Analgesia for OA in elderly cat

Re: Analgesia for OA in elderly cat

Rory Bell — Fri, 20 Dec 2013 12:54:41 GMT

Good points there David

I think the caveat on the meloxicam / CRF tolerability should be that the cats in these papers tended to have IIRC, generally mild (a few in IRIS stage 3, most below that) and stable CRF. I was one of the folk who mentioned amantadine for this cat, any my reason for so doing as that it was already on pred and it was not clear whether the pred could be discontinued without ill effect prior to introducing NSAIDs

As a very general point, in most cases if I see a progressive increase in liver enzymes I'd be concerned, even if liver function was normal. By the time parenchymal liver disease had progressed to the point of liver dysfunction, you're usually looking at something thats irreparable due to replacement fibrosis.

cheers!

Re: Analgesia for OA in elderly cat

David Mills — Fri, 20 Dec 2013 01:17:07 GMT

[quote user="Martin Atkinson"] I'd go along with that is more kidney sparing than meloxican.[/quote]

Some thoughts.

- fairly large study (>300 cats) recently showed that in cats with CRF, meloxicam administration for OA had no effect on MST and in some cats actually increased MST. There is no convincing evidence in human medicine that NSAIDs worsen CRF. They can, in some individuals, cause ARF, but this is likely a spurious pharmacogenetic effect. In CRF they are, apparently, very safe, and in cases where inflammatory kidney disease is the cause, beneficial.

See these three excellent papers:

http://www.ncbi.nlm.nih.gov/pubmed/23531076

http://www.ncbi.nlm.nih.gov/pubmed/22821331

http://www.ncbi.nlm.nih.gov/pubmed/21906984

[PM me if you want the full papers]

- liver enzyme rise does not mean catastrophic liver damage. If liver function deteriorates then worry, otherwise, as our human colleagues say 'liver enzymes don't mean shit'. There is no evidence in cats that NSAIDs cause any liver damage whatsoever.

- remember that amantidine, gabapentin and tramadol should be considered only ever useful as adjunct therapy to targeted therapy. Neither are anti-inflamms, neither have dose ranges well (or even nearly well) defined, and the syrups taste absolutely disgusting to cats.

- in terms of joint supplements, and evidence, anecdote has absolutely zero significance. In fact, probably less than zero

Re: Analgesia for OA in elderly cat

Martin Atkinson — Thu, 19 Dec 2013 14:04:11 GMT

[quote user="Anthony Dennison"]If you're looking for an NSAID, Onsior (Robenacoxib) may be a good bet. [/quote] I'd go along with that is more kidney sparing than meloxican. Of other suggestions the morphine based things are worth trying and the fact several have been mentioned shows there are several approaches. Despite my own and other's scepticism, I've found joint supplements have helped my cat a lot, Synoquin being best. Although I've had good success with it in cats with OA (better than dogs actually), I'd be wary of using Cartrophen in an animal with renal failure, I gave it to one dog with renal disease and it made it much worse although fortunately it recovered when we stopped plus it does mention using with caution in animals with hepatic disease in the data sheets and not to use with steroids or NSAIDs..

Re: Analgesia for OA in elderly cat

Anthony Dennison — Thu, 19 Dec 2013 12:55:41 GMT

If you're looking for an NSAID, Onsior (Robenacoxib) may be a good bet. Very tissue specific, only has a plasma half-life of 30 minutes so risks of side effects are lowered.

It is only licensed for 6 days use, but we have spoken to novartis about long term use and they it can be done off license

Re: Analgesia for OA in elderly cat

Michael Woodhouse — Thu, 19 Dec 2013 10:19:41 GMT

[quote user="Emily Herskind Nightingale"](ps.. wondering about the acroynm TEETH.. treat everything except the.. and then cant think what the last bit might be.. any ideas?)[/quote]

I believe it is Tried Everything Else, Try Homeopathy

Re: Analgesia for OA in elderly cat

Emily Nightingale — Thu, 19 Dec 2013 09:34:59 GMT

Brilliant! Thank you all. Just the type of info I needed. vetsurgeon is such a GREAT resource!!

Happy Christmas to you all!

(ps.. wondering about the acroynm TEETH.. treat everything except the.. and then cant think what the last bit might be.. any ideas?)

Re: Analgesia for OA in elderly cat

Dagmar Steele — Thu, 19 Dec 2013 09:30:01 GMT

+1 for Gabapentin or Amantadine. Be warned that the may get sleepy on gabapentin at the beginning, but this should resolve quickly and so far I have never seen any side effects.

Re: Analgesia for OA in elderly cat

Rory Bell — Thu, 19 Dec 2013 09:26:11 GMT

Hi Emily

Its difficult to advise regarding analgesics (or other therapies) without knowing the full details regarding nature and severity of this cat's comorbid conditions. If he's also been under the care of a particular referral centre over this time, then it might be worthwhile having a chat to the clinicians there, simply because they'll be best placed to advise regarding his treatment.

For what its worth, I don't think OA should cause a marked granulocytosis (assuming this is a neutrophilia) unless associated pain is causing severe stress. The prednisolone might contribute to a neutrophilia, particularly if this was a mature neutrophilia unaccompanied by a left shift.

I have used (anecdote alert) amantadine for both dogs and cats with osteoarthritic pain with some success. There is evidence to suggest that its useful for dogs with osteoarthritic pain. It comes in a syrup which can make oral dosing easier in a cat. I'd usually start around 2mg/kg q24hrs and titrate the dose upwards to effect. Little is known about its metabolism, but in people the most common side effects are sedation and occasional GI upset. I've not seen any side effects (so far) in cats where I've used it.

rory

Re: Analgesia for OA in elderly cat

Hannah Wynne Richards — Thu, 19 Dec 2013 07:45:18 GMT

Forgot in my 1st post to say add joint supplements.

Wynne

Re: Analgesia for OA in elderly cat

Liz w — Thu, 19 Dec 2013 07:43:34 GMT

I was also going to suggest acupuncture.

Re: Analgesia for OA in elderly cat

Rob Loxley — Wed, 18 Dec 2013 23:58:51 GMT

[quote user="Emily Herskind Nightingale"] liver supplements[/quote]

If you're not already on SAMe, there's some decent human evidence for efficacy in osteoarthritis to levels as good as NSAIDs and Coxibs

Re: Analgesia for OA in elderly cat

Laurence Webb — Wed, 18 Dec 2013 23:39:45 GMT

Personally I'd go for something safe for the kidneys as my main priority - sublingual buprenorphine would be fine for the kidneys an, at low doses, not to bad for the liver although I'd ideally do some bloods before and after starting to make sure I'm not upsetting the apple cart.. My second choice would be Tramadol, either get some from Summit or make up a suspension yourself using OraPlus from Fagron

If necessary I'd use an NSAID. Theoretically a coxib would be better than meloxicam but I have heard well respected vets say that they don't really think there is a massive difference in safety between different NSAIDs from a renal point of view. Giving NSAIDs to a cat predisposed to dehydration (even if subclinical) is more of a worry. Of course NSAIDs can also be hepatotoxic and you'd either need to reduce steroids or add in an H2 antagonist or a proton pump inhibitor to avoid GI ulceration.

My personal opinion (based on gut feeling and a wife with rheumatoid arthritis and chronic pain syndrome) is that gabapentin on its own isn't great for arthritis although it can work a treat for neurological pain. Side effects should not be underestimated either.

Neutraceuticals, acupuncture etc can also be tried but I remain uncertain if they have anything more than a placebo effect, not that would advise against trying them.

For the acronym lovers, if all else fails, TEETH.

Re: Analgesia for OA in elderly cat

Stephen Courtney — Wed, 18 Dec 2013 23:20:43 GMT

Don't take the cat of preds and start nsaids - you will upset the apple cart and the liver is already unhappy. Increasing the pred dose is not a bad idea - doesn't need to be by much either.

Another option is gabapentin, there is a liquid formulation available on special order - and we have had some good results with that. Summit Veterinary will make 10mg tramadol tablets, but they don't seem to agree with most cats, certainly in my hands.

I also like seraquin or yumove, and most cats will take it ( seraquin seems to be more popular)

I'd also second the B12 idea, it can really perk them up. I usually give half a cc weekly for 4 weeks, then monthly if the owner thinks it has helped. most of these cats come in at least monthly anyway. It's a water-soluble vit so can't overdose, but it can be stingy - i use a green needle and make sure it is properly subcut, this minimises the sting - but can be tricky in a skinny old kidney cat.

Finally, have you checked the BP? Is there proteinuria? I've started using Semintra lately and had some encouraging feedback, owners definitely perceive a lift, and it drops the BP more than fortekor will, so can avoid amlodipine with the mildly hypertensives.

My flock of knackered old regulars are actually my most rewarding patients, you get to know them and their owners well, and they are always the nicest folk who will go to this much trouble for their cats. Make up for a lot of aggro....

Re: Analgesia for OA in elderly cat

Hannah Wynne Richards — Wed, 18 Dec 2013 23:11:04 GMT

Despite haematological concerns I'd be tempted to add cartrophen toregime- initial course once weekly for 4 weeks then do once a month (off label - but works).Alsoadd fortekor for kidneys and monthly b12 injections for both liver and kidneys Good luck The juggling act with these "golden oldies" can be really challenging- at least this owner will let you treat

Wynne

Re: Analgesia for OA in elderly cat

Mark Hedberg — Wed, 18 Dec 2013 22:47:25 GMT

Also, when doing a higher dose, do an increased interval between doses; i've spoken to a few referral vets who say that this manages side effects better. (Your mileage may of course vary.)

Re: Analgesia for OA in elderly cat

Suzanne Kelly — Wed, 18 Dec 2013 22:44:32 GMT

Acupuncture would be well worth a go here. Cats are generally very tolerant of being needled and some do very well. I've used metacam in CRF cases and their renal parameters have not worsened so that's worth a chat with the owners. I've tried gabapentin and tramadol on some old cats but not had a huge response. Apparently amitryptiline is good too but I haven't tried it on cats. A human friend was on it though and she said it was brilliant :)

Re: Analgesia for OA in elderly cat

Mark Holmes — Wed, 18 Dec 2013 22:07:44 GMT

Personally I would just increase his pred. It might not suit his renal disease but then what would? It would make him happy and mobile.