Help managing severe unremitting joint pain in 8yo labrador

RE: Help managing severe unremitting joint pain in 8yo labrador

Gillian Mostyn — Sun, 21 Apr 2019 20:33:51 GMT

[quote user="Andrew Henfrey"]Surely the point of joint replacement surgery is to render the joint pain free? If she needs both elbows, doing, so be it. [/quote]

Fair enough. I hope it all goes well.

RE: Help managing severe unremitting joint pain in 8yo labrador

Beats — Sun, 21 Apr 2019 19:21:03 GMT

[quote user="Andrew Henfrey"]We've had a think about stem cells. However, our orthopaedic diplomate friends really don't seem to have a lot of time for it[/quote]

even the liberal avma felt the need to comment on this trend:

https://www.avma.org/KB/Policies/Pages/Therapeutic-Use-of-Stem-Cells-and-Regenerative-Medicine.aspx

RE: Help managing severe unremitting joint pain in 8yo labrador

Julian Earl — Sun, 21 Apr 2019 17:42:51 GMT

In addition, I've just coped a summary from one paper about hip therapy with bone marrow-concentrate in people. They conclude:

CONCLUSIONS:

The use of BMC as coadjuvant in arthroscopic intervention of FAI injuries results in pain reduction and improvement in functionality as showed in VAS, mHHS, and iHOT-33 scores at 12 and 24 months of follow-up.

RE: Help managing severe unremitting joint pain in 8yo labrador

Julian Earl — Sun, 21 Apr 2019 17:39:40 GMT

There are several papers listed in this link for the EntrezPubMed site...:

https://www.ncbi.nlm.nih.gov/pubmed/?term=osteoarthritis+and+stem+cell+therapy

Take your pick.

RE: Help managing severe unremitting joint pain in 8yo labrador

Andrew Henfrey — Sun, 21 Apr 2019 17:28:56 GMT

We've had a think about stem cells. However, our orthopaedic diplomate friends really don't seem to have a lot of time for it, especially in a case as severe as she is. A client recently went for stem cell therapy for a young dog with HD and was quoted a cool £5k for the process. While money (to a large extent) is no object for our dog, we would really like to see some good quality research papers on the efficacy of stem cell therapy in end-stage severe DJD before lashing out that sort of sum. If anyone has seen any papers like this, could they post a link please?

RE: Help managing severe unremitting joint pain in 8yo labrador

Andrew Henfrey — Sun, 21 Apr 2019 17:19:44 GMT

[quote user="Beats"]

[quote user="Andrew Henfrey"]carprofen 2mg/kg sid[/quote]

For a 27kg dog in bad elbow pain where euthanasia is being considered, I'd give 100mg carprofen daily (50mg morning and 50mg evening). I'd add 750mg paracetamol twice daily. Tramadol 100mg QID if helps. If that wasn't working, then I'd add 5mg prednisolone daily (with or without reducing carprofen dose to 50mg daily and giving omeprazole 20mg omeprazole twice daily).

I don't use a lot of carprofen, but have seen it used at 4mg/kg/d by a number of vets (many of whom were unaware that that dose was supposed to be for a limited time period only...) over the years for extended periods of time with no more ill-effects than I have seen with any other NSAID.

[On the subject of NSAID intolerance generally (the sort of case where owner says can't take NSAIDs as has tried a couple with disastrous GI upsets resulting), I simply love Trocoxil - most of dogs not tolerating NSAID appear to be direct GI effects in my experience, i.e. diarrhoea and/or vomiting rather than pharmacological consequences of systemic therapy such as gastric ulceration; simply not hitting the GI tract daily seems to be met with less resistance in many of these patients - an injection of maropitant at same time and you know the drug will stay in there]

[/quote]This is pretty much what we have done. She's on carprofen, Pardale and Tralieve at the moment and is now bright, happy, playing with her toys, trying to start wild games with our other dog and starting to try and insist on going for a walk again (not hppening!). She is now weight bearing on the left fore again.

Unfortunately she really is intolerant of NSAID's generally to the point of gastric ulceration (confirmed by endoscopy and biopsy last time we tried). Omeprazole gives her uncontrollable diarrhoea and muscle tremors. Pred makes her vomit too, although we haven't scoped her after the pred-induced vomiting to see exactly what was happening. She really is an awkward dog to medicate! The carprofen-Pardale-Tralieve combination has really hit the spot though.

RE: Help managing severe unremitting joint pain in 8yo labrador

Andrew Henfrey — Sun, 21 Apr 2019 17:06:36 GMT

[quote user="Gillian Mostyn"]

[quote user="Andrew Henfrey"] She can just about manage to get around hopping on the right leg at the moment but would have no long term future without the left leg.[/quote]

Do you think it is in her best intetests then to have the joint replacement surgery done? She is going to be in considerable pain for a very long time, probably the rest of her life.

I'm happy to see animals go through painful procedures if their likelihood of returning to a fun, pain-free quality of life is good. I'd be concerned that in this case you are prolonging her life, but perhaps not to the quality the life you'd want?

It is difficult, I know.

[/quote][quote user="Gillian Mostyn"]Do you think it is in her best intetests then to have the joint replacement surgery done? She is going to be in considerable pain for a very long time, probably the rest of her life.[/quote]

Why would she be in pain for the rest of her life? Surely the point of joint replacement surgery is to render the joint pain free? If she needs both elbows, doing, so be it. I wouldn't be booking myself into Dignitas just because I needed a couple of new hips!

RE: Help managing severe unremitting joint pain in 8yo labrador

Anthony Dennison — Sun, 21 Apr 2019 10:00:15 GMT

[quote user="Emily Rainbow"]

Where in the country are you? Could consider stem cells before invasive surgery?

[/quote]

They can ship stem cells out to all over the UK. One of the vets at my practice has used it in a case which showed a degree of clinical improvement.

RE: Help managing severe unremitting joint pain in 8yo labrador

Emily Rainbow — Sun, 21 Apr 2019 08:51:29 GMT

Where in the country are you? Could consider stem cells before invasive surgery?

RE: Help managing severe unremitting joint pain in 8yo labrador

Beats — Sun, 21 Apr 2019 00:00:41 GMT

[quote user="Andrew Henfrey"]carprofen 2mg/kg sid[/quote]

RE: Help managing severe unremitting joint pain in 8yo labrador

Robert FalconerTaylor — Wed, 17 Apr 2019 17:03:09 GMT

Just a thought, this is the story of one of our rescues - he lost a foreleg as a pup and then the other developed OA. http://springerrescuescotland.org/rescue-dog-bens-story?id=8&start2=0&category_id=0&hash=499b0a56cdcba4a207ff3144d537230d8e5d7923080

RE: Help managing severe unremitting joint pain in 8yo labrador

Gillian Mostyn — Wed, 17 Apr 2019 12:41:47 GMT

[quote user="Andrew Henfrey"] She can just about manage to get around hopping on the right leg at the moment but would have no long term future without the left leg.[/quote]

Do you think it is in her best intetests then to have the joint replacement surgery done? She is going to be in considerable pain for a very long time, probably the rest of her life.

It is difficult, I know.

RE: Help managing severe unremitting joint pain in 8yo labrador

Bob Russell — Wed, 17 Apr 2019 12:21:43 GMT

Perhaps a bit of a tangent but why would anyone seriously consider amputation in an osteoarthritic labrador?

How often do we see arthritis in only one leg? We may only see lameness in one limb but quite often that is because it is the most painful leg.

RE: Help managing severe unremitting joint pain in 8yo labrador

Andrew Henfrey — Wed, 17 Apr 2019 11:50:15 GMT

Thanks Julian, we didn't go for intra-articular steroids initially as we were concerned about possible joint infection, and also because the medial compartment looks virtually completely collapsed. However, the joint tap is clear and we may try this now to give some relief before surgery.

RE: Help managing severe unremitting joint pain in 8yo labrador

Andrew Henfrey — Wed, 17 Apr 2019 11:46:54 GMT

Hi Clive, sadly she is not a candidate for amputation as the right elbow is just as severely affected on xray and CT. She can just about manage to get around hopping on the right leg at the moment but would have no long term future without the left leg.

RE: Help managing severe unremitting joint pain in 8yo labrador

Clive Ansell — Wed, 17 Apr 2019 11:25:23 GMT

[quote user="Andrew Henfrey"]She is not a candidate for a CUE procedure as the lateral compartment is also involved. Her two options are euthanasia or surgical management - total elbow replacement/arthrodesis.[/quote]

Given

[quote user="Andrew Henfrey"]She is still on 3 legs[/quote]

maybe consider amputation?

RE: Help managing severe unremitting joint pain in 8yo labrador

Julian Earl — Wed, 17 Apr 2019 10:32:57 GMT

What about intra-articular steroids and local anaeshetic for a short to medium-term relief? It is used a lot in humans Ibelieve and works quickly due to the local of course.I speak from experience. I had this in my shoulder and the effect lasted for about six years before I relapsed! Subsequent doses have also worked for more years!

Re. ketamine. I used to try this but it never seemed to have a dramatic effect. The theory is good for hyperalgesia and I'd try it once per week. I'd have to look up the dose but I used to give a regular Dobermann 1ml sub-cut. As far as I'm aware based on the owner's comments, the dogs did not appear unsteady afterwards at all. Worth a try though perhaps. because the theory is sound.

RE: Help managing severe unremitting joint pain in 8yo labrador

Andrew Henfrey — Tue, 16 Apr 2019 17:35:13 GMT

Hi all and thanks for continued help. She does not have septic arthritis (joint tap clear). Her radiographs and CT show severe OA, with complete joint collapse on the medial compartment of the left elbow. A very experienced orthopaedics diplomate has reviewed all the images and commented he has not seen such severe changes in an 8yo labrador. She is not a candidate for a CUE procedure as the lateral compartment is also involved. Her two options are euthanasia or surgical management - total elbow replacement/arthrodesis. She is still on 3 legs, but is much more cheerful and we have her pain much more under control. No yelping with the slightest movement anymore, sleeping OK, managing to get outside to relieve herself and coping well with being confined to a small room. So she is going for surgery to give her a chance, despite the horribly high incidence of serious complications.

RE: Help managing severe unremitting joint pain in 8yo labrador

Christina Smith — Tue, 16 Apr 2019 16:13:59 GMT

Sounds quite extreme given it's a chronic oa in a Labrador. I would also be looking for secondary septic arthritis. Also consider opiate hyperalgia. It is well documented in humans.

RE: Help managing severe unremitting joint pain in 8yo labrador

Joyce Whitehead — Mon, 15 Apr 2019 22:10:14 GMT

I’m with Michael here, I’d up the pardale. We have a similar lab patient except he’s one of the big chunky boned ones (show breeding, not overweight). He has a flare up about once a year, oedema running down leg, pyrexic, very sore. He is also intolerant to every nsaid we have tried. When he has a flare up we get him on iv paracetamol, antibiotics and tramadol (I’m not a fan of tramadol generally but the owner feels it helps). We have also given ketamine for the wind up at times. He usually starts to settle after 2-3 days. And we have discussed pts quite a few times when he is bad, but then he recovers and copes quite well on pardale and tramadol. Good luck.

RE: Help managing severe unremitting joint pain in 8yo labrador

Michael Woodhouse — Mon, 15 Apr 2019 21:53:58 GMT

A 27kg dog should be on 2 Pardale every 8 hours.

RE: Help managing severe unremitting joint pain in 8yo labrador

Andrew Henfrey — Mon, 15 Apr 2019 21:33:24 GMT

Hi she is intolerant of meloxicam, but is currently on carprofen 2mg/kg sid, pardale 1 bid, tralieve 100mg tid, is finishing marbocyl 80mg sid for potential joint infection. 27kg working strain labrador, never been allowed to be overweight.

On CT there is so little medial joint space I am not sure that any injectable will make a difference as it must be bone to bone contact.

Still more settled today and having better nights.

Thanks all.

RE: Help managing severe unremitting joint pain in 8yo labrador

James Dunne — Mon, 15 Apr 2019 16:57:23 GMT

hi Andrew

It doesn't appear that she has had any NSAID; is she intolerant of them? if not, I would start with carprofen at 2mg/kg/bd since at least it can be given twice daily and this may be better initially than the '24 hour' drugs. I would definitely tap the joint to check for an infective process since an OA dog that has been doing well for some time shouldn't become acutely and severely lame, unless it is an arthritic flare, trauma or an infective disorder. I take it being a working dog she is not overweight? Not possible to treat this acutely but it might have a bearing on prognosis. If no infection is present and oral meds are not working, occasionally injecting triamcinolone into the joint can relieve symptoms. Hope that is of some help.

RE: Help managing severe unremitting joint pain in 8yo labrador

Bob Russell — Mon, 15 Apr 2019 16:23:45 GMT

I was going to suggest tramadol!

It is very much out of favour but it can be very useful but not in every dog. It was 'fashionable' for a few years and perhaps there is a mini backlash.

In the olden days I suspect PLT would have worked a treat!

RE: Help managing severe unremitting joint pain in 8yo labrador

Andrew Henfrey — Mon, 15 Apr 2019 14:45:59 GMT

Thank you. It is so frustrating as she has been a naturally thin dog, and her parents, grandparents and great grandparents all scored 0 on the BVA scheme. We've never seen such severe changes on xray and CT at her age.