Podcast: Top 7 Drug Classes to Be Tapered Before Discontinuation With Dr. Waller

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In this episode, host Alyssa Watson, DVM, is joined by fellow VetMedux colleague Jordy Waller, DVM, to discuss a recent Clinician’s Brief article, “Top 7 Drug Classes to Be Tapered Before Discontinuation.” Dr. Watson and Dr. Waller dissect the article from top to bottom, pulling out their most valuable takeaways. They also share their own real world experiences with weaning drugs like steroids, prazosin, and fluoxetine.

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Episode Transcript

This podcast recording represents the opinions of Dr. Watson and Dr. Waller. Content, including the transcript, is presented for discussion purposes and should not be taken as medical advice. No guarantee is given regarding the accuracy of any statements or opinions made on the podcast. The transcript—which was prepared with the assistance of artificial intelligence—is provided as a service to our audience.

Dr. Watson [00:00:10] Hi, everybody. Welcome back to Clinician's Brief: The Podcast, where we have the conversations behind all of our Clinician's Brief content. I'm the host of this program, Dr. Alyssa Watson, and today I have the distinct pleasure of welcoming another brilliant veterinarian on our Clinician's Brief team, Dr. Jordy Waller is here with me today. We are going to be talking about an important topic. There was a recent article in Clinician's Brief that was entitled Top 7 Drug Classes to Be Tapered Before Discontinuation. And this turned out to be just a really popular topic. The article has gotten a lot of traction on the website, and so Dr. Jordy agreed to sit down with me, and we're going to kind of go through this article and talk a little bit about some of our clinical experiences with tapering medications. Before we jump into that, Jordy, thank you so much for coming on the show today. And if you don't mind, could you just introduce yourself to the audience? Just tell us a little bit about your background.

Dr. Waller [00:01:12] Yeah, you bet. Thanks so much for having me. Happy to be here. So, yeah, I graduated from University of Wisconsin in 2009 with my doctorate of veterinary medicine, and I worked for a few years in emergency practice in Madison, Wisconsin, and then jumped over into general practice. And now I'm in Seattle, Washington, and I'm working at a general practice in Burien, Washington, which is a little town just south of Seattle.

Dr. Watson [00:01:49] So, yeah, I guess I hadn't realized that you were a midwesterner just like me. So. So I was born in Iowa and I went to Iowa State. So.

Dr. Waller [00:01:58] Good. Very nice.

Dr. Watson [00:01:59] Yeah. A lot of good friends and colleagues in that area. So Minnesota, Iowa, Wisconsin, all kind of stick together. I can I can hear the twang in your voice.

Dr. Waller [00:02:11] It doesn't take long before the Wisconsin in me comes right out. No doubt.

Dr. Watson [00:02:18] So let's talk a little bit about this article. You know, as I said, it's the top seven drug classes. We're going to be talking about seven specific drug classes. But before we get into those individual classes, I kind of want to just take a minute to just kind of discuss, you know, some of these reasons that we want to be tapering medications. The author of this article, you know, really talked about these two main reasons that you want to be tapering medications. And one is to avoid physiologic withdrawal syndrome, which, of course, is kind of when, you know, we have an exogenous drug that we're giving, and because we're giving that drug, we disrupt the body's physiologic feedback mechanism. And so then when we take that drug away, there's these adverse effects on the body. And then the second is disease recrudescence or, you know, the return of symptoms or clinical signs or the disease condition when a medication is withdrawn and those are the two big things, you know, that that we worry about when we have a medication that we don't want to stop abruptly. I feel like there's kind of a little overlap between them, too. I don't know if you feel that way, but like, you know, when I was reading through this article and when I was thinking about it back on cases, you know, some of the things do tend to kind of overlap a little bit. What are your experiences with either of these? You know, have you seen either of these things occur if you've if you've stopped a medication too quickly?

