The dog's blog no.7 - Rational use of medicines – what’s it got to do with animals

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Rational use of medicines – what’s it got to do with animals?

Yesterday I took a trip to London to meet a friend who is over from Australia. We first met about 20 years ago through an international network of independent medical publications that aimed to promote the rational use of medicines. In 1985, the World Health Organization defined the rational use of medicines as follows: “Patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community” (WHO 2002).

I’ve been giving some thought to the relevance of this definition to veterinary medicine. The first part of the definition is easily applied to animals because it’s logical that animals should only receive treatments appropriate to their clinical needs and in the right doses for the right amount of time. The next part of the definition is more tricky, unless cost is taken to mean harm, as in the adverse effects of medicines on animals. It follows that the rational use of medicines is linked to animal welfare. 

Irrational use includes using medicines inappropriately, using more medicines than are needed and using medicines that cause more harm than equally effective alternatives. The causes of irrational medicines use are complex, and around the world there can be various contributory factors, such as lack of medicines regulation, restricted availability of medicines, lack of public understanding of the benefits and risks of medicines, and over-reliance on promotional information. In the UK, we’re fortunate to have medicines regulation (although it may not be perfect) and good access to the medicines we need, but public understanding about medicines and the influence of promotion are real challenges for us.

My Australian friend is now involved in establishing an important new international organisation – the International Society to Improve the Use of Medicines (ISIUM). It is a network, a think tank and a forum for the exploration of ways of knowing about medicines, their wise use and their role in society, health and illness. I have decided to support this new organisation by becoming a member. The health of humans, animals and ecosystems are interconnected, as is recognised through the One Health Initiative. Likewise, there are interconnections and common issues related to the use of medicines in humans and animals. They include

  • antimicrobial resistance;

  • the use of medicines in animals to prevent zoonotic diseases;

  • harms to humans through contact with veterinary medicines;

  • harms to the environment through use and disposal of veterinary medicines.

There are also other compelling reasons to pay attention to the use of medicines in animals:

  • medicines are being used increasingly to treat acute and chronic diseases in animals; 

  • animals are at risk of harm from the adverse effects of medicines;

  • promotion of medicines;

  • the development of the evidence-based veterinary medicine movement, which brings new challenges.

Maybe in time a veterinary interest group can develop within ISIUM. Membership is open to anyone who is interested in improving the use of medicines. Find out more here: www.isium.org.

 

Andrea Tarr , 10 October 2017

 

 

 

 

 

 

 

The dog's blog no.6 - The unwanted effects of medicines

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The unwanted effects of medicines

When a new medicine is first marketed, knowledge about its unwanted effects (adverse effects or side effects) is limited to what has been learned from using it in pre-clinical and clinical trials. This means it will only have been used in carefully selected groups of animals for a limited amount of time. The total number of animals treated before marketing is relatively small - no more than a few hundred at best. But once marketed, the drug will be used in many more animals, in a much wider range of animals - in different breeds and in animals with concurrent diseases, and for longer durations. So serious and rare effects may emerge only after a drug is marketed, sometimes years later. 

Continued monitoring of the safety of medicines after they are licensed is therefore crucial to helping us learn about the balance between the benefits and harms of treatments. As well as detecting new unwanted effects, this process, known as pharmacovigilance, can help clarify the frequency of known adverse effects and help with understanding what makes some animals more susceptible than others to certain effects. It relies on spontaneous reporting of adverse effects by people who prescribe, supply and use veterinary medicines (vets, vet nurses, SQPs, pharmacists and owners). Reports can be made directly to the Veterinary Medicines Directorate (VMD) or to the relevant companies, which are required to pass them on to the regulator.

According to the results of a recent Europe-wide survey, vets in the UK are pretty good at reporting compared with those in some other countries. But the survey estimates that most adverse events still remain unreported. 

As more becomes known about a medicine, changes to the prescribing information can follow, as has occurred recently for the parasiticide Bravecto, which should now be avoided in dogs with pre-existing epilepsy. 

 

 

 

The dog's blog no.5 - Why I love generic names

Why I love generic names

I was having a check up with my optician the other day. We were talking about maculopathy, which I had had in one eye a few years ago (related to my extreme myopia rather than my age). Were you treated with Lucentis she asked? No, the cheaper one - bevacizumab, I replied. I can tell you’re a pharmacist, she said, remarking on my fluent pronunciation.

