What do I do with the maggots when they arrive? How do I handle and store them? When the maggots arrive, read the label to make sure that they are for you and not the others in your facility. Remove the packing slip/invoice from the outer box, before it gets lost, and send it to the person responsible for accounts payable. Open the box carefully, so as not to damage the dressings inside. Remove the dressings and bubble-pack or Styrofoam box, which will contains the vial(s) of maggots. Open the bubble-pack or Styrofoam box to check the maggots; this will also provide more air (the vial lid is air-permeable). Inspect the larvae by looking through the vial(s), making sure that the larvae are alive (moving around) and the walls --- which may be moist --- are without slime. If the maggots appear healthy and active, place them back into the bubble-pack or Styrofoam box, seal them, and store at room temperature until use, ideally within 24 hours. Don’t forget to notify the doctors and nurses that the maggots have arrived. Gentle heat (80-90oF) will speed their development and make them slightly larger, sooner. Gentle cooling (45-55o F) will slow their development and prevent them from growing much larger. If the maggots can not be seen or if they are very slow moving, place the vial in a warm incubator to speed their development, and check again in one and two hours. If they still appear dead or immobile, or if they appear infected (slimy or foul smelling), notify Monarch Labs immediately. How do I keep the maggots on the wound? Since the maggots’ natural tendency is to wander off before and after they have finished feeding, they must be kept in place by dressings that allow air to enter, allow liquified necrotic tissue to drain out, and still keep the maggots securely over the wound. Instructions and a diagram of the dressing procedures can be found in the package inserts. Our dressings guidance page has detailed information about applying the maggots, including instructional videos. Monarch Labs has developed a new dressing, “Le Flap,” which is a pre-fabricated single-piece, two-layered flap-like maggot cage dressing. Use of this dressing can decrease maggot application time to only a few minutes. More information and instructions can be found in the package insert.

What is maggot therapy? Maggot therapy (also known as maggot debridement therapy [MDT], larval therapy, larva therapy, larvae therapy, biodebridement or biosurgery) is a special treatment for wounds in which the therapist places medical grade fly larvae onto a wound, within a special dressing. What types of wounds might benefit from maggot therapy? Medical Maggots™ are indicated for debriding non-healing necrotic skin and soft tissue wounds, including pressure ulcers, venous stasis ulcers, neuropathic foot ulcers and non-healing traumatic or post surgical wounds. What are the advantages of maggot therapy? Efficacy, as demonstrated in several controlled clinical studies. Excellent safety record. Simple enough that non-surgeons can use it to provide thorough debridement when surgery is not available or is not the optimal choice for other medical reasons. This means that it is also possible to provide surgical quality debridement as an outpatient or in the home. Low cost of treatment. Is maggot therapy regulated by the FDA? Yes, production and marketing of Medical Maggots™ is regulated by the Food and Drug Administration as a prescription only medical device. In January 2004, the U.S. Food and Drug Administration granted permission to Dr. Ronald Sherman to produce and market Medical Maggots brand of medicinal maggots, for the following indications: "Debriding non-healing necrotic skin and soft tissue wounds, including pressure ulcers, venous stasis ulcers, neuropathic foot ulcers, and non-healing traumatic or post surgical wounds." Will maggot therapy hurt? Maggots do not bite. They do not have teeth. They do have modified mandibles though, called “mouth hooks,” and they have some rough bumps around their body which scratch and poke the dead tissue, one of the mechanisms that debrides the wound. It is similar to a surgeons “rasper,” but on a microscopic scale. The maggots are so small when applied that they can not even be felt within the wound. Those patients who already have wound pain before beginning maggot therapy, perhaps due to exposed nerves or other reasons, may have some pain during maggot therapy when the maggots become large enough to be felt crawling over those nerves (usually at about 24 hours). Those patients should be given access to pain medications (analgesics); but if pain medication is inadequate to relieve the discomfort, the maggots can be removed early. Once the dressings are removed, the maggots will crawl out and the pain should cease immediately. If further debridement is necessary, another MDT dressing can always be applied later, but it should be used only for a brief period, again, until the patient is uncomfortable. Can anyone order Medical Maggots™? Is it necessary to have a doctor’s prescription? Medical Maggots™ are regulated by the Food and Drug Administration (FDA) as a Prescription Only medical device. This means that they must be ordered or prescribed by a licensed medical or veterinary therapist. They can not be released without a prescription or an order to do so by an appropriately licensed health care provider. Can anyone do maggot therapy? Maggot therapy is simple enough that the procedure can be performed by physicians and veterinarians, nurses and physical therapists, health care assistants . . . sometimes even by patients and their families. Of course, experience and training helps! Whoever applies the maggot dressings should read all packaging and relevant information thoroughly, making sure they understand the procedure, and that they have all of the necessary supplies at hand. Do I need special training or certification to do maggot therapy? Special training or certification in maggot therapy is not required by law; but it certainly is helpful. Definitely read all relevant package inserts before applying the maggots (and preferably before