Prescription Interval Question

Re: Prescription Interval Question

Martin Atkinson — Fri, 21 Jun 2013 12:32:00 GMT

[quote user="Bob Russell"]

If weight changes, appetite varies, owner becomes worried. In reality most get tested every six months but the real ratbags don't!

[/quote] I may stretch to 6 months for a rat-bag but then it would need to be sedated, you can't have radically different level of care for difficult patients a huge amount can change in that time: renal function, blood pressure etc etc need I elaborate?

Re: Prescription Interval Question

Anthony Dennison — Fri, 21 Jun 2013 11:59:14 GMT

What Martin said.

Clients, with the best will in the world, aren't trained to a level that we as vets are to spot subtle changes. An increase of just 10 units can push T4 from normal to the grey zone, with possible hypertension/end organ damage as a result (yes I know I'm being a bit dramatic but I'm trying to make a point)

Re: Prescription Interval Question

Martin Atkinson — Fri, 21 Jun 2013 10:05:10 GMT

[quote user="Clive Ansell"]How often do folk normal measure T4 in treated hyperthyroid cats? how often is necessary?[/quote] I measure every 3 months and frequently find T4 levels have change sufficiently to warrant a change of dose. This would not have been picked up without the routine test and we know we can't rely on clients to observe subtle changes in their pets that would signal a problem before it becomes major. And yes I would refuse to give further medication if a client persistently refused to come in for a check, maybe not pedantically on 3 months but eventually, there are circumstances where continuing at the wrong dose is worse than withdrawing medication altogether. It seems some people have a fundamental misunderstanding of regulations on this matter: there is no rule that stipulates a time limit but animals are supposed to remain 'under our care', there is a general consensus that means no more than 3 months. It is obviously open to interpretation and a dose of common sense but the RCVS DC may not look too kindly on someone who had been dishing out meds. for a year without seeing an animal and it went belly up. I have a client who when told his pet had to come back every three months for a check thanked me saying how this contrasted with his mother's doctor who just dished out the pills when requested for a repeat for 18 months and the old dear died as a consequence of no-one spotting a change in her condition!!

Re: Prescription Interval Question

Bob Russell — Fri, 21 Jun 2013 09:45:05 GMT

If weight changes, appetite varies, owner becomes worried. In reality most get tested every six months but the real ratbags don't!

Re: Prescription Interval Question

Clive Ansell — Fri, 21 Jun 2013 08:48:20 GMT

How often do folk normal measure T4 in treated hyperthyroid cats? how often is necessary?

I have client in one of my regular practices that point blank refuses any further testing. The cat is seen once a year for its annual check and vaccine, and after 6 months as a nurse appointment to measure weight and heart rate, and the cat is fine and been clinically stable on 5mg Felimazole for years. I recently insisted on a T4 level as part of a pre GA screen for dental work and it was mid normal range.

one of the charity clinics I used to work in don't retest at all after an initial diagnosis, just monitor using clinical signs, weight and heart rate.

Re: Prescription Interval Question

Bob Russell — Fri, 21 Jun 2013 08:27:08 GMT

I try to use common sense. A hyperthyroid cat that is happy, putting on weight, drinking as normal with a relaxed owner will get significantly less monitoring than one with a dodgy appetite, variable appetite, vomits on occasions and has a worried owner.

We have some of the 'worst' monitored chronic endocrine cases around. I am not proud of it but as long as patient and owner are happy then I will not burden them with intervention. We only supply a months medication at a time and expect a verbal update. The owners are informed about the options!

Re: Prescription Interval Question

Anthony Todd — Thu, 20 Jun 2013 15:20:53 GMT

[quote user="John Flynn"]Either there has been a failure to communicate that a blood sample (in addition to weighing the cat...) while under treatment to monitor T4 levels and adjust drug-dose accordingly is advisable (vet's "fault", unless they disagree clinically), or the owner has had the options properly explained to them and decided against this in which case that is surely their call to make whether I (as the vet) agree with it or not?[/quote]

This illustrates my point well. Here is a cat which, on even a casual question, needs seeing and dose modification and my point, which judging by the red star hasn't been understood, is that it doesn't need an exam to ascertain if the animal is OK neither does the interview of the owner need to be at a set interval.

