This article can help in the following CPD competencies: G1c, G1h, G1l, C2a. A list is available at www.uptodate.org.uk/home/PlanRecord.shtml
* To be aware of the most common parasitic infections in cats
* To be able to advise on prophylaxis
* To know what remedies are toxic to cats
* To be aware of your legal position when selling animal medicines
* To be aware of legal changes happening next week
THE COLLEGE OF PHARMACY PRACTICE
This course (module 1353), in association with multiple choice questions being published in C&D November 5, provides one hour’s continuing education
Michael Jepson considers community pharmacists’ important role in parasite control for cats and some imminent legal changes
Community pharmacists should not underrate the range of their specialist knowledge of medicines and its application. In the high street, this expertise is extensively applied to human medication but there is a need to be pro-active when it comes to animal medication. This can be helped by reference to key sources such as the Veterinary Pharmacy textbook and The Veterinary Formulary.1,2
For example, most pharmacists would know that aspirin is toxic to cats but are probably less aware that cod liver oil can also be toxic. As cod liver oil is usually considered a dietary supplement, it is not referred to in the British National Formulary, the Medicines, Ethics and Practice guide, or even the comprehensive Veterinary Formulary.3 This is just a reminder that all animal species have their own distinct metabolic systems, which will often differ markedly from those of humans.
The close association of companion animals with their owners makes hygiene and parasite control all the more important. Zoonotic diseases can be serious and risks must be minimised, as described in the first article in this series (C&D, August 13, p17-19).
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Healthcare of cats has many similarities to that for dogs (C&D, September 24, p23-28). Internal parasitic worms are endemic in free- ranging animals and good animal husbandry means that regular worming programmes are followed. Cats, like dogs, are mainly infected by two types of worms: nematodes (roundworms) and cestodes (tapeworms).
Toxocara cati has a similar life cycle to that of T canis in dogs, but there is no prenatal transplacental infection of the unborn. However, infection from the milk of lactating queens (female cat) does occur and is of correspondingly greater significance. Infection may also be acquired by ingesting eggs. After eggs have hatched to form larvae, they migrate through the liver and lungs before being coughed up and swallowed. They then develop into egg laying adults.
Consequently kittens need worming in a slightly different way from pups, and a pharmacist’s understanding of such differences can reassure pet owners when explaining dosage regimens. Clinical effects are not evident unless there is a particularly heavy worm burden and, contrary to popular belief, a cat or a dog can have worms without showing symptoms. Worms are not normally visible in faeces as it is the egg stage of the parasite’s life cycle that is passed. The exception is that segments of tapeworm may be visible without magnification.
Dipylidium caninum is the most common tapeworm affecting both cats and dogs, and the life cycle includes the flea as intermediate host, so effective flea control is crucial.
The tapeworm life cycle involves gravid (pregnant segments) which are passed out of the anus and subsequently shed their eggs.
The flea becomes infected after ingesting the larvae. The adult flea nurturing the larvae is then eaten by a cat (or dog), which becomes infected by the worm. The flea life cycle is the time controlling factor, which means that re-infection can occur in as little as three weeks.
The more effective products that are authorised (licensed) to treat roundworms and tapeworms are currently classified as PML (see below) and may be supplied to pet owners mainly from pharmacies and veterinary practices.
It is important to guide pet owners through the product information leaflet, especially regarding weight related dosage and frequency. Cats can be conveniently weighed by difference in a cat box on bathroom scales.
For kittens, routine worming should be carried out at four to six weeks of age, followed by regular doses every three weeks up to four months. Subsequent worming should be two to four times a year in accord with the product information.
The life cycle and signs of infestation of fleas were detailed in the previous article on dogs. It has been estimated that nearly half the cat population in the UK contracts fleas each year. Furthermore, although there are distinct species of flea, neither cat nor dog fleas are particularly species specific. They are not averse to biting humans to feed on blood and leave irritating red papules at the site of the bite.
