Joint supplements - thoughts

Re: Joint supplements - thoughts

Virginia Campbell — Mon, 25 Nov 2013 20:25:57 GMT

[quote user="David Mills"]

http://www.ncbi.nlm.nih.gov/pubmed/?term=chondroitin+dog+dublin

This was out about the time I qualified and it was (I think) one of the first 'CS/GA is great' pseudoscience rubbishisms that came across my desk as a new grad.

[/quote]

OK, just read the abstract not the paper and

- sample size 35 hmm not great

- no negative control - if they'd had no treatment, would they be doing just as well by day 70? Maybe unethical to not-treat so negative control perhaps not an option (unless you consider CS/GAG as effectively not-treating), but a better study would have had group C who got NSAID and the glucosamine/chondrotin together, to see if they were any better than CS/GAG alone or NSAID alone

- hurrah they were doing super duper at day 70. Abstract doesn't say what happened at day 98, when treatment had been withdrawn. Were they all doing super duper on no treatment?

Re: Joint supplements - thoughts

John Flynn — Mon, 25 Nov 2013 07:52:52 GMT

[quote user="Robin Grimmer"]True, not all dogs tolerate an NSAID, but in these cases wouldn't tramadol be better? - at least it is an analgesic.[/quote]

Yes, I think that probably would be the case.

Interestingly, owners who have used tramadol are often enthused about its use in their dog; unfortunately the poor bioavailability, rapid metabolism and lack of M1 metabolite formation mean their dog probably doesn't get so much analgesia.

As David suggested, if the owners are willing, many dogs that have had a bad reaction to one NSAID in the past can benefit from an alternative NSAID etc.

I've been surprisingly impressed by Trocoxil with respect to this - I don't know if perhaps the lack of daily NSAID hitting the stomach is of relevance or if it's just a matter of if I'm dispensing it to a dog that has reacted to 2 or 3 NSAIDs in the past and the owner is very reluctant to try another, that I give ranitidine alongside it?

Re: Joint supplements - thoughts

Evelyn Barbour-Hill — Mon, 25 Nov 2013 00:01:56 GMT

[quote user="David Mills"]This was out about the time I qualified and it was (I think) one of the first 'CS/GA is great' pseudoscience rubbishisms that came across my desk as a new grad.[/quote]

A new graduate has a desk?

Re: Joint supplements - thoughts

David Mills — Sun, 24 Nov 2013 23:05:29 GMT

[quote user="Virginia Campbell"]

What crap is that? (sorry prob v ungrammatical question)

[/quote]

http://www.ncbi.nlm.nih.gov/pubmed/?term=chondroitin+dog+dublin

This was out about the time I qualified and it was (I think) one of the first 'CS/GA is great' pseudoscience rubbishisms that came across my desk as a new grad.

I was being unfair on Dublin actually, but that one just sticks in the craw. There are, depressingly, so many more.

This is one of the latest offerings:

http://www.ncbi.nlm.nih.gov/pubmed/21623931

The abstracts in these things make me ashamed to be a fellow professional to them.

Here's hoping the RVC is made of sterner stuff.

Re: Joint supplements - thoughts

Virginia Campbell — Sun, 24 Nov 2013 21:27:28 GMT

[quote user="David Mills"] The crap turned out by Dublin vet school is almost tantamount to research fraud and the investigators that put their name to it should be absolutely ashamed.[/quote]

What crap is that? (sorry prob v ungrammatical question)

[quote user="Utlendigur"]why, with so little evidence to back them up, they are so expensive.[/quote]

cos if it's dear, it must be good, right?

[quote user="robloxley"]by the time we see many cases of OA presented, they'd do better on NSAIDs (and often cheaper) IME[/quote]

Yes. I diagnose more cases of arthritis in animals presented for booster rather than animals presented for lameness. Mental note to discuss with O as the dog heaves itself slowly up onto its back legs then potters its way across the waiting room with abducted thick elbows, O often quite surprised...."what lameness?"

"[quote user="David Mills"]

1. They might not 'do no harm' (we don't know, because they don't need safety testing).

2. They may do indirect welfare harm by encouraging the faddish idea that supplements = good, drugs = bad that some clients have

3. There's more evidence for the use of doxycycline in management of OA.

4. Vets that think stocking them, giving them airtime, encouraging owners to give them a try if they want, saying things like 'they do no harm', can be reconciled with providing the owners with objective information allowing them to make up their own minds are living in the clouds and ignoring the influence indirect endorsement can have on client decisions.

5. It is very ethically difficult to justify vets selling this crap given there's no evidence they work.

6. And we complain about homeopathy...

[/quote]

urgh what a depressingly good and clear-thinking post. I'm guilty of the worth-a-go waffle.

Re: Joint supplements - thoughts

Robin Grimmer — Sun, 24 Nov 2013 20:43:27 GMT

[quote user="John Flynn"]

[quote user="Robin Grimmer"]Not only that, but witholding nsaids in favour of a nutriceutical is a serious welfare issue, as the dog's chronic pain isn't being addressed.[/quote]

To be fair, not all dogs tolerate an NSAID (or at least not on first attempt).

