pre visit pharmaceuticals used in dogs

Previsit Medications

• April 12, 2021

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Scared pets at the vet are displaying perfectly normal fear responses, but it doesn’t have to be like this. Pre-visit medications can be part of a plan to minimize fear, anxiety and stress when your dog or cat needs veterinary medical care. This episode focuses on how pre-visit medications, such as pheromones, gabapentin, and trazodone, may help make your trip to the vet as pleasant as it could be.

[00:01:05] Dr. Lancellotti:  Thank you, everyone, for joining us on the Your Vet Wants You To Know podcast. I am excited to talk about pre-visit pharmaceuticals today. These are medications that we use to decrease stress in pets before they come to the visit. Hence, “pre-visit.” With me today, I have a very special guest, Dr. Hope Jankunas , and she is going to help talk about what these medications are and what they mean for your pets. She is a veterinarian who earned her degree from the university of Florida. Then, she completed a rotating small animal internship at the Animal Medical Center in New York City , where she and I both worked for a brief period of time. She practiced in New York City for a few years and then relocated to the Hudson Valley for her husband’s career. He is also a vet and an equine internal medicine specialist. Tell me about the hospitals that you have, Dr. Jankunas.  

[00:01:57] Dr. Jankunas: Sure. Together we own Companion Pet Hospital , and we have two locations in the Hudson Valley.   Initially, our motivation for wanting to own our own hospital was because we wanted to be able to practice veterinary medicine in a really gentle and stress-free way and saw that there was an opening in the community for that.

Dr. Hope Jankunas, Companion Pet Hospital

Creating a Positive Experience for Pets

[00:02:17] Dr. Lancellotti: That’s great. Providing animals with a stress free experience is so important, and it’s really been this great movement that we’ve seen occurring throughout veterinary medicine. I’m happy that pet owners are getting the benefit of that too. Tell me a little bit about the training that you did with being able to decrease stress in the animals’ visits.  

[00:02:37] Dr. Jankunas: Okay. I was feeling sort of upset that pets that were coming to see me were scared of me, even though I was there to help them. So what we learned, initially, was that the fear response is totally normal, and it is something that we can do to help them not be scared of us. We did some training with Sophia Yin (veterinary behaviorist) , then we completed a Fear Free certification , which is a relatively newer program for veterinarians, veterinary technicians, receptionists, or anybody working in the practice.

[00:03:12] Dr. Lancellotti: Excellent. As a general practice vet, tell us a little bit about what that means as far as a relationship that you have with the pet owners and the pets.  

[00:03:20] Dr. Jankunas: I get to see a variety of cases (which I really like because I never get bored), and one of my favorite aspects of the job is the client education and communication. A lot of people think that we get into veterinary medicine because we actually don’t like people that much, but that’s not true. Over the life of a pet, we build really strong relationships with the pet owners, and that’s the part of my job that I find the most professionally fulfilling.

[00:03:46] Dr. Lancellotti: Yeah. It is really wonderful to establish that relationship when they bring a really young animal in for that first puppy or kitten visit, and then you get to see that animal grow and go throughout the course of the animal’s life with the pet owner.  

[00:03:59] Dr. Jankunas: Yeah, I agree. I love that.  

Russell Sprout, the Your Vet Wants You to Know mascot

[00:04:01] Dr. Lancellotti: To talk about today’s episode a little bit, we’re going to be discussing pre-visit pharmaceuticals, which are medications that are used to decrease stress when the animal comes in to see the vet. Many of the listeners are familiar with my dog, Russell Sprout. He is the Your Vet Wants You To Know mascot. He’s got environmental allergies , he’s on allergy immunotherapy , and he was diagnosed with Cushing’s Disease , so I’ve talked about him quite a bit in some of the other episodes of the show. Also, he is not the most relaxed dog. Our family frequently describes him as being as feisty as he is ugly. Because of these chronic skin and chronic ear problems, he needs to go with me a lot to the hospital to get care. So it was really important for me, as an owner, as well as for my staff, who have to safely work with Russell and keep all of their fingers attached while doing so, that I do everything possible to minimize his stress when he comes in . One of the most helpful tools that I’ve found for Russell is a medication called Trazadone (anti-anxiety med) that just helps take the edge off when he goes to see the vet. It’s made a world of difference with making him more comfortable as a patient, making me more comfortable as his owner, and making my staff a lot more comfortable in handling him. So I’m really excited to discuss this topic because it’s one of those things it’s really personal for me. Plus, I think it’s really important, just as a lot of human healthcare professionals are working to de-stigmatize mental illness, that we, as veterinary professionals, are also trying to de-stigmatize anxiety and stress as mental illness in our pet patients, so that we can, overall, improve their quality of life.  

[00:05:49] Dr. Jankunas: I hear you 100% and I could not agree more. I have a lot of patients that sound just like Russell, so it is one of those topics that I really appreciate the opportunity to talk about. It’s also super important to me and my practice, and anything that we can do to help inform listeners out there so that we can all get together and help their pets, I’m really happy to do that.  

Benefits to relaxed dogs and cats at the vet

[00:06:12] Dr. Lancellotti: That’s great. So we’re going to have a couple of different goals for the episode today. First, we’re going to talk a little bit about what some of the benefits are to decreasing their anxiety and why you and I feel so strongly about this. Then, we’ll touch a little bit on the different anti-anxiety medications that are commonly used, the risks of those medications, as well as the benefits, and what the pet owner can expect when they’re using those and bringing the pet to the visit with those medications on board. I’ve talked, in the previous episode, on methods to decrease stress when bringing a pet to see the vet. What would you say are some of the most important reasons to make sure that pets are as relaxed as possible?  

[00:06:54] Dr. Jankunas: Relaxed pets are going to have a better experience, and ultimately, they’re going to receive better quality veterinary care. I think we can all agree that stress is unpleasant, and so over time, repeated stress or repeated fear can actually be damaging to your health. It can suppress your immune system, and if you’re fearful about having the same sort of repetitive experience, you could actually develop really unhealthy phobias. That’s something that we’re trying to avoid in pets that are coming to see us. One of the things we’ve recognized is that pets that are scared to see us once, if we don’t address that, the times that they come and see us in the future are actually worse for them. So, in our practice, we like to talk about the 4 F’s of the fear response- fight, flight, freeze and   fidget. Some pets’ response to fear is that they’re going to try to flee. They’re trying to get out of the room. They’re pawing. They’re scratching. They’re really upset. Some can be aggressive, so I think it makes sense that pet owners, who are seeing their pets act this way, are going to try to avoid it by not bringing their pet to the vet. So ultimately, some of these pets don’t come to see us for routine care. The owners just don’t want to put their pet through that, so instead they don’t come, but there are other ways to get around it so that we can address the fear and get them into the office in a calm way, rather than just avoiding 100%. That’s one of the ways that it can impact the quality of vet care- if your pet owner can’t even bring their animal to the vet because they don’t want to have to go through that. Lastly, when a pet is relaxed, we can do a really thorough physical exam if they need any treatments. Like with Russell- cleaning the ears, things like this- we can do those treatments in a pet that’s relaxed. It’s a lot more difficult to do what we need to do if they’re stressed out or fearful.  

[00:08:56] Dr. Lancellotti: Yeah. You definitely bring up a great point about receiving better veterinary care. If the pet is relaxed and comfortable with me, I can really get a great look at all of those areas of the body, where things may be hiding from me, that I won’t be able to see if the animal’s too nervous to let me touch. And stress, in and of itself, can cause problems. That stress hormone, cortisol, really has a negative effect on a lot of different body systems. If you want to hear about all the negative effects cortisol can have on the body, just listen to the episodes on steroids and Cushing’s Disease. Those animals are definitely suffering, so being able to minimize that stress is really important for their overall health. And you bring up a good point about pet owners not wanting to bring the pet into the hospital because they think it’s going to be too stressful of an experience. You, as a general practitioner, a family veterinarian who sees pets throughout the course of their life, and I, as a dermatologist, who sees pets that have these chronic skin and ear conditions- we don’t want a pet owner seeing that something’s wrong with their pet and thinking, “Well, is it worth it? They’re going to be so nervous. They’re going to be really anxious. Do I really need to bring them in?” We just want them seeing that something’s wrong and thinking, “Okay. My pet needs to be seen. We’re going to bring him in. It’s not that big of a deal if they do great.” So that’s really important for me.  

[00:10:19] Dr. Jankunas: I agree completely.  

[00:10:20] Dr. Lancellotti: The other thing that I think is important to mention is that by lowering the animal’s anxiety level before they come to the hospital, when they have to have some type of procedure where anesthesia or sedation is needed, we can actually lower the amount of other medications that we need to perform the anesthesia. And that goes a long way towards making those procedures safer for the pet. Oftentimes, if I have a pet that’s really anxious and I know that either I need to sedate them for a skin test or I need to put them under anesthesia for a biopsy, I’ll make sure that the owner has these pre-visit pharmaceuticals to help lower that stress level to make my procedure safer.

Trazodone, gabapentin, and pheromones

Dr. Lancellotti:  So when we’re talking about the different anti-anxiety medications that are used there are different things that we do for different types of animals. Can you describe, for pet owners, some of the most common anti-anxiety medications that a veterinarian might recommend?

[00:11:20] Dr. Jankunas: Sure. First, before we go to the pharmaceuticals, we do always encourage the owners to use pheromones in the home for calming purposes and to work on some of the desensitization and counter conditioning, so that their pets are less fearful of the carrier getting in the car. Then, in cases where that’s not providing enough of a relaxation, we do reach for the medications. In dogs, my first choice is Trazadone. In cats, I typically reach for Gabapentin first.   We find that some pets need a combination of the drugs- either those two or adding in something different. In extremely fearful pets, we sometimes need to use sedatives injectably in the hospital to heavily sedate them for certain procedures.  

[00:12:15] Dr. Lancellotti: Yeah. These are my two favorite medications to use as well. You know, I mentioned Russell does great with Trazadone and we use that before he comes in for his veterinary visits, but also when we have people over to the house (which hasn’t been happening much nowadays because of COVID), we’ll use that in the home as well. Any situation where he’s really anxious, I think this is great therapy for him with just helping him cope much better. So, for dogs, Trazadone is a great anti-anxiety medication that has minimal sedation. And then with cats, Gabapentin is fantastic as well. We generally use this as a pain medication, but it also is really good for helping with their anxiety. And I don’t know if you noticed this as well, but I definitely find that Trazadone and Gabapentin both do a lot for helping to make the animals more inclined to eat food when they come to see me. This really helps with creating a positive experience when they’re in the vet’s office anyway, so if I can lower that anxiety level enough that they are interested in eating, I have a better chance of making that visit pleasant and making them happier to come to see me in the future.  

[00:13:28] Dr. Jankunas: Yeah. You’re right. I find that when I have a pet that comes in the office and they are refusing my super high quality treats (and we’ve got a lot of good stuff to offer), they absolutely need some sort of pharmaceutical. Typically, when they come in with either Gabapentin or Trazadone on board, they are happy to take those treats.  

Safety of gabapentin and trazodone

[00:13:46] Dr. Lancellotti: Absolutely. So, I talk a lot about benefit vs. risk on the show. It’s an overarching theme in how I approach the treatment of each pet, no matter what aspect of their health care I’m dealing with. Tell us some of the risks associated with these particular medications. Does the benefit of using things like Gabapentin and Trazadone outweigh the risk?  

[00:14:08] Dr. Jankunas: In general, both of these medications that we’re talking about here are super safe. Gabapentin, as you had mentioned, is primarily a pain reliever. It’s also used as an anti-seizure medication. And I have prescribed it to pets that are geriatric, senior pets, pets that have other illnesses, where putting them on different classes of drugs might be unsafe and can use Gabapentin really safely in these patients. So, when we’re using it as a pre-visit pharmaceutical, it is a very safe drug. What Gabapentin does is very similar to this chemical in your brain called GABA- and that is responsible for relaxation and calmness. So when your pet is on that, not only is it addressing some pain, but it’s also relaxing them and making them really calm. Trazodone is also super safe. It is an anti-anxiety medication and produces some sedative side effects, as well. This drug works by increasing your serotonin, which is your feel-good chemical in the brain. The times that we can have some issues with Trazodone would be if your pet was taking other medications for an anxiety disorder. So you’d have to talk to your vet about this to make sure that it’s safe to use Trazodone. Sometimes, we would avoid it if your pet is already taking medications to increase serotonin, like Fluoxetine, for example. In describing Gabapentin and Trazodone, you’ll notice that we talked about how they’re producing some sedation and they’re treating anxiety, and it’s important to note that they do both. There are other drugs that just tranquilize a pet. It doesn’t alleviate anxiety.   A drug that comes to mind is Acepromazine, which can certainly be used in combination with another drug that is addressing anxiety. But using Acepromazine alone is something that we try to avoid, just because it will produce sedation or tranquilization, but your pet is still feeling anxious about what’s happening. So you can imagine that after the drug wears off, and if they’re in that situation again, they’re going to be pretty fearful about what happened to them.  

