Cascade self-destructing?

RE: Cascade self-destructing?

Iain Richards — Wed, 11 Dec 2019 16:19:17 GMT

[quote user="bob lehner"]? Set a withdrawal period[/quote]

Correct. I wondered who'd be the first to spot that. One has to justify the withdrawal too. So although the nominal withdrawl for lignocaine is 7 dyas milk it's recognised to be better with 15 days.

RE: Cascade self-destructing?

bob lehner — Wed, 11 Dec 2019 16:17:23 GMT

[quote user="vetbl.locum"]and I can't remember last one [/quote]

? Set a withdrawal period.

RE: Cascade self-destructing?

Iain Richards — Wed, 11 Dec 2019 16:14:37 GMT

For food producing animals it must be in 37/2010. Any other reason is for you, as the vet, to justify. For SA, just the latter.

There will only be a probelm if there is a problem (failed residue, mendacious client) and that's when you will have to justify your choice

RE: Cascade self-destructing?

vetbl.locum — Wed, 11 Dec 2019 15:10:07 GMT

Went on short course about cascade in large animals

To use drugs off label, 4 criteria had to be met : On allowable medicine list

Clinically justified

Vet Record Usage

and I can't remember last one

Is this the same for small animals?

Rgds

RE: Cascade self-destructing?

Bob Russell — Wed, 11 Dec 2019 11:40:26 GMT

Unless things have been updated the BSAVA formulary states that Pardale V cannot be recommended as a source of codeine for general usage.

I assume this would be its use as an antitussive where the dose would involve a very high dose of paracetamol.

I would use 15mg Codeine tablets for this purpose to avoid the need to give paracetamol at all.

RE: Cascade self-destructing?

Richard Carter — Wed, 11 Dec 2019 09:32:06 GMT

the BSAVA formulary states quite clearly the codeine aspect of Pardale is not effective for pain relief.

RE: Cascade self-destructing?

Alistair Graham-Evans — Wed, 11 Dec 2019 00:02:14 GMT

[quote user="Sarah Keir"] I sometimes wonder if the VMD or PSS inspections are worth the paper they are written on![/quote]

It is apparent, whether in a small profession like ours, or the NHS with its vast bureaucracy, that deficiencies in standards often only come to light in the event of publicised tragic and embarrassing failures. I think the only reliable inspection of standards is a randomised inspection system with no prior warning. If a clinic is satisfied with how it operates it should have nothing to fear from this provided the inspectors have common sense, are not draconian in approach and allow time for correction of shortfalls in a reasonable time frame.

RE: Cascade self-destructing?

Iain Richards — Tue, 10 Dec 2019 14:45:34 GMT

[quote user="Bob Russell"]The studies do not suggest it is the best opiate by any measure.[/quote]

It's one rung down from tramadol. Any effect is chance, cyclical disease, care-giver placebo

RE: Cascade self-destructing?

Bob Russell — Tue, 10 Dec 2019 14:35:08 GMT

The studies do not suggest it is the best opiate by any measure. What they don't show is no effect.

Some of my patients are getting straight paracetamol but others are getting supplemented with codeine tablets Owners feel it is needed but we all know how reliable owners can be.

I was under the impression that significant changes were to be made to the Pardale data sheets but then it disappeared from the shelf.

RE: Cascade self-destructing?

Iain Richards — Tue, 10 Dec 2019 13:52:53 GMT

[quote user="Bob Russell"]Plenty of studies out there that show it does albeit perhaps not the best opiate in the world. Cleared rapidly from the system but approx 1/10th the analgesic effect of morphine but just as good as an antitussive[/quote]

I've done a quick Scholar and pub med search, rapid clearance, poor oral bioavailabilty, poor metabolism to active. Some trials showing some effect if injected, none orally.

RE: Cascade self-destructing?

Robert FalconerTaylor — Tue, 10 Dec 2019 13:24:40 GMT

[quote user="Bob Russell"]

Not sure where the 'codeine does not work well in dogs' comes from.

[/quote]

These are my notes from bsava conf. 2016, Karen Walsh lecture "Which opioid for your practice"

CODEINE

Pardale-V

Not a good opioid. Poor oral bioavailability <5%

Low bio-transformation rates to morphine.

