Tramadol Side Effects in Dogs: What to Watch

By Dr. Zubair Khalid, DVM, MS, PhD · 2026-09-20

Tramadol is a synthetic opioid analgesic prescribed to dogs for mild to moderate pain, most often after surgery or during flare-ups of chronic conditions such as osteoarthritis. It is a prescription drug in veterinary use, and the side effects owners most commonly see are sedation, gastrointestinal upset (vomiting, diarrhea, reduced appetite), and a group of neurologic signs tied to serotonin, including tremor, agitation, and elevated body temperature. This article is educational and is not a substitute for veterinary diagnosis or treatment.

The practical problem with tramadol in dogs is that the drug sits in an awkward middle ground. It is a weak analgesic compared with full opioid agonists such as morphine or methadone, its metabolism varies between individual dogs, and the human tablets most owners have at home are not the same product a veterinarian dispenses. Understanding what the drug does, what it does not do, and what a bad reaction looks like is the difference between a manageable side effect and an emergency.

At a Glance

How Tramadol Works in Dogs

Tramadol is unusual among analgesics because it acts through two separate mechanisms. The parent drug and its metabolites interact with mu-opioid receptors, the same receptors that morphine and methadone activate, which is where much of the pain relief comes from. Separately, tramadol inhibits the reuptake of serotonin and norepinephrine in the central nervous system, which amplifies descending pain inhibition [1]. That dual mechanism explains both the therapeutic effect and the distinctive side effect profile. Opioid receptor activity drives sedation, respiratory depression at high exposure, and constipation. Monoamine activity drives the serotonergic signs that make tramadol overdose different from a typical opioid overdose.

The metabolite story matters for dogs. Most of the analgesic potency of tramadol is attributed to its active metabolite, mono-O-desmethyltramadol, usually abbreviated M1. In humans, the enzyme CYP2D6 converts tramadol to M1 efficiently. Dogs produce M1 as well, but a pharmacokinetic study in six healthy male mixed-breed dogs found that M1 concentrations after intravenous tramadol were lower than those previously reported in research beagles [2]. That finding is one reason tramadol's pain control in dogs is inconsistent. Some dogs convert the drug well and get meaningful relief. Others produce little M1 and get mostly the monoamine effects, which means more sedation and more serotonergic risk without much analgesia.

A related interaction was described in a 2026 pharmacokinetic study in nine mixed-breed dogs. When tramadol was given with dipyrone, an analgesic and antipyretic used in some countries, the combination inhibited the conversion of tramadol to M1 [3]. This is a reminder that tramadol does not act in isolation. Other drugs can shift how much active metabolite a dog produces.

What Tramadol Is Used For and What It Does Not Cover

Tramadol is prescribed for mild to moderate pain. Typical clinical settings include postoperative pain after spays, castrations, orthopedic procedures, and dental extractions, and longer-term management of osteoarthritis discomfort. It is also used in some ophthalmology cases, though the evidence for corneal pain is mixed. In a pilot study of dogs with corneal epithelial wounds, only one of five dogs receiving oral tramadol at 4 mg/kg every 8 hours required rescue analgesia, compared with four of five dogs receiving topical nalbuphine and two of four controls, and the difference between groups was not statistically significant [4]. That study was small, and the authors noted no significant difference in treatment failure rates.

What tramadol does not cover is important. It is not a substitute for a nonsteroidal anti-inflammatory drug (NSAID) when inflammation is the dominant source of pain. A randomized clinical trial in dogs undergoing tibial plateau leveling osteotomy found that 8 of 10 dogs receiving tramadol alone had a pain score above 6 after surgery, a significantly greater number than in the firocoxib group or the tramadol plus firocoxib combination group [5]. Limb function was also significantly decreased on days 1 and 2 after surgery in the tramadol-only group. In other words, tramadol alone was not enough for a painful orthopedic procedure. That is a side effect story in itself, because undertreated pain is a welfare problem, not a neutral outcome.

Tramadol is also not interchangeable with stronger opioids when the pain is severe. A study comparing tramadol with morphine for early postoperative pain after ovariohysterectomy found no differences between groups in analgesia, sedation, cardiovascular variables, or stress markers, but the morphine group required a significantly lower end-tidal isoflurane concentration 40 minutes after opioid administration [6]. The takeaway is that tramadol can be adequate for moderate surgical pain in some dogs, but it does not carry the same anesthetic-sparing depth as morphine.

