VetInfo Digest November 2002
General Information on Adverse Drug Reactions
Specific Reactions
New Medication for Pain Relief
Asking Questions
This Month's Note:
Complications of medicine use do occur and they are a concern at all veterinary hospitals. It is not unusual for veterinary clients to call our office and ask about medication side effects. Sometimes I think that it would be fun to write a comedy show centered around phone conversations with veterinary clients. In it I would be able to say the things that I want to say many times, but almost never do, on the phone:
"Why did you give my dog a medication that might kill it?"
"Because there aren't any medications that work that don't kill some patients."
"My neighbors and friends all tell me that prednisone is dangerous and that I shouldn't give it to my dog."
"Gather your neighbors and friends together and form a committee to cure your dog's problem. Then you won't need my advice."
"You gave my dog a medication that almost killed it!"
"If I had set out to kill your dog, don't you think that I know enough about medicine to have succeeded?"
Of course, the reason that I don't say these things is that it is legitimate, in most cases, for veterinary clients to have concerns about their pet's medications and to have those concerns addressed in a reasonable manner. But once in a while, especially on the third or fourth phone call, the temptation to end the conversation with a really zinging one liner is hard to resist.
General Information On Drug Reactions
Veterinarians are probably less suspicious of drug reactions than they should be. We use medications every day that have the potential to cause adverse side effects but we rarely see these effects. For most medications, even over the course of an entire career, a veterinarian will not see the most serious side effect a particular medication can cause. Most veterinarians do see a serious side effect from a few medications during their career but this rarely causes a generalized suspicion of all medications.
Veterinarians are trained to question direct "cause and effect" inferences. When a pet is on a medication it doesn't follow that all new problems are the result of the medication. In fact, in controlled studies, it is often possible to prove that suspected drug reactions experienced in clinical practice are actually not related to medications. Veterinarians, like all people, are somewhat self protective. When faced with the possibility of having contributed to an adverse event by prescribing a particular medication it is easy for a vet to say to himself or herself something along the lines of "I've prescribed that drug a hundred times and it hasn't caused any problems before, so it must not be the problem now." Unfortunately, this logic is no more valid than the logic that any reaction that occurs after a medication is given means the medication caused the reaction.
It would be hard for veterinarians to practice, or perhaps impossible, if we were unwilling to use medications that had the potential for any adverse effect. Reading the package insert for almost any medication reveals a long list of possible side effects. It is important to be aware that side effects might occur but it is also important to be realistic about the need for the medication. When a medication is very likely to be helpful and very unlikely to be harmful, its use is justified, even though some patients will react adversely. When a disease is deadly, using medications that are more likely to have serious effects is also a reasonable choice.
Veterinary clients are probably overly suspicious of medication side effects. When an adverse effect from a medication occurs, particularly when a client was not warned it was a possibility, there is a strong tendency to assume that the reaction occurs commonly and that others should be warned about the risk. Consequently, when a pet is harmed by a medication the story tends to spread rapidly and most people are familiar with at least a few "my pet almost died" or even "my pet died" stories associated with medications. With the advent of the Internet, some of these folks have gone online to spread the word about their pet's reactions to a particular medication, real or imagined. Most of the reactions that occur to medications have been documented over time. The documented "reactions" usually include events that occurred while pets were on a particular medication that may or may not be due to the medication, as all adverse event reports are usually cited, even though that are not proven. It is usually possible to find out if the reported reaction is known to occur and to find the relative frequency of the reaction, often by simply reading the package insert or by asking your veterinarian. Asking your vet to call the manufacturer and report a suspected adverse event also ensures that others will hear of it. While it can't be automatically assumed that a problem with a pet on medication is due to the medication, it is reasonable to ask about the possibility and to keep the possibility of a drug reaction in mind if responses to treatment don't seem to be occurring as expected.
A number of medications occasionally cause adverse effects. In many instances the possibility that an adverse effect can occur isn't mentioned by the veterinarian or the veterinary staff when medications are dispensed. This is partly a matter of practicality. If we tried to cover every possible adverse effect of medications each time we dispensed a medication we would have to schedule office visits that are much longer and consequently much more expensive. To give some idea of how much longer, I know that I have spent as long as an hour explaining the potential for liver disease associated with carprofen and how to view that in relationship to the need to control arthritis pain. I have had one memorable conversation about prednisone usage with a client which took an entire morning. Ordinarily we just concede to the client's desire not to use a medication in these circumstances but I actually thought this particular patient would die without the use of a corticosteroid so the increased effort seemed worthwhile.
