The Team - Spring 2014

Diagnosis: Oral Pain 3 | The Pruritus Workup 8

Osteoarthritis in Senior Cats 15 | Generic Drugs: Profit Potential 21

A Wealth- Enhancing Resource

for Independent Veterinary Practices

Spring 2014 | Vol. 11, No. 2

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www.psi-inc.net | the Team | Spring 2014 1

Sincerely,

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FELINE OSTEOARTHRITIS: AN UNDER-DIAGNOSED DISEASEAn estimated 80 percent to 90 percent of senior and geriatric cats suffer from osteoarthritis, but it’s one of the most under-diagnosed feline diseases.

Cats are masters at hiding pain, and they rarely show signs of limping or lameness. They often resist examination—and many are not receiving veterinary care. But simple changes at home along with treatments such as laser therapy can help cats live more pain-free lives in their golden years.

Get your whole team up to speed on spotting signs of this degenerative disease.

On pg. 15, Dr. Stephanie Gandy Murphy provides an overview of diagnoses and treatment suggestions for everyone on your practice team.

Also in this issue:• Pets with oral pain will often still eat, play and work. Dr. Sharon Hoffman has advice on treatment and compliance on pg. 3.

• Pruritus is a complex problem that requires a methodical workup. Dr. Michael Canfield takes us through the process and offers suggestions for gaining client compliance on pg. 8.

• Are you using generic drugs in your practice? If not, you might want to consider the pricing flexibility—and profits—that come with non-branded drugs. They are just as safe as branded drugs and cover a range of conditions, from osteoarthritis to respiratory and urinary tract infections. Read more on pg. 21.

We hope you find this issue both educational and wealth-enhancing for your business.

Spring 2014 | Vol. 11 | No. 2

The Team is an educational resource published by Purchasing Services Inc., St. Petersburg, Fla.

Comments are welcome at [email protected]

Visit us on the web at www.psi-inc.net

© Copyright 2014. All rights reserved. The Team magazine does not make any representations as to opinions or facts as presented. Reproduction of contents in any form is prohibited without prior written permission of the publisher.

Postmaster: Send address changes to: The Team, 2951 34th Street South St. Petersburg, FL 33711

A Wealth-Enhancing Resource for Independent

Veterinary Practices

From the Desk of Dennis A. Nelson, dvm

Visit us on the web at

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The Team is published to complement Pet Quarterly®, an educational resource for your clients. Look for these articles in the current issue of Pet Quarterly: Does Your Pet Have a Toothache?; There’s the Rub; Ditch the Itch; Going Generic.

Diagnosis: Oral Pain 3 | The Pruritus Workup 8

Osteoarthritis in Senior Cats 15 | Generic Drugs: Profit Potential 21

A Wealth- Enhancing Resource for Independent Veterinary Practices

Spring 2014 | Vol. 11, No. 2

Does Your Pet Have a Toothache?

Generic Drugs:Lower Cost Options

Pet Care News From Your Veterinarian

spring 2014 | Vo lume 11, no. 2

Pet Care News From Your Veterinarian

$4.25

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THERE’S THE RUBTreating feline osteoarthritis

Relief for your pet’s

itching and scratching

DITCH THE ITCH SAVE THE DATE...

Purchasing Services, Inc. announces a new

PSI Member Business Symposium to be held

June 12-15, 2014, in St. Petersburg, Fla.

Stay tuned for more information.


Key causes of oral and dental pain in pets range from periodontal disease to fractured teeth, malocclusion, tooth resorption and stomatitis. Most pets with painful teeth and mouths will still eat, play and work. How then, will the veterinary team diagnose oral pain and increase pet owner awareness?

A pet owner usually won’t see the source of oral pain in a pet. Unlike a sore leg or a visible wound on the skin, broken teeth are hidden behind the lips and periodontal disease is hidden under the gum. Pets with sore mouths may not want their mouths or faces touched. Others will “act old.” These subtle signs of oral pain may go unnoticed. There may not be any signs at all.

Finding the Source of Pain Diagnosing the key causes of oral pain begins with an extraoral and intraoral exam of the conscious patient. This exam will reveal some causes of pain, especially if you find a fractured tooth or malocclusion, or detect an odor. Always compare teeth on the left and right sides of the mouth. If a pet has pain on only one side of the mouth, there may be calculus build-up on that side. The calculus builds up because the pet is avoiding chewing on the painful side.

