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Anxiety Medications for Dogs

Chill Pills: Behavior-altering drugs can help dogs with phobias or anxiety disorders – but you have to learn which ones work best in each case.

Article by Mary Straus, published in the Whole Dog Journal, July 2006

Introduction

Ten years ago, my dog Piglet (pictured above) woke me in the middle of the night, trembling violently and utterly terrified. It took me hours to track the source of her panic to a barely audible high-pitched beep that sounded once every two minutes, coming from a smoke alarm’s low battery indicator.

Thus began Piglet’s long history of noise phobias. Below is the story of my struggle to help her cope with these phobias and, eventually, generalized anxiety disorder. While I would urge anyone dealing with anxiety issues to first try natural methods of treatment, it is important to know there are medications that can offer your dog quality of life that may not be obtainable in any other way.

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A brief history

For years, Piglet reacted only to high-pitched beeping noises, such as cell phones, pagers, the microwave oven, the theme from The Twilight Zone, etc. I tried many natural treatments, including T-Touch , an Anxiety Wrap Adaptil dog appeasing pheromone products (diffuser, collar, and spray now available), counter-conditioning (scary noise = treat) and just about everything else I heard of that can help dogs with anxiety and phobias. Several of these helped a little, but none solved the problem. We dealt with her issues mostly by trying to avoid “scary noises,” including giving up some of my favorite TV shows!

Piglet was normally a confident dog, cautious with people but not fearful, comfortable with other dogs, eager to explore new places. When she was frightened by beeping sounds, she would pant, pace, tremble, try to hide, dig compulsively both indoors and out (to the point of making her nails bleed), and come to me for attention and comfort, though comforting her did not help. I knew enough not to reinforce her attention-seeking behaviors, but I did try various things, such as distracting her with clicker training (which would work only as long as I could keep it up, then she would go right back to her fearful behaviors), giving long, slow strokes, just putting my arm around her, sitting with her while completely ignoring her – nothing made any difference.

As we could avoid “scary noises” most of the time, her anxiety attacks were not frequent and she was able to live with her phobias pretty well. This began to change three years ago, when my next-door neighbors completely rebuilt their house. We were out for a walk one day, soon after construction had started, when a stump digger close to us backfired loudly just as we were passing. After that, Piglet became reactive to all of the construction sounds from next door, which gradually generalized to any loud noise she heard while on our walks. Sounds that had never before bothered her, such as lawnmowers, leaf blowers, loud trucks, and even the sound of other dogs barking, now frightened her. Most of our walks were spent trying to avoid these noises, and when she did hear them, she wanted to turn around and go home.

Eventually, Piglet was startled on a walk by a loud chirping noise from a ground squirrel. After that, she began waking at dawn, reacting to the sound of birds in my yard. Soon she was spending most of the night awake, pacing, panting, unable to rest and pawing at me to get up as well. Her noise phobias had escalated to generalized anxiety disorder (GAD). Neither of us could live like this. We had to find something to help.

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Types of Anxiety Medications

There are several different types of anti-anxiety medications (anxiolytics). Benzodiazepines are fast-acting and can be used on an as needed basis, or combined with longer-acting drugs for a quicker response and when a little more help is needed. Tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and azapirones must be given continuously, and require several weeks to become fully effective. Dogs with frequent or severe anxiety will benefit from these longer-acting drugs to decrease overall anxiety and reactivity.

All of these are prescription medications. It is important that you work closely with your veterinarian, or with a veterinary behaviorist, when using anxiolytic drugs. It is also important to do behavior modification as well, as drugs alone will rarely resolve a severe anxiety problem by themselves, just as behavior modification alone often will not work without drugs. A dog behaviorist (veterinary or otherwise) can help you with this.

Following is a summary of the different types of anti-anxiety drugs, what they are commonly used for, and what you need to know before using them. With the exception of clomipramine, the FDA has not approved the use of these drugs in dogs, as the drug companies have not submitted the necessary research. However, many of these drugs were tested on animals before use in humans, and they have been used off-label by many vets.

I’ve found Plumb’s Veterinary Drug Handbook to have the most current information on drug dosages and interactions. Some of the following is taken from that source, and some from various papers written by noted veterinary behaviorist Dr. Karen Overall and other veterinarians.

See below for more information on dosages, interactions, side effects and contraindications.

Update: Gabapentin may be used in combination with other anti-anxiety medications to increase their effectiveness. See The use of gabapentin to help manage anxiety in dogs (2019) for details, including recommended dosage.

WARNING: Liquid forms of gabapentin may contain xylitol, which is toxic to dogs. More info: How a Lethal Ingredient in Human Medicine Prescribed by Vets is Poisoning and Killing Dogs

Update: Sileo (dexmedetomidine oromucosal gel), designed for pet owners to administer before or at the time of a fear or anxiety-eliciting noise stimulus, is the first FDA-approved treatment specifically for noise aversion. Introduced in 2016 by Zoetis, Sileo has a rapid speed of onset, typically taking effect within 30 to 60 minutes after application. It is squirted into the cheek pouch, and each dose lasts two to three hours. Sileo can be redosed as needed every two hours, up to a total of five doses per event. The company says that the tube is only good for 48 hours after opening, though at least one person reported it lasting longer. If anyone tries this product, I'd be interested in hearing your feedback.

