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For Equine Vets Everywhere

VETERINARY MEDICINES AND THE CASCADE

The prescribing cascade is an essential part of equine practice in the UK. It applies some basic principles that allow veterinary surgeons to treat animals using drugs not licenced for that condition in that species. The cascade is complicated by the classification of horses as food producing animals and further information on food producing animals can be found below

Use this simple interactive flowchart to consider appropriate decision making for use of the cascade in equine clinical practice

 


Further information can be found on the VMD guidance notes 

When using the cascade there is an expectation that key information relevant to the species being treated is included, providing the information that would be included in the package insert were it licensed for use in that species. Such documents will also form the basis of informed client consent, a requirement of the RCVS code of professional conduct.

BEVA has developed a series of client information leaflets that can be downloaded and printed or used electronically and can be accessed here 

OBTAINING INFORMED CONSENT FOR THE USE OF MEDICINES UNDER THE CASCADE

Informed consent should be obtained whenever medicines are used under the cascade. While consent can be given orally, members are encouraged to obtain signed consent for the use of these medicines. Extemporaneous clinical notes can be made to record how clients have been informed and how consent was obtained. Client information leaflets form an important basis of informing clients about the use and adverse events that may be seen with medicines used under the cascade. If you are part of the RCVS Practice Standards Scheme, assessors will expect to see completed written consent forms 

 Special considerations for the responsible use of antibiotics under the Cascade

The VMD have special guidance relating to the use of antibiotics under the cascade that mean it is justified to prescribe an antibiotic on the cascade in the interests of minimising the development of resistance to ensure the most appropriate antibiotics are used. Further details are encapsulated in BEVA's responsible use PROTECTME toolkit

Special considerations when using extemporaneously produced medicines (Special Veterinary Medicines)

BEVA have guidance on the use of these medicines that can be accessed here. 

VETERINARY "SPECIALS" (unauthorised extemporaneous Veterinary Medical Products)

Equine medicines regulations can sometimes appear overly complex and challenging but arises from the desire to maintain the horse's status as a food producing animal, facilitating flexible end of life decisions for owners in some cases, while also maximising access to medicines in all animals. A number of resources can be used to help understand the use of medicines in the horse.

THESE NOTES WERE PREPARED BEFORE THE EQUINE PASSPORT REGULATIONS (262/2015) WERE INTRODUCED INTO UK LAW AND ARE CURRENT AS OF FEBRUARY 2017. SUBTLE DIFFERENCES IN THE TREATMENT OF HORSES WITHOUT A PASSPORT WILL BE INTRODUCED IN THIS NEW LEGISLATION AND MEMBERS ARE ENCOURAGED TO REVIEW THIS PAGE FOR UP TO DATE INFORMATION

  • Permitted medicines for food producing horses

These are medicines licensed for use in the horse that are permitted for use in the human food chain and are listed in table 1 of EC 37/2010 (click to view) 

The ability to use these medicines is usually contained in the SPC (data sheet) included as a package insert or via the VMD Product Information database (click to view)

There are substances (e.g. some anaesthetic agents like ketamine and isoflurane, some antimicrobials like ceftiofur, some NSAIDS like carprofen and some substances used in breeding management like cloprostenol) that are 'allowed' in the European Regulation but which have UK marketing authorisations excluding their use in food producing horses and requiring the horse to be declared not for human consumption. When there is a difference between the European Regulation and the UK Marketing Authorisation:such substances can be used in food producing horses provided that

  • the prescribing cascade is followed
  • a minimum meat withholding time of 28 days is set and a record is made in the passport (although this is at the discretion of the veterinary surgeon) 

There is a requirement for owners to maintain a medicines record if horses are not signed out of the human food chain in their passport. This can be recorded in the passport or in a separate document. 

It is the responsibility of veterinary surgeons to inform owners of the likely withdrawal period although there are medicine for which no MRLs are required (e.g. detomidine, butorphanol, ketoprofen, lidocaine, dembrexine, deslorelin)

  • Permitted medicines for use under the 'prescribing cascade'

These are medicines licensed for use in other species that are permitted for use in the human food chain and are listed in table 1 of EC 37/2010 (click to view) 

They are used under the prescribing cascade when no suitable medicine is licensed for the use in the horse. 

There is a requirement for owners to maintain a medicines record if horses are not signed out of the human food chain in their passport. This can be recorded in the passport or in a separate document. 

It is the responsibility of veterinary surgeons to inform owners of the likely withdrawal period in such cases although there are medicine for which no MRLs are required (e.g. detomidine, butorphanol, ketoprofen, lidocaine, dembrexine, deslorelin)

  • Essential medicines for the treatment of equidae

This list includes medicines that do not have marketing authorisations for use in food producing horses, but that can be administered to horses that are classified as food producing animals (passport section IX not signed) provided that

  • the prescribing cascade is followed
  • their use is followed by a 6-month withholding period before the animals can enter the food chain.
  • their use must be recorded in the horse's passport by the veterinary surgeon

This list includes acetylpromazine, diazepam, dobutamine, morphine and pethidine, sevoflurane, bupivicane, triamcinolone, sucralfate, dantrolene, azithromycin and rifampicin. The full list (122/2013) can be accessed online (click here)

Further details including worked examples can be accessed here

  • Prohibited and unclassified medicines

Drugs not listed in the 'allowed' list (table 1 of EC37/2010) or the 'essentials' list (EC122/2013) must not be used in horses classified as food producing animals

These include those drugs previously listed in annex IV and now listed in Table 2 of 37/2010 (such as metronidazole and chloramphenicol including ocular medication) and those for which MRLs have not been determined (e.g. pergolide, phenylbutazone and suxibuzone).

If no alternative exists for the treatment of these horses then they must be immediately signed out of the food chain


TREATING HORSES WHERE NO PASSPORT IS AVAILABLE

If no passport is available for inspection (or the horse does not match the passport description) and the food producing status of that animal is not already known by a veterinary surgeon you should TREAT THE HORSE ASSUMING IT IS A FOOD PRODUCING ANIMAL

IN AN EMERGENCY you should 

a) use an alternative medicine that can be used to treat that condition that is listed in 37/2010 (e.g. flunixin rather than phenylbutazone)

OR

b) use a prohibited medicine or an essential medicine AND ssue a document detailing medicines given and instruction to owner/keeper to exclude the animal from the food chain if necessary. The original copy of the document should be given to the owner or keeper and a copy retained by the vet. An example document is available for use (click here) 

Try our new interactive tool to help you comply with horse passport legislation



FURTHER INFORMATION

FORM FOR EMERGENCY TREATMENT (NO PASSPORT)

VMD GUIDANCE ON HORSE MEDICINES AND HORSE PASSPORTS and a SUMMARY DOCUMENT

SUMMARY FLOWCHART FROM VMD ON THE USE OF HORSE MEDICINES

INFORMATION FOR HORSE OWNERS ON HORSE PASSPORTS (VMD)

HORSE MEDICINES RECORD TEMPLATE (VMD) 

VMD PRODUCT INFORMATION DATABASE (all UK veterinary medicines)

NOAH COMPENDIUM of data sheets