Watching a dog chew a C.E.T. VeggieDent, Greenie or Tartar Shield chew (www.vohc.org for

list of approved chews) in the exam room may help identify pain on one side of the mouth. The dog may avoid chewing on the painful side. Cats and some dogs will not chew anything in the exam room. Pets in severe pain may not allow an oral exam. This is often the case with stomatitis patients.

Exam Under AnesthesiaThe next part of the oral exam is performed under general anesthesia. This allows you to look in places that cannot be seen in an awake pet. Each step of the exam is essential for a complete and accurate diagnosis.

1. Examine every tooth above and below the gingiva using a dental probe. Measure periodontal pockets and attachment loss. Use a dental explorer to detect tooth resorption and caries.

2. Take dental X-rays of all teeth.3. Record all findings on a dental chart. Some practices schedule a diagnostic oral exam

at the time of the first anesthesia, with a second visit for treatment. This allows time to review photos and radiographic findings with the client prior to treatment. It also makes it possible to create an estimate for needed procedures. Scheduling adequate time prevents time pressure anxiety on the day of the procedure and ensures that there will be enough time to provide the care the patient needs.

Dental Health

>>

Diagnosis: Oral Pain Find the source of oral pain in dogs and cats, and get your team

involved in improving compliance.

By Sharon Hoffman, DVM, Diplomate American Veterinary Dental College

Treating Oral PainAfter you perform a complete oral exam, take radiographs under anesthesia and reach a diagnosis, treatment planning begins. Treatment will require a procedure.

Fractured Teeth. There are two surgical options for fractured teeth in which the pulp is involved: extraction or root canal therapy. (Fig. 1) Watching and waiting for swelling or drainage is not an option, as pain and infection will persist. A fractured tooth cannot heal, and antibiotics will not prevent tooth death or infection. Visit www.avdc.org for a referral to a board-certified specialist if these procedures are not provided in your practice.

Tooth Resorption. Pets diagnosed with tooth resorption will require surgery. (Fig. 2) The type of surgery needed is determined after reviewing the dental radiographs (see www.avdc.org for types of tooth resorption).

Stomatitis. Pets with stomatitis will need surgery involving multiple

extractions. Those with a painful malocclusion may need extractions or referral to a specialist for options such as orthodontics.

Periodontal Disease. Treatment options for periodontal disease depend on the stage of the disease (see www.avdc.org for stages), as determined from radiographs and measurement of attachment loss. Any or all of these procedures may be indicated:

n closed root planingn perioceutic applicationn open root planingn implants n other advanced periodontal

procedures. The periodontal patient will

need professional periodontal treatments two to three times a year to control the disease. Periodontal surgery is time-consuming and requires advanced training.

Painful dental and oral diseases require anesthesia, surgery and pain management. When talking to a pet owner about surgery, address any anesthesia fears the pet owner may have. Discuss what your practice does to decrease risk factors, such as: identifying pre-existing systemic disease with CBC, chemistries, urinalysis and cardiac workups when indicated; constant

Dental Health

Receptionists n When scheduling a dental patient, focus on the importance of the oral exam, including radiographs as well as a dental cleaning. Clean teeth may still be sources of pain.

n Allow enough time in the procedure schedule for diagnostics under anesthesia. More time will be needed if treatment is planned.

Assistants, Techniciansn Have dental models and pictures in each exam room that demonstrate dental disease.

n Create a “Dental Patient Testimony” photo book to include the stories of pets that felt so much better after their dental pain was treated. Feature a “Smile of the Week” case on your Facebook page or website.

Technicians, Veterinariansn Attend continuing-education dentistry seminars to complement your existing knowledge of current veterinary dentistry. Opportunities abound. Resources include www.avdc.org and the Journal of Veterinary Dentistry (JVD).

n Locate your local Board Certified Veterinary Dentist (www.avdc.org). He/she is a

part of your team in delivering optimal dental and oral care to referred patients.

The Team ApproachSMILE OF THE WEEK

1

2

A fractured tooth requires root canal treatment or surgical extraction, plus pain management.

Teeth having tooth resorption require surgery. The type of surgery depends upon the type of resorption as diagnosed using dental radiographs.

4 Spring 2014 | the Team | www.psi-inc.net

Consider featuring a “Smile of the Week” case on Facebook.


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monitoring and recording of vital signs during anesthesia; body-temperature and blood-pressure support; and preemptive and perioperative pain management customized to the needs of the patient.

Patients having high anesthesia risk factors can be referred to a Board Certified Veterinary Dental Specialist. Pets with pre-existing cardiac disease, renal disease, immunosuppressive diseases and diabetes often have painful dental disease that needs to be treated. These patients are candidates for referral.