*** Initial feedback on this medication is mixed:

Sileo: A double-edged sword for dogs with thunderstorm and fireworks phobias Article about Sileo written by a friend.

Article about Sileo written by a friend. How Did Your Dogs Handle the July 4th Fireworks? See Comments below the blog post for how a variety of dogs responded to Sileo.

See Comments below the blog post for how a variety of dogs responded to Sileo. One dog who suffered from separation anxiety and generalized anxiety was helped tremendously by this medication, to the point that she has been weaned off and no longer needs it. The treatment was combined with behavior modification, but behavior modification alone or in combination with alprazolam had not been enough before they tried Sileo. The owner reported using a tube for longer than 48 hours and that it remained effective when properly stored. The owner also tried Sileo with a foster dog and said it worked well for that dog, too.

Another dog slept through Fourth of July fireworks after taking Sileo that would normally cause her to tremble and hide.

One rescue dog who was terrified of thunder and fireworks received about six doses of Sileo over two to three weeks during a time when neighbors were setting off fireworks. While it didn't seem to help at the time, the next time a thunderstorm came through, the dog no longer reacted to the thunder! The improvement has continued, and the dog will even go outside to potty during thunderstorms now. Nothing else changed, so the Sileo is likely responsible for these positve changes.

A dog trainer reports, "So far I have not had a client who felt it was helpful. They all say the same thing, they may see a slight calming at first but it is not very noticeable and definitely not something they would consider refilling or continuing to use. They get better results with non-prescription options, such as rescue remedy, proprietary essential oil blend, thundershirt, etc."

Another person reported that it seemed to have no effect on her dog with major anxiety about long car rides, and that the syringe is only good for 48 hours after opening (although it appears it will last longer if properly stored).

Warning: this product has the potential for overdose if the syringe is not locked into place for the correct dosage. See FDA Drug Safety Communication: FDA warns about risk of accidental overdosing of dogs with the drug Sileo (dexmedetomidine oromucosal gel).

Update 2018: The FDA has approved another new drug for noise aversion, called Pexion (imepitoin tablets). This drug is given twice a day, starting two days before the expected event. Side effects include ataxia (loss of balance), increased appetite, lethargy, and vomiting; 3% of owners reported increased aggression while their dogs were on this drug, which can occur with dogs who are fear-aggressive. Note that Pexion was approved in Europe in 2013 to help control seizures, so apparently it can be given long-term if needed. It has not yet been approved in the U.S. for that purpose. See Dosage and Administration for information from the UK, including links to additional details on the left side of the page (I was unable to find the product insert for the U.S.). If you try this drug for either anxiety or seizure control, please let me know how it works for your dog.

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Benzodiazepines (BZs)

Benzodiazepines are fast-acting drugs that can be used on an as-needed basis for dogs that need periodic help with anxiety, such as those afraid of thunder or fireworks. They can also be used in combination with TCAs or SSRIs when first starting treatment to hasten the effects, or on an ongoing basis, either regularly or as needed to prevent or lessen acute anxiety episodes. For example, one might use a benzodiazepine with tricyclic antidepressants for a dog suffering from separation anxiety with a panic component.

The effects of BZs do not last very long, usually only a few hours. When used continuously, they create a physical dependence.

Benzodiazepines commonly used with dogs include alprazolam (Xanax), clonazepam (Klonopin), and diazepam (Valium). These drugs are used to treat anxiety, noise phobias (including thunder phobia), panic attacks, and separation anxiety. They should be used with caution in fear-aggressive dogs, as they may lower fear-based inhibition and increase the likelihood of the dog biting.

Their safety range is very wide, and they can be combined with most other medications, including TCAs and SSRIs, as well as with pain medications such as tramadol. They can also be used together (with dosage of each reduced proportionately). As with all anti-anxiety medications, you should start with a low dose and increase only as needed.“The key to treatment for noise phobias and panic is to give the benzodiazepines early and often,” says Dr. Overall.

Alprazolam is Dr. Overall’s drug of choice for dogs with storm and noise phobias and dogs who panic. It takes effect very quickly, within 20 minutes of being given, and does not tend to cause sedation. Alprazolam has some effect if given after the dog becomes anxious, but it works far better if given ahead of time. For dogs with thunder phobia, it should be given whenever a storm is expected, rather than waiting until it arrives, though more can be given at that time, if needed. The recommended dosage range is quite wide, with the highest dose being 10 times the lowest dose.

Clonazepam is used less frequently than alprazolam, as it takes a little longer to be effective, but it is also longer lasting. There are two recommended dosage levels for clonazepam: one for seizure control, and one for anxiety. It is important to be aware of this, as the dosage for seizure control is much higher than that used for anxiety. I was reassured to me to realize how high a dose could be given without being dangerous.

Diazepam is more sedating than the other drugs in this class, and may have less anxiolytic effect, so it is generally not recommended for anxiety. It is the shortest-acting of this drug class in dogs, and does not take effect as quickly as the others.

In Piglet’s case, benzodiazepines were a lifesaver. I found an article by Dr. Overall that discussed the use of alprazolam for noise phobias (see “References” below). I started Piglet at 0.25 mg (0.017 mg/kg), but that had little effect, so I went to 0.50 mg (0.03 mg/kg), which did help. I started by giving Piglet this dosage of alprazolam whenever she would wake me up, which was generally a couple of hours after we went to sleep. She would usually settle down within an hour after getting the medication. It was helping, but it wasn’t enough.

