{"id":573,"date":"2014-09-01T15:10:12","date_gmt":"2014-09-01T15:10:12","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=573"},"modified":"2022-02-16T15:41:35","modified_gmt":"2022-02-16T15:41:35","slug":"managing-chronic-osteoarthritis-pain-in-dogs-cats","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/pain_management\/managing-chronic-osteoarthritis-pain-in-dogs-cats\/","title":{"rendered":"Managing Chronic Pain in Dogs and Cats, Part 2: The Best of the Rest in the Management of Osteoarthritis"},"content":{"rendered":"<p><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/06\/T1409F03.pdf\"><img decoding=\"async\" class=\"alignnone size-full wp-image-9886\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" alt=\"pdf_button\" width=\"110\" height=\"27\" \/><\/a><\/p>\n<hr \/>\n<p><em>M<\/em><em>ark E. Epstein, DVM, Diplomate ABVP (Canine\/Feline), CVPP<\/em><\/p>\n<p>In this article, the second of the 3-part series, Dr. Epstein discusses additional modalities for treating osteoarthritis in dogs and cats, including therapeutic exercise, polysulfated glycosaminoglycans, omega-3 fatty acids, and suggested off-label dose s for pain-modifying analgesic drugs.<\/p>\n<p><strong>Part 1<\/strong>\u2014<span class=\"bold\">The Two Most Important Tools in the Management of Osteoarthritis(November\/December 2013, available at\u00a0<\/span><span class=\"aquaboldtimes\">tvpjournal.com<\/span>)\u2014of this 3-part series addressed basic principles of chronic pain and also discussed treatment for its most common manifestation in companion animals: osteoarthritis (OA).<\/p>\n<p>While Part 1 dealt with the 2 most important considerations in OA therapy: weight optimization and nonsteroidal anti-inflammatory drug (NSAID) therapy, this article discusses other modalities\u2014both pharmacologic and nonpharmacologic\u2014for treatment of canine and feline OA.<\/p>\n<h2><strong><span class=\"greenheader\">TOP 3 MODALITIES<\/span><\/strong><\/h2>\n<p>Well-designed, systematic reviews evaluating treatment of OA and nonsurgical management of hip dysplasia in dogs are now available.<sup>1,2<\/sup>\u00a0Very good review articles are also available for cats diagnosed with OA.<sup>3<\/sup><\/p>\n<p>Based on these evidence-based perspectives\u2014once weight optimization and NSAID therapy have been implemented\u20143 modalities rise to the top of the list.<span class=\"brown\">1. <\/span><\/p>\n<h3><strong><span class=\"brown\">1. Polysulfated Glycosaminoglycans<\/span><\/strong><\/h3>\n<p>Veterinary polysulfated glycosaminoglycans (PSGAGs) administered by the\u00a0<strong><span class=\"bold\">parenteral route<\/span><\/strong>\u00a0(ie, IV or IM injection) have met both regulatory scrutiny and quality control measures; independent studies appear to support their clinical utility.<sup>4,5<\/sup>\u00a0Examples include (<strong><span class=\"bold\">Table 1<\/span><\/strong>):<\/p>\n<ul>\n<li>PSGAG (Adequan Canine, novartis.com)<\/li>\n<li>Sodium pentosan polysulfate (Cartrophen Vet for Dogs, biopharmaus.com.au).<\/li>\n<\/ul>\n<p>In contrast, clinical evidence for oral nutraceuticals is limited in dogs and cats and, at best, conflicting in humans. However, it can be argued that initiating use of\u00a0<span class=\"bold\">oral nutraceuticals<\/span>early in life, particularly for at-risk breeds, is safe and may provide some long-term chondroprotective effect.<\/p>\n<p>If nutraceuticals and oral supplements are used, caution is warranted due to the following concerns:<\/p>\n<ul>\n<li>Degree of quality control<\/li>\n<li>Potential drug interactions, especially with NSAIDs, because some over-the-counter products contain aspirin or other cyclooxygenase (COX)-inhibiting agents<\/li>\n<li>Ingredients derived from endangered species<\/li>\n<li>Need for clinical studies to demonstrate efficacy<\/li>\n<\/ul>\n<table border=\"1\" width=\"500\" cellspacing=\"0\" cellpadding=\"1\">\n<tbody>\n<tr>\n<td class=\"GreenAqua\" colspan=\"4\" align=\"center\">TABLE 1. On- and Off-Label Use of Polysulfated Glycosaminoglycans<\/td>\n<\/tr>\n<tr>\n<td align=\"center\" width=\"94\"><\/td>\n<td class=\"greenheader\" align=\"center\" width=\"99\">On-Label Dose: Dogs<\/td>\n<td class=\"greenheader\" align=\"center\" width=\"180\">Off-Label Use<\/td>\n<td class=\"greenheader\" align=\"center\" width=\"109\">Comments<\/td>\n<\/tr>\n<tr>\n<td