Some veterinarians believe that it is best not to mention side effects because they feel that the client is not capable of making a good risk/analysis decision on the use of medications. There is no question that clients occasionally make terrible decisions over the fear of side effects and fail to allow effective treatment of their pets or proper pain relief due to these choices. On the other hand, it is equally true that many veterinary clients are quite capable of making excellent informed decisions, if they are allowed the opportunity to become informed. I favor full disclosure of potential side effects but I know that I often fail to mention side effects of medications on busy days. I also know that once in a while I do decide that a particular client will make a bad decision if I tell them that there is a potential for side effects, so I just don't tell them. This makes it hard for me to be overly judgmental when other veterinarians do the same thing, even if they seem to do it more frequently.
Adverse effects do occur and it is very likely that once in a while your veterinarian will fail to mention a potential side effect. Therefore, I'm going to cover some of the more common reactions, reactions that are sometimes overlooked and a partial list of more devastating drug reactions this month. I am also going to try to cover some of the "mythological" side effects that are often reported but do not seem to actually occur in practice.
Specific Drug Reactions
Perhaps the side effect that I receive the most e-mail about and which we have seen in our practice on four or five occasions is sudden deafness associated with the use of ear medications. This occurs most commonly when medications containing an aminoglycoside antibiotic are used to treat external ear infections. The aminoglycoside antibiotics include gentamicin, kanamycin, amikacin, tobramycin and neomycin. Gentamicin is probably the most toxic of these medications to the ear. Deafness can occur when these medications are used topically (in the ear) and parenterally (injection or other non-oral means of administration). Aminogylcosides are used in the majority of topical ear medications, usually in combination with a corticosteroid and sometimes with an antifungal ingredient, as well. Common brand names of products containing aminoglycosides include Otomax (Rx), TriOtic (Rx), Gentocin Otic (Rx), MalOtic (Rx), NeoPredef (Rx) and Cortisporin (Rx). There are many other medications that contain one of the aminoglycosides, so you should read the medication label looking for these antibiotics if your pet experiences deafness that appears to be due to a medication being used to treat ear disease.
The aminoglycosides appear to cause deafness by causing paralysis of the hairs in the cochlea of the inner ear. Dogs are more likely to be affected than cats but deafness can occur in either species. This effect is more likely if the ear drum is not intact when the medications are used and in very young or older patients. If the deafness is noted by the client and the medications stopped immediately, the chance for recovery is higher than if the medications continue to be used.
Almost any medication that is put into the ear canal can cause deafness in some instances. Deafness has even been reported after ear cleaning with saline solution in cats. Other medications that are suspected to cause deafness in some patients include chlorhexidine, betadine, chloramphenicol (Liquichlor Rx), and DMSO (Synotic Rx). It is best to avoid medications when the ear drums are not intact, if it is possible to determine if that is the case. It is important to treat external ear infections and failing to use medications that are effective in controlling the infections due to the fear of side effects is usually a bad choice. If deafness is noted after starting one of these medications it is best to stop the medication immediately and to attempt to treat the ear infection in some other manner, though.
Aminoglycoside antibiotics can also cause kidney damage when they are used injectably for generalized infections (these medications are not commonly used orally, as they are not absorbed well from the digestive tract). Kidney damage is a well recognized effect and most veterinarians who are going to use aminoglycoside antibiotics for a generalized infection will discuss this possibility with the pet owner. Despite this risk, which is life threatening when it occurs, there are times when the aminoglycosides are the best antibiotic choice as they are often the only antibiotic that some bacterial infections will respond to.
Contact allergies to aminoglycosides also occur. Neomycin probably causes the most contact reactions of all medications but this may be due to the widespread use of it in topical medications. Cats are prone to contact reactions from this medication and many cases of chronic ear disease in cats that do not appear to be responding to topical medications may actually be drug reactions. What probably happens in these cases is that the original infection is cleared by the medications but a reaction to the medication occurs quickly and mimics continuation of the problem. As medication time is extended, the problem continues to occur because now the problem is the medication itself. Contact reactions to other medications can also occur. These can be extremely difficult to discern from ear infections, skin infections, naturally occurring immune mediated disease and even skin cancers. Discontinuing the use of topical medications will resolve contract drug reactions but it may take several weeks for signs of the reaction to totally disappear.
