Long term metacam dose

RE: Long term metacam dose

Kate Richardson — Thu, 06 Apr 2017 12:49:32 GMT

[quote user="Eilidh Corr"] I just ask them to give a week of the full dose once every couple of months because that's a less subjective way of determining whether actually they need the full dose.[/quote]

I do similar, sometimes it is hard to know if they are as good on a lower dose or not, so periodically giving them a full dose and asking the owners to see if they think there is an improvement can work quite well, if they notice no change, then back to the lower dose. Generally these animals are better on a low dose than they were without treatment, and again as time goes on, they may gradually get worse which may not get noticed as quickly, but if there is a sudden improvement back on the full dose it will convince them that its necessary

RE: Long term metacam dose

Eilidh Corr — Wed, 05 Apr 2017 22:19:10 GMT

I agree that long term regular dosing at the full dosage is probably optimal but many clients are convinced their pets do really well on reduced dosages. I just ask them to give a week of the full dose once every couple of months because that's a less subjective way of determining whether actually they need the full dose.

As for bloods, it's the same as any test - first ask yourself what you're going to do with the information. Yes, there are cases where we can use alternatives and modify dosages, but in general these animals are on NSAIDs because they're in pain. I'm not about to withdraw that medication based on a blood test unless I can confidently maintain QOL.

RE: Long term metacam dose

Kathryn Burton — Wed, 05 Apr 2017 19:36:50 GMT

I usually check a urine sample rather than doing blood work unless I have any clinical concerns.

RE: Long term metacam dose

Gillian Mostyn — Wed, 05 Apr 2017 14:31:25 GMT

[quote user="Martin Atkinson"]This is good practice, not cash extraction or 'gold standard'. I recommend a blood test before they go on long term therapy to make sure there aren't any issues we're going to exacerbate. I may not insist on a blood test every 3 months if OK clinically but I would at least annually.[/quote]

Absolutely - but I do get bemused when some practices make it obligatory! I recommend blood tests as necessary, giving my reasons, but will happily accept an owner's decision to decline them. I do, however, insist on check-ups every 3-4 months.

My dog was on NSAIDS for the last couple of years of her life, and had bloods annually.

RE: Long term metacam dose

Martin Atkinson — Wed, 05 Apr 2017 12:21:20 GMT

[quote user="robloxley"]

I suspect it is a cash extraction exercise, but will certainly be sold to the client as 'gold standard care'.

We have clients who taper the dose, but I do wonder how many of them are good at picking up subtle levels of pain breaking through?

[/quote]Equally, I wonder how many are good at picking up subtle levels of side effects breaking through!

This is good practice, not cash extraction or 'gold standard'. I recommend a blood test before they go on long term therapy to make sure there aren't any issues we're going to exacerbate. I may not insist on a blood test every 3 months if OK clinically but I would at least annually.

RE: Long term metacam dose

Thomas Johnson — Wed, 05 Apr 2017 09:19:31 GMT

[quote user="Neil Wheadon"]

[quote user="Thomas Johnson"]I agree that it does seem to be getting a bit obsessive, and I can't remember the last time I picked up a significant problem in a dog when I've blood sampled it for NSAID monitoring and there was no clinical cause for concern. We see them every 6 months for a check-up, but I often only blood sample them once a year.[/quote]

Interesting

Daft question, but anything wrong with looking at specific gravities on an early morning urine sample. Cheap and cheerful

[/quote]

I don't see why not. I've seen a couple of dogs recently with very mild elevations in creatinine on monitoring bloods and have then checked the SG on an early morning urine sample, they were both over 1.035 so I've assumed the kidneys are okay and have continue with Metacam.

RE: Long term metacam dose

Neil Wheadon — Tue, 04 Apr 2017 23:24:39 GMT

Interesting

Daft question, but anything wrong with looking at specific gravities on an early morning urine sample. Cheap and cheerful

Neil

RE: Long term metacam dose

Lucy Fleming — Tue, 04 Apr 2017 21:53:01 GMT

I do encourage clients to reduce the dose a little after long term use if they are on it daily. If chronic pain/ wind up etc has been controlled then many do seem to get the same analgesic effect from a lower dose. I do find some owners reduce it down to silly levels - 25% of the full dose sometimes!

Similarly, in most cases I encourage daily dosing, as I suspect it is more useful in dogs with chronic issues. In some, seen at the earlier stages I will talk about dosing when needed (such as the day after a long walk etc), but I tend to use that advice more for using additional analgesia (paracetamol, for example) to manage breakthrough pain.

RE: Long term metacam dose

Rob Loxley — Tue, 04 Apr 2017 19:34:26 GMT

[quote user="Clive Ansell"]There does seem to be an obsession at the moment in many practices of blood testing every patient on long term nsaid's, whether that is based on clinical need, fear of litigation or a cash extraction exercise I don't know[/quote]

I suspect it is a cash extraction exercise, but will certainly be sold to the client as 'gold standard care'.

We have clients who taper the dose, but I do wonder how many of them are good at picking up subtle levels of pain breaking through?

RE: Long term metacam dose

Thomas Johnson — Tue, 04 Apr 2017 17:55:15 GMT

[quote user="Clive Ansell"]

There does seem to be an obsession at the moment in many practices of blood testing every patient on long term nsaid's, whether that is based on clinical need, fear of litigation or a cash extraction exercise I don't know.

Data sheet states "Response to long-term therapy should be monitored at regular intervals by a veterinary surgeon"

[/quote]

I agree that it does seem to be getting a bit obsessive, and I can't remember the last time I picked up a significant problem in a dog when I've blood sampled it for NSAID monitoring and there was no clinical cause for concern. We see them every 6 months for a check-up, but I often only blood sample them once a year.

RE: Long term metacam dose

Clive Ansell — Tue, 04 Apr 2017 16:58:09 GMT

[quote user="Martin Atkinson"][quote user="Clive Ansell"]I am happy to continue prescribing without regular blood tests, on the basis that the client is informed of and aware of the risks and side effects, and that bloods have been offered and declined.[/quote]Happy is probably not the word, I am prepared to do the same but I do insist on a clinical examination.[/quote]

Of course, I would want to re examine every 3 to 6 months depending up on the case and practice policy regarding rechecks, then may or may not recommend bloods based on findings of the exam.

Data sheet states "Response to long-term therapy should be monitored at regular intervals by a veterinary surgeon"

I did a locum fairly recently where if a NSAID was prescribed, a window appeared asking if the client had been advised of a 3 monthly blood test, a box had to be ticked yes or no before being allowed to proceed. Felt a bit like big brother style management were watching ones every move, or every tick.

RE: Long term metacam dose

Stephanie Wellings — Tue, 04 Apr 2017 14:54:17 GMT

I advise to start on the full dose for body weight unless there's a reason (i.e renal cats) and mobility score after 2-4 weeks (sometimes longer - giving enough time for the other things such as weight loss, physio etc to 'kick in'). If all seems fine I tell them to reduce the dose by 25%, and mobility score the animal after a week or two, and explain that this is how we find the 'right' dose for the animal (if I think this is going to go over the owners' head, I just stick at full dose). I also try to pre empt the owners that try to reduce the dose excessively or only give it once in a blue moon because if it needs it, it needs a therapeutic dose.

RE: Long term metacam dose

Robin Grimmer — Tue, 04 Apr 2017 13:52:38 GMT

All nsaids have a fixed dose apart from carprofen I believe (2 or 4 mg/kg) I generally prefer tablets like previCox or onsoir as it stops owners messing around with the dose. I think with metacam too many owners reduce the dosage because they think drugs are bad, maybe cost saving etc.

RE: Long term metacam dose

Martin Atkinson — Tue, 04 Apr 2017 13:49:36 GMT

[quote user="Clive Ansell"]I am happy to continue prescribing without regular blood tests, on the basis that the client is informed of and aware of the risks and side effects, and that bloods have been offered and declined.[/quote]Happy is probably not the word, I am prepared to do the same but I do insist on a clinical examination.

RE: Long term metacam dose

Clive Ansell — Tue, 04 Apr 2017 13:41:03 GMT

I've seen a second opinion this morning; a 5.0 Kg, 15 year old cat with bilateral hip osteoarthritis, diagnosed with radiography, which is being well maintained on monthly Cartrophen injections and a low, 2.0kg, daily dose of Metacam. Cat is otherwise healthy, but the owners have objected to having the cat sedated for bloods every 3 months on the basis that the cat needs the medication anyway, regardless of blood results.

I am happy to continue prescribing without regular blood tests, on the basis that the client is informed of and aware of the risks and side effects, and that bloods have been offered and declined.

RE: Long term metacam dose

Clive Ansell — Tue, 04 Apr 2017 13:31:56 GMT

[quote user="Bob Russell"]

Conclusion and Clinical Relevance

Dose reduction is a less effective means of pain control compared with maintained dosing. However, NSAID dose reduction with maintained efficacy is possible, but success appears to be individual dog dependent.

[/quote]

That doesn't tell us anymore than common sense does. Some patients will cope with a dose reduction, and some will not.

Depends on the client too; I will discuss with a sensible client the possibility of trying to reduce the dose as long as the clinical effect is the same, whereas others it is just a non starter because they are too stupid, or not interested.

From my own personal use of nsaid's for a soft tissue shoulder injury, I found 200mg Ibuprofen bid to be fully effective and keep me pain free, where the GP had advised 800mg tid (2400mg/day!)

RE: Long term metacam dose

Martin Atkinson — Tue, 04 Apr 2017 12:57:18 GMT

1) I dose once daily 1mg/kg.

2) Some clients will try to reduce the dose and if it is effective, why not?

3) Use continually to avoid hyperaesthesia/allodynia in dogs but as required in cats as the risk of side effects is greater. This was advised by the speaker at the last seminar on anaesthesia/analgesia I went on.

4) Insist they come back for a check-up at least every 3 months and advise a blood test to check for renal function/CBC.

RE: Long term metacam dose

Bob Russell — Tue, 04 Apr 2017 12:43:17 GMT

Conclusion and Clinical Relevance

RE: Long term metacam dose

Neil Wheadon — Tue, 04 Apr 2017 12:39:43 GMT

Can you pop a brief synopsis on here, as many papers quoted here aren't open access

Thanks, interesting stuff

Neil

RE: Long term metacam dose

Kathryn Burton — Tue, 04 Apr 2017 12:16:33 GMT

Wernham BGJ, Trumpatori B, Hash J, Lipsett J, Davidson G, Wackerow P, Thomson A, Lascelles BDX (2011). Dose reduction of meloxicam in dogs with osteoarthritis-associated pain and impaired mobility. Journal of Veterinary Internal Medicine 25:1298-1305

RE: Long term metacam dose

Michael Woodhouse — Tue, 04 Apr 2017 10:21:49 GMT

We used to reduce - now keep dog on 'the' dose. Add in other drugs as required

http://bestbetsforvets.org/bet/335

RE: Long term metacam dose

Bob Russell — Tue, 04 Apr 2017 10:10:38 GMT

Advice from the dim and distant past was to stick to the full dose for 90 days then reduce slowly to find the minimum dose required to keep the owner and patient happy.

Not sure what science this is based upon but it was the Metacam reps comments (when they were allowed to make comments!).

I still mention this suggestion from time to time and it still seems to work for many.

No reason I can see why owners should be given the option as long as they are aware (a) it is not on licence (b) they have to be very aware of signs the patient is painful again.

RE: Long term metacam dose

Neil Wheadon — Tue, 04 Apr 2017 10:00:28 GMT

[quote user="Clive Ansell"]1) why on earth would anyone do that?[/quote]

Bad English on my part maybe. It should read. Weigh the dog, at each visit, then adjust, not weigh the dog on a daily basis!!

Neil

RE: Long term metacam dose

Clive Ansell — Tue, 04 Apr 2017 09:42:25 GMT

1) why on earth would anyone do that? I usually suggest monthly weighing, but tend to dose slightly below weight anyway. Human dose of Ibuprofen is the same whether you're a fit 8 stone or a 32 stone lard arse.

2) Yes. Titrate dose to effect. Many cases seem to do just as well lower, sometimes much lower, doses.

3) Usually advise daily dosing, but have some cases on an as and when need basis and seems to work for them. I only take nsaid's myself as and when I need them.

4) No, alter dose based on weight and efficacy.

RE: Long term metacam dose

Kathryn Burton — Tue, 04 Apr 2017 09:36:40 GMT

I'm not aware of any published studies demonstrating that a 50% dose is as effective as a full dose. A lot of clients seem to like to do it and think it is just as effective, but then owners aren't the best at recognising pain (and they probably prefer spending 50% less on treatment!). Equally I've seen clients who like to split the dose 50:50 BID to give him a little 'boost' in the evening... Or just give a whole extra dose on the evening... Or give a half dose because the full dose makes him drowsy... I think I remember a study that demonstrated that giving Metacam SID was more effective longer term than just giving it when the dog had a bad day, but I can't remember any details or how they quantified this, sorry!