Everybody, and thank you for choosing to watch this webinar in which we're going to focus on the problem of feline arthritis. And I've subtitled this webinar unrecognised and undertreated, because I think that although we are certainly doing a much better job now than we did a few years ago, I think it's still the case that a proportion of cats who suffer with this painful condition. Are either not diagnosed, or if they are diagnosed, they're not treated.

And there are a number of barriers to both the diagnosis and the treatment, which we run up against in the consulting room and which owners run up against it at home. And I want to kind of look at some of those barriers, look at some of those perhaps misconceptions that owners have and see how we can help to overcome them in a very practical and affordable way. And we'll review the really wide number of treatments that are open to us for for managing arthritis in cats, meaning that there really is an effective treatment that is suitable for any cat, whatever their age and stage and whatever concurrent diseases they may suffer from.

So how common is arthritis in cats? The answer, of course, is it's, it's very common. It's, it's almost quite frighteningly common.

If we look at studies that have reviewed X-rays to look for radiographic evidence of arthritis, depending on the population, the study population, we get, of course, slightly different numbers, but overwhelmingly, all of the studies produce the same overall concept, which is that it's a very common problem. There is a strong correlation with increasing age, but absolutely younger cats can suffer with arthritis. Some breeds of cats are more more predisposed and some, some, some injuries and so on will, will, will lead to arthritis in in a single joint in a younger animal.

So looking at the radiographic of evidence, depending again on the study population, 61% of cats aged 6 years and over, 90% of cats over 12 years old had radiographic evidence of arthritis in at least one joint. So that is a Really, really common problem. And what we also need to be aware of, and we'll talk a little bit more about this later, is that actually X-rays are really quite limited in their ability to diagnose arthritis, because, of course, arthritis is a disease of cartilage and joint, and X-rays can only find the bony remodelling, which occurs later in the course of disease.

So it is It's absolutely going to be the case that a large number of joints with arthritis that may be very painful will not have radiographic evidence of bony remodelling. And so if we only rely on X-rays to make our diagnosis, then we certainly will underdiagnose the problem. So no argument that this is an incredibly common problem.

Why then has it been for an awful lot of years been the poor relation been been overlooked and not not recognised. And I think it's because we're very used to looking at dogs and we're very used to the way they present when they suffer with arthritis. And of course, arthritis is is common problem in dogs as well.

But cats behave differently. They present differently to dogs. And if we only apply the the kind of diagnostic algorithms that we would use for dogs to cats, then we absolutely will miss this problem.

And so I think in some ways we've been looking in the wrong direction. And missing a very important problem that is right there in front of us, but for whatever reason, we've perhaps been looking the other way and not seeing the problem that's there. So why do cats show their arthritis in a different way to dogs?

It, it's partly down to their small size and we'll come on to that. But also we need to recognise that cats are very good at hiding their pain. They're very good at hiding the fact that they are unwell.

Because they are independent, self-sufficient hunters. They rely totally on themselves to hunt to catch food for their wellbeing. They don't have a pack a pack structure or a group structure that will allow a weaker or or or ill individual to be looked after by the group.

So they are independent. They are incredibly stoical, which May come as a bit of a surprise to some people who think of them as as very, very reactive and and perhaps very difficult to handle and very, very quick to, you know, very, very quick to cause trouble. But actually cats are incredibly stoical, and they will, they will move on and cope with a level of pain that other animals would, would not, because they can't afford to slow down or show weakness again, because they don't have that, that pack structure to fall back on.

Another reason why, so cats don't show the obvious signs of pain that we might expect, but even if they are showing changes that we might pick up on a physical examination or on gait examination, we don't get that luxury with cats because vets don't see cats walking around in the way that they do dogs. So when a dog at your clinic, you see the dog walking probably into the into the practise, you see the dog walking across the waiting room to come into your room. And already even in those first few seconds, you have analysed the gate and seen that perhaps there is lameness or stiffness, and you're already aware of that issue.

But of course, the cat gets carried in in a basket. It gets taken out of the basket and put onto the table. Even if you take the time to put the cat on the floor and encourage it to walk, most cats, because they're in a strange environment, because they feel threatened, will kind of cower, hunker down, creep to the edge of the room, go under a chair and just slink off and not show themselves walking around.

So we are already at a disadvantage in identifying this problem. And if we do then, as part of our physical examination, come to look at the joints, the orthopaedic examination in a cat is very challenging. We're talking about very small joints, so although they do exhibit the same signs of crepitus, reduced range of movement, effusion, pain, cats are stoical, so they don't tell us when the joint is painful, and the tiny size of the joints makes it much more difficult to pick up things like crepitus and diffusion.

So small joints with subtle changes. And worse still, the cat is often not very receptive or or responsive to having its joints examined if the joints are painful. And in one study, which was looking at looking at other aspects of DJD and cats, but what they identified was that the affected cats tend To be more bad tempered when being handled than cats with healthy joints, which perhaps shouldn't come as too much of a surprise to us.

