Complementary and alternative therapy for behavior problems

Chapter 9 Complementary and alternative therapy for behavior problems



Chapter contents



WHAT IS COMPLEMENTARY AND ALTERNATIVE VETERINARY MEDICINE (CAVM)? 


IS ALTERNATIVE MEDICINE SAFER AND MORE EFFECTIVE? 


NATUROPATHIC THERAPY 


HERBAL THERAPY (PHYTOTHERAPY) AND NUTRACEUTICALS 


Dosing 

VETERINARY NUTRACEUTICALS AND THERAPEUTIC SUPPLEMENTS


Cognitive enhancement and SAMe 

l-theanine 141

Alpha-casozepine 

Melatonin 

Tryptophan 

HERBAL THERAPEUTICS 


Harmonease 

Kava kava 

Passiflora extract 

St. John’s wort 

Valerian 

Skullcap 

Hops 

Panax ginseng 

Catnip 

COMBINATION THERAPEUTICS 


PHEROMONE THERAPY 


AROMATHERAPY 


HOMEOPATHY 


BACH FLOWER REMEDIES 


ACUPUNCTURE 


THERAPEUTIC TOUCH 


MAGNETIC FIELD THERAPY 


VETERINARY CHIROPRACTIC 


Music Therapy 


REFERENCES 


RECOMMENDED READING 



What is complementary and alternative veterinary medicine (CAVM)?


The holistic approach to medicine is designed to examine the whole pet, including the clinical signs (both physical and behavioral), environment, and relationship with the owner, and then to develop a lifestyle and treatment protocol based on the findings. Holistic thinking is centered on love, empathy, and respect, and that treatment modalities should utilize the most efficacious, least invasive, and least expensive and harmful path. However, this is not an approach that is unique to the field of complementary and alternative medicine, as this is how any caring and knowledgeable healthcare provider would practice. In the treatment of behavioral problems, an evaluation of all these factors is essential in making a diagnosis and developing an appropriate treatment plan. In addition, all aspects of veterinary medicine should be held to the same high standards. This includes documenting safety and efficacy for all therapies used.


Current examples of CAVM include modalities such as acupuncture/acutherapy/acupressure, nutraceutical therapy, phytotherapy (herbal medicine), chiropractic, homeopathy, aromatherapy, Bach flower remedies, energy therapy, low-energy photon therapy, magnetic field therapy, and orthomolecular therapy. Indepth discussions of these individual forms of therapy are beyond the scope of this book.



Is alternative medicine safer and more effective?


In traditional medicine, those therapeutic modalities that have not been tested or proven effective using established scientific principles are viewed cautiously or even skeptically. This seems prudent and does not imply that the therapy is not of value. Ideally, all medicaments and therapeutic modalities used in animals should be subject to the same stringent criteria for safety and effectiveness. In fact, if a drug or supplement has not been tested against placebo, has the potential for toxicity, or is used as an alternative to a proven effective drug, this may pose a greater risk to the pet and lead to higher expense for the owner (the antithesis of holistic practice). Over the years, new standards have been set for the safety and efficacy of drugs and supplements so that the unproven, ineffective, and perhaps even dangerous tonics and practices of the past have been replaced by medicaments and techniques that have proven to be safe and effective. Yet, many of the alternative remedies have been revived from civilizations and centuries where knowledge of anatomy, physiology, cellular biology, genetics, disease processes, and even pathogens was virtually unknown.


This is by no means a condemnation of the many complementary modalities now available. In time, some will prove to be effective while others will prove to be ineffective or even harmful. Conventional practitioners must therefore remain cognizant of the potential benefits of complementary medical therapies, while complementary practitioners must validate the therapeutic effects of their treatment protocols. In the field of behavioral medicine, placebo effects of 50% or higher are not unusual (see Chapter 8). Therefore any supplement or medication, whether pharmaceutical, herbal, or homeopathic, that has not been subjected to an objective validated scoring system or has not been proven statistically superior to placebo should be considered untested or unproven with respect to efficacy. This has already sealed the fate of numerous highly promising drugs that did not meet safety or efficacy requirements when subjected to vigorous testing. Conversely, nonprescription treatment modalities that have not been validated continue to thrive.


