The Compounding Conundrum (The Female Human Opines)

I move toward the counter at the pharmacy, thankful for the HIPAA regulations that require a generous space between people in line.  The woman at the register stands, fingers poised over the keys.

“Hello, name please.”

I lean in toward her, whispering, “Aurit, Tucker Aurit.”

She smiles and asks, “Date of birth?” There is an awkward silence.

“Um, well, I’m not 100% sure, uh, I’m not sure if you need his birthdate… he’s a cat.”  I wait for a look of shock or amusement. She continues to smile; nod and moves to the area where filled prescriptions are kept, looking through the “A” section.

This was my first experience picking up medications for my felines at a “human” drugstore and the beginning of my relationship with White Cross Pharmacy. My two 17-year old feline siblings have health issues that require regular treatment and medications. The male, Tucker, spent some quality time at the vet last year with bowel obstruction issues and the regime we follow now includes medications.  

One of the compounded medications proved to be problematic.  Tucker hated the taste, foamed at the mouth and howled when I gave it to him. This was when I was lucky enough to get him out from under the sofa.  After the first few doses he was on to me and ran under the sofa. My vet suggested I contact the pharmacist about the issue and it was through this experience that I began to understand the benefit and complexities of feline medical compounding and the importance of having a pharmacist like Lori Howard.

Veterinary Compounding – the Wild West of Animal Medication

As Lori worked with me to find a solution for Tucker’s issues with the new medication, I was impressed with her knowledge, creativity and passion to solve the problem.  I did some of my own research about veterinary compounding and then decided I wanted to interview Lori as well.

In a July 19, 2018 article in VIN News Service entitled, “USP tackles ‘hot mess’ — veterinary compounding”, Christy Corp-Minamiji, DVM states that,” Veterinary compounding in the United States has been described as the Wild West, with a mishmash of seemingly ever-changing regulations that differ from state to state.” The author says that “while compounding of medications for human patients is coming under increasing oversight by the U.S. Food and Drug Administration, the law pertaining to animal drugs – the Animal Medicinal Drug Use Clarification Act (AMDUCA) — is vague on compounding.”

Some of the difficulty in regulating veterinary compounding is that animals, like cattle, enter the human food chain and their medications must be scrupulously monitored and controlled. Drug dispensation for pets does not require such stringent regulation. This often puts veterinarians on opposite sides of the compounding control debate. A vet that works with livestock will favor stricter controls than a veterinarian who treats companion animals only.

Lori Howard’s journey to pet compounding started with her love of animals and her desire to be a vet. Her career journey took a bit of a turn to pharmacy when, as she said, “pharmacy fell in her lap.” It’s clear as you talk to her and watch her light up about the subject of feline compounding that she loves her work. When she started pharmacy school, there were no pet compounding classes offered so she found classes on her own to add to her knowledge. She recently completed a 27 hour pet compounding course and has done many more in the past. She told me that another great teacher is experience. She’s always working on new pet compounding ideas and keeps a well-worn version of Plums Veterinary Drug Handbook at her desk.

Part of Lori’s self-education in pet compounding came from creating pet treats. Needless to say, dogs were far more appreciative of the treats then cats were. Still, the treats and liquids without active ingredients are part of her repertoire to show veterinarians the vast flavor options she can offer for even the most finicky feline.  

Lori shares her home with two dogs and two cats and all four are willing to let her know their opinion about flavor combinations she provides for them. You might call them her unofficial furry taste testing team.

Cats and Compounding

If she doesn’t recognize me she won’t give me the medicine.

In the words of the AMVA, “Compounding, consistent with the Food and Drug Administration (FDA) Extra-Label Drug Use regulations, is the customized manipulation of an approved drug(s) by a veterinarian, or by a pharmacist upon the prescription of a veterinarian, to meet the needs of a particular patient.” Lori explained that compounding is used when there are human meds that can be prescribed for a cat but the cat would not tolerate the taste. It also is useful to make a veterinary medication more palatable for cats to tolerate. Compounding also comes into play to ensure that dosages for those medications are correct for our felines.

When your feline refuses to accept the taste of a medication it can be compounded into a form that is applied topically.  It takes a little longer for the medication to reach steady state (to the point that the drug is affecting the system) but once it does, it works just as well as medications taken by mouth.  Any of us who have tried to shoot a pill or liquid down a cat’s mouth know the frustration of seeing your feline spit the pill out minutes after you think they’ve swallowed it.

When taste is an issue, as it often is with felines, a compounding pharmacist like Lori is a wonderful resource. She said that cats don’t like sweet and getting a medication to taste like fish is usually a winner.  Getting to that flavor is no easy feat, though.

Lori explained that all medications start as powders. To liquefy them either water or oil is added. When flavoring medication for cats, an oil suspension is the most desirable but medications will have water, alcohol soluble or oil suspensions and a compounding pharmacist will know how to work with those formats. The mode of suspension (liquid or oil) also attributes to the life of the medication. Lori tries to use oil suspension as much as possible to extend the life of prescription. The cost of a three-month prescription is less than a one month prescription and she’s always looking for a way to save pet parents money.

Sometimes the simplest practices are successful and she said that many cats love the water tuna is packed in and “tuna water” often makes medication go down better. I’ve used the “tuna juice” method at my house and it works for several of The Tribe of Five members.

I was amazed when Lori showed me a three-page list, with very tiny writing listing all the medications that can be compounded for cats.  She told me the biggest challenge in compounding medications for cats is the feline’s fussiness and their sensitivity to so many things. 

Final Thoughts about Veterinary Compounding

Tucker and I say “cheers”
for veterinary compounding!

Veterinary compounding is a fairly new area and therefore it’s not surprising that many veterinary practices are not on board yet. As I noted, I am so thankful that my felines are patients of a veterinary practice, Pend Oreille Veterinary Service that takes a broad, holistic approach to veterinary medicine and who use a compounding pharmacist.  

I asked Lori two final questions at the end of our interview. First, “What do you wish vets knew about compounding?” She said she wished that veterinarians would know the range of things compounding pharmacists can do with medications and how much flexibility compounding provides when prescribing medication for felines. The pharmacist can work with that specific cat’s needs and wants and formulate a medication that will work for them.

The final question I asked her was, “What do you wish pet owners would know about veterinary compounding?”

“I wish people would understand that it takes time to make medications that are specially compounded.  Also, we have to comply with the veterinarians instructions. If the bottle says “no refill” we cannot refill until the vet gives an okay.”

I no longer sidle up to the front desk and whisper Tucker’s name when picking up his medication. I march forward boldly and I’m always asked how Tucker is doing. Tucker’s photo is hanging in the pharmacy on their pet board so they can see his cute little cross-eyed face when compounding his medication.  

Cat parents, if you haven’t talked to your vet about compounding I recommend you have that conversation with them soon.