VetInfo Digest           August 2003

Administering Oral Medications

Monitoring Blood Sugar

Eye Drops

Ear Medications

Nail Trims

Expressing Anal Sacs

Figuring Drug Dosages

Administering SQ Fluids

Tooth Brushing

Flea Control Products

New Stuff

 

This Month's Note:

Following your veterinarian's directions can be one of the more challenging aspects of being a pet owner. Your vet, who gives pills everyday to a variety of pets, may not think twice about dispensing pills for your finger eating Chihuahua or your arm shredding cat. Your vet might think that drawing blood for glucose testing when your pet is diabetic is a breeze, while you remember fainting every time you've ever seen fresh blood. Giving subcutaneous fluids on a daily basis is just part of a veterinary technician's job and the directions you get from her on how to do it at home may be missing the most important step -- how do you gather up the courage to stick a needle in your beloved pet?

I would like to spend this issue of the VetInfo Digest discussing various options that you have to accomplish the tasks that your vet feels are important for your pet's health. These are the methods and options that we find useful in our practice. Your vet, or your vet's staff, may have other methods that work and other options for difficult tasks that I am not aware of. Don't ever be afraid to tell your vet that you won't be able to give pills or clean your pet's ears or give it a bath. Don't forget that your vet's staff may be a better source of practical information than your vet. In many veterinary practices the veterinarian makes the diagnosis but the veterinary technicians and veterinary assistants actually perform the routine chores of health care and often know more about the mechanics of these tasks than the veterinarian does. If their advice runs directly counter to the vet's advice you should check back with your vet to make sure you heard the directions correctly, though.

 

Administering Medications

I try to ask all of my clients if they can give their pet a pill before I dispense pills. Most of my clients have figured out some way to get their pet to take needed pills but some struggle with this task and there are even a few patients who I can not give pills to, despite years of practice at giving pills.

When giving pills to cats, the method I like best is to place my thumb just behind the upper canine tooth on one side of the mouth and my index finger behind the upper canine tooth on the other side of the mouth. Then I tilt the cat's head back until its nose is pointing straight up. Most cats will let their mouth open slightly when their head is held in this position. Then I use the little finger of my other hand to pull their lower jaw open and I drop the pill, which I am holding between the thumb and index finger of this hand, into the cat's mouth. I aim for the middle of the back of tongue. Most cats will swallow instinctively when the pill hits their tongue. I don't try to push the pill into the mouth with my finger. If the cat spits it out, I just try the same technique again. If this technique doesn't work, I then try using a "Pill Gun", which is a plunger with a rubber cap that holds the pill. The rubber is soft enough that the pill gun can be quickly introduced into the mouth, the plunger pushed and the pill is then released as far back in the cat's mouth as I can get it. This is an inexpensive tool that can make a big difference when trying to give pills to cats.

Dogs are usually easier to pill than cats. Most dogs will swallow some treat food readily enough that the pill can be hidden in that food. Some of my clients whose dogs catch food treats well will just throw the dog two or three small treats, then a pill, then very quickly another treat. This often works well. When I have to give a dog a pill, I often rely on the same pill gun method as detailed above for cats. However, when the pill won't fit in the piller or when the dog is suspicious of the pill gun but will allow me to put my fingers in its mouth, I do resort to manual pill pushing. To do this, I usually grasp the dog's muzzle with my thumb behind one upper canine tooth and my index finger behind the other one. I use usually use the heel of my other hand to work the dog's mouth open and then reach into it with my fingers until I can feel the fingers passing over the ridge in the tongue. I push the pill just a little farther down than this. As long as the dog isn't prone to biting, it is usually possible to give pills in this manner.

If the medication can be given with food, the easiest method of administration is to find a treat food that your pet can't resist and put the pill in it. This works better for dogs than for cats but even some of the more finicky felines have a food item that they have a hard time resisting. There are a number of foods that my clients hide pills in. The most common ones seem to be pieces of hot dogs, cheese, peanut butter, bread, liverwurst or other soft lunch meats and canned dog food. For cats, the most commonly mentioned treats are cheese, chicken, turkey and pieces of shrimp. I know a veterinarian who advocates giving pills in marshmallows. It is important to check with your vet, or to read the package insert, before giving medications with food, as some medications are not absorbed properly if given at meal times or with food treats.