But there it is. It's going the very, the very group of cats that we need to be looking at their joints will not want us to be looking at their joints. I just want to take a moment here to to draw your attention to a really good resource that is available free, free to access on the Zoeists Learning Academy.

And that's this, quite, quite extensive long video made by Duncan Laces demonstrating how to perform an orthopaedic examination in the cat. It's very detailed. It's very practical.

It runs through all the different aspects, and I found it fascinating. I learned a lot from it. And I hope that that you might find it useful too.

So I'd really encourage you to seek out that, seek out that video and and have a look at that. So we don't see the cats walking. The orthopaedic examination is more challenging.

And these aspects, the gait analysis and the physical examination, are usually a very important part of how we make a diagnosis in veterinary medicine. So if we think about the sort of standard approach that we might take to any, any veterinary problem that presents itself, we start by talking to the owner and taking a history. Then we assess the clinical signs that the cat, the cat or dog or whatever is exhibiting.

We do a physical examination to build further information on top of that. We run some diagnostic tests based on the differential diagnoses that we have reached from those history clinical signs and physical examination. We use those diagnostic tests to come up with either a definitive diagnosis or a working diagnosis.

And then actually, we use response to treatment as well as an important part of that diagnostic approach. So if we, if we start an appropriate treatment, we want to see an appropriate response. And that would be a very standard approach, as I say, to, to the veterinary, to the veterinary consultation and and diagnostic procedure.

But I think when we think about arthritis, we need to rather change the emphasis and the weight of some of those aspects. They're they're all still there. But we need to give more weight to the history and clinical signs that are observed by the owner.

Because the physical examination is going to be more difficult and because we are not going to be able to observe the clinical signs because we're not going to see the cat walking. So we need to rely very heavily on the owner and their observations of their cat. We do need to do a physical examination, of course.

I would argue that in the diagnosis of arthritis, diagnostic tests really have a very limited role to play in the majority of cases, diagnostic tests being fundamentally X-rays in this instance, because certainly the vast majority of cats, we're not going to be in a position to be doing arthroscopy or other more, you know, other more, more involved processes. And I would argue that X-rays have really rather a limited role to play for most cats and owners when we're thinking about the diagnosis of arthritis. So that leaves us with response to treatment, which I think is a very important element and should be given a lot of weight.

We should be quick to suspect arthritis in older cats. We should be quick to recommend treatments that will be rapidly effective so that the owner can assess the response to treatment back in the home to see whether they see that improvement in the history and clinical signs that they have observed. So let's just look at that in a little bit more detail.

If we're going to base a lot of our our diagnosis on the history and clinical signs, what clinical signs should we be educating owners to look for? Certainly lameness is going to be a major clinical sign, but often because this is a multi-joint illness in a lot of older cats, it may be much less obvious to the owner that there is lameness, that the gate changes that we would recognise as multi-joint lameness to an owner may just look like stiffness or a change that they attribute to old age or or weakness. So certainly lameness is there, but if we only talk to owners in terms of lameness, owners won't always understand exactly what we're talking about.

So behaviour change is also a really important element that owners absolutely will pick up on and will understand. Cats who have joint pain will spend more time resting, they will be less playful, they will do less hunting. They will groom themselves less efficiently because it's painful to get round to to to to to to twist and turn in in ways to get to their to their coat.

So particularly at the back end, they will often be quite matted. They will withdraw from the family and other cats, and as we've already alluded to, they can become a bit short tempered. They may become a little bit aggressive when being handled when that's not normally their nature.

And these are certainly changes that owners will recognise. But again, they won't always attribute them to arthritis. So we need to be ready to educate owners and to explain what they need to be looking for.

And these gate changes that that they they will cats will exhibit and owners absolutely will recognise, these characteristic changes have been analysed and looked at and we've and and Duncan and his group have come up with a A range of very simple to identify characteristic gait changes which can clue us in to the presence of arthritis. So cats with arthritis, when they go up or down stairs, very characteristically start to take the stairs one at a time. And they tend to kind of bunny hop with their back legs so that they move both back legs at the same time.

I'm going to show you some videos in a second, but the way cats go up and down stairs if they have access to stairs, can really very rapidly clue you into a problem. They will also hesitate to jump up and often use their forelimbs to reach up and then help to pull themselves up onto a surface that normally a cat would jump on quite freely, and they will also hesitate to jump down, so they will hover a little bit, they will hesitate, and then often they will put their forelimbs, slide their forelimbs down if there's a vertical surface to reduce the height of the jump, and then they often will land quite awkwardly again because of the discomfort. So they will often try to avoid having to jump up or down, and they will choose a rather longer route to get to where they want to be that allows them to go up in smaller increments rather than jumping straight up onto a surface.

When they're moving around the home or the garden, they will walk instead of trotting or running, and they will often pause to rest. And again, we'll see some examples of of of all of this. And these changes together, as I say, very recognisable for owners, but not something that we are going to see in the consulting room because we do not see cats behaving normally.

