Medicating Fear of Travel and Veterinary Visits

While proactive measures are essential to prevent and alleviate fear, anxiety and stress (FAS) and make for a fear free veterinary experience, many pets arrive from travel fearful or anxious, or become fearful, anxious, or painful during the visit. In fact, 77.8% of both dogs and cats are reported to be fearful even before entering the clinic, and over half of the cats are stressed before leaving home.^1,2 In dogs, 74% were fearful when the veterinarian approached and 11% were aggressive. In cats, 85% were fearful on the exam table and 9% were aggressive.

Using an FAS scale, pets should be continually monitored and assessed from travel to hospital to home, and if signs of FAS arise or begin to escalate, recognize, stop and revise to a) be able to proceed calmly and positively b) avoid some or all of the procedures that are not immediately necessary or can wait for a future visit with a modified approach or c) use medication immediately, prior to a future visit or both. Medication addresses the pet’s emotional and physical welfare, helps to ensure safety and successful completion of the procedures, prevents further conditioning of fear of handling and veterinary visits, and can provide for more accurate screening and diagnostic findings.

Pre-Visit Medication

For medications to be effective, they must be administered before the fearful event and at a dose and frequency to achieve optimal effect. As there is extensive individual variability, drugs should be assessed in advance of the fear-evoking situation, to determine effect, side effects, dose, onset to peak effect, duration, frequency and combination use. Depending on the duration of effect, it might be advisable to combine drugs, give an additional dose 8–12 hours in advance or to begin one or more of the medications two to three days in advance.

Natural products might be used alone or combined with drugs. Dog-appeasing pheromone and feline F3 cheek gland pheromone can help to reduce FAS during travel, veterinary exams and hospitalization. A reduction in anxiety might also be achieved with alpha-casozepine, L-theanine, an L-theanine supplement containing Magnolia officinalis, Phellodendron amurense and whey protein, therapeutic diets supplemented with alpha-casozepine and tryptophan, aromatherapy, melatonin and a Souroubea spp. (betulinic acid) and Platanus spp. supplement.

For mild to moderate fear and anxiety in dogs, trazodone, clonidine, benzodiazepines (e.g. alprazolam, diazepam, lorazepam), gabapentin, imepitoin or dexmedetomidine oromucosal gel might be effective for car ride anxiety, veterinary visits and procedures.³ In cats, gabapentin, trazodone and benzodiazepines (e.g. lorazepam, alprazolam) can be effective.^4,5 Buspirone might also be considered in dogs and cats although best started a week or more in advance.

If single products are not sufficiently effective, combinations should be considered. For additional sedation, phenobarbital or acepromazine might be added. Where indicated, also prescribe medications for pain, nausea and as gastrointestinal protectants.

For increased sedation in healthy, fractious pets, transmucosal acepromazine, dexmedetomidine, detomidine gel in dogs, or buprenorphine in cats might be effective given 30–60 minutes in advance.⁶ For more intense fear, a transmucosal combination of dexmedetomidine plus narcotic might be considered (e.g. buprenorphine in cats or butorphanol in dogs), mixed with honey, molasses or maple syrup to increase viscosity, enhance contact with mucosa and slow absorption.

Before the pet leaves the hospital, also consider medication to address the pet’s mental (FAS) and physical state (pain, discomfort, gastrointestinal upset, nausea) for travel home and reintroduction to the household.

Pain and Anxiety

Pain management is essential for addressing welfare. Pain increases stress which further exacerbates pain and can condition fear of handling, stimuli and environments such as the veterinary hospital. In fact, pre-operative fear and anxiety may contribute to increased post-operative pain and slower recovery. Therefore, to prevent or alleviate FAS, pain management must be addressed, while to effectively manage pain, FAS must be addressed.

