What is Pet Poison Helpline?

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1 Clear Eyes, Dry Nose, No Problem? Wrong! Intoxications due to Eye Drops and Nasal Sprays November 14, 2017 Colleen Almgren, DVM, PhD, DABT, DABVT Senior Veterinary Toxicologist Pet Poison Helpline American Blvd. W., #725 Bloomington, MN Pet Poison Helpline 2017 What is Pet Poison Helpline? 24/7 animal poison control center Veterinary & human expertise 20 DVMs, 50 CVTs DABVT, DABT DACVECC DACVIM 7 PharmDs Case fee of $59 includes Unlimited consultation Fax or of case report Educational center Free webinars (archived) Tox tools Wheel of Vomit Pot of Poisons (toxic plants) Textbook iphone app Newsletters for vet professionals Free resources for clinics Videos Electronic material Clings us for info! Pet Poison Helpline and Nationwide 1

2 Nationwide & PET POISON HELPLINE working together Shared mission in highlighting the importance of preparing for accidents and poisonings in small animals Addressing the cost of veterinary care Nationwide covers the $59 Pet Poison Helpline fee when an insured pet is brought in to your hospital for care Enabling best medicine Pet owners with Nationwide spend twice as much on their pets than those without pet insurance 4 Pet Insurance We know what care we d want for our pets, do we made sure we covered it. And with more than 35 years of experience protecting pets, there s nothing we haven t seen. 5 Available plans 2

3 Speaker Introduction Colleen Almgren, DVM, PhD, DABT, DABVT Senior Consulting Veterinarian, Clinical Toxicology Veterinary Toxicologist Pet Poison Helpline Eye drops and nasal sprays: (imidazolines, imidazoline decongestants) Commonly found in nasal sprays and eye drops used to relieve redness and congestion Cause vasoconstriction with topical/nasal application Common active ingredients: oxymetazoline, naphazoline, tetrahydrozoline, xylometazoline Oxymetazoline: Oxymetazoline nasal: Afrin, Afrin Sinus, Nostrilla, Zicam Sinus Relief Oxymetazoline ophthalmic: Visine L.R. Long Acting Redness Relief, OcuClear 3

4 Naphazoline: Naphazoline nasal: Privine Naphazoline ophthalmic: AK-Con, Clear Eyes Redness Relief, Clear Eyes Maximum Redness Relief, Naphcon Naphazoline Multi-ingredient medications: Antazoline/Naphazoline ophthalmic: Vasocon-A Naphazoline/Pheniramine ophthalmic: Naphcon-A, Opcon-A, Visine-A, Eye Allergy Relief Naphazoline/Zinc sulfate ophthalmic: Clear Eyes Maximum Strength Itchy Eye Relief, Clear Eyes Tetrahydrozoline: Tetrahydrozoline nasal: Tyzine Nasal, Tyzine Pediatric Nasal, Tyzine Tetrahydrozoline ophthalmic: Clarine, Tetrasine, Visine Original, Eye Moisturizing Relief Tetrahydrozoline Multi-ingredient medications: Povidone/tetrahydrozoline ophthalmic: Clear Eyes Triple Action Relief, Clear Eyes Traveler s Eye Relief, Murine Tears Plus, Visine Advanced Relief Tetrahydrozoline/zinc sulfate ophthalmic: Visine A.C, Visine Totality Multi-Symptom Relief 4

5 Xylometazoline: Xylometazoline nasal: Otrivin, Balminil Nasal Decongestant, Triaminic Decongestant Spray 5

6 Other Alpha Adrenergic Agonists: Lopidine (Alcon) - Apraclonidine 5 mg/ml; sympathomimetic; alpha-2 adrenergic receptor agonist, weak alpha-1 adrenergic receptor agonist Alphagan (Allergan) - brimonidine tartrate ophthalmic solution; 0.2%, relatively selective alpha-2 adrenergic receptor agonist Alphagan-P (Allergan) - (brimonidine tartrate ophthalmic solution) 0.1% or 0.15%, alpha-adrenergic receptor agonist Topical Ointments for Rosacea: Oxymetazoline topical: Rhofade 1% Brimonidine topical: Mirvaso 0.33% (each gram of gel contains 5mg of brimonidine tartrate equivalent to 3.3mg of brimonidine free base) 6

7 Alpha-1 agonist Alpha-2 agonist Oxymetazoline x X Naphazoline Beta H 1 Tetrahydrozoline X X Xylometazoline Brimonidine Apraclonidine x X X X X H2 Imidazoline Decongestants Alpha-2 Receptor Agonists: Narrow Margin of Safety Medical Emergency! Small bottles - pack a big punch Owners often find the pet collapsed next to the bottle Rapid Onset approx min Duration 12-36hrs Mechanism of Action Sympathomimetic compounds with alpha-agonist activity, primarily on alpha-2 adrenoreceptors Little or no effect on beta receptors Binding to central receptors causes hypotension, bradycardia, and sedation Binding to peripheral receptors causes vasoconstriction and hypertension 7