So here's some some video examples. The first one I'm going to show you is, two cats. The black and white cat is a normal healthy cat, and the ginger cat, as you will see, is struggling with arthritis.

So they're both on the bed as we start the video. The black and white cat jumps off freely, but the ginger cat hesitates and then does that very characteristic reaching down with his forepaws in order to make the jump smaller. And again, owners will, of course, recognise that when you describe it.

Here is a normal cat going downstairs, a normal healthy cat with a smooth flowing movement, running, trotting down the stairs, all in a nice smooth way. Here is a little cat with arthritis coming down the stairs, and I hope you'll see, but also hear the abnormality because you can hear the little back legs thudding as they jump down together, so that bunny hopping. So let's watch and here.

So taking the stairs one at a time with her front legs and jumping her back legs down again, very characteristic of a cat with arthritis. Here's another cat going up some stairs. These are some stairs that the owner has installed to allow the cat easy access to a comfy bed.

But even so, the cat is taking these stairs one at a time with his front legs and hopping up with his back legs, both of the back legs together to get up onto the comfy bed and to follow that treat that the owner is offering. This is the same cat out in his garden, and this is a video of him walking across the garden before he started treatment for arthritis, and you'll see that he's kind of hovering. He's not sitting properly.

He's hovering because he doesn't want to flex his back end to sit right down. He's got a short stilted gait. He's got quite an arched back.

He pauses to rest, but he doesn't sit right down because it's too painful to sit right down. And then he goes again for a little way, and then he pauses again and hovers. And this is again very characteristic of the cat that's uncomfortable with arthritis.

This is again the same cat in the same garden, but this is now after treatment for arthritis, and you can see that he's moving much more freely. His back is flatter, his His, stride is longer, and he walks much further without stopping and pausing to rest because he's that much more comfortable. So very characteristic gait changes that you and owners can recognise.

And as I say, these have been pulled together and and and a whole range of different clinical signs and gait changes that cats with arthritis might exhibit have been looked at and analysed and and refined down to this very simple list of six questions, which have been validated as a simple and clinically expedient tool that you can use with owners to ask those very simple questions. Does your cat jump up normally? Does your cat Jump down normally?

Does your cat climb upstairs or steps normally? Does your cat climb downstairs or steps normally? Does your cat run normally?

Does your cat chase moving objects? And if you ask owners these questions and they answer no to any of them, then that should clue us into the fact that we need to, we, we need to drill in a bit further and find out whether those abnormalities are due to chronic joint pain. And it can be incredibly valuable to ask owners to make a video of their cat at home, going up and down stairs or walking across the room or jumping up onto a surface in order for you to be able to to view that video in the consulting room, and a tiny snatch of a few seconds of video will tell you an awful lot more than you can get from either discussion with the owner or a physical examination of the cat.

And because these questions are quite straightforward, but if owners have not thought about it, they may not, they may not be easily able to answer them in the consulting room with you. It can be helpful to pre-warn them about this by sending out a mobility questionnaire, ahead of a routine wellness exam or in ahead of a vaccine examination or whatever it is. In order again, just to to bring the conversation up to the owner and to save you precious time in the consulting room, where time is very limited, and you might want to spend more of your time talking about treatment options than than going through the process of trying to reach a diagnosis or or persuading the owner of the problem.

And if you feel that sending out information ahead of time is helpful, so I have have produced a printed PDF that you can download and print to send to owners or you may prefer to generate your own branded arthritis questionnaire. But the idea, of course, is, is that that you can email to them or print out to give them in the waiting room. And the idea again is just to focus the owner in on those critical gait changes to make them start to think about whether there actually may be an issue in their cat.

So the history and the clinical signs as observed by the owner, are going to be really key. And then as we've alluded to, a physical examination is going to add extra weight, extra structure to the findings from the owner. But diagnostic tests and as I say in case of arthritis, that's really gonna be radiography X-rays.

Is that, is that useful? Is it justified? And I think I would argue that in many cases, it is not, because to get a really good diagnostic quality X-ray of cats joints, we do need the cat to be at least sedated and most likely actually anaesthetized in order for it to be safe for us and safe for the cat.

So that is going to be quite a financial cost to the owner. It's going to be quite a stress to the cat to be coming in having anaesthetics, having X-rays taken. And, and I would argue that if 90% of cats over 12 years old have arthritis, it isn't realistic to expect that we will be taking radiographs of more than 90% of cats over 12 years old.

Now, of course, if they come in for another reason, if they're coming for dental work or they're under anaesthetic for other reasons, we may well take the opportunity to take those X-rays. But I think the other side of this is to what extent do the does the appearance of the joint on the X-ray actually change our understanding of what is wrong with the cat or what our treatment options are. And if we are going to think about arthroscopy or or or those kinds of more involved treatments, then of course, it may be very helpful.