Improving Client ComplianceTake photos of diseased teeth while pets are under anesthesia. Showing these photos to pet owners can help them achieve awareness of their pet’s pain. Do not focus on pictures of dirty teeth followed by pictures of clean teeth—clean teeth may still be sources of pain. (Fig. 3 & 4) Show photos of fractured teeth and those with abrasion, as well as wounds and dental attrition caused by malocclusion.

Dental radiographs are the most helpful way to demonstrate periodontal disease. First, show radiographs of normal teeth and bone, then compare to radiographs of pets with bone loss due to periodontal disease. This “show and tell” practice is very enlightening. Pictures are worth a thousand words.

Use a chart showing different stages of periodontal disease to demonstrate how the disease progresses. When I show dental

3

4Clean teeth may still be sources of pain. The clean teeth in photo 3 have advanced periodontal disease, as seen in the X-rays in photo 4 taken on the same day as a dental cleaning.

>>


X-rays (Fig. 5) to pet owners, they ask, “How did it [periodontal disease] get so bad?” Periodontal disease is a stealth disease—it happens where you can’t see it. It can begin when the pet is young, especially in small breed dogs. All small breed dogs over the age of two years should have full mouth dental X-rays to screen for periodontal disease.

Specific questions and comments the team may encounter from the client include:

1. What will happen if we do nothing? This is a common question and may be asked for a couple of reasons: fear of anesthesia, financial concerns or the misperception that the pet is not in pain. Be sure to address any anesthesia concerns. Let the client know what payment plans your practice offers. Explain that periodontal disease will progress and cause more pain and damage. Periodontal disease is the leading cause of tooth loss in pets. In untreated severe cases, jaw fractures may occur. Treating periodontal disease early on is less expensive and also prevents more intense oral pain for the pet.

2. How will my cat eat without teeth? This question comes up in those cases of cats with stomatitis when caudal teeth or full mouth extractions are indicated. Reassure your clients that after healing from surgery, the cat will eat without pain. Always discuss how postoperative pain with be managed to address this concern.

3. “The broken tooth doesn’t seem to bother my dog. He is still eating.” This is a common misperception. A pet owner is not trained to recognize signs of pain in pets. Let clients know that pets with fractured teeth will continue to eat, play and work. Some pets with fractured jaws even still eat. Share stories of pet owners who have noticed dramatic rebounds in energy and playfulness after treatment, and didn’t realize until then how much pain their beloved pet had been in. Stress to clients: We don’t know how much pain the pet is in until we take that pain away. n

Dr. Sharon Hoffman is a Board Certified Veterinary Dental Specialist at North Florida Veterinary Dentistry & Oral Surgery in Jacksonville, Fla.

Dental Health

5

Compare this X-ray of teeth and healthy Periodontium to photo #4 of teeth having advanced periodontal disease.


Common Causes of PruritusAllergic

n Flea allergy dermatitisn Atopy

n Atopy-like dermatitisn Food hypersensitivity

n Parasitic hypersensitivitiesn Contact dermatitis

n Drug hypersensitivities

Parasiticn Fleasn Ticks

n Sarcoptesn Demodex

n Licen Mosquitoesn Culicoides

Inflammatoryn Bacterialn Fungal

n Immune-mediated diseases

n Irritant reactions

Neoplasticn Epitheliotropic lymphoma

n Mast cell tumor(s)

Neurogenicn Psychogenic and sensory

neuropathies

spring is upon us, and with the change in seasons we can expect to see a rise in the number of patients presenting with pruritus. This intense feeling of itchiness is the most common symptom in dermatology and is a common presenting complaint in practices across the country. It may stem from a dermatological disorder or may occur without a primary skin disease.

Pruritus in dogs and cats may manifest as chewing, licking, scratching, rubbing and excessive grooming. Early in the course of a disease state, these changes usually go unnoticed by most pet owners. However, as observant clinicians, we can detect early changes and point them out to pet owners, starting the educational process.

Pruritus is a complex problem that can affect the quality of life for pets and their families. With a methodical diagnostic workup, you can help each client along on a journey to discover the cause of the problem and help each pet find relief.

The Road to ReliefEvery clinician should have a list of differential diagnoses for pruritus and an understanding of how to rule out the differential diagnoses: allergic, parasitic, inflammatory, neoplastic and

neurogenic. (See sidebar.) Different types of itch include: dermatologic, systemic, neurogenic/neuropathic, psychogenic and mixed, along with other unexplained causes of pruritus.