Most drugs have at least two names (the proprietary or brand name, and the international non-proprietary (INN) or generic name). A drug’s generic name is approved by the World Health Organization under the International Non-Proprietary Name (INN) scheme. There are a few rules affecting the construction of a generic name: it must be distinctive in sound and spelling, not inconveniently long and not liable to confusion with names in common use. Where possible the names of drugs belonging to a group of pharmacologically-related substances show their relationship by use of a common stem.  For example, -caine for local anaesthetics ; pril(at) for  angiotensin-converting enzyme inhibitors;  -olol for beta-adrenoreceptor antagonists; -mab for monoclonal antibodies.  Generic names are recognised throughout the world and are public property. 

A drug’s brand name is chosen by the pharmaceutical company and approved by the regulatory authority. Brand names are designed for marketing purposes, to be easily remembered with the aim of increasing sales. 

Some drugs have several different brand names created by different companies. There are some rules: brands for use in humans are not allowed to include the generic stem in the name and not allowed to imply benefits. Brand names are often simpler, more euphonious and more easily pronounced, spelled and remembered than generic names. They are aimed at connecting with customers on an emotional level. Apparently Viagra, the brand name for sildenafil (for treating erectile dysfunction) came from a combination of the words vigorous and Niagra that were associated with the concept of a strong flow, an image conjured up when a group of urologists were asked to describe what it was like when the condition went away. 

Brand names are usually short and easier to remember, pronounce and spell: Apoquel or Cytopoint are clearly easier than oclacitinib and lokivetmab for example. Prescribers often remain loyal to the brand names when patents expire. But their multiplicity compels vets and vet nurses to learn needlessly many names. Generic names have many more advantages: they usually indicate the chemical class to which the drug belongs and so give a 'shorthand' account of a drug's pharmacology and clues about the drug’s adverse effect profile.  Generic names are standard throughout the world whereas brand names often differ from country to country. Generic names are crucial for communication between scientists worldwide. They aid communication and help veterinary professionals recognise a treatment’s role and avoid duplicate therapy. The most important advantage of generic names is that they help prescribers to think more clearly about drugs. For instance, it’s impossible to make sense of the vast range of parasiticides without sorting them by generic name.

Learning to understand common stems and using generic names when thinking about, talking about, and prescribing drugs is far more useful than memorising brand names. It’s a good habit to get into, and you might even impress your friends by getting your tongue around complicated drug names.

The dog's blog no. 4 - Parasite protection - who's advising pet owners?

Parasite protection - who's advising pet owners?

I feel I need to apologise for bringing up parasiticides yet again. But for an owner with a healthy dog, these and vaccinations are the main topic of interest where veterinary medicines are concerned. I wanted to find out what kind of advice is on offer from different sources, so I went around my local veterinary practices, pet shops and pharmacies asking what I should do to protect my dog against parasites.

At veterinary practices, I spoke to receptionists and nurses. The main advice was that I should take the dog in to be weighed but I was reassured that there was a variety of options, including tablets, spot ons and collars; and brands were mentioned. I would need to make an appointment to see the vet.

Advice in pet shops varied with better quality information, as expected, in shops that employ an SQP (suitably qualified person). I was offered familiar brands (Frontline, Drontal) although some were keen to point out that they sold a cheaper generic version of Frontline. In one shop I said I'd heard about lungworm and was told that if I was worried about it I should talk to a vet because only they could prescribe medicines for it. 

Many community pharmacies now stock a very limited range of parasiticides and the advice I received was also very limited. 

No one asked me a question, apart from the dog's weight. And I was not helped to understand why my dog might need parasite protection. The reaction everywhere was to offer products from the range that was stocked. This is not the risk-based approach that ESCCAP UK& Ireland recommends for parasite control. So it was heartening to see that a new website aimed at pet owners from the pharmaceutical company Merial presents risk-related advice. However, the ultimate aim of the site appears to be to direct owners to 'participating' veterinary practices that offer Nexgard Spectra and Broadline (isn't this illegal advertising of prescription-only medicines to the public?)