The Three Main Side Effect Groups

Tramadol side effects in dogs fall into three practical categories: sedation, gastrointestinal signs, and serotonergic or neurologic signs. Each has a different mechanism, a different timeline, and a different level of urgency.

Sedation and Central Nervous System Depression

Sedation is the most consistently reported side effect of tramadol in dogs. In the pharmacokinetic study that measured sedation directly, mild dose-related sedation occurred in all six dogs after intravenous tramadol, and nausea occurred in one dog [2]. That study described adverse effects as minimal overall, which matches the general clinical picture: most dogs are quieter than usual for a few hours after a dose, and some sleep more.

Sedation is not always predictable, and it is not always the dominant effect. A study comparing acepromazine alone with acepromazine plus tramadol at 3 mg/kg and 5 mg/kg found that tramadol did not significantly increase sedation scores compared with acepromazine alone, with one exception at 20 minutes after the 3 mg/kg dose [7]. That study also found that tramadol decreased heart rate. So the sedation picture depends heavily on what else the dog received.

When tramadol is combined with a sedative such as medetomidine, the sedation deepens. In a study of eight mixed-breed dogs, dogs receiving medetomidine plus tramadol at 4 mg/kg intramuscularly had higher sedation scores at 30 and 45 minutes than dogs receiving medetomidine alone, and time to lateral recumbency was shorter in the combination group [8]. This is expected. It is also the reason a veterinarian adjusts doses when tramadol is part of a sedation or anesthesia protocol rather than a standalone analgesic.

Paradoxical excitation is the opposite reaction and is more often discussed in cats, but it can occur in dogs. A dog that becomes restless, paces, vocalizes, or seems agitated after a tramadol dose is showing a central nervous system effect, not pain relief. This is one of the signs that should prompt a call to the prescribing veterinarian.

Gastrointestinal Signs: Vomiting, Diarrhea, and Anorexia

Gastrointestinal upset is common with opioids and tramadol is no exception. The mechanisms include direct stimulation of the chemoreceptor trigger zone, which produces nausea and vomiting, and slowed gastrointestinal motility, which can produce constipation or altered stool consistency.

Vomiting after tramadol is reported in the clinical literature. In a study comparing four opioids combined with acepromazine in dogs, retching was observed in five of six dogs and vomiting occurred in one dog in the morphine group, but no vomiting occurred in any dog in the tramadol group [9]. That is a useful contrast. Tramadol was not the most emetogenic drug in that comparison, but individual dogs still vomit on it, and the pharmacokinetic study noted nausea in one of six dogs [2].

Diarrhea and reduced appetite are reported in the broader clinical experience with tramadol, though they are less consistently captured in controlled studies than sedation is. A 10-day study of oral tramadol, meloxicam, and their combination in 20 dogs evaluated fecal consistency, appetite, mental status, hydration, temperature, heart rate, and respiratory rate daily. The authors found no significant difference in gastric injury scores between treatment groups and control, and no deleterious effects on general health status over the study period [10]. That study was short and used a specific dosing schedule, so it does not rule out gastrointestinal signs in a longer course or in a sensitive dog.

Anorexia deserves specific attention because it can be a sign of something more than simple stomach upset. A case report described a 10-month-old Maltese that developed transient Fanconi syndrome, a renal proximal tubulopathy, after receiving firocoxib, cefadroxil, tramadol, and famotidine. The dog presented with lethargy, anorexia, vomiting, and weight loss [11]. The syndrome resolved completely after supportive care, but this case shows that a multi-drug regimen including tramadol can be associated with serious systemic illness, and that anorexia plus vomiting plus lethargy is a combination that warrants prompt veterinary evaluation rather than watchful waiting.

Serotonergic Effects: Tremor, Hyperthermia, and Agitation

Tramadol's monoamine activity means it can produce serotonin syndrome, a potentially life-threatening condition caused by excess serotonergic activity in the central nervous system. The classic signs are agitation, tremor, hyperthermia, tachycardia, hyperreflexia, and altered mentation. In severe cases, seizures and disseminated intravascular coagulation can occur.

