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Module 6: Top 30 Veterinary-Only Prescription Drugs
Part 2: Hormonal Drugs and Selected Individual Agents

INTRODUCTION

Although many drugs may be used legally in both human and animal patients, certain drugs have unique human toxicities and are approved for use only in non-human species. In some cases, these drugs were approved initially for use in humans but withdrawn after serious adverse effects emerged. In other cases, these drugs were identified as toxic to humans early in development and never approved for human use.

Given that pharmacists and pharmacy technicians are the only health care professionals expected by society to provide pharmaceutical care for all species, it is highly likely that pharmacists and pharmacy technicians will encounter prescriptions for veterinary-only medications. Accordingly, it is critically important that pharmacists possess a working knowledge of the names, mechanisms of action, indications, dosing, adverse effects, safety profiles, and counseling points for drugs that may belong to similar therapeutic classes as those used in humans but may cause serious adverse effects if dispensed to a human accidentally. Likewise, remember that many human drugs from similar drug classes (eg, NSAIDs) are also toxic in animals. (See Module 2, Principles of Toxicology in Non-human Species). Even more important, because medication administration to animals by necessity involves a human, pharmacists must be able to advise human caregivers about possible risks from veterinary drugs.

More than 1400 drugs are approved by the Food and Drug Administration (FDA) Center for Veterinary Medicine. Modules 5 and 6 focus on the 30 veterinary drugs most likely to be encountered by community pharmacists and pharmacy technicians. (Because of the sheer number of parasiticides available, the modules do not address flea and tick products, heartworm preventatives, or anthelmintics.)

Module 5 covered antimicrobial agents and nonsteroidal anti-inflammatory drugs (NSAIDs). This module covers hormonal drugs and selected other individual agents.

HORMONAL DRUGS

The veterinary hormonal drugs most likely to be encountered by community pharmacists and pharmacy technicians are capromorelin, diethylstilbestrol, and estriol.

CAPROMORELIN (ENTYCE^®)

Capromorelin (KAP-roe-moe-REL-in), approved under the brand name Entyce^®, is a ghrelin-receptor agonist that stimulates growth hormone release and causes the feeling of hunger and effecting appetite stimulation in animals that will not eat. In premarketing clinical trials, approximately 70% of dogs experienced appetite stimulation and weight gain after receiving capromorelin. Information about dosage by species, pharmacokinetic parameters, contraindications, use in pregnancy, drug interactions, storage, and regulatory considerations is provided in the Capromorelin Summary

Indications
Capromorelin is indicated for the stimulation of appetite in dogs. Capromorelin is not approved for use in cats; however, healthy laboratory cats receiving capromorelin demonstrated a significant increase in appetite and weight gain.^1,2Although the manufacturer recommends using capromorelin with caution in dogs with renal insufficiency, cats with chronic kidney disease enrolled in a pilot study gained weight and tolerated the drug.³

Dosage
The approved dosage for dogs is 3 mg/kg orally once daily for 4 days. It is important to give all doses. Efficacy beyond 4 days had not been evaluated. The drug should be well shaken prior to administration and should use the syringe provided by the manufacturer. The syringe should be washed with water prior to the next dose. In the previously referenced study in laboratory cats, a dosage of 1-3 mg/kg orally once daily for up to 21 days demonstrated significant weight gain. Many veterinary clinicians have a positive clinical impression of the efficacy of capromorelin in inappetent cats.

Pharmacokinetics
Bioavailability is about 44% in dogs and peak blood concentrations are achieved in 30-50 minutes.⁴ Capromorelin is not highly protein bound (51%). Hepatic metabolism is primarily via CYP3A4 and CYP3A5. Elimination half-life is ~1 hour. Capromorelin is metabolized and excreted in urine (~37%) and feces (~62%). Capromorelin displays linear pharmacokinetics and does not accumulate with repeated administration.⁵

Adverse Reactions
Adverse effects reported in dogs include:

Diarrhea
Vomiting
Polydipsia
Hypersalivation
Flatulence
Nausea
Abdominal discomfort
Increased gut sounds
Lethargy
Elevated BUN and phosphorus

Adverse reactions in cats receiving capromorelin at 6 mg/kg/d included the signs below, which resolved within 5 minutes of dosing:

Emesis
Hypersalivation
Lip smacking
Head shaking

The safety of capromorelin in pregnant or lactating animals has not been evaluated.

Monitoring
Animals receiving capromorelin should be monitored for elevated BUN and phosphorus. Owners should monitor the pet for increased appetite and weight gain.

Safety Considerations for Humans
No specific toxicity information is available for human ingestion of capromorelin. The manufacturer’s prescribing information states to call a physician in the instance of human ingestion of capromorelin. The Safety Data Sheet for capromorelin states that it is a skin and eye irritant, so owners should be advised to wash hands after administration.

Pharmacy and Pharmacy Technician Scenario Example: Capromorelin

The owner of a dog weighing 10 kg who is being treated for cancer presents you with a prescription for capromorelin to give 1 mL orally once daily for 4 days and to then call the veterinarian for further instructions. You check the dosing information and determine that 1 mL is equivalent to 30 mg, which is an appropriate dose for a 10-kg dog. You ask the owner if the dog is receiving any other medications, to which she replies that the dog is receiving metronidazole but nothing else. You check to see if metronidazole is a drug that interacts with capromorelin and find that it is not. You choose to dispense the smallest bottle, 10 mL, and inform the owner that she will have some leftover at the end of 4 days but to consult her veterinarian on day 4 to see if further dosing is recommended. You mark the dosing syringe provided with Entyce^® and show the owner the correct dose on the syringe. Additional counseling for the owner will include telling the owner to shake the drug well before drawing up in the syringe and to rinse the syringe after use. You tell her that capromorelin may cause further gastrointestinal upset and to contact her veterinarian if this occurs.

DIETHYLSTILBESTROL

Diethylstilbestrol (die-ETH-il-still-BES-tral)—often referred to by the initials DES—is a synthetic estrogen that increases the responsiveness of urethral smooth muscle to nervous (norepinephrine) control, thereby increasing muscle tone in the bladder neck and urethra.

DES had been approved for use in humans, but it was withdrawn from marketing in 1975 for safety reasons after it was linked to cancers and birth defects in treated women and their offspring. DES appears on the list of drugs that cannot be compounded for humans. Use in food-producing animals also is banned.

No dosage forms are commercially available for use in animals. DES typically is compounded in patient-specific gelatin capsules.

Information about dosage by species, pharmacokinetic parameters, contraindications, use in pregnancy, drug interactions, storage, and regulatory considerations is provided in the Diethylstilbestrol Summary.

Indications
DES is approved for the treatment of (1) estrogen-responsive urinary incontinence in female dogs and (2) benign prostatic hypertrophy in male dogs.

Although estriol also is FDA-approved for estrogen-responsive urinary incontinence, many veterinarians prefer to continue using DES.

Dosage
DES is administered by mouth. The initial dosage in dogs is 0.02 mg/kg (not to exceed 1 mg per dog) every 24 hours for 3 to 5 days. The dosing frequency is then tapered to every other day. Ultimately, dosing is tapered to the longest interval that controls incontinence—a frequency of once weekly for most dogs. Pet owners should be cautioned not to increase the dose or dosing frequency without consulting a veterinarian.

Pharmacokinetics
DES is well absorbed and widely distributed following oral administration. It is metabolized primarily through conjugation with glucuronide and undergoes enterohepatic recycling. DES is eliminated in bile and feces.

Adverse Effects
Estrogens (including DES) cause a dose-related myelosuppression in dogs that may progress to a fatal aplastic anemia. As a precaution, no dog should receive a total daily DES dose greater than 1 mg. All dogs treated with DES should be observed for signs of myelosuppression (abnormal bruising, bleeding, lethargy, fever, infection).

Estrogens (including DES) may cause uterine, cervical, and mammary neoplasia in female dogs.

Other adverse effects include reversible alopecia in male or female dogs and feminization of male dogs. Some spayed females will exhibit estrus-like behavior (ie, signs of being in heat).

Use of DES is contraindicated in cats. Possible consequences of DES exposure include anorexia, progressive weight loss, jaundice, and death.⁶

Monitoring
Dogs treated with DES should have CBC and serum chemistries performed at baseline, 1 month, and then every 3 to 6 months to monitor for myelosuppression. Dogs also should be observed for clinical signs of toxicity.

Safety Considerations for Humans
DES is carcinogenic in humans. Women who took DES during pregnancy have a higher rate of breast cancer than the general population.⁷ Female offspring exposed to DES in utero (“DES daughters”) have a substantially increased risk of developing clear cell adenocarcinoma of the vagina and cervix.⁷ Male offspring exposed to DES in utero (“DES sons”) may have an increased risk of testicular and prostate cancer.⁷

DES also is teratogenic. DES daughters and sons have a high rate of structural reproductive tract abnormalities that can contribute to infertility.⁷ For example, female offspring may have a T-shaped uterus; male offspring may have epididymal cysts or undescended testes.

To the extent possible, humans should avoid contact with DES. Pregnant women (or women who are trying to conceive) are cautioned to avoid any contact with DES. Pharmacists and pharmacy technicians who compound DES capsules should wear proper personal protective garb and work in appropriate containment hoods. Owners should be advised to wear gloves when handling and administering DES and to wash hands thoroughly afterward.

Pharmacy and Pharmacy Technician Scenario Example: Diethylstilbestrol

The owner of a 10-kg female Beagle presents a prescription for diethylstilbestrol 0.2 mg capsules, quantity 30. The instructions are to administer 1 capsule by mouth every 24 hours for 5 days, then 1 capsule every 48 hours for 5 days, then 1 capsule every 2 to 3 days as needed to control urinary incontinence. You verify the weight-based dose and ask if there are any girls or women in the household who are pregnant or attempting to become pregnant (the answer is no). You don protective garb and prepare 30 capsules in the containment hood.

