmacology and toxicology of the antifungal agents in current use for systemic mycosis and introduces some of the newer antifungal agents that anecdotally show very promising results.

Fluoroquinolone-induced retinal degeneration in cats.

Although the exact mechanism of fluoroquinolone-induced retinal degeneration in cats remains to be elucidated, it appears from the literature that a similar retinal degeneration can be reproduced from either direct intravitreal injection of high concentrations of drug or exposure to UVA light and drug in laboratory animals. (19,25) The fluoroquinolone molecular structure is also similar structurally to other drugs that are known to directly induce retinal degeneration, including the cinchona alkaloids and halogenated hydroquinolones. Experimental evidence suggests that both the parent compound and its breakdown products via metabolism and photodegradation are active inducers of retinal degeneration. (18,25) Development of toxicoses also appears to be dependent on the maximum concentration of active drug, metabolite, or both reaching the retina over time. (18) Evaluation of the literature suggests that risk factors predisposing cats to fluoroquinolone-induced retinal degeneration may include the following: 1) large doses or plasma concentrations of drug, 2) rapid IV infusion of the antibiotic, 3) prolonged courses of treatment, and 4) age. Theoretically, other risk factors may also be involved including the following: 1) prolonged exposure to UVA light while the antibiotic is being administered, 2) drug interactions, and 3) drug or metabolite accumulation from altered metabolism or reduced elimination. To date, there are no published reports suggesting that the dose of fluoroquinolones should be reduced in geriatric cats or those with renal or hepatic failure. However, accumulation of fluoroquinolone metabolites in dogs and of the parent compound in humans with decreased renal function has been reported. (8-10) In humans with decreased renal function has been reported. (8-10) humans, fluoroquinolone doses are typically decreased in response to the degree of renal impairment. (28) In general, all fluoroquinolone antibiotics should be reserved for severe or recurrent infections, and whenever possible their use should be based on results whenever possible their use should be based on results of culture and susceptibility tests. When indicated, the fluoroquinolones, including enrofloxacin, can be used with limited risk of developing retinal degeneration in cats, provided the manufacturer's guidelines are adhered to and dose reduction is considered in geriatric cats or those with renal impairment. Dosing on renal impairment. Dosing on exact body weight using split dosing (2.5 mg/kg, PO, q 12 h) and avoidance of rapid IV infusions, and drug interactions may help to reduce the risk of retinal degeneration in some cases. Furthermore, monitoring cats for mydriasis and avoidance of UVA light while undergoing treatment may also be of benefit. Further evaluation of the pharmacokinetics of enrofloxacin and the other fluoroquinolones is required in geriatric cats or those with mild to moderate renal or liver impairment to determine whether drug accumulation, elevated peak concentrations of drug, or both may be occurring in this subset of cats. Therapeutic monitoring of drug concentrations may not always be feasible because of time and cost, but renal panels with dose or frequency reduction in response to the degree of renal impairment and the site and severity of infection may help to reduce retinal toxicosis.

Stability of three commonly compounded extemporaneous enrofloxacin suspensions for oral administration to exotic animals.

OBJECTIVE: To evaluate the stability of 3 extemporaneous oral suspensions of enrofloxacin mixed with readily available flavoring vehicles when stored at room temperature (approx 22°C). DESIGN: Evaluation study. SAMPLES: 3 commonly compounded oral suspensions of enrofloxacin. PROCEDURES: On day 0, commercially available enrofloxacin tablets were compounded with a mixture of distilled water and corn syrup (formulation A) or cherry syrup (formulation B) flavoring vehicles to create suspensions with a nominal enrofloxacin concentration of 22.95 mg/mL, and 2.27% enrofloxacin injectable solution was compounded with a liquid sweetener (formulation C) to create a suspension with a nominal enrofloxacin concentration of 11.35 mg/mL. Preparations were stored in amber-colored vials at room temperature for 56 days. For each preparation, the enrofloxacin concentration was evaluated with high-performance liquid chromatography at prespecified intervals during the study. The pH, odor, and consistency for all suspensions were recorded at the start and completion of the study. RESULTS: Relative to the nominal enrofloxacin concentration, the enrofloxacin concentration strength ranged from 95.80% to 100.69% for formulation A, 108.44% to 111.06% for formulation B, and 100.99% to 103.28% for formulation C. A mild pH increase was detected in all 3 suspensions during the study. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that, when stored in amber-colored vials at room temperature for 56 days, the enrofloxacin concentration strength in all 3 formulations was retained within acceptance criteria of 90% to 110%. Subjectively, cherry syrup flavoring was better at masking the smell and taste of enrofloxacin than were the other mixing vehicles.

Pharmacologic advances in canine and feline reproduction.

Substantial improvements in therapeutic options for companion animal reproduction and gynecologic emergencies have been made over the last decade. New, alternative drug treatments, with fewer side effects and improved efficacy, are available. This has widened the spectrum of therapeutic possibilities for diseases that were previously treated only by surgical intervention. New drugs are available for estrus induction and pregnancy termination, as well as for the treatment of pyometra. This review summarizes the pharmacology and toxicology of reproductive agents currently in use for contraception, pyometra, dystocia, eclampsia, premature labor, agalactia, mastitis, metritis, and prostatic disorders, and compares their efficacy and safety with newer agents. Drug use and exposure during pregnancy and lactation, and subsequent risks to the fetuses, are also explored, with emphasis on antimicrobials, antifungals, anthelminthics, anesthetics, and vaccinations.