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| On YOur BesT BehaViOr Today's Veterinary Practice July/August 2014 66 tvpjournal.com product) and clomipramine were approved by the FDA for use in canine separation anxiety; either agent can be ben- eficial for other anxiety-related problems. Anxiolytic antidepressants should be given daily on a regular basis. Adverse effects may include agitation, increased anxiety, undesirable sedation, inappetence (fluoxetine), and lowered seizure threshold. Side effects may be dose-dependent; initiat- ing treatment with a lower dose may help. Table 2 (page 65) lists the behavioral medications for use in dogs discussed in this section, along with doses and side effects. Benzodiazepines & Trazodone In cases when sedation or an extra boost of anxiolysis would be helpful, shorter-acting drugs can be given on an as-needed (PRN) basis; examples are benzodiazepines (eg, alprazolam) or trazodone. Benzodiazepines are anx- iolytic drugs and, used longer-term, can elicit anxiolysis without sedation. Trazodone can be dosed either regularly or PRN; an example of the latter would be its use in fearful dogs during thunderstorms. However, if used in combination with SSRIs, TCAs, or MAOIs, it should be used with caution due to the potential for serotonin syndrome (see Beware of Serotonin Syndrome). Benzodiazepines are often useful for PRN sedation in cases, such as separation anxiety or thunderstorm fear, when a focused need for anxiolysis is needed. Side effects include polyphagia, aggression disinhibition, and paradoxical agi- tation and ataxia without adequate anxiolysis, and may be dose dependent. The dose range tends to be wide; owners can use a start- ing dose while they are home to observe, and increase the dose on subsequent days with veterinary guidance. The goal should be relaxation and mild sedation. Drugs in this class may vary significantly in their clinical effect for individual patients. • Alprazolam is relatively short-acting and, therefore, may be useful for separation anxiety (because af- fected dogs are typically distressed just after owner departure). • Clorazepate is longer-acting and perhaps more useful overnight or when a thunderstorm is predicted several hours after administration. Buspirone Buspirone, a nonsedating anxiolytic, can be useful for gen- eralized anxiety. Because it has been anecdotally associated with aggression disinhibition, it may be best limited to treat- ment of anxiety with no history of aggression to humans or to other dogs. However, it is important to keep in mind that any psychotropic drug may cause increased agitation or aggression. Combination Therapy Combination therapy can be helpful for some individual patients, and may include a: • Standing antidepressant + benzodiazepine • Standing antidepressant + trazodone (with caution) • Standing antidepressant + benzodiazepine + trazodone. However, monotherapy with an antidepressant (or the PRN benzodiazepine) is recommended initially so that side effects can be identified and linked to the drug being ad- ministered. Other Agents To further effect anxiolysis or other behavior change, nonphar- maceutical agents can also be added to therapy (Table 3). Case Application: Buttercup Buttercup tends to be distressed during Mrs. Jones' book club meetings and dinner parties, and is now often restricted to the back bedroom during these times. administration of a sedative and a special, long-lasting, food-filled toy could help Buttercup relax and be less worried in these situations. Beware of Serotonin Syndrome Because trazodone, ssris, TCas, and MaOis boost serotonin levels, their use in combination (any 2 of these drugs together) may potentially trigger serotonin toxicity, or serotonin syndrome, a potentially fatal reaction. Tell owners to watch for early signs of serotonin syndrome, which can be ambiguous, but include agitation, tremors, and seizures. at the doses typically used in veterinary behavioral medicine such reactions are rare, but the potential for them indicates monitoring the dog's response. TaBLe 3. Complementary nonpharmaceu- tical agents for Behavioral Therapy NONPHARMACEUTICAL AGENT EXAMPLES l-theanine • anxitane, virbacvet.com • Composure, vetriscience.com Pheromone diffusers, collars, or sprays • adaptil, ceva.us • Feliway, ceva.us Prescription diets • Veterinary Diet Calm, royalcanin.us • hills b/d, hillspet.com S-adenosylmethionine (SAMe) • nOViFiT (novisaMe), virbacvet.com Vitamins & natural compounds • senilife, ceva.us