Other antibiotics sometimes cause really severe side effects, as well. Enrofloxacin (Baytril Rx) has been implicated in retinal atrophy leading to sudden blindness in cats. The mechanism of this effect is not known but it is a more frequent problem when attempting to use a once daily, but higher dosage schedule. Unfortunately, even at low doses some cats will develop blindness. If this is noted quickly there is some chance for recovery but the blindness is usually permanent. It is probably best to use enrofloxacin for critical cases only in cats. This effect has not been seen in dogs, but enrofloxacin can cause cartilage damage in growing dogs, so it is also not a good choice for a growing puppy.
Even though it doesn't generate the most mail, diarrhea and vomiting associated with antibiotic use is the most common side effect of medication that we deal with in our office. Almost all antibiotics can cause vomiting or diarrhea in some patients. If vomiting occurs shortly after administration of the antibiotic and it happens more than once, it should be reported to your veterinarian. In most cases of vomiting induced by antibiotics we find it necessary to change the antibiotic to resolve the problem. When diarrhea occurs, it will often last two to three days whether the antibiotic is changed, or not. So we tend to continue the use of an antibiotic that causes diarrhea and to treat for the diarrhea as a separate problem. Often we will choose a different antibiotic in the future if antibiotics are necessary again, though.
Vomiting is a frequent side effect when metronidazole, erythromycin, tylosin and lincocin antibiotics are used. It is the most common reason that methimazole (Tapazole Rx) has to be discontinued as a treatment for hyperthyroidism in cats. Vomiting is a particularly vexing side effect since it usually limits the use of the offending medication, but it rarely causes really serious problems.
Severe allergic reactions to drugs can occur. This is something that veterinary clients often suspect but probably occurs less frequently than most people imagine. Anaphylactic (sudden shock) type reactions are well recognized as a problem with penicillin and related antibiotics but can also occur due to angiotensin-converting enzyme inhibitors such as enalapril (Enacard Rx), opioids (morphine especially) and nonsteroidal anti-inflammatory medications such as aspirin. These reactions are severe enough to kill and it is extraordinarily important to be careful to monitor medications used in a pet if there is a history of this type of reaction. This is especially important when using antibiotics, because pets that react to penicillin may also react to a wide number of related medications such as amoxicillin, ampicillin, amoxicillin/clavulonic acid (Clavamox Rx) and sometimes to cephalexin (Keflex Rx) and cefadroxil (CefaTabs Rx). Pets having this type of reaction to a medication have vomiting, difficulty breathing, rapid heart rates, fainting, hives and can die if the reaction is not treated. If your pet has vomiting combined with any other sign, or develops hives after medication administration, it is best to take your pet to your veterinarian or a veterinary emergency facility immediately.
Allergic reactions can also occur indirectly, due to the effects of medications. This is a well known problem with diethylcarbamazine, the ingredient in daily heartworm prevention medications. If microfilaria (baby heartworms) are present in the blood stream when this medication is given it is very likely that an extreme reaction will occur. This effect can also occur with ivermectin (Heartgard Rx, IverHart Rx) and potentially with the other monthly heartworm medications but is not nearly as common.
A number of medications can cause liver damage. The medication that most people are familiar with in this regard is carprofen (Rimadyl Rx). Approximately 14 dogs out of 100,000 that this medication is administered to will develop severe liver damage. It is critical to stop carprofen administration if a dog stops eating or shows other signs of illness while on the medication, because recognizing the problem early seems to control the damage, Patients who continue to the get the medication may die and in a few cases this happened even though carprofen was withdrawn. This is considered to be an idiosyncratic reaction, which means that it occurs due to an unknown sensitivity that only a few dogs have. Other medications used in veterinary medicine can cause similar idiosyncratic liver disease. This is a problem with Filaribits Plus (Rx) due to the oxibendazole (dewormer).
Diazepam (Valium Rx) can cause severe liver damage in some cats. In most cases cats affected in this manner will die. The effect is most common after daily use of diazepam for several days but has been reported to occur in some cases after a single dose of diazepam. This is considered to be a rare reaction in cats but it is definitely something to watch for if it is necessary to use diazepam to control seizures or for other purposes.
