Behavior Modification, Pt. 2

Question 1

What are 8 indications for short-term psychotropics?

Answer 1

1. veterinary visits
2. car travel
3. separation anxiety (+ long-term meds)
4. visitors
5. noise aversion
6. new baby/family members
7. bridge medication (switch from one medication to another)
8. adjunct to daily medication

Question 2

What are 5 common classes of short-term psychotropics?

Answer 2

1. serotonin antagonist and reuptake inhibitors (SARIs) - Trazodone
2. α2 agonists - Dexmedetomidine gel (Sileo)*, Clonidine
3. GABA analogues - Gabapentin, Imepitoin (not in US)
4. benzodiazepines - Diazepam (Valium), Alprazolam (Xanax), Clonazepam (Klonipin), Lorazepam (Ativan)
5. phenothiazine neuroleptics - acepromazine (PromAce)

Question 3

What is the mechanism of action of SARIs?

Answer 3

(Trazodone)

blocks serotonin 2A and 2C receptors and blocks serotonin reuptake

Question 4

What receptor does Trazodone have an affinity for? What is it a partial agonist for?

Answer 4

5-HT2A receptor

• histamine H1 receptors
• α1 adrenergic receptors
• 5-HT1A**

Question 5

What are the 4 most common situations that Trazodone is used for? 2 additional?

Answer 5

1. situational fear and anxiety
2. event stress (vet visit, thunderstorm, fireworks)
3. noise aversion
4. bridge - immediate relief while waiting on SSRI/TCA

• post-op confinement (keep pets from hurting themselves after surgery)
• stress in shelters

Question 6

How many/what percent of dog owners seek treatment for their dog for noise aversion (storm phobia, fireworks, etc.), per recent studies?

a. nearly all or most (>75%)
b. many (51-75%)
c. half (~50%)
d. some (25-40%)
e. few (<20%)
f. none (0%)

Answer 6

E

Question 7

Trazodone can be used as an adjunct with SSRIs and TCAs (careful: serotonin syndrome!). How is this possible?

Answer 7

antagonizes 5-HT2 receptors, which augments efficacies of SSRIs

(can be long-term, but not typically first choice)

Question 8

How is Trazodone classified? What other effect does it have?

Answer 8

atypical antidepressant (via SERT inhibitor, which increases serotonin)

sedation due to antihistaminic, α1 adrenergic antagonist

Question 9

Why is Trazodone recommended to be given with food?

Answer 9

slows down absorption —> sticks around

Question 10

Why isn’t Trazodone commonly used in cats?

Answer 10

large, bitter pills

Question 11

What is Trazodone’s efficacy onset?

Answer 11

quick —> 30-45 mins
duration —> 4+ hours

Question 12

Why is Trazodone so commonly used in dogs?

Answer 12

well-tolerated with high margin of safety
- 5-HT2A/C antagonism = less side effects
- fewer anticholinergic effects
- lower seizure risk
- less cardiac issues

Question 13

What are 3 less common adverse effects of Trazodone?

Answer 13

1. GI - vomiting, hyporexic, diarrhea
2. tachycardia, increased anxiety
3. behavior disinhibition, aggression

Question 14

In what 3 cases should Trazodone use be avoided? What is a common drug interaction?

Answer 14

1. severe cardiac disease
2. hepatic and renal impairment, glaucoma
3. those taking MAOIs

Fluoxetine

Question 15

What is the most common use of Dexmedetomidine orotransmucosal (Sileo)? What else can it be used for?

Answer 15

(α2 agonist)
noise aversion in dogs

reduce fear/anxiety during vet visits

Question 16

How is Dexmedetomidine dosed? What happens if it is swallowed?

Answer 16

applied to gums - orotransmucosal gel
- no treats within 15 mins
- administer 30-60 mins before adverse stimulus

loss of absorption/efficacy

Question 17

What are 3 side effects of Sileo? What are 3 important aspects owners should know about?

Answer 17

1. sedation
2. emesis
3. depression of CNS (peripheral and cardiac vasoconstriction, bradycardia, respiratory depression)

• adjust dose stopper BEFORE dispensing
• wear gloves
• tube only lasts 4 weeks once opened

Question 18

What is the reversal of Sileo (Dexmedetomidine)?

Answer 18

Atipamezole

Question 19

What is the mechanism of action of Clonidine? What are 2 common uses?

Answer 19

α-2A and imidazoline receptor agonist

1. fear-based behavior problems and anxiety in dogs
2. quick calming in overly hyperkinetic dogs

Question 20

What are 5 possible adverse effects of Clonidine?

Answer 20

1. high sedation
2. α2: transient hyperglycemia, dry mouth, constipation
3. aggressive behavior
4. hypotension, collapse, bradycardia
5. gradual reduction over 2-4 days due to withdrawal symptoms (agitation, nervousness, hypertension)

Question 21

What is Gabapentin? What are 4 uses/indications?

