You won't see them walking into Kohll's Pharmacy & Homecare for inhalers, ibuprofen and in vitro fertilization, but they're patients nonetheless.

Kohll's operates the largest compounding lab in the Midlands for exotic animal drugs and one of the largest in the Midwest for horse medications. Its customers include veterinarians and about a dozen zoos around the country, including the Henry Doorly, San Diego and Denver Zoos.

No government agency or professional group keeps statistics on the number of animal compounding pharmacies, but zoo officials know of only 10 or so in the country that do significant work with exotic animals.

Drug compounding, for people and animals, is big business, generating about $12 billion a year for U.S. pharmacies, hospitals, and cancer and surgical centers, said Loyd V. Allen Jr., editor-in-chief of the International Journal of Pharmaceutical Compounding.

“It is particularly valuable to us,” said Dr. Doug Armstrong, a veterinarian at the Omaha zoo.

Veterinarians, like physicians, usually prescribe drugs that are manufactured by major pharmaceutical firms. But if those medications aren't mass-produced, or the dosages, flavors or forms don't meet a particular animal's needs, vets turn to compounding labs.

It takes creativity — and sometimes a run to the supermarket for canned salmon and tuna — to get large zoo animals to take oral medications.

“You can't walk up to a hippo and hand them a medicine to eat,” said Justin Kohll, co-owner of the company and a pharmacist.

Kohll's has made alfalfa-flavored amoxicillin for hippos and fish-flavored dewormer for polar bears.

“You want to make it as stinky as possible,” Kohll said.

One project at the Omaha zoo involved Kohll's creating a slow-release hormone gel for tigers to help zoo officials stimulate egg production to use with in vitro fertilization, said Naida Loskutoff, director of reproductive sciences at the zoo. Unfortunately, the gel had to be administered through blow dart, which dispersed the gel and reduced its effectiveness, Loskutoff said.

Tigers can be injected several days in a row while awake or put under anesthesia and injected once with the hormone, but those options can be stressful to the animals, Loskutoff said.

“So far it hasn't worked, but we'll keep trying,” Loskutoff said of the gel project. “Kohll's is always very willing and interested to help us.”

Robert Hilsenroth, executive director of the American Association of Zoo Veterinarians, said compounding is essential, because large pharmaceutical companies can't invest the time and resources necessary to produce specialty drugs for the relatively small number of zoo animals.

“There's not enough money in those smaller amounts of drugs. It's different if the drugs are used for 100 million dogs,” he said.

For example, of the 11,000 mammals, fish, birds, amphibians and reptiles at the Henry Doorly Zoo, only about 40 might be on medication at any one time, either for chronic conditions or for injuries and other short-term problems, officials said.

Kohll said setting up a compounding lab requires about $500,000 in equipment. The price of special-order medicines for exotic animals varies widely, from $150 for polar bear dewormers to $15,000 for a drug that kills tapeworms in sharks.

That might sound like an exorbitant amount, but zoo officials feel morally obligated to treat ill animals regardless of the cost, said Dr. Jenny Waldoch, another vet at the Omaha zoo.

“We have a responsibility to these animals,” she said. “We brought them here and we take care of them. And we're pretty attached to some of them.”

Exotic animals generally are healthy, but special long-term medications can be needed for problems like cardiac disease. And like people, some older animals develop joint pain or arthritis, Waldoch said.

Vets diagnose problems during annual or every-other-year exams, or checkups done routinely before zoo residents are transported anywhere. Zoo workers also act as the vets' eyes and ears, noting changes in behavior, such as irritability, lack of eating or inactivity, that signal illnesses.

Sick animals are similar to young children who can't say what's wrong but become fussy or hold their stomachs, Waldoch said.

“For animals, they might stretch differently, or not move around as much, curling up in the corner of the exhibit. It's the same with cats or dogs at home.”

Waldoch's latest patient is a lemur named Rhea with diabetes.

