Intra-articular injections in dogs

RE: Intra-articular injections in dogs

James Dunne — Tue, 29 Aug 2017 21:27:19 GMT

Thanks, Malcolm. At the moment, disease modification is a holy grail and not one we are likely to achieve; pain relief for an individual non-responsive patient can be equally elusive and I guess I sometimes reach the point of trying unconventional medicines to alleviate suffering - is it valid or voodoo.... We have a salvage for hips, somewhat satisfactory measures for cruciates and very unsatisfactory measures for elbows so we are still left treating the secondary effects. With regard to the condylar fractures - that is a very interesting consideration. We certainly see loads of these. Nearly all accurately reconstructed [usually spaniels] ones go back to work, but we do see clinically significant OA in at least a portion of these dogs over time - not as many as one would expect I guess. This is presumably related to surgical skill and the degree of trauma to the periarticular soft tissues apart from the violence to the joint at the time it falls apart among other factors.

As for ending up describing something as homeopathic, I apologise - not a treatment modality I am a fan of!! We should certainly test and measure more - presumably outcome measures using LOAD or similar for IA injections would be a starting point? How could we investigate these medicines if we 'notice' a response to treatment was what I should have asked/suggested perhaps...

RE: Intra-articular injections in dogs

Malcolm Ness — Tue, 29 Aug 2017 18:06:18 GMT

[quote user="James Dunne"]Would it also be fair though to say that by the time OA is well established, for example, in the elbow joint, that altering the mechanics to reduce instability can be like closing the door after the horse has bolted?[/quote]

Certainly, the cartilage biochemists like that story. I am less convinced. First, I take issue with the concept of "treating" OA. I have yet to see any convincing evidence of disease modification. What we can do, and often quite effectively, is manage patients with OA - despite the overblown claims made for many of the medications used in patients with OA, it is difficult to discern any beneficial effect beyond their control of joint pain. I am not suggesting that that is unimportant, but it is distinct from modifying a disease process.

If the "inciting factor" is dealt with effectively then we can expect the progression of OA to be avoided/halted - consider the humeral condylar fracture - a massive insult to the joint but following good fracture repair, we expect these dogs to return to normal and NOT to develop significant OA. In most other cases, including cruciate failure, HD, elbow dysplasia etc, the " inciting factor" is not just an inciting factor but a continuing mechanical defect that persists and continues to "drive" the OA.

[quote user="James Dunne"]but equally a dramatic clinical response to a treatment should not either be dismissed as our imagination or wishful thinking![/quote]

That sounds worryingly homeopathic!! Unless and until some evidence is brought forward to support the supposition that the treatment and the improvement are linked causally, and not just coincidentally, then not only can we be dismissive, we are scientifically compelled to be so. (Dismissive wasn't my word)

RE: Intra-articular injections in dogs

James Dunne — Tue, 29 Aug 2017 16:09:05 GMT

Hi Malcolm

Would it also be fair though to say that by the time OA is well established, for example, in the elbow joint, that altering the mechanics to reduce instability can be like closing the door after the horse has bolted? Or, that regardless of the primary cause [cruciate ligament disease excepted] that treatment of advanced OA will be similar and the inciting factor rather academic? I thoroughly agree that a waxing and waning ailment may lead us to believe things that aren't but equally a dramatic clinical response to a treatment should not either be dismissed as our imagination or wishful thinking! Before the advent of diagnostic arthroscopy and other advanced non-invasive imaging, I suspect intra-articular injections were used much more commonly, particularly for shoulder lamenesses. At least some of those animals improved much more dramatically than they would have with chronic problems.

RE: Intra-articular injections in dogs

Malcolm Ness — Mon, 28 Aug 2017 21:16:21 GMT

I have used intra-articular injections in dogs only very occasionally Most commonly in so-called Bicipital tenosynovitis where I have used a corticosteroid.

I think the use of intra-articular injection in dogs for OA to be, at the very least, controversial for a number of reasons. First and foremost is that while so-called primary OA - a disease centred on cartilage biochemistry and involving degradation of cartilage mediated by a range of inflammatory mediators - is commonly recognised and diagnosed in humans and horses it appears to be considerably less common in dogs.

In dogs, the vast majority of OA is secondary to a mechanical defect (instability - as in cruciate failure; malformation - as in HD, elbow dysplasia etc or trauma - as in a healed articular fracture) that leads to overloading and "wear and tear" degradation of cartilage as well as a range of other important sequelae. Inflammation is often a relatively minor player in this game. Clinically, the patient usually reaches a degree of "clinical equilibrium" manifest as minor, sometimes unrecognisable pain, lameness, stiffness etc. This clinical equilibrium is punctuated by occasional acute flares characterised by exacerbation of clinical signs. These flares typically last several weeks to a few months before settling back to clinical equilibrium. This bit of natural history is important as it allows us clinicians to mislead ourselves into believing that our favourite therapy is effective as we observe the majority of our patients "getting better" coincident with the use of our favourite treatment.

Intra-articular injections, at best, have some potential to modify cartilage biochemistry, but no potential to modify the important mechanical/structural defects that underlie and drive OA in dogs.

RE: Intra-articular injections in dogs

Julian Earl — Mon, 28 Aug 2017 11:00:04 GMT

My experience is that dogs can respond extremely well because my first boss did this regularly in dog's stifles. However their stifles palpated like bean-bags due to the immense crepitus so I tend to believe later information received that the steroids help destroy the articular cartilage. Alternatively, what about Cartrophen directly into where it is needed? Has that been used? I think that joint flushing with sterile saline is beneficial as well, remving the pro-inflammatory chemicals washing around. Intra-articular bood is very pro-inflammatory as well CPD tells me, rather sadly after all the cruciate cases that received this from me early in my career.

First choice for me: flushing the joint, under GA if necessary. Cleaning the joint has logic and science behind it. The science being the removal of known inflammatory cytokines etc.

RE: Intra-articular injections in dogs

nikki — Mon, 21 Aug 2017 21:58:04 GMT

[quote user="Lucy Fleming"]

[quote user="Evelyn Barbour-Hill"]while pet people are just concerned with the comfort of their pet? [/quote]

Perhaps I'm just feeling extra misanthropic today, but I am convinced that the majority of pet people are completely ignorant of the [dis]comfort of their arthritic pet...

[/quote]

mmm, the whole he's limping but he's not in pain thing.

RE: Intra-articular injections in dogs

Lucy Fleming — Mon, 21 Aug 2017 16:50:50 GMT

[quote user="Evelyn Barbour-Hill"]while pet people are just concerned with the comfort of their pet? [/quote]

Perhaps I'm just feeling extra misanthropic today, but I am convinced that the majority of pet people are completely ignorant of the [dis]comfort of their arthritic pet...

RE: Intra-articular injections in dogs

Evelyn Barbour-Hill — Mon, 21 Aug 2017 15:55:14 GMT

[quote user="KMurphy"]

[quote user="nikki"]

we do it so routinely and repetitively in horses I've always wondering why not so much in dogs.

[/quote]

Yes, it's a strange one!

[/quote]

Maybe it's because, on the whole and as a gross generalisation of course, horse people are concerned with the athletic performance of their expensive investment while pet people are just concerned with the comfort of their pet?

RE: Intra-articular injections in dogs

KMurphy — Mon, 21 Aug 2017 15:21:14 GMT

[quote user="nikki"]

we do it so routinely and repetitively in horses I've always wondering why not so much in dogs.

[/quote]

Yes, it's a strange one!

We're going to get that done this week with our dog so I'll let you know how I get on, if anyone's interested.

Thanks for all the advice/opinions :)

Karen.

RE: Intra-articular injections in dogs

Jill Butterworth — Mon, 21 Aug 2017 11:23:11 GMT

Apparently intra articular ketamine is being trialled as it works well for pain and lasts a few months. I haven't tried it, so would have to research the detail.

RE: Intra-articular injections in dogs

Michael Woodhouse — Sun, 20 Aug 2017 03:18:19 GMT

Depomedrone licensed for intra-articular use in dogs and horses and has instructions on the data sheet.

RE: Intra-articular injections in dogs

Judith Archbold — Sat, 19 Aug 2017 23:10:12 GMT

I've used a combination of HY-50 ( hyaluronic acid) injection and triamcinolone as an intra-articular injection in OA cases ( elbows) in a few dogs now. So far had good a response in all cases.

the effect seems to last for about 6 months. i have repeated it in one case ( a young adult Labrador with moderate OA) and again it really helped.

Off the top of my head I think the dose was 1.5ml HY-50 and about 0.4ml triamcinolone into each elbow.

RE: Intra-articular injections in dogs

nikki — Sat, 19 Aug 2017 21:35:17 GMT

we do it so routinely and repetitively in horses I've always wondering why not so much in dogs.

RE: Intra-articular injections in dogs

Niall Taylor — Fri, 18 Aug 2017 17:59:29 GMT

Don't do them routinely but I have used them on occasions in the past and they seemed to help (the caregiver placebo effect notwithstanding, nach ).

Also, my mum used to have them to treat her horrendous rheumatoid arthritis and she described the feeling afterwards as 'coming out of the clouds', the improvement was so great. And if anyone had suggested the placebo effect to her she would have lamped them one!

Niall