There needs to be a joined up approach to parasite protection that does not promote a false distinction between non-prescription and prescription products and that will help educate owners. There are important differences between prescription and non-prescription parasiticides but this is clouded by meaningless and misleading ideas, such as products being 'vet strength'. A new approach will require frontline (no pun here) staff in practices to be better informed about parasites and parasiticide products and for practices to offer non-prescription as well as prescription-only parasiticides. Staff in pet shops and pharmacies also need to adopt a risk-based approach to selling products and know when to refer an owner to a vet. This will put professionals, not drug companies, in charge of advising pet owners.

The dog's blog no. 3 - Choosing a vet practice

Choosing a vet practice

Now we have Moscow, a 2 year old rescue German Shepherd, I find myself in the new position of needing to find a vet. But how do I choose one? To be honest it's not immediately obvious to me what to look for.

I think the first thing is to ask myself what I want from a veterinary practice. If Moscow has an accident or falls ill I want to know immediately who to contact. I also want advice on keeping Moscow healthy (vaccines, parasites, diet) and maybe on behaviour too. I have no doubts that the people in any practice will be caring and want to do their best for my dog. Of course I need to know about opening hours and out-of-hours cover. And I want to be able to trust that any procedures will be performed to the highest standard. But I also want any treatments offered to be guided by evidence, to know if there is a choice of options, be told about uncertainties and be involved in making decisions where possible.

I start with an online search to 'find a vet'. Top of the list is the RCVS site. I see that there are five practices in my area. I can refine my search to find practices that have car parking or disabled access, by type of animal treated, speciality, advanced practitioner status, whether it is a training practice, and by special interest (e.g. behaviour, complementary medicine). It also tells me which practices have RCVS Practice Standards Scheme (PSS) accreditation. I find out that the PSS badge is intended to give reassurance that the practice premises have met a range of minimum standards including hygiene, 24-hour emergency cover, staff training, certain types of equipment and cost estimation procedures. It seems a no-brainer to go for an accredited practice. This narrows the field to three practices.

I try to make a choice by looking at practice websites, through personal visits and by asking around. People have good things to say about all the practices. Practice websites helped me compare opening hours, out of hours cover, staffing and pet health plans. Through visits I met friendly and welcoming receptionists. One is an independent practice, another is a hospital (part of a large chain) with a hydrotherapy pool. One (part of a different chain) had an open day and I was able to take a tour of the practice: this engagement almost won me over.

As the new owner of an adult rescue dog rather than a puppy, I found helpful advice on 'Visiting the vet for the first time' on the website mypetonline.co.uk (a site belonging to the drug company MSD for pet owners). Practices should think of including similar information on their sites.

Moscow's vaccinations aren't due until the start of next year. So the most pressing need is to get parasite coverage. At every practice I've found that I need to have a veterinary consultation to get advice on parasite protection. I sense that the parasite protection aspect is very product focused, and that I will probably only be offered the most expensive prescription-only products. I could go to a pet shop to buy parasiticides. For me, this highlights the undefined distinction between vet and pet shop parasiticides, which I think is confusing for pet owners. What I would like is to be able to walk into a practice and speak to someone knowledgable who will assess my dog's needs, help me understand why parasite protection is needed and offer me a choice of products to buy (which might include prescription-only products) to suit the dog's and my needs.

Well I'm still not sure which practice to go for. The three are a bit different from each other, but not in ways that make any one an obvious choice. I realise I can't get answers to some of my questions without using a practice. So on the face of it, I would be happy to use any of the practices. Maybe I'm spoilt for choice.

The dog's blog no. 2 - Pesky parasites

This is me, Moscow - a two and a half year old German Shepherd. I'm a rescue dog, although I don't like to think of myself as that. I moved from one loving home (where I was just a bit too strong for my owner) to another.  I love being out in the garden, where I like nothing better than chasing a ball.  And it's becoming even more fun out in the garden now the weather is warming up. There are flying and buzzing creatures that I can chase and snap at in the air. There are puzzling crawly creatures that I can follow along the ground with my nose. I'm particularly enjoying pushing my snout around among the bushes in the border - I'm sure I saw a frog heading for the new pond in there. And there's some nice long grass between the raised beds that I sometimes feel the urge to chew. There are lots of fat wood pigeons to chase off but I never catch them even though they look so fat. No such luck, and so no supplement to my regular diet of a fish and vegetable dry food (which was settled on after a lot of trial and error and suits my sensitive tummy).

