Flunixin Meglumine (Banamine)

Flunixin meglumine is a potent non-steroidal anti-inflammatory drug belonging to the anthranilic acid (fenamate) class that provides powerful analgesic and anti-inflammatory effects in reptile patients. This medication works by inhibiting cyclooxygenase enzymes responsible for prostaglandin synthesis, thereby reducing pain, inflammation, and fever responses throughout the body. Flunixin has earned particular recognition for its effectiveness against visceral (internal organ) pain, making it especially valuable in reptile medicine where coelomic pathology including reproductive disorders, gastrointestinal conditions, and organ inflammation commonly occurs. The medication's potency necessitates careful use under veterinary supervision to maximize benefits while minimizing the potential for adverse effects.

The development of flunixin meglumine for veterinary use originated in equine medicine, where it became one of the most widely utilized NSAIDs for managing pain, inflammation, and the effects of endotoxemia associated with colic and other conditions. Its reputation for effective visceral analgesia in horses translated into interest for similar applications in other species, including exotic animals. In reptile veterinary practice, flunixin meglumine has found a niche for managing severe pain and inflammatory conditions where its potency provides advantages over some other available NSAIDs. The medication's effectiveness must be balanced against its potential for adverse effects, requiring judicious use by experienced practitioners.

Flunixin meglumine is available in several formulations developed primarily for large animal and equine use, which veterinarians adapt for reptile patients through appropriate dose calculation and administration technique modification. The injectable solution provides the most precise dosing capability and is commonly used in hospitalized reptile patients or for initial treatment of severe conditions. Oral formulations including paste and granules present greater dosing challenges in reptiles but may be utilized in specific circumstances. The relatively high concentration of injectable preparations requires careful dilution or precise measurement for accurate dosing in small reptile patients.

Clinical use of flunixin meglumine in reptiles requires thorough understanding of both its benefits and significant risks. The medication's potency as an anti-inflammatory and analgesic agent provides genuine therapeutic value for appropriate conditions, but the potential for gastrointestinal ulceration and nephrotoxicity is considerable with this particular NSAID. Flunixin is generally reserved for situations where its specific properties provide clear advantages, rather than serving as a first-line analgesic for routine applications. The reptile veterinarian's decision to use flunixin meglumine reflects careful assessment of the clinical situation, patient status, available alternatives, and the risk-benefit balance for the individual case.

Flunixin meglumine serves specific therapeutic roles in reptile veterinary practice, with its exceptional effectiveness against visceral pain defining its primary niche. Pain originating from coelomic organs including the reproductive tract, gastrointestinal system, and hepatobiliary structures often responds well to flunixin therapy. Conditions such as egg binding (dystocia) in female reptiles, gastrointestinal obstruction, and hepatic inflammation present clinical scenarios where flunixin's visceral analgesic properties prove particularly valuable. The medication's ability to address internal organ pain distinguishes it from some other NSAIDs that may be more effective for musculoskeletal conditions.

In lizard species, flunixin meglumine finds application for managing severe painful conditions and systemic inflammatory states. Female bearded dragons experiencing reproductive complications including follicular stasis, dystocia, or post-ovulatory complications may receive flunixin as part of comprehensive management protocols. The medication can address the significant visceral discomfort associated with these conditions while other interventions address underlying causes. Iguanas with coelomic masses, gastrointestinal disorders, or severe inflammatory conditions represent additional candidates for flunixin therapy. Large monitor lizards suffering trauma or severe infections with significant inflammatory components may benefit from flunixin's potent anti-inflammatory effects.

Chelonian patients frequently present with conditions where flunixin meglumine's properties prove therapeutically valuable. Egg binding remains one of the most common reproductive emergencies in female turtles and tortoises, causing significant visceral pain that responds to flunixin therapy while other treatments address egg passage. Gastrointestinal conditions including obstruction, impaction, and severe enteritis may warrant flunixin use for pain management and anti-inflammatory effects. Tortoises suffering from severe shell trauma with associated coelomic injury may benefit from flunixin's ability to address both visceral and somatic pain components. Bladder stone disease in tortoises, while primarily requiring surgical intervention, involves significant pain that flunixin can help manage perioperatively.