I have to repeat that it depends on the case, [not on a "rule of the practice" ]and the animal's condition but you must always interview the owner, at least; and an exam if in doubt.

Re: Prescription Interval Question

John Flynn — Thu, 20 Jun 2013 15:13:30 GMT

[quote user="Anthony Dennison"]

Got one that my receptionist is currently on the phone to now. Hyperthyroid cat, looking back at the system repeat medication checks every 3 months have said should have bloods next time. Look further back - last blood sample was 3 years ago (almost to the day), when it was first diagnosed. Cat is showing hyperthyroid signs (weight loss, tachycardia etc) for the past 6 months.

Who is at fault here? The vet for not taking a stand and refusing to dispense more medications until a blood test is taken, or the owner for refusing veterinary advice?

[/quote]

I'm lost.

This may be a cultural thing.

Why would refusing to allow the owner to continue hyperthyroid treatment in a cat with known hyperthyroidism ever be a good thing to do???

What use would a blood test on a known hyperthyroid cat that you had stopped from having further treatment be???

Either there has been a failure to communicate that a blood sample (in addition to weighing the cat...) while under treatment to monitor T4 levels and adjust drug-dose accordingly is advisable (vet's "fault", unless they disagree clinically), or the owner has had the options properly explained to them and decided against this in which case that is surely their call to make whether I (as the vet) agree with it or not?

Re: Prescription Interval Question

Clive Ansell — Thu, 20 Jun 2013 15:12:50 GMT

The owner.

If blood test were repeatedly advised and not carried out then you are in the clear.

What is the point of 3 monthly checks if the advised blood test are not carried out and the medication is dispensed anyway, may as well not do the checks??

Re: Prescription Interval Question

Anthony Dennison — Thu, 20 Jun 2013 15:00:43 GMT

Fair point.

Who is at fault here? The vet for not taking a stand and refusing to dispense more medications until a blood test is taken, or the owner for refusing veterinary advice?

Edit: He's just booked in for a blood sample on Monday...

Re: Prescription Interval Question

Clive Ansell — Thu, 20 Jun 2013 14:41:48 GMT

[quote user="Anthony Dennison"]

[quote user="Clive Ansell"]

Fair point.

If the condition was diagnosed long ago and the dog has been stable for months to years. In a newly diagnosed case I would agree with a 3 month check, but once stable it seem over the top.

[/quote]

POM-Vs are dispensed to animals under our care. Our practice policy is 3 monthly checks, unless authorised for longer periods of time by the Clinical Lead Vet. I wouldn't want to leave any animal with endocrine disease too long, hormones are good at messing the animal around.

[/quote]

playing devil's advocate here, but you could use your clinical acumen, ignore protocol and make a decision to recheck at 6 months if you wanted too. As the professional, the MRCVS, it is your call entirely.

In the latest RCVS DC case thread, a colleague has been slated and was possibly struck off for following protocol, maybe we should start to question them all the more?? discuss.

Re: Prescription Interval Question

Anthony Dennison — Thu, 20 Jun 2013 14:28:21 GMT

[quote user="Clive Ansell"]

Fair point.

If the condition was diagnosed long ago and the dog has been stable for months to years. In a newly diagnosed case I would agree with a 3 month check, but once stable it seem over the top.

[/quote]

Re: Prescription Interval Question

John Flynn — Thu, 20 Jun 2013 14:26:17 GMT

[quote user="Hannah Wynne Richards"]

Are thyroid hormones POM(V) in Ireland? If you never reassess unless asked to by the owner,you could be on dodgy grounds legally in UK

Wynne

[/quote]

I have worked in UK in the past and perhaps legislation has changed since I did - out of interest, what is the specific legislation and how have you come to interpret that as seeing a stable thyroid dog every 3 months? Would you actually withhold its thyroid supplement if the owner didn't want to bring it to see you every 3 months? Unless you do this free-of-charge as a crazy legal tick-box-exercise, it would drive up the cost of treating hypothyroidism in dogs for little to no gain in my opinion.

Situation in Ireland is based on same EU directives I would have thought, but without UK-style gold-plating.

Aims are to prevent medicines residues in food-producing animals (irrelevant to thyroid supplement in dogs) and to prevent abuse of medicines.

