Dr. Patty, you may have your wishes from a clinical standpoint, but as a customer I'd be much happier if the veterinarian simply gave me a photocopied sheet like I get from the (human) pharmacy with the possible side effects, common interactions, and danger signs.

Turns out that one of my pups is allergic to Previcox; if I hadn't known to watch for things like low capillary refresh rate in the gums and known how fast she usually bounces back from anesthesia, I might not have caught the subtle warning signs in time that made me call my vet at midnight and ask her what the "danger signs" list for the drug is.

Karl Katzke May 7th, 2009 10:54:17 AM

Dr Khuly, does the problem lean more toward the information not being organized anywhere accessible, or is it more that most drug interactions just aren't known or documented at all? Creating a system to organize and compile scattered information sounds like a doable project but if it's largely a matter of "no one knows", then it sounds like there's a much larger problem with lack of research and documentation.

Karl - I agree, getting a print out with any vet meds would be lovely. I've had one pet prescription filled at a compounding pharmacy and I got the full consult with a pharmacist where they went over all the details, but usually it's just picking up a bottle of pills at the front desk from the receptionist after they've been dispensed in the back, and all the information you're given is the vet telling you how much, when and how long, with no discussions about contraindications, side effects or danger signs. Vet medicine could definitely do better when it comes to informing patients about prescriptions.

Anlina Sheng - abnormalloveofcats.com May 7th, 2009 11:09:44 AM

Assuming you have Plumb's, that would be a good start (also available for Palms if you have one).  Maybe invest in some of the newer additions of drug formularies for your practice, ask members on VIN what their favorites are.  Consider collecting your own monographs in a binder and labeling appropriately for easy access in your clinic's "library" space.

lexipup May 7th, 2009 11:22:58 AM

I have access to all the advanced drug resources VIN offers and still have trouble. Often. Barbara's question is spot-on. Some of it is just not well studied. But it seems like every time I find a clinical pharmacologist, I get smart answers. So you would think someone would compile a reasonable list of possibilities. Unfortunately, it may well be more a matter of "we don't know the answers well enough to risk our necks on missing some possible interactions."

Dr. Patty Khuly May 7th, 2009 11:39:36 AM

IMO, Medscape is a beta test and I'm being generous.  But at least they had a starting place.  If vets and pet people want this, don't follow their lead of starting with the drug company's claim that a drug is relatively safe.  You need somewhere that will take reports from vets and owners and compile the data.  If you really got that off the ground and running, you'd have that data from a more reliable source and you'd probably end up doing more for humans than you can possibly imagine as well.  So glad I insisted on good dentures and refused to use that gunk called "denture cream".  FDA, yeah, sure, whatever.

PJBoosinger May 7th, 2009 12:16:23 PM

Karl: Yes, package inserts for every single drug would be great. That's why I tend to use the small, prepackaged pain relievers for one-time-only cases. That's also why I'm gunning for a better computer system (paperless medical records) with easily printable package inserts.  

Dr. Patty Khuly May 7th, 2009 12:17:17 PM

We gave our Vet two tickets to a big Art Exhibit at the Museum as a show of appreciation.

Evet May 7th, 2009 12:56:00 PM

Ah, now I see why it took my vet a day (instead of an hour or so) to look up a possible interaction and get back to me.  At the time, I just thought she was probably overwhelmed with emergencies, or something; there'd even been one that came in during our checkup.  She also told me that she couldn't find a definitive answer, so we decided to just play it safe.

There are so many drug interaction resources for people, it never occurred to me that they might not be so handy and ubiquitious for pets.  That's gotta be stressful.

Galadriel May 7th, 2009 12:56:26 PM

If there are tools for human medicines, why not use those? It's likely that the interactions will be similar. Even if you're using a veterinary-only drug, such as Rimadyl, you can check for similar drugs.

I went onto the Medscape site you gave and entered Cyclosporin (oral) and Ibuprofen (oral), since ibuprofen is an NSAID, same as Rimadyl. Here's what it said:

MECHANISM OF ACTION: Cyclosporine increases the production of prostaglandin E2 and I2. Prostaglandin E2 has been shown to prevent cyclosporine -induced renal toxicity in animals. NSAIDS may increase cyclosporine-induced renal toxicity by blocking the formation of prostaglandins.

CLINICAL EFFECTS: Concurrent administration of cyclosporine and a NSAID may result in a decrease in renal function, with or without an alteration in cyclosporine levels.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Patients receiving concurrent therapy should be monitored for a decrease in renal function. The NSAID may need to be discontinued.

DISCUSSION: A decrease in renal function has been reported with concurrent cyclosporine and diclofenac, sulindac, mefenamic acid, ketoprofen, piroxicam, and naproxen. Decreasing the cyclosporine dose without discontinuing the NSAID does not appear to improve renal function.

Pretty useful, and it took me less than a minute to find.

Mary Straus May 7th, 2009 01:05:55 PM

Drugs don't act in pets the way they do in people.  The particular drug combo my vet was checking, for example, was one *I* had been on with no problems.  My vet couldn't find anything like a study that showed interactions between the two, but did find one comment about "significant morbidity"...

Galadriel May 7th, 2009 01:51:50 PM

Any of you vets scanning those package inserts and posting them somewhere?  (They probably have a copyright symbol on them but they're intended for distribution...)

PJBoosinger May 7th, 2009 02:08:35 PM

well with animals, you also have the species and breed differences, making it all that more complicated.

A shepherd mix? That would ring bells for me about some kind of atypical genetics kind of reaction to the drug combination - but again, that's just a sneaking, unconfirmed suspicion.

