Time flies

Illustration by Jon Williams

To close out the year, VIN News Service reporters caught up on a variety of topics, from difficulties by solo practitioners in North America to sell their thriving, if small, practices; to whether isoxazoline flea-and-tick control drugs are still being found to cause neurological side effects in some pets.

The news team also checked on regulatory actions around the veterinary tranquilizer xylazine, which has gained notoriety as a street drug; and efforts by advocates of a veterinary education specialty to elevate attention to teaching skills.

Here's what we learned.

Solo practitioners still struggling to sell

During recent Black Friday and Cyber Monday sales, millions of folks worldwide had a chance to snap up consumer goods from smartphones to laptops for cats (including one outfitted with a "fluffy mouse") at steeply discounted prices.

At least one asset may be left on the bargain table after the festive season ends: a veterinary practice in Powell River, British Columbia.

The practice was professionally valued a few years ago at 1.4 million Canadian dollars (US$1.06 million). The practice owner and aspiring retiree, Dr. Bryce Fleming, recently dropped the sale price to CA$700,000 (US$530,000), including the real estate.

That drew only three nibbles, all of which led to nothing, prompting Fleming to drop the price again — to CA$400,000 (US$303,000), shaving a million dollars off the original price.

His accountant's calculations show that lower sum as his break-even price including the real estate, an exasperated Fleming told the VIN News Service. "I'd be basically giving the practice away for the price of the real estate alone," he said.

Fleming's struggles may seem counterintuitive amid reports of large private equity firms paying top dollar to grow their veterinary medicine empires. The problem, as outlined by VIN News in February, is that Fleming's is a solo practice, which are harder to sell.

Corporate consolidators may have deep pockets, but they tend to like larger businesses for their economies of scale, especially companion animal practices in densely populated urban centers. A shortage of veterinarians has made solo practices even less appealing to consolidators because they'd have to find a replacement doctor in a tight labor market.

Moreover, rising inflation and interest rates have pushed up the cost of borrowing, making it harder for prospective buyers to secure financing.

In upstate New York, Dr. Alan Hans, owner of the Woodstock Animal Hospital, is in a similar situation as Fleming. "The latest is that the practice has not sold, with minimum inquiries," said Hans, a septuagenarian solo practitioner who rebuffed a corporate consolidator that tried to force him to merge with a rival five miles away before it would make an offer.

He's hired a practice broker, although he's dubious it'll make much difference. "Usually a complete waste of time, but hey, you've got to have it out there!" he said. "It's a real shame, as the town continues to grow, as does our gross."

The businesses both Hans and Fleming are trying to sell are profitable.

"The really bitter bit about this is the numbers," Fleming said. "I netted over CA$700,000 (US$530,000) this year. I'm selling everything, real-estate included, for CA$400,000 (US$303,000), plus inventory. The buyer could potentially clear their corporate debt in one year. Imagine that: one year to debt-free."

Fleming said he's not terribly concerned about selling for a low price: He's worked hard and banked plenty of retirement savings. But he does worry about the state of a profession in which younger practitioners lack the means, or the enthusiasm, to go it alone.

One potential buyer — a veterinarian working for a colleague three blocks away — has taken a look at the financials, Fleming said. She's raised some concerns about disrupting her work-life balance. "We'll see what the next few months brings," he said.

Neurologic effects still reported with isoxazoline flea controls

Five years ago, the U.S. Food and Drug Administration warned that a particular class of flea and tick control drugs, relatively new at the time, was causing neurological problems, including seizures, in some dogs and cats.

Products in the class, called isoxazolines, were Bravecto (fluralaner), Credelio (lotilaner), NexGard (afoxolaner) and Simparica (sarolaner), all oral chews or tablets.

Today, those products remain on the market, and the brands are available in expanded variety, including as topical solutions. Another brand has joined the lineup, as well: Revolution Plus, a topical drug for cats that contains selamectin and sarolaner.