Dr. Waller [00:03:48] Yeah, I think I can probably speak more to the idea of disease recrudescence, mainly because when it comes to tapering drugs, I'm probably really overcautious because I'm I take the first do no harm idea really seriously. So I probably overdo it a little bit when I'm tapering medications. But, you know, I have definitely seen a few cases in my career where even with an appropriate taper, I've seen diseases come back. The first one, I had a dog that came in that turned out to have IMHA, and we got it under control and ended up being able to taper off both the prednisone and azathioprine. And the dog was doing great, and then it returned a number of months later and it had developed not only IMHA again, but also ITP. And no matter what we did, we couldn't get it under control with drugs at all. And so, you know, I ended up doing a splenectomy, and the dog ended up doing okay. But it, you know, it it just shows that, you know, tapering too quickly can certainly cause these things to happen. And unfortunately, they can even happen when you've done what would be considered an appropriate taper. So, you know, tapering drugs is a very important thing to to make sure you're doing. Another case that I can think of where I wasn't aware that tapering was required, it was a little earlier in my career. I had started using prazosin in my kitty cats that ended up with urethral obstruction. And one of the first cases that I used it, I sent the cat home on it for maybe two weeks, and then they ran out of it, which I thought was okay. And that cat came back in maybe a day after and was blocked again. So that was a really tough lesson for me to learn. That prazosin is definitely a drug that requires some tapering because you can have some like rebound problems if you taper it too quickly or don't taper it at all in that particular case.

Dr. Watson [00:06:15] Yup. That's one of the ones that's on the list of classes that we're going to be talking about later. So yeah, you know, I've had that too. And, and sometimes the tapering is out of our control because a client stops a medication without our knowledge. I know. I think you're the same. I have so many drug labels that I have written all over in capital letters don't stop abruptly. Don't stop. Call me. You know all of those things in order to try to prevent something like what you just talked about from happening. The, you know, talking about these two sequela, there was, you know, when the author lists out these seven drug classes, she really kind of talks about them from the stance of of which which sequela are we really more worried about? Are we more worried about physiologic withdrawal syndrome? Are we were more worried about disease recrudescence? And corticosteroids were a little bit unique. They were the only class of the seven that she mentioned both. And so I was trying to think back, you know, I've been in practice 20, 21 years now. I'm getting old and.

Dr. Waller [00:07:30] I feel the same way.

Dr. Watson [00:07:31] I was trying to think back on if I've ever had, you know, the two things happen really simultaneously. And but I assume it certainly could be possible. And just like you said, you know, that ITP case or the or the Evans syndrome case is where I think I would really worry about something like that. You know, not only getting some of those signs and symptoms from withdrawal of the corticosteroids, you know, the body becoming dependent on them, but then also, you know, just like you said, having those those disease processes come back worse and not being able to get a handle on them. I also had a case early on in my career that came to me that had been on both Pred and azathioprine both for years and years. And I ended up, you know, I had I had talked to the owner and I think I had called and talked to, you know, an internal medicine specialist at the time about trying to get that the dog off. And and this was years and every time we tried to taper that dog, you know, started to regress and and the hematocrit started to drop again. And so I think I managed that dog for a couple of years on both of those. And after, after a year or two years, the refills would just come through. And I'm like, Yup, do it. Do it. He needs It.

Dr. Waller [00:08:49] Eventually you just stop trying. And I mean, that's where I always in I've had cases like that where I want to take, you know, a patient off of a medication, but they keep on getting sick every time you try. And I always tend to feel like I'm doing something wrong. But I do think that sometimes there are those cases out there where there's just really no option but to keep them going as best you can on the meds that keep them healthy. And you know, what else can you do?

Dr. Watson [00:09:22] Yep. Another thing that I loved about this article and I found so useful was that the author was very specific about, you know, some of these tapering schedules and as well as, you know, kind of these bullet point questions to ask yourself when your tapering. You know, you mentioned that you feel like you're overly cautious and you you go with a very long taper. Sometimes that's not possible. You know, I've had a couple of cases throughout my career where the animal is having a really bad side effect of the medication. You know, I had a dog on phenobarbital. I remember that had like a blood dyscrasia, and we had to get that dog off of phenobarbital quickly. And, you know, looking at some of the recommendations in this article, I might have gone a little bit too quickly, but there was nothing. You know, sometimes your hands are tied with that. And so those are the kind of the points that that she looked at. So, you know, what are some let's talk about some characteristics of the drug itself that that we should be looking at when we're when we're looking at dose reduction.