[00:16:23] Dr. Lancellotti: Yeah. I think that’s a great point to bring up. I think using these medications in combination with a conversation with your veterinarian is really important because not all pets respond to these medications the same way. There’s a pretty wide dosing range with them, so having that discussion about how your pet reacts to them, and what you can do to make adjustments to find the right fit, is an important part of having that relationship with your veterinarian.

What to expect with gabapentin and trazodone

Dr. Lancellotti:  When a pet owner is giving these medications, what can they expect to see? Do you have advice as far as setting the pet and the owner up for success when we give them a pre-visit medication?    

[00:17:03] Dr. Jankunas: You can expect mild to moderate sedation. Some pets will be a little bit wobbly on their feet, so you certainly wouldn’t want to leave them unattended, off-leash outside. Some cats, in particular, will be extremely affectionate on Gabapentin, so pet owners may notice that, as well. But to be honest, some pet owners notice nothing, and they actually question whether or not the drugs are working, and we don’t notice that they are until the pet comes into the hospital and there’s a significant change in their behavior. But in the comfort of their home, they may not notice there’s any change at all. So, in setting up the best expectations for success, there’s a couple things that you’ll want to do. First, you’ll want to make sure that you try the medication at home prior to when you need it for the appointment, just because all pets do have a variable response to the medication. You just want to see how your pet would react, so that if dosing changes need to be made, you know that ahead of time from when the medication actually needs to be used. Next, you’re going to want to make sure that you give the medication at the right time. Both of these drugs will reach their peak about 2 hours after they’re given. You’ll want to have them on board about 90 minutes before you leave the house for your vet visit, so that they’re reaching their peak during the exam and that they’re on board when your pet needs them most. Some pets, will actually benefit from having an additional dose given the night before, or even the day before, having 2 extra doses on board if they’re really anxious. The last thing for setting up for success is to make sure that pet owners are putting in the effort to do that desensitization and counter conditioning for the car and for the carrier .  

[00:18:54] Dr. Lancellotti: Well, your cat, Mittens, is absolutely adorable. I’ve got a picture that we’ll put up on the website of Mittens hanging out in his carrier prior to a vet visit. Showing Mittens and the carrier there is a great example of what I talked about on the previous episode about getting that carrier out before the vet visit, and leaving it out, so that the cat gets comfortable- hiding some treats in there, so that they get really fond and very happy with their carrier. That’s a great way to decrease stress. So, there’s a very cute picture that we’ll have up on the website.  

Watch for motion sickness

[00:19:26] Dr. Jankunas: Thanks. And I will note that my cat, Fiona, used to have a terrible time coming to the vet. She was yelling, scratching at her carrier, and she’d be foaming at the mouth when we took her out. Initially, she was not really responding fully to pre-visit pharmaceuticals until I realized that she was carsick. Once we added a medication for motion sickness to her pre-visit cocktail, she was like a whole different cat. So that’s something else for owners to be on the lookout for, as well. If their pet is carsick, addressing that too, will help with that general level of anxiety.

[00:20:05] Dr. Lancellotti: Yeah. Certainly, if I know that I’m going to get motion sickness from doing something, I’m going to be a little bit anxious about doing it. One of the things that I like to mention to pet owners when they’re giving that dose the night before (I know you said that sometimes the pet owner won’t notice anything with that medication on board), sometimes, we see that the pet will actually be a little bit sedated the night before, when they give that night before dose. The reason for that is because they’re in a non-stressful environment. That sedative effect may be a little bit stronger than when they come into the vet, where they’re a little bit more anxious, so the sedation’s not going to be as strong. And that’s okay. I equate it to the best man at a wedding having a beer or two before he gets up to give the speech. It’s not enough to make him sedated and falling over, it’s just enough to take the edge off and make it okay. In a non-stressful environment, they may be a little bit more sleepy the night before, but we want them to be comfortable when they come into the vet visit and not anxious to see us.

Scared pets are not bad pets!

Dr. Lancellotti:  What are some of the big takeaway points that you want pet owners to remember when they’re thinking of using pre-visit pharmaceuticals for their pet?

[00:21:15] Dr. Jankunas: Well, I think at the top of the podcast when we talked about reducing the stigma- that’s how I feel. I want there to be a no judgment zone here. We are not saying that your dog is bad. Your cat is not bad. We recognize that these are scared pets and they’re displaying perfectly normal fear responses, but what we want you to know is that it doesn’t have to be like this. There is a better way and pre-visit medications can be part of the solution. As veterinarians, we care about the pet owners, we care about the pets, and we want be their partner in making a trip to the vet as pleasant as it could be.

[00:21:56] Dr. Lancellotti: Yeah. I definitely think that the more veterinarians are talking to pet owners about these medications, and the more that we’re addressing the mental health aspect of the veterinary visit, we’re going to see such a huge change in the pet owner’s willingness to bring their pet in when they notice something going on, and the pets, themselves, being happier and happier for us to provide them with good medical care. Overall, I think it’s part of a very strong veterinary client patient relationship. Do you have any other resources for pet owners as far as if they want more information about minimizing stress when their pet comes into the veterinary clinic?

[00:22:34] Dr. Jankunas: Yes. In the show notes, we have links to 2 blog entries that I wrote that are about, specifically, bringing scaredy-cats to the vet . It describes the visit to the vet from a cat’s point of view, which is kind of interesting if you put yourself in their shoes. They’re getting stuffed into this box and carried it into the vet office. It can be very scary if you think about it from their point of view, so it’s just talking about ways that pet owners can minimize that stress, starting in the home, prior to the visit. Then, there’s another article about how fear-free visits can actually promote better veterinary care , and those can be found on our hospital’s website.  

[00:23:19] Dr. Lancellotti: Awesome. Thank you so much. We’ll definitely have a link to that in the show notes, as well as on the episode page on the website. And there are some really cute pictures that you’ve provided with us. There’s an adorable puppy getting a Fear Free treatment, using a lick mat with peanut butter during his exams and vaccines. I love these lick mats. We use them quite a bit in our derm clinic. Also, I recommend that for dogs that are a little bit anxious in the bath (because I prescribe a lot of medicated bathing), the pet owners can use those in the bathtub too, to make bath time more pleasant. There’s a really cute picture of a kitten getting a Fear Free treatment of tuna squeeze-ups during his exam and vaccines. He’s so happy. Oh my gosh. The tuna has a smiley face for a happy visit.  

[00:24:07] Dr. Jankunas: That’s right. Oh, yes!  

Scratching the Itch

[00:24:09] Dr. Lancellotti: To end this happy episode with happy segment, we’re going to finish up with a Scratching The Itch segment. It’s a short segment that I like to have at the end of each episode that highlights something, whether it’s a human interest story, a product or a website that provides relief, or just makes people feel good. I would love to hear if you have a ‘scratching the itch’ for our listeners today.

[00:24:33] Dr. Jankunas: I sure do. I live here, as I mentioned, in the Hudson Valley in New York. This has been a growing area for craft beer, craft distillery, and wineries. My husband, my son, and I will visit them pretty often, and especially during the pandemic (because most of these places have outdoor), it’s been a great way to get out and support the local businesses. So, we noticed that there are often cats around these places, and when we talked to some of the employees at these breweries and distilleries, they were telling us that the cats work there. They call them ‘blue-collar’ cats, because they’re cats that have a job. Their job is mostly to be “mousers,” but they’re also super Instagramable- lots of adorable pictures of these cats can be found on Instagram. And they will socialize with guests as they wish, and some of them don’t, but I thought it was really interesting that these cats had jobs. So when I looked into it more deeply, I found that there are some local shelters that have pet cats that would not otherwise do well inside of a traditional home, for a variety of reasons. Some of them are semi feral or stray. Some of them have litter box issues. But they make really great working cats, so you can actually adopt a cat to be a barn cat or a blue collar cat. I thought that was really great because they’re helping these businesses by controlling pests without having to use any chemicals. And then, these cats are also getting to live these amazing lives, when they might not have otherwise been adopted. So, I felt like it was a really happy, feel-good story, and I bet if people went to local businesses in their areas, they would find a blue collar cats everywhere.  

[00:26:26] Dr. Lancellotti: That’s great. We always think of dogs as being working dogs or working animals, but I don’t always think of cats as having jobs, in that sense of the word, so that’s a very cool concept. I don’t think I would mind having working job on a winery or a brewery.  

[00:26:43] Dr. Jankunas: Yeah. It sounds pretty amazing.

[00:26:45] Dr. Lancellotti: Not so bad. Right? Well, thank you so much for coming on and talking to pet owners about pre-visit medications and decreasing anxiety and stress. I really hope this goes a long way towards helping pet owners and making their pets more comfortable when they go to the vet.  

[00:26:59] Dr. Jankunas: Yes. Thank you so much for having me. I really appreciate the opportunity to talk about this important subject, and I hope that owners will be able to get some of the information they need to help their pets.  

[00:27:11] Dr. Lancellotti: We’ll have a lot of links to different resources on the show notes for today’s episodes. Many family veterinarians are comfortable managing pets with anxiety, but if you are interested in talking to a veterinary behaviorist, there is a link to find a veterinary behaviorist near you on the website – if you want to consult with a specialist. Then, I would encourage you to join the Facebook group . Tell us about your experience with your pet’s anxiety (I can certainly sympathize, being a pet owner of an anxious pet), or what types of medications or changes have worked for you. Maybe something that’s worked for you could help somebody else out too. Follow us on Instagram @yourvetwantsyoutoknow . Thank you very much for listening today. Again, thank you so much to our guest, and I look forward to your next visit with Your Vet Wants You To Know.

References:

• FearFreePets.com
• Trazodone: https://veterinarypartner.vin.com/default.aspx?pid=19239&id=7756524
• Gabapentin: https://veterinarypartner.vin.com/default.aspx?pid=19239&id=4952756

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• v.62(9); 2021 Sep

Language: English | French

A review of pre-appointment medications to reduce fear and anxiety in dogs and cats at veterinary visits

This review focuses on pre-appointment medications used to decrease fear and anxiety in dogs and cats related to veterinary visits. A review of the literature revealed data on 4 medications from 4 medication classes that have been used to ameliorate acute situational fear and anxiety in dogs and cats: gabapentin, trazodone, oral transmucosal dexmedetomidine, and alprazolam. The available information on use, mechanism of action, and pharmacokinetics is reviewed.

Résumé

Examen des médicaments pré-rendez-vous pour réduire la peur et l’anxiété chez les chiens et les chats lors des visites vétérinaires . Cette revue se concentre sur les médicaments pré-rendez-vous utilisés pour diminuer la peur et l’anxiété chez les chiens et les chats liées aux visites vétérinaires. Une recension de la littérature a révélé des données sur quatre médicaments de quatre classes de médicaments qui ont été utilisés pour diminuer la peur et l’anxiété situationnelles aiguës chez les chiens et les chats : la gabapentine, la trazodone, la dexmédétomidine transmucosale orale et l’alprazolam. Les informations disponibles sur l’utilisation, le mécanisme d’action et la pharmacocinétique sont passées en revue.

(Traduit par D r Serge Messier)

Introduction

Dogs and cats show behavioral and physiologic indicators of stress at veterinary appointments and in veterinary hospitals ( 1 – 8 ). Fewer than half of dogs enter a practice calmly ( 2 , 3 ) and most show behavioral signs of stress in the waiting room ( 6 ). Cats have significantly lower signs of physiologic stress when examined at home than in a clinic ( 4 , 5 ). Only 26% of cats were calm upon arrival at a clinic and 60% exhibited ongoing distress upon return home ( 9 ). Behavioral medicine is an unmet need for veterinary staff, clients, and patients in most veterinary practices, posing a threat to the welfare and longevity of companion animals ( 7 , 10 ), for whom behavioral problems are the leading cause of abandonment and euthanasia ( 7 ).