While I love the garden, I do enjoy a walk out. I'm lucky that there are some great fields really close to home. And we're only a car ride (which I also love) from the New Forest. What could possibly go wrong? Well I wouldn't want to be ill for a start.

ESCCAPUK&Ireland, the veterinary parasite specialists say all dogs should have regular basic protection against the two ubiquitous parasites: fleas (better to prevent than have to treat) and roundworm (a wormer every 3 months for most dogs, but monthly if you're a dog that catches prey or lives with a susceptible human - a young child or person with a disease or on treatment that affects their immune system). But some dogs need more protection than this, depending on how they live their lives, and there are three more parasites to think of. 

If you're a dog that gets fed raw meat or that catches prey, then you also want to think about protection against tapeworm. That's not me.

If you've ever had a tick on your body (which I have), then you should be thinking about protection, especially if you live in an area where ticks carry diseases (like around here), and definitely if you're going abroad  - you wouldn't want to be responsible for helping new tick-borne diseases get established here. But you can't rely completely on tick protection products - and so it's still a good idea (and rather pleasant) have someone run their hands over you after a walk.

Finally, there's lungworm, a pesky disease that is carried by slugs, snails, frogs and the like. There might be slugs on the grass I chew and I can't promise that I wouldn't eat a frog if I could catch one. But are the creatures in my garden infected? How could I know? Knowing if other dogs in my area have been affected would help. I'm sure my vet will help my owner understand whether I need protection, and also what to look out for if I were ever to become ill. 

Got to go now. There's a ball to catch.

The dog's blog no. 1 - Parasite risk assessment

Moscow came to live with us a couple of weeks ago. He's a 2-year old rescue German Shepherd. He was clearly loved and well cared for by his previous owners and arrived with a large quantity of food, toys and a few medicines. The medicines, prescribed by Moscow's vet, were pancreatic enzymes (for a sensitive tummy) and parasiticides.

I haven't owned a dog before but I am steeped in knowledge about parasiticides through the work Veterinary Prescriber has done on the subject. So for me this is a fascinating exercise in seeing at first hand what happens in practice together with having the point of view of a dog owner.

Moscow came with:

  • a Seresto collar - imidacloprid (insecticide and larvicide) + flumethrin (acaricide and tick repellent)

  • Advocate spot-on - imidacloprid (insecticide and larvicide) + moxidectin (endectocide, including roundworm and lungworm)

  • 2 weeks before starting Advocate he had received a dose of Milquantel - milbemycin (endectocide, including roundworm and lungworm) + praziquantel (tapeworm)

At first glance, there's a doubling up on imidacloprid. But now Moscow has a new life, it's time to re-assess his need for parasite control. First, I can't ignore my own principles and beliefs. In general, I don't want to add expose people, animals or the environment to unnecessary chemicals. And I admit I don't like the idea of using regular preventive parasiticides. But I must be realistic and consider the risks of not using parasite control measures.

Fleas first. They're everywhere - on other animals he might encounter (including cats and hedgehogs) and the warming climate means they are more likely to be around all year. I don't want to invite fleas to set up home with us nor subject Moscow to the misery of an infestation. I've never had to deal with dogs and fleas. But I have had a lot of experience with children and head lice. That's tricky enough to tackle and they don't even infest your furnishings and carpets. But if fleas get into your house, it can take months to get rid of them. I don't fancy that. Fleas can also transmit the tapeworm Dipylidium caninum, so stopping fleas prevents that too.

Next, roundworm. Roundworm is more of a problem for humans than for adult dogs. All dogs are likely to carry roundworm and shed it from time to time. and so I need to do what I can to reduce environmental contamination. Of course, I am a diligent picker up of poo and hand washer. But its not certain if roundworm can be transmitted through contact with fur. So regular worming will protect me, my family, and others who come into contact with the dog. As Moscow doesn't hunt (so is unlikely to eat prey carrying roundworm) and there are no young children or other people vulnerable to infection in our household, 3-monthly worming is sufficient.