Endotoxemia and severe systemic inflammatory conditions represent additional indications where flunixin meglumine provides recognized benefits. When gram-negative bacterial infections release endotoxins into circulation, the resulting inflammatory cascade causes significant morbidity that flunixin can help mitigate. Septic reptile patients may receive flunixin as supportive care alongside antimicrobial therapy and other treatments addressing the underlying infection. The medication's ability to modulate systemic inflammatory responses provides value beyond simple analgesia in these serious clinical situations.

The decision to use flunixin meglumine requires careful consideration of whether its specific properties match the clinical need and whether the benefits outweigh the risks for the individual patient. This medication is not typically chosen as a first-line analgesic for routine post-surgical pain or minor inflammatory conditions where other NSAIDs with potentially better safety profiles are available. Flunixin's role centers on severe pain, visceral pathology, and systemic inflammatory states where its particular potency and mechanism of action provide clear advantages. The reptile veterinarian evaluates each case individually, selecting flunixin when its therapeutic profile aligns with patient needs and when the clinical situation justifies accepting its associated risks.

Dosing of flunixin meglumine in reptile patients requires determination by a qualified reptile veterinarian who can assess the individual animal's species, condition severity, and specific clinical requirements. The potency of this medication and its potential for significant adverse effects necessitate conservative dosing approaches guided by clinical judgment rather than extrapolation from dosing used in other species. Specific numeric doses should not be applied without direct veterinary guidance, as the therapeutic window for flunixin in reptiles requires careful navigation to achieve pain control while minimizing toxicity risk. The veterinarian considers multiple factors including the severity and nature of the condition, expected treatment duration, and patient health status when formulating dosing protocols.

Temperature-dependent metabolism profoundly influences flunixin meglumine pharmacokinetics in reptile patients, as it does with all medications administered to ectothermic animals. Reptiles maintained at their Preferred Optimum Temperature Zone (POTZ) demonstrate more predictable drug absorption, distribution, metabolism, and elimination compared to hypothermic animals. Cold reptiles metabolize flunixin much more slowly, creating potential for drug accumulation with repeated dosing and significantly increased toxicity risk. Before initiating flunixin therapy, the veterinary team ensures the patient is appropriately warmed and that environmental conditions support maintenance of POTZ throughout treatment. The temperature dependence of metabolism also influences dosing interval determinations.

The route of administration for flunixin meglumine varies based on formulation availability and clinical circumstances. Injectable administration provides the most accurate dosing control and is preferred for hospitalized patients or initial treatment of severe conditions. Intramuscular injection must be administered exclusively in the anterior half of the body due to the renal portal circulation system present in reptiles. Blood from the posterior body passes through the kidneys before systemic circulation, which could reduce drug efficacy and increase nephrotoxic potential if injections are placed in hindlimbs or tail regions. Appropriate anterior injection sites include forelimb muscles, pectoral region, and anterior epaxial muscles. Intravenous administration provides rapid onset and may be preferred in critical patients when vascular access is available.

Dosing frequency for flunixin meglumine in reptiles typically involves extended intervals reflecting both the medication's duration of action and the need to minimize cumulative toxicity. Unlike in horses where daily dosing might be employed short-term, reptile protocols commonly utilize single doses or limited treatment courses with intervals of 24 to 72 hours or longer between doses. The veterinarian determines appropriate timing based on clinical response, species metabolism, temperature status, and risk assessment. Prolonged or repeated dosing increases the likelihood of adverse effects, and flunixin therapy should generally be limited to the shortest duration necessary to achieve therapeutic goals.

Species-specific considerations significantly influence flunixin meglumine administration protocols. Small reptiles require precise dosing calculations and often benefit from dilution of the concentrated injectable formulation for accurate measurement. The commercial preparations designed for horses and cattle contain high drug concentrations that make direct use in small reptiles impractical without dilution. Large chelonians may receive injection into accessible soft tissue areas while monitoring for any injection site reactions. The veterinary team adapts administration techniques to the anatomical and physiological characteristics of each species while maintaining focus on accurate, safe drug delivery.

Owner administration of flunixin meglumine at home is generally discouraged due to the medication's potency and potential for serious adverse effects. When ongoing treatment is necessary beyond the hospital setting, the veterinarian may consider transition to alternative analgesics with wider safety margins for home administration. If circumstances require continued flunixin therapy with owner involvement, detailed instructions regarding dose, route, timing, and monitoring must be provided along with clear guidance about concerning signs requiring immediate veterinary attention. The serious nature of conditions warranting flunixin use often necessitates continued hospitalization or frequent veterinary follow-up regardless of where medication administration occurs.