Serotonin syndrome from tramadol has been documented in cats, and the veterinary literature on the condition draws heavily on the human experience because the syndrome is the same across species. A case report and literature review described tramadol toxicity in a cat manifesting as serotonin syndrome, and recommended decontamination, monitoring, and supportive care as soon as clinical signs develop, with prolonged hospitalization possible in severe overdose [1]. The same review examined the pharmacology of tramadol overdose and the manifestations of serotonin syndrome in cats, humans, and dogs, which underscores that this is a cross-species risk.

In dogs, serotonergic signs are most likely when tramadol is combined with another serotonergic drug. The list includes selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors, and other opioids such as fentanyl and methadone. A dog on fluoxetine for behavior issues that is then prescribed tramadol for pain is a classic setup. The combination is not absolutely contraindicated in every case, but it requires a veterinarian to weigh the risk and to give the owner clear instructions about what to watch for.

Tremor is the sign owners most often notice first. It may be subtle, such as fine muscle fasciculations, or obvious, such as whole-body shaking. Agitation and restlessness can look like the dog cannot get comfortable, which owners sometimes mistake for unrelieved pain. Hyperthermia is the most dangerous sign because it can escalate quickly. A dog that feels hot to the touch, is panting heavily without exercise, or has a measured temperature above the normal canine range of roughly 101 to 102.5 degrees Fahrenheit needs immediate veterinary attention.

Species Differences: Dogs Versus Cats

Tramadol is used in both dogs and cats, but the side effect profile is not the same. The differences come from metabolism, receptor sensitivity, and how each species handles the monoamine effects.

Cats metabolize tramadol differently from dogs. The feline liver produces different proportions of metabolites, and the practical consequence is that cats may show more dysphoria and more mydriasis (pupil dilation) than dogs at comparable doses. Dysphoria in a cat can look like agitation, vocalization, pacing, or a fixed stare. Mydriasis is often the first thing an owner notices, and it can persist for hours.

Cats also appear more sensitive to the serotonergic effects. The documented case of tramadol toxicity in a cat presented as serotonin syndrome [1], and the review accompanying that case emphasized that cats with suspected serotonin syndrome need decontamination, monitoring, and supportive care started as soon as signs appear. The same review noted that severe overdose may require prolonged hospitalization.

Dogs, by contrast, more often show sedation as the primary central nervous system effect, with paradoxical excitation as the less common opposite reaction. The sedation finding is consistent across studies. Mild dose-related sedation occurred in all dogs in the pharmacokinetic study [2], and tramadol deepened sedation when combined with medetomidine [8]. The paradoxical excitation picture in dogs is described in clinical practice and is a recognized reason to stop the drug and call the veterinarian, but it is not the typical response.

The practical implication for owners is straightforward. A cat on tramadol that becomes agitated, vocal, or wide-eyed is showing a species-typical reaction and needs veterinary guidance. A dog on tramadol that becomes profoundly sedated is showing the more common canine reaction, which is usually manageable but still worth reporting if it is excessive.

Human Tablets: Why They Are Not a Safe Substitute

This is the safety warning that matters most for pet owners. Human tramadol tablets are not the same product a veterinarian prescribes, and giving them without direction can cause serious harm.

The first problem is the fillers and excipients. Human tablets contain binders, coatings, disintegrants, dyes, and sometimes additional active ingredients in combination products. Some of these are harmless in people but can cause gastrointestinal upset or allergic reactions in dogs. Combination products that pair tramadol with acetaminophen or an NSAID are particularly dangerous because acetaminophen is toxic to dogs and cats at doses far below the human therapeutic range, and the NSAID adds its own gastrointestinal and renal risks.

The second problem is dose. A full human tablet can contain far more tramadol than a dog should receive. A 50 mg tablet given to a 10-pound dog is a massive dose on a per-kilogram basis. Accidental ingestion of a full human dose can cause serious toxicity, including profound sedation, respiratory depression, tachycardia, tremor, agitation, hyperthermia, and in severe cases seizures. The serotonin syndrome literature makes clear that tramadol overdose is a medical emergency requiring decontamination, monitoring, and supportive care, and that severe cases may need prolonged hospitalization [1].

The third problem is that human tramadol is often prescribed to the owner for their own pain, which means it may be sitting in a purse, on a nightstand, or in a pill organizer within reach of a determined dog. Dogs that swallow pills whole are common, and the resulting exposure is unpredictable because the tablet may not dissolve at the same rate as a veterinary product.

