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Prescriptions to get cheaper medication
Was there medical error
Vet/client communication problem
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Prescriptions to get cheaper medication
Q: My veterinarian recently refused to give me a prescription for
Sentinel, stating that I really didn't need one because I could purchase it
there at the office. I informed her I could get it for 1/2 of the cost
through the internet, but needed the script. I was told that the office
would match the price but I would have to purchase it from the office. Is
this practice legal?Maria-
A: I can not answer the legality of this question for all states. In many
states, though, it is not legal to refuse to write a prescription for a
veterinary patient as long as a valid doctor/patient relationship exists
and pre-conditions for safe use of a medication, such as heartworm testing,
have been done by the veterinarian within a reasonable time.I do understand the frustration of veterinarians in this circumstance,
though. Veterinary clinics are not exactly like physician's offices in
their pricing structures. Because pharmaceuticals have traditionally been
sold at veterinary hospitals the money derived from them offsets the price
of office visits, surgeries and other procedures. Veterinarians can not
change their prices to cover the loss of pharmaceutical income in
isolation, so the profession is slowly coping with the pressure of mail
order and internet pharmacy pricing on pharmaceutical items but at present,
there is still a net loss to veterinary practices. In the long run,
professional veterinary services (things that require the vet) will just
cost more and people will pay less for pharmaceuticals. The overall pricing
for people who take good care of their pets will actually probably increase
slightly (the vet will still have to make about the same salary -- and the
pharmaceutical supplier will want to make a profit). I don't think that
this change can be stopped at this time and therefore I think efforts by my
profession to stop it just make us look bad, but I still think people
should understand what the whole picture is.Mike Richards, DVM
5/3/99
Questions after dog's death - was there medical error
Q: I lost a diabetic cushings dog 4 days after surgery for hind leg parlysis due to disk injury (not known if from natural circumstances or injury). I am looking for info on dopamine loss and adverse reaction drugs. Has anyone done any scientific research on any of the following drugs which were given together(at the same time): Reglan(a dopamine antagonist), Ranitidine(HCL), Sulcralfate, Baytril ,Valium and increased insulin(dog wasn't eating,but there was vomiting and diarrhea after drug medications).After the first drug combination the dog also experienced seizure like activity and later at night what appeared to be a grand mal seizure and was given valium.The following morning all drugs (except Valium) and increased insulin were given again.The dog became comatose and remained so until I arrived and asked for corn syrup (approx.1.00 -1.30 p.m. I brought him around and asked for water .He was extremely thirsty but had difficulty getting it as his mouth was stiff and pointed. I got him sitting up but he was extremely weak and did everything possible to try sitting.He was like he was drunk.His head was flattened on one side from lying on it and the eyes were wide open with an upward stare. He had gone from 8k down to 1.8k over the 4 days.(no food ,but lots of drugs and vomiting and diarrhea.) An hour later he tried to take a few sips of clear soup but was too weak. He took a fit and I asked a student to get the vet because he appeared very still and lifeless.He was dead.
I have read info with regard to Reglan being toxic in an animal pretreated with an MAO inhibitor and have also found a warning on the internet about giving it to small children.There are precautions in drug books also. I always found his blood glucose elevated after Baytril.When the hospital gave him Baytril his glucose went up to 22 and they increased his insulin even though he wasn't eating .They also had changed the type of insulin.He was on a 40 i.u.before admittance and they changed it to a 100 i.u. insulin(which when previously tried on him made him lethargic).They also thought that they were giving him one half of his regular dosage. I do not believe that 3.5 of a 100i.u. insulin is the same as one half of a 40 i.u. insulin which he was receiving at home. They were also jumping from one insulin to another(NPH,Lente and Ultralente) The medical society has informed me that drugs given were within acceptable standards. Due to the severity of his case they had to try to stablize him. It is my felling that they did not treat his cushing's disease and gave him the incorrect insulin. By doing what they did I feel that they gave him drugs that increased the cushing's disease symptoms , increased his ACTH which drove his glucose higher causing increased vomiting, diarrhea and eventual seizure , coma and death. Since there was no food intake I also feel that he was living on his body's toxic fat which also contributed to the enormous weight loss and toxicity . His reports show his tests after drugs on the third . Many of the cushing disease symptoms appear there. I would like to get any info on anything relating to this type of case. I also would not want anyone else to experience this trauma. E.
A: Evelyn- I am sorry to hear of the loss of your dog. I don't think I can answer all of your questions but can help with some of them.
Enrofloxacin (Baytril Rx) will react in some cases with sucralfate but in this instance the sucralfate interferes with absorption of the enrofloxacin and lowers the antibiotic's blood concentration. I have not heard of an interaction between enrofloxacin and blood glucose levels but this does occur with some antibiotics and falsely elevated levels appear in some instances when antibiotics are present in serum being tested for glucose. We have had difficulty with this problem in evaluation of diabetes when using cephalexin in diabetic pets.