My vet then suggested that I give an increased dosage of alprazolam at bedtime, before Piglet became anxious. Rather than giving her 0.5 mg (barely enough to help), after she had awakened me with her anxious behavior, I began giving her 1 mg (0.07 mg/kg) at bedtime. This made a huge difference. The alprazolam did not sedate Piglet; it just relaxed her enough to be able to sleep, without anxiety waking her up during the night. By giving it to her before she became anxious, she was able to sleep through most of the night.

After consulting with a veterinary behaviorist, I started giving Piglet 1 mg alprazolam every eight hours, to try to prevent her from becoming anxious. Her anxiety was under control, but she seemed to be on something of a roller coaster, becoming more reactive each hour after the alprazolam was given. I generally had to get up once during the night to give her a dose, as it was too short-acting for her to be able to make it all the way thru the night without waking and becoming anxious.

I decided to switch to clonazepam, as its effects last longer. Because the recommended dosage range of clonazepam for anxiety in dogs is similar to that for alprazolam, I tried giving Piglet the same dosage (1 mg), but quickly found out that was not enough. I increased the dosage to 2 mg (0.13 mg/kg), still well within the recommended range. I gave this amount twice a day, at bedtime and after breakfast. With clonazepam, Piglet was able to sleep through the whole night.

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Azapirones

There is only one drug in this class used with dogs:. Buspirone is used to treat cats for inappropriate urination, but is now also being used to treat dogs for phobias and other anxiety disorders, including fear aggression, especially if accompanied by signs of poor socialization. It is not helpful for panic disorders, but is effective for more generalized anxiety.

Because buspirone has few side effects and does not cause sedation, it is an excellent first choice for treating dogs with aggression or anxiety that is not too severe. It must be given continuously for at least four to six weeks in order to determine whether or not it will help. Again, it’s best to start at a low dose and increase if needed. Buspirone can be combined with TCAs or SSRIs, though it is questionable whether this helps or not.

I learned about buspirone from Amy Cook, a dog trainer in Oakland, California, who has a special interest in fearful dogs. Amy has dealt with fear and anxiety in many dogs, including two of her own, and has learned a lot about the medications used for treatment.

Buspirone helped a number of Amy’s clients, as well as the dog of a colleague that had developed noise phobias and was unable to continue her flyball participation because of it. That dog responded wonderfully to Buspirone and was able to return to her flyball team with the help of this medication.

We started Piglet on a low dose (10 mg, or 0.7 mg/kg) twice a day for a month, and then increased to 15 mg (1 mg/kg) twice a day for another month. Unfortunately, it did not help, and I weaned her off it.

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Tricyclic Antidepressants (TCAs)

Tricyclic antidepressants are used with dogs to treat anxiety, panic, phobias, and obsessive compulsive disorders, such as shadow chasing and lick granulomas. They are also used to treat aggression that is caused by underlying anxiety.

The tricyclic antidepressants most commonly used with dogs are amitriptyline (Elavil) and clomipramine (Clomicalm). The general recommendation is to start with a low dose, then increase every two weeks as needed. These drugs do not take effect immediately, and several weeks’ treatment may be needed before their effectiveness can be fully ascertained.

The most common side effect of TCAs is sedation. Anorexia (loss of appetite) is also common, but usually goes away after a few days. Giving with food and dividing the dosage between meals may decrease gastric side effects.

My own vet prefers to use amitriptyline as the first choice when treating anxiety, not because it is the most effective drug, but because he feels it is safer than clomipramine. It is also inexpensive.

Amitriptyline’s most common side effects are dry mouth and sedation. It is well suited to dogs with relatively mild anxiety disorders, including anxiety-related aggression and submissive urination. It is not useful for compulsive disorders. Amitriptyline can relieve chronic pain, and has some action as an antihistamine.

Clomipramine is best suited for situations involving anxiety, including separation anxiety, as opposed to reactivity. Clomipramine is also very effective at treating compulsive disorders.

TCAs can cause bone marrow suppression. It’s important to do blood work a couple of weeks after starting this drug (as well as before, for older dogs), then monitor every six months to a year thereafter.

I tried giving Piglet amitriptyline for her noise phobia before she developed generalized anxiety disorder. With my veterinarian's guidance, I started Piglet on 25 mg (1.7 mg/kg) twice a day, then increased to a very high dosage of 25 mg three times a day after a month.

Piglet tolerated the drug very well, and she did not have problems with sedation or other side effects. However, as time went on, I noticed no improvement in her behavior, even after we increased the dose, so I weaned her off it.

After Piglet’s anxiety worsened, my vet and I decided to try clomipramine (Clomicalm). We started at 20 mg (1.3 mg/kg) twice a day. After two weeks, I increased to 25 mg (1.7 mg/kg) twice a day. Again, Piglet tolerated it well; she had no stomach upset, and blood work was normal after two weeks. She was on clomipramine for a total of only three weeks before I began weaning her off, as I did not feel it was helping, but in retrospect, I realize that she got much worse when I weaned her off the drug. It is very important not to give up too soon when giving TCAs or SSRIs.