When the dog owner returns, you counsel him to watch the Beagle for tiredness, bruising, bleeding, fever, or other signs of myelosuppression.

ESTRIOL (INCURIN^®)

Estriol (ESS-tree-ol) is a synthetic estrogen that increases the responsiveness of urethral smooth muscle to nervous (norepinephrine) control, thereby increasing muscle tone in the bladder neck and urethra.

Estriol is not approved for use in humans in the United States. It is possible that some people might attempt to obtain veterinary estriol tablets for personal use.

Information about available dosage forms, dosage by species, pharmacokinetic parameters, contraindications, use in pregnancy, drug interactions, storage, and regulatory considerations is provided in the Estriol Summary.

Indications
Estriol is approved for the control of estrogen-responsive urinary incontinence in ovariohysterectomized (spayed) female dogs.

Dosage
Estriol is administered by mouth. The dose is tapered according to the following schedule:

2 mg every 24 hours for the first 14 days
1 mg every 24 hours for 7 days
5 mg every 24 hours for 7 days

Once the lowest effective dose is determined, the frequency of administration can be decreased to every 48 hours, or as infrequently as possible to control incontinence. Pet owners should be cautioned not to increase the dose or dosing frequency without consulting a veterinarian.

Estriol is available commercially as scored tablets. If an alternate dosage form must be compounded, the commercially available tablets—not bulk drug substance—should be used as the source of active ingredient.⁸

Pharmacokinetics
Estriol is well absorbed and widely distributed following oral administration. It is metabolized primarily through conjugation with glucuronide and undergoes enterohepatic recycling. Estriol is eliminated in bile and feces.

Adverse Effects
Estrogens (including estriol) have been associated with bone marrow changes (dose-related myelosuppression that may progress to a fatal aplastic anemia) and an increased risk of mammary tumors. Targeted animal safety study results and foreign postmarketing pharmacovigilance data for estriol tablets show that dogs are at low risk of developing these conditions.⁹ Nonetheless, dogs treated with estriol should be observed for signs of myelosuppression (abnormal bruising, bleeding, lethargy, fever, infection).

Some spayed female dogs treated with estriol may develop a swollen vulva and exhibit estrus-like behavior (ie, signs of being in heat). They also may become sexually attractive to male dogs.

Other adverse effects include reversible alopecia, gastrointestinal effects such as anorexia or vomiting, hypersalivation, polydipsia, anxiety, and somnolence.

The safe use of estriol has not been evaluated in intact female dogs, pregnant or lactating dogs, male dogs, or dogs younger than 1 year of age.

Use of estriol is contraindicated in cats.

Monitoring
Dogs treated with estriol should have CBC and serum chemistries performed at baseline, 1 month, and then every 3 to 6 months to monitor for myelosuppression. Dogs also should be observed for clinical signs of toxicity.

Safety Considerations for Humans
Estriol is produced naturally by human females and is used commonly in bioidentical hormone replacement in perimenopausal women. Estriol may be administered by the transdermal route in women, so female pet owners should wash their hands thoroughly after administering estriol to dogs. Women who are of child-bearing age or currently breastfeeding should avoid contact with estriol if possible, or use caution when handling.

Pharmacy and Pharmacy Technician Scenario Example: Estriol

The pet owner in the previous diethylstilbestrol scenario is concerned about handling diethylstilbestrol and no longer wishes to use this preparation to treat urinary incontinence in her female dog. She asks if you are aware of any other alternatives. You tell her that there is an estrogen product called Incurin^® that contains estriol and is FDA approved for treating urinary incontinence in female dogs. She notes that she is currently receiving compounded estriol cream from you for her own perimenopausal symptoms and wonders if you can compound estriol for her dog as well. You tell her that since there is an appropriately sized, FDA-approved tablet labeled to treat urinary incontinence in dogs that you will not be able to compound a copy of a commercially available product and suggest that she contact her veterinarian to discuss switching to Incurin^® tablets.

INDIVIDUAL AGENTS

The veterinary drugs discussed in the remainder of this module represent various drug classes and indications.

DEXMEDETOMIDINE (SILEO^®)

Dexmedetomidine (DEKS-meh-deh-TOE-mih-deen) is the dextrorotatory enantiomer of the alpha-2 adrenergic agonist medetomidine. Dexmedetomidine is used as a preanesthetic agent and for sedation and analgesia in dogs and cats. Use of the injection is almost exclusively limited to use in the veterinary clinic. Pharmacists and pharmacy technicians are most likely to encounter the oromucosal gel, which is approved for noise aversion in dogs and is commonly used as an anti-anxiety and sedative to transport aggressive dogs to the veterinary clinic. This activity will focus only on use of the oromucosal gel.

Indications
Dexmedetomidine transmucosal gel (Sileo^®) is approved for the treatment of noise aversion in dogs. Dexmedetomidine gel has been used in an extra-label fashion to sedate both dogs and cats for car trips to the veterinary clinic for minor and husbandry (eg, grooming) procedures. It is not recommended to be used for sedation in animals that will not be observed throughout the duration of sedation (eg, travel by air cargo; when owner is not home with the pet).

Dosage
For treatment of noise aversion (eg, before fireworks or a thunderstorm) 125 mcg/m² body surface area administered onto the oral mucosa between the dog’s cheek and gum. Ideally, the first dose should be given 30 to 60 minutes before the known noise stimulus. Upon recognition of a noise stimulus that causes fear or anxiety, a dose should be given immediately after the dog shows the first signs of anxiety or fear. Dexmedetomidine is inactivated if swallowed, so it is important to counsel the pet owner to administer the medication in the cheek flap between teeth and gums and not on the tongue. Dosing should only be performed by an adult caregiver who is wearing disposable, impermeable gloves. Interestingly, the manufacturer recommends dosage in a number of “dots” delivered by the Sileo^® dot dosing syringe. The manufacturer offers a “dot” dosing chart below.¹⁰Dexmedetomidine orotransmucosal gel should never be dispensed in any other container than the Sileo^® dot syringe, which is calibrated by the dot. For a complete tutorial on how to use the Sileo^® dot syringe visit www.sileodogus.com. Syringes should be discarded 2 weeks after opening.

Pharmacokinetics
The mean bioavailability of the oral transmucosal gel (Sileo^®) in dogs is 28%, so it must not be swallowed and works best by the oromucosal route. Peak levels occur at approximately 0.6 hours. Volume of distribution is 2.2 L/kg and elimination half-life is approximately 1 hour. Metabolites are eliminated primarily in the urine and, to lesser extent, in the feces. When comparing oromucosal vs intramuscular dexmedetomidine 20 mcg/kg combined with buprenorphine 20 mcg/kg, cats in the intramuscular group were more sedated than in the oromucosal group, but the oromucosal dexmedetomidine administration allowed placement of an IV catheter in 75% of the cats.¹¹

Adverse Reactions
Adverse effects include:

Bradycardia
Vasoconstriction
Muscle tremors
Transient hypertension
Reduced tear production
Occasional arrhythmias (second-degree AV block, supraventricular tachycardia [SVT] ventricular escape beats, premature ventricular complexes [PVCs])
Decreased respiration
Hypothermia
Urination
Vomiting
Hyperglycemia

Rarely, the following adverse effects have been reported:

Prolonged sedation
Paradoxical excitation
Hypersensitivity
Pulmonary edema
Apnea
Death from circulatory failure

If administered soon enough after onset, adverse effects may generally be reversed with atipamezole by a veterinarian.

Monitoring
Heart rate, breathing, and the level of sedation should be monitored in animals receiving dexmetomidine oromucosal gel. Animals experiencing excessive lethargy, sedation, sleepiness, slow heart rate, loss of consciousness, shallow or slow breathing, trouble breathing, impaired balance or incoordination, low blood pressure, and muscle tremors should be immediately taken to their veterinarian for evaluation.

Safety Considerations for Humans
Female pet owners should be advised to avoid handling if pregnant. Dexmedetomidine oromucosal gel can be absorbed through damaged skin, mucous membranes (mouth/gums), and eyes, so impermeable disposable gloves should be worn when handling. In case the medicine contacts skin, thoroughly wash affected area with soap and water. In case of accidental eye exposure, flush eye(s) with water for 15 minutes.

Pharmacy and Pharmacy Technician Scenario Example: Dexmedetomidine Oromucosal Gel

A client brings in a syringe of Sileo^® that she has received from her veterinarian earlier in the day. The Sileo^® was dispensed because her 30-lb dog is tremendously afraid of thunderstorms, and severe storms are forecast for later that evening. She has lost the dosing instructions that the veterinarian gave her and her veterinarian’s office is now closed. She asks you to help. You tell her that the labeled dose of Sileo^® for a 30-lb dog is 2 dots given 30 to 60 minutes before the noise-causing event. She says that now she remembers that is what the veterinarian told her to give her dog. You then ask her if she remembers how the veterinarian told her to use the syringe to dose her dog. She says that she does not. You then offer to let her look at the sileodogus.com video for how to use the syringe and administer a dose correctly. She watches the video with you. You then ask if she has disposable gloves and she replies that yes, the veterinarian gave her some. You then write down the sileodogus.com website for her just in case she needs to watch it again when she gets home.