But we need to be again aware that there is poor correlation between the presence of bony change and the presence of pain. And indeed we need to be aware that as the disease progresses and the bony remodelling becomes more and more extreme, it actually more or less arthrodes is the joint, and the joint may become much less mobile but also much less painful. So sometimes the joints that look worse on the X-rays are actually less painful than the joints that either show very mild, subtle changes or indeed no changes at all.

And again, this comes back to the fact that we're really not terribly good at identifying pain in cats and joint pain in particular. And X-rays are also limited in their ability to identify the problem. And so to me, all of this adds up to saying, well, to what extent will the X-rays change my approach to the problem?

And again, I would argue that response to treatment may be a much, much more reliable and valuable tool than the expense and risk of anaesthesia and and X-rays. And response to analgesia is, you know, we should, we shouldn't run, run shy of of of using trial treatments wherever we suspect pain, response to analgesia is an important part of the, of the diagnosis. And again, we've seen a little video of of that cat called Harry walking across his garden before and after treatment.

I've got another couple that I can show you here. So here is a little black and white cat who has a keen interest in the food that that it's being offered, but is unable or unwilling to jump up onto the bed or even to reach up on its hind legs to access the food, even though you can see the cat's quite keen to eat. That was before treatment.

Then after after starting in this example, meloxicam, this is the same cat, the same bedroom, the same id down on the bed, in comes the cat, and you can see that on this occasion, it jumps up very freely straight onto the bed without any issue. So the power of treatment as a diagnostic tool to confirm that the cat's mobility problems were down to discomfort. Oops.

We'll move on to another example. So here is a little cat. This is a Siamese cat called Ellie, and you can see in the first video, how she was walking before she had treatment for arthritis.

You'll notice that she's got a very short stride of jerky gait. You can see even on the still picture that she has this hunched back, which is very characteristic of cats in pain. She walks a few painful steps and then she sits down and you can see how lame she is.

So that was before treatment. This next video is taken 6 days after an injection of Salencia, and no word of a lie. This is the same cat just 6 days after starting treatment.

In she trots, ears up, flat back, comfortable coat, much less lameness, and she's now trotting rather than walking. So again, The, the, the power of, of using the response to analgesia to confirm the diagnosis. And I think we do need to encourage owners to allow us to implement these diagnostic treatment trials, because often owners will will recognise that that their cat is not behaving the way that it used to behave, but they will often assume that that's down to old age.

Rather than pain. And I think we do unfortunately need to open owners' eyes to the fact that it is pain, not stiffness or weakness or creakiness. There's all sorts of words that owners will use to describe this without actually saying, I think my cat's in pain.

I think my cat is lame. So owners will recognise that their cat is affected, but they won't necessarily recognise the reason. And unfortunately, as vets, we often do recognise that the cat has arthritis, but we may be reluctant to treat older cats, largely perhaps because of a concern about adverse effects, a concern about costs to owners, because as vets, we generally do worry about that.

Sometimes we worry too much about that, but of course, it's an important factor. But particularly in this older cohort of animals, if we can if we consider that there might be kidney disease or liver disease or the cats on other medications for other reasons, then we may be reluctant to add in an additional treatment. But I think we do need to overcome this because as we've seen, this is a really common problem.

It is a cause of chronic pain. There is an awful lot that can be done, but unfortunately, many cats are left in pain and are not being treated. So why, why are they not being treated?

I think there are barriers to treatment that come partly from the owner, and as I've alluded to, partly from, from us as vets, and I think we have to take responsibility for that too. So there are these misconceptions regarding pain versus old age and stiffness. Owners, even if they recognise that their cat has arthritis, often are not aware just how effective and, and how many treatments are available to them.

So they often feel that nothing can be done about it. And unfortunately for a variety of reasons, possibly vets also feel a little bit overwhelmed at the prospect of trying to encourage an owner to take up treatment for their cat because of concerns regarding adverse effects, because of the practical difficulties of delivering long-term medication to cats, which we know is a big factor for a lot of owners. Because of the cost of treatment and in some cases of monitoring for adverse effects, which again can inhibit us from even recommending the treatment if we perceive that the owner is not going to be open to it.

And above all, really, the the the the lack of time in the consulting room, the pressure of time, meaning that we sometimes feel that we just simply cannot take on this this challenge of discussing this with the owner, outlining all the options and and and So it's easier just to slide by if the owner is not presenting the problem as something that is concerning them. It's easy for us to just let it slide while we talk about other issues in their older cat, whether it's dental disease or weight loss or appetite changes and so on. So anything we can do to reduce the time that is required to educate owners so that they come to us in a more open-minded approach and and and more willing to to accept the conversation.

Anything we can do with that is clearly going to help us to help more cats. And again, we, we come back to the, the fact that owners don't necessarily associate the changes that they see in their cat with actual pain. And I think we have to use that word pain when we are talking to them about arthritis.