Not every case will be easy. Pruritus is the hallmark of clinical signs for allergic dermatitis, but pruritus is not specific for allergies. An orderly process will help you provide exceptional care and gain compliance.

Start with the patient’s signalment, history and physical examination. In particular, note the age of onset. A puppy or kitten presenting with

pruritus will have a different list of differentials than an older dog or cat. Sarcoptic acariasis, demodicosis, dermatophytosis, internal parasites and food sensitivity are much more common in young patients. If an older patient with no prior history of skin disease now has erythema, scale and pruritus, the culprit could be epitheliotropic lymphoma or, less commonly, allergic dermatitis.

Base your diagnostic algorithm for pruritus on the information gathered. Although you don’t need to perform every diagnostic test on every patient,

THE PRURITUS WORKUPHow to approach the often-complex issue of itchiness—

and improve client compliance. By Michael Canfield, DVM, DACVD (Diplomate, American College of Veterinary Dermatology)


Parasites & Dermatology

>>

Diagnostic Tree for Pruritus

SOURCE: ADAPTED FROM MULLER & KIRK’S SMALL ANIMAL DERMATOLOGY, 7TH EDITION, MILLER GRIFFIN CAMPBELL (ELSEVIER 2013).

Coproscopic exam/ Fecal Analysis

Skin scrapingsTape preparations

Flea combing

Endoparasites

6No

6No

4Yes

4Yes

Ectoparasites

Ascarids, Hookworms, Tapeworms,

Whipworms, Coccidia

Fleas, Sarcoptes, Ticks, Notoedres, Lice,

Cheyletiella, Mosquitoes, etc.

CytologyTherapeutic Trials

+/- Biopsy

Look for Underlying or Predisposing

Cause

TreatEmpirically treat.

Preventatives where appropriate

Inflammation

Elimination Trial

Response

Flare upon challenge

Food Hypersensivitivy

Psychogenic or neurologic

diseaseAtopic

Dermatitis


6No

4Yes

VeterinariansDecide on the educational process that makes the most sense for the practice. Consider covering a single topic in detail at a monthly team meeting, focusing first on the more common disease processes. Consider training your technical teams on how to perform the various diagnostic tests for pruritus.

Technicians/Veterinary AssistantsYou are key for interactive client education, but getting prepared to talk about pruritus requires an investment of time. Although much information is available through journals or online, the messages may vary and this is less than ideal for the practice. Practice presenting topics to

the entire team to learn from each other, get your messages consistent and polish your deliveries. Practice answering questions to simulate an examination room setting.

ReceptionistsParticipate in the team training on pruritus. You should be able to reiterate and reinforce the recommendations made by the

hospital team. Document any information you gather related to the pet.

Practice ManagersAllot ample time for mandatory team training about pruritus. Reward the team for furthering their knowledge base. Consider modifying performance evaluations to reflect each team member’s level of participation.

The Team ApproachHere’s how the whole team can work together to educate clients about pruritus.


Mosquito bite hypersensitivity

Demodex mite from cat

Atopy

Flea allergy

Hookworm ova

Whipworm ovaDog louse egg


every practice should have a list of core diagnostics that are performed on every pruritic patient. All pruritic patients should have:

n flea combingn skin scrapingsn cytology of the skin and ears.

Diagnostic TestsHere’s an overview of those core tests, as well as other tests that may uncover the cause of pruritus.

n Flea combing can be an invaluable diagnostic test to screen for fleas, flea feces, Cheyletiella and lice.

n Skin scrapings and hair plucks should be performed to rule out demodicosis, Notoedres and pelodera or to screen for Sarcoptes mites. Always use caution when attempting to eliminate Sarcoptic mange or Demodex gatoi, due to frequent false negative scraping results. Adjust the method you use to collect the samples to fit the differentials. For example, Demodex canis mites are often found in the hair follicles, requiring deeper scrapes, while Demodex gatoi and Sarcoptes scabei are more superficial, generally requiring broad superficial scrapes.

n Fine needle aspirates and cytology should be performed to evaluate for lesions such as mast cell tumors and epitheliotropic lymphoma, among other things.

n Fecal centrifugation should be performed regularly to screen for intestinal parasites such as hookworms, roundworms, whipworms and coccidia. These have been documented to result in parasitic hypersensitivities, which may result in the development of pruritus. This diagnostic test is seldom thought of for pruritic patients, but it should be a part of the minimum database in most cases. Interestingly, there are times when Demodex gatoi, a cause of pruritus in some cats, may be found in a fecal analysis more readily than with skin scrapings. Fleas, mites and lice may also be seen, especially in allergic animals that have escalated grooming.

n An empirical scabies treatment serves as a diagnostic test. Any patient for which atopy will be pursued should be empirically treated for sarcoptic mange.