Dr. Waller [00:10:32] Yeah, absolutely. I mean, one of the things that I well, one of the things that I learned reading this article, which I was mistaken on and turns out for quite a while. So half life is a really important factor to consider when you're thinking about how long do you need to take to taper a drug appropriately. Well, it turns out if you have a long half life, the tapering process doesn't have to be as long because the drug just stays in the body longer. So Fluoxetine is a drug with a very long half life. And also it has an active metabolite with a long half life. And for years I've been tapering fluoxetine very, very carefully in all my patients because I thought they would have terrible side effects if I didn't. But it turns out that fluoxetine is actually a drug that can be tapered quickly because the body is going to hold on to so much of that drug just based on its half life. So that was a great a great point that I learned from this article.

Dr. Watson [00:11:42] I also find that just the formulation of whatever drug you're looking at is helpful when I'm trying to come up with a tapering schedule. Certainly I find liquids so much easier to taper. I always find if I've got pills, you know, especially, you know, I mean, corticosteroids just come to mind over and over because there are so many different indications for them. Right. You know, we can be dealing with with allergic diseases. We can be dealing with an autoimmune diseases, you know, so many things. And so but oftentimes I'm like, I'd like to reduce that dose by 25%, but that's, you know, a quarter of a pill. How am I supposed to do that in this patient? And so, you know, just even having something like a liquid formulation where it's easier to taper and you can taper in smaller steps if you need to reduce by 10% because some of these, you know, some of these tapering schedules that were listed out, you know, we're reducing the dose by anywhere between 10 and 25% and then, you know, waiting anywhere between a week to even a month, you know, four weeks between, you know, the step downs. And so I thought that that was really helpful as well. Anything else that you thought that struck you or you found really useful in that first table?

Dr. Waller [00:13:00] Yeah. I mean, I feel like one of the things that was useful in the table, a thing that needs to be considered, is, you know, some of these patients that have chronic diseases, you know, they're on drugs for years and, you know, for whatever reason, at some point they need to be that drug needs to be discontinued and they need to be switched to something else. And certainly, you know, the length of time that a patient has been on a drug has to play into how long you're going to take to taper that same drug. And so I found that to be a really useful idea and that, you know, if you think about it, if you've got a patient that's been on, you know, phenobarbital for five years, you're not going to want to taper that drug off over a couple of weeks if you can possibly help it, you're going to want to do that over like 5 or 6 months probably so that it can be a safe process.

Dr. Watson [00:13:58] I think piggybacking on that too, is how many drugs are they on for this particular condition? You know, that was another thing that they highlighted. If you're on 6 or, you know, 6 or 7, there's a lot. But 3, 2 or 3 different immunomodulator drugs, you know, in order to control that immune mediated disease, you might be able to safely do a little bit more rapid taper because you've got those other drugs in the system coming at that from that multimodal approach. You know, and and hopefully, you know, stopping that disease, those clinical signs from occurring. So that was another one. And then what else? Oh, disease severity. Right. That was that was one like, how bad is it? Are we talking about atopy and and yeah, they're going to get itchy and it's going to be annoying and we might get some secondary infections. Or are we talking about something like your case where we might end up with life threatening Evans syndrome and need our spleen taken out so.

Dr. Waller [00:14:58] Yup. Yup. Absolutely. And yeah. And in fact that dog that I remove the spleen I did keep I just, you know, if we already took the spleen out and then, you know, what else can we do if this disease process comes back? So I kept that dog on a low dose of prednisone for pretty much the remainder of its life. And I mean, you know, that dog ended up transferring care somewhere else. So I don't know how it all turned out, but that dog was well for years. And yeah, certainly a case where, you know if that IMHA or ITP came back, we were going to be extremely limited in how we were going to control it.

Dr. Watson [00:15:47] So that kind of leads really well into the first drug class. The first drug class on the list is corticosteroids. And we've talked a little bit about it already. I loved the fact that the author broke this down with suggested taper times, depending on how higher doses as well as how long you've been using it. You know, because obviously, if I'm using steroids for otitis, you know, that's going to be a, you know, a week or, you know, maybe two weeks at the most. Whereas, you know, some of these other indications I've got got animals on steroids for four months or longer. And so so the having that guidance when we're using steroids for those shorter courses was really helpful to me. What kind of experience do you have? Do you usually have those patients on shorter courses of steroids or are you using them longer in practice?