Ticks? Our house is right next to lovely wooded and farming countryside containing livestock and deer. Great for walks. And we're not far from the New Forest, where Lyme disease-causing Borrelia is endemic. So it's possible Moscow might pick up ticks, although I haven't seen any yet. We're not planning to take Moscow abroad or to areas in the UK where Babesia has been reported. I could rely on checking for ticks, but he's a big hairy dog and it would be easy to miss one. But I'm not certain if a chemical protection with an acaricide or tick repellent is essential. It might be that the flea control I choose also covers ticks. 

Tapeworm? Moscow doesn't have raw food, or hunt, or roam on land where he might eat a carcass. Tapeworm control seems unnecessary.

Lungworm (Angiostrongylus vasorum)? This is more tricky to decide about. It's a potentially fatal disease which can develop insidiously. But it is treatable. I've noticed that Moscow eats grass and there are definitely slugs and snails in our garden which would put him at risk if the molluscs in this area are infected. I looked at the Bayer map of reported cases of A.vasorum infection. There has been one unconfirmed case in this town. The IDEXX map tells me there are 20 registered cases in this postal area. It's difficult to know how to use this information, which relies on voluntary reporting, because the absence of reported cases does not mean absence of the parasite. I think I'm going to wait until I've looked at what my options are for preventive therapy overall. It may be that the choice offers protection against lungworm as well as other other parasites

So in summary fleas - yes; roundworm - 3-monthly; ticks - not sure; tapeworm - no; A. vasorum - not sure. The next step is to look at the product options. With over 100 to choose from, this seems a more difficult task than assessing parasite risk. Thank goodness for the Veterinary Prescriber Parasiticide Guide! I'll let you know how I've got on with choosing parasiticides next time.

Andrea Tarr, founder Veterinary Prescriber

Lungworm clinical scenario - prevention

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The scenario

 

Your new client Mrs Hollyer brings her dog, Mia, a 3 year-old Border Collie to your clinic. She has seen TV adverts warning about the deadly lungworm disease. She says there are an awful lot of slugs around her house and she worries herself sick about lungworm. She wonders how she can protect her dog. She knows she needs to use flea and worm control products and currently uses monthly Frontline (fipronil) for fleas and ticks, and monthly Panacur (fenbendazole) for worms but she wonders if this covers everything including lungworm? She has read on Mumsnet that it is not safe to give Advocate (moxidectin + imidacloprid) to her collie dog.

What advice would you give her?

Need to brush up on the latest research on the management of lungworm? Then the Veterinary Prescriber module Lungworm (Angiostrongylus vasorum) in dogs: reducing the risks is for you. We commissioned a specialist (Dr. Hany Elsheikha, Associate Professor and European diplomate in veterinary parasitology, University of Nottingham) to summarise current knowledge about the management of canine lungworm, ensuring that questions important to veterinary practitioners were addressed. They include:

  • How widespread is the parasite?
  • How is it spread?
  • How likely is a dog to die from the infection?
  • What are the diagnostic tests and how effective are they?
  • Treating angiostrongylosis - what's the evidence?
  • Assessing risk of infection
  • Preventing angiostrongylosis - what's the evidence?
  • Product choice

Our editorial process involves integrating referees’ comments, critical appraisal of the evidence and rigorous checks. The result is a succinct, reliable and impartial presentation of the facts. You can read or listen to the module. At the end there are MCQs and clinical scenarios (this is one of them). We'll send you a personalised CPD certificate for your records. So subscribe today.

Lungworm clinical scenario - treatment

Lungworm clinical scenario - treatment

The scenario

An 8-month old Cavalier King Charles Spaniel dog presented with a recent history of coughing. On clinical examination, body temperature, and heart and lung sounds were normal. Palpation of the trachea provoked wheezing and a persistent dry cough. After a diagnosis of tracheitis, the dog was treated with prednisolone 0.5mg/kg daily for 5 days and the respiratory signs disappeared. One month later, the dog was seen at the clinic again because of a relapse and worsening of respiratory signs and episodes of weakness in the hind limbs. Auscultation of the lungs revealed crackles and thoracic radiographs showed a bronchial pattern and an increase in the radiopacity of pulmonary vessels. There was no evidence of arrhythmia, heart failure or other abnormalities on echocardiographic examination. The dog was prescribed another course of prednisolone together with antibiotic therapy (enrofloxacin 5mg/kg) but after 3 days it presented with tachypnoea, abdominal breathing and a heavy dyspnoeic crisis. Further radiographic examination showed a serious increase in radiopacity in the peribronchial regions, an alveolar pattern compatible with severe pulmonary oedema or haemorrhage, and bulging of the main pulmonary artery in ventro-dorsal view. Infection with Angiostrongylus vasorum was suspected. A Baermann’s test was positive for L1 larvae and an AngioDetect test was positive for A. vasorum antigens. The dog was immediately treated with moxidectin + imidacloprid but died a few hours later of a severe pulmonary haemorrhage.