The reason for this recommendation is that a patient with sarcoptic mange may have a low number of mites, which will often yield a negative skin scraping. Unfortunately for us, sarcoptic mange mites will cross-react with dust mites during allergy testing. Since dust-mite hypersensitivity is common in pets, this simple lapse in diagnostic planning could result in a patient being on immunotherapy the remainder of its life

for a problem it may not have. n Fungal cultures (DTM) should

be collected and utilized any time you suspect dermatophytosis—and it should be suspected in any young dog, cat or immunosuppressed patient presenting with fractured or broken hairs.

n A Wood’s lamp examination is an inexpensive screening tool for dermatophytosis, but false negatives and false positives are frequent.


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Exercise caution with this test.n Cutaneous cytology should be performed on all

cutaneous lesions to determine if secondary infections exist and to aid in determining appropriate treatments.

n Biopsy of masses or cutaneous lesions should be performed in cases where cytology and other diagnostics are inconclusive or suggestive of immune-mediated disease.

n Intradermal or serum allergy testing should be performed when history and physical examination findings are supportive of atopic dermatitis and other causes of pruritus have been ruled out. Atopic dermatitis is a diagnosis of exclusion.

Educate for ComplianceEducation is the key to compliance in a pruritic patient workup and treatment recommendations. Focus the discussion on the most likely diagnoses based upon the information collected during the examination and history-gathering process. Practice your delivery. Speaking to a client about epitheliotropic lymphoma or mast cell tumors can be much more difficult than a discussion about a histiocytoma or fleas.

Clients should hear a unified voice from the practice. With a clear, consistent message from the team, you’ll have the best chance of gaining owner compliance and helping each patient find relief. n

Dr. Michael Canfield is a board-certified dermatologist at Animal Dermatology South and Animal Hospital of Regency Park, with Florida offices in New Port Richey, Melbourne and Fort Pierce.


New Drug OptionA new pruritus drug is an exciting addition to the veterinary pharmacy. Apoquel® (oclacitinib) is a new treatment option for pruritic dogs at least 12 months of age. Its novel mechanism of action is unlike anything we have had in veterinary medicine to date.

Apoquel inhibits Janus kinase enzymes, particularly Janus kinase 1 and Janus kinase 3, which inhibits pruritogenic, proinflammatory and proallergic cytokines while sparing Janus kinase 2 (important in hematopoiesis and innate immunity).

Apoquel’s onset of action has been shown to exceed that of dexamethasone, prednisolone and Atopica in some studies. It is indicated for the control of acute and chronic pruritus and, unlike glucocorticoids, can be used in conjunction with NSAIDs. Allergy testing can be performed while patients are on Apoquel, whereas glucocorticoids preclude allergy testing.


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NEED TO KNOW: FELINE OAAn overview of osteoarthritis, a common but under-diagnosed disease in senior cats.

By Stephanie Gandy Murphy, DVM

Senior Wellness

advances in our profession are enabling our patients to live longer, making the human-animal bond stronger than ever before. Veterinary teams are seeing more geriatric patients, and with this shift we see more common diseases treated in human medicine. One of the most common (yet under-diagnosed) diseases of our feline patients is osteoarthritis.

Recent studies indicate 80 percent to 90 percent of senior and geriatric cats suffer from this progressive, degenerative disease involving the joints. Over time, the cartilage breaks down and bones start rubbing together, creating friction, pain, reduced joint motion (more commonly in dogs than cats) and sometimes bone spurs.

So why has this condition gone largely undiagnosed in the feline species? Some reasons are:

n Cats not receiving veterinary caren Cats resisting examinationn Cats’ small size and flexibilityn Cats rarely show signs of limping/lamenessn Radiographic changes in cats being more subtle

than those in dogsn Cats are good at hiding signs of pain.

Diagnosing Feline OAWhen examining a senior cat for OA, start with a general physical examination followed by a more comprehensive orthopedic exam, isolating and >>

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Laser Therapy: A Healing Light



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ReceptionistsMake it a habit to get as much information as possible from the client when scheduling an appointment, regardless of the reason for the visit. Ask questions such as: How old is your cat? Have you noticed any changes in your cat’s behavior such as reduced grooming, inappropriate urination/defecation, or being reclusive? If owners report any inappropriate urination or defecation, ask if they would take a picture of their

cat’s litter box. Always ask pet owners if they have any questions or concerns about their cat’s visit today. Encourage the owner to call with any issues that may arise.