IMEPITOIN (PEXION^®)

Imepitoin (ih-meh-pi-TOYN) is a low-affinity partial agonist at the benzodiazepine binding sites of the GABA_A-receptor used to treat noise aversion in dogs. Because the receptor binding affinity of imepitoin is approximately 600 times less than diazepam, this partial agonist has the potential advantage of causing less severe adverse effects and a lower risk for tolerance and dependence development than other benzodiazepines. As a GABA_A agonist and weak neuronal calcium channel blocker, imepitoin causes inhibitory effects on neurons and raises seizure threshold, thereby preventing seizures. Imepitoin also possesses anxiolytic effects.

Indications
Imepitoin is FDA-approved for the treatment of noise aversion in dogs. Clinical trials for approval focused on noise created by fireworks and not from storms. No published efficacy for storm phobias has been published.

Imepitoin is approved in the United Kingdom and European Union for the reduction of anxiety and fear associated with noise phobia in dogs as well as for the reduction of the frequency of generalized seizures due to idiopathic epilepsy in dogs after careful evaluation of alternative treatment options. The product label states: The pharmacological response to imepitoin may vary and efficacy may not be complete. Nevertheless, imepitoin is considered to be a suitable treatment option in some dogs because of its safety profile. Safety or efficacy of imepitoin as an adjunct to other antiepileptic drugs is not known. Imepitoin has been demonstrated to have comparable efficacy to phenobarbital in treating idiopathic epilepsy and has significantly fewer adverse effects compared to phenobarbital (sedation, polydipsia, polyphagia).¹² The American College of Veterinary Internal Medicine (ACVIM) has developed a clinical consensus statement on seizure management in dogs which identifies imepitoin as having Level IA evidence for monotherapy, and Level IIIC evidence for add-on treatment.¹³

No information on use of imepitoin in cats was found at time of writing.

Dosage
For the treatment of noise aversion in dogs (FDA-approved) imepitoin is dosed at 30 mg/kg orally every 12 hours. Therapy should be initiated 2 days prior to the day of the expected noise event, and continue throughout the noise event. For reduction of seizures refractory to other treatment methods (European Union and United Kingdom approved, and extra-label in the United States) 10 mg/kg orally twice daily (approximately 12 hours apart) and then adjusted weekly up to 30/mg/kg orally twice daily according to therapeutic effect. The manufacturer states that tablets can be halved. The previously referenced consensus guideline states that the initial dose of imepitoin for epilepsy should be 15 mg/kg orally every 12 hours.

Pharmacokinetics
Imepitoin does not accumulate with repeated doses and demonstrates linear kinetics in dogs over the therapeutic dosing range. It is well absorbed after oral administration in a fasted state with a bioavailability of approximately 92%. Peak levels occur approximately 2 hours after dosing. The presence of food may reduce the total AUC by 30%, but does not significantly affect peak levels or time to peak. Volume of distribution ranges from 0.6-1.6 L/kg; protein binding is relatively low (60%-70%). It is extensively metabolized via oxidative mechanisms to 4 major inactive metabolites. Clearance ranges from 260-570 mL/h/kg. Elimination half-life is about 1.5 to 2 hours. The majority of a dose is eliminated via fecal routes. Although imepitoin absorption is greater in a fasted state, efficacy for noise aversion in dogs has been demonstrated when administered in either a fed or fasted state.¹⁴

Adverse Reactions
Adverse effects include the following:

Ataxia (may require discontinuation of imepitoin)
Increased appetite
Lethargy
Emesis
Hyperactivity
Aggression (due to inhibition of fear)
Somnolence
Hypersalivation
Mild (but not usually clinically significant) elevations in plasma creatinine and cholesterol

Reproductive safety or safety during pregnancy or nursing is not known.

Monitoring
Patients receiving imepitoin should be monitored for clinical efficacy and appearance of adverse effects. The ACVIM consensus guideline does not recommend monitoring for imepitoin; however, baseline and post-treatment lab work for serum creatinine and cholesterol should be considered.

Safety Considerations for Humans
Imepitoin was originally targeted for approval for treatment of human epilepsy; however, significant interpatient variation in metabolism caused the drug to be abandoned for human use. The Freedom of Information Summary for imepitoin states “Not for use in humans. Keep this and all medications out of reach of children. Consult a physician in case of accidental ingestion by humans.”

Pharmacy and Pharmacy Technician Scenario Example: Imepitoin

It is July 3 and you receive a prescription for imepitoin 400 mg orally every 12 hours for a 13- kg dog who is afraid of fireworks. The owner lives very close to a park where an Independence Day fireworks celebration is scheduled for the evening of July 4. You consult a veterinary reference and determine that this is an appropriate dose for a 13-kg dog. You fill the prescription and then counsel the owner to give 1 tablet orally every 12 hours on an empty stomach. Ideally, the drug should be started 2 days prior to the fireworks, but since that is not possible, the owner should give a dose as soon as she gets home, then give every 12 hours until the event is over early on the morning of July 5.

MIRTAZAPINE, TRANSDERMAL (MIRATAZ^®)

Mirtazapine (mir-TAZ-ah-peen) is an a-2 antagonist that causes a net increase in norepinephrine resulting in antidepressant activity as well as appetite stimulation. Mirtazapine is also a potent inhibitor of the 5-HT2 and 5-HT3 receptors and of histamine (H1) receptors. Antagonism at the 5-HT3 receptors give mirtazapine both antinausea and antiemetic effects, and its action at H1 receptors produces sedation. The effects on appetite stimulation are also thought to be due to changes in circulating leptin. Mirtazapine is used systemically in animals as an appetite stimulant as well as an antiemetic agent and is available in oral dosage forms (human label) and a transdermal ointment (veterinary approved). Since the transdermal form is a veterinary only product, this activity will focus on that dosage form.

Indications
The manufacturer’s labeling for the transdermal ointment (Mirataz^®) states that it is “indicated for the management of weight loss in cats.” However, this is a very misleading statement implying that it can be used for weight reduction in cats, when in fact, its primary pharmacological action is appetite stimulation, with the goal of causing weight gain. Although the transdermal ointment is labeled only for cats, systemic mirtazapine has been given orally to dogs for both appetite stimulation as well as antinausea effects.

Dosage
The transdermal ointment is available in a concentration of 2% (20 mg/g of ointment) and is labeled for dosing as: “Administer topically by applying a 1.5-inch ribbon of ointment (approximately 2 mg/cat) on the inner pinna of the cat’s ear once daily for 14 days.”¹⁵ The manufacturer also recommends alternating between ears every other day when applying and using a dry cloth or towel to wipe the pinna of the ear clean prior to application. The efficacy of transdermal mirtazapine in dogs could not be located; however, oral use of mirtazapine in dogs at 1 mg/kg orally once daily have been used clinically to stimulate appetite in this species.

Pharmacokinetics
In cats, the mean half-life of transdermally applied mirtazapine is approximately 27 hours, compared to the half-life of orally administered mirtazapine which is 10 hours. Peak blood concentrations after transdermal administration occur in 6 hours, with steady state being achieved in about 14 days. Mirtazapine displays nonlinear pharmacokinetics in the feline species due to saturation of glucuronide and accumulates with repeated dosing. A reduced frequency of administration is recommended for cats with chronic kidney disease.

Adverse reactions. The most commonly reported adverse effects include:

Erythema at application site
Vocalization
Hyperactivity
Ataxia
Aggression
Elevated hepatic enzymes

Other less common adverse effects reported during clinical trials include ear infection and urinary tract infection.

Monitoring
Patients should be monitored for increased appetite, weight gain, and cessation of vomiting (if applicable). The Freedom of Information Summary for mirtazapine states to “monitor for and respond to adverse reactions, including adverse effects that may occur after cessation of the drug.”¹⁶The package insert states “Monitor your cat’s food intake. Your cat’s food intake may lessen after discontinuation of mirtazapine transdermal ointment. If food intake diminishes dramatically (> 75%) for several days or if your cat stops eating for more than 48 hours, contact your veterinarian.”

Safety Considerations for Humans
Mirtazapine for oral administration has been approved for use in humans as an antidepressant; however, human caregivers should wear gloves when applying transdermal mirtazapine to animal patients. The manufacturer’s labeling for Mirataz^® states: “After application, care should be taken that people or other animals in the household do not come in contact with the treated cat for 2 hours because mirtazapine can be absorbed transdermally and orally. However, negligible residues are present at the application site and the body of the cat at 2 hours after dosing. In case of accidental skin exposure, wash thoroughly with soap and warm water. In case of accidental eye exposure, flush eyes with water. If skin or eye irritation occurs seek medical attention. In case of accidental ingestion, or if skin or eye irritation occurs, seek medical attention.”

Pharmacy and Pharmacy Technician Scenario Example: Transdermal Mirtazapine

A cat owner is in your pharmacy to pick up a prescription for herself and mentions that her cat’s ear is very red after receiving transdermal mirtazapine for appetite stimulation. She wants to know if you think this could be related to the medication. You ask her to demonstrate about how much she is applying (it should be a 1½-inch strip), ask her if she is alternating between the right and left ears, and ask if she is cleaning off the residue on the pinna prior to each new application. She responds that she has only been applying it to 1 ear and has not been wiping the ear clean prior to each dose. You recommend that she alternate ears every other day and to clean the application site with a dry cloth prior to administration, but to contact the veterinarian to see what she should do about the erythema that has occurred.

PHENYLPROPANOLAMINE (PROIN^®)

Phenylpropanolamine (fen-il-PROPE-a-NOLE-a-meen) is an α-adrenergic agonist that has been reported to increase urethral tone in dogs. Its mechanism of action is not well established. Phenylpropanolamine is believed to stimulate norepinephrine release by acting indirectly on both α-adrenergic and β-adrenergic receptors of smooth muscle, resulting in increased tone of the urethra, bladder neck, and internal urethral sphincter.