Seizure control medications cause significant liver damage in up to 5% of patients. Primidone is more likely to cause liver damage than phenobarbital, even though these are related compounds. The difference in toxicity is enough that most veterinary neurologists recommend avoiding the use of primidone entirely.
Acepromazine (PromAce Rx) is used in veterinary medicine as a preoperative sedative, for car sickness and sometimes for general anxiety. It is generally regarded to be very safe but it may lower the seizure threshold in dogs prone to seizures (some veterinary anesthetists dispute this) and it has also been reported to lead to sudden death reactions in some dogs, most commonly boxers. This effect has also been disputed but we try to avoid its use in boxers and seizure prone pets, anyway.
Corticosteroids cause liver changes in many patients that are insignificant clinically. They can also cause moderate liver damage in a number of patients, which is usually responsive to withdrawing the medications. In some patients, there is such a strong need for the corticosteroid that the liver effects must be tolerated. Even in these patients, it is uncommon for the damage to reach a point that it is life threatening. However, it is obviously best to withdraw corticosteroids if it is possible to do so when there is evidence that it may be causing more than minor liver disease.
We have seen sudden worsening of clinical signs associated with cardiomyopathy (heart muscle weakness) in several cats after giving long acting corticosteroid injections such as methylprednisolone ( DepoMedrol Rx). These cases have occurred in the day or so after injection of the methylprednisolone (often referred to as "depo" shot and have involved acute respiratory distress, sudden weakness and lethargy. If there is any evidence of preexisting heart disease the long acting corticosteroids should be used with extreme caution.
Megestrol acetate (Ovaban Rx, MegAce Rx) is sometimes used for skin disease in cats in an effort to avoid the effects of corticosteroids. I had a running argument with one of my associates over which of these medications caused more side effects. My opinion is that corticosteroids, used properly, are safer than megestrol acetate in cats. This medication induces diabetes in approximately 5% of cats with long term use and it can cause mammary gland tumors, even in male cats. These effects do not appear to be a problem in dogs for use in estrus control, which is the approved use for this medication.
Nonsteroidal anti-inflammatory medications such as aspirin, phenylbutazone, ketoprofen and naproxen are well known for causing gastrointestinal irritation. A less well known but much more serious side effect of the NSAID family of medications is a tendency to cause kidney failure in some patients. This is not a common side effect but it can cause death. Pain relief is important for pets but it is also important to report any changes in eating, drinking and urinating behaviors that occur while a pet is on one of these medications. Acetaminophen, a relative of this group, is extremely toxic to cats and should not be used in any form for the treatment of cats.
Etodolac (Etogesic Rx), one of the newer NSAID medications, causes decreased tear production in some dogs with chronic use. It is important to be aware of this side effect. When tear production is not sufficient most dogs will have a mucous exudate that may be mistaken for pus that accumulates along the eyelid margin. Some dogs hold their eyes partially shut. As the problem progresses the clear portion of the cornea turn brown or opaque. If any sign of tear deficiency is noted and etodolac is discontinued there is a much better chance that the tear deficiency will not be permanent. Tear deficiency is a painful condition so don't ignore any sign of eye irritation that may occur while using etodolac.
Enalapril (Enacard Rx) is used for chronic heart failure and in some forms of chronic renal failure. In most pets the use of this medication is beneficial for the kidneys. In some pets, though, it can cause or contribute to kidney failure. It is important to keep this possibility in mind and to consider checking for kidney damage within a few days of starting this medication and to watch for increased water consumption or increased urine volume while using enalapril. If diuretics are being used at the same time kidney damage is more likely and the use of diuretics, which increase urine volume, can mask signs of kidney failure.
Methimazole (Tapazole Rx) is used in cats in the treatment of hyperthyroidism. Most cats who have reactions to this medication have nausea or diarrhea. A small percentage of cats will develop aplastic anemia (lack of production of red blood cells and sometimes white cells) due to the methimazole. It also can cause decreases in platelet numbers and function leading to poor blood clotting. It is extremely important to check for anemia after a week to two weeks on this medication and then every few weeks until a maintenance dosage is established. These types of problems can also happen with the use of azathioprine (Imuran Rx) in both dogs and cats. Diethylstilbestrol (DES), which is used to treat estrogen dependent incontinence in female dogs, can also cause aplastic anemia although it is considered to be a rare side effect for this medication.
