The fax from the Internet pharmacy PetCareRx requesting authorization to dispense two drugs for a dog named Ginger mystified the people at Rehoboth Beach Animal Hospital.

Ginger is their patient, but the 13-year-old standard poodle had never been prescribed either of the requested prescription drugs. One was azathioprine, an anticancer immune suppressant; the other, EtoGesic, a medication for osteoarthritis.

Ginger’s puzzled veterinarian, Dr. Sarah Hirsch, asked a technician to contact the dog’s owner. She learned that the pharmacy had suggested the drugs for “bone health” and “GI health” after Ginger’s owner apparently recorded on the pharmacy website that her poodle occasionally had lameness and gastrointestinal issues.

Ginger’s owner, Pam DiBiaso, confirmed that she’d placed the order but thought she was buying over-the-counter supplements along the lines of vitamins.

As DiBiaso explained later to the VIN News Service: “When I went to the website, this popped up, and it was quite a great price and seemed like something she could use because she’s old and has trouble getting around. I thought, ‘Oh, this would be a great supplement.’ ... I wouldn’t have ordered it if I’d known it was a prescription drug.”

PetCareRx’s computerized drug recommendations appear to be an online variation of the direct-to-consumer drug marketing commonly seen on television and in magazines — a variation that some pharmacy experts consider ethically dubious, if not illegal.

PetCareRx calls it consumer education and guidance.

“All this is, is a way for us to try to curate the shopping experience for our consumers and make it easier for them to find the things they might want,” Jonathan Shapiro, CEO of PetCareRx.com, said in an interview.

“We do not make treatment suggestions,” Shapiro said. “The most important thing here is that we never fill a prescription without the veterinarian’s approval, period, end of story. It never, ever happens. We understand and respect the importance of the veterinarian-client-patient relationship.”

Shapiro said the product-recommendation tool debuted on July 8 as part of a website redesign. Since then, he said, the company has “de-emphasized” the feature as it tests other methods of promoting sales. Shapiro said the recommendations tool currently is active for some customers but not all.

However, he added, “We may bring versions of it forward in the future as we do feel putting the right potential set of products in front of the pet parent saves them time and effort.”

In veterinary and pharmacy circles, opinions are divided on whether recommending prescription drugs to specific patients falls into the realm of practicing medicine without a license.

On a message board of the Veterinary Information Network, an online community for the profession where Hirsch posted a description of the experience, some veterinarians said the recommendations sounded like advertising, while others said it was a clear violation of professional standards.

“There's a big difference between ‘ask your doctor if _____ is right for you’ (implying, make an appointment, see your doctor about the problem, and ask about the medication), and the pharmacy faxing your doctor scripts out of nowhere. … This seems black-and-white illegal to me,” said Dr. Chris Benton, a practitioner in Wisconsin.

Thinking the same, Hirsch said she emailed the boards of pharmacy and veterinary medicine in New York state where PetCareRx is based to ask whether the activity was permitted. Her queries went out in July. To date, she’s received no reply.

The VIN News Service likewise was unable to elicit an assessment from state pharmacy regulators. Mike Duteau, chair of the New York Board of Pharmacy, referred questions to board staff. Board Executive Secretary Lawrence Mokhiber did not respond to repeated calls and emails. A staff member in Mokhiber’s office referred calls to the communications office of the Department of Education, within which the Office of Professions operates.

Department of Education Communications Director Tom Dunn responded by email: “At this point, it is hypothetical as to whether what you describe is a basis for unlawful practice or misconduct.”

In other states where pharmacy regulators are familiar with veterinary pharmacy issues, officials were more forthcoming. Chris Humberson, executive director of the Washington State Pharmacy Quality Assurance Commission, said, “I have concerns that they’re practicing veterinary medicine … in the absence of (a required) veterinary-client-patient relationship,” he said.

Were his state board to receive a complaint on such an issue, Humberson said, “I venture to say that they’d take a hard look at it.”

In Oregon, pharmacy board Executive Director Gary Schnabel, noting that state rules vary, said nothing in his state’s regulations directly prohibit such activity.

