The Team - Spring 2014

Spring 2014 | Vol. 11, No. 2

A WealthEnhancing Resource for Independent Veterinary Practices

Diagnosis: Oral Pain 3 | The Pruritus Workup 8

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

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From the Desk of Dennis A. Nelson, dvm FELINE OSTEOARTHRITIS: AN UNDERDIAGNOSED DISEASE

Spring 2014 | Vol. 11 | No. 2

A Wealth-Enhancing Resource for Independent Veterinary Practices Your Veterinarian Pet Care News From ®

$4.25

A WealthEnhanc ing Res for Inde ource penden Veterina ry Practic t es

11, no. 2 spring 2014 | Volume

CH DITITCH

Spring 2014

| Vol. 11,

No. 2

THE

Relief for your pet’s itching and scratching

THERE’S THE RUB is Treating feline osteoarthrit

Diagno

sis: Ora l Pain 3 | The Pruritu

s Worku

p8

Does Your Pet Have a Toothache?

Generic Drugs: Lower Cost Options Osteoa

rthritis

in Sen ior

Cats 15 | Gen eric

Drugs:

Profit

Potent

ial 21

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.

An 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 Purchasing Services, Inc. announces a new examination—and many are PSI Member Business Symposium to be held not receiving veterinary care.

But simple changes at home June 12-15, 2014, in St. Petersburg, Fla. along with treatments such as Stay tuned for more information. 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.

SAVE THE DATE...

A lso in this issue: Visit us on the web at

www.psi-inc.net

The Team is an educational resource published by Purchasing Services Inc., St. Petersburg, Fla. Comments are welcome at info@petquarterly.com

• 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 nonbranded 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 wealthenhancing for your business.

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

Sincerely,

Dennis A. Nelson, DVM Vice President, Operations Purchasing Services Inc.

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

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

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 Anesthesia The 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. >> www.psi-inc.net | the Team | Spring 2014 3

Dental Health

1

Treating Oral Pain After 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

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

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 planing n perioceutic application n open root planing n implants no ther 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 preexisting systemic disease with CBC, chemistries, urinalysis and cardiac workups when indicated; constant

2

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

The Team Approach Receptionists 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. n

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

SMILE OF THE WEEK

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. n

Technicians, Veterinarians Attend continuingeducation 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

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

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

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 Compliance Take 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 >>

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4 Clean 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. www.psi-inc.net | the Team | Spring 2014 5

Dental Health 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.

5

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

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

www.psi-inc.net | the Team | Spring 2014 7

Parasites & Dermatology

THE PRURITUS WORKUP How to approach the often-complex issue of itchiness— and improve client compliance.

By Michael Canfield, DVM, DACVD (Diplomate, American College of Veterinary Dermatology)

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 Relief Every 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,

Common Causes of Pruritus Allergic

Parasitic

Inflammatory

Flea allergy dermatitis n Atopy n Atopy-like dermatitis n Food hypersensitivity n Parasitic hypersensitivities n Contact dermatitis n Drug hypersensitivities

Fleas n Ticks n Sarcoptes n Demodex n Lice n Mosquitoes n Culicoides

Bacterial n Fungal n Immune-mediated diseases n Irritant reactions

n

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

n

n

Neoplastic n

Epitheliotropic lymphoma n Mast cell tumor(s)

Neurogenic n

Psychogenic and sensory neuropathies

>>

Diagnostic Tree for Pruritus Endoparasites

Coproscopic exam/ Fecal Analysis

Ectoparasites

Inflammation

6

4

No

Yes

Skin scrapings Tape preparations Flea combing Cytology Therapeutic Trials +/- Biopsy

Elimination Trial

Ascarids, Hookworms, Tapeworms, Whipworms, Coccidia

Treat

Fleas, Sarcoptes, Ticks, Notoedres, Lice, Cheyletiella, Mosquitoes, etc.

4

No

Yes

Response

6

4

No

Yes

Look for Underlying or Predisposing Cause

Flare upon challenge

Empirically treat.

Preventatives where appropriate

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

6

Psychogenic or neurologic disease

Atopic Dermatitis

Food Hypersensivitivy

www.psi-inc.net | the Team | Spring 2014 9

Parasites & Dermatology

Mosquito bite hypersensitivity

Demodex mite from cat

Hookworm ova

Atopy

Flea allergy

Dog louse egg

Whipworm ova

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

Veterinarians Decide 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 Assistants You 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

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

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.

Receptionists Participate 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 Managers Allot 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.

every practice should have a list of core diagnostics that are performed on every pruritic patient. All pruritic patients should have: n flea combing n skin scrapings n cytology of the skin and ears.

Diagnostic Tests Here’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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11 Source code: ADAL0313BG

Parasites & Dermatology 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 Compliance Education 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.

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

New Drug Option A new pruritus drug is an exciting addition to the veterinary pharmacy. ApoquelÂŽ (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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www.psi-inc.net | the Team | Spring 2014 13

Better medicine together You joined PSI to leverage the collective strength of veterinary practices just like yours. At IDEXX Telemedicine Consultants, we also know how collaboration can lead to better outcomes for you and your patients.

To learn more, call 1-800-726-1212.