Behavioral distress is not only harmful to a patient’s mental well-being ( 11 ), but it can affect patient health, client compliance, diagnosis and treatment, and overall patient care ( 8 ). Pets that have negative experiences during veterinary visits are likely to be fearful and distressed during their next visit, further impeding delivery of care ( 8 , 12 ). Low stress environments and handling, alone, may not significantly lower anxiety, but the addition of behavioral medications may aid in mitigating anxiety and fear associated with veterinary care. Decreasing patient fear and anxiety improves veterinary visits for patients, clients, and the veterinary team, and decreases risk patients may pose to veterinary staff ( 11 , 12 ).

This review focuses on common medications that are used to facilitate less stressful veterinary visits. Peer-reviewed information was available for 4 medications from 4 medication classes for ameliorating acute situational fear and anxiety in dogs and cats: gabapentin, trazodone, oral transmucosal (OTM) dexmedetomidine, and alprazolam. All use is extra-label. The literature was reviewed for data on use, mechanism of action, and canine/feline pharmacokinetics ( Table 1 ).

Summary of uses, dosages, potential adverse effects and evidence available for 4 drugs used to reduce fear and anxiety in dogs and cats at veterinary visits.

BSA — body surface area; TNR — trap neuter release/return.

Selected medications for use during veterinary appointments

Gabapentin, a gabapentinoid, was developed as an anticonvulsant but has analgesic and anxiolytic effects ( 13 , 14 ), often with single dose administration before surgery ( 15 ). Gabapentin is anxiolytic in cats ( 16 ). Gabapentin is a controlled substance in some jurisdictions since it is often used illegally with opiates, greatly increasing the risk of opioid-related deaths.

How does this medication work?

Gabapentin binds as a ligand to the α 2 δ subunit of voltage gate calcium channels, causing a decrease in the release of neurotransmitters such as the excitatory neurotransmitter, glutamate ( 17 ). Gabapentin was developed as a chemical analogue to γ-aminobutyric acid (GABA) but does not affect GABAergic neuronal systems. Any effects on GABA are likely secondary to calcium channel effects, neuronal type, and regional responses ( 18 ).

Clinical studies

The use of gabapentin in cats and dogs is extra-label. Although gabapentin is increasingly used in the treatment of anxiety, there are no peer-reviewed efficacy or dose determination studies for this indication.

van Haaften et al ( 19 ) examined the effects of a single pre-appointment dose of gabapentin (100 mg/cat) on signs of stress in cats during transportation and veterinary examination. In a randomized, placebo-controlled, crossover study, 20 healthy pet cats [3.4 to 7.7 kg; 13.0 to 29.4 mg/kg body weight (BW)] with a history of fractious behavior or signs of stress during veterinary examination at 2 veterinary visits 1 wk apart, were investigated. Cats received 1 of 2 treatments (gabapentin or placebo) for the first visit and the second treatment for the second visit. Owners gave the capsule 90 min before placing the cat into the carrier. Owners and veterinarians scored the cats’ compliance with examination and behavior using the 7-point cat stress score (CSS). Gabapentin significantly reduced perceived distress and increased compliance for the cats.

Gabapentin was evaluated as an anxiolytic for spay/neuter surgery in 53 community cats in a trap-neuter-return (TNR) program ( 20 ). Using a double-blinded, placebo-controlled design, cats were given a single dose of placebo, low dose gaba-pentin (50 mg/cat), or high dose gabapentin (100 mg/cat) in a 1-mL sugar solution. A blinded observer scored each cat for fear, sedation, respiratory rate, and facial injuries at the time of administration, 1, 2, 3, and 12 h after administration. Regardless of dose, gabapentin reduced fear compared to placebo. Cats in this study weighed 1.4 to 5.4 kg (mean: 3.4 kg in 50 mg/cat group; 3.0 kg in 100 mg/cat group), resulting in dosages of 9.2 to 24.4 mg/kg BW (mean: 16.3 mg/kg BW) and 23.1 to 47.6 mg/kg BW (mean: 35.3 mg/kg BW), respectively. The cats in the placebo group overlapped with the excitement range on the CSS and mg/kg BW given overlapped for the 2 dosages, blurring evaluation of CSS by group. Feral cats are considered fractious which may affect CSS scores in ways not relevant for companion cats.

In a randomized, single-blinded, crossover study of 16 companion cats, Hudec and Griffin ( 21 ) administered either gaba-pentin or no treatment, then the reverse, in a 2-visit study to determine any effect of gabapentin on intradermal testing, cortisol, and glucose. Gabapentin was administered in capsules using a pre-determined mg/kg BW range, with an increase of 25 mg of gabapentin for up to each additional kilogram of weight beyond 2 kg. The maximal dosage range was 25 to 35.7 mg/kg BW. There was no effect of gabapentin on cortisol or glucose, but gabapentin correlated with lower stress assessments, although sedation could not be ruled out.

At the time of writing, there are no published studies on the use of gabapentin for anxiety/fear in dogs.

Pharmacokinetics

Intravenous (IV) (4 mg/kg BW) and oral (10 mg/kg BW) gabapentin pharmacokinetics were compared in a randomized, crossover study in 6 female adult shorthair cats ( 16 ). Disposition was best described by a 1-compartment model for oral administration, but a 3-compartment model for IV administration. The terminal half-life for IV gabapentin was 170 ± 21 min (range: 151 to 198 min) and the t 1/2 for orally administered gabapentin was 177 ± 25 min (range: 151 to 211 min). T max for orally administered gabapentin was 100 ± 22 min (range: 58 to 175 min). Based on the effective human plasma concentrations for analgesia in neuropathic pain and feline pharmacokinetics, the recommended dose was 3 mg/kg BW, PO, q6h.

In a non-randomized, block design, single dosages of 10 and 20 mg/kg BW of gabapentin were given to 6 healthy grey-hound dogs, 1.5 to 3 y old, to determine pharmacokinetic parameters ( 22 ). Mean dosages administered were 10.2 mg/kg BW (range: 9.1 to 12.0 mg/kg BW) and 20.5 mg/kg BW (range: 18.2 to 24 mg/kg BW), respectively. C max occurred at 1.3 and 1.5 h, and the terminal half-lives were 3.3 and 3.4 h, respectively for each dose group. These findings were similar to the 2.9 h C max reported for intravenous dosing in dogs at 25 mg/kg BW per day for 14 d and 100 mg/kg BW per day for 28 d ( n = 2 beagle dogs) ( 23 ). The t 1/2 of oral gabapentin was 3 to 4 h in dogs, 2 to 3 h in rats and 5 to 6 h in humans ( 24 ). Rapid absorption and elimination suggest the need for frequent dosing to maintain targeted plasma concentrations ( 24 ). Dogs, unlike cats and humans, metabolize about 34% of gabapentin to N-methyl-gabapentin ( 23 , 24 ).

Rhee et al ( 25 ) compared a gabapentin 600 mg single dose sustained release formulation with a single dose immediate release formulation in 4 fasted beagle dogs, 10 to 12 kg (50 to 60 mg/kg BW). There were concerns with dissolution and absorption of the sustained release tablet, but the plasma concentration versus time curves were similar for both formulations with fully overlapping error bars. For the immediate release formulation, used in all studies reported here, time to reach C max (T max ) was 2.0 ± 0.0 h and t 1/2 was 3.2 ± 0.2 h.

Because gabapentin is excreted through the urine, renal tubule impairment can concentrate gabapentin in renal tubules ( 23 ), and dosages may need to be decreased in animals with renal disease.

Recommended use

The range of gabapentin dosages reported ( 19 , 20 ) is large: 13.0 to 29.4 mg/kg BW for companion cats and 9.3 to 71.4 mg/kg BW for community cats. We lack clinical and dose determination studies, but based on available data, 3 to 10 mg/kg BW may be a reasonable dose for cats. Reported adverse effects include sedation and ataxia ( 16 , 19 ), and vomiting and hypersalivation ( 20 , 21 ). Gabapentin is given by capsule or compounded in liquid. Dogs should not be given the commercially available oral gabapentin solution as it contains xylitol.

Although there are multiple pharmacokinetic studies in dogs and gabapentin is widely used by specialists for fear and anxiety at the equivalent dose recommended for pain (20 mg/kg BW) or greater ( 26 ), there are no published clinical studies on the use of gabapentin to decrease situational anxiety in dogs. Such studies are needed. Given the studies in cats and anecdotal specialist usage ( 26 ), the anxiolytic dose of gabapentin may be higher than the analgesic dose, as in humans ( 14 , 15 ), but this clinical impression requires testing.

Based on pharmacokinetics, gabapentin may be given to dogs and cats to prevent fear or anxiety at veterinary visits at least 90 min before the visit. Some benefit has been anecdotally reported for some dogs of starting the gabapentin the evening before and the day of the veterinary visit, with the final dose coming 90 min before the appointment ( 26 ). Based on pharmacokinetic data, to overcome troughs in plasma values, dosing should be at least every 8 h ( 22 – 24 ).

Trazodone is a serotonin antagonist and reuptake inhibitor (SARI) that is commonly used to mildly sedate cats and dogs for veterinary care. It has also been used to prevent distress, anxiety, and hyper-arousal during transport and during examinations ( 27 ). In human psychiatry, trazodone’s primary use is as an hypnotic in insomnia and disordered sleep, including that occurring with depression and post-traumatic stress disorder, because it decreases sleep latency and increases sleep duration ( 28 ).

How does trazodone work?

Trazodone acts as an antagonist, primarily blocking the serotonin 2A (5-HT2A) and 2C (5-HT2C) receptors. The 5-HT2A and 2C receptors affect cognition and movement, respectively, with both affecting sleep, in a dose-dependent manner. Considered a multi-functional medication ( 29 ), trazodone only functions as an antidepressant in humans at a dose that blocks the serotonin transporter (SERT). The antidepressant/SERT blocking dose in humans is 10- to 50-fold higher than that necessary to block 5-HT2A receptors. Similar data are unavailable for dogs and cats. Trazodone’s intermediate metabolite, meta-chloro-phenyl piperazine (mCPP), functions as an agonist, and has high affinity for several serotonin receptors, with the 5-HT2C receptor preferred. Trazodone has more minor reuptake inhibition effects at other presynaptic serotonin receptors, acts as a 5-HT1A agonist stimulating release of serotonin, and is a potent histamine 1A and α-1 adrenergic antagonist.

Concurrent use with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) should be monitored closely due to an enhanced risk of serotonin syndrome. Concurrent use with monoamine oxidase inhibitors is contraindicated since the shared neurochemical synthesis pathways enhance risk for serotonin syndrome. Signs of serotonin syndrome include tachycardia, hypertension (particularly in cats) ( 30 ), altered mental state or behavioral changes, diarrhea, hyperthermia, shivering, tremors, and seizures ( 12 ). Death ensues without treatment. Most reports of serotonin syndrome in companion animals are iatrogenic (high or incorrect dosages) or due to accidental ingestion of bottles of medication ( 12 ). Heart rate can be monitored since increased heart rate (> 30% of baseline) may be an early indication of excessive serotonin and the activation that follows ( 12 ). Heart rates > 150 beats/min are reported for dogs with serotonin syndrome due to overdose associated with accidental ingestion. Hepatotoxicity has been documented in 1 dog treated with trazodone 4 mg/kg BW, q12 to 24h ( 31 ).

Trazodone is used extra-label in dogs and cats, and has undergone no dose determination studies.

In a randomized study ( n = 6 cats), evaluation was as a sedative for transport and examination ( 32 ). Each cat served as its own control and was given a single dose of each of 4 treatments over 4 wk: placebo and 1 dose each of 50, 75, and 100 mg trazodone (10.6 to 16.7 mg/kg BW, 16.0 to 25 mg/kg BW, and 21.3 to 33.3 mg/kg BW, respectively). Sedation was measured by accelerometry, the CSS, and behavioral measures. Peak sedation occurred 2.5 h after the 100 mg dose, although the range across this small group of cats was wide, extending to 3 h. CSS did not differ at any time point between placebo and treatment groups, suggesting that the clinical effect was one of true sedation, not anxiolysis. The largest proportional sedative effect occurred after the 50 mg dose, suggesting that it may be sufficient for transport and clinical evaluation.

Stevens et al ( 32 ) compared a 50 mg trazodone dose (7.7 to 15.2 mg/kg BW) to a placebo in a single-blinded, randomized study with 10 client-owned cats with a history of distress related to transport and/or examination. Cats were medicated 90 min before travel and examination. Clients used the CSS and a tool to score tractability before, during, and after transport and examination. Veterinarians evaluated the cats before, during, and after examination. Cats given trazodone exhibited less stress before transport ( P = 0.02), in the waiting room ( P = 0.02), during veterinary examination ( P = 0.04), and after ( P = 0.008) the examination. This study did not differentiate between sedation and anxiety relief, nor did it evaluate post-examination recovery. The difference between anxiety relief and sedation may not matter to clients or patients since the cat does not experience distress, but clients should know about it and that recovery period from sedation is variable.