What would you do?

What information might have helped achieve an earlier diagnosis of A. vasorum infection?

Need to brush up on the latest research on the diagnosis and treatment of lungworm? Then the Veterinary Prescriber module Lungworm (Angiostrongylus vasorum) in dogs: reducing the risks is for you. We commissioned a specialist (Dr. Hany Elsheikha, Associate Professor and European diplomate in veterinary parasitology, University of Nottingham) to summarise current knowledge about the management of canine lungworm, ensuring that questions important to veterinary practitioners were addressed. They include:

  • How widespread is the parasite?
  • How is it spread?
  • How likely is a dog to die from the infection?
  • What are the diagnostic tests and how effective are they?
  • Treating angiostrongylosis - what's the evidence?
  • Assessing risk of infection
  • Preventing angiostrongylosis - what's the evidence?
  • Product choice

Our editorial process involves integrating referees’ comments, critical appraisal of the evidence and rigorous checks. The result is a succinct, reliable and impartial presentation of the facts. You can read or listen to the module. At the end there are MCQs and clinical scenarios (this is one of them). We'll send you a personalised CPD certificate for your records. So subscribe today.

Another lungworm article - what's different about this one?

Lungworm (Angiostrongylus vasorum) infection in dogs is a hot topic at the moment. The disease is potentially fatal and difficult to diagnose, and so it naturally arouses fear (which may have been enhanced by a very emotive publicity campaign). There is also quite a bit of confusion as a result of incomplete information (e.g. about prevalence, mortality rate) and different opinions on how often dogs should be wormed. But most practitioners don't have time to read, and keep up to date with, all the latest research on lungworms. So the need for a concise and impartial presentation of the facts made A. vasorum infection an obvious topic for a Veterinary Prescriber module.

We commissioned a specialist (Dr. Hany Elsheikha, Associate Professor and European diplomate in veterinary parasitology, University of Nottingham) to summarise current knowledge about the management of canine lungworm, ensuring that questions important to veterinary practitioners were addressed. Our editorial process involves integrating referees’ comments, critical appraisal of the evidence and rigorous checks. The result is a succinct, reliable and impartial presentation of the facts. Just as important, the module clearly highlights what is still not known about lungworm.

The module has the following headings: • About Angiostrogylus vasorum and other lungworms in dogs • How do dogs become infected? • Lifecycle of A. vasorum (slideshow) • Pre-patent period • Clinical signs of infection • How likely is a dog to die from infection? • Diagnosis • Spread of A. vasorum in the UK • Treatment of angiostrongylosis • Clinical trials of angiostrongylosis treatment • Preventive therapy • Assessing risk • Product choice • Published trials of preventive therapy • Conclusion

It gives veterinary surgeons the information they need to be able to advise clients confidently about the risks of A. vasorum and make informed decisions about the management of the disease in individual dogs.

http://www.veterinaryprescriber.org/subscribers-content/lungworm-in-dogs-reducing-the-risks.

Veterinary Prescriber is completely independent and funded by subscription. 

VET 2016 talk

This is the brief talk given by Andrea Tarr, founder of Veterinary Prescriber, at the Sceptical Vets debating evening during the RCVS Veterinary Evidence Today conference in Edinburgh on 1st November.

This is the brief talk given by Andrea Tarr, founder of Veterinary Prescriber, at the Sceptical Vets debating evening during the RCVS Veterinary Evidence Today conference in Edinburgh on 1st November.

I believe that rational use of veterinary medicines is unachievable while the veterinary profession is in the grip of the pharmaceutical industry.

Medicines need to be used rationally. This is because, as well as benefits, they can cause harm to the animals they are used to treat, and to humans handling them.  And they can cause serious problems like antibacterial resistance and environmental pollution. So medicines must be used in a way that maximises their benefits and minimises their harms.

