Veterinary Vertex

Exploring the Impact of Anxiety Medication on Dogs: GMA Protocol Insights

October 17, 2023 AVMA Journals
Veterinary Vertex
Exploring the Impact of Anxiety Medication on Dogs: GMA Protocol Insights
Show Notes Transcript Chapter Markers

Get ready to uncover the remarkably transformative world of veterinary anesthesia and analgesia, as we navigate through a ground-breaking clinical trial that has the potential to change the lives of anxious and aggressive dogs. Our special guest, Renata Costa from Murdoch University, Australia, sheds light on her innovative research involving gabapentin, melatonin and acepromazine. This study has opened up new doors in the realm of veterinary medicine, demonstrating remarkable success in reducing stress in over 90% of dogs during hospital visits. As we journey through this fascinating exploration, we also touch upon the vital role of clear communication and client compliance in administering these life-altering medications.

Moving forward, we venture into the intricacies of the GMA protocol, an essential discussion for veterinarians and pet owners with anxious dogs. The conversation spotlights the importance of patient-specific sedation and the various implications of the prescribed drugs. We discuss not only the benefits of these protocols but also their limitations and side effects, offering a comprehensive understanding of this complex subject. The conversation evolves to focus on the hospital visit experience, managing expectations and the pivotal role of mentors and parents in nurturing motivation and resilience. An episode guaranteed to enrich your knowledge in the realm of veterinary medicine, make sure you tune in.

Full article: Gabapentin, melatonin, and acepromazine combination prior to hospital visits decreased stress scores in aggressive and anxious dogs in a prospective clinical trial in: Journal of the American Veterinary Medical Association - Ahead of print (avma.org)

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Sarah Wright:

You're listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode, we chat about a clinical trial evaluating gabapentin, melatonin and acepromazine prior to hospital visits for aggressive and anxious dogs with our guest Renata Costa.

Lisa Fortier:

Welcome to Veterinary Vertex. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Today we have Renata joining us from Murdoch University in Australia. Thank you, Renata, so much for being here and taking the time out of your busy schedule to be with us here today.

Renata Costa:

Thank you very much for having me, and it's always a pleasure to discuss the GMA or chill protocol.

Sarah Wright:

All right, let's dive right in. Renata, your manuscript has received a lot of attention on social media. We promoted it last Monday and so far it's received over 600 different kind of interactions and the reach is over several thousand people, which is fantastic. And it discusses a combination of gabapentin, melatonin and acepromazine prior to hospital visits and how that reduced signs of stress in 91.1% of dogs. This study also received a fear-free research grant. Can you give our listeners a bit of background on this clinical trial?

Renata Costa:

Yeah, so the target population for this prospective study were dogs with a known history of anxiety fear or fear aggression during hospital visits. So we had these dogs coming into the hospital without any drugs on board and we're evaluating them using a standardized examination and video recording them and that was to get a baseline of the behaviors and levels of stress. That after about two weeks we had them coming back and the owners were sent home with a medication, so gabapentin, melatonin and acepromazine, and the owners were, you know we explained to them how to administer those drugs. So basically, all dogs received 20 to 25 milligrams per kilogram of gabapentin the night before the appointment and again 20 to 25 milligrams per kilogram of gabapentin in the morning of the appointment, plus melatonin tablet as well, three milligrams or five milligrams per dog. So dogs over 10 kilos received the five milligram tablet plus ACE, so acepromazine at 0.05 milligrams per kilogram oral transmacosal. So we use for the CHIL protocol or GMA protocol. We use injectable acepromazine and we sent the owners with ACE syringe without a needle and they would apply that ACE under the patient's tongue. And the main thing we highlighted is to make sure that in the morning drugs were given 90 to 120 minutes before the appointment so they had time to work and then we assess the patients again in their stress behaviors and also sedation levels post GMA or chill protocol.

Sarah Wright:

Thank you. This is a little off script, but some people on social media were commenting when they promoted the manuscript, asking about owner client compliance. What would you recommend to increase client compliance of this protocol, since it does involve a few different sedatives prior to their visit?