In an open-label, prospective study of 36 dogs, Gruen et al ( 33 ) evaluated calmness in dogs given trazodone (~3.5 mg/kg BW, PO, q12h) in combination with tramadol (4 to 6 mg/kg BW, PO, q8–12h) for pain management during post-surgical confinement. After 3 d, the tramadol, which also affects serotonin, was stopped and trazodone was increased to 7 mg/kg BW, PO, q12h and maintained for 4 wk. Clients could increase trazodone to 7 to 10 mg/kg BW, PO, q8h. Clients evaluated their dogs for confinement tolerance, calmness/hyperactivity level, and responses to specific provocative situations, before surgery and at 1, 2, 3, and 4 wk and at the post-surgical evaluation (8 to 12 wk) using an electronic survey. Clients reported that trazodone enhanced confinement tolerance and calmness, that the onset of action was 35 to 45 min, and that effects lasted at least 4 h. Almost all clients (32/36) thought that trazodone was moderately or extremely helpful for calming the dog.

Trazodone has been evaluated for use in management of anxiety in hospitalized dogs ( 34 ). Hospitalized dogs displaying any behavioral signs of stress or distress ( n = 59) were administered trazodone at 4 mg/kg BW, PO, q12h, with the dose or frequency increased to 10 to 12 mg/kg BW or to every 8 h when needed for desired calming and anxiolytic effects (not to exceed 300 mg/dose or 600 mg/24 h). In this observational study, dogs were matched with an untreated nearby dog ( n = 58) to control for environmental effects. Dogs were evaluated at 45- and 90-minute post-treatment for 22 stress-related behaviors. Lip licking, panting, and whining decreased significantly in the dogs receiving trazodone. Sedation and other functional and physiological parameters were not measured. The results suggest that trazodone be given 90 min before the examination.

A randomized, placebo-controlled, double-blinded study ( 35 ) tested the efficacy of trazodone to specifically relieve anxiety — distinguished from sedation — in the confinement period after orthopedic surgery. This study compared 14 dogs treated with trazodone to 15 dogs treated with a placebo over 4 wk. The dosage range intended was 5 to 7 mg/kg BW, PO, q12h. Because clients were permitted to increase or decrease the amount of the tablet they were given depending on response, the actual final dose used was 5.6 to 21.6 mg/kg BW per day (mean ± standard error = 15.13 ± 1.6 mg/kg BW per day) or 2.8 to 10.8 mg/kg BW, PO, q12h. This study is the only fully randomized, placebo-controlled, blinded study to date and there were no statistically significant differences between the treatment and placebo groups in any of the behavioral categories. This outcome should not be surprising. Trazodone is best used in humans for its mild-to-moderate sedation and hypnotic effects, as explained by its receptor profile ( 28 ). It is not a first-line anti-anxiety agent.

In a randomized, controlled, crossover study, 6 beagle dogs were given a single dose of 100 mg (8.26 ± 0.26 mg/kg BW) of trazodone orally and 8 mg/kg BW, IV ( 36 ). Neither mean nor systolic arterial blood pressure was correlated with trazodone concentration, route or time, but all dogs developed transient tachycardia following IV administration and 3/6 dogs became uncharacteristically aggressive within 5 min after IV administration.

The T max for oral trazodone was 445 ± 271 min (7.4 ± 4.5 h), with peak plasma concentrations reached in 8 to 12 h for 5/6 beagles tested and 30 min for 1 dog ( 36 ). Plasma concentrations of trazodone varied by dog: for 2/6 dogs, plasma concentrations were maintained at > 130 ng/mL for 4 h, for 2/6 dogs for 14 h, for 1/6 dogs for 10 h, and for 1/6 dogs for 20 h.

Following oral administration, the elimination half-life was 166 ± 47 min, comparable to the 169 ± 53 min reported for IV dosing.

Bioavailability following oral dosing was 84.6 ± 13.2%, higher than that reported for humans. Dogs in this study had a C max of 1.3 ± 0.5 g/mL when given 8 mg/kg BW, compared to humans, who had a C max of 1.47 ± 0.16 g/mL when given 100 mg trazodone (1.3 to 2 mg/kg BW). This finding suggests the need for a full pharmacokinetic and dose determination study for use of oral trazodone since it suggests that one must give 4 times the dose used in humans to dogs to obtain similar blood concentrations. Because of the multi-functional nature of trazodone ( 29 ), higher dosages affect primarily the 5-HT2C receptor. This receptor is the target for mCPP, which is a potent serotonergic agonist. In humans, ~20% of the parent compound is metabolized to metabolically active mCPP. Such data are lacking for dogs and CYP 450 activity varies across species and genotype ( 12 ). mCPP can be anxiogenic: panic, anxiety, dysphoria, and psychosis are reported in humans. Similar effects have been reported anecdotally in dogs receiving high dosages of oral trazodone.

Studies evaluating medications are inconsistent in their use of terminology and fail to differentiate between calming versus anti-anxiety versus sedative effects. These differences matter. This lack of clarity complicates recommendations for use. For licensed medications, regulatory agencies require that anxiolytic and sedative effects are distinguishable and that the anxiolytic effects occur without overt sedation. These distinguishing data are lacking for most of the published studies involving trazodone.

Wide dosage ranges have been reported for trazodone in both cats and dogs. No source stated a recommended dose, although Gilbert-Gregory et al ( 34 ) recommended a maximum of 300 mg/dose or 600 mg/24 h in dogs.

The differences between sedation and anxiolysis should be explained to clients so that they can understand the benefits of both and thereby formulate realistic expectations.

For mild-moderate sedation in dogs that are hospitalized or undergoing veterinary examination, the cumulative dosage range reported is 3.5 to 12 mg/kg BW, PO up to q8h ( 34 , 35 ). Administration should be 90 min before the procedure for one-time use. For cats undergoing veterinary examination, the cumulative dosage range is 7.7 to 33.3 mg/kg BW once, 90 min before the procedure ( 32 , 33 , 37 ).

Oral transmucosal (OTM) dexmedetomidine

Injectable dexmedetomidine is widely used for sedation in dogs due to its reversible nature and favorable cardiovascular and respiratory risk profile. Because the oral cavity has a rich vascular supply, the injectable formulation has been used by the OTM route in clinical settings and a specific low-dose OTM gel, (Sileo; Zoetis, Parsippany, New Jersey, USA) has been developed and approved in the European Union and the United States for dogs that fear noises. Other uses are extra-label.

How does dexmedetomidine work?

Dexmedetomidine, an enantiomer of medetomidine, is a centrally acting α-2-adrenergic receptor agonist which has anxiolytic, sedative, and hypnotic actions. These actions are mediated through inhibiting locus coeruleus (LC) firing. Neurons from the LC project to the limbic system, providing noradrenaline for the forebrain. The LC modulates sympathetic tone, vigilance, and attention. Inhibiting noradrenaline release from the LC decreases arousal by reducing the stimulation of the hypothalamic pituitary axis sympathetic outflow, decreasing fear and anxiety ( 26 ).

Use of this medication in cats is extra-label, as are some canine usages.

In a block randomization study comparing injectable versus oral buprenorphine (20 μg/kg BW) combined with dexmedetomidine (20 μg/kg BW) to facilitate catheter insertion in cats, OTM injectable dexmedetomidine allowed for easier catheter placement than did injectable dexmedetomidine, and produced less sedation ( 38 ). Benefits of OTM administration were decreased aversion for cats to the administration route and decreased risk of accidental needle sticks to humans ( 38 ). Differences in sedation associated with route may be due to decreased bioavailability associated with salivation, vomiting, and swallowing (which inactivates the compound). Less compound crossed the mucous membranes into the bloodstream than occurred with injection. When salivation or vomiting was minimal, oral and injectable administration had similar sedative effects ( 38 ).

Injectable dexmedetomidine as an OTM solution was used to sedate 4 aggressive or anxious dogs ( 39 ). The range of dog body weights was 21.8 to 38.7 kg. The dosage ranges for sedation for this weight range would have been 14.5 to 18 μg/kg BW (250 μg/m 2 ) and 11 to 13.4 μg/kg BW (500 μg/m 2 ) for IM and IV administration, respectively. The mean dosage for the OTM administration was 32.6 μg/kg BW (range: 16.1 to 40 μg/kg BW), 2 to 3 times the upper range for IM and IV administration. Three of the 4 dogs had a sedation score of at least 12 within 13 to 34 min.

A blinded, single observer, randomized, crossover study ( 40 ) compared IV dexmedetomidine (5 μg/kg BW) with OTM administration (20 μg/kg BW) of injectable dexmedetomidine in dogs for short procedures. The OTM dexmedetomidine resulted in a similar degree of sedation and prolonged duration of action, compared with results for IV administration, despite relatively low bioavailability.

Oral transmucosal dexmedetomidine gel (Sileo; Zoetis) was tested for alleviation of fear of fireworks noise in a randomized, double-blinded, placebo-controlled clinical study ( 41 ). With sub-sedative doses of 125 μg/m 2 (~4.65 μg/kg BW in a 20 kg dog), dogs in the treatment group were statistically significantly less distressed and fearful than dogs in the placebo group, with an excellent or good effect reported for 72% of the dogs treated with dexmedetomidine than 37% of those treated with a placebo. Dogs in the dexmedetomidine treatment groups expressed significantly fewer signs of fear and anxiety (panting, trembling, pacing, elimination) while listening to fireworks. Based on a functional alertness assessment scale, > 85% of the dogs in the treatment groups remained fully functional throughout the event. The most severe effect reported was emesis ( 41 ).

A blinded, placebo-controlled, crossover study involving 40 dogs tested with OTM dexmedetomidine gel used off-label at the labeled dose (125 μg/m 2 ) reduced fear and anxiety during veterinary visits when administered at home by owners before the visit ( 42 ). Use of OTM dexmedetomidine gel at the labeled dose decreased the likelihood that the dogs would exhibit stress/fear vocalization (whining, yelping, grumbling) ( P < 0.01), avoidance behaviors (oriented toward the door, attempting to exit the room, trying to jump from the table) ( P < 0.01), and the group of behaviors including panting, trembling, urination, defecation ( P < 0.016) during the physical examination, although neither the veterinarian nor the clients thought that the dogs were easier to examine.

Bioavailability of oral dexmedetomidine is poor due to extensive first-pass metabolism, but when administered via the oral mucosa, enhanced bioavailability resulted from absorption in the oral cavity and the avoidance of first-pass metabolism in the liver. The oromucosal mean bioavailability of OTM dexmedetomidine gel was 28% ( 43 ).

Dexmedetomidine is biotransformed and has a half-life in dogs of 0.5 to 3 h after OTM administration. More than 98% of it undergoes hepatic metabolism and fecal elimination. The maximum concentration occurs ~0.6 h after intramuscular or oromucosal administration ( 43 ). The onset of action is approximately 20 min ( 43 ).

When comparing OTM injectable dexmedetomidine with IV administration, C max was 3.8 ± 1.3 ng/mL) for OTM administration, and T max was 73 ± 33 min. C max for IV administration was 18.6 ± 3.3 ng/mL and T max was 1.5 ± 0.6 min. The mean terminal-phase t 1/2 was 152 ± 146 min for OTM administration and 36.6 min for IV administration. Bioavailablity for the oral administration was 11.2 ± 4.5%, 40% of that reported for the OTM dexmedetomidine gel ( 43 ).

Peak sedation scores did not differ significantly between routes of administration, but time to peak sedation score was lower for IV administration [10 min (range: 2 to 45 min) versus 38 min (range: 30 to 60 min)] and time to return to baseline was shorter (240 versus 480 min for OTM).

The fast onset of action (20 min) and rapid T max (30 min) for the OTM gel suggests that it may help anxious dogs in a clinical setting. Blocking the arousal phase of distress, fear, and anxiety by blocking an noradrenaline pulse from the locus coeruleus has applications for anticipatory fear of and distress caused by veterinary visits ( 42 ), and for other situations involving arousal and acute anxiety including departures for dogs with separation anxiety and approaches from other dogs or humans for dogs which are fearful.