Sucralfate is not absorbed well from the digestive tract, so most of its actions occur at the local level in the GI tract. It can decrease the absorption of several medications (including Baytril) so it is usually used several hours before or after administration of these medications.
Metoclopramide (Reglan Rx) is used for its ability to stimulate intestinal activity and to decrease vomiting. The method of action for the decrease in vomiting is probably dopamine antagonism. It may cause extreme hypertension in patients with pheochromocytoma (this is a cancer that is an unusual cause or concurrent problem in some cases of Cushing's disease in dogs) but patients with this problem seem to be prone to sudden death even without drug interference. It is very difficult to tell if pheochromocytoma is present (it is an adrenal gland tumor) without computerized tomography (CT) or magnetic resonance imaging (MRI). Metoclopramide may increase the absorption of diazepam (Valium Rx) from the small intestinal tract but probably not sufficiently to cause toxicity problems. It is also possible that metoclopramide would enhance the sedative effect of diazepam (or vice versa). Despite this, I can not find any warnings in the pharmcological references about using these medications concurrently.
I had a hard time following two parts of your note. It seems almost impossible for him to lose 6kg (13 lbs) of body weight in four days but that was the only interpretation I could make of the change from 8k to 1.8k. Perhaps I am misinterpreting this.
On the insulin dosing, if 0.35cc of U100 insulin was given, that would be 35 units. If 0.5cc of U40 insulin was given, that would be 20 units. If there was this much difference in the dosing then insulin shock does seem like a possible problem but there may be labwork supporting the need for the change or suggesting that it did not have an effect since you didn't mention low blood glucose in the labwork. I don't understand dosing with differing types of insulin except that changing from U40 to U100 of the same type of insulin should have no effect if the dosage is adjusted so the units are the same.
If you continue to believe that there was a medical error the best advice I can give is to contact your state board (I am not good with internet addresses -- I am hoping you live in the U.S.). They have the authority to review these cases and to take action if it seems appropriate. It is also a good idea to take your concerns to your vet and discuss them, if this is a feasible option. Ultimately, everyone gains if the research and discussion leads to a deeper understanding of the situation and it may help prevent problems for someone else or help you to resolve your concerns which would also be a good and important outcome.
Mike Richards, DVM
Vet /client communication problem
Q: First let me say how gratefull I am for you response to my questions. We live in a small town with two clinics and no emergency rooms (the vets swap out being on call after hrs). When our dog was initially diagnosed with "Diabetes Mellitus", I of course not being familiar with the condition did some research(on the internet) and took some printouts to my Vet and asked him some questions in reguards to the home testing and regulation of the insulin, and was promptly told that my research had given me more info than I needed and that I would do better to listen to him rather than dubios material that I moght dig up on the Internet. I of course went to our other clinic, and was a bit taken back when I was told to take my dog back to the other clinic and rest assurred that my Vet would take good care of my dog and they(I assume do not want to make waves) could not interfear with his treatment. In 20 years of taking my animals to this Vet this is the first time I have ever questioned his judgment or proffesionalism, but I am considering taking my pets out of town for treatment, something I don't want to do, but I can think of no other solution. There is one thing I am curious about. In the past I have always had large working dogs (Labs, German Shorthairs and others), and now since I purchased this Yokshire Terrier for my wife I have noticed how many people have a dislike for small dogs(lap dogs). I personally have very rarely met an animal that I didn't like. I can only assume that this is true of some Vets as well, if so how can I be assured when I am looking for a Vet that I am not making the same mistake again.
PS, I am very greatfull for your help, being a small business owner in the computer industry for 14 years I understand that time and knowlege are your (as well as my stock in trade). If you would like to emil a bill for you services I will send you a check. I am sincerley yours, Al
A: Al- It takes more time to talk to clients who are searching for information about the conditions affecting their pets than it does to diagnose and treat a pet with no questions from the owner. It can be frustrating to try to explain the difference between information that is scientifically valid and information that is anecdotal or even blatantly false. I think it is very important to discuss these things with my clients. I really believe that well informed clients take better care of their pets so I try hard to make the time available to answer questions and make the necessary explanations. Once in a while a client accuses me of promoting veterinary medicine for my own self interest when I try to explain why I think that homeopathy is not useful or when I point out that the benefits of chromium for diabetes may be real but that doesn't mean you can stop giving insulin. Over time, it becomes easier to act the way your veterinarian acted. It is a constant struggle not to do that in my practice. So I understand, but can not condone, your vet's stance. Over the years I have learned a great deal about pets, about people and about medicine from my client's questions. I would have missed a lot by not listening and by not being willing to research and defend my choice of therapies. On more than one occasion I have discovered through research that a client had information more current or more accurate than the information in my memory. I used to be embarrassed when this happened but lately I have come to realize that there is no chance I will ever be able to be current on all aspects of veterinary medicine relating to dogs and cats. As long as a client is willing to listen to what I have to say about the information they bring me I am always willing to discuss it with them and research it for them. We both learn from this exchange.
