Esafoxolaner + Eprinomectin + Praziquantel

What is esafoxolaner + eprinomectin + praziquantel (EEP)?

The combination of esafoxolaner + eprinomectin + praziquantel (NexGard COMBO™) is a topical antiparasitic medication used to prevent heartworms and to prevent and treat intestinal parasites (hookworms, roundworms, and tapeworms), ear mites, fleas, and ticks (black-legged tick, lone star tick) in cats over eight weeks of age.

Its use in cats to treat skin mites is off label (extra label). Many drugs are commonly prescribed for off-label use in veterinary medicine. “Off label” means the drug is being used in a way that has not been reviewed or approved by the U.S. Food and Drug Administration (FDA) or Health Canada. 

In these instances, follow your veterinarian’s directions and cautions carefully, as they may be significantly different from those on the label.

How is EEP given?

• EEP is applied topically to the skin on the back of the neck.
• Follow the label directions for the correct application.
• During the first 30 minutes after application, monitor to ensure that your cat does not lick the medication.
• Do not apply this medication to irritated skin.
• Do not bathe your cat for at least four days after application.
• Do not touch this area until the medication is no longer noticeable.

This medication should start working within 24 hours, but its effects may not be noticeable for a few days.

What if I miss giving my cat a scheduled dose?

If you miss a dose, give it as soon as you remember and start a new monthly dosing schedule. For example, if you forgot to give your pet their dose on June 1 and remember on June 18, give the dose on June 18 and start a new monthly schedule. You will give your cat the next dose on July 18. Do not give the pet two doses at once. Contact your veterinarian if you are concerned about a missed dose.

Are there any potential side effects?

EEP may cause the following side effects:

• Vomiting
• Hair loss at the application site
• Itching
• Diarrhea
• Lethargy
• Excessive drooling
• Salivation and vomiting (if ingested)

Esafoxolaner belongs to the isoxazoline class of drugs, which have been associated with tremors and seizures. EEP can also cause neurologic toxicity in cats with two copies of the MDR1 mutation. Signs may include:

• Unsteady gait (ataxia)
• Drooling
• Tremors
• Weakness and/or partial paralysis
• Coma
• Seizures
• Death

Drug sensitivities can develop over time, with repeated exposure. Your pet may have no reaction after the first few doses but may develop a sensitivity later. It is important to watch for signs of an allergic reaction over the entire course of treatment and notify your veterinarian if you have any concerns.   

Other side effects may occur. If you notice anything unusual, contact your veterinarian immediately. This long-acting medication is designed to work for at least four weeks. However, negative side effects are usually short-lived if they occur at all.

Are there any risk factors for this medication?

DO NOT USE EEP in:

• Cats that are hypersensitive or allergic to any of its components
• Cats that are under eight weeks old
• Cats that weigh less than 1.8 lb (0.8 kg)
• Cats that are sick, debilitated, or underweight
• Cats that are known to have two copies of the MDR1 mutation

USE WITH CAUTION in:

• Cats with known neurologic disorders
• Cats that are breeding, pregnant, or nursing, as safety has not been established

Are there any drug interactions I should be aware of?

There are no documented drug interactions for this medication. However, interactions theoretically may occur when EEP is given with some medications, including:

• Albendazole
• Amiodarone
• Azole antifungals
• Clarithromycin
• Cimetidine
• Cyclosporine (Atopica®)
• Dexamethasone
• Fluoxetine (Reconcile®)
• Phenobarbital
• Spironolactone

Be sure to tell your veterinarian about any medications (including vitamins, supplements, or herbal therapies) that your cat is taking before starting any treatment.

Is any monitoring needed with this medication?

• Your veterinarian will let you know when and how they want to reassess your pet to ensure the medication is working and not causing side effects.
• At home, monitor for any side effects such as those noted above. If any occur, stop using the medication and contact your veterinarian.

How do I store this medication?

• Store this medication in its unopened blister pack and box.
• Store between 59°F and 86°F (15°C and 30°C).

What should I do in case of an emergency?

If you suspect an overdose or adverse reaction to the medication, call your veterinary office immediately. If they are not available, follow their directions in contacting an emergency facility. Be prepared to provide information about the product and your pet's weight and symptoms. Report any adverse effects to the FDA or Health Canada.