Although phenylpropanolamine was approved for use in humans as an anorectic and decongestant, it has not been available since 2005, when the FDA reclassified phenylpropanolamine as “not generally recognized as safe and effective” (see Safety Considerations for Humans section). Phenylpropanolamine also has been used in the illegal production of methamphetamine; the Combat Methamphetamine Epidemic Act of 2005 further limited the distribution of phenylpropanolamine by designating it as a List I chemical. Pharmacists still are able to obtain bulk phenylpropanolamine after completing extensive paperwork, but Proin is the only commercially available product. It is possible that some people might attempt to obtain veterinary phenylpropanolamine tablets for personal use or misuse.

Indications
Phenylpropanolamine is indicated for the control of urinary incontinence due to urethral sphincter hypotonus in dogs. It sometimes is used off-label for the same indication in cats, but this use is not recommended.

Dosage
Phenylpropanolamine is administered by mouth. The usual dosage in dogs is 2 mg/kg every 8 to 24 hours. It may take several days before therapeutic effects are evident and incontinence is controlled.

When phenylpropanolamine is used to treat cats, the usual dosage is 1–2.2 mg/kg orally every 8 to 24 hours.

Phenylpropanolamine is available commercially as chewable liver-flavored tablets. If an alternate dosage form must be compounded, the commercially available tablets—not bulk drug substance—should be used as the source of active ingredient.⁸ The commercially available tablets should not be used to compound dosage forms for dogs allergic to liver.

Pharmacokinetics
Absorption of phenylpropanolamine is rapid and complete (98% bioavailability) when administered orally to fasted dogs. Food delays the rate but not the extent of absorption.

Phenylpropanolamine is widely distributed into various tissues and body fluids, including the cerebrospinal fluid and brain.

Phenylpropanolamine undergoes minor hydroxylation. Most (80%–90%) of an administered dose is excreted unchanged in the urine.

Adverse Effects
Phenylpropanolamine can cause an increase in thirst. Dogs treated with phenylpropanolamine should have plenty of fresh drinking water available.

Many common adverse effects are associated with sympathetic activity; they include hypertension, anorexia, weight loss, and anxiety or behavior change. Phenylpropanolamine also can cause vomiting, diarrhea, and proteinuria.

Monitoring
Dogs treated with phenylpropanolamine should undergo regular physical examination to monitor for the development of hypertension.

Safety Considerations for Humans
Phenylpropanolamine was used widely in humans until 2000, when results of the Hemorrhagic Stroke Project showed it to be an independent risk factor for hemorrhagic stroke.¹⁷ The FDA took steps to remove phenylpropanolamine from all drug products and asked all drug companies to discontinue marketing products containing phenylpropanolamine. Pharmacists are advised to observe refill patterns to guard against human abuse or misuse of veterinary phenylpropanolamine (eg, as a weight loss aid or for the manufacture of methamphetamine).

Pharmacy and Pharmacy Technician Scenario Example: Phenylpropanolamine

A veterinarian calls you regarding a canine patient that is very sensitive to phenylpropanolamine and requires an unusually small dose (4–5 mg). You recommend compounding capsules containing 4 mg or 5 mg of phenylpropanolamine, using the Proin^® liver-flavored tablets as a starting ingredient.

TRILOSTANE (VETORYL^®)

Trilostane (try-LOW-stain)—a synthetic steroid analogue—is a competitive inhibitor of 3-β-hydroxysteroid dehydrogenase in the adrenal cortex. It inhibits the conversion of pregnenolone to progesterone, thereby blocking synthesis of cortisol, progesterone, estrogens, and androgens.

Trilostane was marketed for use in humans as Modrastane^® until it was withdrawn for safety reasons (see Safety Considerations for Humans section) in 1994.

Indications
Trilostane is approved for the treatment of pituitary-dependent hyperadrenocorticism in dogs and hyperadrenocorticism caused by adrenal tumors in dogs. It has been used off-label to treat Alopecia X, a disease that affects Nordic breeds, Poodles, and Pomeranians.

Trilostane also has been used to treat hyperadrenocorticism in cats and pituitary pars intermedia dysfunction (PPID, also referred to as Equine Cushing’s Disease) in horses.^18,19 Trilostane has no effect on the pituitary gland and is unlikely to be effective in horses with pituitary-dependent PPID.¹⁸

Dosage
Trilostane is administered by mouth. The labeled dosage for dogs with hyperadrenocorticism is 2.2–6.7 mg/kg every 24 hours. However, veterinary endocrinologists typically recommend starting therapy at a dosage of approximately 1 mg/kg every 12 hours to avoid adverse effects.²⁰ When used to treat Alopecia X, the dosage is 3 mg/kg every 12 hours for 4 to 6 months.²¹

In cats, the usual dosage of trilostane for the treatment of hyperadrenocorticism is 0.5–12 mg/kg every 12 hours or every 24 hours.¹⁸However, many clinicians use 10-30 mg/CAT up to 12 mg/kg PO q12h due to the strength of available dosage forms.

In horses, the usual dosage of trilostane for the treatment of PPID is 120–240 mg every 24 hours (dosing is not weight-based).¹⁹

Trilostane is available commercially as capsules. If an alternate dosage form must be compounded—for example, an oral suspension for a small dog—the commercially available capsule (not bulk drug substance) should be used as the source of active ingredient.²²

Pharmacokinetics
Trilostane is absorbed rapidly but erratically when administered orally. Distribution in dogs has not been characterized; trilostane has a low volume of distribution in monkeys and rats.

Trilostane is metabolized via hydroxylation and glucuronidation to several active metabolites, including ketotrilostane. Metabolites are excreted primarily in the urine.

Adverse Effects
Adverse effects reported most commonly during trilostane therapy include poor or reduced appetite, vomiting, lethargy or dullness, diarrhea, and weakness. Less common but more serious reactions include severe depression, hemorrhagic diarrhea, collapse, hypoadrenocortical crisis, and adrenal necrosis or rupture. These reactions can occur without warning and have resulted in animal death in some cases.

Both intolerance to trilostane therapy and overdosage can result in hypoadrenocorticism (Addison’s disease). Adrenal function may return slowly; some dogs never regain adequate adrenal function.

Some dogs experience a corticosteroid withdrawal syndrome when therapy is initiated, characterized by weakness, lethargy, anorexia, and weight loss. Serum electrolytes should be measured to rule out hypoadrenocorticism. If symptoms are severe, trilostane can be withdrawn and then restarted at a lower dose when symptoms resolve.

Monitoring
When trilostane therapy is initiated, pet owners should monitor the animal’s water consumption (ideally < 80 mL/kg/d) and urine production for evidence that the drug is working.

Animals treated with trilostane should be observed for signs of corticosteroid withdrawal or hypoadrenocorticism. Owners should contact a veterinarian immediately if their pet develops vomiting, diarrhea, lethargy, poor or reduced appetite, weakness, or collapse.

An adrenocorticotropic hormone (ACTH) stimulation test should be performed 2 weeks after trilostane therapy is initiated, as well as 2 weeks after any dosage adjustment. Once an effective trilostane dosage has been achieved, a physical examination, ACTH stimulation test, and serum chemistries and electrolytes should be performed at 30 days, 60 days, and then every 3 months. The importance of honoring recheck appointments for laboratory tests and physical examination should be emphasized to pet owners.

Safety Considerations for Humans
Trilostane had been approved for use in humans, but it was withdrawn from marketing in 1994. Because it inhibits 3-β-hydroxysteroid dehydrogenase, trilostane also inhibits the formation of progesterone, estrogens, androgens, glucocorticoids, and mineralocorticoids. Trilostane causes miscarriage through inhibition of progesterone formation. Women who are pregnant (or intending to become pregnant) should avoid any contact with trilostane.

Pharmacy and Pharmacy Technician Scenario Example: Trilostane

A veterinarian requires the ability to adjust trilostane doses in 1-mg increments for a 1-kg Chihuahua with Cushing’s disease. You offer to compound either a 10 mg/mL oral suspension or gelatin capsules containing trilostane 1 mg, using the commercially available product as the source of the active ingredient. The veterinarian consults with the pet owner and asks you to prepare the oral suspension.

PERGOLIDE MESYLATE (PRASCEND^®)

Pergolide mesylate (PURR-go-lide MEH-sill-ate)—a synthetic ergot derivative—is a potent dopamine receptor agonist. It exerts negative feedback on the pituitary gland to halt production of ACTH, pro-opiomelanocortin (POMC), and other hormonally active substances responsible for the clinical signs of PPID in horses.

Pergolide was approved for the treatment of Parkinson’s disease in humans but was withdrawn from the market in 2007 for safety reasons (see Safety Considerations for Humans section).

Indications
Pergolide is indicated for the control of clinical signs associated with PPID in horses. It is the therapy of choice for PPID.

Dosage
Pergolide is administered by mouth. The usual dosage in horses is 2–4 mcg/kg every 24 hours, rounded to the nearest 0.5 mg (½ tablet). Clinical response may not be apparent for several weeks.

If an alternate dosage form must be compounded, the commercially available tablet—not bulk drug substance—should be used as the source of active ingredient.²³ USP has developed a validated compounded preparation monograph for pergolide 1 mg/mL oral suspension.

Pharmacokinetics
Pergolide is rapidly and completely absorbed following oral administration. It is widely distributed with high protein binding.

Pergolide is metabolized extensively to at least 10 active metabolites. Excretion is primarily via the urine.

Adverse Effects
The most common adverse effect of pergolide therapy is inappetence. Horses treated with pergolide also may experience abnormal weight loss, lethargy, colic, or diarrhea or loose stools. Lameness and heart murmur have been reported.

