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I opened my first practice in the Medical Arts Building at Northwest Hospital. I practiced there over a year before moving to my current office at 7201 5th Avenue NE. While at Northwest, I was invited by Bill Turska N.D. in Mist, Oregon to come and help him. He was my first mentor. He was an old-timey Naturopath that had a history of incredible cures. I would work with him on Mondays, Wednesdays, and Saturdays, and at my practice in Seattle on Tuesdays, Thursdays, and Fridays. One night when we had finished working with clients, Dr. Turska and I stayed up and talked for a long time into the night. When I woke up the next morning, I felt different, like I was no longer a young Doc working with a mentor but two colleagues working together.

December 18 2008

ANTIDEPRESSANT INTERACTIONS

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ANTIDEPRESSANT INTERACTIONS

The latest generation of antidepressants, the selective serotonin reuptake inhibitors — fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox), sertraline (Zoloft), and nefazodone (Serzone) –seem to have fewer side effects than their predecessors. However, as laboratory studies indicate, many of these newer agents have the potential to do more than elevate mood; they may also affect the metabolism of other drugs. The SSRIs do so by acting on the cytochrome P450 system — a family of approximately 30 closely related enzymes. These enzymes play a vital role in breaking down certain drugs in the liver so that they can be used by and eliminated from the body.

The cytochrome P450 system isn’t completely understood, but researchers have discovered that most of us don’t make all of the enzymes in the system and that our ability to make the enzymes diminishes with age. For that reason, each of us responds to drugs somewhat differently, and we often need to use a trial-and-error approach to find the right medication.

Taking an SSRI can further alter our individual response to other drugs. Each of the SSRIs inhibits one or more of the cytochrome P450 enzymes. As a result, medications that are metabolized by these enzymes — be they antihistamines, analgesics, or other antidepressants — may be absorbed less rapidly and remain in circulation for longer periods in people who are taking SSRIs. In some cases, an SSRI may increase the effectiveness of a second drug, allowing lower doses to be used; in others, an SSRI may cause toxic levels of the other drug to accumulate. For that reason, if you are taking one of the SSRIs it is important to let your clinician know the other medications — prescription and over-the-counter — that you are taking.

The chart below lists the SSRIs and the medications with which they might interact.

POSSIBLE INTERACTIONS AMONG COMMON DRUGS

Prozac, Zoloft: Elavil, Anafranil, Norpramin, Tofranil, Pamelor, Ludiomil, Valium, Xanax, Versed, Halcion, quinidine, Hismanal, Seldane, Lopressor, Inderol, Procardia, Adalat, Clozaril, Haldol, Moban, Triavil, Risperdal, Mellaril, codeine, Percodan, Talwin, Iidocaine, Mevacor, tamoxifen, testosterone, dextromethorphan

Paxil: Elavil, Anafranil, Norpramin, Tofranil, Pamelor, Ludiomil, Lopressor, Haldol, Moban, Triavil, Risperdal, Mellaril, codeine, Percodan, Talwin, dextromethorphan

Luvox: Elavil, Tofranil, Pamelor, Norpramin, Lopressor, Inderol, Clozaril, Haldol, Moban, Triavil, Risperdal, Mellaril, codeine, Percodan, methadone, Talwin, dextromethorphan, tacrine, caffeine, theophylline

Serzone: Norpramin, Xanax, Valium, Versed, Halcion, quinidine, Hismanal, Seldane, Cardizem, Procardia, Adalat, Iidocaine, hydrocortisone, dexamethasone

December 03 2008

PROZAC FOR PETS?

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Ruby was always nervous. When her companion, Chris, would go to work, Ruby panicked. Loud noises, especially the vacuum cleaner and the lawn mower, sent her into a frenzy. And Ruby seemed to have difficulty focusing on what Chris was saying. Ruby was seeing a therapist, but behavioral therapy wasn’t doing enough. So the therapist suggested she take the antidepressant Prozac.

After about a month, Ruby was better at paying attention. Noises and being alone upset her less. Overall, Ruby was able to take life a little less seriously. Sound like a success story from Dr. Peter Kramer’s bestseller Listening to Prozac? Well, maybe, except that Ruby is a Shetland sheepdog.

Prozac is one of the newest human psychoactive drugs (a drug that alters brain chemistry) to be used for canine and feline behavior problems. Vets have prescribed a variety of them for many years, with some success.

ANIMAL IMPACT

The antidepressants are usually not used for “depression” in animals–pets don’t experience that illness the way humans do. Instead, the antidepressants are prescribed for an assortment of other biopsychological problems common to animals. One is separation anxiety.

Some dogs become excessively miserable when their owners leave for a period of time. They bark, cry, become destructive or urinate and defecate in the house. It’s bad for the owner, the neighbors and the animal.