This is some data from some market research done by Zoettas quite recently. And you can see that on the On the left hand side of the slide as you look at it, if an owner has been told that their cat has arthritis, they are much more likely to recognise that the cat is in pain than if they have not been told the cat has arthritis. So in cats who owners have not been told their cat has arthritis, only 10% of those owners attributed stiffness and slowing down and so on to pain.

The majority attribute it to old age. Whereas once the idea of arthritis has been planted and the diagnosis has been made, everyone understands that arthritis is a painful condition. If they have any family members who struggle with arthritis, they will certainly know that.

And so now 65% of owners believe their cat is in pain. Still not 100%, you notice, so we still have a barrier to overcome. But once we identify the problem for the owner, they are much more ready to accept and recognise that it's a painful condition.

And I think the problem, and this is alluded on the, on the right hand side of this slide, is that owners don't really understand how cats exhibit pain. So if the cat is, is vocalising, if it's aggressive, if it's limping, if it's withdrawn and sensitive to handling, then yes, they will recognise that that is likely because they're in pain. But all these other changes which we know are very characteristic and often much more likely to be present than the more extreme examples, hesitation to jump, stiff or stilted walk.

Decreased play, decreased activity and grooming changes in the way they use their litter tray. These are things which owners will not naturally attribute to pain until or unless we educate them. So again, this, this misconception that nothing can be done about it.

And we do need to address this as vets and we need to understand ourselves that there is a lot that we can do. If if our parents or our grandparents had arthritis, we would expect that they would be on treatment for that painful condition. If their dog had arthritis, we would expect that that animal is being treated for its pain.

But the poor little cat gets overlooked for all the reasons that we've outlined. And yet there is an awful lot that can be done about it. And I've listed here on the right hand side of this slide a whole range of treatments that you might consider to be appropriate in treating a dog with arthritis, and I would encourage you to recognise that all of these things are options for cats too.

We do not have a more restricted level of treatment options open to us. I will grant you that the last item on that list of hydrotherapy is not for every cat. So maybe I'm stretching a point there, but actually, there are some cats who absolutely will, will, will take to hydrotherapy and can get very good results from it.

So none of these items on this list would be appropriate necessarily for every cat. But any or all of them can be appropriate for some cats, and from this long list, we can come up with a treatment plan that is tailored to an owner's pocket and tailored to the cat's particular conditions. So non-steroidal anti-inflammatories have long been a standby for treatment of arthritis, and as we'll see, they can absolutely be safely used in cats in the long term, even in cats with concurrent disease.

I hope you're aware of Calencia, the the new product that's been launched relatively recently by Zwetis, an anti nerve growth factor monoclonal antibody. And we'll talk a bit more about that because it is a bit of a new, a new addition. Cartraphan is the trade name for pentosan polysulfate injections licenced for use in dogs, not licenced for use in cats, but absolutely can be used in the same way as you would use it in dogs.

A whole range of nutraceuticals and dietary supplements that can be very helpful, especially in combination with other treatments. Environmental modification is very, very important. Just making adjustments to the home and the environment to allow the cat easier access to the key resources.

And then some other unlicensed products, which, which, which, which is they don't have a veterinary or a cat licence, but absolutely can be safely used. Gabapentin can be very helpful. Opioids in the form of buprenorphine and or tramadol.

Buprenorphine in the UK anyway is available as a syrup formation for giving to cats directly into their mouth. Tramadol more difficult to dose orally because it is so very bitter. But again, here in the UK we have a transdermal.

Preparation that that can be useful in some cases, and acupuncture, if you have an acupuncturist in your clinic or in one of your neighbouring clinics, cats can respond really well to, to acupuncture. So it's a huge range of, of treatment options available to us and say, combinations of them can be used in order to find an effective treatment for any and every cat. So before we get into the drugs, I do just want to to highlight the importance of environmental modification, which any owner can of course do.

And it doesn't need to be anything, anything fancy. It can be very simple steps up to high cat flaps, steps up to allow cats onto beds or onto high resting places, and they can be pre-manufactured, they can be DIY or they can even be Simple as a pile of books or or just a sturdy box that the cat can use as a halfway house to step up to to its high resting places. So steps and ramps, easy access to food and water and making sure that the cat can easily and comfortably access its resting places is really important and very simple for owners to do without expense.

And then we come on to the the medication options. So, as I said, the non-steroidal anti-inflammatory drugs have long been the, the absolute standby for the management of arthritis in people, in dogs, and indeed in cats. They're very effective.

We have them available to us in very palatable, easy to use products, either liquid or tablets. And absolutely, they, they, they can have a really big role to play. There are of course concerns regarding side effects, especially with regard to the intestines, the gastrointestinal tract and the kidneys, but nevertheless, we know that these drugs can be safely used in a large number of cats.

Imperative that we use accurate dosing, so it's imperative that we weigh the cat accurately and that we keep an eye on its weight as time goes on, because of course, older cats do tend to lose weight as they age, and if they are losing weight, we may need to rate the dose down somewhat. Anyway, we can titrate the dose down to the minimum effective daily dose, and as you'll see, that is very often half or less than the labelled dose can be enough to keep cats comfortable. And of course, the lower the dose we use, the less adverse effects we're likely to run into.