Dr. Waller [00:16:43] I would say that far and away I tend to see cases where I'm using steroids like anti-inflammatory doses, short and short courses. I would say that, you know, ears and skin and that kind of thing are kind of the bread and butter probably of any general practice. So, you know, in those cases, put them on a steroid for a couple of weeks, you know, do a quick taper and no problem. Thankfully, immune mediated disease and such things tend to be less common and always make me more nervous because I'm using what seem to be really high doses and I'm using them for quite a long time and obviously worry a lot about side effects in those cases and what the consequences are going to be when you start to decrease the dosing. And so yeah, far and away, I'd say itchy dogs. That's pretty much the main the main purpose for steroids in my practice.

Dr. Watson [00:17:50] Yep, I think we're in agreement there. But it's it's nice to have that resource, you know, for those those cases that you see a little bit less frequently. The author also talked about, you know, noncorticosteroid immunomodulating drugs. So yeah things like cyclosporine, azathioprine, and mycophenolate. So what did you take away for best practices for tapering those and what monitoring strategies we should be using?

Dr. Waller [00:18:20] Sure. I mean, I think, you know, the the the main point that I took away from it is, you know, usually when you're dealing with drugs like this, when you do go ahead and and taper them off, most of them don't have a physiologic withdrawal syndrome associated with them as much as a drug like prednisone would. And many times you are dealing with a disease process that you're controlling with multiple drugs. And so in a case like that, you're also, you know, with tapering one of maybe three drugs, you're not going to be quite so worried about the disease rearing its head. Again when you when you do taper that drug. And so typically not as a life threatening of a situation if you are dealing with a serious disease, like IMHA.

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Dr. Watson [00:19:49] So the next class of drugs on the list and that we're going to talk about is anticonvulsants. And I would say secondary to corticosteroids, this is another drug that I use really frequently in practice. There have been I have personal experience, a couple different personal experiences with having to take animals off of their anticonvulsant. One I mentioned the the bad reaction to the Phenobarbital. I also actually had a case early on in my career where I had a pair of dogs in the same household that had been put on anticonvulsants. And they were they had actually been misdiagnosed. Probably through no fault of the the clinician, the you know, it was just a funny story, but it ended up I finally got a video of these dogs because the owners kept saying they were having breakthrough seizures. And by this time we had them on three different anticonvulsants and these dogs were actually having reverse sneeze episodes. And so. And they had been on anticonvulsant therapy for years. But it always makes you think, you know, when an owner comes in and says something like, my dog's having seizures, you know, it's good to just take a step back and, you know, actually have them describe what they're seeing at home. It was a very valuable lesson that I learned early on in my career that, you know, we want you have to, you know, sometimes tease out a little bit more of these details. So so I did end up having to take both those dogs off of anticonvulsants. Three of them. Three anticonvulsants each. And so one of the things that really surprised me in this article is that there's really a lack of evidence based recommendations for dogs and cats. We extrapolate a lot of things from humans, but I was a little bit surprised by how little information there is out there on on how quickly or what could potentially be the negative consequences if we taper too quickly in animals on anticonvulsants. And so I don't know. How about you? Do any like cases come to mind where you've had to stop an anticonvulsant?

Dr. Waller [00:22:10] I have a little digression related to the case that you were just talking about where the patients weren't actually having seizures. When I was in vet school, there was a dog that came in and the owner said that it had been having seizures and they brought it in an emergency and the person then brought the dog in himself was actually a human neurologist. And we were taking a look at this dog and it did appear to be convulsing, but it was also kind of screaming. And we eventually sorted out that this dog was experiencing pain from an atlantoaxial subluxation in its neck. And it was having like painful episodes where it was like kind of like flailing around and and all these things. And so to your point, you know, it it's really important, like if anytime I can get somebody to send me a video of episodes that their pets having at home because people all the time say, I think my dog is I think my cat is coughing or I think my cat is trying to get up a hairball. And it's like, turns out that cat was coughing and it actually has asthma and wasn't trying to get up a hairball. Things like that. So just a little digression there that related to your story. But yeah, I guess the other thing for me is I don't think I've ever had to take a dog or a cat off a phenobarbital because of adverse effects. But I have had to do a dose reduction in cases where I get bloodwork back and the phenobarbital level is too high and I haven't had too much of a problem getting those back down without big problems. I don't think I've ever tried to reduce the dose more than maybe 25% at a time to get those drug levels back, you know, into under control. But but certainly it's important to just do it slowly.

