VETgirl April 2024 Beat e-Magazine

QUARTERLY BEAT / APRIL 2024

THE CHILL PROTOCOL (see resources, p13).

NON-INJECTABLE DRUG ADMINISTRATION AT THE TIME OF APPOINTMENT DOGS: Transmucosal detomidine gel (Dormosedan Gel®, detomidine hydrochloride, 7.6 mg/mL, Zoetis, US): Published studies report that doses between 0.35 and 2.0 mg/m2 result in good sedation, with an onset time of less than 15 minutes. In these studies, the gel was placed in the buccal pouch but clearly for aggressive dogs alternatives must be used. These may include mixing it with peanut butter, whipped cheese, or thick syrup and placing it on a plastic plate or smearing it on a favorite toy for the dog to lick. A dose of 1.0 mg/m2 produced lateral recumbency in approximately 40 minutes. 11,12 If needed, the effects can be reversed with atipamezole (0.1 mg/kg IM). 13 In a study of 8 cats, transmucosal detomidine gel produced moderate sedation but all subjects vomited. 14 CATS: Transmucosal tiletamine/zolazepam (100 mg/mL): Following buccal administration of 0.1 mL/kg, cats were laterally recumbent (but some could raise their head), did not respond to clippers being turned on, and did not resist physical restraint within 15 minutes. 15 With cats that cannot be approached, I have been successful spraying the tiletamine/zolazepam orally into the mouth through the cage or carrier, or offering it mixed with gravy or maple syrup. Compared to oral ketamine, there is less salivation, but it may still occur. INJECTABLE DRUG COMBINATIONS Many injectable protocols will result in deep sedation or anesthesia. In dogs, combinations of ketamine, alpha2-adrenergic drugs (dexmedetomidine, medetomidine), acepromazine, and an opioid are often used. If you have a total intramuscular anesthetic technique you use to anesthetize cats for surgery (e.g., some version of “kitty magic”), use this.

ORAL DRUGS

This protocol combines gabapentin, melatonin, and acepromazine and is recommended to facilitate interactions with aggressive and fearful dogs in a clinical setting. It is a three- step process. All three drugs can be administered by the owner, but this protocol requires planning as the shortest lead time needed for it to work is 2 hours (if the first dose of gabapentin is omitted). The protocol also works in cats.

DOGS: Individual drugs are listed below; however use of a single drug is rarely sufficient in many fearful and aggressive dogs and it cannot be emphasized enough that responses are highly variable.

T razodone : Individual variation in response to administration of trazodone is common and not surprising based on a pharmacokinetic study in which time to peak plasma concentration and oral bioavailability were highly variable. 4 Suggested doses range from 3 -18 mg/kg; however, some dogs will be sedate on doses at the lower end of the range, and some will appear unaffected. Doing a “test dose” before the scheduled visit is suggested to assess the individual dog’s response. G abapentin : Gabapentin can also be used in dogs with a wide range of recommended doses (10-80 mg/kg) the evening before the appointment and 1 to 2 hours prior to the appointment. This drug has anxiolytic properties and can “slow” some dogs down. Because the drug is renally excreted gabapentin may have more profound and prolonged effects in dogs with renal disease. A lprazolam : Alprazolam is often used as an adjunctive drug in anxious and / or aggressive dogs and those that show panic reactions to specific triggering events. Alprazolam should be administered 30-60 minutes before a known

triggering event (e.g. the presence of a stranger). Its use in aggressive dogs is controversial because there may be paradoxical reactions, including worsening of anxiety and aggression. Because it is not possible to predict the response, evaluating a dose ahead of the appointment would be ideal. Suggested doses range from 0.02 – 0.1 mg/kg. A cepromazine : Acepromazine is a sedative / tranquillizer (it is not an anxiolytic) and is available in liquid (injectable), tablet, and gel formulations. It should not be used as a sole drug in fearful dogs as they can be aroused and paradoxical reactions can occur. Tablets can be used but the onset time is variable with suggested doses ranging from 0.5 to 4 mg/kg. If the liquid formulation can be given transmucosally (on the gums, or into the buccal pouch, or with peanut butter or whipped cheese that is licked from a plate) onset time is usually more predictable, noticeable sedation usually occurs within 20-30 minutes, and lower doses are often sufficient (0.02-0.05 mg/kg). C ombinations of drugs : Alprazolam and acepromazine can be combined as can gabapentin and acepromazine (this latter combination is part of the “Chill protocol,” discussed next, and in resources, p. 13).

ORAL DRUGS

CATS: G abapentin : Gabapentin has a suitable pharmacokinetic profile for oral administration, with a reported mean systemic availability of 90 to 95%. 6 It is frequently used to decrease stress and anxiety in cats caused by transport and veterinary visits. Gabapentin was shown to reduce fear responses in community cats (i.e., unsocialized or feral cats). 7 The time to maximum plasma concentration and peak clinical effect is between 1 and 2 hours. Doses are usually given as “mg per cat;” most often 100 mg, 150 mg, or up to 200 mg in large cats. In published studies the effective dose on a mg/kg basis range from 10 to 30 mg/kg. Oral gabapentin often results in a very sedated or “sleepy” cat, but do not let your guard down as they are still arousable. Because the drug is predominantly renally excreted, dose adjustment is required for cats with chronic kidney disease. 8 P regabalin : Pregabalin was recently approved by the FDA for “the alleviation of acute anxiety and fear associated with transportation and veterinary visits in cats.” It is an oral solution with the trade name Bonqat® (Zoetis, US). Bonqat is administered orally as a single dose of 5 mg/kg (0.1mL/kg) approximately 1.5 hours before the start of a journey or veterinary visit.

TRANSMUCOSAL DRUGS

T razodone : This drug has variable effects in cats, but 50-100 mg/ cat is suggested. 9,10

Transmucosal dexmedetomidine gel (Sileo® dexmedetomidine oromucosal gel, 0.1 mg/mL, Zoetis): At the label dose, Sileo® alleviated fear and anxiety during veterinary visits; the ability to perform a physical examination or short minor procedure was 41% in treated dogs compared to 4% in the placebo group. 5

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