Erythropoietin (Epogen Rx, ProCrit Rx) is a hormone that stimulates the production of red blood cells. It is used in dogs and cats who have chronic renal failure which is resulting in anemia from lack of production of the natural hormone and in pets on medications that interfere with production of blood. Up to 30% of dogs and cats who are given this hormone will develop antibodies to it. Unfortunately, when antibodies form against the pharmaceutical version of the hormone (which is derived from human cell lines) they will also commonly attack the natural hormone. This can result in a total inability to produce red blood cells. For this reason, it is important to closely monitor the red blood cell numbers while using erythropoietin and to stop the injections if there is a drop in red blood cell numbers, or even if they just don't increase as anticipated after an initial positive reaction to the medication.
Some of my clients think that their pets are itchy after application of topical flea and tick control products. This is a recognized side effect. In some cases the itchiness is severe enough, especially in cats, that the patient will actually damage its skin in a frantic attempt to control the itch. At the present time this is thought to be a reaction to the alcohol used to dissolve the active ingredients in these products. It is usually possible to control these reactions by repeatedly bathing a pet but in some cases it is necessary to briefly use medications to control the itching. We have seen several cats who were itchy when imidocloprid (Advantage Tm) was applied and then were just as itchy when fipronil (Frontline Topspot Tm) was applied at a later date. Selamectin (Revolution Rx) seems a little less likely to cause itchiness and sometimes works as a substitute to maintain good flea control.
Amitraz (Mitaban Rx), which may be unavailable at this time, is used to treat demodectic mange. It causes headaches in many people who are exposed to it and often causes sedation or lethargy in dogs when it is applied to kill mites. In some dogs this medication will cause death within a few hours to a day or so after application of the sponge on product. If you have to use this medication to control demodectic mange it should be used cautiously and directions followed carefully. If extreme sedation occurs there is an antidote to the effects of the medication and it is best to seek emergency care immediately.
The new once a month injectable heartworm medication, moxidectin (ProHeart Rx) is popular with some of my clients, especially forgetful clients. However, it is suspected to occasionally cause an extremely severe skin reaction referred to as toxic epidermal necrolysis (TEN, sometimes TENS when "syndrome" is added). When this condition occurs the skin may become so inflamed that it appears to have been burned and will sometimes even slough if touched. It takes intensive therapy to get a dog through this condition and some affected dogs will die. This condition is also a rare complication of the use of nonsteroidal anti-inflammatories and sulfa containing antibiotics. While this appears to be a rare reaction it is a devastating reaction since it appears to cause intense pain.
On two or three occasions we have had clients cone to us with mysterious tissue sloughing, to the point that muscle and bone were visible. All of these wounds occurred just below the elbows on the front legs. These reactions occurred several days to a week or more after heartworm treatments or anesthetic procedures and in all cases that I can remember we were the second or third opinion veterinarians. I think that was due to a reluctance on the part of some veterinarians to admit a mistake may have been made. When really irritating injectable medications meant to be given intravenously are given under the skin, because the vein is missed while injecting, the medications will sometimes kill the tissue around the vein. This can result in very deep wounds in some cases. We have not seen this problem recently, probably because the newer heartworm treatment is given intramuscularly and pentothal and thiamylol (anesthetics) are used less frequently than in the past. There is actually a naturally occurring vasculitis that can cause similar lesions but it is most common in Doberman pinschers.
The proper use of vaccinations has become somewhat controversial in the last few years due to the recognition of serious problems that sometimes occur with vaccine administration. In cats, vaccinations appear to induce cancer in about 1 in 3500 vaccinated cats. The cancers occur at or near vaccination sites and are referred to as vaccine associated sarcomas. This problem has really made it necessary to evaluate each individual cat patient to assess the need for various vaccinations and to consider longer intervals between vaccinations when possible. In dogs, vaccinations seem to cause an increased frequency of immune mediated hemolytic anemia (IMHA) in the weeks immediately following vaccination, although this is still thought to be an uncommon problem. Small white dogs (and sometimes other colors) are prone to vasculitis at the site of rabies vaccinations, which can lead to a localized area of itchy inflamed skin and even hair loss over the vaccination site. The reactions in dogs are minor compared to cats but they are still important and are stimulating an effort to determine how long the various vaccine components actually provide protection. The goal is to give vaccinations as often as is necessary to prevent the diseases they protect against but no more frequently than that. There is no consensus among veterinarians at the present time over the correct interval between vaccinations. Most of the U.S. veterinary schools use a three year interval after puppy shots and a one year booster have been given, for the vaccinations most commonly used.