Oral transmucsoal dexmedetomidine gel is dosed at 125 μg/m 2 body surface area (each mL = 0.1 mg dexmedetomidine; 3 mL per syringe; 1 dispensing dot = 0.25 mL/25 μg) ( 43 ). For those lacking access to the licensed product, 25 to 40 μg/kg BW of the injectable dexmedetomidine has been given OTM ( 39 ). The anti-anxiety dose is lower than the sedative dose, but not established for OTM injectable dexmedetomidine.

In a survey of 1225 clients with dogs that reacted to fireworks, Riemer ( 44 ) reported that of all the treatments used, 74% of those using OTM dexmedetomidine gel said it was effective.

Alprazolam is a benzodiazepine, a class of medications typically used in pre-anesthetic and sedation protocols and for the treatment of anxiety, fears, phobia, and panic in cats and dogs, and in humans. Benzodiazepines have anxiolytic, panicolytic, relaxing, antiepileptic, and muscle relaxing effects in humans and in cats and dogs, and a label for use for specific anxiety in humans. The exact mechanism of these effects is undescribed and dependent on dosage and individual response.

How does alprazolam work?

Benzodiazepines bind to specific sites on the gamma-aminobutyric acid A (GABA A ) receptors, increasing flow of chloride ions into the neuron, enhancing the inhibitory effects of GABAergic neurons. Alprazolam, a triazolobenzodiazepine, is commonly used for behavior due to the rapid onset, anxiolytic, and truly panicolytic properties ( 12 , 45 ). Benzodiazepines have amnesic effects at clinically relevant doses, which is useful for sedation protocols and in animals experiencing profound fear or phobias ( 12 , 26 , 45 ). The muscle relaxation caused by benzodiazepines is independent of sedation and may help with patient fear and anxiety, as fearful animals typically have increased muscle tone ( 12 , 26 , 45 ).

Use of this medication is extra-label. Crowell-Davis et al ( 46 ) conducted an open-label trial evaluating clomipramine, alprazolam, and behavior modification for the treatment of storm phobia in dogs. Clomipramine (2 mg/kg BW) was given every 12 h. Alprazolam (0.02 mg/kg BW) was given 1 h before the expected storm and every 4 h as needed thereafter. Of the 32 dogs that completed the study, 30 were deemed by the clients and clinicians to have improved. When baseline scores were compared to those post-treatment 4 mo later, the signs of storm-specific anxiety that significantly decreased following administration of alprazolam were panting, pacing, trembling, remaining near the caregiver, hiding, excessive salivation, destructiveness, excessive vocalization, self-trauma, and inappropriate elimination. Improvement was best demonstrated during storms involving rain, thunder, and lightning, compared to those involving only rain.

The pharmacokinetics of alprazolam have not been described in cats and dogs. In human medicine, alprazolam is considered an intermediate-acting benzodiazepine with peak plasma concentration occurring 1 to 2 h after ingestion and mean plasma elimination t 1/2 of 11.2 h (range: 6.3 to 26.9 h).

Alprazolam may have a role in reducing anxiety and fear in patients during veterinary visits, although there are few reports in the literature ( 12 ). Use may also be interventional when a dog becomes distressed or panicked while undergoing veterinary care ( 12 ). This panicolytic effect has been observed in humans ( 45 ) and in cats and dogs ( 12 ). In cats, alprazolam has been primarily used to prevent fear and anxiety associated with travel and handling during examinations and procedures, but given the role that olfaction plays in contributing to feline reactivity, alprazolam may also be considered for use in cats returning from the hospital to a multi-cat household because of the altered olfactory social environment ( 12 , 26 ).

Alprazolam can be used interventionally if a patient becomes severely distressed or fearful during an appointment, and preventatively 30 to 60 min before the appointment to help relieve fear and anxiety and/or over 2 to 3 d before the appointment to reduce anticipatory anxiety ( 11 ).

The starting range is 0.02 to 0.04 mg/kg BW ( 44 ), but dosages as high as 0.1 mg/kg BW have been reported ( 12 , 47 ). In cats, the published dose range is 0.0125 to 0.025 mg/kg BW/0.125 to 1 mg/cat ( 48 ). There are no dose determination studies for alprazolam in cats and dogs.

The major adverse effect reported with use of benzodiazepines is sedation. Alprazolam is less sedative than diazepam and most adverse effects of benzodiazepines, including sedation and ataxia, are dose-dependent ( 12 , 49 ). Paradoxical excitement has been reported in cats and dogs, as has disinhibition of previously inhibited behavior (e.g., aggression) ( 12 , 46 , 49 ). Benzodiazepines are well-known for highly individually variable responses so recommendations are to start at a low dose and have clients give the first dose or two when they are at home to monitor their pet for any adverse reactions. Extremely rare, long-lasting adverse reactions or those posing a risk to the patient can be reversed with IV flumazenil.

Riemer ( 44 ) reported that 90% of 1225 owners surveyed who used alprazolam, alone, on an “as needed” basis reported it effective at reducing signs of fear in their dogs during fireworks. Using alprazolam as needed and clomipramine twice daily was effective for treating dogs with storm phobias in a prospective trial ( 46 ). Alprazolam has also been used successfully as an adjunctive therapy for separation anxiety and as a preventative or interventional treatment for noise phobias ( 12 ).

Alprazolam may facilitate less stressful and fearful visits to veterinary hospitals if given 1 h before the anticipated appointment. Due to the amnesic, anxiolytic, and panicolytic effects, alprazolam may be useful interventionally when patients become profoundly distressed during an appointment.

The concern for abuse potential

All benzodiazepines are abusable by humans and are controlled substances. Gabapentin is increasingly listed as a controlled substance due to its concomitant use with opioids in addiction and the subsequent increased risk of fatal overdose.

Not all medications belong in all client households. In addition to asking clients if there is anyone in the household or who visits the household who has a substance abuse issue, risk can be minimized by prescribing small amounts of medications that can only be renewed by talking with the veterinarian and with evidence of a beneficial effect (video, completed patient logs). Medication must be secured within the household, and clients should be cautioned not to advertise its presence. Re-examinations present an opportunity to review risks and benefits. All medications can be dispensed using a schedule and oversight that make abuse both difficult and more obvious.

This review focuses on behavioral medications for preventing or treating anxiety, stress reactions, and distress that occur in the context of veterinary care. Covariates of anxiety/distress before/during veterinary care include increased client stress, patient panic, enhanced patient aggression and oppositional responsiveness, and increased risk to the veterinary staff ( 6 , 7 , 9 , 11 ). Clients whose dogs and cats are fearful are less likely to use veterinary care except in an emergency, and worry about their companion’s welfare when they do seek care ( 6 , 9 , 50 ).

Of the 4 medications for which there was published information, 3 are not licensed for use in dogs or cats. Except for the licensed OTM dexmedetomidine, pharmacokinetic data are sparse and dose determination studies are lacking. This pattern is problematic. The existence and publication of these data would provide veterinarians with a greater comfort level in dispensing the medications discussed.

There are no published clinical studies on the use of gabapentin to address anxiety in dogs in any situation. Although there are some data on pharmacokinetics of gabapentin in dogs that suggest that the dosages discussed here are reasonable, dose-determination and efficacy studies are needed.

Trazodone needs to be more closely monitored in terms of dosages, systemic activating effects of serotonin, especially if TCAs or SSRIs are given concomitantly, or if high dosages are used, and other adverse events ( 31 ). Trazodone may be best used for its hypnotic properties for dogs in hospital settings in which sedation of some level is desired; this has been the focus of most of the published work ( 33 , 34 ). There are no dose determination studies for trazodone.

Oral transmucosal dexmedetomidine gel can be conveniently used to decrease anxiety and prevent distress ( 40 , 41 ). Oral transmucosal injectable dexmedetomidine may also be useful for decreasing anxiety and preventing stress at low dosage levels, but published studies are lacking. There are no dose determination studies for injectable dexmedetomidine used OTM as either a sedative or anxiolytic agent. Alprazolam is commonly used “as needed” for anxiety, fears, and phobias ( 44 ). There are no dose determination studies for alprazolam.

Behavioral medicine uses a multifactorial approach to treatment ( 12 , 47 ), with treatment plans tailored to a dog or cat’s individual needs ( 37 ). Behavioral medications stimulate translational changes involved in learning and so enhance and speed the effects of behavior modification ( 12 ). Combined with changes in handling, difficulty, stress, and distress involved in veterinary visits can be minimized for everyone ( 7 ).

Acknowledgments

This paper was researched and written by 4th year veterinary students (listed alphabetically) in the UPEI Atlantic Veterinary College rotation, Special Topics in Clinical Behavioral Medicine, that was offered to new clinical students during the COVID-19 pandemic. The research, discussion, and writing of the paper was coached and guided by Dr. Karen Overall. Dr. Overall is a consultant for numerous pharmaceutical companies, including Orion Pharma, the producers of Sileo. CVJ

Use of this article is limited to a single copy for personal study. Anyone interested in obtaining reprints should contact the CVMA office ( gro.vmca-amvc@nothguorbh ) for additional copies or permission to use this material elsewhere.

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Fear Free: What is a PVP? How Does It Help My Fearful Pet?

If you have a dog or cat who is fearful, anxious, or stressed during veterinary visits, the veterinary team may have recommended that you give your pet a PVP, or pre-visit pharmaceutical.

Originally printed in Fear Free Happy Homes.

These are medications that may be used in addition to training or behavior or environmental modifications to treat fear, anxiety, or stress associated with veterinary visits. PVPs can help to make veterinary visits more likely to be successful. The goal is to make your pet’s veterinary visit more enjoyable and less stressful. Because they reduce stress and anxiety, these medications can help to change the way your pet feels about specific procedures such as being handled or receiving a vaccination.

I Don’t Want to Drug My Pet

Giving an animal a medication with the intent to sedate or to slow down reaction time in order to address aggression or anxiety in the veterinary hospital is inappropriate. That’s not what is being recommended by your Fear Free veterinary team. The veterinary team wants to reduce fear, stress, and anxiety so your pet can receive lifelong care without concern. If this is not addressed, your pet may continue to have negative associations with the veterinary team and may be limited in the amount of medical care received.

PVPs maybe recommended with additional training, behavioral, or environmental modification. Your veterinary team will discuss how to conduct medication trials at home. And may schedule Victory Visits for your pet to trial the medications prescribed.

PVPs and How They Work

For feline patients, options include the following:

All these medications are used “off label” in dogs and cats. This means the FDA has not approved these medications for use in dogs and cats. This may raise a red flag, but the medications listed above have been documented, studied, and practiced in veterinary behavior literature and in veterinary practices for years and are considered safe for use. Side effects to watch for with any of these medications are increased lethargy, vomiting, diarrhea, or changes in appetite. With any anti-anxiety medication, there is the risk of dis-inhibition of aggression (loss of conscious control of the aggression response) or paradoxical excitement (in which the patient experiences the reverse effect of the medication).

Most of the medications listed above are known as “quick” acting. This means that once the medication is given it will take one to two hours to see the full effect. For most patients, the medication is in and out of the system in eight to 12 hours. It is a good idea to trial the medication at home first and report the effects to the veterinary team so they can assess the animal for possible side effects or negative responses. Your veterinary team will want to know three pieces of vital information:

• Amount of time before the medication takes effect in your pet
• Effects seen (less barking out the window, for instance)
• How long the effects lasted (returned to normal behavior after 7 hours)

Once you document this information, call the veterinary team and discuss your findings. They can then advise you on the next steps and potentially set up a Victory Visit to assess how your pet responds to the medications in a veterinary setting.

Your veterinary team cares greatly about your pet’s wellbeing: the state of being comfortable, healthy, and happy. This means that while we are trying to keep your pet healthy medically, we cannot ignore the signs of unhappiness such as fear, stress, and anxiety that are present while your pet is in our care. The goal of using PVPs is to improve your pet’s wellbeing at the veterinary hospital so we can keep him happy and healthy for as long as possible.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT. and the Animal Hospital of North Asheville. Rachel Lees, a Level 3 Fear Free Certified Professional, is a veterinary technician specialist in behavior, a KPA certified training partner, and lead veterinary behavior technician at The Behavior Clinic in Olmsted Falls, Ohio. She loves helping people create and maintain a strong human-animal bond.

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What’s a PVP? An Expert Explains

By Rachel Lees, RVT

If you have a dog or cat who is fearful, anxious, or stressed during veterinary visits, the veterinary team may have recommended that you give your pet a PVP, or pre-visit pharmaceutical. These are medications that may be used in addition to training or behavior or environmental modifications to treat fear, anxiety, or stress associated with veterinary visits.