Flunixin meglumine carries significant potential for adverse effects that require serious consideration by veterinary professionals and understanding by reptile owners. Gastrointestinal toxicity represents the most common and potentially severe adverse effect associated with this medication. Flunixin is more likely than some other NSAIDs to cause gastrointestinal ulceration, which can progress to erosion, bleeding, or perforation in severe cases. These effects reflect the medication's potent inhibition of prostaglandins that normally provide protective effects on the gastrointestinal mucosa. Clinical signs of gastrointestinal toxicity may include anorexia, regurgitation, bloody stool, or general deterioration, though reptiles often mask early signs of internal problems.

Temperature status significantly amplifies the risk of adverse effects from flunixin meglumine in reptile patients. Cold reptiles with depressed metabolism accumulate drugs with repeated dosing, and flunixin's potency means that accumulation creates serious toxicity potential. A reptile maintained below its POTZ while receiving flunixin therapy faces dramatically elevated risk of gastrointestinal and renal complications. This temperature-dependent effect makes maintaining appropriate husbandry conditions not merely recommended but essential for safe treatment. The veterinary team emphasizes temperature management as a critical component of the treatment protocol, and any inability to maintain appropriate conditions should prompt reconsideration of flunixin use.

Nephrotoxicity represents another major concern with flunixin meglumine use in reptile patients. All NSAIDs reduce prostaglandin synthesis in the kidneys, compromising renal blood flow and potentially causing or exacerbating kidney damage. Flunixin appears to carry higher nephrotoxicity risk than some other NSAIDs, making patient selection and hydration management critical. Reptiles presenting in dehydrated or hypovolemic states require fluid therapy before and during flunixin treatment. Signs of nephrotoxicity in reptiles may include lethargy, anorexia, changes in urate production or appearance, and general decline. Patients with pre-existing renal disease face substantially elevated risk and may not be appropriate candidates for flunixin therapy.

Injection site reactions can occur with intramuscular flunixin administration, ranging from mild local irritation to tissue necrosis in severe cases. Proper injection technique, appropriate site selection in the anterior body, and avoiding repeated injections at the same location help minimize this risk. Any swelling, discoloration, or apparent discomfort at injection sites should be reported to the veterinary team. These local effects, while generally less serious than systemic toxicity, can cause significant patient discomfort and may affect subsequent treatment options.

Reptile owners should understand the serious nature of potential flunixin side effects and maintain close contact with the veterinary team throughout treatment. Signs warranting immediate veterinary attention include any decrease in appetite, vomiting or regurgitation, bloody stool or urates, unusual lethargy, swelling at injection sites, or any other concerning changes. The severe conditions that warrant flunixin use often require hospitalization or intensive monitoring regardless, but owners should be prepared to respond quickly to any deterioration. While flunixin meglumine provides genuine therapeutic value for appropriate indications, its significant risk profile demands respect and vigilance throughout the treatment course.

Several absolute and relative contraindications govern flunixin meglumine use in reptile patients, requiring careful veterinary evaluation before therapy initiation. Known hypersensitivity to flunixin or other NSAIDs absolutely contraindicates use, as serious reactions could occur with re-exposure. History of adverse reactions to any NSAID should prompt consideration of alternative analgesic approaches. Reptiles that have experienced gastrointestinal complications with previous NSAID therapy face elevated risk with flunixin, which tends to have higher gastrointestinal toxicity potential than some alternatives.

Renal disease represents a major contraindication for flunixin meglumine use given this medication's significant nephrotoxicity potential. Reptiles with known or suspected kidney disease, elevated uric acid suggesting renal compromise or gout, or history of renal problems should not receive flunixin unless extraordinary circumstances justify accepting the substantial risk. Dehydration similarly contraindicates flunixin therapy due to the kidneys' vulnerability when prostaglandin-mediated renal blood flow maintenance is impaired during volume depletion. Adequate hydration must be established before initiating treatment and maintained throughout the therapy course. Concurrent use of other nephrotoxic medications creates additive risk that may preclude safe flunixin use.