If a dog or cat has swallowed a human tramadol tablet, the correct response is to contact a veterinarian or a pet poison control service immediately. Do not wait for signs to develop. Do not induce vomiting unless specifically instructed to do so. Bring the pill bottle or a photo of it so the veterinary team knows exactly what was ingested, including the strength and any combination ingredients.

Monitoring Checklist for Owners and Veterinary Staff

Monitoring a dog on tramadol is mostly about tracking trends rather than single readings. A dog that is slightly quieter than usual after a dose is different from a dog that cannot be roused. A single episode of soft stool is different from repeated vomiting with refusal to eat. The checklist below covers the parameters that matter.

Mentation

Assess alertness, responsiveness, and behavior at baseline and then at regular intervals after each dose. Note whether the dog is calm, sedated, difficult to rouse, restless, agitated, or vocalizing. A sedation scale and a numeric rating scale are both used in the veterinary literature to grade this [7]. For owners, a simple description is enough: more sleepy than usual, much more sleepy than usual, or not acting like themselves in the other direction (restless, pacing, agitated).

Heart Rate

Tramadol can decrease heart rate, particularly when combined with other sedatives. In a study of acepromazine with or without tramadol, tramadol administration decreased heart rate [7]. In a study of dexmedetomidine combinations, heart rate decreased in all treatment groups including the tramadol combination [12]. A dog with a heart rate that is significantly lower than expected for its size and activity level, especially with marked sedation, should be evaluated. Tachycardia is the opposite concern and is more often associated with serotonergic excess or with pain.

Respiratory Rate

Respiratory rate is a core monitoring parameter in every tramadol study that includes cardiorespiratory variables. In the dexmedetomidine combination study, respiratory rate decreased in all treatment groups compared with baseline, with no significant difference between treatments [12]. In a study comparing subcutaneous and intravenous tramadol after ovariohysterectomy, respiratory rates remained normal and did not differ between groups [13]. The practical rule is that a respiratory rate that is normal at rest is reassuring, and a rate that is unusually slow, unusually fast, or associated with labored breathing needs attention.

Temperature

Rectal temperature is monitored in most tramadol studies because opioids and sedatives can cause hypothermia, while serotonergic excess can cause hyperthermia. In the dexmedetomidine combination study, rectal temperature decreased from 45 minutes onward in all treatments [12]. In the subcutaneous versus intravenous tramadol study, rectal temperatures remained normal and did not differ between groups [13]. Both directions matter. A dog that feels cold and is deeply sedated may be hypothermic. A dog that feels hot, is panting at rest, or has a measured temperature above the normal canine range is a serotonergic emergency until proven otherwise.

Gastrointestinal Signs

Track appetite, vomiting, stool consistency, and stool frequency. Vomiting and diarrhea are the signs owners most often report. Reduced appetite is the sign most often overlooked. In the 10-day oral tramadol and meloxicam study, fecal consistency, appetite, mental status, hydration, temperature, heart rate, and respiratory rate were all evaluated daily, and no significant adverse effects on general health status were found over that period [10]. That is reassuring for short courses, but it does not mean a longer course is risk-free, and it does not apply to every dog.

A Practical Monitoring Schedule

For a dog starting tramadol at home, a reasonable schedule is to check mentation, respiratory rate, and appetite at baseline, then at 1 to 2 hours after the first dose, then at 4 to 6 hours, and then daily. Check heart rate and temperature if the dog seems unwell, if sedation is deeper than expected, or if any serotonergic sign appears. Keep a written log for the first few days. Patterns are easier to see in writing than in memory.

Which Dogs Should Not Receive Tramadol

Tramadol is not appropriate for every dog. The prescribing veterinarian makes the final call, but owners should know the situations that warrant extra caution or an alternative drug.

Dogs with known hypersensitivity to tramadol or to other opioids should not receive it. Dogs with severe respiratory disease or compromised respiratory function are at higher risk because opioids can depress respiration. Dogs with significant liver or kidney disease may clear the drug and its metabolites more slowly, which can prolong and intensify side effects. Dogs with a history of seizures are a gray area. Tramadol lowers the seizure threshold in some patients, and the serotonergic effects add another layer of risk, so many veterinarians choose a different analgesic.