In humans a certain percent that codeine has minimal analgesic effect - some get very sleepy, others no effect at all. This is due to an inability to metabolise to morphine. Probably the same in dogs. Little evidence of efficacy.

Not ref'd

But mainly high first pass effect I think, which is the case for all oral opioids in dogs.

RE: Cascade self-destructing?

Bob Russell — Tue, 10 Dec 2019 10:22:58 GMT

Not sure where the 'codeine does not work well in dogs' comes from.

Plenty of studies out there that show it does albeit perhaps not the best opiate in the world. Cleared rapidly from the system but approx 1/10th the analgesic effect of morphine but just as good as an antitussive.

RE: Cascade self-destructing?

Sarah Keir — Tue, 10 Dec 2019 09:41:57 GMT

[quote user="Lucy Fleming"]

It doesn't change our (current) legal obligations. We can campaign or lobby against the regulations but we can't simply ignore them.

[/quote]

I agree. However, having worked and visited a number of clinics over the past couple of years, there is a huge variation in 'interpretation' of the regulations, all the way from minor digressions to full on illegal practices. I sometimes wonder if the VMD or PSS inspections are worth the paper they are written on! I even had one practice that I phoned about a possible job, boasting on the phone that they don't believe in discard dates/times and don't throw any medication away!

RE: Cascade self-destructing?

Lucy Fleming — Mon, 09 Dec 2019 17:55:02 GMT

[quote user="Anthony Todd"]Sorry to labour the point but you miss out the crux; the unnecessarily inflated price for exactly the same drug via the POMV regs.[/quote]

I don't think Gillian is missing the crux of the matter, I'm sure she's perfectly aware of it. It doesn't change our (current) legal obligations. We can campaign or lobby against the regulations but we can't simply ignore them.

RE: Cascade self-destructing?

Michael Woodhouse — Mon, 09 Dec 2019 12:17:12 GMT

[quote user="Iain Richards"]

Codeine doesn't work in dogs, so it will be the higher dose (or just Yorkshire dogs)

[/quote]

Give me some credit, Iain, these dogs were on the same dose of paracetamol, I didn't give 1/3 of the dose and wonder why it wasn't working. We are using human co-codamol (8/500) at 1 per 15kg, scales the paracetamol dose with a slightly lower codeine dose.

All sounds a bit like tramadol, people say it doesn't work (and I use very little now I admit) but some dogs were better on it than off it. I understand evidence based medicine and lets not forget that the patient experience of the treatment is one of the considerations.

RE: Cascade self-destructing?

Iain Richards — Mon, 09 Dec 2019 11:33:43 GMT

Codeine doesn't work in dogs, so it will be the higher dose (or just Yorkshire dogs)

RE: Cascade self-destructing?

Robert FalconerTaylor — Mon, 09 Dec 2019 09:38:12 GMT

[quote user="Michael Woodhouse"]

Love Pardale V. The 33mg/kg dose vastly more effective than the BSAVA 10mg/kg. Never seen an adverse effect and I've had dogs on the big dose for years. Tried straight paracetamol when couldn't get Pardale but quickly moved to co-codamol as it clinically seems better even when people tell me codeine isn't supposed to do much in dogs.............

[/quote]

[quote user="Joyce Whitehead"]

I agree with Michael, we also had quite a lot of dogs on long term Pardale (off licence of course) who were nothing like as good on paracetomol alone. And no adverse effects seen here either.

[/quote]

That's interesting - higher dose of PC, addition of CD, or both? Perhaps user="Jo Murrell" could comment?

RE: Cascade self-destructing?

Joyce Whitehead — Mon, 09 Dec 2019 08:57:33 GMT

I agree with Michael, we also had quite a lot of dogs on long term Pardale (off licence of course) who were nothing like as good on paracetomol alone. And no adverse effects seen here either.

RE: Cascade self-destructing?

Michael Woodhouse — Sun, 08 Dec 2019 23:56:07 GMT

[quote user="bob lehner"]

Pardale surely we can happily live without?

The paracetamol dose is far higher then the BSAVA Formulary recommends and the codeine dose is too low to be therapeutic unless you increase the dose rate such that the paracetamol component would then become toxic. Data sheet limits Pardale to five days use.

[/quote]

RE: Cascade self-destructing?