Two drugs often prescribed for people with early-stage diabetes, glipizide and metformin, have been given to Rhea in smaller doses, with fruit flavoring to encourage her to eat them, Waldoch said.

Kohll's pharmacists knew exactly which flavoring and pill size would work, she said.

“We aren't pharmacists,” Waldoch said of veterinarians. “They (pharmacists) have better ideas about what will work with this pill, get it to the right concentration, what to mix it with. It's their area of expertise.”

Medicating a small lemur is one thing, but tigers are quite another.

Vets don't like to tranquilize even large dangerous animals because it can cause stress, Kohll said. So zookeepers often train them to, for example, walk through a cage — where a shot is administered — in return for a treat.

Some medicines can be mixed into food they like, he added.

Kohll's expanded into animal medicine in 1993 after Kohll attended a conference on compounding in Houston.

The 49-year-old pharmacist said he is an animal lover who grew up with guinea pigs, gerbils, snakes and dogs. His only pet now is a chocolate Lab named Bo. Until a few years ago, he owned two horses and fox-hunted them. He also owns a racehorse, a Thoroughbred named Big Lou.

When he returned from the Houston conference, Kohll contacted the Ak-Sar-Ben racetrack and the Henry Doorly Zoo. Their veterinarians responded positively, inviting Kohll to join them on their rounds.

He still remembers those visits.

“I dressed in a white shirt and jeans. No tie. I might have been a little overdressed.

“They wear boots. They're walking through horse crap, they're in barns,” he said of racetrack vets.

Kohll learned that the Omaha area lacked a pharmacy that could formulate medicine for horses with joint pain, or to prevent internal bleeding, or to euthanize animals that broke legs or suffered some other extreme injury.

“Every time I went to a vet I walked away with an order, 90 percent of the time. They had so many needs. It was a nice niche to have.”

As they became necessary, Kohll purchased sterile filters, freeze-drying equipment and books and other materials about treatments and flavors for animals.

“Birds like fruit flavors, cats like fish flavors and dogs like anything,” Kohll said.

Kohll hired more pharmacists and had them attend conferences and go into the field with veterinarians so they had a rounded view of the business. “Some just couldn't figure it out. They couldn't problem-solve. We have a great staff now.”

Kohll said he never thought about becoming a veterinarian, however, partly because the pharmacy business was in the family.

The Essential Pharmacy Compounding division, which employs four pharmacists, operates from the company's 620 N. 114th St. location in the Miracle Hills shopping area. The lab, equipped with medicine, beakers, work stations and wood cupboards and gray countertops, is about 2,000 square feet. Pharmacists wear white lab coats and gloves, hairnets and face masks as necessary. One large white room is equipped to handle sterile materials.

A privately owned company with seven stores in the metro area and one in Boulder, Colo., Kohll's doesn't release financial details.

Making drugs for horses and domestic and exotic animals accounts for about one-third of the compounding division's yearly revenue. The remainder comes from special-order drugs for people, including chemotherapy medications for cancer patients and bioidentical hormone therapy.

Kohll's ships horse medications to veterinarians nationwide and to Thoroughbred owners at more than 150 racetracks, including Churchill Downs in Louisville, Ky., home of the Kentucky Derby.

Dr. Lowell Smalley, an Omaha equine veterinarian and consultant, has been a client for years. For example, when Smalley needed help for a horse suffering from a syndrome that inhibits shedding and causes foot pain, he turned to Kohll's.

“This horse has been off and on this product for a couple of years, and it does control the syndrome,” Smalley said.

There are other compounding pharmacists around the country, Smalley said, but he likes Kohll's.

“Justin is very exacting.”

Kohll said the need for compounded drugs is growing, as veterinarians and medical doctors become more adept at devising drugs and dosages to target health problems and specific size, weight and other characteristics. But Kohll's is licensed to ship to all 50 states, so establishing another compounding lab is unlikely, he said.

It has been a satisfying career, Kohll said.

“There are so many specialties in pharmacy you can get into: hospitals, nuclear medicine, compounding. I like where I'm at.”

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