Veterinary Assistants/TechniciansWhen handling senior cats, be mindful that many of these patients are experiencing some discomfort from osteoarthritis. Use thick towels on the examination table. If the exam

room is cold, consider warming a towel in the dryer before use; the cat and owner will appreciate it. When restraining a cat, avoid quick, rapid movement of the patient’s body. Cats can experience neck and back pain just as humans can. Be aware that signs of osteoarthritis in cats are typically subtle and are often brushed off as “just old age” or behavioral issues. Learn to ask specific questions (sometimes in multiple ways) and to interpret the owner’s response.

Boarding Managers and Kitty CaretakersIdentify cats within the boarding facility that may be suffering from pain associated with osteoarthritis. Document the cat’s behavior during playtime. Do you notice that a boarder seems stiff when first let out of the cage? Make sure older cats have soft bedding that is easy to get in and out of (consider towels or mats). Always feel a boarder’s bedding material. Sometimes older cats will

The Team Approach The whole team can work together to make sure your cat owners are aware of feline osteoarthritis: what it is, how it affects a cat’s behavior, and the most current treatment options.


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urinate on bedding instead of the litter box. This could be due to incontinence, pain or fear. Familiarize yourself with the therapy laser and its benefits for cats with chronic pain, so that you can offer this additional service to cat owners.

Practice ManagersMake sure your practice has easy-to-follow protocols to assess and address pain in cats. These protocols should include details about factors that could affect drug selection, such as other systemic diseases and the patient’s attitude (i.e., renal insufficiency patient, grumpy

patient). By utilizing the same method of evaluation, all team members will be consistent when assessing a patient’s pain. American Association of Feline Practitioner (AAFP) Guidelines, available online at www.catvets.com/guidelines/practice-guidelines/pain-management-guidelines, include great questions that should be included in the protocol.

Be sure your veterinarians have all the necessary medications and formulations to treat a variety of pain levels, regardless of the ease of administration. Make sure all team members are trained how to safely use the therapy laser.

VeterinariansReview and follow the current recommendations for senior care in cats and pain set forth by the AAFP. Use a protocol but customize a treatment for each patient as an individual. Consider all formulations of medications you have dispensed (some come in liquids, pills, chews, injections). Demonstrate physical therapy exercises that owners can try at home. Familiarize yourself with products available to help cats as they age, such as elevated food and water bowls, heated blankets and beds, steps to help cats get onto beds, using puppy pads or litter trays instead of boxes, and utilizing

a space heater. Follow up with your clients! Make sure your clients know you are here to support them. If they are having difficulty with one product or another, offer other solutions and encourage their feedback. >>


manipulating each joint. You could take radiographs as well, but keep in mind that it is usually difficult to detect indicators of OA in cats. Ask the client questions about how the cat moves and any changes in behavior. Compare your results with those of earlier exams, looking at weight loss, muscle atrophy and pain response. In some cases, you may recommend a

trial of medication to see if the cat responds positively to treatment.

When obtaining a history from your client, know the common signs of OA in cats: weight loss, muscle atrophy, behavioral changes (such as irritability or depression), inappropriate elimination, loss of appetite, reduced activity, stiffness (primarily when the cat wakes, often seems to resolve throughout

the day), inability or reluctance to jump down from or up onto areas, reduced height of jumping, poor hair coat due to lack of grooming, constipation, and joint swelling.

Treatment: Challenges and OptionsTreating feline OA can be difficult due to several factors. For example, owners may have difficulty

Senior Wellness

Keeping Cats ComfortableSuggest these options to clients to help keep their senior cats comfortable at home:

n Litter pans with lower sides for ease of entering and exiting

n Puppy pads or blue pads with a small amount of litter on them for cats that cannot get in and out of litter boxes

n Elevated food and water bowls

n Steps to help cats to get to their favorite places

n Soft bedding. Foam microfiber bath mats are a great bedding option for older arthritic cats. These mats are slightly thicker than a traditional bathmat, easier for a cat to lie on than some cushioned cat beds, and very easy to wash.

n Heated cat beds (cold, damp conditions seem to worsen clinical signs)


pilling a cat or with the palatability of recommended diet/treats. Owners may be noncompliant and reluctant to pursue treatment, assuming that they are stressing their cat with repetitive veterinary visits.

Physical examinations can be difficult. Some cats freeze; others will not allow manipulation of joints to assess for pain; others may require sedation. You may also have difficulty with owner assessment—since cats are not as active as dogs, its not easy to determine if a treatment plan is working.