I would not hand out thyroid supplement that could then be sold on the internet or taken by the owner or similar, but there would have to be something pretty suspicious to make me insist on seeing the dog was still alive every 3 months and looked as if it had been taking the medicine itself!

Re: Prescription Interval Question

Anthony Todd — Thu, 20 Jun 2013 14:25:34 GMT

sorry, duplicated so deleted

Re: Prescription Interval Question

Anthony Todd — Thu, 20 Jun 2013 14:24:26 GMT

[quote user="Clive Ansell"]I would be happy with a 6 monthly check for a previously stable and otherwise well hypothyroid dog[/quote]

This has been a recurring query in my practice and some vets even insist "it's the law".

It's purely up to the vet so that if the circumstances and the owner's input make one decide that it was fine to continue dispensing then I did for indefinite periods. There is no set period it's down to veterinary common sense which does involve the vet taking responsibility for the decision and the prescription.

eg Hypothyroid geriatric cat ,stable on dose, can't be handled at the surgery, [ripped the last vet to pieces] vet insisted on visit, cat couldn't be handled and "hid under the bed for three days" so yes, I continued the script with intelligent input and observation from the owner.

The certain feeling by most clients is that , often, it's a device to generate income.

Mind you I did demur when the dose was "as directed" or "as before" and when the dog was "still fitting"!!

Re: Prescription Interval Question

Hannah Wynne Richards — Thu, 20 Jun 2013 14:09:38 GMT

Are thyroid hormones POM(V) in Ireland? If you never reassess unless asked to by the owner,you could be on dodgy grounds legally in UK

Wynne

Re: Prescription Interval Question

Clive Ansell — Thu, 20 Jun 2013 14:07:44 GMT

But a patient could deteriorate at any time, so weekly or even daily check ups could be advised and the same argument for them put forward.

I would be happy with a 6 monthly check for a previously stable and otherwise well hypothyroid dog

Re: Prescription Interval Question

John Flynn — Thu, 20 Jun 2013 14:05:33 GMT

[quote user="Hannah Wynne Richards"]

How do you know it's stable without reassessing? Serious question-as after 33 years of experience, I can't work out how to assess it remotely.

Wynne

[/quote]

In general you can ask the owner who sees the dog day-to-day and is usually much more atuned to any mild lethargy etc that may be the result of underdosing.

Assuming the dog was diagnosed properly in the first place and is well stabilised, I can see little advantage to re-examining it every 3, 6 or 12 months unless the owner notes a change in demeanour etc.

Re: Prescription Interval Question

Hannah Wynne Richards — Thu, 20 Jun 2013 14:01:32 GMT

Cross ref with DC case Agreed partly defensive medicine,but if 3 monthly check up offered ansd refused by owner,then if animal deteriorates, and owners refusal is documented then the veterinary surgeon is in the clear. If check ups not offered, then maybe DC hearing

Wynne

Re: Prescription Interval Question

Clive Ansell — Thu, 20 Jun 2013 13:55:38 GMT

Fair point.

If the condition was diagnosed long ago and the dog has been stable for months to years. In a newly diagnosed case I would agree with a 3 month check, but once stable it seem over the top.

Re: Prescription Interval Question

Hannah Wynne Richards — Thu, 20 Jun 2013 13:52:51 GMT

How do you know it's stable without reassessing? Serious question-as after 33 years of experience, I can't work out how to assess it remotely.

Wynne

Re: Prescription Interval Question

Clive Ansell — Thu, 20 Jun 2013 13:49:30 GMT

Why does a dog with hypothyroidism that is stable on medication need assessing every 3 months? every 6 or even 12 would be fine maybe?

My elderly mother is on an ACEi for hypertension and an occasional use corticosteroid inhaler for asthma. She has annual reviews with a doctor that are strictly enforced.

Re: Prescription Interval Question

Anthony Dennison — Thu, 20 Jun 2013 13:42:27 GMT

I had a client kick off once that his hypothyroid dog had to have 3 monthly prescription checks. His wife is apparently also on thyroxine supplementation, has been for 17 years and hasn't once had to go back to see her GP.

I bit my tongue to stop a retort about GPs and the NHS