{"id":1058,"date":"2014-05-01T01:16:08","date_gmt":"2014-05-01T01:16:08","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1058"},"modified":"2022-02-16T16:05:01","modified_gmt":"2022-02-16T16:05:01","slug":"acute-pain-in-cats-treatment-with-nsaids","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/pain_management\/acute-pain-in-cats-treatment-with-nsaids\/","title":{"rendered":"Acute Pain In Cats: Treatment With NSAIDs"},"content":{"rendered":"<p>&nbsp;<\/p>\n<p><span class=\"helvbold-9-5\">A<\/span><span class=\"garamond-9-5\">t some point in a cat\u2019s life, it will most likely suffer from pain related to an injury, disease, or surgery, and veterinarians have a duty to try to alleviate this pain. In the January\/February 2014 issue of <\/span><span class=\"garamon-italics\"><em>Today\u2019s Veterinary Practice<\/em><\/span><span class=\"garamond-9-5\">, Dr. Sheilah Robertson addressed the challenges of acute pain assessment in cats. However, deciding how to effectively treat this pain presents its own difficulties.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Pain in cats\u2014both acute and chronic\u2014is difficult to treat because cats:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Metabolize some drugs more slowly than dogs, potentially increasing the risk of adverse drug reactions<sup>1-3<\/sup><\/span><\/li>\n<li><span class=\"garamond-9-5\">Are prone to a gradual decline in renal function; one recent study found that up to 50% of cats may have chronic kidney disease<sup>4<\/sup><\/span><\/li>\n<li><span class=\"garamond-9-5\">Can be difficult to medicate and often resist administration of oral medication<\/span><\/li>\n<li><span class=\"garamond-9-5\">Often do not show obvious outward signs of pain or illness, making evaluation of medication efficacy a challenge, especially in stoic cats<sup>5<\/sup><\/span><\/li>\n<li><span class=\"garamond-9-5\">Have a limited number of options when it comes to veterinary approved pain medications.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">NSAIDs are one of the most common drug classes used to treat pain, and there is a robust body of information indicating that NSAIDs are effective in treating acute pain in cats.<sup>6,7<\/sup> They have antipyretic, analgesic, and anti-inflammatory properties, which make them appealing therapeutic options; however, remember that there is not, and never will be, a completely safe NSAID for use in cats.<\/span><\/p>\n<h2 class=\"left-justified\"><span class=\"brown\">IS THERE AN IDEAL NSAID FOR USE IN CATS?<\/span><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Based on our current understanding and the information available, if we were to design an ideal NSAID for use in cats, it would have certain important characteristics (<\/span><strong><span class=\"garamond-bold\">Table 1<\/span><\/strong><span class=\"garamond-9-5\">).<\/span><\/p>\n<table id=\"table-1\" border=\"1\" cellspacing=\"0\" cellpadding=\"10\">\n<tbody>\n<tr>\n<td>\n<p class=\"left-justified\"><strong><span class=\"bluboldheader\">Table 1. Characteristics of an Ideal NSAID for Use in Cats<\/span><\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td bgcolor=\"#daecc8\">\n<p class=\"tabs-and-bullets\"><span class=\"helvetica-9-pt\">1. Spares COX-1 and targets COX-2<\/span><\/p>\n<p class=\"tabs-and-bullets\"><span class=\"helvetica-9-pt\">2. Provides targeted action<\/span><\/p>\n<ul>\n<li><span class=\"tabs-and-bullets\">Prolonged action in targeted tissues<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Appropriate duration of action in the central nervous system<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Spares \u2018non target\u2019 tissues<\/span><\/li>\n<\/ul>\n<p class=\"tabs-and-bullets\"><span class=\"helvetica-9-pt\">3. Can be administered with ease and accuracy<\/span><\/p>\n<ul>\n<li><span class=\"tabs-and-bullets\">Injectable and oral forms available, which are interchangeable<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Simple dose determination and titration<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Palatable and easy-to-administer oral form<\/span><\/li>\n<\/ul>\n<p class=\"tabs-and-bullets\"><span class=\"helvetica-9-pt\">4. Displays wide safety margins and evidence-based clinical safety in target population<\/span><\/p>\n<ul>\n<li><span class=\"tabs-and-bullets\">Toxicity studies demonstrate a wide safety margin in cats<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Appropriately safe in the target population (eg, cats undergoing elective surgeries)<\/span><\/li>\n<\/ul>\n<p class=\"tabs-and-bullets\"><span class=\"helvetica-9-pt\">5. Demonstrates robust evidence of clinical efficacy<\/span><\/p>\n<ul>\n<li><span class=\"tabs-and-bullets\">Effective for acute and postoperative pain control<\/span><\/li>\n<li><span class=\"tabs-and-bullets\">Effective for alleviation of prolonged, maladaptive pain associated with chronic diseases<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3 class=\"left-justified\"><span class=\"bluboldheader\">1. Spares COX-1 &amp; Targets COX-2<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">NSAIDs work by inhibiting the production of prostaglandins (see <\/span><strong><span class=\"garamond-bold\">The Role of Prostaglandins<\/span><\/strong><span class=\"garamond-9-5\">) from arachidonic acid by the enzyme cyclooxygenase (COX). There are 2 forms of the COX enzyme:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-bold\">COX-1:<\/span><span class=\"garamond-9-5\"> Generally constitutive and involved in production of prostaglandins that protect gastric mucosa and maintain normal platelet function and renal perfusion<\/span><\/li>\n<li><span class=\"garamond-bold\">COX-2:<\/span><span class=\"garamond-9-5\"> Generally induced during inflammation and plays a role in healing and pain signaling;<sup>8<\/sup> however, its activity also produces prostanoids involved in the normal function of certain tissues, such as the kidneys, brain, and reproductive system.<\/span><\/li>\n<\/ul>\n<p><span class=\"garamond-9-5\">The ideal NSAID strikes a balance between COX-1 and COX-2 inhibition:<\/span><\/p>\n<ul>\n<li><strong><span class=\"garamond-bold\">Nonselective COX inhibitors<\/span><\/strong><span class=\"garamond-9-5\"> equally inhibit COX-1 and COX-2.<sup>9<\/sup> These NSAIDs tend to be associated with classic NSAID side effects, such as gastrointestinal (GI) ulceration, anorexia, vomiting, diarrhea, and renal and liver toxicity.<sup>10<\/sup><\/span><\/li>\n<li><strong><span class=\"garamond-bold\">COX inhibitors that selectively inhibited COX-2<\/span><\/strong><span class=\"garamond-9-5\"> demonstrated a greater safety margin than nonselective COX inhibitors in initial studies in healthy humans. However, this greater safety margin does not hold true for humans at risk for GI side effects.<sup>11<\/sup> Nothing is known about the relative risk of selective COX-2 inhibitors in veterinary medicine.<\/span><\/li>\n<li><span class=\"garamond-9-5\">The ideal NSAID should, therefore:<\/span>\n<ul>\n<li><strong><span class=\"garamond-bold\">Spare COX-1<\/span><\/strong><span class=\"garamond-9-5\"> as much as possible<\/span><\/li>\n<li><strong><span class=\"garamond-bold\">Inhibit COX-2<\/span><\/strong><span class=\"garamond-9-5\"> sufficiently for efficacy against pain and inflammation<\/span><\/li>\n<li><strong><span class=\"garamond-bold\">Spare enough COX-2 <\/span><\/strong><span class=\"garamond-9-5\">to allow it to function in normal everyday processes.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<div class=\"orange-box\">\n<h2><span class=\"brown\">The Role of Prostaglandins<\/span><\/h2>\n<p>Prostaglandins are required for both everyday and compensatory functions of all organs and tissues. For example, prostaglandins are involved in GI protection <em>and<\/em> healing of GI ulcers as well as normal renal function and compensatory protective mechanisms of the kidney during hypovolemia.<sup>10 <\/sup>Prostaglandins are a predominant player in the production of pain in the periphery through sensitization of nerves. They are also involved in the processes of facilitation and amplification of noxious stimuli during central sensitization <em>at the level of the dorsal horn<\/em> of the spinal cord (<strong>Figure 1<\/strong>).<sup>12<\/sup> Central sensitization has been shown, in veterinary species, to become established within 24 hours of a surgical procedure, and it contributes to postoperative pain and likely chronic pain.<\/p>\n<div id=\"attachment_4727\" style=\"width: 488px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-11.02.04-AM.png\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-4727\" class=\"wp-image-4727 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-11.02.04-AM.png\" alt=\"Screen Shot 2015-06-18 at 11.02.04 AM\" width=\"478\" height=\"500\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-11.02.04-AM.png 478w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-11.02.04-AM-287x300.png 287w\" sizes=\"(max-width: 478px) 100vw, 478px\" \/><\/a><p id=\"caption-attachment-4727\" class=\"wp-caption-text\">Figure 1. The role of prostaglandins in the periphery as sensitizers of pain fibers is well known. They are also involved in the facilitation and amplification of pain signals at various levels in the central nervous system; for example, central sensitization is assisted by prostanoids found in the dorsal horn of the spinal cord. Additionally, recent information suggests that locally produced prostanoids help decrease brain function in the areas involved in descending control over pain (endogenous analgesic systems).<\/p><\/div>\n<\/div>\n<h3 class=\"tabs-and-bullets\"><span class=\"bluboldheader\">2. Provides Targeted Action<\/span><\/h3>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Current thinking suggests that an ideal NSAID should have prolonged action at the site of inflammation and a short half-life in the central compartment, limiting exposure of normal, noninflamed, nonpainful tissues (<\/span><strong><span class=\"garamond-bold\">Figure 2<\/span><\/strong><span class=\"garamond-9-5\">). This is because, given the broad distribution and role for prostaglandins throughout the body, if prostaglandins needed for normal, everyday functions are inhibited, there is potential for unwanted side effects.<\/span><\/p>\n<div id=\"attachment_4728\" style=\"width: 405px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-11.02.15-AM.png\"><img decoding=\"async\" aria-describedby=\"caption-attachment-4728\" class=\"wp-image-4728 size-full\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-11.02.15-AM.png\" alt=\"Screen Shot 2015-06-18 at 11.02.15 AM\" width=\"395\" height=\"258\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-11.02.15-AM.png 395w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-11.02.15-AM-300x196.png 300w\" sizes=\"(max-width: 395px) 100vw, 395px\" \/><\/a><p id=\"caption-attachment-4728\" class=\"wp-caption-text\">Figure 2. This figure illustrates the difference between 4 examples of NSAIDs, each dosed every 24 hours. All examples show tissue selectivity but have different half-lives. NSAID 1 has a short half-life, and is cleared quickly from the central compartment (blood), thus, theoretically limiting exposure of noninflamed tissues. In contrast, NSAID 4 has a relatively long half-life, exposing noninflamed tissues to the NSAID for most of the 24-hour period. The clinical significance of this difference between individual NSAIDs is not known.<\/p><\/div>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Dr. Kay Brune, a leader in the field of NSAID research, has described a theory of \u201ctargeted tissue selectivity\u201d that is a combination of enzyme specificity (selective COX-2 inhibition) and tissue selectivity, which, he has argued, might result in better toleration of the drug, while maintaining efficacy (see <\/span><strong><span class=\"garamond-bold\">Concept of Tissue Selectivity<\/span><\/strong><span class=\"garamond-9-5\">).<sup>13<\/sup><\/span><\/p>\n<div class=\"orange-box\">\n<h2><span class=\"brown\">Concept of Tissue Selectivity<\/span><\/h2>\n<p>Tissue selectivity is a concept that involves the highly protein-bound nature of NSAIDs and the acidic environment of inflammation.<\/p>\n<p>During the process of inflammation, there is extravasation, or leakage, of protein from blood vessels into the extracellular environment. Since NSAIDs are known to be &#8220;highly protein bound&#8221; at normal physiological pH, if an NSAID has been administered, it will be bound to this protein.<\/p>\n<p>The acidic extracellular environment of the inflamed tissue causes dissociation of the drug from the protein due to the low pK<sub>a<\/sub>\u2014acid dissociation constant\u2014of the drug. After the drug dissociates from the protein, the increased free fraction of the active drug facilitates its movement into the cells where it then remains due to a phenomenon called ion <em>trapping<\/em> (passive movement of the drug into cells due to differences in pH between the intracellular and extracellular environment).<sup>13<\/sup><\/p>\n<p>This theory explains why NSAIDs may have a prolonged presence in inflamed tissue, while having a more rapid clearance from the central compartment\u2014blood stream and other noninflamed organs.<sup>14<\/sup><\/p>\n<\/div>\n<h3 class=\"indent-125\"><span class=\"bluboldheader\">3. Administered with Ease &amp; Accuracy<\/span><\/h3>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Ideally, for optimal practical administration, NSAIDs should be:<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">Available in an injectable and palatable, oral formulation<\/span><\/li>\n<li><span class=\"garamond-9-5\">Easily titrated and have an easy-to-determine dose.<\/span><\/li>\n<\/ul>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">These 2 formulations should be usable and approved for use, interchangeably. For example, an injectable formulation facilitates both perioperative and immediate postoperative pain management, when it may be difficult or impossible to medicate animals orally. However, an oral formulation is beneficial for postoperative pain management upon discharge and long-term chronic pain management because it allows the drug to be administered in the home environment.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">For cats specifically, palatable oral formulations facilitate administration and compliance\u2014important components of pain management. Cats are selective about what they eat, and it is difficult to hide an unpalatable pill or medication in food or a treat, as is often done with dogs. If the cat won\u2019t willingly take the medication, it must be restrained and dosed.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">An NSAID formulation should be easily titrated, if necessary, and\/or have an easy-to-determine dose. In tablet form, it should have a wide dose range that allows for administration of whole tablets, rather than fractioning tablets in order to stay within the therapeutic range.<\/span><\/p>\n<h3 class=\"tabs-and-bullets\"><span class=\"bluboldheader\">4. Displays Wide Safety Margins &amp; Evidence-Based Clinical Safety<\/span><\/h3>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">First, toxicity studies of NSAIDs should demonstrate a robust and wide safety margin in healthy cats. No one has yet defined what a <\/span><em><span class=\"garamon-italics\">wide safety margin<\/span><\/em><span class=\"garamond-9-5\"> is, but veterinarians are encouraged to read the package inserts and Freedom of Information Summaries for the various NSAIDs.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Additionally, NSAIDs should have been evaluated and deemed to be appropriately safe in normal cats undergoing elective surgeries\u2014the most common scenario for use of NSAIDs in general practice. Ideally, this information should be in the form of peer-reviewed literature, which gives the clinician a degree of comfort about the validity of the data.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Further, it would be ideal to have safety data in other target populations that would benefit from NSAID-induced pain relief, including cats with concurrent diseases, such as chronic kidney disease or cardiomyopathy.<\/span><\/p>\n<h3 class=\"tabs-and-bullets\"><span class=\"bluboldheader\">5. Demonstrates Robust Clinical Efficacy<\/span><\/h3>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">For feline acute pain, there should be robust evidence of clinical efficacy for the target problems, such as perioperative pain control. For feline chronic pain conditions, efficacy should be demonstrated for alleviation of prolonged, maladaptive pain associated with chronic disease in cats, such as degenerative joint disease, spinal pain, stomatitis, cystitis, and cancer. Until very recently, efficacy of NSAIDs was very difficult to measure, and there was little evidence they provided pain relief. A recent breakthrough in clinical study design, along with a Clinical Metrology Instrument, may now allow NSAIDs to be tested for efficacy in a wide variety of chronic diseases.<sup>15<\/sup><\/span><\/p>\n<div class=\"orange-box\">\n<h2>Safe NSAID Use for Chronic Pain<\/h2>\n<p>With respect to chronic administration of NSAIDs, there is an urgent need for more safety data in older cats that:<br \/>\n1. Suffer from painful conditions requiring long-term pain management <em>and<\/em><br \/>\n2. Have concurrent diseases, such as renal impairment, hyperthyroidism, and liver disease.<\/p>\n<\/div>\n<h2 class=\"indent-125\"><span class=\"brown\">AVAILABLE NSAIDS FOR USE IN CATS<\/span><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">In the U.S., there are 2 FDA-approved NSAIDs for short-term use in cats: robenacoxib and meloxicam.<sup>16<\/sup><\/span><\/p>\n<h3 class=\"left-justified\"><span class=\"bluboldheader\">Robenacoxib<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Robenacoxib (Onsior, novartis.com) is FDA-approved for control of postoperative pain and inflammation associated with orthopedic surgery, ovariohysterectomy, and castration in cats.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">It has high selectivity for the inhibition of COX-2, sparing COX-1.<sup>17<\/sup> The clinical benefit of sparing COX-1 in the cat has not been demonstrated; however, benefits associated with COX-1 sparing in other species have been described.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Elegant work by Ludivig Pelligand at the Royal Veterinary College in the UK has demonstrated that robenacoxib has a very short half-life (3 hours) in the blood, yet persists, and is active, for at least 24 hours in inflamed tissue in cats,<sup>17<\/sup> which demonstrates \u201ctissue selectivity.\u201d<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Robenacoxib is approved for short-term administration (up to 3 days in the U.S.) in cats \u2265 4 months of age, weighing \u2265 5.5 lb (2.5 kg) (<\/span><strong><span class=\"garamond-bold\">Table 2<\/span><\/strong><span class=\"garamond-9-5\">).<sup>6<\/sup> In the U.S., robenacoxib is available in 6-mg, yeast-flavored tablets that can be taken with or without food. It should not be given in conjunction with any other NSAID or corticosteroids.<\/span><\/p>\n<h3 class=\"left-justified\"><span class=\"bluboldheader\">Meloxicam<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Meloxicam (Metacam, us.boehringer-ingelheim.com) is FDA-approved for use in cats as a single, SC injection for postoperative pain. It is an example of a preferential COX-2 inhibitor that has greater inhibition of COX-2 than COX-1. <\/span><strong><span class=\"garamond-bold\">Table 2<\/span><\/strong><span class=\"garamond-9-5\"> lists the recommended doses for meloxicam. Meloxicam is also considered tissue selective, but differs from robenacoxib in that it has a longer half-life and is, therefore, present in the central compartment longer.<\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">Although the oral liquid suspension of meloxicam\u2014approved for control of pain and inflammation associated with osteoarthritis in dogs\u2014is not approved for cats, it has been used off-label for chronic pain management.<\/span><\/p>\n<ul>\n<li><span class=\"garamond-9-5\">The <\/span><strong><span class=\"garamond-bold\">2010 Consensus Guidelines: Long-Term Use of NSAIDs in Cats<\/span><\/strong><span class=\"garamond-9-5\"> (available at www.catvets.com\/guidelines\/practice-guidelines\/nsaids-in-cats) provides recommendations from the International Society of Feline Medicine (ISFM) and American Academy of Feline Practitioners (AAFP) for long-term daily dosing of meloxicam oral suspension in cats.<sup>16<\/sup><\/span><\/li>\n<li><span class=\"garamond-9-5\">In addition to standard dosing protocols (<\/span><strong><span class=\"garamond-bold\">Table 2<\/span><\/strong><span class=\"garamond-9-5\">), meloxicam has also been recommended at lower doses, such as 0.02 mg\/kg\/daily.<sup>18<\/sup> At this dose, it is well tolerated, but there is currently no information on whether it is efficacious.<sup>19<\/sup> However, a recent masked, placebo-controlled clinical study found a dose of 0.035 mg\/kg to be efficacious over a 3-week period.<sup>15<\/sup><\/span><\/li>\n<\/ul>\n<table border=\"1\" width=\"100%\" cellspacing=\"0\" cellpadding=\"5\">\n<tbody>\n<tr>\n<td class=\"bluboldheader\" style=\"text-align: left\" colspan=\"3\" align=\"center\"><strong>Table 2. Recommended Doses: NSAIDs for Acute Pain Management in Cats<\/strong><\/td>\n<\/tr>\n<tr>\n<td>NSAID<\/td>\n<td>RECOMMENDATION SOURCE<\/td>\n<td>RECOMMENDED DOSE<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#daecc8\">Robenacoxib<\/td>\n<td valign=\"top\" bgcolor=\"#daecc8\">Recommended dose from manufacturer (FDA-approved)<\/td>\n<td valign=\"top\" bgcolor=\"#daecc8\"><strong>1 mg\/kg<\/strong> PO Q 24 H for 3 doses<br \/>\nDose range, <strong>1\u20132.4 mg\/kg<\/strong> Q 24 H<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#daecc8\">Meloxicam<br \/>\n(injection)<\/td>\n<td valign=\"top\" bgcolor=\"#daecc8\">Recommended dose from manufacturer (FDA-approved)<\/td>\n<td valign=\"top\" bgcolor=\"#daecc8\"><strong>0.3 mg\/kg<\/strong> SC (single injection)<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#daecc8\">Meloxicam<br \/>\n(oral suspension)*<\/td>\n<td valign=\"top\" bgcolor=\"#daecc8\">Recommended dose from ISFM\/AAFP for daily use<sup>14<\/sup><\/td>\n<td valign=\"top\" bgcolor=\"#daecc8\"><strong>0.1 mg\/kg<\/strong> PO for 1 day;<br \/>\nthen <strong>0.05 mg\/kg<\/strong> PO Q 24 H<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#daecc8\">Meloxicam<br \/>\n(oral suspension)*<\/td>\n<td valign=\"top\" bgcolor=\"#daecc8\">Other recommendations<sup>18<\/sup><\/td>\n<td valign=\"top\" bgcolor=\"#daecc8\"><strong>0.05 mg\/kg<\/strong> PO every other day or <strong>0.025 mg\/kg<\/strong> PO Q 24 H<\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\"><em>* Not FDA approved for use in cats<\/em><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><span class=\"garamond-9-5\">In the U.S., the FDA issued a black box warning for meloxicam in 2010 (see <\/span><strong><span class=\"garamond-bold\"><a href=\"https:\/\/todaysveterinarypractice.com\/focus-on-pharmacology-management-of-chronic-pain-in-cats\/\" target=\"_blank\" rel=\"noopener noreferrer\">Management of Chronic Pain in Cats<\/a><\/span><\/strong><span class=\"garamond-9-5\">, November\/December 2012, at tvpjournal.com), indicating that repeated use of meloxicam in cats has been associated with acute renal failure and death. It is most likely that the combination of the higher perioperative dose and then follow-up dosing was responsible for these adverse events, but no details are available in the public domain.<\/span><\/p>\n<p class=\"left-justified\"><span class=\"helvetica-9-pt\">AAFP = American Academy of Feline Practitioners; COX = cyclooxygenase; GI = gastrointestinal; ISFM = International Society of Feline Medicine; NSAID = nonsteroidal anti-inflammatory drug<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; At some point in a cat\u2019s life, it will most likely suffer from pain related to an injury, disease, or surgery, and veterinarians have a duty to try to alleviate this 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