Injectable Sedation

Medicating before the pet is stressed is safest, most effective and requires the lowest dose. Sedation before stress addresses the physical and emotional health and welfare of the pet, helps to ensure safety and allows for the procedure to be successfully completed. An alpha 2 agonist such as dexmedetomidine can sedate, reduce anxiety and provide pain management. Dexmedetomidine should be avoided in pets with cardiovascular compromise due to the potential for vasoconstriction and hypertension. As levels of sedation with dexmedetomidine alone are variable, optimal sedation can best be achieved with low dose intramuscular dexmedetomidine combined with a narcotic such as butorphanol.⁷ Midazolam might be added as an anxiolytic, muscle relaxant, and potential amnesic (but might lead to paradoxical excitation). In place of butorphanol, buprenorphine might provide more analgesia but less sedation, while mu agonists such as hydromorphone and morphine offer greater pain control and sedation and are reversible. Dexmedetomidine can be reversed with atipamezole for faster recovery. However, if the patient is not reversed, recovery may be smoother and less stressful. As an alternative to dexmedetomidine, acepromazine might be substituted; however, acepromazine has a shorter duration of action, less profound sedation, no analgesic or anxiolytic effect and is not reversable. In more fractious patients or for greater chemical restraint, ketamine or alfaxalone for cats and small dogs might be added.⁷

In a recent study when manual restraint was compared to dexmedetomidine and butorphanol or to dexmedetomidine alone, manual restraint required more personnel and longer contact time, while the combination of dexmedetomidine and butorphanol required less (or no) restraint, less time and had the best behavioral and cooperative scores. Response to dexmedetomidine alone was intermediate.⁹ This is consistent with human studies in which patient tractability, costs, and hospital stays are shortened in patients sedated with dexmedetomidine.

Doses for oral pre-medication

Doses for transmucosal administration

Doses for intramuscular sedation

a. For moderate pain can substitute buprenorphine at 0.01–0.03 mg/kg. For moderate to severe pain can substitute morphine at 0.3–2 mg/kg (dog) or 0.05–0.3 mg/kg (cat), or hydromorphone at 0.05–0.2 mg/kg (dog) or 0.05–0.1 mg/kg (cat) or for greater pain management methadone 0.3–0.5 mg/kg (dog) or 0.3 mg/kg (cat).
b. Increase to 0.04 mg/kg in dogs and cats if greater sedation required.
c. Can substitute acepromazine at 0.01–0.03 mg/kg dogs and 0.03–0.5 mg/kg cats (up to maximum 0.2 mg/kg dogs or cats) or alfaxalone at 2–5 mg/kg in cats.
d. May provide anxiolytic, muscle relaxation and amnesic effect but may cause paradoxical excitation. For geriatric or ill dogs and cats: Butorphanol 0.2–0.4 mg/kg+midazolam 0.2 mg/kg.

References

1.  Mariti C, Bowen J, Campa S, Grebe G, Sighieri C, Gazzano A. Guardians’ perceptions of cats’ welfare and behavior regarding veterinary visits. J Appl Anim Welf Sci. 2016;19(4):375–384.

2.  Mariti C, Pierantoni L, Sighieri C, Gazzano A. Guardians’ perceptions of dogs’ welfare and behaviors related to visiting the veterinary clinic. J Appl Welf Sci. 2017;20(1):24–33.

3.  Korpivaara M, Huhtinen M, Aspergren J, et al. Dexemedetomidine oromucosal gel for alleviation of fear and anxiety in dogs during minor veterinary or husbandry procedures. In: Proceedings from The 11th International Veterinary Behaviour Meeting, September 14–16, 2017; Samorin, Slovakia.

4.  Stevens BJ, Frantz EM, Orlando JM, et al. Efficacy of a single dose of trazodone hydrochloride given to cats prior to veterinary visits to reduce signs of transport- and examination-related anxiety. J Am Vet Med Assoc. 2016;249(2):202–207.

5.  van Haaften KA, Forsythe LRE, Stelow EA, Bain MJ. Effects of a single pre-appointment dose of gabapentin on signs of stress in cats during transportation and veterinary examination. J Am Vet Med Assoc. 2017;251(10):1175–1181.

6.  Santos LC, Ludders JW, Erb HN, Basher KL, Kirch P, Gleed RD. Sedative and cardiorespiratory effects of dexmedetomidine and buprenorphine administered to cats via transmucosal and intramuscular routes. Vet Anaesth Analg. 2010;37(5):417–424.

7.  Ko JC, Barletta M, Sen I, et al. Influence of ketamine on the cardiopulmonary effects of intramuscular administration of dexmedetomidine-buprenorphine with subsequent reversal with atipamezole in dogs. J Am Vet Med Assoc. 2013;242(3):339–345.

(VIN editor: References 8 and 9 not available at time of publication.)