Gastrointestinal disease or history of gastrointestinal ulceration creates strong contraindication for flunixin meglumine given its propensity for gastrointestinal complications. Reptiles with active gastrointestinal bleeding, known ulcerative lesions, recent gastrointestinal surgery, or significant digestive tract compromise should not receive this medication. Even history of gastrointestinal problems without current active disease should prompt consideration of alternative analgesics with better gastrointestinal safety profiles. Hepatic disease may also contraindicate flunixin use due to altered drug metabolism and the liver's role in handling any gastrointestinal complications that might arise.

Temperature-related contraindications apply particularly stringently to flunixin meglumine given its potency and toxicity potential. Severely hypothermic reptiles absolutely should not receive flunixin until appropriate body temperature is restored, as profoundly impaired metabolism creates unacceptable accumulation risk. Even moderately cool reptiles warrant careful consideration of whether flunixin is truly necessary or whether less potent alternatives might suffice. Debilitated reptiles in critical condition may lack physiological reserve to tolerate potential adverse effects. Very young reptiles, whose organ systems are still developing, may face heightened vulnerability. The veterinarian carefully weighs all patient factors to determine whether flunixin represents an appropriate and acceptable treatment choice for each individual situation.

Understanding drug interactions helps ensure safe flunixin meglumine use in reptile patients receiving concurrent medications. Combination with other NSAIDs is contraindicated due to dramatically increased risk of gastrointestinal ulceration and nephrotoxicity without proportional therapeutic benefit. Different NSAIDs should never be administered simultaneously, and appropriate washout periods must be observed when changing between NSAID medications. The duration of washout depends on the specific drugs involved and the patient's metabolic status, with cold reptiles requiring longer intervals for drug clearance. Corticosteroids similarly should not be combined with flunixin, as concurrent use substantially increases gastrointestinal ulceration risk.

Nephrotoxic medications require particularly careful consideration when contemplated alongside flunixin meglumine. Aminoglycoside antibiotics such as amikacin and gentamicin, commonly used in reptile medicine for serious bacterial infections, carry inherent nephrotoxic potential that could be compounded by concurrent flunixin therapy. While clinical circumstances occasionally necessitate concurrent use of both drug classes, the combination demands aggressive hydration support and enhanced monitoring. The veterinarian weighs the competing needs of infection control and pain management against cumulative nephrotoxicity risk when designing treatment protocols. Other potentially nephrotoxic medications similarly require careful evaluation before combining with flunixin.

Diuretics and medications affecting renal blood flow may have their effects altered by concurrent flunixin use. NSAIDs reduce prostaglandin-mediated vasodilation in the kidneys, potentially counteracting the effects of some diuretics and compromising renal perfusion. While these medication classes are uncommonly used in reptile medicine, awareness of the interaction applies when they are employed. Anticoagulant medications could have enhanced effects due to flunixin's inhibition of platelet function and potential for gastrointestinal bleeding. Any medications with hepatic metabolism may potentially interact through competition for metabolic pathways.

Despite these significant interaction concerns, flunixin meglumine can be combined with various medications when clinical circumstances warrant and appropriate precautions are implemented. Antibiotics other than aminoglycosides generally do not pose significant interaction risks. Fluid therapy not only is compatible with flunixin but actively mitigates nephrotoxicity risk through supporting renal perfusion. The veterinarian maintains complete awareness of all concurrent medications when using flunixin, implementing appropriate monitoring and supportive care to minimize interaction-related complications. Complete medication disclosure from owners, including any supplements or over-the-counter products, enables informed treatment planning.

Temperature maintenance represents an absolutely critical precaution when using flunixin meglumine in reptile patients. The medication's potency and significant toxicity potential mean that temperature-related alterations in metabolism create genuine danger. Reptiles must be maintained at their species-appropriate Preferred Optimum Temperature Zone (POTZ) before initiating therapy, throughout treatment, and during recovery. Cold reptiles cannot metabolize flunixin appropriately, leading to drug accumulation and dramatically increased adverse effect risk. The veterinary team provides explicit temperature guidance and verifies that appropriate husbandry conditions exist before prescribing flunixin. Any owner inability to maintain appropriate temperatures should prompt selection of alternative analgesics.