I'd be a bit careful about wishing for a too-solid drug interaction tool, because 1) the costs involved in doing the standardized tests might make some medications cost-prohibitive and 2) the ethics of carrying out such tests are shaky, imo. Let's test a bunch of drug combinations on healthy animals! (As long as no one OWNS them...it's OK. Right? Um...)

So we're basically relying on experience, and it's necessarily going to be incomplete, and take a long time to collect. 

Great topic, by the way. :-) 

brebis noire May 7th, 2009 02:30:29 PM

Mary, I missed your post - that is a good find...it backs up my own impression that general Internet resources are sometimes useful in these kinds of problems (I don't have access to VIN, and I get impatient with the kind of situation Dr Khuly describes, calling up experts and not getting an answer right away. I'm lucky to get answers the same week...)

brebis noire May 7th, 2009 02:33:17 PM

I think that sounds like a really fun app to build, actually, and a nice programming project. But I don't know where I'd get the info to plug into it.

Cait May 7th, 2009 04:50:00 PM

I'm curious but how did human doctors develop their drug interaction databases? Is it just experience that tells them and this is cataloged or is there some kind of science that enables one to take two (or 3 or 4) disparate drugs and pharmacokinetically predict how they'll interact?

Alex May 7th, 2009 10:19:03 PM

Mary, I've gotten incredibly good a finding multiple sources about drugs and assimilating them (thanks in large part to your website; THANK YOU) but, in the end, as everyone's saying, it's time sucking and still a crap shoot guess most of the time.  Would be nice if there were at least an on line database for vets to easily report their experiences so they have access to a collective rather than each one doing their own trial and error; even nicer if there was public access just for viewing if nothing more.  (You get credit for me not being the least bit shy about insisting on post op pain meds for my dog a few months ago too.  Found your site before Dr. K's. :)

PJBoosinger May 7th, 2009 10:25:44 PM

Alex: Human doctors?? Are you kidding? They don't even take responsibility for drug interactions. My gosh, my Mom was on up to twelve different medications a day, not counting occasional courses of antibiotics, prescribed by : oncologist, cardiologist, pulmonary spec., neurologist, gastroenterologist....it was insanity! And not a one, would address the meds prescribed by the other, or possible negative interactions...the answer was "ask your primary care Dr."

My elderly Dad had to become the pharmacist!

Barb A./NH May 7th, 2009 10:57:46 PM

Alex, When I was young, we depended more on our pharmacist to point out issues like that because he (yes, usually a "he" in those days) knew all the drugs a person was taking, often prescribed by multiple doctors, and usually knew us on a more personal level.  FDA doesn't have a handle on it, most of the databases are fee based services of varying quality, I certainly wouldn't trust the volume driven pharmacist at Wal-whatever to do it (especially when most of us go to multiple pharmacies these days).  The whole issue of evaluating drugs is really new anyway http://www.fda.gov/cder/about/history/Histext.htm  1500 government employees v. the drug industry.  Hmmm, think I'll do my own research.

PJBoosinger May 7th, 2009 11:36:18 PM

Alex: Great question. It's actually a combination. 

For example, basic research is conducted into how the liver's enzymes break down drugs. This information helps tell us whether we can expect certain interactions based on one or more enzymes' ability to handle more than one at a time. Pharmacokinetics of individual drugs play into this calculation so that we might predict how two or more drugs handled by these enzymes might interact.

Then there's the reporting of reactions--crucial to our greater understanding of the body's processes, pinpointing the need for more specific research on this. Keeping track of these reactions happens at the level of the FDA and the individual drug companies. But getting that out to the practitioners and the public? that's not always so easy.

Ideally, we need a centralized database for these to at least help guide us better. 

Dr. Patty Khuly May 8th, 2009 07:54:31 AM

I could wish for better information about interactions (and side effects) for human meds - that said, my current doctor has a lovely program that pulls up what I'm currently on, adds in whatever he's thinking of giving me, and puts a big red flag in the middle of the screen if something is going to go badly!  I can certainly see how something like that would be incredibly useful for vets, Dr Khuly, but oh boy it would have to be more complicated than the human version...

Mel Redcap May 8th, 2009 07:49:36 PM

A centralised database for all of North America (ideally Europe as well) would be nice, one based on reports of adverse effects, and reactions with combinations. The different pharmaceutical companies to come together and set it up but I'm not holding my breath.

In theory, it doesn't sound very complicated, but it would require most vets being online, and entering the name of the drugs the animal is taking, the nature of the event and various details. I.e. - they'd have to know about its existence. Best way to do that would for it to be regulated. Who would take responsibility for the costs and logistics?

I'd like to think it would make a great project for a graduate student...

brebis noire May 9th, 2009 08:45:16 AM

brebis noire: Since writing this, I have heard rumors of a veterinarian in Baltimore (I think) who's got the largest database for veterinary drug interactions in the world. He's probably sitting on a tool he doesn't know how to monetize. The big drug companies or one of the online pet portals might be able to help, I would think.

Dr. Patty Khuly May 9th, 2009 05:09:30 PM

How did the veterinarian in Baltimore build his database?  One way to start would be by filing a Freedom of Information request with FDA CVM for all adverse drug event reports scored as possibly or probably related to the drug and which include concomitants.  In fact, since FDA CVM is receiving adverse drug event reports from the public, veterinarians, and drug companies, listing concomitants, and scoring the reports why don't they identify combos identified with high regularity in adverse event reports?  That would be a start.     

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