Some of the medications used long term in cats, such as methimazole for hyperthyroidism, are really bad tasting if the pill is bitten into or dissolves in the cat's mouth. Putting the pill into a capsule can help to alleviate this problem. It is possible to buy empty gelatin capsules at many pharmacies. This can also be helpful when cats have to have more than one medication at a time, as it is often possible to put two different pills in the same capsule, so that it is only necessary to administer one capsule instead of two tablets. This works for dogs who get tired of being pilled multiple times, as well.

Many of the medications that come in tablet form can be flavored by a compounding pharmacist and some veterinarians have purchased the equipment and flavorings to make pills into flavored "treats", as well. This can be really helpful when a medication only comes in pill form and pet refuses to take the pills. When pets won't take flavored medications directly, there is still a better chance that a flavored medication will be eaten by a pet when mixed with other foods. Some veterinary medications come in flavored tablets and in regular tablet form. If you have problems giving the tablets it is always worth asking if the medications comes in a flavored form.

Cat owners often prefer liquid medications to tablets or capsules, when there is a choice. Personally, unless the cat will eat the liquid mixed with its food, I find liquids harder to administer. However, many of my clients really do prefer giving liquid medications to cats. When I need to give liquids I usually give them with a syringe rather than an eye dropper. The syringe can be placed into the fold of the lips and then pushed gently back into the cheek pocket that the lips form and the medication slowly administered while the cat's head is held slightly elevated. If you can hold your cat in this position it is usually possible to get them to swallow the complete dose of medication in this manner.

For cats and dogs who are really difficult to pill and who won't take medications in a flavored form, there is the potential to make a transdermal gel from many medications. Transdermal gels are carriers for medication that can be applied to the skin. In dogs and cats the best place to put the gel is usually in the ear, or on the non-haired portion of the ear flap, where they are more uniformly absorbed. Transdermal gels have only been proven to work for a handful of medications but they seem to work well based on clinical experience for a number of other medications. We are most comfortable using transdermal gels for medications that have a measurable effect, such as methimazole for hyperthyroidism. We know the medication is being absorbed properly if the thyroid level drops in this case, so there isn't as much worry about whether the gel is working properly. We use transdermal gels for medications in which they haven't been proven to work and where we don't have a measurable result in some cases, simply because they give some hope of medication administration for a few pets who will not allow any other method.

There are some special instances in which we use other methods of medication administration, as well. I am not opposed to teaching my clients to inject certain medications. This has been a long standing norm for insulin administration and there are a few other medications that can be administered subcutaneously, as well. We have dispensed injectable acepromazine for a couple of dogs with severe thunderstorm anxiety who will not take oral medications once they are upset by thunder, for instance. It is also a reasonable approach to emergency therapy for asthmatic cats, using terbutaline (Brethine Rx) injections at home when an attack occurs. We teach most of our clients who choose to try hyposensitization for allergies to given the allergy shots themselves, as well. Your vet may be reluctant to dispense an injectable medication but if the situation justifies this approach it is worth asking if it would be acceptable for you to administer injections yourself.

When dogs have cluster seizures, we dispense diazepam (Valium Rx) to be given rectally, to stop the seizure activity. Diazepam is very irritating to tissue, so it must be diluted with an appropriate substance, such as K-Y Jelly (tm), before being administered in this manner. This is a dosing option that works even when a dog is seizuring, though. Many pet owners really appreciate having the ability to stop the seizures in an emergency, rather than having to resort to making a trip to the emergency clinic.

 

Monitoring Blood Sugar

Diabetic patients should have their blood sugar measured on a regular basis. In addition, it is very helpful if veterinary clients can perform blood sugar measurements for blood glucose curve analysis at home, where the pet is most comfortable. For some reason, there are veterinarians who are reluctant to help their clients learn to get blood from diabetic cats and to help in management of diabetes. There is absolutely no question that regular blood sugar measurement is beneficial when insulin must be used to control diabetes. The only really practical approach to this is for pet owners to learn to get a blood sample and to use one of the readily available blood sugar monitors to analyze the blood sample for sugar levels. I try to teach my clients to understand blood glucose curves so that they can learn to adjust the insulin levels appropriately without having to rely totally on me. Many of my clients become very good at this over time and get quite comfortable making minor adjustments in insulin dosing on their own.