Renata Costa:

I think, just clear communication, which is always key. If you explain to the owners how important and how much better and less stressful the protocol is going to make their paths, then they tend to follow the guidelines better. Having it all written down, really clear information on how to give, the time to give If you want to specify give at 10 pm the night before, it's actually better for the owners in the 90 to 120 minutes, also highlighted in yellow or something, I also tend to send them with at least normally two syringes with the ACE in case they spilled it. If for some reason the dog moved or something, then I sent them with a two little one extra dose of a acepromazine, but making sure to tell them do not give both. It's probably okay anyways, but just making sure that they know that just if something goes badly wrong then they have an extra syringe.

Sarah Wright:

Great. What were some of the important findings from this study?

Renata Costa:

I think the most important finding was the increased compliance right after the GMA protocol was on board. So, the animals were much easier to handle. They were the severely stressed dogs were mildly to sometimes moderately stressed after the GMA protocol but basically managed to do the standardized examination so much easier after they had the drugs on board. We had eight dogs out of 45 that we couldn't do parts of the exam because it was dangerous. They were really aggressive, and it was just not safe for anybody, for example like palpate abdominal palpation or auscultate the heart and lungs. Now, after the GMA or chill protocol, most of the animals we managed to do the complete examination. It was great, I think. Another finding that was not unexpected it was that we had an increased sedation levels on those patients. However, the animals were mildly to moderately sedated so most of them were not like heavy sedated or heavily sedated. We didn't actually notice any other adverse effects. We didn't notice and the owners also didn't report any other adverse effects, which is good.

Lisa Fortier:

Yeah, good old acepromazine, Renata. I've been an equine surgeon for 30 years and a writer for a lot longer than that. Acepromazine was definitely our friend and got forgotten for a long time when dexmedetomidine and all the others came along. Acepromazine is an amazing drug. You're a lecturer I think a senior lecturer in anesthesia and analgesia. What of that component inspired you to do this research? Interest in animal behavior?

Renata Costa:

It was. I think it started with my training, especially during residency, the exposure to extremely high caseload during my residency. We had to be really efficient. We also had a large number of aggressive or fear aggressive patients. We had to be fast, but we also needed to provide good patient care. The management of these animals with the chill protocol on board was so much easier. I was introduced to this protocol at University and seeing the results that was just impressive. Obviously, it's not 100 percent. Patients are different, but the success rate is really good. I think, also as an anesthesiologist later on, I have a more in-depth knowledge and understanding of pharmacology that, in addition to the clinical experience and our good old, thorough literature review, really provide the tools for us to be able to design studies and hopefully evaluate these protocols that are out there.

Lisa Fortier:

Yeah, it's actually obviously so, so important. Let's stress it'd be nice if you could measure the stress on the owners too, and the front office staff and everybody in the client waiting room. On my side it's how do you get the dang horse back on the trailer after it's gone through its examination? Managing stress in clients and patients is super important.

Renata Costa:

Absolutely. I think that these protocols really help not only decrease the stress for the patient, but also owners, everybody that's involved. It makes a huge difference.

Lisa Fortier:

Yeah, and if it's a protocol, it's easier for implementation, right? Rather than Lisa uses this, Sarah uses that or Nadi uses something else, Like everybody just knows the dosage and you don't have all these various combinations Exactly. Yeah, you talked about how you learned about this protocol at Tufts and during your residency, but how did that training really help you prepare to write the manuscript, to gather the data? Do the revisions, all of those things that it takes to get in the manuscript completed?

Renata Costa:

Well, I love research anyways. So, I've been doing a lot of research and I think, looking at the anecdotal evidence that we had implementing the chill protocol, especially in the beginning, there was especially with the dose of ACE. For example, there was 0.025 to 0.05 milligrams per kilogram and over time, using the protocol over and over again, I've noticed that the higher dose it was much better, it was much more efficient for most of my patients. So that clinical experience helped me focus a little bit more and get that design a little bit less, with less variables. I guess the same thing for gabapentin. Although I say 20 to 25, I always try to round up. So, I try to get the 25 milligrams per kilogram of the gabapentin as well on those patients and if you see, like the manuscript you'll look, most of the patients got more towards like the 25 milligrams per kilogram. I think, looking at the success rate and thinking about what would be how can we make this anecdotal evidence or based on clinical experience, an interesting study that provides like safety of the combo and reliability of the combo. So that's why I thought let's record these patients so we don't miss anything and we can assess body posture, eye position, and I did have an amazing behaviorist helping with this study, Dr Borns-Weil, so she was really helpful in gathering and creating those stress scales for us to truly be able to, because it's something so subjective that we tried to make it as objective as possible to get the more reliable data on those protocols. There are so many protocols out there and there's not a lot of studies looking at them right, so it's important, yes, clinical experience. It is important, but it's also important to study to make sure that the anecdotal evidence remains true when you actually look at doing a new perspective study.