We should titrate down the, the amount we give and not space out the interval between dosing, because if you adopt an every other day approach, for example, all that means is that the cat will be relatively comfortable for one day and then uncomfortable for the next day, whereas by reducing the total volume of liquid or the amount of tablet given, but still giving it every day, you can maintain that, that good effect. And very important that owners understand that they should not use the anti-inflammatory if the cat is off its food or becomes dehydrated for whatever reason. So non-steroidals are not toxic to kidneys, but if the cat is dehydrated or hypotensive, that is when they are in what's described as a prostaglandin dependent state and therefore inhibiting prostaglandins with a non-steroidal does then create an issue.

And this is why we need to be so careful with non-steroidals around the time of anaesthesia, because unfortunately, under anaesthesia, we often induce hypotension. And any cap that is off its food should not be given a non-steroidal. But by following those very simple guidelines and reiterating them to owners on a regular basis to make sure they don't get forgotten, then we can certainly very safely use non-steroidals in cats with arthritis.

And I've pictured on the slide here, the consensus guidelines that were published by ISFM, the International Society of Feline Medicine. And the AAFP, the American Association of Feline Practitioners. These were published a good number of years ago now, but they are still a really useful resource again, free, free, free to access, even if you're not a member of either of those organisations, very, very deep.

Detailed running through all aspects of the long term use of non-steroidals in cats, and again, really just highlighting how to use them safely, but also the important role that they have to play in a wide range of conditions, not least arthritis. And we do have a a a a a couple of really good studies that that can can can affirm for us that these, these drugs can be used safely in older cats and even in older cats who have kidney disease. So I just want to highlight this particular study.

There are, there are a couple of others as well now, but in this study, 38 cats with degenerative joint disease that were treated with meloxicam. And 22 of them were known to have chronic kidney disease, and 16 of them had normal renal parameters, so were classed as non-renal, I they, they are assumed to have healthy kidneys. They also recruited 38 control cats, 22.

With stable chronic kidney disease, and they even age and iris stage matched the control cats to the groups that were in the treatment group. So this is a must have been a really quite challenging study to, to, to put together, but it gives us really interesting data. So 22 cats with kidney disease, 16 with normal renal parameters, which again were age matched to the study group.

They were treated with meloxicam on a daily basis using the lowest effective dose, and again, this highlights the fact that by gradually titrating down the dose, you can usually use a much lower dose of meloxicam than the labelled dose. And in this particular study for both groups. There was no difference in the in the median dose across the two groups, and the median dose was 0.02 milligrammes per kilogramme set against a label dose of 0.05 milligrammes per kilogramme.

So again, we can titrate down and find the lowest effective dose. And this was a long term study, so that the the the cats were treated for, for, for a really good long period of time. It was, it ended up being a slightly different median treatment duration for each group.

Obviously, they, they stopped treatment when the cats either died or, or treatment was stopped for other reasons. But the, the even the non-renal group was treated for nearly a year with, with meloxicam and the, and the kidney disease group, you can see well over a year. So a good long study.

And the main findings, the important findings to highlight really, is that first of all, there was no difference in the sequential creatinine and urine specific gravity measurements between the non-renal group who were treated with the meloxicam. Compared to the non-renal group that were not treated with meloxicam. So what this tells us is that meloxicam did not contribute to cats developing chronic kidney disease.

Some will have developed chronic kidney disease through that time because it's a common problem in older cats, but the group that were treated with meloxicam were not more likely to develop kidney disease. So as I say, the the meloxicam is not primarily toxic to kidneys. Interestingly, looking at the group that had chronic kidney disease and were treated, there was less progression of kidney disease in the group that were treated compared to the group that were not treated.

And so again, this tells us that meloxicam was not causing progression of kidney disease in those cats. And indeed, the cats who are on treatment did better. Live longer than the cats that were not receiving treatment and and perhaps that's because they were feeling more comfortable and they were feeling that, you know, they were, they were happier and and perhaps eating better and and generally their owners would assess them as having better quality of life.

So the, the, the meloxicam did not cause kidney disease and it did not cause kidney disease to progress when used in an appropriate way in cats that were well hydrated with stable chronic kidney disease and that were eating and were receiving a low dose of meloxicam. So absolutely non-steroidals are very appropriate treatment and will remain a mainstay of treatment. I touched on some other options.

The joint nutraceuticals is obviously a big category, available as daily oral supplements that can be added to food or dosed directly to the cats, but also increasingly are being incorporated into prescription diets that are formulated for older cats and all cats with chronic kidney disease, so that the nutraceutical is being delivered with the food without the owner having to buy an additional supplement. It's a little bit fraught here because there are so many different nutraceuticals and supplements out there, and of course every manufacturer will will promote theirs as the best. And when incorporating these supplements into diets, it's important to look at how much of the supplement is in there and how much the supplement the cat will be receiving when it eats a normal amount of food to make sure that the amount is adequate, otherwise, of course, it won't be effective, but nevertheless, joint nutraceuticals have a big role to play.