class=\"brown\" valign=\"top\" bgcolor=\"#bcefcf\">Adequan<\/td>\n<td class=\"arial\" valign=\"top\" bgcolor=\"#9ce8b9\"><strong>4.4 mg\/kg<\/strong>\u00a0IM twice weekly for 4 weeks<\/td>\n<td class=\"arial\" valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li>Dogs and cats<\/li>\n<li>Administer SC<\/li>\n<li>Continue on long-term basis, (eg, Q 1 month and adjust frequency according to patient needs)<\/li>\n<\/ul>\n<\/td>\n<td class=\"arial\" valign=\"top\" bgcolor=\"#9ce8b9\">Caution with patients at risk for bleeding dyscrasia<\/td>\n<\/tr>\n<tr>\n<td class=\"brown\" valign=\"top\" bgcolor=\"#bcefcf\">Cartrophen Vet<\/td>\n<td class=\"arial\" valign=\"top\" bgcolor=\"#9ce8b9\"><strong>3 mg\/kg<\/strong>\u00a0SC Q 5\u20147 days, 4 times<\/td>\n<td class=\"arial\" valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li>Continue on long-term basis, (eg, repeat protocol Q 4\u20146 months)<\/li>\n<\/ul>\n<\/td>\n<td class=\"arial\" valign=\"top\" bgcolor=\"#9ce8b9\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><strong><span class=\"brown\"><br \/>\n2. Omega-3 Fatty Acids<\/span><\/strong><\/h3>\n<p>Several randomized placebo-controlled blinded studies<sup>6-10<\/sup>\u00a0and one systematic review<sup>11<\/sup>have demonstrated the efficacy of diets rich in:<sup>12,13<\/sup><\/p>\n<ul>\n<li>Eicosapentaenoic acid (EPA) for dogs with OA<\/li>\n<li>Docosahexaenoic acid (DHA) for cats with OA.<\/li>\n<\/ul>\n<p>The availability of multiple randomized placebo-controlled blinded studies and systematic reviews place these data high on the evidence-based pyramid. However, this type of supplementation should be reserved for pets at a healthy weight.<\/p>\n<div class=\"orange-box\">\n<h2><strong><span class=\"brown\">Gate Theory of Pain<\/span><\/strong><\/h2>\n<p>The spinal cord has a functional, neurophysiologic &#8220;gate&#8221; that can either block or allow pain signaling to the brain;16 by sending other signals to the brain during exercise (eg, proprioception), pain signaling through the spinal cord &#8220;gate&#8221; is, to a degree, blocked.<\/p>\n<\/div>\n<h3><strong>3. Therapeutic Exercise<\/strong><\/h3>\n<p>While a relatively new modality in veterinary medicine, controlled, prescribed exercise is well established in humans for amelioration of pain related to OA. There is every reason to believe that dogs and cats can benefit as well due to a variety of mechanisms, including:<\/p>\n<ul>\n<li>The Gate Theory of pain<\/li>\n<li>Activation of endogenous opioids<\/li>\n<li>Enhanced strength of periarticular soft tissue (eg, muscle, tendon, ligament) and resulting improved microstability of joints<\/li>\n<li>Weight loss (if needed).<\/li>\n<\/ul>\n<p>Some studies already support use of this modality in painful dogs with OA.<sup>14,15<\/sup><\/p>\n<h2><strong><span class=\"greenheader\">ADDITIONAL OPTIONS<\/span><\/strong><\/h2>\n<p>The evidence for other recommended treatments for OA pain is either limited, weak, conflicting, or based on\u00a0<span class=\"italic\">in vitro<\/span>\u00a0cellular\/molecular rather than clinical data. However, modalities that may play a role in management of OA in dogs and cats include:<\/p>\n<ul>\n<li>Pharmacologic (pain modifying analgesic drugs)<\/li>\n<li>Nonpharmacologic<\/li>\n<li>Biologic.<\/li>\n<\/ul>\n<div class=\"orange-box\">\n<h2><strong><span class=\"brown\">Diagnostic &amp; Treatment Considerations for OA Patients<\/span><\/strong><\/h2>\n<ul>\n<li><strong>Perform diagnostics<\/strong>.<\/li>\n<li><strong>Conduct<\/strong>\u00a0a thorough history, physical examination, imaging, and laboratory evaluation.<\/li>\n<li><strong>Establish treatment goals<\/strong>\u00a0with the owner, and then create the treatment plan.<\/li>\n<li><strong>Explain that the reward for the pet<\/strong>\u00a0can be great in terms of longevity and improved quality of life, but only with good cooperation, compliance, and communication.<\/li>\n<li><strong>Educate owners on how to recognize potential drug adverse events<\/strong>. Explain what to do if adverse events occur.<\/li>\n<li><strong>Follow-up<\/strong>. Schedule the next reassessment before the client leaves. Touch base periodically with one of the validated chronic pain\/disability owner assessment tools.