In behavioral medicine, the treatment program must include behavioral modification and environmental management techniques that identify and address both the underlying cause as well as perpetuating factors. Therefore, regardless of whether a drug or complementary form of treatment is utilized, a holistic approach is needed to address all the issues that may have an impact on the pet’s behavior (i.e., health, nutrition, environment, and behavioral management).



Naturopathic therapy


Supplementation is a popular topic amongst owners, breeders, and veterinarians but there are many misconceptions and myths that need to be addressed and corrected. One of the reasons for supplementing diets is that the known requirements are not necessarily the same as the actual requirements. This was forcefully demonstrated to the cat food industry in 1975, when it was determined that cats require higher levels of taurine than were present in commercial diets at that time.


There is another use for supplements that is often forgotten in the debates between owners, breeders, pet food companies, and veterinarians – some dogs and cats respond to supplements even if there is no dietary deficiency. This is because some nutrients have positive pharmacologic benefits apart from their nutritional claims.1


It is the concept of nutritional therapeutics that often creates a brick wall between conventional medicine and those practitioners who seek out more natural alternatives. Of course, there need be no wall at all. There is more than enough room in healthcare for both perspectives. We are now rediscovering some basic facts about nutritional therapy that today are making headlines – fiber can help prevent colon cancer; fresh vegetables can help prevent heart disease; St. John’s wort may help treat depression. We sometimes forget that aspirin (acetylsalicylic acid) was originally derived from the bark of willow trees or that digitalis comes from the foxglove plant. Even the potent cancer drug taxol was first isolated from the Pacific yew tree. In fact, many of the most popular drugs used today were originally isolated from nature rather than being created in a laboratory.


By law, in order to achieve licensing, veterinary drugs must be proven to be safe and efficacious by government agencies, such as the Food and Drug Administration, Center for Veterinary Medicine (FDA-CVM) in the USA, the Bureau of Veterinary Drugs in Canada, and the European Food Safety Authority and the European Medicines Agency in Europe.


In addition, toxicity, contraindications, drug interactions, and the potential for side-effects must be established. Products that are sold as supplements or natural remedies that do not make claims with respect to health or disease can be sold in most countries in the absence of these same safeguards. However, when botanical and nutraceutical products are used as therapeutic agents, they are indeed being used with therapeutic intent, yet there are no regulations or assurances with regard to product quality, efficacy, tolerance, and safety.


Perhaps the biggest concern with botanicals and nutraceuticals is that there is no protection against substandard products. In addition, there is no standardization between competitive products, and there may even be variation between batches. The different species and different plant parts may vary considerably in their biochemistry and effectiveness, even varying on a seasonal basis. Only relatively recently have companies sought to standardize doses based on active ingredients for some of their products, and reflect this on the label. Yet, independent studies continue to find great ranges in active ingredients from well below to well above the manufacturer claims. In some instances, these products can be found to contain none of the active ingredients listed on the label.


Toxic contaminants are another concern with these products. For example, eosinophilia-myalgia syndrome has been reported in humans due to contaminants in commercially available 5-hydroxytryptophan, which was being promoted for insomnia, depression, and headaches after tryptophan was banned. A number of Canadians developed nausea and vomiting when their dandelion root product was found to contain buckthorn bark. In 2007 the FDA recalled 12 Chinese herbal products containing ephedra, aristolochic acid, and human placenta (www.fda.gov). A 2007 study evaluating Chinese herbs in New York City’s Chinatown found nine different western pharmaceuticals in five samples.2 Another risk is that many people put a great deal of trust in these products because they are “all natural,” yet their side-effects, contraindications, and toxicity may exceed that of comparable prescription drugs.


As mentioned, placebo-controlled studies are generally lacking to prove the efficacy of many of these alternative products and therapies, and some recent studies are finding little therapeutic effect for herbal remedies such as ginseng. Perhaps what is most surprising is that a drug that has met the requirements for efficacy and safety by the FDA is then passed over in favor of a nutraceutical product that is untested and unregulated, just because it is labeled as “natural.” Combination products with a variety of herbal extracts are also available, which may further cloud the true effectiveness of any one particular agent.


Finally, the issue of how to dose and how much to dose has yet to be established for most herbal medicinals in animals. Literature on the use of these alternative medicines suggests that no standard method of dosing exists, that trial and error will be needed to find correct dosages, and that most dosages are based on the human dose (which is based on a 68-kg (150-lb) human male). Even if a dose were to be established, the environment in which the plant grows, the part of the plant used, the age of the plant at harvest, handling after harvest, and the method of administration may all affect dose and efficacy.