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Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are antidepressants and anxiolytics, used to treat aggression, separation anxiety, generalized anxiety, panic disorders, and obsessive-compulsive behaviors. SSRIs are stronger, more effective and longer-acting than TCAs, and may take longer to fully assess their effects. They are considered safer than TCAs, but they can have side effects, including gastric upset and sedation.

It is important to do blood work before starting, especially for older dogs, and monitor periodically after that. SSRIs can be combined with TCAs using low-end doses of each, which may help them take effect faster and lessen the chances of side effects.

Fluoxetine (Prozac) is the most commonly used SSRI with dogs, and has the longest half-life in people. Others include sertraline (Zoloft) and paroxetine (Paxil), all with similar potential side effects, though paroxetine is more difficult to wean off and may have a shorter half-life, leading to more variation in its effects.

The usual methodology is to start with a low dosage, and then increase if no improvement is seen after 3-4 weeks. Treatment must continue for at least 6-8 weeks before you can know for sure whether it helps.

Fluoxetine is used to treat aggression, obsessive-compulsive disorders, separation anxiety, panic and avoidance disorders, including post-traumatic stress disorder. Fluoxetine works well for conditions involving reactivity, including some forms of aggression. Paroxetine is used to treat depression, social anxiety, and agitation associated with depression. Sertraline is useful particularly for generalized anxiety and panic disorder.

After consulting with the veterinary behaviorist, we started Piglet on fluoxetine, at a low dose of 10 mg (0.7 mg/kg) once a day, and then increased to 15 mg (1 mg/kg) after two weeks.

Piglet did have some loss of appetite with this medication. Fortunately, after about a week, this problem went away. It also seemed to sedate her for the first couple of days, but she was normal after that. Her blood work was fine when we rechecked it a couple of weeks after starting the drug. The fluoxetine was helping, but I still felt that she was on edge and overly reactive.

I decided to make one further change and switch her to sertraline instead of fluoxetine. Sertraline is long-acting, similar to fluoxetine, which is desirable. I did discover that it was much more expensive, as there was no generic available at the time (a generic version has since been released and is quite inexpensive, see Cost Comparison below). We started Piglet on a once-a-day dose of 25 mg (1.67 mg/kg).

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Other factors influencing anxiety: chronic pain

Shortly after switching to sertraline, Piglet underwent surgery to remove a broken carnassial (the largest tooth in the mouth), as well as a small tumor I discovered between her toes. Because many medications can be dangerous to combine with SSRIs or TCAs, I had to be careful what pain medication was used.

I wanted to use tramadol, an effective prescription pain reliever, but had seen warnings about combining it with SSRIs, due to the risk of serotonin syndrome, though I later learned that this could be done with caution. Instead, my vet suggested using Buprenex (buprenorphine), which is put into the cheek pouch and absorbed thru the mucosal membranes (this works very well with cats, they don’t really know how well it works for dogs).

After she recovered from this surgery, Piglet’s anxiety level reduced. In fact, she became almost normal again. I believe that she must have been experiencing some chronic pain that lowered her anxiety threshold. Although I know for certain that the tooth had just broken, it’s possible it was cracked and painful for a while before it was removed; she had stopped being an avid chewer some time before that, although my vet could find nothing wrong with her teeth. I also think that the small tumor in her foot may have been bothering her for a long time, though I was unaware of it.

For the next few months after the surgery, Piglet did not have a single anxiety attack. She had a few minor episodes, where she became restless, with some pacing and attention-seeking behaviors, but no panting, trying to hide, waking me up at night, etc. These episodes did not last very long, usually only about 20-30 minutes, before she was able to settle down again. At this time, I was giving her sertraline (25 mg once a day) and clonazepam (2 mg, twice a day).

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Setback

Suddenly, Piglet became progressively worse over several days, culminating in a full-blown anxiety attack; I do not know what caused it. I first suspected a defective batch of clonazepam, which I had just refilled, but when I switched to the name-brand Klonopin, she continued to have problems.

I spent another couple of months trying different things. I took her off Metacam (a prescription arthritis pain reliever), thinking that it might be upsetting her stomach, but that didn’t help. I put her back on Metacam and added tramadol, in case pain was still contributing to her anxiety, but that also did not help. She was not as bad as she had been originally, but she was still having full-blown anxiety attacks periodically, and was on edge most of the time.

After discussion with my veterinarian and the veterinary behaviorist, we increased Piglet's clonazepam to 3 mg (0.2 mg/kg), on the high end of the range for anxiety, but still well below the dosage used for seizures. This helped some, but not enough.

I finally decided to increase her SSRIs, though both my vet and the veterinary behaviorist were concerned with doing this. Because fluoxetine (Prozac) is considered to be two-and-a-half times as effective as sertraline (Zoloft) at the same dosage level in humans, but the dosage ranges given for dogs are similar, I twice tried to switch Piglet from sertraline to fluoxetine, but both times she got much worse and I switched her back. I then increased her sertraline dosage from 25 mg to 37.5 mg (2.5 mg/kg) once a day. Within a few days, she was back to normal.