ordering, which is why we have posted them for you in the next tab. Our Maggot Dressings Guidance Page has written, pictorial, and video instructions to help you construct the best maggot dressings. Additionally, our customers have access to our on-call clinical consultant (Dr. Ronald Sherman) to assist therapists with their clinical questions. Where can I find training to do maggot therapy? Several training courses and workshops are available. The BioTherapeutics, Education & Research (BTER) Foundation produces training workshops, and has many other educational resources posted on its website, including Policies & Procedures, lecture slides, and a patient information booklet. Monarch Labs periodically sponsors training sessions, produced by the BTER Foundation. So does the Wound Care Education Institute, Wild on Wounds Conference, and the University of California, Riverside, Extension. You can even host a maggot therapy workshop in your town by contacting the BTER Foundation (www.BTERFoundation.org). Where can I find a therapist who will prescribe and/or do maggot therapy? The closest therapist may be your own! Ask your doctor about maggot therapy. Monarch Labs and many other organizations provide training, in case s/he has never done it before (don’t worry, the maggots know exactly what to do, even if your doctor doesn’t!). If you need a referral, call or e-mail us. Monarch Labs is not able to post our clients’ names or contact information, but we can give you the names of a doctor or two in your area, if it is OK with the doctors. We can also provide your doctor with a list of therapists to how s/he can refer you and other patients who may benefit. Other sources of referrals are the BTER Foundation. If your doctor does maggot therapy, make sure s/he let’s us know if s/he is willing to have us give out their name. Also, the BTER Foundation is assembling a referral list. How are maggots applied to a wound? Maggots are confined within a cage-like dressing over the wound for two to three days. The maggots are usually allowed to move freely within that cage, with the wound floor acting as the bottom of the cage ("confinement dressing"). Sometimes, the maggots are contained within a sealed pouch, placed on top of the wound ("containment dressing"). The dressing must be kept air permeable because maggots require oxygen to live. When maggots are satiated, they are larger and seek to leave the site of a wound. The dressing must be secure enough to prevent their escape until the therapist can remove the dressing and dispose of the maggots and dressings properly. Multiple two-day courses ("cycles") of maggot therapy may be necessary, depending on the severity of the wound and the extent of the necrotic tissue. Therapists can use pre-manufactured dressings (i.e., Monarch Labs' “Le Flap"; see package insert) or they can construct their own dressings, using commonly available dressing materials (see package inserts or our written and pictographic dressings guidance page). On our dressings guidance page, you can see, step-by-step how to apply maggots to a variety of wounds, and even watch an instructional video showing how to make your own dressings out of readily available materials. That video was produced by the BTER Foundation and publically posted. How many maggots are applied (what is the dose)? The dose is 5 - 8 larvae per cm2 of wound surface area. How do you get all of the maggots out? The maggot dressing is removed as soon as the maggots have finished secreting their proteolytic (tissue-dissolving) enzymes (within 48-72 hours). At that time, their natural instinct is to leave the wound and crawl away as quickly as possible. So when the dressing is opened, the maggots will be “at the gate,” eagerly awaiting their release. If any slow growing larvae remain, they can be removed with a simple wipe, wash, or irrigation. If they are hiding within a crevice, simply cover the wound with saline-moistened gauze, and replace it three time/day; the remaining maggots will leave the wound within the next 24 hours (as soon as they feel it is safe), and burry themselves in the gauze. More about dressing removal can be found on our dressings guidance page How many treatment cycles are necessary? The duration of one course ("cycle") of treatment is 2 - 3 days. The number of treatment cycles depends on the size of the wound and the extent of necrotic tissue. The number of cycles can range from one to ten or more; the average is 3 cycles. Examine the wound after each treatment cycle (and 24 hours later, if possible), to determine if another cycle of treatment is necessary. How do I dispose of the maggot dressings after they are removed? Maggots are germ-free when applied, but become contaminated when they come into contact with the patient’s wound flora. MDT dressings should be handled like all other infectious dressing waste: placed in an appropriate bag and autoclaved or incinerated by the waste management department. Place the maggot dressings in a plastic bag and seal the bag completely. Then place the sealed bag into a second plastic bag and seal completely. Place the bag with the other infectious dressing waste, which should be disposed of (usually it is autoclaved or incinerated) within 24 hours. How do I dispose of the unused medicinal maggots? Unused maggots are germ-free and not a biohazard. They may be discarded in regular trash bins. Make sure the vial is Sealed securely so that they can not escape. What is the usage of maggot therapy in the United States? There are over 800 health care centers in the United States that have utilized maggot therapy. Are other countries using maggot therapy? Yes, over 4,000 therapists are using maggot therapy in more than 20 countries. Approximately 50,000 treatments were applied to wounds last year. Can you do maggot therapy on animals? Yes, veterinarians can request Medical Maggots™ for use in animals. Several studies and references are listed on our Veterinarian web pages, and on our Reference Pages. Discussion about how to make maggot dressings for animals appears on our equine dressings page, which you can open in the next tab.