Antianxiety drugs are sometimes prescribed for noise phobias, especially in dogs. Loud noises, whether thunder or fireworks, are torment for some of them. A dog that hides under the bed, however, may not need medication; she’s comforting herself. But if she is excessively anxious, then it may be time to consider medication.

Medication is also sometimes recommended for animals who exhibit “obsessive-compulsive disorder”; in cats or dogs, that takes the form of chronic tail-chasing or self-licking. Too much licking can lead to an infected sore, commonly known as a lick granuloma.

Finally, psychoactive drugs can reduce spraying in cats. Spraying is a normal behavior performed by both male and female cats to mark their territory and advertise their availability your healey pet during mating season. Castration and spaying greatly reduce spraying but don’t always do the whole job.

CAUTIOUS APPROACH

Before trying to suppress an unwanted behavior with a drug, enlist the aid of a qualified animal behaviorist who can help you understand your animal. (Your veterinarian can make a referral.) Often, providing for a simple need, such as more exercise or play, will alter a problem behavior. And there are specific therapeutic programs that a behaviorist can help you implement. For example, practicing departures and rewarding the dog when she doesn’t become overanxious can reduce separation anxiety. Obedience classes are another simple, enjoyable way to change behavior permanently.

As in humans, medications must be taken with caution. These drugs are not magic pills; they are most useful when prescribed in combination with a behavior-modification program. Many have unpleasant side effects. At this writing, none is officially ap-proved for treatment of behavior problems in animals, and few have been tested on animal behavior in controlled studies. The owner must be fully committed to close monitoring of drug therapy. And you should never try medicating your pet on your own by sharing a drug prescribed for you; this can be extremely dangerous to the animal.

What’s more, some of these drugs must be taken for long periods–weeks or even months–before a benefit can be seen.

POPULAR CHOICES

Here’s a quick guide to some Of the most commonly prescribed psycho-active medications for animals:

Acepromazine. This tranquilizer is often recommended for dogs that suffer from noise phobias. It’s related to the human antipsychotic drug thorazine. It’s a short-term solution, used whenever a stressful situation arises. “Ace” is very sedating; an animal on the drug behaves like she’s drunk, and owners often notice that the animal’s translucent third eyelid comes up and covers part of the eye. Unfortunately, it does little more than knock an animal out during stressful situations; it doesn’t reduce her anxiety.

Benzodiazepines. These are antidepressants with better antianxiety effects than acepromazine. Valium (diazepam) is among the oldest benzodiazepines, but newer ones like Xanax (alprazolam) are also sometimes used to alleviate animal phobias and reduce spraying in cats. The benzodiazepines tend to be sedating and can cause an animal to become wobbly. If they’re used continuously, the animal rapidly becomes addicted to them, which means it is dangerous to stop the drug abruptly. Withdrawal must be gradual or the animal will go through extreme agitation. It’s also important to note that a tiny percentage of cats have died on Valium; vets who specialize in felines believe that it may be due to preexisting liver disease. Cats should have liver-function tests before being given Valium.

Buspirone. This is a nonaddicting antianxiety drug that causes little sedation. It helps dogs and cats with all kinds of fears and reduces spraying in cats. But it’s not available in generic form, so it is more expensive than benzodiazepines.

Elavil (Amitriptyline). This is a tricyclic antidepressant that also has antianxiety effects. It’s quite commonly used to treat dogs that have separation anxiety. Elavil isn’t usually sedating, but like all tricyclics, it does cause a dry mouth and occasional urinary retention and constipation. It can take several weeks to see a benefit.

Anafranil (Clomipramine hydrochloride). This relatively new drug is known for its benefit to humans with obsessive-compulsive disorder. Anafranil has also been shown to be helpful in treating obsessive-compulsive behavior in animals, especially to reduce licking, so sores can heal. As a side effect, it does appear to cause dry mouth.

Prozac (Fluoxitine hydrochloride). Prozac is today’s best-known antidepressant. Unlike Elavil, which affects several brain chemicals, Prozac targets only one, serotonin, so it has few known side effects and is considered very safe. Some veterinarians are prescribing Prozac for anxiety, obsessive-compulsive behavior and even to reduce aggression, though it’s too early to tell how effective it is. Prozac is quite expensive: $2 for a 20 milligram pill. (A large dog may need 40 mg. daily.) It can also take up to two months to see a benefit. I’ve had mixed experiences with Prozac; I’ve seen a few dogs stop eating and become agitated when first given the drug. However, it has helped some of my clients, including Ruby.

Before giving any drug to your pet, remember: Understanding your animal and simple behavior modification can have amazing results. The only side effect will be a better relationship.