Greater study on the pharmacognosy of these plants is needed, and the information to be made available to healthcare professionals. Expect that some naturopathic remedies will eventually become mainstream medications once their active ingredients have been determined, and safe doses established and standardized.



Herbal therapy (phytotherapy) and nutraceuticals


While there are numerous personal claims of efficacy for phytotherapy, most “natural” therapeutics lack evidence of efficacy beyond case reports and anecdotal evidence (level 4 or 5 evidence). More recently however, a number of veterinary products with nutraceutical or herbal ingredients have been tested in either clinical or laboratory trials or both (see Chapter 10 for details). Unlike pharmaceuticals, nutraceutical and herbal products can be brought to market as long as they demonstrate little or no toxicity and make no label claims of efficacy. Therefore, even those “natural” products that have data to support their efficacy are unlikely to have been subjected to the rigors (and cost) that would be required for FDA pharmaceutical licensing.


Practitioners will need to examine the quality of evidence before prescribing or recommending these supplements. Because of the power of the placebo effect (see Chapter 10), especially in the field of veterinary behavior, products that have not yet been assessed using acceptable scientific methods should be used only with client consent and full disclosure of the evidence, if any, to date.



Dosing


For human products, a calculation can be made by taking the adult human male dose and dividing by 68 to achieve a per-kilogram dose or dividing by 150 to achieve a per-pound dose. As absorption and metabolism may vary greatly between dogs, cats, and humans, this method of dose calculation may lead to inefficacy or additional potential for toxicity, so close patient monitoring is essential. There can be no assurance that calculating a per-kilogram or per-pound dosage on the basis of recommendations for adult humans will be safe or effective in dogs and cats.



Veterinary nutraceuticals and therapeutic supplements



Cognitive enhancement and SAMe


Products and diets for enhancement of cognitive function in senior pets are discussed in Chapter 13. Although some products, such as S-adenosyl-l-methionine (SAMe), and apoaequorin may contain a single active ingredient, many of the cognitive supplements and diets are combinations of antioxidants, mitochondrial cofactors, fatty acids, and other ingredients that might collectively improve the signs or slow the progress of cognitive dysfunction. These include gingko biloba, resveratrol, phosphatidylserine, choline, phosphatidylcholine, alpha-lipoic acid, carnitine, omega-3 fatty acids, vitamins C, E, and B6, as well as flavonoids and carotenoids from fruit and vegetables. In humans, SAMe has been purported to improve depressive states.3 In veterinary behavior it might also be used to augment therapy with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs)4 (see Chapter 13 for more details). Yet, SAMe might increase serotonin levels; therefore, cautious monitoring for signs of serotonin toxicity when combining SAMe with drugs that might increase serotonin is indicated (Chapter 8).



L-theanine


l-theanine can be found in a number of veterinary products for treatment of canine and feline anxiety. l-theanine is a product that is naturally found in green tea and may increase gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter, and block glutamate (excitatory neurotransmitter). Anxitane (Virbac Animal Health) is a purified l-theanine product (Suntheanine) in a palatable tablet that may be useful in the treatment of fear and anxiety in dogs (including noise aversion, travel anxiety, and fear of people and other dogs) and in urine marking and avoidance behaviors in cats. Its efficacy has been assessed in both clinical and laboratory studies. In one study, dogs with noise phobias had a greater improvement with Anxitane plus behavior therapy than with behavior therapy alone.5 In a pilot trial in cats, emotional disorders, including signs of inappropriate elimination, fear aggression, fear of humans, and physical manifestations of anxiety, showed improvement after 30 days.6 In addition, in a controlled laboratory trial of dogs displaying fear and avoidance of humans, after 8 weeks Anxitane-treated dogs had significantly improved measures of human approach and interaction compared to placebo, with no evidence of sedation. There have been no reported side-effects or drug interactions.7 Improvement is likely to be seen in 2–4 weeks. The label dose is 25 mg every 12 hours for cats and dogs up to 10 kg, 50 mg every 12 hours for dogs up to 25 kg, and 100 mg every 12 hours for dogs over 25 kg.