[/quote]

True, not all dogs tolerate an NSAID, but in these cases wouldn't tramadol be better? - at least it is an analgesic.

Re: Joint supplements - thoughts

David Mills — Sun, 24 Nov 2013 15:57:01 GMT

[quote user="John Flynn"](or at least not on first attempt)[/quote]

Yes, and it's difficult to talk some people round to trying another once the idea has been implanted that NSAID=reaction. They're actually a remarkably diverse group of drugs (and admixtures), and once you start to throw pharmacogenetics in (Beagles have certain enzymes meaning they metabolise carprofen more quickly...) then the possibilities are endless...

Re: Joint supplements - thoughts

John Flynn — Sun, 24 Nov 2013 15:18:27 GMT

[quote user="Robin Grimmer"]Not only that, but witholding nsaids in favour of a nutriceutical is a serious welfare issue, as the dog's chronic pain isn't being addressed.[/quote]

To be fair, not all dogs tolerate an NSAID (or at least not on first attempt).

Re: Joint supplements - thoughts

Robin Grimmer — Sun, 24 Nov 2013 13:43:18 GMT

Not only that, but witholding nsaids in favour of a nutriceutical is a serious welfare issue, as the dog's chronic pain isn't being addressed.

Re: Joint supplements - thoughts

Utlendigur — Sun, 24 Nov 2013 10:40:14 GMT

[quote user="bob lehner"]Well, judging by the large no. of these products (human and animal) on the market people must be buying them in quantity and I guess they must be rather profitable for the manufacturers.[/quote]

[quote user="bob lehner"]Asa sufferer from pretty severe arthritis I know full-well that it is a disease where the pain symptoms wax and wane naturally over time, regardless of any medications. [/quote]

I think people find it easier to relate to the anecdotal/emotional eg "My dog was limping for weeks, he couldn't go for the walks he loved - then we tried this wonderful supplement and within a few days he was running round like he used to and hasn't had a problem since" than the evidence/factual "a double blind, placebo controlled trial of drug X showed a 50% improvement in lameness scores....". The dog on the supplement probably just got better on its own but throw in a cute picture and some fancy packaging and you've got a winner especially compared to those dangerous drugs the vet wants to use, the ones that the internet says kills your pet - and they keep wanting to check him over just to make money, and do blood tests (so the drugs are obviously dangerous)...

Re: Joint supplements - thoughts

Christopher Saul — Sun, 24 Nov 2013 10:40:06 GMT

The problem with neutraceuticals is to some extent a statistical one. If they make a difference, then such a difference is small. In order to detect a small difference, one needs a very large sample size. I guess it's down to the individual to decide how much importance he/she places on the evidence or anecdote that is out there.

I'm not expressing an opinion either way here!!!!!!

Re: Joint supplements - thoughts

bob lehner — Sun, 24 Nov 2013 10:26:05 GMT

[quote user="Utlendigur"]The thing that puzzles me about nutraceuticals in general is why, with so little evidence to back them up, they are so expensive. [/quote]

Well, judging by the large no. of these products (human and animal) on the market people must be buying them in quantity and I guess they must be rather profitable for the manufacturers.

I've never consciously prescribed any of them. If people ask I just say -'Fine, try it if you want to spend your money on something with little evidence of efficacy'.

Asa sufferer from pretty severe arthritis I know full-well that it is a disease where the pain symptoms wax and wane naturally over time, regardless of any medications. This makes it difficult to judge the efficacy of medication. A year ago my wrists were constantly seriously painful. No medication taken at all and currently they are 95% fine. Very odd.

Re: Joint supplements - thoughts

Rob Loxley — Sat, 23 Nov 2013 23:59:24 GMT

[quote user="David Mills"]encouraging the faddish idea that supplements = good, drugs = bad that some clients have[/quote]

Indeed, a bugbear is that many of the clients buying these 'supplements' have animals with significant joint disease that we know would benefit from safe, cost effective NSAIDs

Re: Joint supplements - thoughts

Evelyn Barbour-Hill — Sat, 23 Nov 2013 22:07:06 GMT

If we are going to have this ghastly made-up word, it would have to be nutroceutical not 'nutraceutical'. It would still not have the implication of medicinal value that its devisors obviously intended.

Re: Joint supplements - thoughts

Malcolm Ness — Sat, 23 Nov 2013 20:52:41 GMT

The evidence that any nutraceuticals has any beneficial effect on OA is weak.

However, the accumulated evidence that nutraceuticals have no clinically significant effect on patients with OA is very strong.