8 Clinical Signs Vomiting Weakness Arrhythmias, usually bradycardia Hypotension (may see hypertension early in syndrome) Delayed CRT Collapse CNS: drowsiness, coma, muscle tremors Treatment Do not induce vomiting (due to rapid onset of signs) exception ointments Blood pressure and ECG monitoring Monitor electrolytes and BG in symptomatic patients Monitor for CNS signs and treat symptomatically IV Fluid Therapy standard crystalloids, 1.5-2X maint If patient is hypotensive (systolic BP < 90 or MAP < 60), bradycardic or depressed Reversal agents Atipamezole (Antisedan) 50 mcg/kg (give ¼ dose IV and remainder IM) Yohimbine (alpha 2 antagonist) 0.1 mg/kg IV Treatment Always Use Specific Antagonists if Available Naloxone 0.02 mg/kg IV or IM PRN (only use if reversals are not available) Bradycardia: Atropine IV mg/kg as needed (if HR < 50 bpm dog; < 120 cat) Vasopressors for significant hypotension not responding to fluid therapy alone For Agitation: Butorphanol mg/kg IV, IM, SQ q2-4 hrs prn For Tremors/Seizures: Diazepam mg/kg IV prn Vomiting: Maropitant 1 mg/kg IV or SQ q 24 hours 8

9 Water (purified), Xylitol, Saline, Grapefruit Seed Extract Alpha-adrenergic agonists Beta-blockers Combination glaucoma drugs Carbonic anhydrase inhibitors Parasympathomimetics Epinephrine Prostaglandins Hyperosmotic agents 9

10 Beta Blockers: Timoptic XE (Merck) - timolol maleate; non-selective betaadrenergic receptor blocking agent) 0.25% contains 2.5 mg/ml of timolol (3.4 mg of timolol 0.5% contains 5 mg/ml of timolol (6.8 mg of timolol maleate). Inactive ingredients: gellan gum, tromethamine, mannitol, and water for injection. Preservative: benzododecinium bromide 0.012%. Istalol (ISTA) - timolol maleate ophthalmic solution 0.5% Betoptic S (Alcon) % betaxolol hydrochloride, a cardioselective beta-adrenergic receptor blocking agent 10

11 Combination Ophthalmics: Combigan (Allergan) - brimonidine tartrate 0.2%, timolol maleate 0.5% Cosopt (Akorn) dorzolamide 2% ( carbonic anhydrase inhibitor), timolol 0.5% (beta blocker) DuoTrav (Alcon) - travoprost 0.004% (prostaglandin F 2α analog, timolol maleate 0.5% ophthalmic Clinical Signs: Bradycardia Hypotension Decreased cardiac contractility Decreased cardiac output Hypoglycemia Hyperkalemia Less Common: bronchospasm, respiratory depression, apnea, delirium, seizures, coma, renal failure secondary to hypoperfusion Possible ECG findings: sinus bradycardia, prolonged PR and QRS intervals, asystole, junctional arrhythmias, V-tach or V-fib Dose >2-3X high end of a therapeutic poses toxicity concern Combigan (Allergan) - brimonidine tartrate 0.2%, timolol maleate 0.5% Treatment: Continuous ECG or frequent heart rate monitoring. Blood pressure q. 2-4 hours; more frequent if patient is symptomatic, bradycardic, or hypotensive. IV crystalloid therapy to help maintain blood pressure Bradycardia: Atropine mg/kg IV Hypoglycemia: bolus 50% dextrose (0.5-1 ml/kg) diluted with additional saline (1:2 ratio), then follow with 2.5-5% CRI of dextrose supplementation in IV crystalloids Hyperkalemia: dextrose, insulin, or calcium gluconate Bradycardia and/or hypotension unresponsive to fluids and atropine: Intralipid or High Dose Insulin/Dextrose 11

12 Carbonic Anhydrase Inhibitors: Trusopt (Merck) - 20 mg/ml dorzolamide (22.3 mg of dorzolamide hydrochloride) Azopt (Alcon)- brinzolamide 1% CAI causes diuresis and bicarbonate loss and can result in electrolyte, metabolic, and renal disturbances. CAI rarely result in serious toxicity Lethargy, confusion, metabolic acidosis, tachycardia, tachypnea electrolyte abnormalities (hyperkalemia and hyperchloremia) can develop. Prostaglandins: Xalatan (Pfizer)- latanoprost 0.005% Lumigan (Allergan)- bimatoprost 0.03% Travatan Z (Alcon)- travoprost 0.004% Rescula (Novartis)- unoprostone isopropyl 0.15%, synthetic docosanoid Lymphocyte function-associated antigen-1 (LFA-1) Antagonist: Xiidra - lifitegrast 5% Binds to the integrin lymphocyte function-associated antigen-1 (LFA-1), a cell surface protein found on leukocytes Blocks interaction of LFA-1 with its cognate ligand intercellular adhesion molecule-1 (ICAM-1). May inhibit T-cell adhesion to ICAM-1 Inhibit T-cell activation Inhibit secretion of inflammatory cytokines in human peripheral blood mononuclear cells Treatment of dry eye disease (DED) 12