IDEXX Telemedicine Consultants radiology l cardiology l specialty services idexx.com/telemedicine © 2011 IDEXX Laboratories, Inc. All rights reserved. • 100104-02 • All ®/TM marks are owned by IDEXX Laboratories, Inc. or its affiliates in the United States and/or other countries. The IDEXX Privacy Policy is available at idexx.com.

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Senior Wellness

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

By Stephanie Gandy Murphy, DVM

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 care n Cats resisting examination n Cats’ small size and flexibility n Cats rarely show signs of limping/lameness nR adiographic changes in cats being more subtle than those in dogs n Cats are good at hiding signs of pain.

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

Laser Therapy: A Healing Light In a therapy laser, a hand-piece is used to deliver a laser light, which sends energy (photons) into bodily tissues, reducing inflammation. This energy is absorbed within the “power-houses” of the cells, the mitochondria. The mitochondria are responsible for the production of adenosine triphosphate (ATP), which is an enzyme our cells use for energy.

Once this light energy is absorbed, the mitochondria increase the production of ATP by a chemical change called “photo-bio-modulation.” This leads to healthier cells and tissues, while the cat experiences a warm, relaxing sensation. Laser therapy usually involves a series of treatments, and while results vary, most clients give positive feedback.

www.psi-inc.net | the Team | Spring 2014 15

Senior Wellness

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.

Receptionists Make 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/ Technicians When 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 Caretakers Identify 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

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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 Managers Make 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/painmanagement-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.

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Veterinarians Review 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. >>

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Senior Wellness 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 Options Treating feline OA can be difficult due to several factors. For example, owners may have difficulty

Keeping Cats Comfortable Suggest these options to clients to help keep their senior cats comfortable at home: nL itter

pans with lower sides for ease of entering and exiting

nP uppy

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

nE levated

food and water bowls

nS teps

to help cats to get to their favorite places

nS oft

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.

nH eated

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

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

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: nW eight loss if a cat is overweight nN on-steroidal anti-inflammatory drugs (NSAIDS) nN utraceuticals (diets, treats, injectables, pills, powders, liquids, etc.), including Omega-3 fatty acids, Glucosamine/Chondroitin, ASU (avocado and soybean unsaponifiables) nN arcotic pain medication nA cupuncture nG abapentin nL aser therapy nP hysical therapy/hydrotherapy (See the current issue of Pet Quarterly for some of the challenges of each.)

8

8

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. www.psi-inc.net | the Team | Spring 2014 19

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General Wellness

PROFITING FROM GENERICS Promoting 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 >>

FAST FACT Drug revenue typically accounts for 25 percent to 30 percent of practice revenue.

GENERIC

BRANDED

DRUG TYPE

Carprofen Caplets

Rimadyl Caplets

Anti-inflammatory

Enrofloxacin Flavored Tablets

Baytril Taste Tabs

Antibiotic

Simplicef

Antibiotic

Cefpodoxime Proxetil Common generics and their brand-name counterparts.

www.psi-inc.net | the Team | Spring 2014 21

General Wellness quality standards as branded drugs.

The most common drugs available in generic form today are those used to treat conditions including osteoarthritis, postsurgery 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.

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.”

Direct Profits These 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

Sample Case For 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.

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Straight 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 Inhouse: 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

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-inpet-owner-purchase-behavior 2. Babson Consulting Alliance Program. Pricing and purchasing behavior analysis. May 2011.

The Team Approach 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.

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

Receptionists Make 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 Managers Keep 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.

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Quiz TEST YOUR KNOWLEDGE

Quiz questions are based on articles in the current issues of The Team and Pet Quarterly ÂŽ

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

A. True B. False

2 What are two options

for treating stomatitis?

A. Orthodontics B. Perioceutic application C. Multiple extractions D. Closed root planing 3 What are the average sav ings on generic drugs?

A. 10 percent to 30 percen t B. 15 percent to 20 percen t C. 25 percent to 60 percen t D. 65 percent to 70 percen t 4 What is the generic name for the branded drug Baytril?

A. Carprofen B. Cefpodoxime Proxetil C. Oxacillin D. Enrofloxacin 5 Which two causes of pru ritis are more common in younger pets than in old er patients?

A. Sarcoptic acariasis B. Epitheliotropic lymphoma C. Allergic dermatitis D. Internal parasites

6 What do skin scrapings and hair pluckings help to detect?

A. Demodicosis C. Lice B. Cheyletiella D. Ringw orm 7 Which statements are tru e about Apoquel, a new pruritus drug?

A. It inhibits Janus kinase 2.

B. It may be used in conjun ction with NSAIDs. C. It may be used during alle rgy testing.

D. It is a steroid.

8 Which statement about fel ine osteoarthritis is not true?

A. An estimated 80 percen t to 90 and geriatric cats suffer fro percent of senior m 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 analg esic drugs used to treat osteoarthritis are not lice nsed for felines.

A. True B. False 10 Which are common health concerns for Great Pyrenees?

A. Osteochondrosis B. Lymphoma C. Exocrine pancreatic insuffi ciency D. Gastric Dilatation Volvul us

1-B; 2-A,C; 3-C; 4-D; 5-A,D; www.psi-inc.net | the Team | Spring 2014 25

6-A; 7-B,C; 8-D; 9-A; 10-A,D

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