Monitoring
Horses treated with pergolide should be observed for clinical signs of efficacy, such as improved haircoat and decreased thirst and urination. A dexamethasone suppression test, fasting serum insulin measurement, or both should be performed 4 to 8 weeks after therapy is initiated as well as 4 to 8 weeks after any dosage adjustment. A complete physical examination, CBC, and serum chemistries should be performed periodically during therapy.

Safety Considerations for Humans
Pergolide had been approved for the treatment of Parkinson’s disease in humans but was withdrawn from marketing in 2007 following association with valve regurgitation, valvular vegetative lesions, and cardiac lesions. These lesions have not been observed in horses receiving pergolide, although 8.2% of horses in a field study of pergolide developed heart murmurs.²⁴ Pergolide must be administered for the duration of the horse’s life; human caregivers should guard against exposure. Women who are pregnant or lactating should wear gloves when administering this product. Humans with ergot allergies should avoid contact with pergolide.

Although the commercially available tablets are scored and the package labeling indicates rounding doses to the nearest half tablet, there have been reports of headache, eye irritation, and an irritating smell after the tablets were split or crushed. The tablets ideally should not be crushed by caregivers because of the potential for increased human exposure; caregivers should be cautious when splitting tablets. Pharmacists who must crush the tablets to prepare compounded suspensions should don appropriate protective apparel (including a face mask).

Pharmacy and Pharmacy Technicians Scenario Example: Pergolide Mesylate

Pharmacists and pharmacy technicians may be asked to compound flavored oral suspensions of pergolide mesylate. The commercially available tablets—not the bulk drug substance—should be used as the source of active ingredient. USP has developed a validated compounded preparation monograph for pergolide oral suspension 1 mg/mL.

DOMPERIDONE (EQUIDONE^®)

Domperidone (dohm-PARE-i-dohne) is a dopamine receptor (D2) antagonist. Dopamine inhibits prolactin secretion. By binding to dopamine receptors, domperidone prevents that inhibition.

Indications
Domperidone is approved for the prevention of fescue toxicosis in periparturient mares. Fescue toxicosis is a clinical syndrome that may occur when pregnant mares ingest tall fescue grass that has gone to seed and is infested with a specific endophyte fungus, Neotyphodium coenophialum (formerly Acremonium coenophialum). The fungus produces ergovaline, which has dopaminergic activity and suppresses prolactin secretion. Clinical signs associated with fescue toxicosis include lack of milk production, prolonged gestation, thickened fetal membranes, premature separation of the placenta, retained fetal membranes, abortion, dystocia, reduced fertility, and increased neonatal mortality.

Domperidone also has been used off-label as a diagnostic tool for horses with PPID, and to induce lactation in non-pregnant mares for adoption of orphaned foals.

Domperidone has been administered as a prokinetic agent in dogs and cats but has not demonstrated efficacy for this use.

Dosage
Domperidone is administered to horses by mouth. The usual dosage for the prevention of fescue toxicosis in periparturient mares is 1.1 mg/kg every 24 hours, starting 10 to 15 days before the expected foaling date. (Domperidone must not be administered more than 15 days before the expected foaling date because of the possibility of premature birth, low birthweight foals, or foal morbidity.) Treatment may be continued for up to 5 days after foaling if mares are not producing adequate milk.

Pharmacists and pharmacy technicians who dispense domperidone should demonstrate proper use of the multidose dosing syringe, including how to set the dial ring for accurate dosing after the first dose.

When domperidone is used to diagnose PPID, a single 2.5 mg/kg dose is administered by mouth, and the ACTH level is measured 4 hours after the dose.

Pharmacokinetics
Domperidone is absorbed rapidly following oral administration. It undergoes significant first pass metabolism; oral bioavailability is approximately 20% in most species. Domperidone is widely distributed in all tissues, but it does not cross the blood–brain barrier readily.

Domperidone is metabolized extensively in the liver by hydroxylation and n-dealkylation. The main metabolic pathway is through CYP3A4. It is eliminated primarily in feces, with small amounts eliminated in the urine.

Adverse Effects
The most common adverse reactions during domperidone therapy are diarrhea, premature leakage of milk from the teats before foaling, and failure of passive transfer (ie, failure to transfer antibodies from the mare to the foal through the mare’s milk).

Monitoring
All foals born to mares treated with domperidone should be tested for serum immunoglobulin (IgG) concentrations.

Safety Considerations for Humans
Domperidone has never been approved for use in humans in the United States. Several studies have indicated that domperidone is torsadogenic; the FDA Pharmacy Compounding Advisory Committee voted in October 2015 to add domperidone to the list of drugs that may not be compounded for humans, based on the risk of sudden death from prolongation of the QT interval. It is possible that women seeking to increase lactation may attempt to obtain domperidone for personal use.

OCLACITINIB MALEATE (APOQUEL^®)

Oclacitinib maleate (oak-lah-SIT-a-nib MAL-ee-ate) is a Janus kinase (JAK) inhibitor. It inhibits the function of pruritogenic cytokines and pro-inflammatory cytokines that are dependent on JAK1 and JAK3 enzyme activity. Oclacitinib has minimal effect on JAK2-mediated hematopoiesis.

Oclacitinib is a relatively new drug. Because supplies have been historically limited, distribution periodically is restricted to board-certified veterinary dermatologists. Pharmacists have been approached by veterinarians who are not dermatologists to compound oclacitinib maleate for their canine patients.

Indications
Oclacitinib is indicated for the control of (1) pruritus associated with allergic dermatitis and (2) atopic dermatitis in dogs at least 12 months of age.

Oclacitinib may be used off-label in cats for the treatment of non-flea, non–food-induced dermatitis.²⁶

Dosage
Oclacitinib is administered by mouth. The recommended dosage is 0.4–0.6 mg/kg every 12 hours for 14 days, then every 24 hours for the duration of therapy. In practice, the reduction in frequency often is accomplished by administering half of the daily dose in the morning and half in the evening (not the entire dose once daily). Veterinarians often find that the full initial dosage (0.4–0.6 mg/kg every 12 hours) must be continued as maintenance therapy in some dogs that experience therapeutic failure when the dosage is reduced.

When oclacitinib is used to treat dermatitis in cats, the usual dosage is 0.4–0.6 mg/kg every 12 hours.²⁶

It is important to note that oclacitinib is available commercially as the maleate salt. There are anecdotal reports of therapeutic failure following use of compounded dosage forms that were prepared using oclacitinib base or the citrate salt.

Pharmacokinetics
Oclacitinib is absorbed rapidly and almost completely (bioavailability ~90%) when administered by the oral route, with low protein binding. It is metabolized extensively via oxidation to several metabolites. Less than 4% of an administered dose is excreted unchanged in the urine.

Adverse Effects
The most common adverse effects during treatment with oclacitinib are vomiting, diarrhea, anorexia, and lethargy. Administering doses with food may help to alleviate gastrointestinal upset.

An increased risk of infection (including demodicosis), increased lymphocytes, neoplasia, and papillomas also were reported during field studies. Oclacitinib should not be administered to dogs with serious infections or neoplasia. Pet owners should contact a veterinarian immediately if they notice signs of infection or skin growths.

Monitoring
Dogs treated with oclacitinib should be monitored with periodic CBC and serum chemistries. Dogs also should be observed for signs of infection and abnormal skin growths.

Safety Considerations for Humans
Oclacitinib is a strong eye irritant. Caregivers should wash their hands thoroughly after administering oclacitinib and avoid crushing tablets. In case of accidental eye contact, the eyes should be rinsed with water or saline for 15 minutes, and the affected person should seek medical attention.

Little else is known about human exposure to oclacitinib. Data from laboratory animal studies suggest a low potential for acute oral or dermal toxicity. Oclacitinib does not appear to be a skin irritant or sensitizer.

Pharmacy and Pharmacy Technician Scenario Example: Oclacitinib Maleate

A dog owner whose pet is being treated with oclacitinib mentions that the dog seems to be developing growths that look like warts. She wonders if the growths could be caused by the drug. You inform the dog owner that skin growths are indeed a serious adverse effect of oclacitinib therapy; you advise her to consult the veterinarian or a veterinary dermatologist immediately.

MAROPITANT (CERENIA^®)

Maropitant (ma-RAHP-i-tent) is a neurokinin-1 (NK1) receptor antagonist that blocks the action of Substance P in the central nervous system (CNS). Substance P is the primary CNS mediator of vomiting.

Indications
Maropitant is indicated for the prevention of (1) acute vomiting and (2) vomiting due to motion sickness in dogs and cats.

Dosage
Maropitant is administered by mouth or by subcutaneous or intravenous injection. When administered to dogs to control acute vomiting, the dosage is 2 mg/kg every 24 hours for oral administration and 1 mg/kg every 24 hours for parenteral administration.

When used to prevent motion sickness in dogs, the dosage is 8 mg/kg orally every 24 hours for a total of 2 doses. The dog must be fasted 1 hour before administration, and administration must occur 2 hours before travel. Pet owners should be advised to feed the dog a small amount of food 3 hours before travel, then withdraw food until after travel is complete.

The usual dosage in cats is 1 mg/kg every 24 hours orally or by subcutaneous or intravenous injection. In cases of chronic kidney disease, a dose of 4 mg/CAT can be considered.²⁷

A 50% dosage reduction is recommended for animals with hepatic insufficiency (see Pharmacokinetics section).

Pharmacokinetics
Maropitant is rapidly and completely absorbed following subcutaneous administration. High first-pass metabolism results in an oral bioavailability of only 24%–37%.

Distribution of maropitant is limited. It crosses the blood–brain-barrier and exhibits concentrations nearly 4 times higher in brain than plasma at 8 hours.