<\/li>\n<\/ul>\n<\/div>\n<h3><strong><span class=\"brown\">Pharmacologic Therapy Options (Table 2)<\/span><\/strong><\/h3>\n<p><em><span class=\"navyblueheader\">Gabapentin<\/span><\/em><br \/>\nNo clinical studies evaluating gabapentin\u2014as a single agent or an adjunct to NSAIDs\u2014for the treatment of OA have been conducted in humans, dogs, or cats. However, a neuropharmacologic rationale exists for gabapentin&#8217;s ability to diminish central and peripheral sensitization, which is supported by a number of rodent studies.<sup>17,18<\/sup><\/p>\n<p>One canine study suggests that gabapentin may provide a chondroprotective effect in experimentally induced OA,<sup>19<\/sup>\u00a0and a pending study in cats appears to demonstrate the clinical efficacy of gabapentin for pain associated with naturally occurring feline hip OA.<sup>20<\/sup><\/p>\n<blockquote><p><em>Macrostability<\/em>: Gross subluxation<br \/>\n<em>Microstability<\/em>: Diminished laxity of joint that cannot be grossly appreciated<\/p><\/blockquote>\n<table border=\"1\" width=\"500\" cellspacing=\"0\" cellpadding=\"1\">\n<tbody>\n<tr>\n<td class=\"GreenAqua\" colspan=\"3\" align=\"center\">TABLE 2. Recommended Doses for Pain Modifying Analgesic Drugs<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\"><\/td>\n<td class=\"greenheader\" align=\"center\" valign=\"top\">SUGGESTED DOSE<\/td>\n<td class=\"greenheader\" align=\"center\" valign=\"top\">PRIMARY ADVERSE EFFECTS &amp; NOTES<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#bcefcf\"><span class=\"brown\">Acetaminophen<\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#9ce8b9\"><span class=\"arial\"><strong>10\u201415 mg\/kg\u00a0<\/strong>PO Q 12 H<sup>39<\/sup><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Contraindicated in cats<\/span><\/li>\n<li><span class=\"arial\">No special proclivity toward hepatotoxicity in dogs; judicious use recommended<br \/>\n<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#bcefcf\"><span class=\"brown\">Amantadine<br \/>\n<\/span><span class=\"BrownItalics\">NMDA receptor antagonist\u00a0<\/span><span class=\"brown\"><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#9ce8b9\"><span class=\"arial\"><strong>3\u20145 mg\/kg<\/strong>\u00a0PO Q 12 H<sup>21<\/sup><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Primary adverse effects include agitation and diarrhea<\/span><\/li>\n<li><span class=\"arial\">Anticholinergic<br \/>\n<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#bcefcf\"><span class=\"brown\">Amitriptyline<sup>a<\/sup><\/span><span class=\"arial\"><br \/>\nTricyclic antidepressant<br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#9ce8b9\"><span class=\"arial\"><em>Dogs, initial dose<\/em>:<br \/>\n<strong>1\u20142 mg\/kg<\/strong>\u00a0PO Q 8\u201412 H<sup>39<\/sup><br \/>\nIncrease as needed to:<br \/>\n<strong>3\u20144 mg\/kg<\/strong>\u00a0PO Q 8\u201412 H<sup>29<\/sup><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Primary adverse effects include, in humans, dry mouth, sedation, behavioral changes, and seizure potentiation<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#bcefcf\"><span class=\"brown\">Codeine<sup>b<\/sup><\/span><span class=\"arial\"><br \/>\n<\/span><span class=\"BrownItalics\">Opioid<\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#9ce8b9\"><span class=\"arial\"><strong>0.5\u20142 mg\/kg<\/strong>\u00a0PO Q 12 H<sup>39<\/sup><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Some suggest dogs only<\/span><\/li>\n<li><span class=\"arial\">Pharmacokinetics, but no clinical data, available<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#bcefcf\"><span class=\"brown\">Gabapentin<\/span><span class=\"arial\"><br \/>\n<\/span><span class=\"BrownItalics\">Anticonvulsant<\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#9ce8b9\"><span class=\"arial\">Initially\u00a0<strong>3\u20145 mg\/kg<\/strong>\u00a0PO Q 12 H, taper upwards to effect; doses as high as\u00a0<strong>20 mg\/kg<\/strong>\u00a0or more may be needed PO Q 8\u201412 H<sup>39<\/sup><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Primary adverse effects include somnolesense, which can be minimized by starting with lower doses and gradually increasing to effect<\/span><\/li>\n<li><span class=\"arial\">For smaller animals, may be compounded into 50 mg\/mL nonxylitol containing suspension<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#bcefcf\"><span class=\"brown\">Hydrocodone<sup>b<\/sup><\/span><span class=\"arial\"><br \/>\n<\/span><span class=\"BrownItalics\">Opioid<\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#9ce8b9\"><span class=\"arial\"><strong>0.22\u20140.5 mg\/kg<\/strong>\u00a0PO Q 8\u201412 H<sup>39<\/sup><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Some suggest dogs only<\/span><\/li>\n<li><span class=\"arial\">Pharmacokinetics, but no clinical data, available<\/span><\/li>\n<li><span class=\"arial\">Primary adverse effects include sedation<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#bcefcf\"><span class=\"brown\">Morphine\/lidocaine\/ketamine CRI<\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#9ce8b9\"><span class=\"arial\"><em>Dogs<\/em>:<br \/>\nMorphine,\u00a0<strong>4 mcg\/kg<\/strong>\/min<br \/>\nLidocaine,\u00a0<strong>50 mcg\/kg<\/strong>\/min<br \/>\nKetamine,\u00a0<strong>10 mcg\/kg<\/strong>\/min<br \/>\nCRI for 24\u201448 H<br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Clinical utility for chronic pain holiday anecdotal only<\/span><\/li>\n<li><span class=\"arial\">Administer combined or individually<\/span><\/li>\n<li><span class=\"arial\">Primary adverse effects include, in humans, GI effects, behavioral changes, seizure potentiation, hypertension, bleeding dyscrasia, sedation<\/span><\/li>\n<li><span class=\"arial\">Unfavorable pharmacokinetics in dogs; better in cats<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#bcefcf\"><span class=\"brown\">Tramadol<sup>a<\/sup><\/span><span class=\"arial\"><br \/>\n<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#9ce8b9\"><span class=\"arial\"><em>Cats<\/em>:<br \/>\n<strong>1\u20144 mg\/kg<\/strong>\u00a0PO Q 12 H<sup>39<\/sup><\/span><span class=\"arial\"><em>Dogs<\/em>:<br \/>\n<strong>2\u201410c mg\/kg<\/strong>\u00a0PO Q 8\u201412 H<sup>29<\/sup><\/span><\/td>\n<td valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">No safety or toxicity data in dogs or cats; limited to no data to support efficacy in dogs<\/span><\/li>\n<li><span class=\"arial\">Higher doses may increase risk for adverse effects<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td valign=\"top\" bgcolor=\"#bcefcf\"><span class=\"brown\">Venflaxine<sup>a<\/sup><\/span><span class=\"arial\"><br \/>\n<\/span><span class=\"BrownItalics\">SSNRI<\/span><\/td>\n<td valign=\"top\" bgcolor=\"#9ce8b9\"><span class=\"arial\"><strong>3\u20144 mg\/kg<\/strong>\u00a0PO Q 8\u201412 H<sup>31<\/sup><\/span><\/td>\n<td valign=\"top\" bgcolor=\"#bcefcf\">\n<ul>\n<li><span class=\"arial\">Not in clinical use for chronic pain in dogs or cats<\/span><\/li>\n<li><span class=\"arial\">No safety or toxicity data<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"3\">\n<ol type=\"a\">\n<li>Caution should be exercised when using these and other serotoninergic, monoaminergic drugs in combination.<\/li>\n<li>If used in combination with acetaminophen, base dosage administered on calculated acetaminophen dose.<\/li>\n<li>Higher doses are more likely to lead to adverse effects, and it is prudent to initiate dosing at 2\u20144 mg\/kg.<\/li>\n<\/ol>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"references\" colspan=\"3\">NMDA = N-methyl-D-aspartate; SSNRI = serotonin-norepinephrine reuptake inhibitor<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><strong><span class=\"navyblueheader\">Amantadine<\/span><\/strong><\/h3>\n<p>One study in dogs with refractory OA demonstrated the efficacy of amantadine and an NSAID versus NSAIDs alone.<sup>21<\/sup><\/p>\n<h3><strong><span class=\"navyblueheader\">Tramadol<\/span><\/strong><\/h3>\n<p>The pharmacokinetics of oral tramadol do not favor its use for OA pain in dogs.<sup>22-25<\/sup>In fact, the pharmacokinetics of oral tramadol are not favorable in the dog, in general, and especially not for chronic use (plasma levels, low to begin with, diminish rapidly to near negligible levels after sequential use over several days). Even with IV tramadol, dogs do not produce the mu receptor active metabolite that occurs in humans.<sup>26<\/sup>\u00a0It may be better suited pharmacologically for cats,<sup>27<\/sup>\u00a0but its extremely bitter taste may limit its use.<\/p>\n<p>At this time, no studies have been published that demonstrate tramadol&#8217;s efficacy for treatment of OA in cats or dogs, either alone or as an adjunct to NSAIDs. The results of one canine study suggested that dogs with OA improved with tramadol according to owner assessments; however, the placebo group also improved, and there was no improvement in the tramadol group according to objective gait analysis.<sup>25<\/sup>\u00a0However, one study submitted for publication may reveal more encouraging results.<sup>28<\/sup><\/p>\n<div class=\"orange-box\">\n<h2><strong><span class=\"brown\">The Role of Constant Rate Infusions<\/span><\/strong><\/h2>\n<p>Intravenous constant rate infusions (CRI) of ketamine, lidocaine, opioids, or a combination can be used for a 24 to 48 hour\u00a0<em>pain holiday<\/em>\u00a0and to also reduce central sensitization. Used for severe neuropathic pain states in humans, this methodology has been anecdotally used but not yet investigated in canine and feline patients with OA.<\/p>\n<\/div>\n<h3><em><span class=\"navyblueheader\"><br \/>\n<\/span><\/em><strong><span class=\"navyblueheader\">Tricyclic Antidepressants &amp; Selective Serotonin\/Norepinephrine Reuptake Inhibitors<\/span><\/strong><\/h3>\n<p>Although known for their ability to treat chronic and neuropathic pain conditions in humans, as of yet, no data support the use of these drugs for management of canine or feline OA.<\/p>\n<ul>\n<li>Duloxetine (Cymbalta, lilly.com), a selective serotonin\/norepinephrine reuptake inhibitor, is labeled for musculoskeletal and low back pain in humans, but has very poor oral bioavailability in dogs.<sup>29<\/sup><\/li>\n<li>Oral venlafaxine (Effexor, pfizer.com), labeled as an antidepressant in humans, has been demonstrated to diminish pain intensity and improve function in humans with OA.<sup>30<\/sup>\u00a0In dogs, it has approximately 50% bioavailability and a half-life of 3 hours.<sup>31<\/sup><\/li>\n<li>There is no strong evidence for the pain modifying effect of fluoxetine, a selective serotonin reuptake inhibitor.<\/li>\n<\/ul>\n<h3><strong><span class=\"navyblueheader\">Corticosteroids<\/span><\/strong><\/h3>\n<p>Intra-articular corticosteroid injection is a first-line therapy for OA in humans and horses. In dogs, studies in experimentally induced OA demonstrate that corticosteroid injections may have a disease modifying and, possibly, chondroprotective effect,<sup>32-35<\/sup>\u00a0but clinical studies are lacking.<\/p>\n<h3><strong><span class=\"navyblueheader\">Acetaminophen<\/span><\/strong><\/h3>\n<p>Acetaminophen remains a first-line therapy for acute and chronic pain in elderly humans,<sup>36<\/sup>and unlike cats, a literature search for toxicity in dogs does not reveal any special sensitivity to adverse effects or toxicity in this species. Judicious use can be considered in dogs but not in cats.<\/p>\n<h3><strong><span class=\"navyblueheader\">Oral Opioids<\/span><\/strong><\/h3>\n<p>Dogs have a robust first-pass effect with oral opioids, limiting their usefulness compared with human patients, but pharmacokinetic studies reveal the possible efficacy of codeine<sup>37<\/sup>and hydrocodone<sup>38<\/sup>\u00a0in this species.<\/p>\n<h3><strong>Nonpharmacologic<\/strong><\/h3>\n<p><span style=\"line-height: 1.5\">Nonpharmacologic treatment of OA in dogs and cats includes a variety of therapies (<\/span><strong><span class=\"bold\" style=\"line-height: 1.5\">Table 3<\/span><\/strong><span style=\"line-height: 1.5\">). While unsupported at this time by strong clinical evidence, these modalities:<\/span><\/p>\n<ul>\n<li>Have plausible, if yet unproven, beneficial effects<\/li>\n<li>Are generally safe with proper use<\/li>\n<li>May be employed as an adjunct to other therapies, or when nonpharmacologic modalities are indicated or preferred.<\/li>\n<\/ul>\n<p>As part of an integrated approach to treating pain, acupuncture, in particular, has been accepted by both the National Institutes of Health (nih.gov) and International Veterinary Academy of Pain Management (ivapm.org) in their respective position\/consensus statements.<\/p>\n<table border=\"1\" width=\"500\" cellspacing=\"0\" cellpadding=\"10\">\n<tbody>\n<tr>\n<td align=\"center\"><span class=\"GreenAqua\">Table 3. Common Nonpharmacologic Therapies for Canine &amp; Feline OA<\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"arial\" bgcolor=\"#9ce8b9\">\n<ul>\n<li>Acupuncture<\/li>\n<li>Myofascial trigger point therapy<\/li>\n<li>Therapeutic laser (photobiomodulation)<\/li>\n<li>Pulsed acoustic wave therapy<\/li>\n<li>Pulsed electromagnetic field therapy<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><strong><span class=\"brown\">Biologic<\/span><\/strong><\/h3>\n<p>The relative merits and roles of intra-articular stem cell therapy, platelet-rich plasma therapy, extracellular matrix bioscaffolds, hyaluronate, and even botulinum toxin remain areas of interest and research. How these modalities will fit into management of OA remains undetermined at this time.<\/p>\n<p>One commercial autologous conditioned serum product (IRAP, arthrexvetsystems.com) is labeled for intra-articular injection in horses with OA; it suppresses the highly pro-inflammatory cytokine Interleukin-1. There is no similar commercial product for use in dogs, but there is indication that the modality may have a disease-modifying effect in this species.<sup>41<\/sup><\/p>\n<p>A commercial systemically administered anti-nerve growth factor monoclonal antibody product is currently in development for the treatment of canine OA. Investigations are also in progress for treatment of canine OA with Interleukin-10, a potent inhibitor of spinal cord glial activity.<\/p>\n<h2><strong>IN SUMMARY<\/strong><\/h2>\n<p>The ideal pain management protocol for a particular OA patient will vary by stage of disease, doctor and client values, and of course, individual needs and responses.<\/p>\n<p>COX = cyclooxygenase; CRI = constant rate infusion; DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; NSAID = nonsteroidal anti-inflammatory drug; OA = osteoarthritis; PSGAG = polysulfated glycosaminoglycan<\/p>\n<p>&nbsp;<\/p>\n<h2>READ MORE<\/h2>\n<p>Read Part 1 of this article, <a href=\"https:\/\/todaysveterinarypractice.com\/managing-chronic-pain-in-dogs-cats-part-2-the-best-of-the-rest-in-the-management-of-osteoarthritis\/\">Managing Chronic Pain in Dogs and Cats (Osteoarthritis)<\/a>.<\/p>\n<p>Read Part 3 of this article, Managing Chronic Pain (Nonosteoarthritic Pain Conditions).<\/p>\n<h3><strong>References<\/strong><\/h3>\n<ol>\n<li class=\"references\">Marshall W, Bockstahler B, Hulse D, Carmichael S. A review of osteoarthritis and obesity: Current understanding of the relationship and benefit of obesity treatment and prevention in the dog.\u00a0<em>Vet Comp Orthop Traumatol<\/em>\u00a02009; 22(5):339-345.<\/li>\n<li class=\"references\">Kirby KA, Lewis DD. Canine hip dysplasia: Reviewing the evidence for nonsurgical management.\u00a0<em>Vet Surg<\/em>\u00a02011; [epub ahead of print].<\/li>\n<li class=\"references\">Bennett D, Zainal Ariffin SM, Johnston P. Osteoarthritis in the cat: 1. How common is it and how easy to recognise? and 2. How should it be managed and treated?\u00a0<em>J Fel Med Surg<\/em>\u00a02012; 14:65-84.<\/li>\n<li class=\"references\">Fujiki M, Shineha J, Yamanokuchi K, et al. Effects of treatment with polysulfated glycosaminoglycan on serum cartilage oligomeric matrix protein and C-reactive protein concentrations, serum matrix metalloproteinase-2 and -9 activities, and lameness in dogs with osteoarthritis.\u00a0<em>Am J Vet Res<\/em>\u00a02007; 68(8):827-833.<\/li>\n<li class=\"references\">Smith JG, Hannon RL, Brunnberg L, et al. (2001) A randomised double blind comparator clinical study of the efficacy of sodium pentosan polysulfate injection and carprofen capsules in arthritic dogs.\u00a0<em>J OARSI\u00a0<\/em>2001; 9(b):S21-S22.<\/li>\n<li class=\"references\">Moreau M, Troncy E, Del Castillo JR, et al. Effects of feeding a high omega-3 fatty acids diet in dogs with naturally occurring osteoarthritis.\u00a0<em>J Anim Physiol Anim Nutr (Berl)<\/em>\u00a02012; [epub ahead of print].<\/li>\n<li class=\"references\">Roush JK, Dodd CE, Fritsch DA, et al. Multicenter veterinary practice assessment of the effects of omega-3 fatty acids on osteoarthritis in dogs.\u00a0<em>JAVMA<\/em>\u00a02010; 236(1):59-66.<\/li>\n<li class=\"references\">Roush JK, Cross AR, Renberg WC, et al. Evaluation of the effects of dietary supplementation with fish oil omega-3 fatty acids on weight bearing in dogs with osteoarthritis.\u00a0<em>JAVMA<\/em>\u00a02010; 236(1):67-73.<\/li>\n<li class=\"references\">Fritsch DA, Allen TA, Dodd CE, et al. A multicenter study of the effect of dietary supplementation with fish oil omega-3 fatty acids on carprofen dosage in dogs with osteoarthritis.\u00a0<em>JAVMA<\/em>\u00a02010; 236(5):535-539.<\/li>\n<li class=\"references\">Fritsch D, Allen TA, Dodd CE, et al. Dose-titration effects of fish oil in osteoarthritic dogs.<em>\u00a0J Vet Intern Med<\/em>\u00a02010; 24(5):1020-1026.<\/li>\n<li class=\"references\">Vandeweerd JM, Coisnon C, Clegg P, et al. Systematic review of efficacy of nutraceuticals to alleviate clinical signs of osteoarthritis.<em>\u00a0J Vet Intern Med<\/em>\u00a02012; 26(3):448-456.<\/li>\n<li class=\"references\">Hahn K. Nutritional management of cats with arthritic discomfort: Results from a controlled clinical trial.\u00a0<em>Hill&#8217;s Global Mobility Symposium Proceedings<\/em>, 2008, p 27 (hillsvet.com\/conferenceproceedings).<\/li>\n<li class=\"references\">Corbee RJ, Barnier MM, van de Lest CH, Hazewinkel HA. The effect of dietary long-chain omega-3 fatty acid supplementation on owner&#8217;s perception of behaviour and locomotion in cats with naturally occurring osteoarthritis.\u00a0<em>J Anim Physiol Anim Nutr (Berl)<\/em>\u00a02012; [epub ahead of print].<\/li>\n<li class=\"references\">Krontveit RI, Trangerud C, S+\ufffdvik BK, et al. Risk factors for hip-related clinical signs in a prospective cohort study of four large dog breeds in Norway.\u00a0<em>Prev Vet Med<\/em>\u00a02012; 103(2-3):219-227.<\/li>\n<li class=\"references\">Conzemius M. Personal communication 2012.<\/li>\n<li class=\"references\">Melzack R, Wall PD. Pain mechanisms: A new theory.\u00a0<em>Science<\/em>\u00a01965; 150(3699):971-979.<\/li>\n<li class=\"references\">Ivanavicius SP, Ball AD, Heapy CG, et al. Structural pathology in a rodent model of osteoarthritis is associated with neuropathic pain: Increased expression of ATF-3 and pharmacological characterisation.\u00a0<em>Pain<\/em>\u00a02007; 128(3):272-282.<\/li>\n<li class=\"references\">Hanesch U, Pawlak M, McDougall JJ. Gabapentin reduces the mechanosensitivity of fine afferent nerve fibres in normal and inflamed rat knee joints.\u00a0<em>Pain<\/em>\u00a02003; 104(1-2):363-366.<\/li>\n<li class=\"references\">Bioleau C, Martel-Pelletier J, Brunet J, et al. PD-0200347, an alpha2delta ligand of the voltage gated calcium channel, inhibits in vivo activation of the Erk1\/2 pathway in osteoarthritic chondrocytes: A PKCalpha dependent effect.\u00a0<em>Ann Rheum Dis<\/em>\u00a02006; 65(5):573-580.<\/li>\n<li class=\"references\">Troncy E. Personal communication, 2013; publication pending.<\/li>\n<li class=\"references\">Lascelles BD, Gaynor JS, Smith ES, et al. Amantadine in a multimodal analgesic regimen for alleviation of refractory OA pain in dogs.<em>\u00a0J Vet Intern Med<\/em>\u00a02008; 22(1):53-59.<\/li>\n<li class=\"references\">Giorgi M, Saccomanni G, Lebkowska-Wieruszewska B, Kowalski C. Pharmacokinetic evaluation of tramadol and its major metabolites after single oral sustained tablet administration in the dog: A pilot study.\u00a0<em>Vet J\u00a0<\/em>2009; 180(2):253-255.<\/li>\n<li class=\"references\">Kukanich B, Papich MG. Pharmacokinetics and antinociceptive effects of oral tramadol hydrochloride administration in greyhounds.\u00a0<em>Am J Vet Res<\/em>\u00a02011; 72(2):256-262.<\/li>\n<li class=\"references\">Matthiesen T, W+\ufffdhrmann T, Coogan TP, Uragg H. The experimental toxicology of tramadol: An overview.\u00a0<em>Toxicol Lett<\/em>\u00a01998; 95(1):63-71.<\/li>\n<li class=\"references\">Malek S, Sample SJ, Schwartz Z, et al. Effect of analgesic therapy on clinical outcome measures in a randomized controlled trial using client-owned dogs with hip osteoarthritis.\u00a0<em>BMC Vet Res<\/em>\u00a02012; 8:185.<\/li>\n<li class=\"references\">McMIllan CJ, Livingston A, Clark CR, et al. Pharmacokinetics of intravenous tramadol in dogs.\u00a0<em>Can J Vet Res\u00a0<\/em>2008; 72(4):325-331.<\/li>\n<li class=\"references\">Pypendop BH, Ilkiw JE. Pharmacokinetics of tramadol, and its metabolite O-desmethyl-tramadol, in cats.\u00a0<em>J Vet Pharmacol Ther<\/em>\u00a02008; 31(1):52-59.<\/li>\n<li class=\"references\">Troncy E. Personal communication, 2013; abstract presented: Lembert 2003 WCVA p 157.<\/li>\n<li class=\"references\">KuKanich B. Outpatient oral analgesics in dogs and cats beyond nonsteroidal antiinflammatory drugs: An evidence-based approach.<em>\u00a0Vet Clin N Am Small Anim Pract<\/em>\u00a02013; 43(5):1109-1125.<\/li>\n<li class=\"references\">Sullivan M, Bentley S, Fan MY, Gardner G. A single-blind placebo run-in study of venlafaxine XR for activity-limiting osteoarthritis pain.<em>\u00a0Pain Med\u00a0<\/em>2009; 10(5):806-812.<\/li>\n<li class=\"references\">Howell SR, Hicks DR, Scatina JA, Sisenwine SF. Pharmacokinetics of venlafaxine and O-desmethylvenlafaxine in laboratory animals.\u00a0<em>Xenobiotica<\/em>\u00a01994; 24(4):315-327.<\/li>\n<li class=\"references\">Pelletier JP, Mineau F, Raynauld JP, et al. Intraarticular injections with methylprednisolone acetate reduce osteoarthritic lesions in parallel with chondrocyte stromelysin synthesis in experimental osteoarthritis.\u00a0<em>Arthritis Rheum<\/em>\u00a01994; 37(3):414-423.<\/li>\n<li class=\"references\">Pelletier JP, Martel-Pelletier J. In vivo protective effects of prophylactic treatment with tiaprofenic acid or intraarticular corticosteroids on osteoarthritic lesions in the experimental dog model.<em>\u00a0J Rheumatol Suppl<\/em>\u00a01991; 27:127-130.<\/li>\n<li class=\"references\">Pelletier JP, Martel-Pelletier J. Protective effects of corticosteroids on cartilage lesions and osteophyte formation in the Pond-Nuki dog model of osteoarthritis.\u00a0<em>Arthritis Rheum<\/em>\u00a01989; 32(2):181-193.<\/li>\n<li class=\"references\">Pelletier JP, DiBattista JA, Raynauld JP, et al. The in vivo effects of intraarticular corticosteroid injections on cartilage lesions, stromelysin, interleukin-1, and oncogene protein synthesis in experimental osteoarthritis.<em>\u00a0Lab Invest<\/em>\u00a01995; 72(5):578-586.<\/li>\n<li class=\"references\">Abdulla A, Adams N, Bone M, et al. British Geriatrics Society. Guidance on the management of pain in older people.\u00a0<em>Age Ageing<\/em>\u00a02013; 42(suppl 1):i1-i57.<\/li>\n<li class=\"references\">KuKanich B. Pharmacokinetics of acetaminophen, codeine, and the codeine metabolites morphine and codeine-6-glucuronide in healthy greyhound dogs.\u00a0<em>J Vet Pharmacol Ther<\/em>\u00a02010; 33(1):15-21.<\/li>\n<li class=\"references\">KuKanich B, Paul J. Pharmacokinetics of hydrocodone and its metabolite hydromorphone after oral hydrocodone administration to dogs.\u00a0<em>ACVIM Proc\u00a0<\/em>2010.<\/li>\n<li class=\"references\">Plumb DC.<em>\u00a0Plumb&#8217;s Veterinary Drug Handbook<\/em>, 7th ed. Ames, IA: Wiley-Blackwell, 2011.<\/li>\n<li class=\"references\">Muir WW 3rd, Wiese AJ, March PA. Effects of morphine, lidocaine, ketamine, and morphine-lidocaine-ketamine drug combination on minimum alveolar concentration in dogs anesthetized with isoflurane.\u00a0<em>Am J Vet Res<\/em>\u00a02003; 64(9):1155-1160.<\/li>\n<li class=\"references\">Caron JP, Fernandes JC, Martel-Pelletier J, et al. Chondroprotective effect of intraarticular injections of interleukin-1 receptor antagonist in experimental osteoarthritis. Suppression of collagenase-1 expression.\u00a0<em>Arthritis Rheum<\/em>\u00a01996; 39(9):1535-1544.<\/li>\n<\/ol>\n<p><span class=\"author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/11\/F04_B.png\"><img decoding=\"async\" class=\" wp-image-6410 alignleft\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/11\/F04_B.png\" alt=\"F04_B\" width=\"80\" height=\"98\" \/><\/a>Mark Epstein<\/strong>, DVM, Diplomate ABVP (Canine\/Feline), CVPP, is the senior partner and medical director of Carolinas Animal Pain Management &amp; TotalBond Animal Hospitals, a group of AAHA-accredited practices in the Charlotte and Gastonia, North Carolina, areas. He is a member of the American Academy of Pain Management and International Veterinary Academy of Pain Management, and a past president of the IVAPM and ABVP, and an author and lecturer on the recognition, prevention, and treatment of pain. Dr. Epstein received his DVM from the University of Georgia.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Part 2 of a comprehensive look at managing chronic pain in dogs and cats.<\/p>\n","protected":false},"author":1,"featured_media":11677,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":1085,"footnotes":""},"categories":[368],"tags":[13],"class_list":["post-573","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-september-october-2014","tag-peer-reviewed","column-features","clinical_topics-orthopedics","clinical_topics-pain_management"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Managing Chronic Pain in Dogs and Cats, Part 2: The Best of the Rest in the Management of Osteoarthritis | Today&#039;s Veterinary Practice<\/title>\n<meta name=\"description\" content=\"Part 2 of a comprehensive look at managing chronic pain in dogs and cats. 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