Sarah Wright:

So I have to ask are cats next on the docket? There's so many cat protocols out there too.

Renata Costa:

Yeah. So I'm working on another study as well and that's with cats as well, with pre-appointment medications for cats. I can tell you that the chill protocol, a GMA protocol, also works well for cats, although cats tend to be I don't know if I can say they're easier, they're not but they often sedate quite well with gabapentin, even alone. So you know, oftentimes I prescribe the gabapentin alone. But the chill protocol itself also I've used on some of my feral cats and it works as well. It works really well.

Sarah Wright:

Excellent. Well, I'll definitely be reading that manuscript whenever that one comes out. One of my cats is pretty spicy and she looks at gabapentin and is like that's not going to do anything for me. I actually took her on a plane once and I gave her the recommended dose and it made her worse, I think. She just howled and howled the whole time. So she's the outlier there.

Renata Costa:

Yeah, that's sometimes when the ACE has such a bad rough. I love ACE. Obviously, we need to know the effects inside the facts of each of the agents, right, everything has limitations, but ACE does provide an extra sedation extra. It makes them chilled and I know there's a lot of conversation and controversy with some behaviorists, but at least the people I work with they're like yes, yeah, ACE it always works well, we'll see with another cat study. Hopefully then that comes out soonish. It's not going to be really soon, but soonish.

Sarah Wright:

Great, we'll be on the look board, and this next set of questions are very important to our listeners. The first one what is the most important piece of information the veterinarian should know before discussing this topic with the client?

Renata Costa:

I think the two main points before recommending the drug protocol or any drug protocol. The first one is to understand that the GMA protocol could result in patient specific sedation, and then we need to let the owners know that, obviously, if for some reason this is a patient that gets moderately sedated, then we don't want to let the dog jump from the car or be near stairs. So, then knowledge of that and that discussion with the owners is really important. And second is what we talked about before prescribing any drugs, you should definitely know their effects and side effects and their limitations, and you need to know your patient to see if there's a specific comorbidity that would make that protocol and those agents are relatively safe, but maybe there's something that will make it contraindicated. There's not a lot of concern at the moment with what we know with the administration of gabapentin and the melatonin. It's ace promazine, like I said, some people tend to be afraid of it, but it is quite safe. But if you have a patient that is noticeably dehydrated or hypovolemic, maybe you should consider decreasing the dose of ACE or maybe they're not recommending this specific protocol. So, as long as the veterinarian knows their patients, the drugs and is able to communicate well with the owners. I think we're good to go.

Sarah Wright:

Excellent. Thank you so much for sharing. And then, what is the most important information the client should know about this topic.

Renata Costa:

So, thinking about this from the other side of the relationship, For me the biggest thing is for the client to understand that this drug protocol is designed to help their pet. Oftentimes they're like, oh, you just want to give drugs to my animal, but why? It's fine, right, you can. Just, you know, I think before a few years ago hopefully several years ago that forceful restraint and struggle that used to be you know the way to go. But we know now clinical experience and also the literature showed that that is not good as really harmful to the animals. Not only it makes them really stressed, it makes everybody stressed, it puts everybody in danger and it actually worsens their behavior in the future. They can become even like if they're just fearful, then later they can become aggressive. So I think really highlighting how the protocol was to just provide what we say fear-free technique, you know, and to allow us to perform our physical examination or procedure in a gentle way and also decrease the stress levels that that pet is feeling when it's coming to the hospital. So I think, as long as like what I've noticed, when you specify and really highlight that with the owners and discuss that and explain that we're doing this for their pet's benefit, which is true, right, we're improving animal welfare. That's why we're recommending these drugs and we don't recommend the chill protocol, GMA protocol for everybody. And I had lots of people asking like, oh, do you think we should give to everybody? I don't think so. I think there's specific patients that require that the anxious, the fearful, the fear-aggressive. Those patients require those. You know this type of technique right, they need some chemical restraint, they need some, you know, tranquilization or sedation or being a little bit chilled. So I think that is the biggest thing to highlight and explain to them that we're doing that for their pet. And I think the second thing, if I you know like one more point, is to also manage expectations. I think that not all animals respond the same Like we're. You know, we're all individuals. We'll respond differently to different drugs, right, and so some dogs will be like we saw, many of them will have, you know, decreased distress levels and some will be medecinated and they will be perfect. So we can do everything the examinations or procedures or premedication right, and so that allows us to do a safe and less stressful premedication. But some of them can get more sedated. So that's why they need to monitor those animals and some others it's not going to work straight away. So the moment that you manage their expectations and they will be probably much less frustrated, they have to come back a third time because you probably will have to tailor that protocol, keep the doses right or maybe change some things in that for so you can actually perform the procedure or the examination safely. So as long as they are prepared for that. So like just explaining and managing expectations, I think it all goes back to good communication with the owners and with the clients.

Lisa Fortier:

Yeah, that's pretty key for all of our things that we do in veterinary medicine. I remember as a first year veterinary student being taught how to towel mean cats and I was like I can't, it was so stressful for me and like the people that did it and they were like oh, this is good for them and you're like really Like you just made a sausage out of that cat and it's in there like howling. So it's actually one of the reasons I didn't go into small animal. The mean cat in the cage was I would rather get into a stall with a bowl any day than get that mean cat out of the cage. So maybe, maybe my career would have been different with this protocol. But you're clearly very accomplished and you know, moving around from Tufts back to Australia it takes a lot of determination and resilience. Where do you think your determination, resilience, came from?

Renata Costa:

As cliche as it sounds. I think my parents. It comes from my parents. They're my main source of inspiration and they're both really resilient and successful professionals, both retired now, so they're living the best life, but they were, and I always knew I wanted to be a veterinarian and later on I knew I wanted to specialize. I love anesthesia and analgesia and then I have been so lucky throughout my career to have amazing mentors and amazing people helping me out and teaching me all the things that I need to learn. You know Anthea Raisis she's one of the anesthetists here Murdoch University was my supervisor. Lois Wetmore, she was my supervisor at Tufts. There's a lot of people I think my parents and all these other specialists and veterinarians that helped me along the way. I think they made it and you see your work making a difference, so it just makes you just want to work harder and do more.

Lisa Fortier:

Yeah, that's fantastic. We do hear parents a lot, which is a wonderful attribute as a parent myself, but also a shout out to mentorship is super important, so just keep passing it on. Yes, Renata, as we wind down a little bit, something a little bit more personal what is the most interesting or scenic trip you've been on?

Renata Costa:

My husband and I love traveling, so we used to travel a lot more, but COVID happened and we decreased a little bit. But I think I truly loved and fell in love with Florence in Italy. It was so nice and so calm and it reminds me a little bit of my hometown, but also New Zealand. New Zealand is breathtaking, so I think New Zealand is another place that's amazing. It's hard to pick. Vietnam and Cambodia are also amazing. They're so different. I never thought about going there. My husband organized the trip and I was amazed with the history and everything. So maybe three US per one, maybe a couple.

Sarah Wright:

That's awesome. Those places are definitely on my list. I love traveling. Especially after the pandemic, I feel like I had the travel bug, so I'd be emailing you for some trip tips in the future.

Renata Costa:

Oh, yes, I will send you pictures if you want.

Sarah Wright:

But thank you so much, renata. I would just really appreciate your time today, and thank you too for your contribution to JAVMA.

Renata Costa:

Thank you very much for having me and yeah, I'm always here, always available to answer any questions about the GMA chill protocol as well.

Sarah Wright:

And to our listeners. You can read Renata's manuscript in print JAVMA or on our journal's website. I am Sarah Wright with Lisa Fortier. We want to thank each of you for joining us on this episode of the Veterinary Vertex podcast. We love sharing cutting edge veterinary research with you and we want to hear from you. Be sure to leave us a rating and review on Apple podcasts or other platforms that you use too.

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