In 2018, the year it sounded the alert, the FDA asked the drug manufacturers to disclose on product labels the potential for neurologic side effects. They have since done so, according to agency spokesperson Juli Putnam.

For example, the back of a box of NexGard, in addition to providing information on dosage and administration, states: "Precautions: Afoxolaner is a member of the isoxazoline class. This class has been associated with neurologic adverse reactions including tremors, ataxia, and seizures. Seizures have been reported in dogs receiving isoxazoline class drugs, even in dogs without a history of seizures. Use with caution in dogs with a history of seizures or neurologic disorders."

Between Sept. 20, 2018, when the FDA posted the alert, and Oct. 31 this year, the agency received reports of 15,489 cases of dogs showing neurological signs — loss of body control (ataxia), muscle tremors and/or convulsions — associated with the use of an isoxazoline product, Putnam said. Those cases constitute 17.6% of the 88,077 total number of reports related to isoxazoline during the period, she said, adding that other reports could include "any other clinical sign, medication errors, lack of effectiveness, etc."

The proportion is greater than before the 2018 alert. Previously, 5,467 cases of dogs with at least one neurologic sign had been reported out of 53,158 adverse events, or 10.3%, according to Putnam.

A subset of cats, too, continue to experience neurological side effects. Before its 2018 alert, the FDA received 2,600 adverse event reports in cats related to the single feline isoxazoline product then available. Of those, 200 involved neurologic signs, according to the agency.

Since then, five more products have come on the market for cats (for a total of six), and the agency has tallied 1,493 cases of neurological signs out of 13,507 isoxazoline-related adverse event reports received through Nov. 30.

The overall risk to all dogs and cats exposed to isoxazoline products is unclear, and which individuals are apt to experience neurological side effects from isoxazolines is unknown. Putnam said no pattern has emerged.

On the whole, the agency says in a fact sheet, it "considers products in the isoxazoline class to be safe and effective for dogs and cats."

At the time of the alert in 2018, veterinarians discussed the concerns on message boards of the Veterinary Information Network, an online community for the profession and parent of the VIN News Service. The discussions have since subsided.

One of the early posts came from a practitioner in Illinois, Dr. Joe Frost, who wrote in spring 2019 that he'd seen a case. Frost told VIN News recently that it was of a dog that had a seizure after a dose of NexGard. The dog did not have lasting effects, he said, and that case was the only one he's had

A veterinarian in Pennsylvania, Dr. Elizabeth Kieffer (formerly Carney), fielded a barrage of pet owner concerns about isoxazolines after blogging in late 2014 about the new class of antiparasitic drugs. The reader response led her to file a federal Freedom of Information Act request for the adverse event reports, which she posted online.

Carney no longer blogs or tracks isoxazoline adverse events. "It seems the products are here to stay," she said.

Governments strive to curb illicit xylazine use

xylazine_closeup

VIN News Service photo

Xylazine is approved for use in veterinary medicine and is an important sedative in equine, large animal and wildlife practice. Illicit use among people has caught the attention of lawmakers and regulators across the country.

Urgent calls early this year to criminalize xylazine in the wake of its proliferation as a street drug immediately raised concerns among some veterinarians. They worried lawmakers would create a confusing patchwork of regulation and onerous restrictions on the legitimate use of an essential animal sedative.

Government actions in 13 states this year bear out some of those concerns.  

Xylazine is approved by the FDA for use only in veterinary medicine, for which it is an essential drug in equine, large animal and wildlife practice. Use in humans can have hazardous side effects, including severe sedation, low blood pressure and slow heart rate. Experts say that its use as a cutting agent or adulterant — it's often mixed with fentanyl — increases the chance of fatal overdose.

Since March, new laws, executive orders and bills have classified xylazine as a controlled substance, which is how the federal government and states regulate dangerous drugs with the potential for abuse and physical and psychological dependency. A handful of those measures exempt veterinary use from the restrictions and requirements associated with a controlled substance classification. 