Eye drops containing corticosteroids are commonly used for their anti-inflammatory effect when there is eye irritation due to allergic conjunctivitis or because of uveitis (inflammation inside the eye). It is extremely important not to use eye drops that contain cortisone when there is an ulceration of the cornea. Corticosteroid (usually dexamethasone or hydrocortisone) eye drops can cause an ulcer that might have healed on its own to perforate the eye. When cats have herpes virus irritation of the cornea it is possible to make the condition much worse by using corticosteroid containing eye drops. When your pet has a sore eye and you are tempted to use eye drops prescribed for a previous problem, resist the temptation, especially if you are unsure if the drops contain a corticosteroid.
Many over the counter medications and any prescription medications that may be in use without your vet's knowledge, such as "left over" antibiotics or corticosteroids may cause drug reactions or may interact with drugs that your veterinarian prescribes. It is important to have a list of all medications that your pet has taken recently whenever your pet is ill enough to require veterinary examination. Don't hide the possibility of an adverse reaction to medication from your vet by withholding the fact that you have been giving other medications. It is even more critical to let your vet know if your pet was under another veterinarian's care in the last few days. If you think a second opinion is important you should seek it, but you must let the second veterinarian know what medications have been used, what tests have been run and what the results were.
Over the counter (OTC )medications can cause reactions, too. The worst case of skin inflammation that I have seen occurred after a client bathed her dog in a shampoo containing pennyroyal. I really thought that the dog might die for the first two or three days that we treated the inflammation. We have seen reactions to aspirin, topical cortisone ointments, flea control medications and many other OTC medications.
There are probably many side effects of veterinary medications that we will never know about. Many medications cause headaches, for instance. I have never figured out how to tell if a pet has a headache unless the pet has really severe symptoms, like head pressing against a wall. If hypertension (high blood pressure) occurs in pets due to a medication, it may never be noted, because it blood pressure assessment is not yet a common part of veterinary health examinations. A medication that causes tinnitis (ringing in the ears) may have this effect in pets but it is not likely that we will ever know for sure. With this in mind, it seems reasonable to me to assume that effects noted in humans may occur in pets and to be willing to change medications based on behavioral signs that anything is wrong, as long as there is a suitable replacement medication. If a medication is being used for a nonessential reason it is reasonable to discontinue it and try to tell if a pet feels better without it.
Avoidance of drug reactions and early detection at the best methods of limiting problems associated with medications. Medications are best used when it has been possible to establish a definite diagnosis, when they are used according to directions, when the least toxic drug that is likely to work is chosen, when appropriate instructions are given with the medication including information on potential side effects, when appropriate follow-up visits and laboratory monitoring are done and when both the client and veterinarian keep the potential for adverse side effects in mind.
If your pet has an adverse drug reaction it is best to ask your vet to report the reaction. It is acceptable to call the manufacturer as long as the veterinarian specifies that an adverse drug reaction is suspected, so that it is recorded as one. Manufacturers are required to keep track of adverse drug reports. It is also acceptable for your veterinarian to call the FDA directly at 1-888-FDA-VETS and to report the reaction.
New Medication for Pain Relief in Dogs
Deracoxib (Deramaxx Rx) was approved in August as a pain relief medication for dogs. This is a close relative of Celebrex (Rx) and Vioxx (Rx) which have been successful pain relief medications for people. It is given once daily for up to 7 days, based on the package insert directions. Side effects in the clinical trials were minimal but it is not uncommon for additional adverse effects to surface as medications have wider use after approval.
Asking Questions
We are continuing to answer questions from subscribers and for the most part we are keeping up with the questions at this time. This is mostly the result of a decrease in subscriptions that has occurred as we have posted on the site a notice that we have discontinued the Ask Dr. Mike feature of our site. I enjoy answering questions when they are not an overwhelming responsibility, so please feel free to submit your questions. The address for questions is mervet@inna.net and I am much less likely to accidentally delete your question if you put "Subscriber Question" in the subject line.
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This page was last edited 06/20/04
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