That was over three months ago, and she has continued to do great since. On the rare occasion that she starts showing signs of anxiety, or if I have to leave her alone for too long, I give her melatonin (3 mg) plus a very small dose of alprazolam (0.25 mg). I am in the process of very slowly reducing her clonazepam dosage (it is addictive, so I am making only small changes every two weeks), and she is continuing to do well with the reduced dosage.

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Don’t stop too soon

In hindsight, I believe that the SSRIs (fluoxetine and sertraline) and the TCAs (particularly clomipramine) helped more than I realized at first. Because they must be given for a few weeks before they reach full effectiveness, and because Piglet needed the addition of benzodiazepines, which are quicker-acting, I discounted the effect of the other medications.

I no longer question the impact of these slower-acting drugs. I would encourage anyone who tries TCAs, SSRIs or buspirone to not give up too soon, keep using them for at least one to two months and preferably longer, before deciding that they’re not working and trying something else. If needed, you can combine them with the quicker-acting benzodiazepines to get some relief while waiting for the other drugs to take effect.

Piglet enjoys her walks and explores new places again, and no longer avoids the areas where she might hear loud noises. Although they still disturb her a little, she doesn’t want to head for home when she hears them. She sleeps thru the night peacefully and is relaxed during the day, even playful again. She is more interested in everything. It’s a small miracle, at her age (she is now 14), to see such improvement.

Although only the benzodiazepines are physically addictive, it is important to wean off all anti-anxiety medications slowly, reducing dosage gradually every one to two weeks, rather than stopping abruptly. Stopping SSRIs and TCAs too quickly can result in symptoms returning. Stopping benzodiazepines too quickly can lead to seizures; they must be weaned slowly as they create physical dependence.

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Final (I hope!) notes

Piglet's current drug regimen consists of sertraline (37.5 mg/day) and clonazepam (1 mg in the morning and 2 mg twice a day, and decreasing).

I have learned that when you find medications that work, you need to continue to give them for some time. A dog must be treated with SSRIs or TCAs for a minimum of three to five weeks before you are able to assess the effects; then, you must maintain treatment until all the dog's symptoms are gone or are at the same low, consistent level, for at least another one to two months. Treatment should be continued after that for at least as long as it took to achieve that level, before even beginning to think about weaning them off. Total length of treatment should be a minimum of four to six months.

One of the mistakes I made was always trying to give the minimal drugs possible; every time I would see improvement, I would try to reduce the amount of drugs she was getting, and then she would get worse again. I have learned that it takes time to overcome anxiety disorders; they do not go away overnight.

If needed, I am prepared to keep Piglet on these drugs for the rest of her life. She is tolerating them well, with no side effects and continued normal blood work, and the improvement in her quality of life is so dramatic that I no longer fear having her on them. I have come to realize that there is no harm in relying on drugs when they are needed.

In hindsight, I wish I had tried using alprazolam for our walks when Piglet's reaction to outside noises first escalated; I think she would not have gotten so bad if I had treated the problem early. I would never recommend anxiety drugs as a first choice, before trying to address anxiety with natural methods, but when a dog's quality of life is at stake, the drugs can perform miracles. They have given Piglet back her life, and for that I am grateful.

Update March, 2007: Piglet is now 15, and still doing great. She continues to take the same dosage of sertraline (37.5 mg once a day), but her clonazepam has been reduced to 1 mg in the morning and 2 mg at night. It appears she will need to stay at that level, as she has developed problems when I tried to reduce it further. I continue to give melatonin (1.5 to 3 mg) occasionally at night if she seems restless, and will give small amounts of alprazolam (0.25 mg) as needed when she shows signs of anxiety, or if I have to leave her for too long. On the rare occasion that her anxiety escalates (usually, I believe, due to vomiting medication), I give more alprazolam every half hour to an hour until she settles down. She is doing great overall, still enjoying her walks and no longer letting anxiety ruin her life.

Update July, 2008: Piglet is now 16 1/2, and still doing great. She had some problems with "breakthrough" anxiety last fall, and I ended up increasing her dosage of sertraline to 50 mg daily. Clonazepam remains at 1 mg in the morning and 2 mg at night. She has not needed any extra medications in seven months, other than the small amount of alprazolam plus melatonin that I give prophylactically when I have to leave her for long periods at night.

Update December, 2008: Piglet just turned 17. Because she has been doing so well since increasing her sertraline to 50 mg once a day, I have gradually reduced her dosage of clonazepam from 3 mg daily (1 mg AM and 2 mg PM) to 1 mg in the AM only. Interestingly, although she had no problems with the reduction, she did react when I tried to eliminate that last 1 mg, so I'm leaving her on that. I have not needed to give her any extra medication, even when I have to be gone for long periods.

Epilogue: Piglet was euthanized on March 5, 2009, at the age of 17. She had lost most of her vision due to a combination of factors, and had developed canine cognitive dysfunction. As a result, she was getting stuck in corners and could no longer enjoy her walks, or her life. I made the difficult decision to let her go.

Looking back on her life after she was gone, I became more aware of how different Piglet was after developing generalized anxiety disorder, even when the medications were able to keep her symptoms under control well enough for her to function. My takeaway message is to take early signs of anxiety seriously, and to start medication sooner rather than later, particularly if signs are getting worse. Do whatever is necessary to shield your dog from whatever is causing anxiety, and use medications along with behavior modification to prevent anxiety and phobias from taking over your dog's life.