In order to do this, you need different types of information about medicines:

  1. First you need to know what medicines are available.
  2. Secondly you need to know whether the medicines are licensed, and about the terms of the licence (things like the specific indications, contraindications and so on). All that sort of information is included the summaries of product characteristics or SPCs;  these are important sources of evidence – because they’re summaries of evidence gathered during the licensing process.
  3. You also need information about unlicensed medicines, which are used a lot in veterinary medicine.
  4. And, to be able to select the most appropriate treatment, you need information about how different medicines (licensed or unlicensed) compare with each other, and in some cases how they compare with non-drug treatments (like surgery, or radiotherapy) or no treatment.
  5. The problem is that the pharmaceutical industry has the dominant role in disseminating information about medicines. The result is that the available information is swayed towards certain products and interferes with the rational choice of treatments.

To illustrate the problem I’ll use the example of companion animal parasiticides because I think it’s probably the most extreme example. This is an area in which is there is an overwhelming choice of products. But until recently there was no reference source that listed all the available products and in a way that helped you choose between them. That’s why I created the Veterinary Prescriber Parasiticide Guide. Many rely on the NOAH data sheet compendium to know what’s available. NOAH, which stands for the National Office of Animal Health and sounds like an animal welfare organisation, is a trade association of the UK veterinary pharmaceutical industry. Not all veterinary pharmaceutical companies are members of NOAH and so the Compendium doesn’t contain information on all the available licensed products.  So there’s a need for a comprehensive and easy to use resource that contains the SPCs and package inserts for all licensed medicines. How can you know that you’re using the best treatment for a patient if you don’t know about all the available options?

There’s intense promotion of certain products. Look at any recent issue of the Veterinary Times, and you’ll see a high proportion of pages devoted to adverts for parasiticides. The trouble with promotional information is that it understandably focuses on benefits (which are often vague or theoretical). Companies aren’t keen to talk about the disadvantages of their products and they don’t like comparing them with alternatives. And of course you don’t get to hear about medicines that are not being promoted regardless of their value. The result is vets are understandably confused by all the claims and counterclaims about parasiticides.

It’s not only the obvious promotional activities like advertising that companies are involved in. They’re also providing a lot of CPD on medicines. CPD on medicines is often free – either because it’s provided directly by, or else sponsored by, a company.

I’m not saying companies shouldn’t be doing these things. They’ve got a job to do which is to sell medicines. And we need medicines. But they’re not the best people to tell us which medicines to use.

So it’s crucial that vets have access to impartial information that tells them about the disadvantages as well as the advantages of medicines, that is able to compare products and be critical of evidence and promotion, and put evidence about medicines in the context of clinical practice. This is what Veterinary Prescriber does.

If it’s left mainly to the industry to inform us, medicines are more likely to be used on basis of the weight of promotion rather than the weight of evidence. 

@BBCr4today @ChrisGPackham @ESCCAP_UK Babesia outbreak in the UK

I woke this morning to hear Chris Packham on the Radio 4 Today programme alerting us to the new threat from the tick-borne pathogen Babesia, which has been reported to have caused disease in four dogs in Essex. The dogs had not been abroad and so it seems that the pathogen has arrived in the UK and in all likelihood will begin to spread across the country. Chris urged dog owners to go to their vet if they find a tick on their dog. This will create opportunities to educate dog owners about ticks (and other parasites) and the risk of disease. It will also be an opportunity to encourage preventive measures, including the use of products containing acaricides and tick repellents. I think it's important to be aware that Chris Packham is the celebrity face of the tick awareness campaign sponsored by MSD, a pharmaceutical company which will be at least as interested in selling its parasiticide products as it is in increasing awareness of tick-borne diseases. 

The parasite specialists, ESCCAP recommend a risk-based approach to managing parasites in cats and dogs. This means using parasiticide drugs rationally,  according to need. Assessing need can be done by asking dog owners a few simple questions. The big challenge is that there is a huge range of parasiticide products to choose from and very intense promotion of a few of these. Veterinary Prescriber aims to help put vets in charge of decisions about product choice by giving access to information on the whole range of products through the unique, independent Parasiticide Guide and, over the coming months, practical modules on using parasiticides rationally. 