Dogs already taking serotonergic medications are the highest-risk group for serotonin syndrome. This includes SSRIs such as fluoxetine, sertraline, and paroxetine, tricyclic antidepressants such as amitriptyline and clomipramine, monoamine oxidase inhibitors, and other opioids including fentanyl, methadone, and codeine. The combination is not automatically forbidden, but it requires a deliberate risk assessment and clear owner instructions.

Dogs taking anticoagulants or drugs that affect platelet function deserve attention because tramadol can affect platelet aggregation. In a 28-day study of reduced-dose ketoprofen with or without tramadol in dogs with osteoarthritis, platelet aggregation time was not different between groups but increased over time in all groups [14]. That finding does not establish tramadol as a major bleeding risk, but it is a reason to mention all medications and supplements to the veterinarian before starting tramadol.

Pregnant or nursing dogs should receive tramadol only under direct veterinary supervision, because the safety data in that population are limited.

Drug Interactions to Know

The interaction list for tramadol is short but important. Serotonergic drugs are the headline concern, as described above. Monoamine oxidase inhibitors are a specific contraindication in human medicine because the combination can precipitate serotonin syndrome, and the same caution applies in veterinary patients.

Sedatives and anesthetics are the second group. Tramadol deepens sedation when combined with medetomidine [8], dexmedetomidine [12], acepromazine [9][7], and other central nervous system depressants. This is often intentional in an anesthesia protocol, but it means the dog should be monitored more closely, not less.

NSAIDs are the third group, and the interaction is more about pain control than about toxicity. The tibial plateau leveling osteotomy trial found that tramadol alone was inferior to firocoxib alone and to the combination for postoperative pain and limb function [5]. The reduced-dose ketoprofen study found that the combination of reduced-dose ketoprofen and tramadol was well tolerated over 28 days, with gastrointestinal lesion scores and glomerular filtration rate better in the reduced-dose groups than in the standard-dose ketoprofen group [14]. The 10-day meloxicam and tramadol gastroscopy study found no significant difference in gastric injury between treatment groups and control [10]. Taken together, these studies suggest that tramadol plus an NSAID is a reasonable combination when the NSAID dose is appropriate, and that the combination often provides better pain control than tramadol alone.

The dipyrone interaction described earlier is worth knowing for owners who travel internationally or who obtain medications outside the United States, because dipyrone is not available in the US but is used in some other countries. When tramadol was given with dipyrone in dogs, the combination inhibited the conversion of tramadol to its active M1 metabolite [3].

How Tramadol Compares With Other Analgesics

Tramadol occupies a specific niche. It is weaker than full mu-opioid agonists such as morphine and methadone for severe pain, and it is weaker than NSAIDs for inflammatory pain. Its advantages are that it does not carry the gastrointestinal and renal risks of NSAIDs, it does not require the controlled-substance handling of some stronger opioids in the same way, and it can be used when NSAIDs are contraindicated.

The comparative studies are informative. In dogs undergoing castration, tramadol at 3 mg/kg subcutaneously produced different electroencephalographic responses to surgical stimulation than morphine at 0.5 mg/kg subcutaneously, with higher median frequency and lower total power in the tramadol group [15]. In dogs undergoing ovariohysterectomy, tramadol at 3 mg/kg subcutaneously and morphine at 0.5 mg/kg subcutaneously produced no difference in electroencephalographic responses or postoperative pain scores [16]. In the ovariohysterectomy study comparing morphine at 0.2 mg/kg intravenously with tramadol at 2 mg/kg intravenously, there were no differences in analgesia, sedation, cardiovascular variables, or stress markers, though the morphine group needed less isoflurane [6]. In dogs undergoing orthopedic surgery, tramadol at 4 mg/kg intramuscularly produced higher visual analogue scale pain scores at 4 hours than methadone at 0.5 or 0.7 mg/kg [17].

The pattern is consistent. Tramadol can be adequate for moderate pain in some procedures and some dogs. It is not the strongest option, and it should not be expected to carry a severely painful case alone.

Clinical Relevance, Limitations and Common Mistakes

The clinical relevance of tramadol side effects is that they are common, mostly mild, and occasionally serious. The common ones (sedation, mild gastrointestinal upset) are manageable with dose adjustment or a change of drug. The serious ones (serotonin syndrome, severe overdose from human tablets) are emergencies that require immediate veterinary care.