Dr. Watson [00:24:29] Another key point is that there aren't really many recommendations for when we're using anticonvulsants for other purposes, which, you know, we do a lot. I mean, when you really think about it, that's what gabapentin is, right? Gabapentin is an anticonvulsant and I don't use it for seizures ever. I use it for, you know, analgesia and I use it for, you know, anti-anxiety. But I think there's other are there other indications for even like phenobarbital too. Like, like cialis colitis or.

Dr. Waller [00:25:06] Yeah that's true. I, I don't know. I've never used it for that. But I definitely remember seeing it in a drug book somewhere. I also had a, I had a colleague that used it for a dog that needed really strict activity restriction after an orthopedic surgery. And the dog just seemed to be refractory to everything we were trying to give it. That was a normal, like sedative type drug like acepromazine or gabapentin. So that dog was put on phenobarbital, which worked beautifully. And in that case, the dog didn't have any pre-existing seizure problems. And so, you know, when the activity restriction was lifted, that dog was tapered really quickly off the phenobarbital. And there were no, you know, ill effects from that. But certainly that was an unusual usage of the drug.

Dr. Watson [00:26:06] Absolutely. And not something that I would have thought about, even though even though I know phenobarbital is a taper drug, if I was using it for something besides seizures, I'm not sure my mind would have gone there, you know, And I would just be like, just stop it. So so just something, you know, things that stood out to me that we should all keep in mind.

Dr. Waller [00:26:27] Absolutely.

Dr. Watson [00:26:29] Let's see. Another class of drugs that was brought up was proton pump inhibitors. Okay, So things like omeprazole. I don't use a ton of these. I just, I, I probably should use more than them. You know, I'm sure I see a lot of, like, esophageal related disease that I probably these animals could be benefiting from PPIs. But I just I'm I haven't use them a lot that way. I do know that in at least on the human side, there are some concerns with long term PPI use. I don't know if that translates over to to our canine and feline patients or not. I just I had a client once that the one time I did want to use PPI, she refused to use them because she had read something that they cause, you know, stomach cancer in people. And so she absolutely refused to use a PPI on her dog. So I can I can certainly imagine, you know, that there are reasons that we might need to come off of them. And certainly it's very well documented that with long term use of PPI, as you know, you can get this rebound, a gastric acid secretion. You know, if you taper them too, too quickly. So what factors do you would you do you use them a lot or what? You know, what would you prioritize if you if you needed to get an animal off of a PPI?

Dr. Waller [00:27:56] Yeah. So I would say that my experience with PPIs is usually more short term. You know, dogs that have like, you know, the classic, you know, garbage, you know, eating situation where they've got a really sour stomach, not so much of a long term situation. But what I what I do know is that I don't I don't know what the evidence is for for dogs and cats as far as the side effects that you get for long term use. I don't know if it's comparable to humans, but but I do know that if you use them for a long time, it actually changes the structure of some of the cells in the stomach and it makes the, you know, the acid producing cells of the stomach bigger and they make more acid. And so if you take away those drugs very rapidly, you end up with this huge load of acid being produced in your stomach. So you end up with a pretty sick dog and a pretty uncomfortable dog, I would say. So certainly in those cases it's important to stop it really slowly, you know, over, you know, a matter of months to prevent that sort of rebound hyper acidity.

Dr. Watson [00:29:23] So that brings us to our sympatholytics, which, you know, you had given your little story earlier, which was a great one. So, you know, in these drugs, are we primarily worried more about the physiologic withdrawal or are the disease recrudescence? So hard for me to say that word, recrudescence. I don't know why. Recurrence!

