Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

Beats — Tue, 02 Feb 2021 21:22:51 GMT

[quote userid="2249" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29636/platelet-therapy-in-osteoarthritis---evidence-and-novel-treatments---ethics/228289#228289"]And at what point do we consider a treatment not to be 'experimental'?[/quote]

When it surpasses the "Cartrophen" threshold?

Evaluation of pentosan polysulfate sodium in the postoperative recovery from cranial cruciate injury in dogs: a randomized, placebo-controlled clinical trial - PubMed (nih.gov)

Or one it passes the glucosamine threshold?

Or once it passes the palmitoylethanolamide threshold?

Or once it passes the turmeric threshold?

If it's still around as a trendy treatment in 10 years time?

Personally, something is no longer "experimental" if it has been proven, on the balance of probabilities, to work sufficiently well to have a meaningful effect, and there is a logical rationale why I might expect it to be useful.

I have no problem with vets giving experimental treatments - I do it all the time. Ideally that would be as part of an experiment to see if that treatment actually worked, but for many reasons that is rarely achievable, and frequently it may not even be desirable.

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

Sarah Keir — Tue, 02 Feb 2021 18:25:21 GMT

Canapp SO Jr, Canapp DA, Ibrahim V, Carr BJ, Cox C, Barrett JG. The Use of Adipose-Derived Progenitor Cells and Platelet-Rich Plasma Combination for the Treatment of Supraspinatus Tendinopathy in 55 Dogs: A Retrospective Study. Front Vet Sci. 2016;3:61. Published 2016 Sep 9. doi:10.3389/fvets.2016.00061

- different disease and treatment

Venator KP, Frye CW, Gamble LJ, Wakshlag JJ. Assessment of a Single Intra-Articular Stifle Injection of Pure Platelet Rich Plasma on Symmetry Indices in Dogs with Unilateral or Bilateral Stifle Osteoarthritis from Long-Term Medically Managed Cranial Cruciate Ligament Disease. Vet Med (Auckl). 2020;11:31-38. Published 2020 Mar 9. doi:10.2147/VMRR.S238598

- I'll read this paper.

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

Sarah Keir — Tue, 02 Feb 2021 16:33:39 GMT

Thank you, I will look up these references James Dunne

The paper the practice owner asked us to read and assess is 'Alves, J.C., Santos, A., Jorge, P. et al. A report on the use of a single intra-articular administration of autologous platelet therapy in a naturally occurring canine osteoarthritis model - a preliminary study. BMC Musculoskelet Disord 21, 127 (2020). https://doi.org/10.1186/s12891-020-3140-9' which happens to be a very poor paper. But as you say there is other published data out there so I will go and find these.

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

James Dunne — Tue, 02 Feb 2021 13:59:18 GMT

Hi Sarah. Some of the platelet-rich-plasma treatments (+/- stem cells) have been validated and have promising clinical outcomes in case series (Venator et al, 2020; Canapp et al 2016) but these authors did recommend further research be carried out despite these promising initial outcomes . The effects seem to be temporary also. It is hard to always do a prospective, placebo-controlled, double-blinded clinical trial in our patients and we rely on evidence that, if we use the EBVM 'gold-standard', is considered 'weak'. I'm uncomfortable with the idea that we have to constantly look over our shoulders at human medicine and accept results in human patients and apply them to ours - using entirely different species as some sort of surrogate for an outcome measure seems risky at best and daft at worst. I agree we should strive for the best quality evidence we can get for our patients, but who is going to pay for it all??? And at what point do we consider a treatment not to be 'experimental'? Nearly every treatment used every day in every practice could be brought into question. I think once we have a number (what number??) of clinical papers documenting results and showing a benefit to patients, it could be argued that we have justification in using it, provided an honest discussion with owners is had and other standard treatments are not working. I agree that dumping PRP into dog's arthritic joints willy-nilly without having tried weight loss and licensed pain relief, is not good practice either!

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

Sarah Keir — Sun, 31 Jan 2021 11:31:41 GMT

Anthony Dennison This is n=1, a personal observation so not a very strong level of evidence. Interesting still.

Dinu Catilina This is not about waiting for good evidence. There is evidence out there and quite a lot in the medical field and it is very mixed success i.e. no clear benefit. Cochrane is currently in the process of doing a systematic review so that will be interesting when it is published.

Nutraceuticals - the practice owner is also very keen on these due to unseen evidence from the rep who says (conveniently) that they cannot publish the evidence otherwise it becomes a medicine. We can only judge something on the evidence we can see and assess.

David Mills I'm sorry to be stupid but what is ASPA? "recognised veterinary practice" - we recognise the therapy in that it is visible/known but it is not recognised as in accepted or approved or established.

