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Reducing anxiety around veterinary visits

Stevens BJ, Frantz EM, 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;249:202-7.

Even when aware of the importance of regular veterinary care for cats, about two-thirds of cat owners express concerns about difficulty getting the cat to the veterinarian. The American Veterinary Medical Association reported that veterinary visits by cats in the United States decreased by 14% from 2001 to 2011.

In a 2016 practice management conference sponsored by the American Association of Feline Practitioners, four essential things cats and their owners want when they visit a veterinary practice were identified:  a cat-friendly practice designed to make them comfortable; cat-friendly handling and examination; doctor and team members who understand cats and feline health care; and cat-friendly transport  to and from the practice.  The more a veterinary practice can prepare clients and their cats for comfortable transport of the patient to the clinic, and provide a relaxed, supportive atmosphere during the examination and any recommended procedures, the more readily owners will choose to bring their pets in regularly for health care.

A number of non-pharmaceutical behavioral and environmental interventions are available to practices and their clients that may increase the comfort level of both the patient and owner, but a safe, effective, and easy-to-administer single dose medication could further facilitate stress reduction for many feline patients who need to see the veterinarian.  To date, safe and reliably effective, easily administered tranquilizer or sedative options for cats that can be given at home are limited.

In this double-blind, placebo-controlled randomized crossover study of 10 healthy client-owned cats aged 2 to 12 years who had previously demonstrated anxiety during transport or veterinary clinic visits, the safety and efficacy of a single 50 mg oral dose of trazodone hydrochloride for reduction of patient anxiety was evaluated.  Trazodone, an atypical antidepressant which acts as a serotonin antagonist/reuptake inhibitor, has been researched in dogs as an anxiolytic and mild sedative.  It blocks presynaptic serotonin reuptake, thereby globally increasing serotonin levels, and is usually prescribed as an augmenting agent to selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).

Cats enrolled in the study had to be in good health and have historically demonstrated one or more behavioral signs of anxiety associated with transport or veterinary examinations.  Owners of these cats had to be able to administer an oral medication to their pet and be willing to transport the cats to a university veterinary clinic for two visits 1-3 weeks apart.  The cats were randomly assigned to receive a 50 mg tablet of trazodone hydrochloride or a placebo.  It was acceptable for the cat to receive the tablet in a manner that would be best tolerated by the cat such as hidden in canned cat food, inside a treat, or by direct pilling. The cat was placed in a carrier 60 to 90 minutes after administration of the tablet and transported by car to the clinic, and then had a brief wait (approximately 30 minutes) in the clinic lobby prior to entering an examination room where a veterinarian and technician performed a structured 20-minute examination.  The examination included weighing on a tabletop scale, visual examination of the head, eyes, and oral cavity without instrumentation, thoracic auscultation, abdominal and lymph node palpation, otoscopic and direct ophthalmoscopic examination, aural temperature measurement, and determination of arterial blood pressure by Doppler ultrasonography after shaving a small patch of hair at the base of the tail.

The same veterinarian and technician examined all cats enrolled in the study.  A second clinic visit and examination took place one to three weeks later using the same protocol; each patient again received oral medication, either placebo or trazodone, prior to this event.  The examination sessions were designed to be as cat-friendly as possible:  with owner present, the cat’s carrier was placed on the examination room floor, and the carrier door was opened to allow the cat to choose to exit voluntarily.  If the cat did exit the crate voluntarily, it was allowed to explore the room briefly and then was placed on the examination table, which was covered with a nonslip rubber mat.  In the case of cats who chose not to exit the carrier voluntarily, the crate lid was removed whenever possible and the cat gently lifted out from the bottom of the crate, or the cat was gently extracted from the crate and placed on the examination table.

For each clinic visit, owners were asked to complete a form assigning perceived stress scores to their cat at various time points—before transport, during transport, after transport while in the waiting room, during the examination, and immediately after examination.  For each assessment point, they also had to record the presence or absence of anxiety-associated signs such as urination, defecation, anal gland release, vomiting, salivation, trembling, open-mouth breathing, and vocalization.

The examining veterinarian also assigned a cumulative stress score based on a 7-point scale ranging from “fully relaxed” (1) to “terrorized” (7). In addition, the veterinarian also recorded behavioral data for each of the 12 examination procedures, which involved scoring four specific behaviors:  vocalization, struggling or attempts to escape, aggression (ears back, tail lashing, batting) and severe aggression (biting, attacking, hissing, and growling). After the examination both the veterinarian and the owner independently assigned a tractability score based on the ease with which each examination procedure could be performed.  A 5-point scale was used to assign a tractability score, ranging from 0 (completely relaxed) to 5 (unable to examine).

Cats receiving placebo generally had more anxiety-related signs than those that received trazodone; 6/7 cats that had anxiety-related signs during transport when on placebo did not display these signs when on trazodone.  Anxiety-related signs were displayed after transport by 9/10 cats on placebo, while only 3/10 cats had them when given trazodone.  There was also less vocalization by the cats before, during, and after transport when on trazodone than on placebo.  Owners indicated that the reduction in their pet’s vocalization when given trazodone signaled to them that the cat was experiencing less distress during transport.  Tractability scores during examination assigned by owners also improved when the cat received trazodone.  All owners except one speculated correctly that their cat had received trazodone rather than placebo prior to the clinic visit.

Use of trazodone in all cats except one improved behavioral and tractability scores during examination activities compared to placebo. There were no significant differences in physiologic parameters such as heart rate, blood pressure, or aural temperature between trazodone and placebo, and all physiologic parameters for all cats were within reference ranges after administration of trazodone and placebo. Respiratory rate in patients receiving trazodone was nonsignificantly lower than in those receiving placebo,  which could be an indication of reduced anxiety. No serious adverse effects were noted with trazodone use; however, caution must be exercised when using trazodone in patients receiving other serotonergic agents such as fluoxetine, tricyclic antidepressants, and/or monoamine oxidase inhibitors, as there is a potential risk of serotonin syndrome.

As more veterinary practices embrace the Cat Friendly Practice and “fear free” paradigms, availability of trazodone, a safe, effective, and easily administered oral sedative/anxiolytic for home use prior to veterinary visits, can help further promote regular veterinary care for cats and support the human-animal bond by reducing owner anxiety and reluctance to transport the cat to the veterinarian.  Increased veterinary usage by cat owners for routine wellness care will in turn enhance the health and welfare of cats, and in some cases tip the balance  of feline veterinary care towards prevention and wellness rather than crisis management. [PJS]

See also:
Orlando JM, Case BC, et al.  Use of oral trazodone for sedation in cats:  a pilot study.  J Feline Med Surg 2016;18(6):476-82.