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Drug Dosages, Interactions, Side Effects and Contraindications Dosages below are given in mg (milligrams) per kg (kilogram) of body weight of the dog. A kg is 2.2 lbs, so my 33 lb dog weighs 15 kg. I’ve given the most commonly recommended dosage range, followed by other ranges I’ve seen, where applicable. Note that some of these drugs are available in liquid form if smaller doses are needed, or you could use a compounding pharmacy. BENZODIAZEPINES Alprazolam (Xanax®): 0.01 – 0.1 mg/kg as needed (I’ve seen higher dosages listed in one place, up to 2.2 mg/kg two to four times a day, but most recommendations are within the 0.01 – 0.1 range, 2 to 4 times a day)

(Xanax®): 0.01 – 0.1 mg/kg as needed (I’ve seen higher dosages listed in one place, up to 2.2 mg/kg two to four times a day, but most recommendations are within the 0.01 – 0.1 range, 2 to 4 times a day) Clonazepam (Klonopin®): 0.01 – 0.1 mg/kg as needed or 0.05 – 0.25 mg/kg once or twice a day for phobic or panic attacks. Updated dosage recommendation from Dr. Overall: 0.5 mg/kg every 8 to 12 hours (start lower and increase as needed). Note that dosage for seizures is 0.1 – 1.0 mg/kg twice a day

(Klonopin®): 0.01 – 0.1 mg/kg as needed or 0.05 – 0.25 mg/kg once or twice a day for phobic or panic attacks. Updated dosage recommendation from Dr. Overall: 0.5 mg/kg every 8 to 12 hours (start lower and increase as needed). Note that dosage for seizures is 0.1 – 1.0 mg/kg twice a day Diazepam (Valium®): 0.5 – 2.2 mg/kg every four to six hours as needed I have frequently seen a limit of 4 mg/day for alprazolam and clonazepam. This limit apparently comes from human guidelines. However, dosages for dogs are relatively higher than for humans, and dosages for seizure control are also much higher than this. I have given my 15 kg dog as much as 3 mg/day of alprazolam or 6 mg/day of clonazepam, with no side effects. I believe that a larger dog could handle correspondingly larger doses, based on the ranges given above, without regard to the 4 mg/day limitation. I have frequently seen a limit of 4 mg/day for alprazolam and clonazepam. This limit apparently comes from human guidelines. However, dosages for dogs are relatively higher than for humans, and dosages for seizure control are also much higher than this. I have given my 15 kg dog as much as 3 mg/day of alprazolam or 6 mg/day of clonazepam, with no side effects. I believe that a larger dog could handle correspondingly larger doses, based on the ranges given above, without regard to the 4 mg/day limitation. When using benzodiazepines for noise phobias or separation anxiety, it is best to give them one to two hours before the anticipated noise or stimulus, and then repeat as needed. Benzodiazepines should not be given with the antifungal medications ketoconazole or itraconazole. Cimetidine (Tagamet), erythromycin, propranolol and valproic acid will slow the metabolism of these drugs and can create excessive sedation. Antacids decrease absorption and should be given separately, at least two hours apart. Benzodiazepines should be used with caution in the case of liver or kidney disease, or narrow angle glaucoma. Side effects such as sedation or increased appetite usually go away with continued usage.

AZAPIRONES Buspirone (BuSpar®): 1 mg/kg, one to three times a day for mild anxiety (recommendations range from 0.5 - 2 mg/kg two or three times a day; older recommended dosage was 10-15 mg/dog every 8-12 hours) Buspirone should be used with caution in dogs with severe liver or kidney disease. Side effects are uncommon. Combining buspirone with MAOIs (see below) may cause dangerous hypertension (high blood pressure). TRICYCLIC ANTIDEPRESSANTS (TCAs) and SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) Buspirone should be used with caution in dogs with severe liver or kidney disease. Side effects are uncommon. Combining buspirone with MAOIs (see below) may cause dangerous hypertension (high blood pressure). I have grouped these two types of drugs together, as they have similar properties and side effects. TCAs: Start with a low dose and increase as needed every two weeks up to the maximum dosage. It may take four to six weeks to see improvement. Amitriptyline (Elavil®): 1-2 mg/kg, twice a day (recommendations range from 0.25 to 6 mg/kg once or twice a day)

(Elavil®): 1-2 mg/kg, twice a day (recommendations range from 0.25 to 6 mg/kg once or twice a day) Clomipramine (Clomicalm®): 1-3 mg/kg, twice a day (one site said dosage could be increased to 4 mg/kg twice a day, if needed to be effective) SSRIs: Fluoxetine (Prozac®): 1mg/kg, once or twice a day (recommendations range from 0.5 - 3 mg/kg once a day)

(Prozac®): 1mg/kg, once or twice a day (recommendations range from 0.5 - 3 mg/kg once a day) Paroxetine (Paxil®): 0.5 - 1 mg/kg, once a day. Dosages of up to 3 mg/kg once a day may be used for compulsive disorders