Most of the time it is not too difficult to get a blood sample from a pet, although there are definitely exceptions. Cats are actually easier to get blood from than dogs, on the average. We usually advise using a small gauge needle to puncture the ear vein or artery along the margin of the ear flap in cats. This can be seen easily by shining a light through the ear but that is usually only necessary for the first sample or two because the location doesn't vary from day to day. Putting a little bit of water or petroleum jelly on the ear before sticking it with the needle will help the blood well up in one spot into a usable drop.

It is often possible to get enough blood from the non-haired portion of a dog's ear by gently warming this area with a warm compress or blow dryer and then sticking it anywhere in the warmed area. It is also possible to get blood from the lip margin or from the edge of a foot pad in most dogs. Be careful if you use a foot pad, because dogs vary a lot in their sensitivity to puncture wounds in this area and some will resent it a great deal. In a few cases we have shown clients how to place a needle into a vein to obtain a sample. There are some animals that are just more tolerant of this, especially when it is hard to find a spot to get blood and they are getting poked repeatedly with a needle.

Some veterinarians really fight the whole idea of clients drawing blood on their own and checking blood glucose levels. I am not sure why this attitude exists because there just isn't any better way to regulate blood glucose levels well in diabetic dogs and cats. As more articles come out supporting this approach the reluctance among veterinarians to encourage clients to participate in blood glucose monitoring should lessen.

 

Eye Drops

I have a few clients who almost run from the exam room when I start to discuss treating a pet's eyes with eye drops or eye ointments. A few people seem to have a genuine fear of causing eye damage and a few are just queasy about eyes in general, but most people just assume they are going to have a hard time getting their pet to cooperate.

There are very few pets who make it so difficult to use eye drops that we can not administer them. There isn't anything special about our techniques, but describing them might be helpful.

Most eye drops actually work best if just one drop is placed in the eye. Putting more than one drop in the eye can cause tearing that washes more of the medication away than the additional drops provide. So an effort should be made to get the first drop in the eye each time. Eye ointments are a little different but it is generally not necessary to use more than 1/4th inch strip of the ointment even though it doesn't usually hurt to use more than that.

When we put eye drops in an uncooperative cat's eye our most important tool is a big towel. We usually put the cat on the middle of the towel and then we pull the two corners closest to his neck together around it, just snug enough to keep the front feet contained. Then we fold the back of the towel over his back to contain his back feet. For more excitable cats we just throw the towel over the cat and gather it up. Most cats will figure out how to get their head out and then we try to contain the feet. For really excitable cats a fish net works great. A net with a metal loop holding it open can be placed over the cat and then the loop turned over, to trap the cat in the net. It is usually possible to contain the cat tightly enough that her head can be controlled and drops placed in one eye. Of course, this can be a trying thing for everybody if it has to be done over and over again but it works pretty well.

For cooperative cats and for most dogs, I hold the eye drop bottle with the thumb and index finger of my right hand (because I'm right handed) and I put this hand under the pet's chin with my palm steadying the chin. Then I use the other hand to pull back the upper eyelid on dogs and either eyelid on cats. This allows me to put the drop on the surface of the eye without missing too often, because both of my hands move with the cat or dog if it struggles slightly. I know lots of vets who prefer to reverse the hand placement, using the left hand to steady the chin and the right hand, with the drops in it, to retract the upper eyelid and then place the drops. While I don't have as much success using this method, it does seem to work for a lot of people. If I'm using an eye ointment I use the same technique except that I am willing to just squeeze an ointment through the gap between the lids, if necessary. Eye drops do not have to hit the cornea (transparent part of the eye) to be effective. They can be applied to the sclera, or white part of the eye, if that is all that is visible.

 

Ear medications

Dogs and cats who have ear problems often have enough pain that they are extremely reluctant to allow anyone to touch or medicate their ears. I think that there have been more instances of sudden aggression in our office over ear exams and toe nail clipping than any other procedures. If you know that your dog or cat will respond aggressively to any attempt to medicate the ears, tell your vet and ask for oral medications as an alternative. There are not many ear conditions that won't respond to oral medications, although the response to the medication may be slower than with topical medications.