To summarize:

• Five states classified xylazine as a controlled substance this year. Louisiana and Tennessee included exemptions for veterinarians; Delaware, Rhode Island and West Virginia did not.
• Governors in Ohio and Pennsylvania issued executive orders to make xylazine a controlled substance with no veterinary carve-out. However, the Pennsylvania House in October passed a bill that would exempt licit use in animals.
• Lawmakers in Illinois, Michigan, New York and South Carolina are considering legislation. Only South Carolina and one of several bills in NY include provisions making an exception for veterinary use.
• Governors in California and South Dakota recently proposed measures for the coming legislative sessions. An announcement from California said the legislation would maintain veterinarians' access to the drug for their patients.
• In Florida, xylazine has been a controlled substance without a veterinary exemption since 2016.

In Congress, a bill introduced in March and endorsed by the American Veterinary Medical Association aims to balance the needs of law enforcement with veterinary use. However, the measure appears stalled in committees and has been overtaken by the Support for Patients and Communities Reauthorization Act, which passed the House on Dec. 12.

Language in the Support Act would classify xylazine federally as a controlled substance while exempting the FDA-approved animal drug, allowing veterinarians to use it as they always have under federal law. The AVMA supports the bill but believes it could face headwinds in the Senate. "The AVMA does anticipate pushback ... by those who want to see greater controls placed on the FDA-approved product," according to a report in the AVMA Advocate newsletter.

Classifying xylazine at the federal level would help the U.S. Drug Enforcement Agency track any diversion from legal channels, something multiple federal agencies have said is happening. "We know where this xylazine comes from," DEA Administrator Anne Milgram said recently. "It comes as powder from China and as liquid diverted from veterinary supply chains."

Meanwhile, the FDA is working as part of a "whole-of-government response" to the emerging threat, according to agency spokesperson Siobhan DeLancey.

"FDA is aware that there have been instances of diversion from the lawful veterinary supply," she said by email, declining to elaborate because active investigations are underway.

Veterinary teaching credentialing group finds its footing

"Sometimes you don't get what you want but get what you need."

That's how Dr. Katherine Fogelberg characterizes the origin of the Academy of Veterinary Educators, founded last year after attempts to establish a board-certified veterinary education specialty ran into stiff resistance.

The proposal to establish an American College of Veterinary Medical Education encountered doubts about the need for such a specialty and concerns that all academics would be expected to become board-certified. In response, advocates retracted the application and instead formed the academy to create a community and a credentialing program designed to foster excellence in veterinary education.

In October, 32 educators from North America and Europe were recognized as founding members with "distinguished expertise." The group includes non-veterinarians who educate veterinary students. Six hail from North Carolina State University, representing the largest group from a single institution.

Fogelberg, chair of credentialing for the academy and associate dean for professional programs at Virginia-Maryland College of Veterinary Medicine, attributes NC State's robust showing to its inclusivity and commitment to high educational standards. "They have a string of outstanding educators there and were among the first schools to overtly recognize the expertise of trained educators who might or might not be veterinarians," she said.

The academy has partnered with the American Association of Veterinary Medical Colleges to offer an Academy Certified Expert Educator credential. The members designated as distinguished experts will help shape the credentialing process, help develop an exam and serve as mentors. Applications will open sometime in 2024, with the process involving submitting a portfolio and taking an exam.

In the meantime, the academy is building its general membership, which currently numbers 600, of whom 509 are veterinarians. Others are students, veterinary assistants and technicians. Fogelberg said the academy will include qualified educators, regardless whether they have a degree in veterinary medicine.

"While we felt strongly this should be a specialty recognized by the ABVS," she said, referring to the American Board of Veterinary Specialties, "only veterinarians would have been allowed to become diplomates. But being a veterinarian or a specialist doesn't mean you're a good teacher. We're working really hard to be as inclusive as possible and expand what it means to be successful in veterinary education."