When you have a pet who is fearful, medication can help to make veterinary visits more likely to be successful. The medications are intended to address specific neurotransmitters associated with fear, anxiety, or stress related to the veterinary setting. The goal is to help make your pet’s veterinary visit more enjoyable and less stressful. Medications can help to reduce stress and anxiety so the veterinary team can work to change the way your pet feels about specific procedures such as being handled or receiving a vaccination.

I Don’t Want to Drug My Pet

Giving an animal a medication with the intent to sedate or to slow down reaction time in order to address aggression or anxiety in the veterinary hospital is inappropriate. That’s not what is being recommended by your Fear Free veterinary team. The veterinary team wants to reduce fear, stress, and anxiety so your pet can receive lifelong care without concern. If this is not addressed, your pet may continue to have negative associations with the veterinary team and may be limited in the amount of medical care received.

PVPs are never recommended alone without training, behavioral, or environmental modification.  Your veterinary team will discuss how to conduct medication trials at home and will schedule Victory Visits for your pet to trial the medications prescribed.

PVPs and How They Work

Many different medications can be used to reduce your pet’s fear, anxiety, and stress. For canine patients, the following medications may be suggested:

For feline patients, options include the following:

All these medications are used “off label” in dogs and cats. This means the FDA has not approved these medications for use in dogs and cats. This may raise a red flag, but the medications listed above have been documented, studied, and practiced in veterinary behavior literature and in veterinary practices for years and are considered safe for use. Side effects to watch for with any of these medications are increased lethargy, vomiting, diarrhea, or changes in appetite. With any anti-anxiety medication there is the risk of disinhibition of aggression (loss of conscious control of the aggression response) or paradoxical excitement (in which the patient experiences the reverse effect of the medication).

Most of the medications listed above are known as “quick” acting. This means that once the medication is given it will take one to two hours to see the full effect. For most patients, the medication is in and out of the system in eight to 12 hours. It is a good idea to trial the medication at home first and report the effects to the veterinary team so they can assess the animal for possible side effects or negative responses. Your veterinary team will want to know three pieces of vital information:

• Amount of time before the medication takes effect in your pet
• Effects seen (less barking out the window, for instance)
• How long the effects lasted (returned to normal behavior after 7 hours)

Once you document this information, call the veterinary team and discuss your findings. They can then advise you on the next steps and potentially set up a Victory Visit to assess how your pet responds to the medications in a veterinary setting.

Your veterinary team cares greatly about your pet’s wellbeing: the state of being comfortable, healthy, and happy. This means that while we are trying to keep your pet healthy medically, we cannot ignore the signs of unhappiness such as fear, stress, and anxiety that are present while your pet is in our care. The goal of using PVPs is to improve your pet’s wellbeing at the veterinary hospital so we can keep him happy and healthy for as long as possible.

This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.

Rachel Lees, a Level 3 Fear Free Certified Professional, is a veterinary technician specialist in behavior, a KPA certified training partner, and lead veterinary behavior technician at The Behavior Clinic in Olmsted Falls, Ohio. She loves helping people create and maintain a strong human-animal bond.

Published August 26, 2019

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For veterinary teams, pre-visit pharmaceuticals (PVPs) are often the key to more accurately evaluating patients without causing them unnecessary fear, anxiety and stress. According to Dr. Robin Downing, an Elite Fear Free Certified Practitioner, prescribing PVPs and treating pain with analgesics “are supported by sound bioethical principles, and these principles apply to the patient, the pet owner and the veterinary health care team.” When used correctly and conscientiously, PVPs and analgesics can contribute to a practice’s profitability.

EDITOR’S NOTE

This is the third in a three-part series on using sedation and analgesics to improve veterinary care and boost the bottom line. This Clinic Consult series is brought to you by Dechra .

How They Increase Revenue

Recommending PVPs and analgesics financially benefits the pharmacy profit center — more sales mean more revenue. In addition, such medications can lead to:

• Better compliance: Clients are more likely to bring a pet for regular wellness care and recommended rechecks if they aren’t anxious about the animal’s travel and in-clinic behavior. Pets that benefit most from pre-visit pharmaceuticals are those whose anxiety begets anxiety. It’s a vicious cycle that escalates the client’s apprehension. PVPs help ensure the pet’s veterinary experience is more pleasant and that the client is more likely to provide needed care when they see the results.
• Clinic efficiency: Frightened or anxious pets are often uncooperative, making diagnostics difficult. PVPs simplify procedures, helping the veterinary team work more efficiently and be more productive.
• Improved patient care: When the pet is calm and cooperative, the team can more easily recognize issues that might need further diagnostics like X-rays or ultrasound. Those services also increase revenue.

“When we are proactive with communication about why sedation is necessary and use early intervention, we see a more relaxed patient and client,” said consultant and Today’s Veterinary Business columnist Dr. Natalie L. Marks . “This leads to a boost in revenue because we now have the ability to do a thorough and complete physical examination and recommend diagnostics.”

More for the Team

Ensuring your team members are well-versed in client communication and the promotion of pre-visit pharmaceuticals and analgesics supports consistent messaging. Practice leaders should explain to the team that the sensible use of PVPs and analgesics spurs greater profitability, a bounty that can be shared through wage increases and more fringe benefits.

Elevating Client Trust

When pet owners see their dog or cat struggling during an examination, the veterinarian-client-patient relationship becomes strained. On the other hand, a veterinary professional’s recommendation that a pet be sedated during the visit or receive a PVP communicates to the client that the patient’s best interests are front and center. The understanding immediately puts the owner and health care team on the same side, with everyone focused on a positive experience for the pet.

Once clients see the difference a medication can make, they greatly appreciate the team’s efforts to maximize the pet’s comfort during a visit. In addition, effective pain management can restore the activities a pet once enjoyed and improve the cat or dog’s quality of life, elevating the owner’s trust.

“Witnessing and participating in these lifestyle improvements can cement a client’s commitment and loyalty to a practice,” said Dr. Downing, who heads the Downing Center for Animal Pain Management. “Their trust increases, and the probability of their accepting and carrying through with veterinary recommendations improves as well.”

A Competitive Advantage

When administered appropriately, pre-visit pharmaceuticals and analgesics can help a practice retain clients and attract new ones by:

• Reducing frustration: Pets that become severely stressed during an exam or diagnostics might need their appointment to be rescheduled, which can frustrate owners who took time out of their day for the visit. PVPs allow the team to perform necessary tasks without delay.
• Improving the veterinary experience: Many clients whose pets need PVPs might have had negative encounters at previous appointments, so they typically arrive worried and anxious. When they witness a positive experience, they’re often grateful and relieved that their pets can be cared for without stress and anxiety.
• Addressing acute pain: Managing a pet’s pain after surgery or dentistry work communicates that your practice is serious about pain control.
• Addressing chronic pain: Proper long-term management of chronic maladaptive pain can significantly improve a pet’s quality of life. Most owners will seek clinics that demonstrate compassionate care and effective pain-relieving medication protocols.
• Inspiring positive publicity: Satisfied clients are more likely to recommend your veterinary practice to friends and family and post complimentary reviews.

Proper Pricing

If you don’t charge appropriately for pre-visit pharmaceuticals and sedation, you can create the perception that the services aren’t helpful, undermining their value. However, overpricing them can make the medications cost-prohibitive for some clients. That can be a problem for the team because many veterinary professionals are reluctant to recommend a product or procedure they deem too costly.

The goal is to ensure that all patients receive PVPs and analgesia as needed, which typically requires a volume-based, margin-pricing structure. You must determine the best strategy for your practice by assessing the number of patients that will or should require medication and determining the pharmaceuticals or cocktails your team is most comfortable using.

“I look at sedation as a tool to allow a complete physical exam, formulate thorough recommendations and move forward with additional diagnostics,” Dr. Marks said. “A price that is cost-prohibitive for most clients creates a big obstacle to further workups.”

AFTER SEDATION

When you discharge a pet recovering from sedation, provide the owner with detailed, transparent information. For example:

• When the patient’s behavior will return to normal.
• How a “normal” recovering patient looks.
• When and how much to feed the pet.
• When exercise may resume and any restrictions.
• Any nuances of the pharmaceutical or its administration.
• When to call the veterinary practice or seek after-hours care.

“PVPs have changed the landscape of our practice,” said Dr. Robin Downing of the Downing Center for Animal Pain Management. “The rewards are tremendous when we work cooperatively with patients — better for pets, better for the people who love them and better for the veterinary health care team.”

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Pre-Visit Medications for Your Pets!

Over 80% of dogs and cats experience fear and anxiety when they visit the vet’s office. Why is this important? Fearful and scared patients may not be able to be examined as thoroughly, and may not be able to have needed testing like a blood draw. They may have fear-based aggression which is a safety risk to not only staff, but also themselves and to the owners handling them. On top of this, it is not great for the patients to be experiencing so much stress!

So what does fear, anxiety, and stress (FAS) look like in dogs and cats? They can both display a range of behaviors.

• Excessive pacing, activity, jumping, and not relaxing
• Panting when there is no reason to pant like hot temperature or exercise
• Lip-licking
• “Wet dog” shaking when not wet
• Hiding and trying to move away
• Freezing with stiff posture
• A hard stare or side-eye
• Struggling and flailing during restraint
• Raising their lip (snarling)
• Growling, barking, lunging
• Warning snaps or biting
• Not coming out of the carrier
• Trying to “tuck” and make themselves small
• Wide eyes and dilated pupils
• Hissing, growling
• Swatting, attempting to bite

Some signs are more subtle. If you ever want help assessing your pet’s fear level at the office, just ask the veterinary staff. Veterinarians, veterinary technicians, and many other staff members are trained to assess each patient’s level of stress for both the patient’s welfare and our safety.

One of our goals during your pet’s visit is to make them as comfortable as possible, in addition to achieving the best exam and necessary testing. There are many methods we use including different handling techniques, calming pheromones, positive training, and treats and food. One tool is “Pre-Visit Medications”. (These may also be called pre-visit pharmaceuticals, short-acting anxiety medications, and pre-meds; among other terms).

Pre-visit medications are given to a pet to reduce their anxiety, make them more comfortable, improve ease of handling for owners and staff, and facilitate better exams and testing. There are a variety of medications we use depending on the patient, health conditions, level of fear, and individual patient response. These medications include but are not limited to: trazodone, gabapentin, clonidine, acepromazine, and dexmedetomidine (Sileo). Specific recommendations and methods can be made by your veterinarian.

Will the medication make your dog sedated or have other side effects? Some of the medications may make your pet a little sleepy, especially when they are at home. Your pet may seem sedated until they actually come into the vet office where they are more nervous. Most of the time, the goal is not excessive sedation – and in the worst case, we would prefer that our patients are feeling sleepy instead of feeling terrified. Other types of side effects are limited and rare in normal healthy patients, but any veterinarian who is prescribing these medications will select them with your pet’s health in mind, and can discuss any concerns.

Sometimes pre-visit medications may be recommended even if your pet is not highly fearful or aggressive. Your pet may be experiencing more subtle signs (such as the panting, avoidance, or hiding behaviors), and intervening BEFORE they become more fearful is important as well!

We commonly use these tools at Montgomery Animal Hospital to achieve the best visit for you and your pet. If you would like to discuss adding pre-visit medications into your pet’s visit, please feel free to call our office or schedule a behavioral consultation.

Here are resources on FAS in the veterinary setting, as well as using pre-visit medications:

• Using Medication to Lower Veterinary Visit Stress in Dogs and Cats – Veterinary Partner – VIN
• How to Make Veterinary Visits Less Stressful – Veterinary Partner – VIN
• Understanding Your Dog’s Body Language – Veterinary Partner – VIN
• Cats 101 | Fear Free Happy Homes
• Fear Free Vet Visits | Fear Free Happy Homes

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Table of contents.

• Front Matter
• Anesthesiology of Small Mammals, Birds, Reptiles
• Birds, Exotics, Rabbits
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• NAVC (How I Treat)
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There is no “one way” to make a visit a Fear Free℠ experience. Individual animals and clients will have individual preferences. While performing procedures we often have to touch our patients in sensitive areas. Creating a plan of action for each patient can be a quick process that saves time and creates a more pleasant experience for the veterinary healthcare team, the patient, and the client.

Considerate Approach, Gentle Control, and Touch Gradient

The following are definitions from the Fear Free℠ Certification Program. Considerate approach encompasses the interaction between the veterinary team and the patients and inputs from the environment while veterinary care is being administered. Gentle control is how the veterinary team comfortably and safely positions the patient to allow the administration of veterinary care. The goal of considerate approach and gentle control is to alleviate fear, anxiety, and stress (FAS) in your patients.

