Monitoring patients on chronic medications: Resources and recommendations

In the AAHA Community, members recently posed questions about monitoring recommendations for patients who take chronic medications and what to do when clients decline the recommended monitoring diagnostics. Other members chimed in with the wording they use to explain the importance of monitoring in these cases, the resources they use to determine when to recommend monitoring, and what kinds of monitoring they perform (along with how often).  

To learn more, we spoke to Audrey Cook, BVM&S, MSc Vet Ed, FRCVS, Dip ACVIM, Dip ECVIM, Dip ABVP (Feline Practice), Professor of Small Animal Clinical Sciences at Texas A&M University College of Veterinary Medicine. She explained that while there is some degree of consensus about monitoring recommendations for pets taking chronic medications, there is still much that is left to individual practitioner discretion. 

“As is so often the case in vet med, many of these recommendations are based on small amounts of data, rely heavily on personal opinion (in the case of some textbook chapters), or are derived from the human field,” she said. 

Types of monitoring 

While bloodwork is often the indicated form of monitoring, it is not the only one. In some cases, monitoring can look like urinalysis, blood pressure checks, or physical exams. 

There are multiple reasons pets on chronic medication might need ongoing monitoring in some form. Cook explained that bloodwork monitoring is sometimes needed to identify organ toxicity, especially reno- or hepatotoxicity associated with medications like NSAIDS or certain antibiotics. It is also useful to identify changes in metabolic status, like hyperkalemia, in patients taking ACE inhibitors. 

Sometimes drugs that normally wouldn’t require any monitoring protocol when used alone (like angiotensin II blockers) can be associated with a higher risk of complications when used in combination with other drugs (like ACE inhibitors), making monitoring more essential.  

For pets taking immunomodulators or chemotherapeutic agents, complete blood counts are often monitored for evidence of myelosuppression.  

In patients with conditions such as Cushing’s syndrome or diabetes mellitus, monitoring is helpful to look for evidence of complications of both the disease process and the treatment.  

In some cases, monitoring is needed to ensure that the pet is receiving enough medication to be helpful, such as with phosphate binders for chronic kidney disease patients. In others, therapeutic monitoring may be needed to ensure drug levels are in a therapeutic range and not a toxic one, such as with phenobarbital.  

Resources for monitoring recommendations 

Cook listed multiple types of published resources that veterinary teams can use to create a monitoring protocol.  These include formularies, textbooks, and review articles.  

In some cases, product inserts may contain monitoring recommendations, and Cook explained that veterinary teams should always convey monitoring recommendations published by the manufacturer to clients. “Failure to do so puts you at substantial liability,” she said. But this doesn’t mean you should stop your efforts there. 

“Vets are also obligated to keep up with the general expert consensus on monitoring,” Cook said, “as sometimes these have evolved with clinical experience and do not always match the product insert.” 

Veterinary professionals can also consult drug manufacturers’ websites, where up–to-date prescribing information is usually available. Other sources of evidence-based, peer-reviewed information include ACVIM Consensus Statements on topics like the management of urinary incontinence in dogs and AAHA Guidelines that cover everything from oncology to pain management.  

Missed opportunities 

Cook pointed out some areas where veterinary teams tend to be inconsistent about recommending monitoring for their patients taking medication long term. 

“I think many vets fail to appreciate the need for monitoring if the animal appears to be feeling OK,” she said. This can be particularly common with drugs like carprofen that many dogs use without experiencing any adverse effects. “One can become complacent and forget that toxicity is still a concern and can randomly hit any animal,” she added. 

Apart from organ toxicity, Cook has noted a hesitancy in some cases to use bloodwork monitoring when initially titrating the dose of supplements like potassium and drugs like phosphate binders.  

Addressing client refusal 

Regardless of the specific monitoring protocol chosen, there will sometimes be cases where a client declines the recommended monitoring but requests that their pet’s medication continue to be refilled anyway. This can create serious challenges for veterinary teams who recognize the importance of appropriate monitoring to optimize their patient’s health and response to treatment, but who understand the implications of discontinuing medications for their patients.  

Cook explained that there is no one answer as to how to approach these scenarios. “This has to be balanced on a case-by-case basis, weighing up the risk to benefit ratio for that disease and that drug,” she said. In some cases, veterinary teams may be able to help clients understand the reasons for the recommended monitoring and convince them to agree to it. In other cases, clients may elect to pursue a different form of monitoring or less frequent monitoring than originally recommended.  

But there will undoubtedly still be cases in which the client continues to decline any form of monitoring. In these cases, veterinarians must decide if they are still comfortable prescribing the medication. Each individual’s risk tolerance and confidence in their client’s understanding of the risks presented to them factor into the decision to refill medication in these circumstances.  

Cook advised that those who are on the fence about refilling should go with their gut. “I think if a vet is truly uncomfortable refilling a medication without appropriate monitoring, he or she should decline to refill,” she said. 

Whatever decision is made, Cook stressed that it is essential to carefully document any discussion had with the client and any continued refusal to pursue recommended monitoring in the pet’s medical record.  

As a member of the AAHA Community, you can also learn more from your colleagues and AAHA accreditation specialists on this topic on this thread: 

Medication refills and bloodwork requirements 

Photo credit: Georgijevic/E+ via Getty Images 

Disclaimer: Trends™ content is meant to inform, educate, and inspire by providing an array of diverse viewpoints. Any content published should not be viewed as an official stance, position, or endorsement by the American Animal Hospital Association (AAHA) or its Board of Directors.