Maropitant undergoes extensive hepatic metabolism through CYP2D15 and CYP3A12. Saturation of these enzymes causes dose-related nonlinear pharmacokinetics. Maropitant should be used with caution in animals with compromised hepatic function; a 50% dosage reduction is recommended for animals with hepatic insufficiency.

The original package insert warned veterinarians not to administer maropitant for more than 5 consecutive days to avoid potential drug accumulation, and to have at least a 2-day drug vacation between 5-day intervals. However, postmarketing clinical use has not revealed any risk of drug accumulation after chronic use, and the warning was removed from the package insert in 2015.

Less than 1% of an administered dose of maropitant is eliminated via the urine.

Adverse Effects
Maropitant may cause pain when administered by subcutaneous injection in dogs and cats. Refrigerating the solution reportedly decreases pain and stinging on administration;²⁸ this may be because cyclodextrin used to solubilize maropitant binds strongly to maropitant at lower temperatures.

Adverse reactions reported during field studies of maropitant or post-approval experience include drowsiness, lethargy, anorexia, and diarrhea. Vomiting and hypersalivation are possible at the higher motion sickness dose.

Maropitant causes prolongation of the QT interval.²⁹ Safe use of maropitant in animals with underlying cardiac disease has not been studied. Maropitant should be used with caution in animals that have pre-existing cardiovascular disease or require concomitant therapy with drugs that prolong the QT interval.

Some animals treated with maropitant have experienced ataxia, seizures, and anaphylaxis or anaphylactoid reactions (including swelling of the head and face). Dogs or cats that exhibit any of these symptoms require immediate veterinary care.

Monitoring
Dogs and cats treated with maropitant should be monitored for efficacy (cessation of nausea and vomiting). Animals also should be observed for signs of serious adverse effects (anaphylaxis/anaphylactoid reactions, including swelling of the head or face; ataxia; seizures) that require immediate veterinary attention.

Safety Considerations for Humans
Maropitant has never been approved for use in humans. It is a strong contact irritant and eye irritant. Pet owners should wash their hands thoroughly after handling maropitant. In case of accidental eye contact, the eyes should be flushed with water for 15 minutes, and the affected person should seek medical attention.

Pharmacy and Pharmacy Technician Scenario Example: Maropitant

A veterinary oncologist has prescribed 14 days of consecutive maropitant therapy for a dog undergoing chemotherapy for canine lymphoma. While searching the Internet for additional information about maropitant, the dog owner discovered information stating that maropitant should be used for no more than 5 consecutive days. He is concerned about this information and asks what he should do. You tell the dog owner that this warning was removed from the package insert in 2015; you also explain that the risk of breakthrough vomiting during chemotherapy from skipping doses of maropitant outweighs any risk associated with accumulation of the drug.

CISAPRIDE

Cisapride (SIS-a-pride) is a serotonin 5HT4 receptor antagonist that causes release of acetylcholine at the myenteric plexus.

Cisapride was marketed for use in humans as Propulsid^® until 2000, when it was withdrawn from active marketing following reports of serious cardiac arrhythmias and fatalities. Although cisapride remains available through an investigational limited access program, it must be compounded for veterinary use. USP has developed validated compounded preparation monographs for cisapride oral suspension 10 mg/mL and cisapride injection 3 mg/mL.

Indications
Cisapride is a prokinetic drug used to manage gastrointestinal paresis, esophageal reflux, esophagitis, megacolon, and constipation.

Dosage
Cisapride is administered by mouth or by intravenous injection. The dosage varies by species (see Cisapride Summary).^30-32

Rectal administration of cisapride suspension in horses is not effective.³²

Pharmacokinetics
Cisapride is absorbed rapidly and distributed widely. Oral bioavailability is low (30%–40%). Cisapride is highly protein bound (97%).

Cisapride undergoes extensive hepatic metabolism through CYP3A4.

Adverse Effects
The most common adverse effects associated with cisapride therapy are diarrhea, abdominal pain and cramping, and nausea. Headache was a commonly reported adverse effect in humans.

Arrhythmias have not been reported in animals but may be possible, especially if cisapride is administered concurrently with other drugs known to prolong the QT interval (eg, maropitant).

Monitoring
Animals treated with cisapride should be observed for signs of gastrointestinal obstruction (cisapride is contraindicated in gastrointestinal obstruction). Animals with cardiovascular conditions should be monitored for arrhythmias.

Cats being treated for megacolon or constipation should be observed for straining, painful defecation, or blood in the stool. Early intervention is most likely to avoid fecal impaction. Cats with megacolon should be examined frequently to ensure that they do not become obstructed.

Safety Considerations for Humans
Cisapride was removed from the human market in 2000 after more than 300 cases of serious cardiac arrhythmias, including ventricular tachycardia, ventricular fibrillation, torsade de pointes, and QT prolongation. Those cases resulted in 80 deaths. Most of the deaths were caused by increased blood levels of cisapride resulting from drug interactions.

Human caregivers should exercise caution when handling cisapride and avoid exposure to the extent possible.

Pharmacy and Pharmacy Technician Scenario Example: Cisapride

The owner of a 6-kg cat diagnosed with megacolon presents a prescription for cisapride 5 mg by mouth every 12 hours for 30 days. She requests a liquid formulation. You consult the USP Compounding Compendium and identify a standardized formula for cisapride 10 mg/mL oral suspension. You confirm with the veterinarian that this formulation is appropriate for the cat, and you prepare and dispense a 30-day supply.

POTASSIUM BROMIDE

Potassium bromide (po-TASS-ee-um BROE-mide) raises the seizure threshold by competing with chloride ions across neuronal membranes. The overall result is hyperpolarization of neuronal cell membranes and depression of neuron excitability.

Bromides had been approved for use in humans. They were withdrawn from marketing in 1975 because humans are at particular risk for bromide toxicity (bromism; see Adverse Effects section).

No manufactured versions of potassium bromide are approved by the FDA, so there are no legally available commercial products. The labeling for the widely marketed tablets (K·BroVet^®) bears the federal prescription drug legend and has an NDC number, but it is not approved by the FDA fully, conditionally, or under any terms of the Minor Use and Minor Species Act.

Because some dogs require customized dosage forms of potassium bromide (eg, liquids), USP has developed a validated compounded preparation monograph for potassium bromide oral solution 250 mg/mL. The solution should be clear, with no visible particles. Concentrations greater than 250 mg/mL are not recommended because of a higher likelihood of precipitation, especially when refrigerated. Caregivers should be warned not to administer solution with evidence of crystals; doing so could result in bromide toxicity.

Indications
Potassium bromide is indicated for the management of epilepsy in dogs, either as monotherapy or as an adjunct to other neuroleptic drugs.

Use in cats is not recommended. Potassium bromide can cause serious lower respiratory adverse effects in cats, including cough, dyspnea, and eosinophilic bronchitis. Although these effects usually are reversible when therapy is discontinued, they also can be fatal.

Dosage
Potassium bromide is administered by mouth. Because potassium bromide has a very long half-life in dogs (days, not hours; see Potassium Bromide Summary) and takes a very long time to reach steady state, many veterinarians initiate therapy with a loading dose of 400–600 mg/kg, administered as several divided doses over 1 to 5 days.

The usual maintenance dosage of potassium bromide is 30–35 mg/kg every 24 hours. The daily dose also can be divided into 2 equal doses.

Administering doses with food helps to decrease gastrointestinal upset and erosion.

Pharmacokinetics
Potassium bromide is well absorbed from the small intestine following oral administration. Oral bioavailability in dogs is approximately 46%.

Potassium bromide is distributed primarily in the CNS and extracellular fluid. It is eliminated almost exclusively in the urine, as unchanged drug.

Adverse Effects
Symptoms of gastrointestinal upset—nausea, vomiting, and diarrhea—are the most common adverse effects during potassium bromide therapy. Polyphagia, polydipsia, and polyuria also may occur. Dogs treated with potassium bromide should have easy access to water and ample opportunities to go outside to urinate, especially when therapy is initiated.

Sedation accompanied by vomiting is possible when loading doses of potassium bromide are administered to dogs. Each dose should be given with food to lessen gastrointestinal upset, and food bowls should be elevated to prevent aspiration of food into the lungs if vomiting occurs while sedated.

Bromide toxicity (bromism) may occur at blood levels exceeding 2.5 mg/mL. It is manifested by neurological signs such as deep sedation, stupor, ataxia, coma, and mydriasis. Bromism can be treated on an inpatient basis with intravenous administration of sodium chloride.

Bromides compete with chloride at the neuronal membrane, as well as for renal tubular reabsorption. Chloride intake from all sources—eg, dietary salt, sea water, swimming pool water—should be regulated carefully in dogs receiving bromides to avoid loss of seizure control. If potassium bromide is administered with food, the chloride content of the food should be consistent from dose to dose. Excessively salty foods and treats should be avoided.

As mentioned earlier, potassium bromide can cause potentially serious lower respiratory adverse effects in cats, including cough, dyspnea, and eosinophilic bronchitis. Many veterinarians consider potassium bromide to be contraindicated in cats, using it only as a treatment of last resort.

Monitoring
Bromide blood levels should be measured 1 month after initiation of therapy and then again 8 to 12 weeks later. The therapeutic blood level target range is 1–3 mg/mL, although many clinicians prefer that blood levels not exceed 2 mg/mL because of the risk of bromism.

Animals treated with potassium bromide should undergo physical examination and have routine serum chemistries performed every 6 months. They also should be observed for signs of bromism (deep sedation, stupor, ataxia, coma) or subtherapeutic dosing (breakthrough seizures). Dogs that display signs of either bromism or breakthrough seizures should receive immediate veterinary care.