Dr. Waller [00:29:47] Recurrence is so much easier. I actually practice recrudescence in front of the mirror for like an hour before this. Just kidding. I think that, you know, with, you know, alpha and beta adrenergic antagonists, you can you could probably see both disease recrudescence and physiologic withdrawal. With physiologic withdrawal in particularly though if you're God, if you have a patient that's on one of these drugs, like a beta blocker, like atenolol, for example, if you withdraw it rapidly, you can end up with reflex tachycardia because all those, you know, receptors that you've been blocking in there are suddenly hypersensitive and they're very reactive. So that would be a really good one to to taper slowly as well. But also if you have a disease process where you require a beta blocker and you just stop it, I mean in a worst case scenario, you could end up in a situation where you're, you know, ending up in heart failure. So certainly important with those drugs to remind people to get their refills on time and try not to skip any doses.

Dr. Watson [00:31:07] Yep. Another one that gets a big alert on right on the drug label for me. You know, don't stop. You know, certainly medications for hypertension to you know, I'm like, don't stop this suddenly because we had some pretty severe rebound hypertension if we don't taper those drugs accordingly.

Dr. Waller [00:31:29] Absolutely.

Dr. Watson [00:31:32] The author did talk about opioids, which, again, I thought the the discussion about opioids, as well as the very specific, you know, this is when we need to be thinking about tapering opioids. If you've been giving them more than more than two weeks, I think 2 to 3 weeks was what the author said. You know, I don't prescribe a lot of opioids, although, you know, for a long for a while there, the Tramadol was the big, you know, drug that everybody was handing out. And so so definitely I've had patients, you know, while I don't prescribe a lot of Tramadol anymore, I still will reach for it in certain cases. But I have I still have patients come to me that that, yeah, they've moved or they've switched veterinarians and they've been on tramadol for for years and years and years. And I might want to try maybe something else, you know, especially I've, I went through the whole switching of tramadol from a non controlled substance to a controlled substance, you know, during my time in practice. So that might have been when I stopped prescribing it quite as much or it may have been, you know, the studies that showed that it just didn't seem to do what we had hoped that it did for dogs at least. And so. So anyway, I thought I thought that that was really helpful, you know, talking about, you know, the opioids and when you know, when you need to consider tapering them. What types of adverse effects are we looking at when we stop opioids too quickly in these patients?

Dr. Waller [00:33:13] Yeah. The main side effects that are seen when opioids are stopped are going to be GI related. So you can see some vomiting and diarrhea. And the other side is neurologic. So some of these pets will come in and they'll be shaking or trembling. And, you know, it brings up a good point of like, you know, when you see a dog coming in like that, you know, even if you did maybe do surgery or something, you know, a couple of weeks ago, it might not be on, you know, front of mind that, you know, this could be a result of opioid withdrawal or at least it wouldn't necessarily cross my mind. So I think it's a really good reminder that it's important to look back at drug histories in the chart. It's important to, you know, really talk to people about, you know, when was the last time you gave X, Y and Z drugs to your pet? Because it sometimes these things are a result of withdrawal symptoms. And if you can identify that, it's a lot easier to make these patients comfortable.

Dr. Watson [00:34:30] Yeah. Or tacking on to that too. I've had clients that, you know, they had a prescription for a pet that passed away and then, yeah, they had a dental or a surgery or something like that, and they perceived their animal being painful and they were the same size. They didn't call the check. And so it can be news. You know, if you don't ask, you're not going to know. And so because I definitely have had that situation where I where I've had clients, you know, sometimes a little sheepishly, sometimes with, you know, they had no idea that it could possibly cause a problem, say, yeah, I was giving fluffy tramadol that I had left over from three years ago.

Dr. Waller [00:35:14] Yeah, I think, I think we've all had those moments of like, really, from three years ago? Okay. I might have made a different choice. You know, desperate times call for desperate measures, right?

Dr. Watson [00:35:29] Exactly. Exactly. Well, you know, I can see sometimes I need to step back to you and have a little empathy and put myself and some patients in my client's shoes. You know, I've got their they're about nine months old now, but we got two puppies around Christmas time at the exact same time. And I will tell you, there were some nights, especially with, you know, getting into the trash or diarrhea or something, where I was that person. I was just going through the medicine bin like, what do I do? I don't care that it's from four years ago.