Other systemic diseases may interfere with your treatment plan. For example, older cats with OA may have some degree of chronic renal insufficiency, and many clinicians are reluctant to use NSAIDs in these patients due to kidney clearance. In addition, many analgesic drugs used in other species are not licensed, not available or not tested for use in cats.

Available treatment options include:n Weight loss if a cat is overweightn Non-steroidal anti-inflammatory

drugs (NSAIDS)n Nutraceuticals (diets, treats,

injectables, pills, powders, liquids, etc.), including Omega-3 fatty acids, Glucosamine/Chondroitin, ASU (avocado and soybean unsaponifiables)

n Narcotic pain medicationn Acupuncturen Gabapentinn Laser therapyn Physical therapy/hydrotherapy

(See the current issue of Pet Quarterly for some of the challenges of each.)

Get your whole team—and cat owners—involved in watching for signs of the disease in senior cats. Encourage team members to video patients in the exam room and watch the videos at your next team meeting. Ask cat owners to do the same at home in an environment that’s less stressful than a clinic visit. This may help you identify symptoms to show to your clients so they will be more likely to participate in treatment options. n

Dr. Stephanie Gandy Murphy is a feline veterinarian and owner of Catisfaction Cat Clinic in Madison, Ala.

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PROFITING FROM GENERICSPromoting generic drugs in your practice adds up to profits

in more ways than one.By Paula Andruss

everyone’s looKing to save money these days, and pet owners are no exception. Research shows that one-third of pet owners are postponing visits to their veterinarians because of the costs associated with those services.1 For dog owners and cat owners alike, one of the biggest concerns is the high cost of prescription drugs.

Veterinarians can assuage some of those client concerns while boosting their own profits by offering veterinary generic drugs when available to treat a variety

of common conditions. With prices that average 25 percent to 60 percent lower than their brand-name counterparts, generic drugs can help practices pass along much-appreciated savings to their clients. They can also help build client trust, grow other services and protect practice pharmacy revenue.

Veterinary generic drugs are approved equivalents of branded drugs, with the same active ingredients of the original formulation, says Dr. Tracy Revoir, manager of veterinary

support at Putney Inc., a Portland, Maine-based veterinary generic pharmaceutical company. In order to obtain approval from the U.S. Food and Drug Administration (FDA), generic animal drugs must have the same potency, or amount of active ingredient, as the branded drug, she notes. They also must be bioequivalent, which means they are absorbed in the blood equally to the brand product, and therefore, have the same safety and effectiveness as the brand drug. Generic drugs are also manufactured using the same

GENERIC BRANDED DRUG TYPE

Carprofen Caplets Rimadyl Caplets Anti-inflammatory

Enrofloxacin Flavored Tablets Baytril Taste Tabs Antibiotic

Cefpodoxime Proxetil Simplicef Antibiotic

Common generics and their brand-name counterparts.

FAST FACTDrug revenue typically accounts

for 25 percent to 30 percent of practice revenue.

>>


quality standards as branded drugs.The most common drugs

available in generic form today are those used to treat conditions including osteoarthritis, post-surgery pain, and skin, respiratory and urinary tract infections. They include Carprofen Caplets, the generic form of the analgesic Rimadyl; Enrofloxacin Flavored Tablets, the generic counterpart to Baytril Taste Tabs; and Cefpodoxime Proxetil Tablets, the generic form of Simplicef.

Direct ProfitsThese drugs can be profitable in a variety of ways, says Revoir. The first, of course, is based on cost. Because you pay less for generics, you have more flexibility in terms of how much you want to mark up that drug.

“It’s up to practices how to price these drugs based on their philosophy and the cost sensitivity of their clients,” she says. “At the

very least they can make the same amount of money per prescription as they would on the branded drug and save their clients a lot of money. Or they can choose to mark up the generic more, which still saves their clients money. It’s completely up to them in terms of how to approach it.”

Sample CaseFor example, says Revoir, to treat a 75-pound dog with hip dysplasia, a 60-tablet bottle of 75-milligram generic Carprofen Caplets would cost the practice $21, while the branded drug would cost $48. If

both drugs are marked up by one time the cost of the branded drug ($48), so that the practice would make the same amount on both drugs, the client cost for the generic would be $69, and the client cost for the branded drug would be $96. In both cases, the practice makes $48. Or, the practice could mark up the generic drug three times and charge the client $84, a $63 profit for the practice while still offering $12 savings for the client over the $96 cost of the branded drug.