“We’re getting into an area where ‘appropriate’ isn’t part of the vocabulary,” Schnabel said. “These guys are operating in an area where all they have to say is, ‘This is legal, so we can do it.’ It may not be ethical or appropriate, and it may be misleading, but it’s legal as long as they have a prescription (before dispensing the drug) and are licensed in the jurisdiction where they physically exist and where they send the product.”

In Delaware, where Ginger and her owner live, Dave Dryden, executive secretary of that state’s Board of Pharmacy, had a similar assessment. “There’s nothing in our law that says they can’t do that,” Dryden said. “A vet still has authority over the prescribing.”

Asked whether he considers the practice ethical, Dryden replied, “I guess something seems to rub me raw there, but at the same time, there is nothing in our law that says they can’t do that.”

The practice of making automated drug recommendations is under investigation by the National Association of Boards of Pharmacy (NABP), which administers an accreditation program called Veterinary-Verified Internet Pharmacy Practice Sites, or Vet-VIPPS. PetCareRx is one of 24 pharmacies with Vet-VIPPS accreditation.

NABP Executive Director Carmen Catizone said the organization received an anonymous complaint in August that “some pharmacies are engaged in this” activity. He said the caller did not identify which pharmacies.

“We’re looking at it from the VIPPS perspective to make sure there’s nothing that happens there that violates the (accreditation) standards,” Catizone told the VIN News Service.

After hearing a description of PetCareRx’s program, Catizone likened it to direct-to-consumer drug advertising, as did other pharmacy experts.

“We vehemently oppose direct-to-consumer advertising for prescriptions,” Catizone said, but noted that such advertising is considered constitutionally protected free speech.

“All those ads on television and radio, it looks like they’re moving into the veterinary area,” Catizone said.

PetCareRx CEO Shapiro said his company’s drug recommendations are more general than classic direct-to-consumer ads. “Our educational efforts do not favor any particular brand or therapy,” he said. “If there’s a common treatment for an ailment, we say, ‘Here are the common treatments, the ones that we’re aware of.’ And if that fosters a conversation with the vet, we think that’s great, because that will be a more educated consumer.”

Shapiro said company pharmacists and experienced non-pharmacist staff created the computerized database that matches health conditions with common treatments.

By way of example, during the interview, Shapiro created a profile for a fictitious dog and listed arthritis as an ailment. The program recommended Rimadyl, a prescription non-steroidal anti-inflammatory drug (NSAID); Novox, which is generic Rimadyl; Previcox, another NSAID; and Companion Promise Joint Health, a glucosamine/chondroitin supplement that’s sold over the counter.

PetCareRx has no full-time veterinarians in its employ, but two veterinarians consult for the company on a part-time basis, Shapiro said; they were not involved in developing the database.

Shapiro suggested that confusion on the part of one or a few customers about the website’s prescription-drug recommendations does not necessarily mean all customers would be confused. “We are constantly testing our site-user interface and are cautious before extrapolating the experience of one or two individuals to the one-plus million that have been our customers over the last few years,” he said.

If regulators have questions or concerns about the automated recommendations, Shapiro said, his company would be amenable to adjusting the approach to address the concerns. “We have a 15-year track record of following the rules,” he said.

Dr. Diane Levitan, a private practitioner and member of the New York Board of Veterinary Medicine, reviewed the PetCareRx website after receiving an inquiry from the VIN News Service.

Speaking personally, not in an official capacity, Levitan complimented the website — “very clever, draws you in” — but expressed concern that customers aren’t prompted to consult their veterinarian about the specific drug recommendations.

However, she did not think the automated recommendations amount to illegal practice.

That’s not to say the program doesn’t pose a potential risk to patients. Levitan predicted that the system could lead to a patient receiving the wrong drug if a veterinarian, in a busy moment, were to approve an authorization request for an inappropriate medication.

With that in mind, Levitan said, “Veterinarians must be very careful to double-check everything and not be cavalier. Pull records every time and make sure the medication is not contraindicated and is appropriate for the condition. Don’t be afraid to call the pet owner to discuss their request.”

She added: “...People are driven to make money (and) they’ll find the legal way to sell medications cheaper than we can. We as veterinarians must accept what the future holds and make sure that we are always recommending what is best for our patients and not what the pet owners may be manipulated to believe is best for their pet.”