The less extensive problems associated with mites mentioned in the dogs article are also applicable to cats. Many ectoparasiticide products are also effective against mites, which is important as they have a zoonotic potential and can cause scabies in humans. The wide range of authorised veterinary medicinal products for dealing with fleas includes pour-on and spot-on preparations, sprays, tablets, powders, shampoos and flea collars. Some of the more effective spot-on products are currently classified POM, but this restriction may change.
Pour-on and spot-on preparations (GSL) containing permethrin must not be applied to cats, as the agent is extremely toxic for them. Product information must be carefully followed. Most flea collars are classed GSL and several contain the effective organophosphorus dimpylate (diazinon). Care must be taken to ensure that children do not play with the collars and that other animals are not able to chew the collars.
* The cat flea is the most common flea in the UK, affecting both cats and dogs.
* Fleas on pets have mostly bred in the pet’s home.
* As fleas prefer warmth, they breed rapidly in the summer, but central heating ensures a year round problem.
* Fleas are the most common cause of skin disease in cats and dogs.
* Sensitisation to flea bites is an important cause of eczema.
* As fleas are tapeworm vectors, infection can result from swallowing a flea during grooming.
* Successful treatment requires the breaking of the flea life cycle and so it is not enough to kill only adult fleas on pets.
This an infection caused by the protozoa Toxoplasma gondii, which can affect all domestic animals, birds and humans. The cat is the definitive host where oocysts are produced.
It is rare for clinical signs to be seen in cats, but intermediate hosts can have severe clinical signs.
Humans and others are usually infected from cat faeces. While infection in humans is common, clinical signs may only develop in pregnancy, in children or in cases of immunodeficiency.
Cats respond to treatment with clindamycin for a minimum of two weeks, but this is an example of the prescribing cascade (see later under Legal and ethical issues) to use the drug of choice, as clindamycin is not authorised for this indication in the UK. Risk of toxoplasmosis infection from cats is aggravated by their habit of burying faeces in locations such as children’s sand pits.
Hence good hygienic practice is important; pregnant women should wear gloves when handling cats and avoid contact with cat faeces.
The wide risk of infection to other species was highlighted in the Veterinary Record journal, in a report of two kangaroo fatalities in a UK zoo from toxoplasmosis that had apparently been transmitted by feral cats.
It was stated that the high susceptibility of marsupials to toxoplasmosis might be a consequence of their evolution in isolation from cats.4 In contrast, although a marked proportion of the UK human population tests positive to toxoplasmosis (up to 40 per cent in some studies), there have been few cases where eyesight has been adversely affected.
Other possible areas for pharmacist awareness include vaccines, which unlike those for many prophylactic needs of livestock, are classified as POM for cats. However it is worth noting that immunological preparations are of increasing importance in improving the levels of health care in domesticated animals. Vaccines are available for feline leukaemia, feline panleucopenia, feline viral respiratory disease and for rabies. Further information is available in the texts listed at the end of this article.
Good health requires a preventative programme including suitable diet and exercise, worming, flea control, vaccination and preferably an annual veterinary check. Diet will influence dental hygiene, but daily brushing will prevent the accumulation of plaque and help maintain healthy gums and teeth. Specially formulated feline toothpaste may be used two or three times a week. Human toothpastes contain foaming ingredients and are not suitable for cats.
Hygiene generally deserves more attention, which should include:
* The thorough washing of hands after handling pets.
* The provision of pet feeding utensils that are washed and cleaned separately from those for human use.
* Providing pets with their own bedding; many pet owners fail to understand the significance of this.
Recent reports, such as the BBC You and Yours programme, have quoted how much money many pet owners spend on grooming and health insurance. This can be up to #1,700 a year, or #20,000 for the lifetime of a cocker spaniel! This should perhaps help to put the cost of regular prophylactic animal medicine into a more meaningful perspective.
Legal and ethical issues
Under the Veterinary Surgeon’s Act 1966 only veterinarians and the animal owner may diagnose and treat animal diseases. Considerable emphasis is placed on veterinarians taking responsibility for “animals under their care”. There are certain exemptions, which include emergency first aid for saving life or relieving pain.