Answer 21

GABA analogue —> anti-convulsant, treats chronic and neuropathic pain (spinal chord injuries, limb amputation)

1. high doses: sedative, anxiolytic
2. reduce fear responses associated with handling and vet clinic visits in cats**
3. storm phobia in dogs, but must be dosed earlier than storm
4. long-term/chronic pain

Question 22

When does Gabapentin reach peak plasma concentrations?

Answer 22

1-2 hours after administration
- half-life of 2-4 hours

Question 23

Why should Gabapentin not be used in patients with kidney disease? What are 2 possible adverse effects?

Answer 23

eliminated exclusively via kidneys —> adjust dose

(generally low side effect profile)
1. sedation and ataxia in higher doses
2. cats: hypersalivation and vomiting

Question 24

Gabapentin, controlled drug:

Answer 24

Question 25

What are the main 2 indications/uses of Imepitoin? What are 4 issues with use?

Answer 25

(GABA analogue) 1. noise aversion in dogs (Pexion) not available in US 2. reduce fear/anxiety - administration must start 2 days before noise event - administration should continue 2x daily as long as noise stimuli is expected - caution with hepatic, renal, and cardiovascular disease - ADVERSE: ataxia, lethargy, emesis, aggression, hypersalivation

Question 26

Are Benzodiazepines controlled drugs? What are the 4 most common ones used? What is their reversal?

Answer 26

yes 1. Diazepam (Valium) 2. Alprazolam (Xanax) 3. Clonazepam (Klonipin) 4. Lorazepam (Ativan) Flumazenil

Question 27

How is the type of Benzodiazepine to use chosen?

Answer 27

based on duration of action Clonazepam (10-12hr) > Lorazepam (6-8hrs) > Diazepam (4-6hr) > Alprazolam (2-3hr)

Question 28

What are 6 uses of Benzodiazepines? How can it affect learning?

Answer 28

1. panic, profound fear 2. sedative/hypnotic 3. anxiolytic 4. muscle relaxant 5. appetite stimulant 6. anticonvulsant potential amnesic ---> wont remember anxiety-inducing event ---> no learning

Question 29

What are 4 adverse effects of Benzodiazepines? What is a common contraindication?

Answer 29

1. paradoxical excitation in 1/3 dogs 2. ataxia 3. dependence/tolerance if used daily 4. withdrawal: anxiety, seizures AGGRESSIVE animals ---> disinhibition of aggression

Question 30

When is it best to use Alprazolam compared to other Benzodiazepines?

Answer 30

events of BRIEF duration ---> storm phobia, anxiety-related stress (shortest acting)

Question 31

How does Diazepam compare to Alprazolam? In what animals should it not be used?

Answer 31

(Alprazolam = shortest duration) longer duration, better for storm phobia in cases where storm is delayed CATS = idiosyncratic hepatic failure

Question 32

What is the best Benzodiazepine for cats? Why?

Answer 32

Lorazepam no active liver metabolites ---> noo hepatic necrosis

Question 33

Why is Lorazepam good for behavioral modification?

Answer 33

- less sedating than other BZDs - increases appetite

Question 34

What is the longest acting Benzodiazapine? What 2 characteristics make it a good option?

Answer 34

Clonazepam (10-12hr) 1. readily available and affordable 2. best for daily treatment of global fear and a daily panicked dog

Question 35

What makes Acepromazine unique compared to other psychotropics? What is it FDA-approved for use in?

Answer 35

NOT and anxiolytic ---> does not decrease anxiety, it is a sedative/tranquilizer (best used in addition to anxiolytic) dogs, cats, horses as an aid in controlling intractable animals (anti-pruritic, antiemetic, preanesthetic)

Question 36

How do clinical doses of Acepromazine compare to the label? In what 2 dogs should it be used carefully?

Answer 36

clinical doses are significantly lower 1. aggressive dogs ---> startle response and worsening of aggression and CNS stimulation 2. dogs with MDR1 mutation ---> need drug reduction or avoidance

Question 37

What medications are most commonly used for separation anxiety? Repetitive, obsesive-compulsive behaviors? Aggression? Inter-cat conflict? Noise aversion? Canine cognifive dysfunction?

Answer 37

Fluoxetine or Clomipramine Fluoxetine (only with behavior modification and thorough behavioral work-up) - Fluoxetine Fluoxetine Sileo transmucosal. or trazadone Selegiline

Question 38

Which psychoactive drugs can be used for daily (long-term) AND/OR event (short-term) use? a. Fluoxetine b. Trazodone c. Clomipramine d. Gabapentin e. Buspirone f. Acepromazine g. Lorazepam

Answer 38

B, D

Question 39

What are 4 important considerations veterinarians should take into account when evaluating the efficacy of psychotropics?

Answer 39

1. What is success? Change in duration, intensity and frequency of behavior? DON'T abruptly stop medication ---> need to solidify desirable behavior (taper) 2. dosing strategy: start low to minimize side effects and possibly increase for longer efficacy 3. client compliance: ability, schedule, causing more stress and anxiety (Fear Free), enough time on therpeutic dose 4. monitor health and responses: follow up with PE, CBC, chem panels, T4, urinalysis prior to and repeated at least yearly