This series gives readers the opportunity to consider and contribute to discussion of some of the ethical dilemmas that can arise in veterinary practice. Each month, a case scenario is presented, followed by discussion of some of the issues involved.
In addition, a possible way forward is suggested; however, there is rarely a cut-and-dried answer in such cases, and readers may wish to suggest an alternative approach. This month’s dilemma, 'Not a dry eye in the house: treating rescue dogs with off-licence cyclosporine', was submitted and is discussed by David Williams. Readers with comments to contribute are invited to send them as soon as possible, so that they can be considered for publication in the next issue.
The series is being coordinated by Steven McCulloch, senior lecturer in human animal studies at the Centre for Animal Welfare, University of Winchester. It aims to provide a framework that will help practising veterinarians find solutions when facing similar dilemmas.
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David Williams qualified from the University of Cambridge in 1988. He teaches veterinary ophthalmology at Cambridge veterinary school and is director of studies in veterinary medicine at St John's College, Cambridge. He is also involved in animal ethics and welfare teaching and research at both undergraduate and postgraduate levels, and is a diplomate of the European College of Animal Welfare and Behavioural Medicine.
Not a dry eye in the house: treating rescue dogs with off-licence cyclosporine
Mr Hardup has rescued another dog from a Welsh puppy farm. The puppy has abnormal eye discharge and, on inspection, you immediately suspect it has dry eye. Sure enough, the Schirmer tear test in both eyes displays only 1 mm of tear uptake on the strip after 1 minute. The obvious answer is topical cyclosporine, which is likely to restore tear production while alleviating the discomfort that is clearly a welfare issue for the animal. Without such treatment the quality-of-life for the puppy reduces dramatically due to chronic corneal pain. The only problem is that the owner has no way of affording the licensed treatment. You remember the days before cyclosporine ointment was licensed, when the oral formulation of cyclosporine used for atopic dermatitis was diluted in corn oil and worked perfectly well. What should you do?
Issues to consider
By prescribing the diluted form of oral cyclosporine you could provide the drug at a price that the owner could easily afford, resulting in a healthier puppy without emptying the owner’s wallet. However, this form of treatment is prohibited by the cascade, which states that where a licensed product is available, another formulation should not be used. Further to this, a ‘home-made’ treatment, such as the one you are considering here, is classified as an extemporaneous preparation and anyone producing it must be a holder of a manufacturing specials licence.
Readers with views to contribute on ‘Not a dry eye in the house: treating rescue dogs with off-licence cyclosporine’ should email them to firstname.lastname@example.org so that they can be considered for publication in the next issue. The deadline for receipt of comments is June 28, 2019. Please limit contributions to 200 words.
There are a large number of other treatments available for dry eye which consist of carbomer-based products. For example, tear replacement therapy can prove highly effective, and treatments such as cross-linked hyaluronan topical drops or carboxymethylcellulose gels (drug-free) do not require a prescription. So topical cyclosporine is not the only treatment available for canine dry eye although, arguably, it is much more effective than supplements such as tear replacement drops.
Possible way forward
On admission to the RCVS we all adhere to the statement, ‘I promise and solemnly declare that I will pursue the work of my profession with integrity and accept my responsibilities to the public, my clients, the profession and the Royal College of Veterinary Surgeons, and that, above all, my constant endeavour will be to ensure the health and welfare of animals committed to my care’ (RCVS 2012).
Arguably, this statement – and more specifically the ‘Above all, my constant endeavour will be to ensure the health and welfare of animals committed to my care’ – acknowledges the vet's primary responsibility is to the welfare of the animal and, in this case, requires them to formulate and administer the corn oil dilution of cyclosporine to alleviate the dog's ocular discomfort. It is a treatment that we adhered to 30 years ago and is documented in the literature (Kaswan and Salisbury 1990).
Contrary to this statement is the clause that we, as vets, also promise to act with integrity and accept our responsibilities to the public, the profession and our Royal College. So, when the cascade regulations state that administering cyclosporine diluted in corn oil because of financial issues is not appropriate, we may have a conflicting duty to follow these terms, even though it may be against our better judgement.
An option you might consider is providing Mr Hardup with a prescription for the licensed product so that he can obtain it from an online pharmacy where the price is likely to be considerably less than that charged by most veterinary practices. While it is in a practice's interests to dispense medications itself, arguably, it is our duty to direct Mr Hardup to these alternative sources. Perhaps you might even provide him with an initial prescription free of charge or maybe a topical tear lubricant, given frequently but at a fraction of the price, as prescribed in the days before the lacrimogenic activity of cyclosporine was discovered.
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