Propranolol For Trauma In Dogs

[Beldene]

I have a severely abused dog.  I have been working with a wonderful force-free trainer, and a vet who specializes in canine behavior.  We are using classical conditioning to change the emotions.  We are making some progress, but my dog still shows extreme aggression towards strangers.  He triggers when strangers get to close to him, or look at him the wrong way, or carry a stick, etc.  

I have recently become aware of the use of propranolol for the treatment of PTSD, and I am really excited about this research.  I found your name because I saw a previous post where you say you used propranolol successfully on dogs before.  My vet is not familiar with the current research and it would be really helpful if you could point us to a source, or even discuss this option with him.  

ANSWER: For years a veterinary associate and I used propanolol in actively aggressive dogs(fear related) with success combined, of course, with carefully designed protocols for behavior modification.  The use of other drugs designed to treat depression and psychiatric problems(in humans) has to be determined extremely carefully in each individual case, as some of these drugs can precipitate aggression, elevated anxiety, suicidal ideation, as well as other serious physical side effects(in humans) and dogs CANNOT tell us if any of these side effects are occurring(other than with their behavior).  An actively aggressive dog is a clear and present danger, the use of drugs has to be undertaken very carefully; if even the slightest escalation in aggression occurs as a result of the drug, it is not acceptable.

Propanolol is a benign substance(psychologically) which helps the body's reaction to the fight/flight mechanism.  It is my understanding that no adverse physical or behavioral side effects were ever seen(in our practice) and I can remember several instances where this physical affect upon the nervous system absolutely assisted in our efforts to desensitize the dogs' fears.

Here are sources of information regarding this, and other drugs, the first being a text book:

"Small Animal Clinical Pharmacology and Therapeutics", Dawn Merton Boothe

Below are individual QUOTES from sites discussing this drug:

QUOTE:

Source: PetPlace veterinarians:

#  The autonomic(involuntary) nervous system is divided into the sympathetic(fight or flight response) and parasympathetic branches.

# Sympathetic activity is communicated to tissues through involuntary(autonomic) nerve impulses and through the blood.

# Cells contain targets, called receptors, which are stimulated by chemicals released from nerves or glands.

# In the sympathetic system, the chemical transmitter released by nerves is called norepinephrine. The transmitter chemical released by the adrenal glands is called epinephrine or adrenaline. The receptors for these chemicals are the alpha and beta-adrenergic receptors.

# The effects of beta-adrenergic receptor stimulation include increases in blood sugar, faster heart rate, stronger heart contraction and increased oxygen consumption, resulting in an increase in the blood pressure. In addition, stimulation of the receptors also results in relaxation of the bronchial tree, causing opening of the airways as well as dilation of some blood vessels.

# Propranolol

belongs to a general class of drugs known as beta blockers. Other related drugs in this class include Brevibloc®(esmolol), Tenormin®(atenolol) and Lopressor®(metoprolol).

# The effects of beta-blockers are especially prominent in the heart, though other organs also can be affected.

# Propranolol decreases heart rate, cardiac output, the amount of oxygen the heart muscle needs and blood pressure.

# Propranolol is a prescription drug and can only be obtained from a veterinarian or by prescription from a veterinarian.

# This drug is not approved for use in animals by the Food and Drug Administration but it is prescribed legally by veterinarians as an extra-label drug.

Brand Names and Other Names

# This drug is registered for use in humans only.

# Human formulations: Inderal®(Wyeth/Ayerst), Intensol®(Roxane) and various generic preparations

# Veterinary formulations: None

Uses of Propranolol

# The primary use of beta-adrenergic blockers in animals is treatment(and sometimes prevention) of cardiac arrhythmias. Commonly treated heart-rhythm disturbances are atrial fibrillation and flutter.

# Propranolol is also used to treat supraventricular tachycardia and premature ventricular complexes(PVCs).

# Propranolol reduces cardiac output and lowers high blood pressure(systemic hypertension).

# Reducing the heart rate and strength of heart muscle contraction can be beneficial to some cats and dogs suffering from the condition called hypertrophic cardiomyopathy, especially when the heart muscle contracts so vigorously it obstructs the path of the blood.