When used as a treatment of last resort in cats, the animal should be monitored closely for development of respiratory signs (cough, dyspnea). Cats that display these signs should receive immediate veterinary care.

Safety Considerations in Humans
Given the risk of bromism, caregivers should take precautions to avoid exposure to potassium bromide. Direct skin contact in particular should be avoided; rash is common after contact. Caregivers should wash their hands thoroughly after administering potassium bromide to pets.

Pharmacy and Pharmacy Technician Scenario Example: Potassium Bromide

You receive a prescription to compound potassium bromide solution 500 mg/mL for a large dog. You become concerned that this high concentration may result in bromide precipitation, especially if flavorings and other excipients are used. You contact the veterinarian to make sure that the formulation specified in the USP compounded preparation monograph (250 mg/mL) will work for this patient.

PIMOBENDAN (VETMEDIN^®)

Pimobendan (pi-moe-BEN-den) is a negative inotrope that decreases heart rate by inhibiting phosphodiesterase enzyme type 3 (PDE3) and increasing intracellular calcium channel sensitivity.

Indications
Pimobendan is indicated for the management of mild, moderate, or severe congestive heart failure in dogs.

Pimobendan also is used off-label in cats to manage congestive heart failure.

Dosage
Pimobendan is administered by mouth. The commercially available tablets are formulated with ingredients designed to facilitate oral absorption.

The approved dosage for dogs is 0.25 mg/kg every 12 hours. However, the effective dosage recommended by an American College of Veterinary Internal Medicine Specialty of Cardiology consensus panel convened to formulate guidelines for the diagnosis and treatment of chronic valvular heart disease in dogs is 0.3 mg/kg every 8 hours.³³

When pimobendan is used in cats, the dosage is 0.25 mg/kg every 12 hours. This usually translates into individual doses of 1.25 mg per cat every 12 hours.

Commercially available pimobendan tablets are large and oblong, and they can be difficult to administer to some animals (especially cats). Tablets may be fractionated and hidden in empty gelatin capsules for cats and dogs that refuse the intact tablets.

Pharmacokinetics
Pimobendan is readily absorbed following oral administration. Although food can decrease the bioavailability of oral solutions of pimobendan, the effect of food on absorption from the tablet formulation has not been studied.

Pimobendan is widely distributed, with a high volume of distribution. It undergoes hepatic demethylation with subsequent conjugation with sulfate or glucuronide. Active metabolites contribute to the duration of action.

Excretion of pimobendan is mainly in feces.

Adverse Effects
The most common adverse effects associated with pimobendan therapy are gastrointestinal upset, inappetence, cough, dyspnea, and lethargy. Arrhythmias also have been reported.

Monitoring
Animals treated with pimobendan should be observed for evidence of clinical efficacy and signs of disease progression. Pet owners should monitor the animal’s heart rate, respiratory rate, body weight, appetite, and medication adherence and keep written documentation for evaluation by the veterinarian at recheck appointments. Recheck appointments also will include monitoring of renal function and blood work; the importance of honoring these appointments should be emphasized to pet owners.

Safety Considerations for Humans
Although pimobendan has been studied in multiple clinical trials for use in humans with congestive heart failure, it is not approved for human use in the United States. The pimobendan Safety Data Sheet indicates little likelihood of human hazard through contact (it is not an eye, skin, or respiratory irritant) but does advise caregivers to wash their hands after handling the product.

Pharmacy and Pharmacy Technician Scenario Example: Pimobendan

A cat owner has struggled to administer a 1.25-mg tablet of Vetmedin to her cat twice daily. She asks if you have any suggestions for administering the tablet successfully. You recommend that she try splitting the tablet into smaller pieces and placing the pieces in an empty gelatin capsule, then coating the capsule with something the cat likes (for example, tuna oil or anchovy paste) to increase acceptance. The cat owner agrees to give this a try; you provide her with the empty gelatin capsules.

CLENBUTEROL (VENTIPULMIN^®)

Clenbuterol (klen-BYOO-ter-ol) is a β2-adrenergic receptor agonist that causes bronchodilation through production of cyclic AMP. It is more specific for smooth muscle relaxation (β2) in the bronchi, uterus, and blood vessels than for cardiac muscle relaxation (β1). Its bronchodilatory actions are blocked by β-adrenergic antagonists (β-blockers).

Indications
Clenbuterol is indicated for the management of horses affected with airway obstruction, such as occurs in chronic obstructive pulmonary disease (COPD) or heaves (recurrent airway obstruction). Efficacy is increased if caregivers can decrease airborne irritants from bedding, feedstuffs, or straw. Soiled bedding should be removed to minimize airway irritation.

The product labeling states that clenbuterol should not be used in pregnant mares near term, because the drug antagonizes the effects of prostaglandin F2α and oxytocin (and thus inhibits uterine contractions). However, because clenbuterol has specific smooth muscle relaxation properties on the uterus, it sometimes is given to mares with dystocia (obstructed labor) to relax the uterus and facilitate in utero repositioning or delivery of foals.

Clenbuterol is not used in dogs or cats because of cardiotoxicity.

Dosage
Clenbuterol is administered by mouth. The usual dosage for the treatment of horses with airway obstruction is 0.8 mcg/kg every 12 hours.

When used in mares with dystocia, clenbuterol is administered as a single 10-mL dose.

Pharmacokinetics
Clenbuterol is well absorbed following oral administration; bioavailability in horses is 84%. It is widely distributed.

Clenbuterol is excreted primarily as unchanged drug in the urine. Unchanged drug persists in urine for 12 days following the last dose.

Adverse Effects
The most common adverse effects during treatment with clenbuterol— primarily during the first few days of therapy—are mild sweating, muscle tremor, restlessness, urticaria, and tachycardia. Severe ataxia was observed in some horses during field studies.

Sweating in horses is mediated through β2-adrenergic receptors. Long-term use of clenbuterol may reduce ability to sweat over time. If this occurs, the horse should be examined by a veterinarian.

Recent investigations suggest that prolonged continuous exposure to clenbuterol (> 2–3 weeks) may result in decreased bronchodilatory effects.³⁴ Periodic drug vacations may help to delay tolerance to clenbuterol.

Clenbuterol may cause elevated creatine kinase (CK) serum levels.

Monitoring
Horses should be observed for evidence of clenbuterol tolerance. If tolerance is suspected, a brief drug vacation should be considered.

Safety Considerations for Humans
Clenbuterol is not approved for use in humans. Adverse effects include tachycardia, cardiomyopathy, and hypertension, possibly leading to myocardial infarction.

Because of its anabolic properties, clenbuterol is a target of drug-seeking athletes, body builders, and others who seek to lose body fat rapidly. It is known on the street as the “Size 0 Drug” or “Clen.” Clenbuterol use is banned by both the International Olympic Committee and the World Anti-Doping Agency.

Clenbuterol also recently has become popular as an adulterant for heroin.

Pharmacists should be vigilant for attempts by drug seekers to obtain clenbuterol illegally for human use. Suspected fraudulent prescriptions should be brought to the attention of veterinarians.

Pharmacy and Pharmacy Technician Scenario Example: Clenbuterol

A pharmacy receives a prescription for clenbuterol for a 45-kg dog with instructions to administer 1 mL orally every 12 hours for 30 days for asthma. The pharmacy technician does not recognize the name of the veterinarian who prescribed the medication. The pharmacy technician asks the client for contact information for the veterinarian, which the client subsequently provides. Upon further scrutiny of the prescription, the pharmacist determines that (1) clenbuterol is not approved for use in dogs due to cardiotoxicity, (2) that the dose is for a 90-kg, not 90-lb, dog, and (3) that the information provided for the prescribing veterinarian is not verifiable. Suspecting a fraudulent prescription for use by humans to lose weight or build muscle, the pharmacist declines the prescription and gives it back to the client.