“In that case, the client still saves $12 on the generic, and the hospital makes $15 more profit with each generic prescription,” says Revoir, adding that those profits can add up when treating chronic conditions such as osteoarthritis, where the animal may take the drug for the rest of its life. Most importantly, the pet may be more likely to receive the medication it needs to be pain-free.

Side ProfitsStraight dollars aside, veterinary generics can drive profits in other ways in the practice as well:

n Client Retention: If clients feel that their veterinarian is not overcharging them on their medications, they may be less likely to think they’re being overcharged in other areas as well. “That builds trust with them, which is important to client retention,” Revoir says.

n Keeping Prescriptions In-house: Another issue is that clients are getting savvier about where to get the best prices for their prescription drugs, from online sources to big box stores such as Walmart. “If veterinarians keep their prescription prices reasonable, clients are more likely to have their prescriptions filled at the practice,” says Revoir, noting that drug revenue typically accounts for 25 percent to 30 percent of most practice revenue.

n Boosting Services: Also, if clients are not spending as much on pet medications, it frees up more

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money for them to pay for important diagnostics or other treatments for their pets. Not only will that allow the veterinarian to treat more pets and improve patient outcomes, those additional services will increase the overall practice revenue as well.

“When veterinarians can have more prescribing options, it’s good for everyone,” says Revoir. “The pet will be treated, pet owner compliance can increase and the practice veterinarian can retain that pharmacy business and improve their bottom line.” n

Paula Andruss is Cincinnati-based writer.

1. Trone Brand Energy, Inc. Economy driven changes in pet owner behavior. http://www.trone.com/2010/09/economy-driven-changes-in-pet-owner-purchase-behavior

2. Babson Consulting Alliance Program. Pricing and purchasing behavior analysis. May 2011.

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Research shows that roughly one-half of pet owners are unaware that some veterinary drugs are available in generic form2. Because your clients are familiar with generics for humans, educating them about the availability and cost of these prescriptions is often all it takes for them to try generic animal drugs for their pets when available. Here’s how each team member can contribute:

Veterinarians Educate yourself about the quality behind generics as well as the financial benefits. Research which generics are available and stock them. Educate clients about the availability of generics and help them understand the advantages.

TechniciansEducate clients and build trust with anecdotes and personal stories about the benefits of generics.

ReceptionistsMake sure educational materials about generics are visible in the office. Be informed and available to answer client questions. Reinforce the messages that have already been delivered when clients are leaving the office.

Practice ManagersKeep a close eye on drug inventory costs. Stay informed about what is and isn’t available in generic form to help clients save money while making the practice more profitable.

The Team Approach

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1 True or false: Antibiotics can help prevent infection and tooth death in a pet’s broken tooth.A. True B. False

2 What are two options for treating stomatitis?A. OrthodonticsB. Perioceutic applicationC. Multiple extractionsD. Closed root planing

3 What are the average savings on generic drugs?A. 10 percent to 30 percentB. 15 percent to 20 percentC. 25 percent to 60 percentD. 65 percent to 70 percent

4 What is the generic name for the branded drug Baytril?A. CarprofenB. Cefpodoxime ProxetilC. Oxacillin D. Enrofloxacin

5 Which two causes of pruritis are more common in younger pets than in older patients?A. Sarcoptic acariasisB. Epitheliotropic lymphomaC. Allergic dermatitisD. Internal parasites

6 What do skin scrapings and hair pluckings help to detect?A. Demodicosis C. LiceB. Cheyletiella D. Ringworm

7 Which statements are true about Apoquel, a new pruritus drug?A. It inhibits Janus kinase 2.B. It may be used in conjunction with NSAIDs.C. It may be used during allergy testing.D. It is a steroid.

8 Which statement about feline osteoarthritis is not true?A. An estimated 80 percent to 90 percent of senior and geriatric cats suffer from osteoarthritis.B. Radiographic changes in cats are more subtle than those in dogs.

C. Cats rarely show signs of limping/lameness.D. Loss of appetite is not a sign of osteoarthritis.9 True or false: Many analgesic drugs used to treat osteoarthritis are not licensed for felines.

A. True B. False10 Which are common health concerns for Great Pyrenees?

A. OsteochondrosisB. LymphomaC. Exocrine pancreatic insufficiencyD. Gastric Dilatation Volvulus

QuizTEST YOUR KNOWLEDGE

Quiz questions are based on articles in

the current issues of The Team and

Pet Quarterly ®


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Documents

The Team - Spring 2014