(Paxil®): 0.5 - 1 mg/kg, once a day. Dosages of up to 3 mg/kg once a day may be used for compulsive disorders Sertraline (Zoloft®): 1 to 3 mg/kg, once a day (recommendations range from 0.25 - 4 mg/kg once a day) SSRIs must be given a minimum of three to five weeks in order to assess the effects, and may take six to twelve weeks to reach full effectiveness. Paroxetine can be particularly difficult to wean off. In humans, 20 mg Prozac is considered equivalent to 50 mg Zoloft. SSRIs must be given a minimum of three to five weeks in order to assess the effects, and may take six to twelve weeks to reach full effectiveness. Paroxetine can be particularly difficult to wean off. In humans, 20 mg Prozac is considered equivalent to 50 mg Zoloft. Both TCAs and SSRIs may cause side effects, including dry mouth (which may show up as frequent lip licking), urine retention, heart rate disturbances, constipation and gastrointestinal effects such as vomiting or inappetence. The most common side effect is sedation. Loss of appetite is also common, but usually goes away after a few days. Giving with food and dividing the dosage between meals may decrease gastric side effects. TCAs can cause bone marrow suppression and may affect the liver. They may also lower seizure threshold in epileptic patients. These side effects may be more likely with clomipramine. It is best to check blood work two weeks after staring these drugs to make sure that your dog is not having any adverse effects, then continue to monitor every six months to a year thereafter. They should be used with caution in dogs with liver or kidney impairment, heart problems or seizure disorders. Older dogs should have blood work done and possibly an ECG to check for cardiac arrhythmias before starting these drugs. The dosage may need to be reduced in dogs with liver or kidney disorders. TCAs and SSRIs can be dangerous to combine with each other or with other drugs, including antihistamines, anticonvulsants, anesthetics, MAOIs (see below), and even herbs such as kava kava or St. John’s wort, and l-tryptophan, an amino acid. TCAs can be combined with SSRIs cautiously, using low dosages of each, which may reduce the potential for side effects and speed the time they take to become effective. The most common risk when combining SSRIs or TCAs with each other or with other drugs is serotonin syndrome, characterized by lethargy or agitation, incoordination, fever, tremors or seizures. Serotonin syndrome can be dangerous, even fatal. TCAs may lower seizure threshold, and may make glaucoma worse. They may lower thyroid levels, which is not a problem but could lead to a misdiagnosis of hypothyroidism. They can have cardiovascular effects, so care and monitoring is needed during general anesthesia. The use of cimetidine (Tagamet) may slow the removal of these drugs from the system, allowing them to build to toxic levels. Cyproheptadine (an antihistamine sometimes given for allergies) may decrease or reverse the effects of SSRIs. Both TCAs and SSRIs have some effect against chronic pain.

Other Drugs MAOIs

Never combine SSRIs, TCAs, buspirone, or trazodone with monoamine oxidase inhibitors (MAOIs), such as selegiline (Anipryl, used to treat senility [canine cognitive dysfunction] and Never combine SSRIs, TCAs, buspirone, or trazodone with monoamine oxidase inhibitors (MAOIs), such as selegiline (Anipryl, used to treat senility [canine cognitive dysfunction] and Cushing’s Disease ), or amitraz (used in the Preventic and other Tick Collars, and in Mitaban, which is used to treat demodectic mange). You should wait at least 2 weeks after discontinuing MAOIs before starting any SSRI or TCA. Because of the long half-life of drugs such as fluoxetine (Prozac), you should wait at least 5 weeks after discontinuing use of SSRIs or TCAs before using Anipryl or amitraz. MAOIs may also lead to high blood pressure when combined with buspirone or DLPA (dl-phenylalanine, used to treat chronic pain). Tramadol (Ultram)

While I have seen warnings against using the pain medication tramadol with SSRIs or TCAs due to the potential for serotonin syndrome, the veterinary behaviorist I consulted said that her colleagues have used them together with caution, and I have done so with Piglet. It makes sense that if high doses are not being used, the risk of serotonin syndrome should be reduced. Tramadol is safe to combine with benzodiazepines. Melatonin

Although no studies have been done, pharmacists have told me it is safe to combine melatonin with any of these other drugs, at least on an occasional basis. Melatonin is a hormone used to treat jet lag in humans. It has been found to be effective in 80 percent of dogs with thunder phobia. Recommended dosage is 3 mg for dogs over 35 lbs, 1.5 mg for smaller dogs, maybe less for really tiny dogs, given no more than once every 8 hours, as needed for short term use. Higher doses for larger dogs are sometimes used. I am using melatonin with Piglet on occasion when I feel a little extra help is needed. Propranolol (beta blocker)

Beta blockers are prescription medications used to treat heart disease. They help reduce anxiety by decreasing the "flight or fight" response. Propranolol takes about an hour and a half to take effect, and the effects last for a few hours. A longer-acting (up to 8 hours) version called Inderal is also available. Typical dosage for anxiety is 0.15 to 0.5 mg per pound (0.3 to 1.0 mg/kg) three times daily. Side effects are uncommon, but heart rate may be decreased, which can cause weakness. May interact with sedatives, cimetidine, insulin, lidocaine and theophylline. May slow metabolism of benzodiazepines, increasing their effects. Clonidine (alpha 2 agonist)