Iain Richards — Sun, 08 Dec 2019 18:52:46 GMT

[quote user="Anthony Todd"]

I'm not sure the clients forced to buy common generics at massive over-prices via the cascade would agree.

Not to mention morality, truth and common-sense!

[/quote]

Plenty of generic human ampicillin were sold at very nice margins that were not passed on to the poor deserving public.

RE: Cascade self-destructing?

Gillian Mostyn — Sun, 08 Dec 2019 18:52:42 GMT

Anthony .genuinely.. How would you sort it out? We need to achieve 2 aims:

-that all vets only use drugs that are tested and are proven efficacious and of reasonable safety in animals. This prevents vets from using 'untried and untested' products simply because they think they work. No 'blue tonic' or home made mixtures.

- that vets are able to use their own judgement to decide what drugs are OK to use that aren't licensed for use in animals.

It is actually quite difficult to find a solution that fits. Afterall, if you allow some human generic equivalents, where do you draw the line? What if the tablet sizes are massively different so dosing is subject to significant error? What if the generic has undesirable additional ingredients?

I don't think you'd find many vets who wouldn't prefer to lower the drugs bill to their clients. However, the cascade is there for a reason. If you genuinely care about the risk to animal welfare caused by this legislation, then get involved in veterinary politics and in getting better systems in place.

RE: Cascade self-destructing?

Anthony Todd — Sun, 08 Dec 2019 15:23:10 GMT

[quote user="Robert FalconerTaylor"]

Also this quote form VMD -

“The Cascade provides a legal mechanism
allowing veterinary surgeons to use their clinical
judgement to prescribe a suitable medicine
where no authorised medicine exists”
• “Use and prescription by vets of human generic
medicines where a suitable veterinary product is
available is a criminal offence and contrary to the
RCVS Guide to Professional Conduct”
Steve Dean Chief Executive, VMD

[/quote]

Oh sure, and our profession, in total, just meekly swallowed it without a murmur, let alone any query regarding justification, cost differential, or even just plain old common-sense.

RE: Cascade self-destructing?

Robert FalconerTaylor — Sun, 08 Dec 2019 15:08:44 GMT

Also this quote form VMD -

RE: Cascade self-destructing?

Anthony Todd — Sun, 08 Dec 2019 14:40:38 GMT

[quote user="Gillian Mostyn"]It is not a vet's problem if the client has difficulty sourcing their drug easily. They could always buy it from the practice! [/quote]

Sorry to labour the point but you miss out the crux; the unnecessarily inflated price for exactly the same drug via the POMV regs.

Sometimes the printed word may be different from some understandings or interpretation.

Found them: and, if you think unnecessary euthanasia is "suffering" then:

What do vets need to do to comply with the cascade?

If there is no medicine authorised in the UK for a specific condition, the veterinary surgeon responsible for treating the animal(s) may, in order to mitigate unacceptable suffering, treat the animal(s) in accordance with the following sequence:

1a veterinary medicine authorised in the UK for use in another animal species or for a different condition in the same species; or, if there is no such product that is suitable;

2either;

aa medicine authorised in the UK for human use, or........

which, conveniently doesn't mention comparative cost or copy-cat drugs.....!!

RE: Cascade self-destructing?

Gillian Mostyn — Sun, 08 Dec 2019 13:46:14 GMT

[quote user="Anthony Todd"]The prescribing vet probably has the wit to realise that most chemists don't stock POMVs so would just write "pred 5mg", realising that, actually, all "pred 5mg" is the same.....[/quote]

What you write on the prescription is the bit that is regulated ... Not the actual dispensing. Therefore, if I wrote 'prednisolone 5mg' knowing full well that prednicare or prednidale 5mg are freely available, then I would be the one who is breaking the rules ... Not the pharmacist who does the dispensing.

I had this issue recently when I refused to give out a written prescription for tramadol. The owner had found that generic tramadol was cheaper than vet licensed tralieve, so requested that was written on the prescription. I refused on the basis that we have to use tralieve. And, as has been said a few times, the pharmacist is not allowed to substitute generic tramadol instead of tralieve.

[quote user="Anthony Todd"]If the prescribing vet does write a POMV then the client will be on the phone, having trailed all over town, and common-sensibly, be not very happy![/quote]

It is not a vet's problem if the client has difficulty sourcing their drug easily. They could always buy it from the practice!