And then I alluded to the off licence use of other appropriate medications, Cartrophin injection can be given, as with dogs, once a week for 4 weeks at that dose of 0.3 of a mL per 10 kilogrammes, so that's the same dose as the dog, and then repeating those courses as required. It's not recommended to give non-steroidals on the same day as that injection, but that they can be used concurrently as long as you just avoid, avoid the owner giving the non-steroidal on the day that the cat is going to have the cartrophin injection.

And for a lot of cats, particularly with relatively early stages of arthritis, a combination of Cartrophin and a joint nutraceutical can be a really powerful and effective treatment. And then there are the straightforward analgesics. We recognise that these are not improving joint health.

They, they, they're not having any anti-inflammatory effect, but nevertheless, it's a painful condition and treating the pain can be clearly recommended for most cats. So if for whatever reason, other treatment options have been tried or are not available, then falling back on analgesics, buprenorphine. Tramadol as I've alluded to in the transdermal formulation, gabapentin, all of these are very well tolerated and can be very effective and again can be used in combination with each other or in combination with the other treatments that we are talking about.

And and of course, very often a multimodal approach will produce a more powerful effect than relying on a single agent. And then that brings us around to the subject of Silencia, which I do want to just, just spend a few minutes talking about because it is quite a new treatment depending on where, where you are in the world where you're where you're listening from, you may have this available to you, or you may not yet have it available, but I know it is being rolled out and launched in in different countries throughout Europe and across Australia and America. We've been fortunate to have it available to us in the UK for for well over a year now.

So we perhaps have a little bit more experience of its use than than some than some other countries. So it's an anti nerve growth factor, monoclonal antibody, and monoclonal antibodies are a really interesting class or or group of drugs which have been widely used in human medicine now for some time. But much less so in the veterinary world, and this is the first monoclonal antibody product specifically for for cats.

And, and it is, of course, a very specific treatment. So, it absolutely does need to be species specific that the the product that you use. So nerve growth factor is known to be elevated in arthritic joints.

And if we can neutralise the nerve growth factor, that relieves pain. It also reduces the release of the pro-inflammatory mediators which drive the inflammation within the joint. So although the monoclonal antibody is not itself an anti-inflammatory.

Because nerve growth factor is one of the stimuli for release of pro-inflammatory mediators, by removing that stimulus, we do actually reduce inflammation in the joint. And there is also a kind of feedback loop whereby neutralising nerve growth factor reduces the release of nerve growth factor and again helps to relieve the pain and reduce the pro-inflammatory mediators. You're probably aware that this is an inject an injection, it's a subcutaneous injection given once a month.

And being a monoclonal antibody, it is a very specific treatment. It is highly specific to the target molecule of, in this case, nerve growth factor, and that makes it really a very well tolerated treatment with, with really minimal risk of adverse effects. And because it's an antibody, it's a protein, it's metabolised as all proteins, just by normal digestion and and protein degradation, rather than requiring handling by the liver and excretion through the kidneys.

So that in an older animal with with perhaps compromised kidney or liver function, it this is a very, this is a very useful treatment that will have minimal adverse effects on those, on those other organs. There are potential adverse effects. The the main one that we recognise and was identified in the in the drug trials that that led to the launch of Salencia, is that in some, some cats will develop a skin reaction, manifesting as as over grooming or or self trauma, not at the site of injection necessarily, but often on the limbs, or the flanks, .

And it's not entirely clear what the mechanism for this skin reaction is, but it certainly seems more likely to occur in cats who have a previous history of pruritic skin disease. So those cases you may want to discuss with the owner whether this might be more of an issue for their cat, whether this is an appropriate treatment. And as I say, the mechanism is, isn't known.

Unfortunately, it's not an allergic reaction. So corticosteroids don't tend to be all that effective in managing it. And although there isn't a licenced anti nerve growth factor monoclonal antibody in use in people, in studies and trials that have been done, people often reported that they got a kind of tingling sensation, again, possibly related to, to, to nerve stimulation.

And it may be that that that's what we're seeing in these cats that they're getting a kind of tingling feeling, and then they're reacting to that tingling feeling by over grooming and then that can lead to the, the skin, the skin signs that that we sometimes see. Generally, it lasts for 1 to 2 weeks, . If there is this tingling feeling is what's causing it, it may be that gabapentin might be a useful treatment because of its it's value for for neuropathic type of, of pain or sensations.

. Not every cat gets it repeatedly, although I think it would be a relatively brave vet who decided to continue the treatment if if the cat has exhibited the skin, the skin problem. So that's really the main adverse effect. One of the nice things about Calencia is that we can use it concurrently with corticosteroids.