Dr. Waller [00:36:07] Yeah, precisely. That is, I think we've all been there at one time or another, haven't we? Absolutely.

Dr. Watson [00:36:17] So the last class of drugs that the author talks about is behavior modifying drugs. And just like you, that fluoxetine thing like, blew my mind. I But it makes sense, right? It makes sense that a drug with a long half life, you know, is going to stay in the system. And just like you said, Fluoxetine is metabolized into an active metabolite that's still in the system. And so you you don't necessarily need, you know, a long taper like you would with some of, you know, with maybe some of these other other behavior modifying medications. You know, you think about serotonin reuptake inhibitors and things like that. You know, those are ones that I often am pretty, pretty careful with. And just to be on the safe side, I you know, I say let's go ahead and taper slowly as long as the animal is not experiencing severe side effects or, you know, I don't want to get them off quickly so that I can get them on something else, you know.

Dr. Waller [00:37:15] Yeah, absolutely. You know, and I don't know how I missed the memo on the fluoxetine. I, I feel like they really drilled that one into us. And I even thought about it at times, like, it's kind of funny that we have to taper it so slowly because it has such a long half life. But then I never really looked it up. So now that just it's like, Hello? It came as a surprise for certain. But yeah, and I would say that for the most part, Fluoxetine is the drug that I that I grab off the shelf the most often for behavior cases. A couple of times I've used clomipramine or I've had a patient transferred to me that was put on clomipramine by a different vet. And, you know, the withdrawal symptoms of drugs like that in humans are can be quite severe and very unpleasant. And so I do always try to be really cautious about doing a really slow taper because as we know, you know, they can't really communicate with us to let us know how it's feeling to be taken off a drug like that. So we want to do it so that it can be, you know, you know, not a not a terrible experience for these for these for these dogs and cats.

Dr. Watson [00:38:40] Yeah. You know, we're taking them off the medication so hopefully they can feel better. We can get them on something that's a better fit for them, you know? Absolutely. So. Well, I've loved sitting down and talking to you about this. I really I really, really liked this article. And so I am. I was really happy that somebody else on the team, you know, wanted to just kind of sit down and chat about it. And hopefully our audience found it really useful as well. You can check out the article for yourself. That's on our website at www.cliniciansbrief.com. And so that brings us to the end of the episode. And I know you had some questions about what is Rapid Fire? Rapid Fire is a little game that we play at the end of the the podcast episodes and it is just for fun. They are would you rather questions. There's no right or wrong answer. It's actually something that our audience really enjoys. So will you play with me, Jordy?

Dr. Waller [00:39:43] I will play with you, but. But I do want to remind you that I am a veterinarian. And so I am. You know, I really want to perform my best here. And, you know, I really did want to prepare in advance, but I'm gonna do the best I can.

Dr. Watson [00:39:56] Type A personality and I wouldn't let you. And you were like, what is it? I'm like, I'm not telling you.

Dr. Waller [00:40:02] All right, all right. This is way outside of my comfort zone. But. But I'll. I'll do it.

Dr. Watson [00:40:06] Okay. All right. First question, would you rather spay a fat dog or would you rather extract a carnassial tooth with a slab fracture?

Dr. Waller [00:40:18] Going to have to go with the slab fracture on that one.

Dr. Watson [00:40:22] Really? I'll spay the fat dog any day. I'm not a teeth person.

Dr. Waller [00:40:29] I've gotten more comfortable with the teeth over over the years.

Dr. Watson [00:40:34] Okay. Do you abbreviate subcutaneous SC or SQ? I said there's no right or wrong answers, but there's actually a right answer.

Dr. Waller [00:40:44] I know. Exactly. I'm like I think that technically I should say SC, but I definitely don't. I use the SQ.

Dr. Watson [00:40:53] Team SQ over here. Awesome. All right. Would you rather place a catheter in a dehydrated kitten or an obese bulldog?

Dr. Waller [00:41:06] Oh, I'm going to. I'm going to go. I'm going to go with the kitten on that one.

Dr. Watson [00:41:11] All right. Confident.

Dr. Waller [00:41:13] I think that I might be the cat whisperer at my practice, so I would pick the cat any day.