If your pet is just reluctant to allow ear medication to be used but isn't aggressive, there are some things that seem to help.

If you are using a refrigerated ear medication, allow it to warm up to room temperature before putting drops in the ear.

If ears absolutely have to be medicated topically it can be helpful to use a local anesthetic such as pramoxine in the ear prior to using other medications, especially any that might sting. Ear cleansing products such as Corium-TX (tm) are available with the local anesthetic agent in them.

Gravity will work in your favor with ear drops and ear ointments. If you get the medication into the top of the ear canal it will usually spread down the ear canal. Most dogs and cats are more accepting of ear medication if you can manage to put the drops into the ear without touching the surface of the ear much. Ear ointments always come with a long tip that just looks like it should be used to get the medication deep into the ear canal. This just isn't necessary in most cases, though. Not trying to push the tip of the ear ointments into the ear helps to prevent pain and less pain means your dog or cat is more likely to allow you to use the medication on a regular basis without trying to bite or scratch you.

Using a good quality ear cleanser can be helpful in prolonging the interval between ear infections in dogs who are prone to infections. I like EpiOtic (tm) but there are lots of other ear cleaners and your vet may prefer a different one. In cats, it is usually better to use plain saline solution, or even just warm water to clean ears. It is usually only necessary to clean the ears once or twice a month. Dogs with allergic otitis who swim a lot can benefit from the use of ear medications that help to keep the ear dry and inhospitable to bacteria. White vinegar mixed with water can be a good solution for this. We usually use a 1 part vinegar, 2 parts water mixture. This can be done daily if necessary. A small number of dogs seem to be irritated by the vinegar solution and it is best not to use it if your dog's ears seem uncomfortable or inflamed after use.

 

Nail Trims

Trimming a pet's nails can be difficult, especially when the pet is uncooperative. However, it is possible for most pet owners to learn to trim nails and to work with their pet to get the job done.

While there is always room for disagreement, my favorite toenail clippers for dogs are the ones that look like wire cutters. The "guillotine" or Rescoe (tm) type nail clippers just seem to be easier to use improperly, resulting in nails that are cut too short and bleed. My favorite nail clippers for cats are a good pair of Trim (tm) nail clippers made for people. If these are turned sideways they will work quite well on most cat's nails and seem less prone to splitting and cracking cat's nails than the other types of clippers.

It is unusual not to be able to see the pink nail bed in cats. This makes it easy to avoid cutting the cat's nails too short. It may be necessary in the case of long haired cats to carefully move hair away from the nails. Clipping hair often results in the hair being pulled out, which is painful to the cat and makes them resent the nail trimming.

Dogs often have black toenails. This makes it harder to figure out how short the nail can be cut. As a general guideline, it is usually possible to trim the nail to match the angle of the front of the pad of the toe. An alternative approach is to cut very thin slices of toenail until the nail is solid throughout the cut. If the nail is cut too short and this results in bleeding, don't panic. In the entire time I have been in practice, I have not seen a single case in which nail trim bleeding led to a serious problem in a dog. It is acceptable to do nothing and just wait for the nail to stop bleeding, although this sometimes causes quite a mess. Dipping the nail into flour will usually stop the bleeding and there are several commercial products that help to control bleeding from nails that are cut too short.

Dogs who resist nail trimming will often allow one or two nails to be trimmed before struggling. If this is the case, there is nothing wrong with just cutting one or two nails a day until the job is done. Over time, many of these dogs will become more accepting of the process. Just like in cats, avoiding catching hair in the clippers and avoiding cutting the nails too deep will help to make the process less scary for your dog. Clients sometimes ask me for sedatives they can give at home to facilitate nail trimming. We are somewhat reluctant to dispense sedatives for this purpose because they lower inhibitions in some dogs and lead to increased aggression, sort of the way alcohol produces a "mean drunk" in certain people.

Despite years of practice, I cut toenails too short pretty frequently. Any serious effort to control the length of overgrown nails can result in bleeding, even when being pretty careful to avoid it. Don't let one episode of bleeding deter you from ever trying nail trimming again.