Injection site selection demands strict adherence to anterior body administration for intramuscular flunixin meglumine. The renal portal circulation present in reptiles carries blood from the posterior body through the kidneys before systemic circulation. Injecting a potent nephrotoxic medication like flunixin into hindlimbs or tail concentrates the drug in renal tissue before systemic distribution, substantially increasing kidney damage risk while potentially reducing therapeutic effect. Appropriate injection sites include forelimb muscles, pectoral muscles, and anterior epaxial muscles only. This restriction applies to all intramuscular medications in reptiles but carries particular importance for flunixin given its nephrotoxicity profile.

Hydration requirements during flunixin therapy reflect the medication's effects on renal prostaglandin synthesis and the kidneys' critical role in drug elimination. Dehydration dramatically increases nephrotoxicity risk by compromising renal perfusion in the absence of prostaglandin support. Before initiating flunixin treatment, hydration status must be assessed and deficits corrected through fluid therapy. Throughout treatment, adequate hydration should be maintained through parenteral fluid support or ensured oral intake. The veterinary team monitors hydration closely, particularly in patients with conditions that might impair normal water intake or increase fluid losses.

Monitoring requirements during flunixin meglumine therapy include vigilant observation for both therapeutic response and adverse effects. The serious conditions warranting flunixin use typically require hospitalization or very frequent veterinary assessment. Monitoring should include assessment of appetite, stool and urate production, injection site evaluation, overall demeanor and activity level, and any signs of gastrointestinal or renal complications. Blood work including renal parameters may be appropriate for patients receiving extended treatment. The veterinary team responds promptly to any concerning changes by adjusting treatment, providing additional supportive care, or discontinuing flunixin if adverse effects threaten to outweigh benefits.

Human safety considerations apply to handling flunixin meglumine and caring for treated reptiles. The medication can cause skin and eye irritation with direct contact, and gloves should be worn during preparation and administration. Accidental self-injection requires immediate medical attention due to the medication's potency. The medication should be stored securely away from children and household members, with clear labeling indicating its veterinary prescription status. Proper disposal of unused medication and administration equipment follows applicable pharmaceutical waste guidelines. Staff members who are pregnant or attempting pregnancy should avoid handling flunixin due to potential reproductive effects. Maintaining rigorous safety protocols protects both human handlers and ensures appropriate medication management.

Proper storage of flunixin meglumine formulations ensures maintenance of drug potency and safety throughout the product's shelf life. Injectable flunixin solution should be stored at controlled room temperature, typically between 59°F and 86°F (15°C to 30°C), protected from light and extreme temperature fluctuations. The medication should remain in its original container, and multi-dose vials require aseptic handling to prevent contamination. Freezing should be avoided as it may alter product characteristics. Any visible changes in the solution's appearance including discoloration, cloudiness, or particulate matter indicate potential degradation, and such products should not be used. Oral paste and granule formulations should be stored according to specific manufacturer guidance, typically at controlled room temperature in original packaging.

Shelf life and stability considerations guide appropriate product management in veterinary practice. Unopened flunixin products maintain stability until the manufacturer's expiration date when stored appropriately. Multi-dose injectable vials, once punctured, maintain sterility for a limited period depending on handling and storage conditions; specific timeframes should be verified against manufacturer guidelines. The concentrated nature of flunixin formulations designed for large animals means that diluted preparations for reptile use may have shortened stability and should be prepared fresh when possible. Expired products should never be administered to patients, and veterinary practices should implement inventory systems ensuring appropriate product rotation and removal of outdated stock.

Safe handling and disposal practices protect veterinary personnel, owners, and the environment from potential flunixin exposure. The medication can cause irritation with skin or eye contact, making glove use during handling appropriate. Careful technique during injection preparation prevents needlestick injuries and accidental exposure. Spills should be cleaned promptly with appropriate absorbent materials. Unused medication, expired products, and contaminated materials should be disposed of through pharmaceutical waste channels rather than household trash or drainage systems. Sharps containers must be used for needles and syringes. The Material Safety Data Sheet for flunixin meglumine provides specific guidance on handling, spill cleanup, and exposure management that should be accessible to all staff members. Owners receiving medication for continued treatment require clear disposal instructions for any unused product.