# Propranolol can be used in the management of an overactive thyroid gland(hyperthyroidism) in cats.

Precautions and Side Effects

# While generally safe and effective when prescribed by a veterinarian, propranolol can cause side effects in some animals.

# Propranolol should not be used in animals with known hypersensitivity or allergy to the drug.

# Propranolol can depress heart-muscle function and heart rate, reducing cardiac output. This can be a problem in animals with congestive heart failure and requires very careful dosing.

# Propranolol may interact with other medications. Consult with your veterinarian to determine if other drugs your pet is receiving could interact with propranolol. Such drugs include sedatives, cimetidine, inslin, lidocaine and theophylline.

# Propranolol may cause some animals to become weak due to a slow heart rate or low blood pressure. Rarely, a pet may faint.

How Propranolol Is Supplied

# Propranolol is available in 10 mg, 20 mg, 40 mg, 60 mg, 80 mg and 90 mg tablets.

# Propranolol extended-release is available in 60 mg, 80 mg, 120 mg and 160 mg capsules.

# Propranolol oral solution is supplied as 4 mg/ml, 8 mg/ml and 80 mg/ml.

# Propranolol injectable is supplied as 1 mg/ml concentration.

Dosing Information

# Medication should never be administered without first consulting your veterinarian.

# The typical dose administered to dogs is 0.15 to 0.5 mg per pound(0.3 to 1.0 mg/kg) three times daily.

# The typical dose administered to cats is 2.5 to 5 mg per cat twice to three times daily.

# Frequently, propranolol is given with other drugs, especially in pets undergoing treatment for heart failure or arrhythmias(abnormal heart rhythm). In these situations, a lower initial dose may be prescribed.

# The duration of administration depends on the condition being treated, response to the medication and the development of any adverse effects. Be certain to complete the prescription unless specifically directed by your veterinarian. Even if your pet feels better, the entire treatment plan should be completed to prevent relapse or prevent the development of resistance.

END QUOTE

QUOTE:

Source:  Gary Landsberg BSc, DVM, DACVB

Drugs

a) Antidepressants such as the tricyclic antidepressants amitriptyline and clomipramine or SSRI’s such as fluoxetine or paroxetine may help to control anxiety and panic attacks and help to decrease the intensity of outbursts. In most cases they do not calm or sedate, and do not inhibit memory or learning. TCA’s act by blocking reuptake of noradrenaline and / or serotonin and may also affect muscarinic, adrenergic, and histaminic receptors which would account for differing side effects. SSRI’s are selective in their blockade of the reuptake of 5HT1A into the

presynaptic neurons. Antidepressants cause little or no sedation and are unlikely to inhibit learning or memory.  Antidepressants may not achieve their full clinical efficacy for one to two months from the onset of therapy.  Antidepressants should not be used concurrently with MAO inhibitors such as selegiline, and should be used cautiously in pets with seizures or cardiac disease. TCA’s and paroxetine should be avoided in pets where anticholinergic side effectgs might be a concern. SSRI’s may occasionally cause restlessness, weight loss and

gastrointestinal upset. Since SSRI’s inhibit cytochrome P-450 enzymes, they can lead to increased toxicity when combined with drugs that are metabolized by these enzymes.

b) Buspirone, an azapirone, is a serotonin(5HT1A) receptor agonist and also acts as a dopamine(D2) agonist.  Buspirone has been used for mild forms of fear and anxiety as well as for urine marking in cats. It is non-sedating, does not stimulate appetite and has not been associated with major side effects. It generally takes a week or more to reach effect and is therefore not useful for situational anxieties.

c) Benzodiazepines potentiate the effects of(GABA), an inhibitory neurotransmitter. In general they cause decreased anxiety, hyperphagia, muscle relaxation and decreased locomotor activity. They reach peak effect shortly after each dose and can therefore be used on an as needed basis alone, or in combination with other drugs such as antidepressants. Clonazepam, oxazepam and lorazepam have no active intermediate metabolites and may therefore be safer for pets with compromised hepatic function. Benzodiazepines need to be dosed frequently and there is

likely to be a rebound effect upon withdrawal(so that gradual withdrawal is recommended). Benzodiazepines may lead to paradoxical effects such as excitability. Liver function should be monitored prior to and during therapy.  Rare cases of hepatotoxicity and death have been reported in cats within the first week of initiation of treatment.  Therefore, if gastrointestinal signs arise(vomiting, decreased appetite) the pet should be immediately reassessed.

