Advanced DJD

Re: Advanced DJD

The SkepVet — Sun, 26 Apr 2009 12:59:36 GMT

I was attempting a little humor myself when I said I was an American and English was not my first language. Maybe we should stop trying to be comedians and get back to the discussion of advanced djd that is so common in our patients.

art malernee dvm

Re: Advanced DJD

Julian Earl — Sat, 25 Apr 2009 22:08:07 GMT

Oh. I thought "smilies" were a recognised attempt to express humour/comments of a less-than-serious nature etc., and that they were widely recognised on the internet. Obviously not. Ah well, apologies if the comment was misunderstood - I didn't expect you to take offence.

Re: Advanced DJD

The SkepVet — Sat, 25 Apr 2009 16:07:45 GMT

>>>Btw, it's "studies".

I am an American so English is not my first language.

I dont think pointing out errors in grammer advaces the points

you are trying to make and pretty much relegates you to my "do not bother

trying to discuss this topic with this person any more" category on this

list. You will find that even the most literate / erudite among the

regulars here occasionally mistype something and/or miss other minor errors

in proofing / editing. This is, after all, a relatively informal forum.

Calling such gaffes to their attention, outside of a genuine need to

clarify, is unbecoming and makes you look like a pompous ass. Which I will

give you the benefit of the doubt and assume you're not.

art malernee dvm

Re: Advanced DJD

Julian Earl — Sat, 25 Apr 2009 14:11:45 GMT

[quote user="The SkepVet"]

<<<(After all, we thought NSAIDs worked... ) >>>

study's prove they do short term [/quote]

I would have a problem believing a study that suggested nsaids do not work long-term - try stopping treatment in a dog that has been on them for years. It's not pretty.

Btw, it's "studies".

[quote user="The SkepVet"]

<<<Well actually, a rheumatologist tells me that it is shown to work in human hips and knees, but not hands or wrists - so how the hell can we extrapolate across species if it is inconsistent in one single species' joints?>>>>

does he sell glucosamine? how many years ago did he say that? [/quote]

Nope. How many years ago? About 1/4 of a year ago.

[quote user="The SkepVet"]

>>>>. No-one disputes that cruciate dogs develop OA eventually no matter what, but when those dogs are walking relatively soundly after a few days or weeks, you cannot tell me that the surgery is not preferable to the early development of arthritis.>>>>>

Science is what we have learned about how to keep from fooling ourselves.
Faith is a highly effective substitute for data in human
decision-making processes. Questions about common sense cannot be answered by looking to the
fields of science (respectability) or ethics (shame).
It would be better to look for answers in the field of
economics.[/quote]

It is way too cynical to suggest that observing a dog walking significantly better a few days after surgery is merely influenced by economics. Although I haven't costed it out, there is probably not a huge difference in the profit from the extra years of nsaids compared to, say, cruciate surgery.

[quote user="The SkepVet"]

I would look into elbow replacement trials first if it was my patient.

[/quote]

That's not always possible though.

PS. If this post appears twice, it's because it didn't appear the first time I sent it. Is there a time lag?

Re: Advanced DJD

The SkepVet — Sat, 25 Apr 2009 12:40:53 GMT

<<This is a depressing thread. >>>

science can appear impenetrable, and the explanations obtuse.
It's not necessarily comforting, either, what with it
being inherently dismissive of bad ideas. No
compassion there. That's life, however.

<<<NSAIDs don't work long-term, and run the risk of killing the dog in the meantime; surgery is a sham; surgery doesn't work as well as medication - which doesn't work long-term, remember? So we resort to unlicensed human drugs and acupuncture, both of which could work, but we don't really know, do we? >>>

A successful medical procedure should be consistently effective in a large majority of trials, and be repeatable in the hands of most therapists. Acupuncture does not satisfy these basic criteria.

The American Medical Association's Council on Scientific Affairs stated in a 1981 report that since acupuncture is an experimental procedure, it should be performed only in research settings by licensed physicians or others under their direct supervision. The report urged state medical societies to seek appropriate laws to restrict the performance of acupuncture to research settings

<<<(After all, we thought NSAIDs worked... ) >>>

study's prove they do short term

<<<Not only that, but glucosamine is unproven by independent trials, although it works in humans, doesn't it? >>>>

I doubt it. Although many other studies have claimed positive results, the best-designed
ones are negative, which usually means that negative evidence will
eventually prevail. [Barrett S. Glucosamine for arthritis: Benefit is
unlikely. Quackwatch, Sept 30, 2008]
http://www.quackwatch.org/01QuackeryRelatedTopics/DSH/glucosamine.html

does he sell glucosamine? how many years ago did he say that? the good studys that proved it worked done at the start of usage years ago could not be repeated by independent researchers. Stuff occuring like that is why the FDA usually requires two good studys. Millions of dollars were spent by govenments just testing glucosamine and i suspect billions spent buying it. Of course if you sold glucosamine like i did in the old days there was some benefit to your check book.

<<No, I think many of the posts here have given an unduly black picture of OA treatment options; they clearly do work, just not forever. Sadly, that's what euthanasia is for.>>>>

I would look into elbow replacement trials first if it was my patient.

art malernee dvm

Re: Advanced DJD

Julian Earl — Fri, 24 Apr 2009 22:44:46 GMT

This is a depressing thread.

NSAIDs don't work long-term, and run the risk of killing the dog in the meantime; surgery is a sham; surgery doesn't work as well as medication - which doesn't work long-term, remember? So we resort to unlicensed human drugs and acupuncture, both of which could work, but we don't really know, do we? (After all, we thought NSAIDs worked... )

Not only that, but glucosamine is unproven by independent trials, although it works in humans, doesn't it? Well actually, a rheumatologist tells me that it is shown to work in human hips and knees, but not hands or wrists - so how the hell can we extrapolate across species if it is inconsistent in one single species' joints?

Someone asked about intra-articular cortisone: my first boss used to inject Depo-med into dog stifles. They seemed to walk better, for a while , but they certainly had BBC in the joints i.e. Bean Bag Crepitus.

But hang on a mo'.

NSAIDs don't work long-term? Are we certain that it isn't just natural progression of the pathology out-weighing the effects? (Maybe not helped by cartilage deterioration being aided and abetted by the NSAIDs?) Is it not better to delay the development of pain even if it returns eventually? And I'm not convinced by this "doesn't work long-term" argument. Try stopping a dog for a week when it has chronic and severe OA, because we can all see them deteriorate rapidly if/when owners do this.

Are there any actual figures for dogs killed by non-steroidals? Should we be giving antacids routinely with NSAIDs as they do in people? Blood testing the liver regularly - as they do with people? Probably so.

And surgery. No-one disputes that cruciate dogs develop OA eventually no matter what, but when those dogs are walking relatively soundly after a few days or weeks, you cannot tell me that the surgery is not preferable to the early development of arthritis.

No, I think many of the posts here have given an unduly black picture of OA treatment options; they clearly do work, just not forever. Sadly, that's what euthanasia is for.

Re: Advanced DJD

toby travis — Wed, 22 Apr 2009 15:55:39 GMT

in response to the original question.......

in our practice we use hydrotherapy which works well for weight reduction and also for building up muscles if there is weakness or atrophy but some of the more advanced patients dont olerate it well so it's certainly no quick fix.

We also use acupuncture to which some patients respond really well but in my experience this is fairly short-lived and many clients will only go for it once things are really advanced.

I'm always willing to try switching to previcox and have no particular s/effects but I know that in my wife's practice they switched lots of dogs onto it (from Rimadyl) and have had 2 dogs with gastric bleeds and now no longer use it - has anyone else had this experience - obviously, being more COX-2 selective this isn't meant to happen!

Jd hasn't been a big seller - we tried it quite a bit with their BOGOF offer (including to my parents in law) but not many have kept coming.

In end stage cases we do use pentazocine up to every 4hours and this usually gives an extra 2-6months before the owner decides that the dog really has had enough.

Re: Advanced DJD

The SkepVet — Wed, 22 Apr 2009 13:40:28 GMT

HillsJ/D is brilliant. Our practice ran a trial (double blind with placebo) and results were astonishing! Significant improvement was seen in most dogs with only dietary intervention. >>>

Were the "brilliant","astonishing" and "significant" results defined in the study with data?

Did someone register this trial before you started it? If so can you give us a Internet link so we can read the protocol of the trial? My concern about trials started before they are registered is that someone can do 20 trials and when one out of the 20 show efficacy just by random chance they will publish just the positive trial and put the other 19 trials in a drawer some where. "Drawer effect" Our best example that I can think of right now in vet medicine is a study has been promoted to be sitting in a drawer in Wisconsin done by the immunologist that teaches at the vet school showing kennel cough vaccine does not work unless it has parainfluenza to it. The study has not been registered or published as far as i can determine just promoted on the internet finished with negative results. We know the bacteria serovars of present day kennel cough are not in our vaccines today which could explain the negative results. If someone does the study twenty times and one study shows positive results just by chance they can publish that one and we would not even know about the 19 negative others.

art malernee dvm

Re: Advanced DJD

The SkepVet — Wed, 22 Apr 2009 12:51:46 GMT

Not a term familiar to me. Could you be more specific?>>>

none of these so called "clean out" knee surgerys have been shown to work so some doctors will remove the torn cruciates some remove the torn meniscus some flush the joint, some shave shaving rough areas of cartilage from the joint and then flushing it. Our "best" randomized controlled knee surgery trials except for patella surgery show after five years radiographically the torn cruciate ones handled surgically do worse than the ones handled medically.

see

A Knee Surgery for Arthritis Is Called Sham

nyt aug 24 2002

By GINA KOLATA

popular operation for arthritis of the knee worked no better than a sham procedure in which patients were sedated while surgeons pretended to operate, researchers are reporting today.

The operation — arthroscopic surgery for the pain and stiffness caused by osteoarthritis — is done on at least 225,000 middle-age and older Americans each year at a cost of more than a billion dollars to Medicare, the Department of Veterans Affairs and private insurers.

It involves making three small incisions in the knee; inserting an arthroscope, a thin instrument that allows surgeons to see the joint; and then flushing debris from the knee or shaving rough areas of cartilage from the joint and then flushing it.

In the study, to be published today in The New England Journal of Medicine, investigators at the Houston Veterans Affairs Medical Center and Baylor College of Medicine report that while patients often said they felt better after the surgery, their improvement was just wishful thinking. Tests of knee functions revealed that the operation had not helped, and those who got the placebo surgery reported feeling just as good as those who had had the real operation.

"Here we are doing all this surgery on people and it's all a sham," said Dr. Baruch Brody, an ethicist at Baylor who helped design the study.
*****

Numerous studies with follow-up periods of 5 years or longer do not support the theory that surgical treatment is the best treatment for restoring knee function. In fact, in 1994 a study examining scintigraphic and radiographic changes in knees managed surgically versus non-surgically found that 5 years after the injury the reconstructed knees showed markedly greater degeneration than those treated non-surgically.

1: Acta Orthop Scand. 1994 Dec;65(6):605-9. Related Articles, Links

Knee ligament injury, surgery and osteoarthrosis. Truth or consequences?

Lohmander LS, Roos H.

Department of Orthopedics, University Hospital, Lund, Sweden.

We reviewed reports that describe development of osteoarthrosis of the knee after anterior cruciate ligament or meniscus injury. The occurrence of posttraumatic osteoarthrosis varied considerably from one report to another. The literature does not lend support to the efficacy of cruciate ligament repair or reconstruction in retarding the progression of osteoarthrosis after knee injury. We encourage prospective, controlled, randomized and masked studies that aim to evaluate the utility of ligament reconstruction, meniscus suture or meniscus transplantation for preventing posttraumatic osteoarthrosis.

Re: Advanced DJD

Evelyn Barbour-Hill — Wed, 22 Apr 2009 01:11:00 GMT

[quote user="The SkepVet"]clean out surgery[/quote]

Not a term familiar to me. Could you be more specific?

Re: Advanced DJD

Emily Nightingale — Tue, 21 Apr 2009 21:12:26 GMT

Hello! Sorry to hear about your case. Sad he/she is so young. I have tried Pentazocine/ Talwin 50mg tablets (dose is in the BSAVA formulary = 2-6mg/kg p.o every 3-4 hours depending on pain assessment) on an elderly GSD with good results (everything else failed: Previcox (which I love and recomment thoroughly although the blister packs are fiddly), Glycoflex (glucosamine+chondroitin), Cartrophen etc.

Gabapentin can also be used (primary function is adjunct in managing some epileptics) but can cause some ataxia. I would probably only use this is nothing else works.

Tramadol is also something I know they use in referral centres but I have no experience of it 1st hand.

I wonder if intra-articular injections of cortisone may help if your patient is really stuck?? I know they advocate them in people. ie. Depomedrone in joints? anyone else any experience of this?

Other things to think about are: hydrotherapy, acupuncture (we have a vet trained in acupuncture who uses our premises to practice on dogs mostly and although I am mega sceptical about most things, this really seems to improve comfort and mobility all round so guess it's worth a try?) HillsJ/D is brilliant. Our practice ran a trial (double blind with placebo) and results were astonishing! Significant improvement was seen in most dogs with only dietary intervention.

Hope that helps.

Emily

Re: Advanced DJD

The SkepVet — Mon, 20 Apr 2009 13:22:55 GMT

If it was my clients dog and I was not happy with rotation of pain killers, physical therapy, wt loss I would let someone who sees more elbow cases then me take a look at the case and ask what they would do if it was their dog and what study's if any supported any additional care. I would also take a look at the elbow surgery data in humans to see what the standard of elbow care is there and what if any randomized controlled trials we have for elbow surgery in two and four legged patients. Study's show numbers count not numbers of speciality degrees but in my case the boarded surgeon, older then me (60) that does a lot of gray hound work in south Florida would be my first choice. He does hip and knee replacements and I bet he has done a lot more elbow surgery than i have. I have done clean out surgery in elbows through the years but I would now want to take a look at the data to see if there were any long term benefits for doing clean out since our best RCT show it does not work in knees. Studys show surgery is one of our strongest placebos. The knee surgery clean out study was ranomized by sham surgery.

art malernee dvm

Re: Advanced DJD

Mark Frost — Sun, 19 Apr 2009 15:12:15 GMT

Systematic review of the management of canine osteoarthritis.

Sanderson RO, Beata C, Flipo RM, Genevois JP, Macias C, Tacke S, Vezzoni A, Innes JF.

Vet Rec. 2009 Apr 4;164(14):418-24.

Is a recent evidence based review of options - however it focuses on efficacy rather than safety.

Re: Advanced DJD

Mark Frost — Sun, 19 Apr 2009 15:02:55 GMT

[quote user="The SkepVet"]

If you have a good study that concludes a longer less painfull life using these drugs continually long term

[/quote]

With most of these patients I believe pain is their main concern, not dragging life out as long as possible regardless of welfare.

Re: Advanced DJD

Evelyn Barbour-Hill — Sun, 19 Apr 2009 14:49:18 GMT

Your points are all taken SkepVet. But what do you suggest the original poster does for her suffering patient, right now?

Re: Advanced DJD

The SkepVet — Sun, 19 Apr 2009 13:08:02 GMT

Putting a dog or cat on long term NAIDS will inevitably have conseqences. But, a long painful life vs shorter life in less pain? >>>

In my opinion the "best" Studies I have do not support "less pain" giving these drugs continually long term. You can make the "DNA argument" if you want ( group of patients in study's I have do not match DNA of patients you treat) but I think doctors need to treat patients using treatments where good randomized controlled trial have shown to help. If you have a good study that concludes a longer less painfull life using these drugs continually long term please post it. Any four legged animal study as long as it was properly randomized and critically reviewed.

art malernee dvm

Re: Advanced DJD

Mark Frost — Sun, 19 Apr 2009 10:25:27 GMT

Exactly.. as mentioned before dogs are not small humans - and quality of life is more important than quantity. It's still a balance, but one that has been lost to a degree in human medicine. Informed use of any drug is important, and owners need to be aware of possible problems, but most rational owners are happy to take a (potential) risk to improve their pet's quality of life. Of course a balanced approach is always the best, involving multimodal treatments to reduce overall risk, and exercise/hydro/weight loss/nutros all play a vital part.

Re: Advanced DJD

Gillian Mostyn — Sat, 18 Apr 2009 21:48:05 GMT

[quote user="The SkepVet"]First let me say it can be difficult for us to know when treating osteoarthritis if NSAID's drugs are causing more harm than good.
[/quote]

Putting a dog or cat on long term NAIDS will inevitably have conseqences. But, a long painful life vs shorter life in less pain? I'll take my chances with NSAIDS (+other drugs as required, obviously.)

Re: Advanced DJD

Gillian Mostyn — Sat, 18 Apr 2009 21:44:59 GMT

[quote user="liza oparaocha"]OTHERS TO PERVICOX.[/quote]

Made me laugh. And laugh. And laugh. Thanks!! I'll never see previcox in the same way ever again!

Re: Advanced DJD

The SkepVet — Sat, 18 Apr 2009 12:13:24 GMT

In a message dated 4/17/2009 12:17:29 P.M. Eastern Daylight Time, support@vetsurgeon.org writes:

Pain versus NSAID? NSAID every time!! >>>>

First let me say it can be difficult for us to know when treating osteoarthritis if NSAID's drugs are causing more harm than good.

http://evidencebasedvet.com/forum/viewtopic.php?t=123

Warning Concerning NSAIDs Arthritis Medications
All Non Steroid Anti-inflammatory Drugs Can Kill

Rimadyl, Etogesic, Dermaxx, Metacam and Zubrin all belong to a class of drugs called non-steroid anti-inflammatory Drugs. The action of these drugs is similar to aspirin, in that they inhibit inflammatory substances called prostaglandins (PGEs), which cause pain, inflammation, and fever. These drugs can be safer than aspirin for some patients but not all patients because they are more selective for the harmful prostaglandins, COX 2 PGEs, and spare certain prostaglandins, COX 1 PGEs, which are essential to protect the G.I. tract, kidneys and other organs.
(This may be an over-simplification)

http://evidencebasedvet.com/forum/viewtopic.php?t=102

There is risk of liver failure with all NSAIDs. Liver necrosis in Labrador Retrievers caused by Rimadyl have been reported in the largest numbers. The manufacturer of Rimadyl alleges these reactions are attributed to the facts that Labs are the most common Breed, and Rimadyl was the first and most commonly prescribed NSAID. Rimadyl may be getting a bad rap but its hard to tell right now. Until more information is available, I prefers to exercise caution, and not to use this drug on most arthritic patients. All NSAIDs have the potential to cause liver failure. Blood tests before administration of NSAIDs cannot predict this liver reaction. The risk of this reaction reported is small. (1:10,000 with Rimadyl)

(This may be an over-simplification) since most cases of harmfull reactions are not reported. Or at least not before the sucessful lawsuit cases.

http://evidencebasedvet.com/forum/viewtopic.php?t=194

art malernee dvm

Re: Advanced DJD

Evelyn Barbour-Hill — Sat, 18 Apr 2009 00:15:57 GMT

I apologise, that was very rude of me.

Re: Advanced DJD

Evelyn Barbour-Hill — Fri, 17 Apr 2009 23:58:42 GMT

[quote user="liza oparaocha"]OTHERS TO PERVICOX[/quote]

Sorry, couldn't resist it.

Re: Advanced DJD

liza oparaocha — Fri, 17 Apr 2009 18:00:27 GMT

hi,I WOULD BE WORRIED ABOUT HEPATIC/RENAL TOXICITY WITH LONGTERM USE OF RIMADYL.

iF SURGERY IS NOT AN OPTION,THEN I SUGGEST ADDING TRAMADOL TO YOUR PAIN MEDICATION AND POSSIBLY H2 ANTAGONISTS,E.G MISOPROSTOL AND OMEPRAZOLE AND POSIBLE WEIGHT LOSE IF NEEDED.

I FIND THAT SOME DOGS RESPOND TO RIMIDAYL,OTHERS TO PERVICOX.

THANKS LIZA

Re: Advanced DJD

Anonymous — Fri, 17 Apr 2009 17:15:45 GMT

humans have a far larger neural component of pain and a far greater ability to consciously modulate pain. Dogs are not humans. Pain versus NSAID? NSAID every time!!

Re: Advanced DJD

The SkepVet — Fri, 17 Apr 2009 15:07:24 GMT

human studies of these type drugs for osteoarthritis Conclude NSAIDs can reduce short term pain in osteoarthritis slightly better than placebo, but the current analysis does not support long term use of NSAIDs.
see

Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2
inhibitors, in osteoarthritic knee pain: meta-analysis of randomised
placebo controlled trials -- Bjordal et al., 10.1136/bmj.38273.626655.63
-- BMJ
Address:http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38273.626655.63v1?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&andorexacttitle=and&andorexacttitleabs=and&fulltext=NSAIDs&andorexactfulltext=and&searchid=1101513454613_21459&stored_search=&FIRSTINDEX=30&sortspec=relevance&resourcetype=1,2,3,4
Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2
inhibitors, in osteoarthritic knee pain: meta-analysis of randomised
placebo controlled trials
Jan Magnus Bjordal 1, Anne Elisabeth Ljunggren 1, Atle Klovning 1, Lars
Slørdal 2
1 Department of Public Health and Primary Health Care, University of
Bergen, 5018 Bergen, Norway
2 Department of Laboratory Medicine, Children's and Women's Health,
Norwegian University of Science and Technology, 7489 Trondheim, Norway
Objective To estimate the analgesic efficacy of non-steroidal
anti-inflammatory drugs (NSAIDs), including selective cyclo-oxygenase-2
inhibitors (coxibs), in patients with osteoarthritis of the knee.
Design Systematic review and meta-analysis of randomised placebo
controlled trials.
Studies reviewed 23 trials including 10 845 patients, median age of 62.5
years. 7807 patients received adequate doses of NSAIDs and 3038 received
placebo. The mean weighted baseline pain score was 64.2 mm on 100 mm
visual analogue scale (VAS), and average duration of symptoms was 8.2
years.
Main outcome measure Change in overall intensity of pain.
Results Methodological quality of trials was acceptable, but 13 trials
excluded patients before randomisation if they did not respond to
NSAIDs. One trial provided long term data for pain that showed no
significant effect of NSAIDs compared with placebo at one to four years.
The pooled difference for pain on visual analogue scale in all included
trials was 10.1 mm (95% confidence interval 7.4 to 12. or 15.6% better
than placebo after 2-13 weeks. The results were heterogeneous, and the
effect size for pain reduction was 0.32 (0.24 to 0.39) in a random
effects model. In 10 trials that did not exclude non-responders to NSAID
treatment the results were homogeneous, with an effect size for pain
reduction of 0.23 (0.15 to 0.31).
Conclusion NSAIDs can reduce short term pain in osteoarthritis of the
knee slightly better than placebo, but the current analysis does not
support long term use of NSAIDs for this condition. As serious adverse
effects are associated with oral NSAIDs, only limited use can be
recommended.
© 2004 BMJ Publishing Group Ltd