 

Expressing Anal Sacs

Lots of dogs and a few cats have persistent problems with anal sac impaction. The anal sacs are located at approximately the 4 o'clock and 8 o'clock positions around the rectum. These are pockets of specialized skin connected to the skin surface right at the rectum through a duct. When the ducts get blocked or inflamed, the exudate collecting in the anal sacs isn't expressed and the dog or cat may experience discomfort or pain. This is usually manifested by scooting along the ground with the legs extended so that the rectum is in direct contact with the ground. Dogs and cats exhibit this scooting behavior because it sometimes does seem to work and cause the anal sacs to be emptied.

When the dog or cat can't relieve the anal sac impaction on their own, it is necessary to have the sacs emptied. Many pet owners can learn to express anal sacs using external pressure. If the thumb and finger of one hand are placed widely across the lower portion of the rectum and then pushed into the skin and pinched together, it is often possible to feel the anal sacs as small swellings. These are pushed together, causing them to be expressed. An exudate that may vary from liquid to thick paste consistency is expressed from the sacs.

If external expression of the anal sacs isn't possible, it may be necessary to place a finger in the rectum and use it to trap the sac on one side between the finger and thumb, allowing it to be expressed. This is then repeated on the other side. Most of my clients don't want to learn this technique and are willing to pay us to express the anal sacs but there is no reason that pet owners can't learn to express anal sacs in this manner on their own, since vinyl or latex exam gloves and KY jelly are readily available for purchase. I have never ruptured an anal sac while attempting to express it but there have been times when I thought it was a possibility. It is important not to be too aggressive about putting pressure on the sac while expressing it.

 

Figuring Drug Dosages for Over-the-counter Medications

It is often possible to find dosages for over-the-counter medications in publications and on web sites. Once you have checked to make sure the dosage is safe and accurate, you still need to figure out how much of the medication to give your pet.

It is really important to pay attention to the weight measurement that the dosage is given in. Kilograms and pounds are different enough that a serious error could occur if they are mixed up. To figure out the weight in kilograms when it is known in pounds, the formula is:

Weight in Pounds / 2.2 = Weight in Kilograms

Once the weight is known, the rest of the process is simple. If a medication dosage is 4mg/kg, then a 20kg dog needs 80mg. To follow the conversion from start to finish for a 25 lbs dog who needs 10mg/kg of amoxicillin, these are the necessary steps:

25 lbs./2.2 lbs/kg = 11.4 kg

11.4 kg x 10mg/kg = 114mg

Amoxicillin comes in 100mg tablets and 250mg tablets. It would be acceptable to give either 1 100mg tablet or 1/2 of a 250mg tablet, as both are close enough to the appropriate dosage.

 

Administering subcutaneous fluids

Many cat owners will eventually have to deal with chronic renal failure in their cats. One of the most important aspects of therapy for chronic renal failure in both dogs and cats is administration of fluids, either subcutaneously or intravenously. Subcutaneous fluid therapy works well in small dogs but it is hard to give adequate fluid volumes to large dogs using this technique. It is fairly easy to learn to administer fluids subcutaneously to both dogs and cats. The most important thing to remember, at least for putting your mind at ease about subcutaneous fluid therapy, is that it is pretty difficult to put the fluids anywhere that will cause a problem. The most common fluids, such as lactated Ringer's solution, can be given intravenously, intramuscularly and subcutaneously. There isn't much that go wrong with this many options.

We do not like to put more than 100cc of fluids in one spot, so cats or small dogs requiring more fluids than this will have to have two injection sites. We prefer to put the fluids in the flanks, just because this seems to more comfortable for the pet. When cats are difficult about taking potassium, we will supplement the fluids with the cat's daily potassium dose. The only problem with this approach is that some cats seem to resent the fluids a little more when potassium is added, probably because there is some stinging sensation.

The GIF-Tube (tm) is a silicone catheter implanted under the skin to make long term administration of subcutaneous fluids easier for pet owners. This is an option to consider but there is a higher infection rate associated with these tubes, although carefully following care directions is supposed to alleviate most of this problem. At the current time we still prefer daily administration of fluids through a needle, though.

This is another area in which some vets seem to think that their territory is being invaded when pet owners wish to administer the fluids at home, themselves. If this attitude interferes at all with adequate fluid administration, it is sufficient reason to change vets. There is no substitute for fluid therapy in the long term care of patients with chronic renal failure.