Alpha-casozepine


Alpha-casozepine is a trypsin hydrolysate of the bovine milk protein, alpha-S1 casein. It is presently available in Europe (Intervet Schering Plough) and Canada (Vetoquinol) as Zylkene and as a supplement to a new diet Royal Canin Calm Canine and Feline. Similar ingredients may also be added to diets (caseinate hydrolysate) or found in combination supplements, typically at lower strengths. The starting dose is 15 mg/kg once daily with efficacy expected in 2–4 weeks. In some cases higher doses (up to 25 mg/kg) and longer treatment (up to 2 months) might be required to achieve maximal effect. In one study it was equally effective as selegiline in reducing anxiety in dogs over a period of 60 days based on EDED scoring (see Chapter 22).8 In a placebo-controlled study in cats, combined with behavior modification, after 56 days alpha-casozepine significantly improved fearful and anxious behavior compared to placebo based on a cat emotional scoring scale.9 In addition, in a recent study with a diet containing caseinate hydrolysate, when comparing anxious to nonanxious dogs in a laboratory environment, some clinical signs improved and cortisol was significantly decreased in anxious dogs fed the supplemented diet.10



Melatonin


Melatonin is an indolamine derivative of serotonin that may inhibit dopamine. Production is primarily within the pineal body and may decline with age. The hormone is secreted into the blood and cerebrospinal fluid at high levels during the night and at low levels during the day. Melatonin has a time-keeping function in many mammals and appears to adjust the timing of circadian rhythm information transmitted from the suprachiasmatic nucleus of the hypothalamus to entrain physiologic rhythms. It may increase serum prolactin and growth hormone; in the long term it may reduce luteinizing hormone. A true physiologic role for melatonin in humans has yet to be clearly established. It may decrease free radical production, reduce central nervous system excitability, and potentiate GABA.11 Although controlled studies are lacking, it has been reported to be useful for jet lag and sleep disorders in people.12 Side-effects in humans may include sleepiness, headaches, and gastrointestinal discomfort.


Melatonin may be useful in pets to treat canine alopecia-X in Nordic breeds, canine-pattern baldness, or canine recurrent flank alopecia.13 Although the mechanism of action is not well understood, it may have direct effects on the hair follicle or alter the secretion of melanocyte-stimulating hormone.14 Melatonin has been reported to be useful in the treatment of anxiety, fear of fireworks and thunder, and sleep cycle disorders in dogs and cats. In one case report, melatonin in conjunction with amitriptyline and behavior modification was used to treat fear and thunder phobia successfully; a dose of 0.1 mg/kg has been suggested.15 A titrated dose ranging from 1.5 to 3 mg in small dogs to 6–12 mg in large dogs either as needed or divided bid has also been used. In cats the dose may range from 1.5 to 3 mg as needed to as high as 6 mg bid.



Tryptophan


Tryptophan is an amino acid precursor in the production of serotonin. Lower levels of tryptophan in the diet have been associated with a fall in serotonin levels that might be associated with impulsivity, sleep disturbances, and mood and memory alterations. In humans, a few small studies have found that tryptophan and 5-hydroxytryptophan may alleviate symptoms of depression, but further studies on efficacy and safety are required. Therefore it has been suggested that tryptophan supplementation might be effective in enhancing mood and memory and treating impulsive behavior in pets. After one small study with reduced protein and tryptophan showed a clinical improvement, more recently additional small studies and a new food with tryptophan supplementation, recently studies of tryptophan supplementation mented with tryptophan showed benefits. However more recently a diet with tryptophan supplemented at an increased ratio to other large amino acids (Royal Canin Calm Canine and Feline) in combination with other natural anxiolytics, have renewed interest in the effects of of diet on behavior (see Chapter 10).


Tryptophan supplementation might be useful as augmentation therapy to increase the serotonin pool in pets where clomipramine or SSRIs do not achieve an adequate clinical response. However, these combinations should be monitored cautiously for signs of serotonin syndrome. Eosinophilia-myalgia syndrome has been reported in humans with 5-hydroxytryptophan supplementation, possibly due to contaminants.16 In addition, ingestion of toxic doses of 5-hydroxytryptophan has been reported in dogs with signs resembling serotonin syndrome (seizures, tremors, depression, hyperthermia, gastrointestinal upset, and death).17

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Jul 24, 2016 | Posted by in SMALL ANIMAL | Comments Off on Complementary and alternative therapy for behavior problems

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