Some clients have injured their pets by pursuing treatments based on bad information in my practice. The worst example of this was a hunter with 24 dogs who read that giving his dogs Atguard (Rx), a deworming medication made specifically for pigs, would cure heartworms. Seen from one perspective, this was true. Administering Atguard to a dog with heartworm disease will almost always kill the dog. The heartworms will die, too, but the cost is high. This man killed 20 out of 24 dogs by following bad advice. If he had felt comfortable asking me for information this may not have occurred. If he was able to discern that the information I had was more valid than the information he possessed I am sure the tragedy could have been avoided. Learning to trust clients to do that takes some effort, too.
I can't tell you if there is a prejudice against small dogs among veterinarians. Mostly I prefer nice dogs! If I have to work on aggressive dogs, I like small dogs better because I tend to think of them as being "safer" patients since we usually have a lot more control of them than big dogs. I can't think of a good way to determine if a vet has bad feelings about small dogs. It make take an office visit or two to determine that.
I work in a rural area. It is important to me to keep relationships with the surrounding veterinary hospitals as good as they can be. If the client seems to need something that they can't get from a surrounding hospital, I have a tendency to work with them. If they are looking for something I can't offer I have a tendency to tell them who can give it to them. If they are getting equal care to that which I can provide, I tend to steer them back to their own veterinarian. If we shared emergency services it would make it particularly difficult to handle situations in which clients wished to change vets. Emergencies are the most emotionally charged visits and often things are said in panic or in anger about other veterinarians. It may very well be necessary to adopt a firm policy of not dealing with criticism of the other veterinary hospital in order to keep the relationship going. So I guess I'd assume that if you want to change the level of care you may have to go out of town. Before you do that, I'd call your vet and ask if you pay for an office visit if he'll discuss the management of the diabetes with you. It may cause him to rethink his previous statement and you may be able to forge a new relationship that is a little better for both of you. If he won't, it makes it easier to accept changing vets.
I am not willing to charge for individual advice given on our site at this time. I want the information to be free and to be useful. It does take a lot of time and I know I have to face the issue of making enough money to support the site, though.
Mike Richards, DVM
Q: Dear Dr. Mike, My wife and I are college students and last year we took in a stray kitty (kitten). We got her initial series of shots but after paying the "start up fee" in addition to the shots, I was appalled at the way the vet handled our animal. I watched him shoot a significant amount of air into her scruff with one of the shots (to the noticable discomfort of our cat). I am reluctant to take her back there and can't afford start up fees (or much treatment really). When she and our other cat had ear mites, I knew they both had ear mites, but the vet made us bring them both in and pay for him to tell us what we already knew and give us ointment I knew we needed. $60 for $10 in medicine.
Now she has small white worms crawling around her anal hair and is scratching and licking her hair off on the area above her tail and neck. Last year she had some trouble in the summer with scabs, but nothing like this, and it isn't even warm yet, and she stays indoors all year. Is there anyway I can treat her at home? I don't want to be cruel and feel terrible, but we are completely broke. Its not like we are eating fast food instead of caring for our animals. Is there any way or place to order animal medicine, or is it just like people medicine. When I was young, our family would give our (numerous) animals their shots. Can that still be done? Sorry for such a long letter. I hope you can help us. Sincerely, T.
A: It would be worth calling your vet and asking if he or she will dispense tapeworm medication (these are the only worms that have the appearance you describe). We will do this as long as the cat is a patient and we have a current weight on record (we would want to reweigh a cat that had grown or any cat in which the owner felt there were weight changes). If your vet will not do this then you are in a bind since any veterinarian will need to establish a doctor/client/patient relationship prior to dispensing a prescription medication, by law. The only safe and effective tapeworm medications are praziquantal (Droncit Rx) and epsiprantal (Cestex Rx) and both are available only by prescription.
It is possible to purchase and give vaccinations yourself. The major problem with doing this is that you will skip the physical exam that veterinarians do in conjunction with the vaccination. This is the most important part of the visit. In fact, if I had to choose between the two, I'd pay for the exam and skip the vaccinations, personally.
There is a wide range of pricing and often big philosophical differences among veterinarians when it comes to when to dispense medications without a visit and when to insist on an exam. You may be better satisfied by finding a veterinarian whose practice philosophy more closely matches your expectations, both in price and in handling of your pets.
Mike Richards, DVM
Last edited 02/15/08