d) Beta blockers such as propranolol have been used successfully to treat some forms of anxiety. By blocking beta adrenergic activity, the physical symptoms of anxiety(rapid heart rate, increased respiratory rate, muscle tremors, palpitations, sweating, trembling, gastrointestinal upset) are decreased. Without these signals, the fear response may be diminished.

e) Neuroleptics are drugs that decrease motor function at the level of the basal ganglia in the brain, elevate prolactin levels and may reduce aggression through their action as dopamine antagonists. Phenothiazines such as acepromazine are used for their sedating effects but do not effectively reduce anxiety. They produce anticholinergic side effects and should not be used in patients with seizures, liver disease or heart problems. Atypical antipsychotics such as risperidone act both as dopamine and serotonin antagonists and may have less potential for extrapyramidal signs since they have a lower affinity for the D2 receptor. They might be considered for self injurious and hallucinatory behavior.

Dosing(for dogs):

Alprazolam 0.02-0.1 mg/kg bid to qid Diazepam 0.5-2 mg/kg prn(e.g. q 6h) Oxazepam 0.2-1 mg/kg sid-bid Clonazepam 0.1-1.0 mg/kg bid-tid Lorazepam 02-.1 mg/kg q24h to tid Amitriptyline 2.0-4.0mg/kg bid Clomipramine 2-4mg/kg/bid Fluoxetine 1.0 – 2.0 mg/kg sid Paroxetine 1 mg/kg sid .

Propranolol 0.5-3.0 mg/kg bid or prn Buspirone 1.0-2.0mg/kg sid-tid Acepromazine: .1-2.2 mg/kg q24h to qid I hope this information helps you and your veterinarian.

---------- FOLLOW-UP ----------

Thanks so much for all your help!  My vet and I have decided to try propranolol.  

I know there are mixed results, is there anything I should know about how to make it as successful as possible?  How successful has it been in your experience?

Also, I am wondering about the prognosis.  I know that how well traumatized dogs do is unpredictable - but how many of them make a full recovery?  How many of them barely improve at all?  I know that even if you were sure that I was doing everything right you could not tell me that he was going to get better, but I am wondering what the typical range of outcomes is.  Of course, I am committed to my pup, and if I have to manage him around strangers his whole life I will do that, but I'd like to know what I can expect. He already has made some progress with the positive reinforcement, it's been slow but steady.

[Jonnie]

From your description of the dog's behavior in your original post, it appears he's suffering from severe fear aggression.  Propanolol is merely a tool that HELPS the fight/flight mechanism not to trigger as severely as it ordinarily would.  Fear aggression is difficult to extinguish and I can't see your dog from here, I can't read his body language or determine at one point in the encounter his fear kicks in.  Hopefully your behaviorist is skilled and able to determine this.  "Flooding" the dog(taking him consistently into areas where there are A LOT of strangers) is NOT an option for this sort of aggression.  It has to be addressed very, very slowly with a change in the dog's focus being the first thing and this has to occur BEFORE the reaction BEGINS; i.e., dog begins reaction when a person is within five feet, redirection of behavior with association to strong reward has to occur when the person is at six feet, etc.  There are no magic cures, it really is a matter of two things: the skill of the behaviorist in the use of counter conditioning and desensitization, and the persistence of the reaction in the dog(which sometimes makes rehabilitation quite difficult).  YOUR stress at the other end of the leash is a HUGE factor, it goes right down the leash to the dog.  Bring Tic Tacs with you and have one in your mouth at all times, they mask the adrenaline.  Learn all you can about dog body language so you can discern what the dog is thinking/learning: read Turid Rugaas' "On Talking Terms with Dogs: Calming Signals".  Even the most seriously abused dog in the world(I recently worked with someone on this site who adopted a Spanish Greyhound, there are few dogs more abused than these) CAN respond to the right combination of counter conditioning, desensitization, positive reinforcement, calm, consistent leadership and a lot of patience.