Currently pharmacists must not attempt to diagnose animal ill health or respond to symptoms, as is common practice for minor ailments in human patients. What pharmacists can do is to assist animal owners with preventive medicine. Advice on the use of medicines, their administration and the need to relate dosage to animal weight can be helpful reassurance for an apprehensive pet owner.
The Royal Pharmaceutical Society’s Code of Ethics expects pharmacists to co-operate with members of other health professions for the benefit of the patient and public.
It is important to recognise that in some situations the best advice a pharmacist may give to a pet owner is to encourage them to make haste to their local veterinary surgeon.
This action can be facilitated considerably if the pharmacist already has a good rapport with the local veterinary practice. Maintaining regular contact with your local veterinarian makes good sense.
Some misunderstanding exists about the “prescribing cascade,” which allows a veterinarian to prescribe legally a medicine authorised only for human use, if there is no authorised veterinary medicine for a particular indication requiring treatment.3 At present, there are no circumstances when it is legal for a pharmacist to supply on his/her own authority a human medicine for animal use. A veterinarian could, if deemed appropriate, write a prescription for a human authorised medicine after having legitimately followed the “cascade”.
These strict restrictions can put pharmacists into unsatisfactory positions especially when faced, for example on a Saturday afternoon, with an urgent request for a travel sickness preventative – rather unlikely for a cat, but maybe for a dog. No authorised non-POM product is apparently available. It is hoped that, in the foreseeable future, such difficulties may be clarified and resolved.
The Pharmacy and Merchants List (PML) category will disappear from October 31, 2005, when the new EU veterinary regulations come into effect. Within the two major classification categories, POM and GSL there will be several sub-categories:
* POM-V (POM-veterinarian) – formerly POM (may include some former P vet medicines, of which there are only 12 at present)
* POM-VPS (POM-vet, pharmacist, suitably qualified person (SQP) – former PML products for food animals. May only be supplied by one of the listed responsible qualified persons
* NFA/VPS (non-food animal – VPS) – former PML and some P products for companion animals. May only be supplied by one of the listed responsible qualified persons
* AVM-GSL (authorised veterinary medicine-GSL) – former GSL vet medicines, supplied from any retailer as at present.
It is expected that some products will be re-categorised and, for example, certain POM flea products could become POM-VPS, available through pharmacies.
1. Kayne S B, Jepson M H (edit). Veterinary Pharmacy, 2004, London, Pharmaceutical Press.
2. Bishop Y (edit). The Veterinary Formulary, 6th ed. 2005, London, Pharmaceutical Press.
3. Medicines, Ethics & Practice, a guide for pharmacists, 29th ed. July 2005, London, Royal Pharmaceutical Society.
4. Veterinary Record, December 2002.
* Compendium of Data Sheets for Animal Medicines 2005, Enfield Middlesex, National Office of Animal Health.
* Cat and dog flea and worming leaflet (new free edition due in November), Veterinary Pharmacists Group, London, Royal Pharmaceutical Society.
* Evans J (edit). The Henston, Small Animal Veterinary Vade Mecum, 23rd ed. 2005, Peterborough, Henston Veterinary Publications.
Dr Michael Jepson is a visiting fellow at Aston University and a former head of pharmacy practice in the School of Pharmacy. He has been course director of the RPSGB veterinary pharmacy postgraduate programme since 1981, a member of the Advisory Committee of the Veterinary Formulary (current 6th edition) and a member of the Veterinary Products Committee 1994-2001.
1. Refer to the tables in the previous article in this series (C&D, September 24, p23-28) to see which preparations are suitable for both cats and dogs. Check which products you stock for cats. Is there a need for you to rationalise or even expand your range?
2. When the new categories of veterinary medicines come into effect, keep a look out in the pharmacy press and on veterinary medicine websites for changes that might affect the products you sell. Do these changes offer more opportunities than before?
3. If you do not already sell pet medicines, will it now be worth your while stocking a range of preventive products for fleas and worms? Think how you might develop a pet medicines section.
4. Revise the differences between de-worming puppies and kittens.
5. Find out the best ways to control animal fleas in the house.
Copyright: CMP Information Ltd.
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