REFERENCES

Rhodes L, Zollers B, Allen J. Capromorelin, an orally active ghrelin agonist, caused sustained increases in igf-1, increased food intake and body weight in cats. Paper presented at: American College of Veterinary Internal Medicine Forum; 2015.
Wofford JA, Zollers B, Rhodes L, Bell M, Heinen E. Evaluation of the safety of daily administration of capromorelin in cats. J Vet Pharmacol Ther. 2017;41(2):324-333.
Allen J. Abolishing anorexia: the use of ghrelin receptor agonists. Paper presented at: American College of Veterinary Internal Medicine Forum; 2016; Denver, CO.
Carpino PA, Lefker BA, Toler SM, et al. Pyrazolinone-piperidine dipeptide growth hormone secretagogues (GHSs). Discovery of capromorelin. Bioorg Med Chem. 2003;11(4):581-590.
Capromorelin (Entyce^®) [product label]. Leawood, KS: Aratana Therapeutics, Inc; 2016.
Dow C. The pathology of stilboestrol poisoning in the domestic cat. J Pathol Bacteriol. 1958;75(1):151-161.
Schrager S, Potter BE. Diethylstilbestrol exposure. Am Fam Phys. 2004;69(10):2395-2400.
S. Food and Drug Administration. Incurin^® (estriol) tablets and Proin^® (phenylpropanolamine hydrochloride) chewable tablets—veterinarians. Issued April 20, 2012. Reissued February 25, 2016. Available at: http://www.fda.gov/animalveterinary/safetyhealth/productsafetyinformation/ucm277198.htm. Accessed October 29, 2019.
Incurin^® [package insert]. Madison, NJ: Merck Animal Health; 2011.
Correct Dosing of Sileo^® for Dogs of sizes. Zoetis, Inc. Accessible at https://www.sileodogus.com/media-assets/sileo_dosing_table(1).pdf. Accessed September 16, 2019.
Santos L, et al. Sedative and cardiorespiratory effects of dexmedetomidine and buprenorphine administered to cats via oral trans-mucosal or intramuscular routes. In: IVECCS and EVECCS Symposium Abstracts: 2009. Chicago, IL: International Veterinary Emergency and Critical Care Symposium; 2009.
Tipold A, et al. Clinical efficacy and safety of imepitoin in comparison with phenobarbital for the control of idiopathic epilepsy in dogs. J Vet Pharmacol Ther. 2015;38(2):160-168.
Podell M, Volk HA, Berendt M, et al. 2015 ACVIM Small Animal Consensus Statement on Seizure Management in Dogs. J Vet Intern Med. 2016;30(2):477-490.
Imepitoin (Pexion^®) Freedom of Information Summary. St. Joseph, MO: Boehringer Ingelheim Vetmedica, Inc; 2018.
Mirataz® [Product Label]. Burlingame, CA: Kindred Biosciences, Inc.
Mirtazapine Freedom of Information Summary. Burlingame, CA: Kindred Biosciences, Inc; 2018.
Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med. 2000;343:1826-1832.
Valentin SY, Cortright CC, Nelson RW, et al. Clinical findings, diagnostic test results, and treatment outcome in cats with spontaneous hyperadrenocorticism: 30 cases. J Vet Intern Med. 2014;28(2):481-487.
McFarlane D. Equine pituitary pars intermedia dysfunction. Vet Clin North Am Equine Pract. 2011;27(1):93-113.
Feldman EC. Evaluation of twice-daily lower-dose trilostane treatment administered orally in dogs with naturally occurring hyperadrenocorticism. J Am Vet Med Assoc. 2011;238(11):1441-1451.
Leone F, Cerundolo R, Vercelli A, et al. The use of trilostane for the treatment of alopecia X in Alaskan malamutes. J Am Anim Hosp Assoc. 2005;41:336-342.
S. Food and Drug Administration. Vetoryl (trilostane) capsules—veterinarians. Issued September 11, 2009. Reissued February 25, 2016. Available at: http://www.fda.gov/animalveterinary/safetyhealth/productsafetyinformation/ucm182038.htm. Accessed October 29, 2019.
FDA Center for Veterinary Medicine. Prascend (pergolide mesylate) tablets—veterinarians. Issued April 20, 2012. Reissued March 2, 2016. Available at: http://www.fda.gov/animalveterinary/safetyhealth/productsafetyinformation/ucm277207.htm. Accessed September 1, 2016.
Prascend (package insert). St. Joseph, MO: Boehringer Ingelheim Vetmedica, Inc; 2011.
European Medicines Agency. Apoquel European public assessment report—product information. Published October 15, 2013. Updated May 19, 2015. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/veterinary/002688/WC500152091.pdf. Accessed October 29, 2019.
Ortalda C, Noli C, Colombo S, et al. Oclacitinib in feline nonflea-, nonfood-induced hypersensitivity dermatitis: results of a small prospective pilot study of client-owned cats. Vet Dermatol. 2015;26(4):235-252.
Quimby JM, Brock WT, Moses K, Bolotin D, Patricelli K. Chronic use of maropitant for the management of vomiting and inappetence in cats with chronic kidney disease: a blinded, placebo-controlled clinical trial. J Feline Med Surg. 2015;17(8):692-697.
Narishetty ST, Galvan B, Coscarelli E, et al. Effect of refrigeration of the antiemetic Cerenia (maropitant) on pain on injection. Vet Ther. 2009;10(3):93-102.
Kukanich B. Geriatric veterinary pharmacology. Vet Clin North Am Small Anim Pract. 2012;42(4):631-642.
Steel CM, Bolton JR, Preechagoon Y, et al. Pharmacokinetics of cisapride in the horse. J Vet Pharmacol Ther. 1998;21(6):433-436.
Adamcak A, Otten B. Rodent therapeutics. Vet Clin North Am Exot Anim Pract. 2000;3(1):221-237.
Cook G, Papich MG, Roberts MC, et al. Pharmacokinetics of cisapride in horses after intravenous and rectal administration. Am J Vet Res. 1997;58(12):1427-1430.
Atkins C, Bonagura J, Ettinger S, et al. Guidelines for the diagnosis and treatment of canine chronic valvular heart disease. J Vet Intern Med. 2009;23(6):1142-1150.
Read JR, Boston RC, Abraham G, et al. Effect of prolonged administration of clenbuterol on airway reactivity and sweating in horses with inflammatory airway disease. Am J Vet Res. 2012;73(1):140-145.

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Module 6: Top 30 Veterinary-Only Prescription Drugs
Part 2: Hormonal Drugs and Selected Individual Agents

INTRODUCTION

HORMONAL DRUGS

CAPROMORELIN (ENTYCE^®)

Pharmacy and Pharmacy Technician Scenario Example: Capromorelin

DIETHYLSTILBESTROL

ESTRIOL (INCURIN^®)

Pharmacy and Pharmacy Technician Scenario Example: Estriol

INDIVIDUAL AGENTS

DEXMEDETOMIDINE (SILEO^®)

Pharmacy and Pharmacy Technician Scenario Example: Dexmedetomidine Oromucosal Gel

IMEPITOIN (PEXION^®)

Pharmacy and Pharmacy Technician Scenario Example: Imepitoin

MIRTAZAPINE, TRANSDERMAL (MIRATAZ^®)

Pharmacy and Pharmacy Technician Scenario Example: Transdermal Mirtazapine

PHENYLPROPANOLAMINE (PROIN^®)

Pharmacy and Pharmacy Technician Scenario Example: Phenylpropanolamine

TRILOSTANE (VETORYL^®)

Pharmacy and Pharmacy Technician Scenario Example: Trilostane

PERGOLIDE MESYLATE (PRASCEND^®)

Pharmacy and Pharmacy Technicians Scenario Example: Pergolide Mesylate

DOMPERIDONE (EQUIDONE^®)

OCLACITINIB MALEATE (APOQUEL^®)

Pharmacy and Pharmacy Technician Scenario Example: Oclacitinib Maleate

MAROPITANT (CERENIA^®)

Pharmacy and Pharmacy Technician Scenario Example: Maropitant

CISAPRIDE

Pharmacy and Pharmacy Technician Scenario Example: Cisapride

POTASSIUM BROMIDE

Pharmacy and Pharmacy Technician Scenario Example: Potassium Bromide

PIMOBENDAN (VETMEDIN^®)

Pharmacy and Pharmacy Technician Scenario Example: Pimobendan

CLENBUTEROL (VENTIPULMIN^®)

Pharmacy and Pharmacy Technician Scenario Example: Clenbuterol

REFERENCES

Maintenance is scheduled for 8/7/2023 7:00 AM EST - 8:00 AM EST.

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Expired activity

Module 6: Top 30 Veterinary-Only Prescription Drugs Part 2: Hormonal Drugs and Selected Individual Agents

INTRODUCTION

HORMONAL DRUGS

CAPROMORELIN (ENTYCE®)

Pharmacy and Pharmacy Technician Scenario Example: Capromorelin

DIETHYLSTILBESTROL

ESTRIOL (INCURIN®)

Pharmacy and Pharmacy Technician Scenario Example: Estriol

INDIVIDUAL AGENTS

DEXMEDETOMIDINE (SILEO®)

Pharmacy and Pharmacy Technician Scenario Example: Dexmedetomidine Oromucosal Gel

IMEPITOIN (PEXION®)

Pharmacy and Pharmacy Technician Scenario Example: Imepitoin

MIRTAZAPINE, TRANSDERMAL (MIRATAZ®)

Pharmacy and Pharmacy Technician Scenario Example: Transdermal Mirtazapine

PHENYLPROPANOLAMINE (PROIN®)

Pharmacy and Pharmacy Technician Scenario Example: Phenylpropanolamine

TRILOSTANE (VETORYL®)

Pharmacy and Pharmacy Technician Scenario Example: Trilostane

PERGOLIDE MESYLATE (PRASCEND®)

Pharmacy and Pharmacy Technicians Scenario Example: Pergolide Mesylate

DOMPERIDONE (EQUIDONE®)

OCLACITINIB MALEATE (APOQUEL®)

Pharmacy and Pharmacy Technician Scenario Example: Oclacitinib Maleate

MAROPITANT (CERENIA®)

Pharmacy and Pharmacy Technician Scenario Example: Maropitant

CISAPRIDE

Pharmacy and Pharmacy Technician Scenario Example: Cisapride

POTASSIUM BROMIDE

Pharmacy and Pharmacy Technician Scenario Example: Potassium Bromide

PIMOBENDAN (VETMEDIN®)

Pharmacy and Pharmacy Technician Scenario Example: Pimobendan

CLENBUTEROL (VENTIPULMIN®)

Pharmacy and Pharmacy Technician Scenario Example: Clenbuterol

REFERENCES

Customers who Purchased
this Activity also Purchased

Module 6: Top 30 Veterinary-Only Prescription Drugs
Part 2: Hormonal Drugs and Selected Individual Agents

CAPROMORELIN (ENTYCE^®)

ESTRIOL (INCURIN^®)

DEXMEDETOMIDINE (SILEO^®)

IMEPITOIN (PEXION^®)

MIRTAZAPINE, TRANSDERMAL (MIRATAZ^®)

PHENYLPROPANOLAMINE (PROIN^®)

TRILOSTANE (VETORYL^®)

PERGOLIDE MESYLATE (PRASCEND^®)

DOMPERIDONE (EQUIDONE^®)

OCLACITINIB MALEATE (APOQUEL^®)

MAROPITANT (CERENIA^®)

PIMOBENDAN (VETMEDIN^®)

CLENBUTEROL (VENTIPULMIN^®)