Clonidine, a prescription medication used to treat high blood pressure, is also used to reduce the "flight or fight" response. The most common side effect is sedation. It can also cause low blood pressure and slow heart rate. Recommended dosage for anxiety is 0.1 mg for dogs <20 lb, 0.2 mg for dogs 20-50 lb, 0.3 mg for dogs >50 lb. It is given once a day with food. Effect lasts about 6 hours; may take one to two weeks to reach maximum effect. Should be weaned off to avoid a sudden spike in blood pressure. Do not change dosage without a vet's approval. May increase the effects of other sedating drugs such as opiates and barbiturates. Combining with TCAs may block the hypotensive effect, but combining with amitriptyline has caused corneal lesions in rats. Due to the cumulative effect on heart rate, caution should be used if combining with beta blockers, calcium channel blockers, or digitalis. Trazodone (new) A 2012 article on anxiolytic drugs, Beyond the Front Line: Trazodone and other Ancillary Treatments for Anxiety, by Margaret E. Gruen, DVM, MVPH, DACVB, discusses the use of Trazodone as an adjunctive medication, something that is added to other drugs to make treatment more effective. Trazodone may work synergistically with SSRIs, such as fluoxetine (Prozac). It can be given daily, or only as needed. Side effects are generally mild and may include gastrointestinal upset, sedation, excitement, and panting. It takes effect in about an hour and is best given before the onset of anxiety (e.g., before a storm starts). Dosages of 5 to 30 mg/kg daily, divided into two or three doses, have been given, but when used as an adjunctive treatment, starting dosage is usually lower, then adjusted as needed to achieve results. If used long term, dosage may need to be increased over time as tolerance develops. Do not combine with MAOIs such as amitraz (see above). The article also contains information on benzodiazepines, clonidine, buspirone, gabapentin, and neutraceuticals, along with recommendations for specific situations.

WARNING: Liquid forms of gabapentin may contain xylitol, which is toxic to dogs. More info: How a Lethal Ingredient in Human Medicine Prescribed by Vets is Poisoning and Killing Dogs Acepromazine "Ace" should not be used to treat anxiety or noise phobias. It is a tranquilizer that makes the dog unable to react but does nothing to decrease his anxiety -- and can actually make it worse. I was advised by both my vet and the behaviorist that Ace could be used for emergencies, to force her to sleep if absolutely nothing else was working, and I did use it once, when she was still up at midnight after being up all the night before, and after giving both alprazolam and melatonin without success, but it is not something I am comfortable using or would recommend. It did knock Piglet out, but she was still groggy and uncoordinated the next day, something I had not seen with any other medication we tried. See these excellent articles on why acepromazine and related drugs are inappropriate for treating anxiety: Acepromazine on the Fearful Dogs site

on the Fearful Dogs site Why You SHOULDN’T Use Acepromazine For Cats and Dogs With Fireworks or Thunderstorm Fears NMDA Blockers Dr. Dodman talked about a new class of drugs used to treat obsessive-compulsive disorder (OCD) in dogs. Examples include Namenda (memantine), which is very expensive; Dextromethorphan (found in some cough medicines); and Huperzine-A (extract of the Chinese Club Moss). Amantadine is a cheaper NMDA blocker; recommended dosage is 3 to 5 mg/kg once a day. Recommended dosage of dextromethorphan is 2 mg/kg twice a day, which he has used successfully for lick granulomas and other self-directed scratching, biting, or chewing in dogs with allergies. Huperzine-A has some anticonvulsant properties and so may help dogs with OCD related to partial seizures. Recommended dosage was 50 mcg twice a day (25 mcg for a small dog).

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Cost Comparison I found the best drug prices at Costco, where even non-members can order online and shipping is free. Not all drugs are available there, but the ones I could get were substantially cheaper than from my local pharmacy. For example, when I started the clonazepam, my local pharmacy quoted me a price of over $85, while Costco charged $11 for the same prescription. I also learned that I could get 50 mg sertraline for the same price as the 25 mg pills, and simply cut them in half with a pill splitter (no longer necessary now that the much cheaper generic version is now available). Costco appears to have a broader range of low-cost generic drugs than the stores below, carrying everything except Clomipramine of the anxiety drugs listed below (Clomipramine is used only for dogs, not humans). WalMart has started a $4 generic drug program that provides 30-day prescriptions for $4. Covered medications include Amitriptyline, Fluoxetine and Buspirone. Target is also offering a $4 generic drug program that includes Amitriptyline, Fluoxetine and Buspirone. Other pharmacies have followed suit, so call around to find the best prices. Drug Prescription Cost (sample) Cost per pill Monthly Cost for Piglet’s highest dosage Alprazolam $12.69/100 for 1-mg $ .13 $11.42 (1 mg 3xday) Clonazepam $19.79/100 2-mg $ .20 $17.81 (3 mg 2xday) Amitriptyline* $14.37/100 50-mg $ .14 $ 6.47 (25 mg 3xday) Clomipramine $25.86/100 50-mg $ .26 $ 7.76 (25 mg 2xday) Fluoxetine* $15.57/100 10-mg $ .16 $14.01 (15 mg 2xday) Sertraline $13.27/90 50-mg $ .15 $ 3.32 (37.5 mg 1xday) Buspirone* $36.94/180 15-mg $ .21 $12.31 (15 mg 2xday) . * Available from Walmart and Target thru their $4 generic drug program. . * Available from Walmart and Target thru their $4 generic drug program.

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