Lizard species receive flunixin meglumine therapy for severe painful conditions where its potency and visceral analgesic properties provide therapeutic advantages. Bearded dragons with reproductive complications including follicular stasis, dystocia, or post-reproductive infections may benefit from flunixin's effectiveness against coelomic pain. These patients require careful temperature management and hydration support throughout treatment. Larger iguanas with severe inflammatory conditions, significant trauma, or visceral pathology represent additional candidates, with their body size allowing somewhat more straightforward dose calculation. Monitor lizards, when suffering conditions warranting flunixin's potent effects, require careful restraint for safe administration given their strength and potential defensive behaviors. Small gecko species rarely receive flunixin due to the extreme precision required for dosing and availability of alternatives with wider safety margins.

Chelonian patients commonly present with conditions where flunixin meglumine's visceral analgesic properties prove valuable. Egg binding (dystocia) in female turtles and tortoises causes significant coelomic pain that flunixin effectively addresses while other interventions work toward egg passage. Large tortoises suffering severe shell trauma with associated coelomic organ involvement may benefit from flunixin's ability to manage both visceral and somatic pain components. Gastrointestinal conditions including obstruction and severe impaction cause visceral pain amenable to flunixin therapy. The slow metabolism characteristic of many chelonian species influences dosing interval considerations, potentially requiring extended times between doses compared to lizards maintained at higher temperatures.

Temperature requirements across reptile species directly influence flunixin meglumine safety and efficacy. Desert species maintained at higher POTZ ranges demonstrate more rapid drug metabolism, while species with lower temperature preferences show correspondingly slower drug handling. The veterinarian must know the specific POTZ range for the species being treated and verify appropriate temperature maintenance before and throughout flunixin therapy. Species that naturally tolerate cooler temperatures still require adequate warmth for appropriate drug metabolism, and owners must understand that flunixin therapy demands optimal husbandry regardless of what the animal might tolerate under normal circumstances.

Size-based considerations apply across all reptile groups receiving flunixin meglumine. The medication's concentrated formulations designed for horses and cattle contain far more drug per volume than appropriate for most reptiles, necessitating dilution for accurate small-patient dosing. Calculation errors in small reptiles can result in dramatic overdosing with potentially fatal consequences given flunixin's toxicity potential. Veterinary staff should double-check calculations and consider having another team member verify doses for very small patients. Large reptiles face proportionally lower risk from minor calculation variations but still require accurate dosing to achieve therapeutic effect while maintaining safety margins. Every patient deserves individualized assessment accounting for species, size, condition severity, and overall health status.

Several alternative NSAIDs may be considered when flunixin meglumine is not appropriate or when medications with different safety profiles are preferred. Meloxicam represents the most commonly used alternative NSAID in reptile medicine, with preferential COX-2 selectivity potentially offering some gastrointestinal safety advantages. Clinical experience supporting meloxicam use in reptiles is extensive, and it serves as a first-line NSAID for many practitioners. Carprofen provides another well-established option with a reasonable safety profile for appropriate patients. Ketoprofen offers similar mechanism of action with its own efficacy and safety characteristics. The choice among available NSAIDs depends on clinical circumstances, with flunixin typically reserved for severe visceral pain or systemic inflammatory states where its particular potency provides advantages.

Non-NSAID analgesic options address pain through different mechanisms and may be preferred when gastrointestinal or renal concerns preclude NSAID therapy. Opioid medications including morphine, hydromorphone, butorphanol, buprenorphine, and tramadol provide analgesia without the gastrointestinal and renal effects associated with NSAIDs. These medications may be used alone for patients with NSAID contraindications or in combination with NSAIDs for multimodal pain management. Local and regional anesthesia techniques provide targeted pain control for surgical procedures or localized conditions. The reptile veterinarian selects among available options based on pain type, severity, and location, as well as patient-specific factors that might influence drug selection.

Multimodal pain management approaches often combine different analgesic classes for comprehensive patient comfort. The combination of an NSAID with opioid analgesics addresses pain through complementary mechanisms, potentially providing superior analgesia while allowing dose reduction of individual medications. When using flunixin as part of multimodal therapy, careful attention to total medication burden and cumulative adverse effect risk remains essential. Local anesthetic techniques reduce systemic analgesic requirements during and after procedures. This comprehensive approach to pain management recognizes that severe pain often requires multiple interventions targeting different components of the pain pathway. The veterinarian designs individualized protocols appropriate for each patient's condition while maintaining awareness of the risks associated with flunixin meglumine and implementing appropriate monitoring and supportive care.