 

Brushing Teeth

Brushing your pet's teeth is one of the best things that you can do for its health. It can be hard to convince your pet that this is a good thing, though. It really helps to start attempts to brush a pet's teeth when it is young but it is possible to start at any age. It is often helpful to start by putting a flavored toothpaste made for pets on your finger and gently rubbing the gum line with it. Progress to a finger toothbrush and then, if possible to a pet toothbrush.. A few of my clients have even gotten as far as using an electric toothbrush but this takes an extremely compliant dog (no cat owners in my practice have tried this that I know of).

Some pets are not going to allow tooth brushing, no matter how hard you try. There are some alternatives. In cats, the tartar control treats, such as Pounce Tartar Control (tm) seem to help some, but not all, cats. This seems to be true for the tartar control foods, as well.

In dogs, real bones can be very helpful in cleaning teeth, although some dogs will break teeth on bones. Rawhide chews are helpful in removing tartar. The tartar control foods seem to help more consistently in dogs but still aren't perfect. If your dog has no other medical problems that require dietary restrictions these can be a good choice, though. We're not sure yet how well DentaBones (tm) and similar products work but they do seem to help at least a few dogs. Feeding dry foods doesn't seem to make a lot of difference, based on our practice experience.

A few dog breeds, especially dachshunds and collies, form heavy tartar on the upper canine teeth. Some cats do this, as well. I think that it is reasonable to make an attempt to remove this tartar accumulation at home because these teeth often require attention much more frequently than the remaining teeth. It is possible to purchase hand scalers in many pet stores or from pet catalogs. It is often possible to catch the edge of this tartar with a fingernail and flick it off the tooth with the fingernail alone. Having some form of magnification, such as an OptiVisor (tm), can make this process much easier and reduces the risk of pinching the gum line and causing your dog or cat to bite or resist the procedure. Take your time if you elect to try to remove tartar from your pet's canine teeth and be careful about being bitten. When working this close to the teeth, it is always a possibility.

 

Applying Topical Flea Control Products.

There are three topical flea control products that work very well. They are fipronil (Frontline Rx, Frontline Topspot Rx), selamectin (Revolution Rx) and imidocloprid (Advantage Rx). These products can cause irritation at the site they are applied, although this seems to be slightly less of a problem with Revolution. In our practice, we have found that the other topicals seem to work better when an effort is made to put the products directly on the skin in several sites, rather than dumping the whole vial of product on one spot. In cats and small dogs spreading the medication over two to four spots works well and in bigger dogs it may be necessary to use 6 to 8 spots to get all the medication directly on the skin. This seems to cause less irritation at the application sites, as well.

 

New Products

Meloxicam (Metacam Rx) has been approved for use in dogs in the United States. This is a non-steroidal anti-inflammatory medication similar to Rimadyl (Rx), Deramaxx (Rx) and Zubrin (Rx). Like all of these medications, it will have side effects in some dogs but it is also likely to provide a great deal of relief for older pets with arthritis. Meloxicam is approved for use in cats in many countries. This is an important point, because there isn't an approved non-steroidal pain relief medication for cats in the U.S. Hopefully, approval of this medication for use in cats will come soon. In the meantime, if there is a strong need, your vet may be willing to dispense it for "off label" use in cats.

Tepoxalin (Zubrin Rx) is another new non-steroidal anti-inflammatory. It is approved for dogs only. The tablets are reported to dissolve rapidly in the dog's mouth, which is supposed to make it easier to administer and to be sure that the medication was administered. With all the choices in NSAIDS for dogs that are currently available, it should be possible to find one that works well for almost any dog.

Hills has come out with a new diet food for cats, m/d (tm) that follows the high protein, limited carbohydrate model that seems to work pretty well for weight control, especially for cats that start out very heavy. This diet may be worth trying if you have tried other weight control methods without success.

 

The VetInfo Digest is published by:

TierCom, Inc.

P.O. Box 476

Cobbs Creek, VA 23035.

 

The opinions expressed in this newsletter are those of Michael Richards, DVM., author.

Copyright 2003, TierCom, Inc.

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