How does reimbursement work? Code separately for the procedure and for the maggots. For the procedure code, consider using a CPT code for selective debridement without anesthesia (97597 if the wound is < 20 sq cm; 97598 if the wound is > 20 sq cm) or a CPT code for misc. skin procedures (17999). When billing for the maggots themselves, consider using either the ABC code for maggots (EAACT) or the HCPCS code for misc. devices (A9270). Appeal may be necessary. The BTER Foundation will assist with appeals. For those without financial resources, the BTER Foundation provides Patient Assistance Grants www.BTERFoundation.org/indexfiles/grants.htm Additional information can be found in the recent press release by the BTER Foundation. Can I still get maggots and maggot therapy even if I do not have insurance or a lot of money? Of course! We at Monarch Labs are dedicated to the proposition that medical care should not be rationed on the basis of ability to pay. Besides, if you haven’t noticed the price sheets, take a look . . . the cost of Medical Maggots is a lot less expensive than most other similar products. Even so, it can be hard to come up with the money to pay for them, so here are some solutions: For those without insurance or other financial resources, the BTER Foundation provides Patient Assistance Grants www.BTERFoundation.org/indexfiles/grants.htm Remember: Never postpone your medical treatment just because you do not have the money yet. Monarch Labs can send the treatments ordered, and bill you later, if you want. Delaying treatment can lead to progression of the underlying infection, circulatory compromise, or other problems, which in turn can leave you with a larger, more difficult-to-treat wound, a worse prognosis, and a need for more costly treatment.

How do I notify you if I find an error or problem on the website, or simply want to comment? We want to hear about any problems with our website or our products. Contact us by phone, fax, e-mail or post. You can get these numbers from our Contact Page How do I notify you if your website is not displaying on my browser? We want to hear about any problems with our website or our products. Contact us by phone, fax, e-mail or post. You can get these numbers from our Contact Page

Can the maggots reproduce in my wound during maggot therapy? No, all larvae are immature, and can not reproduce until reaching adulthood. Will the maggots turn into flies in my wound? No, the immature larvae are removed after just 2 or 3 days and discarded. If not discarded, it would take 2 or 3 weeks for them to turn into flies. If any maggot escapes without re-capture, then it may be possible for it to hide for a couple weeks, pupate, mature, and emerge as an adult fly several weeks later. Indoors, these flies will generally die before having a chance to reproduce or make larvae of their own. Who supplies maggots for maggot therapy in the United States? In the United States, Monarch Labs (www.monarchlabs.com) in Irvine, California, is the exclusive supplier of Medical Maggots™ (disinfected Phaenicia sericata larvae) for maggot debridement therapy. Where can I find more information? Check out these links: BioTherapeutics, Education & Research Foundation at www.BTERFoundation.org. University of California, Irvine, Maggot Therapy Project . Wound Care Education Network. Arrange to attend or sponsor a Maggot Therapy Lecture or Workshop. Where I can hear from patients whom have tried maggot therapy? The BTER Foundation Has recorded and posted several patient interviews. You can find links to these interviews on our Support - Video nterviews Page.