Some key concepts with gentle control include: restraint is frightening and creates FAS; use the least amount of restraint as needed. In general, it is beneficial to use treats before, during, and after procedures. Constant communication between team members is critical.

Touch gradient is a term used to describe how to touch our canine and feline patients to minimize fear, anxiety, and stress (FAS) during veterinary procedures. Touch gradient encompasses both gentle control and considerate approach.

Touch gradient has two components:

• It begins by maintaining continual physical hands on contact throughout the entire procedure or examination whenever possible.
• It includes acclimating a patient to an increasing level of touch intensity, while continuously measuring the patient’s acceptance and comfort.

Plan of Action

There are multiple components to creating a plan of action for a procedure.

1.  Assess the patient.

a.  Observe and notate body language and behavioral indictors of fear, anxiety, and stress.

b.  Notate the current level of FAS based on the FAS scale.

c.  Continuously reassess throughout the procedure.

2.  Assess yourself.

a.  Are you utilizing a considerate approach?

b.  Ask for help if you are feeling uncomfortable.

3.  Assess the environment.

a.  Remove stressors in the environment.

b.  Set up a calming environment.

4.  Create a veterinary plan for care.

When creating the veterinary plan for care, first determine a reinforcement hierarchy/reward ladder for the patient today. You may refer to the emotional record of the patient but reassess the patient’s response today. Next, rank procedures as most to least important procedure. The veterinarian will be responsible for determining the importance of procedures. Now, rank the most important procedures as least to most aversive. Determine if there are stopping points for breaks in the procedure and what behavioral indicators for this patient will be considered a stopping point.

Once you have a high-level reinforcer for the patient, a plan for which order you will perform the procedures, and stop points, now consider the 3 Ws;

• Where will you perform the procedure? The exam room, treatment area, housing area?
• Who will be present? If possible, it is usually best for the owner to be present.
• What do you need to make the environment as pleasant as possible? What items do you need for the procedure? Get everything ready before the patient is brought to the area.

Always be willing to ask for assistance from other team members as needed for re-evaluation of the plan.

Want Versus Need

Wants are things that you would like to perform today. Needs are procedures that must be performed today because they are treatments that are vital to the health of the animal right now and waiting any length of time to perform them would be severely detrimental to the patient’s health.

For wants that are producing FAS in the patient, it does not mean the procedure will never be performed but instead we need to consider other options such as, being willing to reschedule. Perhaps the patient has reached his/her tolerance for today. Another day may be better. In the meantime, schedule some fun/victory visits for the patient to have a pleasant experience at the hospital. The veterinarian may consider dispensing pre­visit pharmaceuticals (PVPs). If rescheduling is not an option, sedation to minimize the potentially emotionally damaging experience should be considered by the veterinarian.

Case Examples and Discussion

Case examples will be reviewed and through audience participation options for a Fear Free℠ plan of action will be determined.

Through early recognition of behavioral signs of fear, anxiety, and/or stress and intervention on our end, we can prevent the escalation of fear in our patients. Thus, we can facilitate pleasant associations with the veterinary hospital and the procedures we want to perform. Creating a veterinary plan for care for each patient, will help facilitate a Fear Free℠ experience for all team members.

For more information on the Fear Free℠ certification program and resources visit: www.fearfreepets.com .

D. Martin, CPDT-KA, KPA CTP, LVT, VTS (Behavior) TEAM Education in Animal Behavior Spicewood, TX, USA

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From now until July 31, 2024: How to Apply for a CDC Dog Import Permit

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• Each person or organization may be granted approval (permits) to bring in a maximum of 2 dogs for one trip during the temporary suspension. People wishing to import dogs for science, education, exhibition, or bona fide law enforcement purposes may be granted approval to import more than 2 dogs.
• be at least 6 months old, as verified by submission of current photos of the dog’s teeth
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• have a valid CDC Rabies Vaccination and Microchip Record
• have a valid rabies serologic titer from an approved laboratory . For dogs older than 15 months with booster vaccinations, make sure the CDC Rabies Vaccination and Microchip Record shows the current rabies vaccination and at least one previous rabies vaccination given when the dog was 12 weeks old or older if your dog’s titer was collected less than 30 days from the date of the current rabies vaccination.
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Read through the required documents below as soon as you can. You should also read the  application instructions on how to fill out the permit application form line by line. Be sure you understand all that is required and what decisions you may need to make before filling out and submitting the permit application form.

CDC Dog Import Permit Application Instructions

An incomplete application will delay the time to process the permit.

If you are granted a permit, the validity dates of the permit may be from 14 days before planned entry up to August 31, 2024, provided the dog meets all entry requirements during that time frame. The dog may only travel to the United States during the period of validity listed on the permit. If your arrival date changes to outside the period your issued permit is valid, please submit a new application and note in the additional comments section that you are requesting changes to a current permit.

The permit can only be used once before the expiration date.

The permit will only be issued to a single person, known as the Applicant. The Applicant must be at least 18 years old to apply. You, as the Applicant, may designate someone (for example, a family member or friend), known as the Permit Holder, to travel with the dog to the United States. If this is the case, then you must make sure the Permit Holder receives the permit so the Permit Holder can present it to a U.S. Customs and Border Protection officer upon arrival.

At the Port of Entry

Once the CDC Dog Import Permit has been received, the applicant must ensure a copy of the permit travels with the dog. The dog must be declared on arrival, and the permit must be presented to U.S. Customs and Border Protection. Once the dog is within the United States, the applicant (or Permit Holder) of the dog listed on the permit must confine the dog at the address listed on the permit. The dog may not be placed at any other location or with any other person until the confinement period has ended. Ownership of the dog can’t be transferred to another person while the dog is in confinement. The confinement period for permitted dogs ends once the dog is revaccinated against rabies in the United States, which must occur within 10 days of arrival.

Don’t forget: In addition to CDC regulations, you must comply with  US Department of Agriculture’s (USDA) and your US destination’s regulations . Regulations of US states or territories may be more strict than federal regulations.

Collect the Documents You Must Submit with the Permit Application Form

You will upload these documents as part of the application process. Give yourself plenty of time to gather all the required documents.

Documents must be submitted in English or be accompanied by a certified English translation. A  certified  translation is a signed statement on professional letterhead issued by a licensed translator declaring that the translation is an accurate and true representation of the original document. The translation must include the name, address and contact information of the translator and have a signatory stamp or elevated seal with the translator’s license number included. A certified translation service provider can be found online.

1. Photographs: Take two clear photographs of your dog’s teeth (make sure the photographs are recent and taken within 10 days of submitting your application) and include them with your permit application:

• Front view of upper and lower teeth
• Side view of upper and lower teeth
• Dogs need to be at least 6 months of age at the time you submit the application to CDC

2. CDC Rabies Vaccination and Microchip Record : This is the only rabies vaccination certificate that CDC will accept from dogs vaccinated outside of the United States. Have your veterinarian completely fill out the  CDC Rabies Vaccination and Microchip Record . The record must document a current rabies vaccination and at least 1 prior rabies vaccination if your dog’s titer was collected less than 30 days from the date of the current rabies vaccination. Remember, if your dog’s rabies vaccination is expired, you cannot apply for a permit.

• For dogs vaccinated for the first time and for dogs younger than 15 months old: Submit a current CDC Rabies Vaccination and Microchip Record showing the rabies vaccine was given on or after 12 weeks of age and at least 28 days before the intended arrival date.
• For dogs older than 15 months with booster vaccinations: Submit a  CDC Rabies Vaccination and Microchip Record  that shows the current rabies vaccination and at least one previous rabies vaccination given when the dog was 12 weeks old or older if your dog’s titer was collected less than 30 days from the date of the current rabies vaccination. Enter the date of the most recent rabies booster into the application and submit a  CDC Rabies Vaccination and Microchip Record  showing both rabies vaccinations with the application.

3. Serologic titer from an  approved laboratory : You must submit serologic titer results from an approved laboratory as part of your CDC dog import permit application.

• Titers must be drawn at least 30 days after your dog's first rabies vaccine was administered.
• For dogs older than 15 months with booster vaccinations, the titer may be drawn at any time, but make sure the CDC Rabies Vaccination and Microchip Record shows the current rabies vaccination and at least one previous rabies vaccination given when the dog was 12 weeks old or older if your dog's titer was collected less than 30 days from the date of the current rabies vaccination.
• Dogs must wait 45 days from the date their titer is collected before they can enter the United States.
• Titers are valid for entry for one year (365 days) from the date the titer was collected.

4. Passport photo: Obtain a clear photo of the identification page of the applicant’s and permit holder’s passports, U.S. visa or U.S. permanent resident card (“green card”).

If you need to request a change to a permit that CDC has already issued, please submit a new application by clicking the blue button above and note in the additional comments section that you are requesting changes to a current permit.

For more information, see: Frequently Asked Questions on CDC Dog Importations

If you have questions or need more information, please contact CDC-INFO at (800) 232-4636.

CDC regulations govern the importation of animals and animal products capable of causing human disease.

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Welcome to the Fear Free Veterinary Certification Program!

As veterinary professionals, we understand the emotional demand of the veterinary field, and we know the impact that stress and anxiety can have on our patients, our team, and our practices. Our goal: Provide veterinary professionals with the tools and knowledge to address different levels of fear, anxiety, and stress; improve client communication; and increase workplace safety.

Fear Free veterinary visits reduce fear, anxiety, and stress and create an experience that is more enjoyable and safer for all involved, including your patients, clients, and team. Learning how to implement Fear Free visits means veterinary teams will see their patients more often, and pet owners will seek advice from them as a trusted source.

This program consists of eight modules, which will need to be taken in consecutive order.

Each module will end with an exam which needs to be successfully completed prior to moving on to the next module. Progress on work can be saved at any time, giving participants the flexibility to self-pace throughout the program. When all eight modules have been completed, the participant will be awarded with a Fear Free certificate.

The purchase of the Fear Free Veterinary Certification Program provides you with an annual membership for the program, which requires an annual renewal fee and completion of additional annual CE to maintain your membership. Be sure to familiarize yourself and your team with the full renewal details for the Fear Free Veterinary Certification Program here.

As a Fear Free Certified Professional, you will:

• Reduce or remove anxiety triggers that can cause pets to become fearful at home, in transport, and at the veterinary hospital
• Help owners deliver calm pets to your hospital
• Enhance the quality of medicine in your practice
• Increase compliance
• Improve safety for the veterinary team

Course Overview

Module 1: fear free behavior modification basics.

This module consists of five lessons.

Lesson 1: The Stress Response

By the end of this lesson, you will be able to:

•  Define stress and the stress response
•  List the body systems affected by the stress response
•  Describe the effect of the stress response on learned behaviors
•  Provide examples of factors that cause patient stress in the veterinary hospital
•  Describe how patient stress impacts the delivery of quality veterinary care

Lesson 2: Body Language

•  Identify five common body language signs that tell you a cat is relaxed
•  Identify five common body language signs that tell you a cat is stressed
•  Identify five common body language signs that tell you a dog is relaxed
•  Identify five common body language signs that tell you a dog is stressed

Lesson 3: Learning Theory

•  Explain what positive reinforcement is and how it affects behavior
•  Explain what positive punishment is and how it affects behavior
•  Identify at least three reinforcers that can be used in a veterinary setting
•  Explain why positive punishment should be avoided in the veterinary setting

Lesson 4: Behavior Modification

•  Define conditioning
•  Differentiate between operant and classical conditioning
•  Explain the goal of classical counter-conditioning
•  Explain why giving a scared pet food will not reinforce fear or fear-based aggression

Lesson 5: Perception of Social and Physical Environments

•  Recognize that behaviors in your patients are connected to their predatory, prey, and social relationships with other animals and people
•  List important aspects of each sensory system (sight, sound, scent, taste, and touch) for each species
•  Recognize how a patient’s perception affects its behavior in the veterinary hospital setting
• List methods for FAS in patients using knowledge about their perception

Module 2: Fear Free Transport of Cats and Dogs to and from the Veterinary Hospital

This module consists of three lessons.

Lesson 1: General Guidelines for Transport of Cats and Dogs

• Recognize the different roles of veterinary team members in ensuring a positive transport experience for patients
• Describe to clients how to prepare their cat or dog for transport to the veterinary hospital
• Describe to clients how to reintroduce their cat or dog to their home environment after the veterinary visit

Lesson 2: Feline-Specific Transport Techniques

• Discuss feline-specific transport needs
• Advise clients on how to meet these needs
• Counsel owners through problem scenarios

Lesson 3: Canine-Specific Transport Techniques

• Discuss canine-specific transport needs

Module 3: Fear Free Reception and Waiting Area

This module consists of four lessons.

