Mild azotemia and OA pain relief. Anything new?

RE: Mild azotemia and OA pain relief. Anything new?

Gwen Covey-Crump — Mon, 30 Nov 2020 09:14:55 GMT

In agreement and with most of what has been said in response to your query Bibs. NSAIDs should not be disregarded, I would opt for Onsior, Previcox or Galliprant (for cox sparing) or meloxicam (for its easy titration). Paracetamol is quite short-acting so you'll find it more effective given at least 3 times a day. I'll stick with 10mg/kg if used alongside NSAIDs but if no NSAIDs on board will routinely go up to 15mg/kg TID and if the dog needs it, discuss doses up to 25mg/kg TID with the caveat that we don't have any long term dosing toxicity data for dogs. Useful info on https://www.veterinaryprescriber.org/ and www.zeropainphilosophy.com, both of which have paracetamol modules/articles.

Regarding acupuncture, don't reject it. I believe it is most useful of myofascial pain associated with a maladaptive gait which can often be worse than joint pain in these dogs. Used alongside physio in my experience can be very useful. Many physical therapies have limited efficacy on their own and It is hard to get good evidence with a treatment modality like this. Some dogs don't seem to benefit. So I take the attitude like any trial therapy - trial for a few weeks and stop if no evidence of effect in the animal, in the knowledge that the placebo effect is high for any treatment for chronic pain.

Supplements can be expensive and you should help the owner decide what is best to spend their money on. The best evidence we do have in experiments with naturally occurring models of OA disease is for marine sourced omega 3 fish oils.

With any of the adjunctive off-licence combinations, use rationally, give a few weeks between each change and reassess! Think carefully about combination therapy. I use combinations with off-licence drugs all the time in animals coming into the referral pain clinic but I am often having to take things away before I can see the wood for the trees. Some dogs come in weak and ataxic on 4 or 5 different drugs because a vet has tried one after the other layered on top of each other without managing to judge individual efficacy.

Lastly, we speak an awful lot about what we can give the dog, but what about removing sources of repetitive strain on weak maladapted muscles and joints. I would encourage you to consult the excellent resource www.caninearthritis.co.uk and look at the page caninearthritis.co.uk/.../ . Our dogs probably spend 95% of their time in our houses but rarely do we consider the impact of environmental hazards - our choices of flooring, access to steps/stairs, potential trips, slips and falls, jumping in/out of car, on/off sofa/bed, uncontrolled exercise etc, have on the dog. Our clients spend huge sums of money on medication to treat pain only to allow their pet to injure themselves again at home.

RE: Mild azotemia and OA pain relief. Anything new?

Iain Richards — Sun, 29 Nov 2020 17:20:59 GMT

It's 13. Treat the pain, the kidneys are not likely to collapse as a result. Tramadol doesn't work. Paracetamol - almost as little evidence, but it should work unlike tramadol where we know it isn't metabolised to the active form

RE: Mild azotemia and OA pain relief. Anything new?

Tafara Mapuvire — Sun, 29 Nov 2020 05:55:55 GMT

Hi Bibs,

Not an expert in analgesia but took a course at postgraduate level. There are several studies that indicate that NSAIDs are not that much more risky in renal than in healthy patients despite the theoretical risks. NSAIDs form the backbone of analgesia protocols for chronic OA. The recommendation in renal patients is to start at a low dose and titrate upwards. I often go for the liquid formulation of meloxicam due to ease of titration. Monitoring renal and clinical parameters regularly is key. In addition to NSAIDs, ketamine at a once off dosage of 1mg/kg SC or as a CRI has been shown to be effective to reverse wind up secondary to neuropathic pain syndromes associated with chronic pain. Different combinations of adjunct drugs such as paracetamol (not in cats) , gabapentin, pregabalin, amantadine and amitryptiline can also be used as part of multimodal analgesic protocols with good results. Use of tramadol in dogs is controversial since there is no consistency of efficacy in this species. However, it is consistently effective in cats. There is weak evidence supporting the efficacy of cannabinoids and their use is often based on anectodal reports.

Cheers,

Tafara

RE: Mild azotemia and OA pain relief. Anything new?

Michael Woodhouse — Sun, 29 Nov 2020 01:53:53 GMT

I'd be very happy keeping this dog on NSAIDs after a sensible conversation with the owners. Personally I would lean towards something more COX sparing (Onsior/Previcox/Galliprant) first and see how the dog did. I'd dose appropriatelly for the animal weight - not a fan of reduced dose to magically protect the kidneys.

Personally I'd dump the Yumove and any expensive supplements. They don't work. No good evidence in people or animals. Similar feelings with acupuncture. You might as well shine a laser at the dog.......

I'm one of those happy using Pardale at full dose (if needed), long term. Have had many dogs on it for many years with zero issues.

We've had good results adding gabapentin in refractory cases.

Have used a bit of ketamine at 0.1ml/10kg (round it up so I'd still give a 16kg dog 0.2). Some go a little wobbly but no observed excitement or heavy sedation. Will even use it in traumatic cases, at the same dose, along with methadone and it anecdotally seems to offer additional analgesia.

RE: Mild azotemia and OA pain relief. Anything new?

niall morton — Sun, 29 Nov 2020 00:57:10 GMT

Hi Rob, out of interest what dose of ketamine do you use and how do you select which patients to use it on?? Any common side effects??
thanks

RE: Mild azotemia and OA pain relief. Anything new?

Bibs — Sat, 28 Nov 2020 13:47:48 GMT

Thanks Rob,

Some of my colleagues here frequently use paracetamol and amantadine as adjunctive pain relief on top of nsaids. Out of interest what sort of ketamine dose are you talking? Not that I think this case will need it at the moment. I have used ketamine CRIs quite often for severe pain but not in the context of OA. Interesting points.

RE: Mild azotemia and OA pain relief. Anything new?

Rob Davis — Sat, 28 Nov 2020 12:48:58 GMT

This is not my area of expertise but....

I see no reason not to use yumove or any of the rest of the plethora of supplements available. I remain sceptical about their efficacy, but they are very unlikely to do any harm.

While there may be a slightly increased risk to using NSAIDs, I think the risk is small and that these patients should not be denied analgesia on this basis. I would be discussing the potential risks with the owner, though not overplaying them. I suspect that the risks are small as long as the patient is well-hydrated, but I would advise the owner to stop medication if any GI signs or if appears unwell for any other reason. I'm not aware of any of the common NSAIDs being particularly more or less of a risk and I would commonly use metacam because of the ease of dosage adjustment with the liquid formulation. I would probably start at a lowered dose in this situation with a view to titrating upwards if it's tolerated ok but not effective.

Paracetamol would also be a useful choice (either instead of or alongside NSAID). I personally tend to use the 10mg/kg BID dose most of the time, though I know some are happy to use the higher dose as in the pardale data sheet.

Tramadol - I think the trend for tramadol is declining, though it is now licensed. Seems to work in some dogs but not in others.

Ketamine - we have had some apparent success with very low dose ketamine given as a one-off injection every few months. I believe it is supposed to reset the wind-up mechanism.

Amantadine - I've not yet prescribed this myself, but I know some of my colleagues have used it with some success.