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

Julian Earl — Sat, 30 Jan 2021 19:47:53 GMT

another suggestion if I may ? At Liverpool our orthopaedics lecturer, the late Derek Lewis described a complicated surgical trestment for s a ruptured cruciate: The Modified Long Digitsal Extenso transefr that Itied once and it was a dister, Breakdown and infection, ongoing stifle degeneration and not something Iriked again. I have never seen any published paper on this technique but when newly qualified I was more gung-ho, alas for that poor individual! But Derek also described a technique for milder cases that relates directly to the OP here. He recommended the injection of autologous blood into the stifle joint. 10-20ml, drawn straiht rom the cephalic vein at the time of the procedure, no storahge involved. The clot is supposed to evntually fibrose and support the ruptured ligament. I used this a lot of times and if the case was severe as judged by the amount of laxity in the joint when testing the drsawer sign, then it seemed to help very little at all. I suspect the increased pressure in the joint dueto the blood volume caused discomfort and encouraged or forced resting the limb? Imust havetried this technique over 20-30 times over the years. Was I experimenting every single time, despite being taught it as an effective mtehod? Not recommemded nowadays regardless!

o that is my key question: Does the fact one is taught a procedure at University excuse one for using a novel technique? I dunno, that' why I am asking all of you!

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

Julian Earl — Sat, 30 Jan 2021 14:26:23 GMT

Has the technique Microfracture been used in dogs, or Horses,, for that matter for cartilage defects after injury or in OA? For those who might not know it is a technique used in humans, especially sportspeople where there is a cartilate defect such as I suffered after an impact to my left knee about 15 or 16 years ago. The excellent consultant at Sheffield, a specialist in sports injurues, Prof. Crister Rolf, described this to me as boring down to the subchondral bone deeply enough to trigger bleeding and then leaving it to clot at the site of the deficit. Over time the clot is organised into fibrous tissue and subsequently into articular cartilage all being well. During the blood-clot stage it is imperative not to disturb the clot with any twisting, nor any impacts of course and the prognosis is usually fairly good if the joint is adequately protected. For me, it seems to have been 100% successful withno further knee pain [ touches wood, quickly!!]

I can see obvious difficulties protecting the lesion and clot post-operatively in animals but my queston is as above, Has this been used in say, dogs with OCD cartilage defects?

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

Beats — Sat, 30 Jan 2021 13:33:15 GMT

I would consider it experimental and describe it as such.

Same goes for various manifestations of "elbow surgery" for arthritic elbows, "laser therapy", various "supplements" etc.

Interestingly, I don't describe visiting me every 2 weeks for a controlled programme of weight loss averaging 1-2% a fortnight as experimental when presented with a patient with presumed hip OA - on the contrary I describe it highly successful, but I can't honestly say I have ever seen any convincing evidence to say that this is an effective treatment? No I have not. I guess I am inconsistent then and really just expressing my opinion when asked.

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

David Mills — Sat, 30 Jan 2021 13:22:44 GMT

Something that probably needs addressing as the legislation is a mess, falling in a grey area between ASPA and the VSA/RCVS code. To be considered non experimental then it has to come under "recognised veterinary practice" but the issue is recognised is not defined and there is a lot of cross over between ASPA and RCVS.

I would be in favour of more things coming under ASPA. Might put the supervets out of business, but would probably reduce their needs for such huge freezers.

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

Dinu Catilina — Fri, 29 Jan 2021 17:36:50 GMT

There aren't many studies and the evidence is weak at best.

[quote userid="9515" url="~/001/veterinary-clinical/small-animal/f/misc-clinical-discussions/29636/platelet-therapy-in-osteoarthritis---evidence-and-novel-treatments---ethics"]So this leads on to the ethics of novel treatments in practice. If the practice was to start offering this as a treatment where do we stand. My opinion is that with only preliminary studies we would be effectively experimenting on our patients but without the framework to reduce bias and safe-guard the patients that true research would give. [/quote]

I disagree completely. What we do is a treatment that to our knowledge shows some benefits without any strong evidence to support it. If we wait for every treatment we give to have good evidence behind it then maybe more than half of our work should change dramatically. Good or bad? I don't know.

However, continuing to sell glucosamine and the like considering recent evidence is to a degree dishonesty.

We just received a new paper from our local rep, how can I upload it here?

RE: Platelet therapy in osteoarthritis - evidence? And novel treatments - ethics?

Anthony Dennison — Fri, 29 Jan 2021 16:54:29 GMT

Our clinical director did it with one dog where all other avenues had been exhausted and the owner was pushing for something else. IIRC it really didn't make much difference.