Dr. Watson [00:41:19] Yeah. I honestly would go with the kitten too. Those the Bulldogs it's just the so much skin.

Dr. Waller [00:41:26] And also the fact that, you know, you're going to get a lot of drool on your hands while putting in the catheter. I mean, it's a whole extra challenge.

Dr. Watson [00:41:36] All right. If you were at a party and just talking with a group of people, would you rather have to explain male nipples or imitate the sound of a reverse sneeze?

Dr. Waller [00:41:50] I think I would go with the I think I'd go with the reverse sneeze. Yeah. Talking about male nipples just makes me way too uncomfortable.

Dr. Watson [00:42:04] And yet we've all had to do it, you know?

Dr. Waller [00:42:07] Yes, we have. It all comes up eventually.

Dr. Watson [00:42:11] It does. That's not a tick.

Dr. Waller [00:42:19] Yeah. Do I have time for a quick digression on that one?

Dr. Watson [00:42:22] Absolutely. Do you have a good that's not a tick story? Because I feel like every veterinarian has a good that's not a tick story.

Dr. Waller [00:42:29] Well, I was. This is a story about about me making a real bone out of myself. But when I was in vet school, I was examining a young little male dachshund dog. And, you know, I'm looking at this dog. And then I just was I got real serious and I was like, I just I'm going to step out for a minute. And I went out to my my the clinician that was overseeing our rotation. And I said, I think that that dog has a bunch of tumors. And she went into the room and she was like, yeah, Dr. Waller, those are nipples. Those are nipples. I and I, I'm pretty sure I just went home. Then I was like, I'm going to go and recover from this experience and I will be back tomorrow.

Dr. Watson [00:43:20] I will be back at it.

Dr. Waller [00:43:23] Yeah. So anyway.

Dr. Watson [00:43:29] Like, I'm I'm sure that nothing is coming to mind right now, but I know I've had horribly, like, embarrassing situations and things and made obvious mistakes that I was like, what on earth did I just do?

Dr. Waller [00:43:43] Happens to the best of us.

Dr. Watson [00:43:44] Last question. This question and this question is in honor of our wonderful producer, who I love so much. But would you rather have all of your support staff talk in movie quotes, nothing but movie quotes or Taylor Swift lyrics?

Dr. Waller [00:43:59] Movie quotes. Movies. Hands down. I'm a I'm a I'm a movie quote aficionado, so.

Dr. Watson [00:44:07] All right, excellent!

Dr. Waller [00:44:07] I'm the one in my practice that's always talking in movie quotes. All the time. So yeah, I could definitely get behind that.

Dr. Watson [00:44:18] I think that that's awesome. Although you may have just been uninvited from the podcast forever because our producer is a huge Taylor Swift fan and shout out to her because she's actually going to be going to the concert in London next week. So.

Dr. Waller [00:44:34] Wow. Well, see, this is why I wanted to know in advance this rapid fire question thing was because I didn't want to give any bad answers and look what happened.

Dr. Watson [00:44:44] So it's not a bad it's actually it's like I'm a movie quote person to you. I love, you know, and I and I the most random ones and my poor staff, you know, a lot of them are, as I mentioned earlier, I'm old now. And so I would throw out these movies and people have no idea what I'm talking about. And then I just get depressed.

Dr. Waller [00:45:01] That happens to me like every day.

Dr. Watson [00:45:02] You did fantastic at rapid fire. I loved it. I had so much fun. I and I'm just kidding. You're absolutely welcome back anytime any day on the podcast. We love having you.

Dr. Waller [00:45:13] Great. Well I had a great time and yeah, I would even do rapid fire questions again if like if I was invited back.

Dr. Watson [00:45:22] One of these days. I think when we have repeat guests, somebody should flip the script and do some rapid fire questions on me. I don't know what I would do. I'd probably freak out.

Dr. Waller [00:45:30] I think that that's a very good idea and we should do that real soon.

Dr. Watson [00:45:34] Okay. Well, I just want to say thank you to our Clinician's Brief audience. I hope that you found this discussion helpful and we'll see you next time.

Dr. Waller [00:45:46] Thanks again.

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