13 Quarterly Newsletters Sign up for Video Series Tox Goodies! Free to order: Our iphone app Details 200+ toxins $

14 Blackwell s Five-Minute Veterinary Consult Clinical Companion: Small Animal Toxicology 2 nd Edition Drs. Lynn Hovda, Ahna Brutlag, Robert Poppenga, Katherine Peterson Provides concise, bulleted information focused on the most important facts needed when treating a poisoned cat or dog Carefully organized for ease of use in an emergency, with important toxicants arranged alphabetically within categories Details clinically relevant information on the most common toxicants encountered by small animals Presents a wealth of color photographs to aid in plant identification Includes 14 new topics to this edition covering cyclosporine A, sleep aids, tacrolimus, bath salts, synthetic marijuana, poisonous lizards, imidacloprid, spring bulbs, and sodium monofluoroacetate Paperback May pages $ CAN $ PPH is hiring! Veterinary technician openings Hire from 23 states Work from home! Daytime opportunities starting February 2018 FT & PT evening/weekend hours available More info: petpoisonhelpline.com/veterinarians/job-opportunities/ 14

15 Thank you for attending! CE credit FAQs 1. When will I get my CE certificate? We ll it to you by the end of the day tomorrow. 2. I attended the webinar but wasn t the person who logged in. Can I still get interactive CE credit? Yes. Send your name and address to info@petpoisonhelpline.com by 1pm central time on November 15, 2017 (strict deadline). 3. Can I watch the recorded webinar online for CE credit? Yes. You can receive noninteractive CE credit. Go to the For Vets page on our website, for more info. Comments? Questions? us! info@petpoisonhelpline.com References: Cote E. Over the counter human medications in small animals. Part 1, Gastrointestinal, urinary and ophthalmic drugs. Comp Cont Ed Prac Vet 1998; 20: Daggy A, Kaplan R, Roberg Rm et al. Pediatric Visine (tetrahydrozoline) ingestion: case report and review of Imidazoline toxicity Vet Hum Tox 2003; 45(4): Fitzgerald KT, Bronstein AC, Flood AA. Over the counter toxicities in companion animals. Clin Tech Small Anim Prac 2006; 21: Volmer P. Oral toxicity of skin and eye products. In: ACVIM 18 th Proceedings, Seattle, WA. 2000;: 45: 47, Waratuke KE. Imidazoline decongestants. In: Hovda LR, Brutlag AG, Osweiler G, Peterson K. The 5 Minute Veterinary Clinical Companion Consult: Small Animal Toxicology, 2 nd ed. Ames, Iowa. Wiley-Blackwell. 2016:pp Welch SL. Imidazoline decongestants. In: Vet Clin Small Anim 2002; 32: 447. References: Doepker B, Healy M, Cortez E, et.al. High dose insulin and ILE therapy for cardiogenic shock induced by intentional calcium channel blocker and beta blocker overdose: A case series. J Emerg Med Apr;46(4): Engebretsen, KM, Kaczmarek KM, Morgan J, et al. High-dose insulin therapy for beta-blocker and calcium channel blocker poisoning. Clin Tox, lger JS, Engebretsen KM, Obetz CL, Kleven TL, Harris CR. A comparison of vasopressin and glucagon in beta-blocker induced toxicity. Clin Tox. 2006; 44: Kerns W, Schroeder D, Williams C, Tomaszewski C, Raymond R. Insulin improves survival in a canine model of acute beta-blocker toxicity. Annals of Emergency Medicine. 1997; 29: Kline JA, Tomaszewski CA, Schroeder JD, Raymond RM. Insulin is a superior antidote for cardiovascular toxicity induced by verapamil in the anesthetized canine. The Journal of Pharmacology and Experimental Therapeutics. 1993; 267: Kline JA, Raymond RM, Leonova ED, Williams TC, Watts JA. Insulin improves heart function and metabolism during non-ischemic cardiogenic shock in awake canines. Cardiovascular Research. 1997; 34: Love JN. The effect of propranolol intoxication on QTc interval in a canine model. The Journal of Emergency Medicine. 1998; 16:1-4. Love JN, Hanfling D, Howell JM. Hemodynamic effects of calcium chloride in a canine model of acute propranolol intoxication. Annals of Emergency Medicine. 1996; 28: