{"id":409,"date":"2014-11-01T18:12:27","date_gmt":"2014-11-01T18:12:27","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=409"},"modified":"2022-02-16T15:21:43","modified_gmt":"2022-02-16T15:21:43","slug":"managing-chronic-nonosteoarthritic-pain-in-dogs-cats","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/pain_management\/managing-chronic-nonosteoarthritic-pain-in-dogs-cats\/","title":{"rendered":"Managing Chronic Pain in Dogs and Cats, Part 3: Management of Nonosteoarthritic Pain Conditions"},"content":{"rendered":"

\"pdf_button\"<\/a><\/p>\n

\n

Mark E. Epstein, DVM, Diplomate ABVP (Canine\/Feline), CVPP<\/em><\/p>\n

Parts 1 and 2<\/em><\/span>\u2014The Two Most Important Tools in the Management of Osteoarthritis and The Best of the Rest in the Management of Osteoarthritis<\/strong>\u00a0(November\/December 2013 and September\/October 2014, respectively; available at\u00a0tvpjournal.com<\/span>)\u2014of this 3-part series discussed therapeutic options for its most common manifestation in companion animals: osteoarthritis.<\/em><\/p>\n

While osteoarthritis (OA) may be the most commonly recognized cause of chronic pain in dogs and cats, other pain syndromes exist. The following scenarios, when evaluated together, may have a prevalence approaching that of OA:<\/p>\n

    \n
  1. Chronic or chronic\u2014active\u00a0inflammatory<\/strong><\/em>\u00a0pain<\/li>\n
  2. Maladaptive<\/em><\/strong>\u00a0chronic pain<\/li>\n
  3. Cancer<\/em><\/strong>\u00a0pain.<\/li>\n<\/ol>\n

    Treatment of these pain phenomena has not been investigated in depth, so therapeutic rationale must be inferred from disease pathophysiology and existing evidence regarding individual treatment modalities.<\/p>\n

    CHRONIC OR CHRONIC\u2014ACTIVE INFLAMMATORY PAIN<\/span><\/strong><\/h2>\n

    A growing body of evidence suggests that peripheral and central sensitization not only exists in chronic inflammatory disease states (Table 1<\/strong>) but may actually advance pathologic abnormalities through proinflammatory neurogenic mechanisms.<\/p>\n

    Few studies have assessed the management of nonOA chronic inflammatory conditions, and such studies may be difficult to perform. However, a treatment sequence for this category of chronic pain can be inferred, in the following approximate order:<\/p>\n

      \n
    1. Anti-inflammatory medications: nonsteroidal anti-inflammatory drug (NSAID) or corticosteroid<\/li>\n
    2. Treatment of underlying disease or aggravating comorbidities<\/li>\n
    3. Neuromodulatory analgesic drugs, such as gabapentin, tramadol, and amitriptyline<\/li>\n
    4. Weight optimization.<\/li>\n<\/ol>\n\n\n\n\n\n
      Table 1. Examples of Chronic & Chronic\u2014Active Inflammatory Pain<\/td>\n<\/tr>\n
      \n

      Chronic periodontal disease<\/p>\n

      Feline lymphocytic\u2014plasmacytic stomatitis\u00a0 Idiopathic feline lower urinary tract disease*<\/p>\n

      Inflammatory bowel disease<\/p>\n

      Meningoencephalitides<\/p>\n

      Otitis externa<\/p>\n

      Pancreatitis<\/td>\n<\/tr>\n

      * Feline interstitial cystitis is increasingly being considered a somatic pain syndrome.1<\/span><\/sup><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

      M<\/span>ALADAPTIVE CHRONIC PAIN<\/span><\/strong><\/h2>\n

      Maladaptive pain occurs through the process of peripheral and central sensitization. Its features include pain that is protracted in duration, exaggerated in severity (hyperalgesia, allodynia), and expanded in field, and can occur in the absence of obvious tissue pathology. These types of disease states (Table 2<\/strong>) include many poorly understood pain syndromes.<\/p>\n\n\n\n\n
      Table 2. Examples of Potential or Existing Maladaptive Chronic Pain2<\/span><\/sup><\/td>\n<\/tr>\n
      \n

      Central nervous system lesions, including post-trauma or vascular accidents, intracranial masses, and congenital defects (eg, syringomyelia)<\/p>\n

      Chronic intervertebral disk disease<\/p>\n

      Diabetic neuropathy<\/p>\n

      Feline hyperesthesia syndrome<\/p>\n

      Feline orofacial pain syndrome<\/p>\n

      Postperipheral nerve injury (eg, trauma, amputation)<\/p>\n

      Postsurgical conditions (eg, fractures, hernia repair)<\/p>\n

      Others<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

      NSAIDs<\/span><\/strong><\/h2>\n

      To the degree that inflammation is considered a component of the underlying pathologic abnormality activating nociceptive pathways, NSAIDs can be considered a first-line drug. However, many maladaptive chronic pain states have progressed to, or are intrinsically, a neuropathic state. In these cases, NSAIDs may contribute a less robust analgesic effect.<\/p>\n

      Other Analgesic Therapies<\/span><\/strong><\/h3>\n

      In humans, systematic reviews of neuropathic pain recommend the following drugs: tricyclic antidepressants, gabapentin, and opioids.3<\/sup>\u00a0While these papers are drawn mainly from trials involving diabetic neuropathy and postherpetic neuralgia\u2014clinical conditions not identified in animals\u2014these drugs commonly play a more prominent role in managing maladaptive pain than NSAIDs.<\/p>\n