Lesson 1: Making the Appointment

• Develop a plan for delivering a calm, Fear Free patient to the hospital, starting with booking the appointment
• Minimize fear and anxiety upon arrival to the hospital by attending to the physical and emotional needs of patients while in the waiting area
• Share and explain concerns about a particular patient to the rest of the healthcare team

Lesson 2: Reception Area

• Identify and resolve issues for patients experiencing fear, anxiety and stress
• Plan ways to separate patients and increase their comfort
• Develop efficient and safe check-in and check-out protocols
• Make use of patient history and past experiences to improve the next visit
• Distinguish between the special species needs of cats and dogs

Lesson 3: The Technician’s Role

• Explain the technician’s role and duties in assisting the CCR as patients enter the hospital and be ready to help where needed
• Apply the appropriate low-stress tools available for use with anxious patients in the waiting area and examination room prior to the exam

Lesson 4: The Veterinarian’s Role

• Show clients the importance of creating a Fear Free trip to hospital to keep the client, pet, and staff safe and relaxed
• Organize the veterinary team to ensure that all pets will be prepared to travel from home to the hospital
• Identify anxious clients and/or patients and be ready to revamp their visit plan accordingly

Module 4: The Fear Free Exam Room

Lesson 1: preparing the exam room.

Understand how patients experience the exam room Create your own Fear Free exam room Apply the benefits of a Fear Free exam room in your practice

Lesson 2: History Taking for a Fear Free Physical Examination

Obtain and record the emotional history of the patient List the reasons recording the patient’s emotional history is important Describe how to note the emotional history in the medical record

Lesson 3: Client Communication

Define the key communication responsibilities of each veterinary team member Establish Fear Free terminology to be used by your team Explain Fear Free techniques to the client

Lesson 4: Patient Interaction

Explain how to use the concept of considerate approach based on history, observation, and understanding of the patient’s behavior Explain how to adjust your tone of voice and movements based on the patient’s behavior Learn how to use considerate approach and gentle control handling

Lesson 5: Physical Examination

Module 5: fear free in-hospital care, lesson 1: patient transport to the treatment area.

• Explain the three important steps of transporting patients from the front of the hospital to the back
• Explain the three types of stimuli that patients may react to along the way
• Comfortably separate the patient from the client on admission
• Lead the patient safely to the treatment area or wards

Lesson 2: The Fear Free Treatment Area

• Understand the reasons for creating a Fear Free experience in the treatment area
• Identify three areas where planning a Fear Free experience may be done
• Provide and utilize strategies for handling different patients
• Provide options when things are not going well

Lesson 3: Fear Free Housing

• Discuss four ways to reduce FAS in hospitalized patients
• Create a stress-reduced environment for your patients

Lesson 4: Recognizing FAS in the Hospitalized Patient

• Explain the impact of long-term stress on a hospitalized patient
• Recognize anxiety behaviors in hospitalized patients
• Understand how anxiety and medical problems overlap
• Implement protocols to respond to stressed hospitalized patients

Lesson 5: Gentle Handling of Patients in the Kennel Area

• Explain which skills are essential for kennel staff to handle and care for patients safely
• Explain how to perform simple treatments on hospitalized patients in a safe and gentle manner

Module 6: Fear Free Procedures

Lesson 1: fear free environmental guidelines for procedures.

• Identify locations where procedures might be performed for cats and dogs to provide for a Fear Free experience • Recognize that fewer team members and less restraint is best in most cases for both dogs and cats • Identify strategies to transition or move a pet for a procedure in the least stressful manner possible

Lesson 2: General Guidelines for Gentle Control and Team Member Roles

• Name the two major reasons veterinary handling is stressful for patients • Identify three options for positioning patients for procedures • List concepts that reduce patient stress and increase their ability to cope with handling and procedures

Lesson 3: Gentle Control Tools

• Explain the potential benefits associated with the use of gentle control tools • Recall the importance of positively conditioning the patient to a muzzle or other tool

Lesson 4: Performing Specific Procedures

• Apply gentle control techniques to several common feline and canine procedures • Identify methods for collecting blood samples using gentle control techniques in cats and dogs

Module 7a: Pre-Visit Protocols: Complementary Therapeutics, Products, and Pharmaceuticals

Lesson 1: complementary and alternative therapeutics.

• Describe the differences between complementary therapeutics and alternative therapy
• Identify complementary therapeutics that might aid in reducing fear, anxiety, and stress associated with travel and veterinary visits
• Describe how these products should be used, including advice that should be provided to pet owners

Lesson 2: Behavior Management Products

• Identify behavior management products that might aid in reducing fear, anxiety, and stress during car travel and veterinary visits
• Identify behavior management products that might aid in low-stress, gentle control for handling and procedures

Lesson 3: Pre-Visit Pharmaceutical Regimens

• Explain the benefits of PVPs for pets, clients, and veterinary staff
• Prescribe appropriate pre-visit pharmaceutical agents used in cats
• Prescribe appropriate pre-visit pharmaceutical agents used in dogs
• Explain pertinent information about timing, methods of administration, expected response, and precautions for PVPs to clients

Module 7b: In-Hospital Protocols for Sedation, Anesthesia, and Analgesia

Lesson 1: in-hospital sedation: when and how.

By the end of this session, you will be able to:

• Describe why sedation and analgesia protocols are necessary
• Explain why protocols should be based on available drugs, patient health, pain level, behavior, and planned procedures

Lesson 2: Pharmaceutical Choices: Advantages, Disadvantages, and Tips for Sedative, Anesthetic, and Analgesic Drugs

• Discuss the advantages and disadvantages of the drugs most commonly used for sedation or anesthesia in patients that experience fear, anxiety, and stress or are aggressive
• Decide which drugs are appropriate or inappropriate for select patients
• Identify patient factors for choosing sedative, anesthetic, or analgesic drugs for Fear Free protocols

Lesson 3: Drugs for Extreme Fear, Anxiety and Stress or Aggression

• Discuss why sedatives work better in patients not experiencing fear, anxiety, and stress and/or aggression
• Discuss why anesthetic drugs may be necessary in patients already exhibiting fear, anxiety, and stress and/or aggression
• Choose a pharmaceutical protocol for a patient who is experiencing fear, anxiety, and stress and becoming aggressive even though a sedative drug has been administered

Lesson 4: Fear Free Pharmaceutical Protocol Suggestions

By the end of this lesson you should be able to:

• Create pharmaceutical protocols for a Fear Free experience for a variety of patients
• Understand that patient response to pharmaceuticals is highly variable
• Understand why multimodal protocols are preferred

Additional Benefits

• Complimentary access to other Veterinary Certification Programs
• Complimentary additional RACE-approved CE courses
• Fear Free Directory Listing
• Private Facebook group
• Fear Free Educational Library
• Fear Free Toolbox with downloadable marketing tools, drug charts, and more
• Exclusive discounts on Fear Free-related products through the Preferred Product Program
• Online store for marketing, branding, and educational handouts and brochures
• Fear Free Job Board
• Certification Gift

Continuing Education

• Upon completion of the modules, you will receive a total of nine RACE-approved CE hours.
• The program is also eligible for seven CVPM-qualified CE hours through the VHMA.

Veterinary Certification Requirements

In order to earn Fear Free certification, veterinary professionals must successfully complete the online certification program. To uphold your certification, you must:

1. Earn 4 additional hours of Fear Free-specific CE annually.

2. Maintain an active membership via an annual renewal fee. Your renewal fee is due annually from the date you initially register and pay for the Fear Free Certification Program. Keep an eye out for reminder emails and instructions on how to pay your renewal fee.

Earning the Elite Fear Free Certified Professional Designation

Becoming an Elite Fear Free Certified Professional is for veterinary members who want to go above and beyond in their commitment to Fear Free. Elite Fear Free Certified Professionals are individuals who are continually committed to a higher level of education. In short, it is an opportunity to set yourself apart from the rest.

The requirements to become an Elite Fear Free Certified Professional are…

• Completion of an individual veterinary certification program
• Completing 35 hours of Fear Free veterinary CE available through the veterinary membership or at industry events and/or conferences
• Continuing to earn 4 additional hours of Fear Free CE annually
• Maintaining an active Fear Free membership via an annual renewal fee

To track your progress toward becoming an Elite Fear Free Certified Professional, follow the CE tracker on your Member Homepage. Once you earn the required 35 Fear Free CE hours, you will receive a congratulatory email (where you can claim your free Elite kit) and an Elite Fear Free Certified Professional badge on your Member Homepage.

I have been in practice for 30 years and this is a game-changer. I have been so pleased at how quickly and effectively I have been able to integrate Fear Free practices into my daily work, even in areas outside of primary care. It has had a significant side effect too: happy, less stressed doctors and staff. Suzanne Cook Olson, DVM, DACVIM

Group Pricing: Fear Free is Better Together! 

$299/person

2-9 MEMBERS

$279/person

10-29 MEMBERS

$169/person

30-99 MEMBERS

$129/person

100 + MEMBERS

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Why? Renewing and keeping an active membership is one of the requirements to maintaining your certification as well as access to member benefits.

Need help? Please contact our Customer Experience team at [email protected] or call us at 303.952.0585 and we will be happy to assist!

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Please note: If you were recently removed from your Fear Free team, your membership will either expire 90 days from the removal date or expire at your current membership renewal date, whichever comes first. Already renewed? Update your account information through the link above. You will continue to receive this notice until your company information has been updated.

Need to join a different Fear Free team or have questions? Please contact our Customer Experience team at [email protected] or call us at 303.952.0585 and we will be happy to assist!

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Great! You want to become a Fear Free Certified ® Practice.

Best decision ever!

Beyond the long-term benefits of your patients and clients, Practice Certification improves career satisfaction and safety. Here are some steps you’ll need to take:

• Implement the Fear Free Certified Practice Standards and complete the online self-assessment
• Certify 100% of your team.
• Complete a successful visit with a Fear Free Practice Certification Consultant

Have questions? Check out the Fear Free Practice Certification page .

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Please note: We don’t currently offer facility certification for non-veterinary facilities. If you want us to contact you when it is available for non-veterinary facilities, click here .

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Veterinary Program $299.00

As a veterinary member, you will have access to all veterinary courses. Which course you would like to start with?

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Animal Trainer Program $229.00

Groomer Program $229.00

Pet Sitter Program $229.00

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A team admin account is best suited for practice and team leaders who wish to register two or more team members for any Fear Free® certification memberships.

• Gives you access to your own team purchasing and management tool. Requires a designated team admin to oversee team progress.
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What is a team admin account?

The team admin account is best suited for practice and team leaders who wish to register two or more team members for any of the Fear Free Certification Programs. The team admin account is intended to serve as a purchasing and management tool for the individual overseeing their team’s progress with Fear Free. Please note what limitations the team admin account will have below.

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The online self-assessment is comprised of the Fear Free Certified Practice Standards and is accessible via the Practice Certification Dashboard (PCD). Access to the PCD is provided to the Team Admin account after the $500 USD non-refundable registration fee is paid.

25% of the entire staff is Fear Free Certified and has active (not expired) memberships. The 25% must include 50% + 1 of your FTE veterinarians.

To become a Fear Free Certified Practice, you will need to:

• Meet the minimum Fear Free Certified and active member staff requirements
• Complete a successful virtual visit with a Practice Certification Veterinarian

You’ll pay a $500 non-refundable deposit to register to start the process of becoming a Fear Free Certified Practice.

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Student and faculty registration.

Fear Free is excited to offer students, faculty, and staff of veterinary schools, veterinary technician/nurse schools, and veterinary assistant schools complimentary registration and renewal for the time they are enrolled in an educational institution. The offer is open to students of all levels above the age of 18 for the duration of their time in school, and we encourage you to take advantage of this offer as soon as possible! You will be required to complete the form in the link below to obtain registration or renewal instructions via email. Please email [email protected] with any questions.

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Fear Free is excited to offer students, faculty, and staff of veterinary schools, veterinary technician/nurse schools, and veterinary assistant schools complimentary registration and renewal for the time they are enrolled in an educational institution. The offer is open to students of all levels above the age of 18 for the duration of their time in school, and we encourage you to take advantage of this offer as soon as possible! You will be required to complete the form in the link below to obtain registration or renewal instructions via email. Please email [email protected] with any questions. Go to the student and faculty registration page.

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