The limitations of the evidence are worth stating plainly. Many of the studies cited here used small numbers of dogs, often six to eight per group, and several used experimental rather than clinical populations. The pharmacokinetic study that found lower M1 concentrations in mixed-breed dogs than in research beagles had only six dogs [2]. The corneal pain study had five dogs per treatment group [4]. Small studies can miss uncommon side effects and can overstate or understate effect sizes. The sedation and cardiorespiratory findings are consistent across multiple studies, which strengthens them. The gastrointestinal findings are less consistent, partly because different studies measured different things over different time periods.

The most common mistakes owners make are worth naming. Giving a human tablet instead of a veterinary product is the most dangerous. Combining tramadol with an over-the-counter human medication that contains acetaminophen or an NSAID is the second most dangerous. Missing the early signs of serotonin syndrome, especially tremor and agitation, is the third. Stopping tramadol abruptly after long-term use without telling the veterinarian is a fourth, because the monoamine effects can produce withdrawal signs. And assuming that a sedated dog is a comfortable dog is a fifth. Sedation is not the same as analgesia, and a dog that is quiet but still painful needs a different plan.

Individual cases vary. A dog's response to tramadol depends on its metabolism, its other medications, its organ function, and the source of its pain. A veterinarian who knows the dog is the right person to decide whether tramadol is appropriate, what dose to use, and what to do if side effects appear.

Frequently Asked Questions

How long do tramadol side effects last in dogs?

Most side effects, especially sedation and mild gastrointestinal upset, appear within a few hours of a dose and improve as the drug clears. The duration depends on the dose, the dog's metabolism, and whether other sedating drugs were given. Serotonergic signs can last longer and may worsen rather than improve, which is why they need veterinary attention rather than waiting.

Is sedation a normal side effect of tramadol in dogs?

Yes. Mild dose-related sedation is the most consistently reported side effect in dogs, and it occurred in every dog in one pharmacokinetic study [2]. Sedation that is deeper than expected, that makes the dog difficult to rouse, or that comes with slow breathing is not normal and should be reported.

Can tramadol cause vomiting or diarrhea in dogs?

Yes. Vomiting, diarrhea, and reduced appetite are recognized gastrointestinal side effects. Vomiting was not seen in the tramadol group in one comparison study [9], but nausea was noted in a pharmacokinetic study [2], and clinical experience shows that individual dogs vary. Persistent vomiting, diarrhea, or refusal to eat warrants a call to the veterinarian.

What does serotonin syndrome look like in a dog on tramadol?

Serotonin syndrome in dogs typically presents as agitation, tremor, hyperthermia, tachycardia, and altered mentation. Severe cases can progress to seizures. It is most likely when tramadol is combined with another serotonergic drug such as an SSRI, a tricyclic antidepressant, or another opioid. Any suspected case is an emergency.

Do cats react differently to tramadol than dogs?

Yes. Cats metabolize tramadol differently and may show more dysphoria and more mydriasis than dogs. Cats also appear more prone to serotonin syndrome, which has been documented as a presentation of tramadol toxicity in a cat [1]. A cat that becomes agitated, vocal, or wide-eyed on tramadol needs veterinary guidance.

Why are human tramadol tablets dangerous for dogs?

Human tablets contain fillers and excipients that can upset a dog's stomach, and combination products may contain acetaminophen or an NSAID that is toxic to dogs. A full human tablet can also deliver far more tramadol than a dog should receive, and accidental ingestion of a full human dose can cause serious toxicity requiring decontamination, monitoring, and supportive care [1].

What should I monitor at home after my dog starts tramadol?

Monitor mentation, respiratory rate, appetite, vomiting, and stool consistency at baseline and after each dose for the first few days. Check heart rate and temperature if the dog seems unwell or if sedation is deeper than expected. Keep a written log so patterns are easy to see.

Can tramadol be given with an NSAID?

Yes, and the combination often provides better pain control than tramadol alone. A clinical trial in dogs undergoing tibial plateau leveling osteotomy found that tramadol alone was inferior to firocoxib alone and to the combination for postoperative pain and limb function [5]. The NSAID dose still needs to be appropriate for the individual dog, and the veterinarian should approve the combination.

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