SPVS/VPMA Congress 2016

SPVS/VPMA Congress 2016

I have very good feelings towards the SPVS organisation. Over 4-years ago now, when I started setting up Veterinary Prescriber, several former, and current SVPS council members independently discovered it and got in touch. Since then, they have become invaluable in developing the content and its functionality and I would go as far to say in some cases become good friends.


So, having been to the SPVS Congress last year for the first time I was really looking forward to going again. The venue (the Celtic Manor Hotel) is fantastic, the programme, though extensive is neither hurried nor shallow, but gives the attendees time to digest what they have just experienced. 

This year there were 4 streams covering client communication and including for the first time a stream for those new to management. Guest speakers, including Alastair Campbell, Claudia Hammond, and Professor Noel Fitzpatrick, were aplenty. SPVS members themselves were also well represented with Brian Faulkner providing talks for several of the streams. Apart from the familiar names and the headline talks, what's really impressive about this organisation is the breadth and depth of support they offer the profession and their members. The veterinary profession is known for is loneliness, isolation and stress and yet here is an organisation really thinking about, and understanding the support its members need. Perhaps that's why everywhere we went we met happy, smiley, congress attendees.

Another personal highlight was seeing our friend and long-time supporter Stephanie Writer-Davies becoming SPVS President.

 

What is also noticeable at this event amongst the trade stands and exhibitors is how many times you hear the phrases:
'it's where all the movers and shakers come' and 'all the decision makers are here' and that's unique to this event. 


Apart from the great speakers, learning streams and delightful venue, this is a really happy congress with much interaction between the events and the delegates. The programme though full never seems excessive, which makes it a great experience when it comes to catching up with old friends in a wonderful environment.

Andrew Herxheimer - a huge influence whose legacy will live on

Andrew Herxheimer - a huge influence whose legacy will live on

A sprightly Andrew Herxheimer on good form during an interview with Andrea Tarr, for Veterinary Prescriber back in January 2016.

Andrew Herxheimer, who passed away on Sunday aged 90, was a medical doctor and clinical pharmacologist who was dedicated to promoting the availability of independent, unbiased, clear and concise information about therapeutic interventions to professionals and the public. I first met him in 1990 on the Drug and Therapeutics Bulletin (DTB), the independent publication of which he had been editor since he founded it in 1962.  DTB was a very special publication that gave readers practical information while helping them to think critically about medicines, and challenged evidence and promotion. The idea for DTB came from when he was on a sabbatical in the USA and was impressed by ideals of The Medical Letter on Drugs and Therapeutics, published by the Consumers' Union. DTB started as a fortnightly 4-page publication, published by the UK's Consumers' Association and was aimed at doctors and pharmacists. The writing style was clear and succinct. It was really the first evidence-based resource on medicines, well before the term 'evidence-based medicine' was coined. I used DTB as a drug information pharmacist in the 1980s. For me it was the first port of call when dealing with clinical questions about medicines as it would so often contain exactly the answer I was looking for. This was down to the way the articles were produced. Drafts were widely circulated, which ensured that articles covered what clinicians needed to know and made it possible to suggest practical solutions based on consensus in the absence of evidence. The published articles were unsigned because of the collaborative approach, but also to protect the people who wanted to speak the truth about medicines without losing industry research grants. 

I visited him in January to record an interview. His clear skin, bright eyes and sharp mind belied his age, and his love of puns was still obvious ("clarity begins at home"). Andrew's legacy is a driving force behind Veterinary Prescriber and I was keen to hear about the beginnings of DTB, and the challenges of establishing an independent publication. He generously shared his memories and knowledge and suggested new ideas. I learned that his interest in the way medicines are promoted preceded the foundation of DTB. One of his stories was about when he and a colleague tested a pharmacologically similar group of drugs, each of which was being marketed by a different drug company for a different medical use. They were able to prove that all the drugs had the same pharmacological effects. 

Andrew retired from the editorship of DTB in 1992, but continued working until the end, encouraging the production of independent information on medicines around the world through the International Society of Drug Bulletins, and in the Cochrane Collaboration and with DIPEX, a database of patients' experience, which he co-founded.  Undoubtedly there will be a lot written about him elsewhere as he was an extraordinary gentleman.

He will be missed,

 


Andrea Tarr

Founder and Director of Veterinary Prescriber


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