Re: Joint supplements - thoughts

David Mills — Sat, 23 Nov 2013 20:14:06 GMT

1. They might not 'do no harm' (we don't know, because they don't need safety testing).

2. They may do indirect welfare harm by encouraging the faddish idea that supplements = good, drugs = bad that some clients have

3. There's more evidence for the use of doxycycline in management of OA.

5. It is very ethically difficult to justify vets selling this crap given there's no evidence they work.

6. And we complain about homeopathy...

Re: Joint supplements - thoughts

Julie Innes — Sat, 23 Nov 2013 19:37:03 GMT

I have been back and forth on this one lots! The referral centres near me seem to use them, so I bow to their wisdom a little! I stock yumove , but also make it clear to clients they can buy the online. I use yumove because its the cheapest, so at least I don't feel like I am ripping them off majorly if it doesn't work...If they are keen to buy online etc that's fine too. I make it clear to clients it is an option, and I explain I'm not entirely 100% sure they do a lot, but they don't seem to do harm, so it's really up to the client if they want to spend the money on them (sitting on the fence, much?!)

Re: Joint supplements - thoughts

John Flynn — Sat, 23 Nov 2013 18:56:57 GMT

[quote user="Christopher Saul"]in summary - the evidence is weak but the logic behind omega 3 is sound [/quote]

I'm not convinced by the 'logic' on this one.

I did try to be open minded - honest! But found little to commend their use, certainly not as a supplement to be endorsing to unsuspecting owners.

I may have missed something in the proposed mechanism of action, but in my simple mind it sounded like trying to block COX up in a non-specific fashion by filling the dog full of calories - a very low dose of meloxicam would surely be a simpler, more specific, more predictable, safer and better evidenced means of achieving this?

My maths is probably way off, but one article reviewing their use ( http://avmajournals.avma.org/doi/pdf/10.2460/javma.239.11.1441 ) seemed to recommend about 300mg/kg for OA in dogs (1750mg combined EPA+DHA for a 10kg dog) and I made this about 10% of a dog's daily calorie requirements?

Given their detrimental influence on weight control (which I do believe in, at least for hip pain associated with djd in dogs), as well as their distractive nature from both this and lifestyle modification +/- NSAIDs (all of which I do consider helpful), I'd consider their discussion an unhelpful distration from managing osteoarthritis generally.

[quote user="Christopher Saul"]What's more, there is some evidence that fatty acids are efficacious in their other possible applications - e.g. chronic renal disease, heart disease and so on - and so if they work for these things then they may also work for OA[/quote]

Oddly I find the reverse... the more things somthing is supposed to treat the more skeptical I become.

Re: Joint supplements - thoughts

Christopher Saul — Sat, 23 Nov 2013 18:44:56 GMT

I cannot compare with other manufacturers, but then I haven't been invited to any of the others.

Re: Joint supplements - thoughts

David Mills — Sat, 23 Nov 2013 18:37:38 GMT

[quote user="Christopher Saul"]

In fairness to vetplus, they are a very high quality manufacturer. I have visited their plant and was impressed with their manufacturing process. the purity and quality of their products are second to none, and would easily pass as pharmaceutical grade.

[/quote]

As compared to what comparison...?

Re: Joint supplements - thoughts

David Mills — Sat, 23 Nov 2013 18:36:45 GMT

[quote user="Bob Russell"]

Apparently the RVS trials are going well and supporting their value in treating OA in dogs! (Actually a near quote from one of the reps!!).

[/quote]

Given the study is supposed to be blinded, funny that (s)he should know...unless (s)he is telling a porkie.

Re: Joint supplements - thoughts

Christopher Saul — Sat, 23 Nov 2013 17:50:21 GMT

I would tend to use their supplements as my first choice

Re: Joint supplements - thoughts

karen jones — Sat, 23 Nov 2013 17:40:37 GMT

My heart sinks and my eyes glaze over when a keen rep starts to tell me in detail about yet another new nutraceutical . The vet plus rep has been trying to see me for 3 months and I keep putting her off. I could give them the speel myself word for word. Theirs is always the best and more efficient....s we are stocking yumove at the moment , cheaper than most , palatable and clients giving us good reports back

Re: Joint supplements - thoughts

Christopher Saul — Sat, 23 Nov 2013 17:30:15 GMT

I would agree that the evidence supporting all joint supplements is weak. Above all I think it is important that we make that clear to owners so that they can make an informed decision

whilst I agree that supporting omega 3 fatty acids is not much stronger than that supporting GAGs, the logic of why fatty acids should work in theory seems more plausible to me. What's more, there is some evidence that fatty acids are efficacious in their other possible applications - e.g. chronic renal disease, heart disease and so on - and so if they work for these things then they may also work for OA

in summary - the evidence is weak but the logic behind omega 3 is sound - so if owners do want to spend some money on supplements then it seems more logical to spend it on omega 3 than GAGs.

just my 2 p

Chris

Re: Joint supplements - thoughts

Bob Russell — Sat, 23 Nov 2013 11:19:22 GMT

Sceptical and cynical here!

Apparently the RVS trials are going well and supporting their value in treating OA in dogs! (Actually a near quote from one of the reps!!).

I will reserve judgement until the results come in. All the papers I have seen for veterinary use have been borderline rubbish. Human studies I have seen generally suggest limited or no value.

If owners ask I will direct them to products that have a fighting chance of containing the right ingredients in the right quantities to the packaging. Beyond this I fear to tread!