There's no adverse, you know, no, no adverse reaction there. And so for that cohort of cats who do need corticosteroids and therefore cannot have nonsteroidal anti-inflammatories, Calencia is a really nice treatment option. We recommend caution when using Salencia alongside long-term non-steroidals.

Generally, if the salencia is effective, you don't need to use concurrent non-steroidals for the arthritis. And the concern arises not actually from anything that's been documented in dogs or cats, but from people who, if treated with both chronic use of non-steroidals and trial formulations of an anti nerve growth factor, monoclonal antibody. A proportion of those people developed a a condition called rapidly progressive arthritis, RPA, which is really very severe.

It's a rare adverse effect in humans, but it's one of the reasons that why there is not an anti nerve growth factor monoclonal antibody for people because This very serious adverse effect, which is rare but but devastating. So it's not been documented in dogs or cats, but really, we don't have the experience of using those two products concurrently in in large numbers. And so we would absolutely advocate caution.

About using the two concurrently in the long term. If, if, if a cat needs a short term amount of non-steroidal, then obviously with, with care and with owner informed consent, I think that's reasonable, but I probably wouldn't rely on the two together in the long term. So again, I just, just to highlight the the the benefit of this, this treatment, you saw this cat earlier on, Ellie, before treatment with her hunchy back, a stiff gait, her lameness, sitting, holding her paws up, sitting and resting and walking, and then just 6 days after treatment, trotting along, ears up, back flat, coat nice, trotting, not walking.

And this is one of the nice things about Salencia is we do see the effect very rapidly. So generally within even 5 or 6 days of giving the injection, we will be seeing the benefit if there is going to be benefit, making it a very appropriate choice for trial treatment if you are using response to analgesia as part of your diagnostic process. There she goes again.

OK. So it is a very useful treatment. It has many, many benefits and advantages, but there is no getting away from the fact that it is an expensive treatment.

But I think we need to to recognise that we should not, we should not prejudge what owners may or may not be able or willing to pay for. And this goes, of course, across all of veterinary medicine. It's, it's kind of human nature to to do that, to make assumptions.

But this was, again, some information. From that is market research in which they described what they termed the standard of care treatment for arthritis being non-steroidals, and they they outlined to owners what was involved in that, and they outlined to owners what was involved in treatment with Salencia. And you can see here, That before they knew about the cost of the drug, 72% of owners felt that the monoclonal antibody would be a good choice, and that's even though they knew it would involve a monthly trip to the vets for for the injection, which sometimes we think might inhibit some owners.

Then they were told about the price, and as you can see here, the price of the monoclonal antibody is more than double, and it is a significant amount of money per month. But even when given that price presentation, 50% of owners still felt that they would opt for the monoclonal antibody over the standard of care treatment. Of course, a proportion jumped ship and thought, wow, OK, at that price, I think I'll go with the standard of care treatment, but nevertheless, a high proportion of people are prepared to pay more money to have a product that they consider to be safer or better or easier to administer, and we should allow them to make that choice rather than us make assumptions and make that choice for them.

So finally, just wanted to finish up with a a another little case example. This is Harry and you you you saw Harry earlier on walking around his lovely garden and going up the stairs that his owner had built for him to get up to bed. He had an extremely dedicated owners who loved him very, very dearly, but Harry was really quite an unwell cat.

I've been treating him for some time for inflammatory bowel. And pancreatitis, which, to cut a long story short, was currently not quite controlled, but at least managed by controlled diet, probiotics, corticosteroids, and occasional additional use of metronidazole when he needed it. But even despite all of that, we were really recognisably fighting a battle that we weren't entirely winning and he was needing increasingly high doses of corticosteroids to control diarrhoea and maintain his appetite, but he was still losing weight.

We had tried many other treatment options, clarrabil and so on, and, and for all sorts of reasons, he, he hadn't tolerated those other treatment options, and this is where we had come to with him. Possibly because of the age and his kidneys, but also because perhaps of the corticosteroids, he also suffered with frequent urinary tract infections, and he tended to get urinary incontinence when when that was happening. So that was an issue.

But his owners were also aware that he had very severe osteoarthritis. Again, he was on a lot of treatment for that. They are extremely dedicated owners and they really were going, going all out to try and manage his discomfort.

So if we use buprenorphine, unfortunately, that tended even at low dose to cause some sensation, he tended to stumble and fall, and that made his joints worse, and it increased his tendency towards urinary incontinence. So that wasn't really an option. He was on gabapentin, he was having laser therapy.

He was even having CBD oil, which is not, in my experience anyway, all that effective in cats, but it's an option that can be tried. Of course, he couldn't have non-steroidals because of the cortic steroids he was on, and his owners, as you've seen have gone a long way down the route of environmental modification with heat beds for him, steps up, low litter trays, soft litter and so on. So They knew that he was reaching the end of his days, but they, they loved him very, very much.

They would do all they possibly could for him, but they were very aware that chronic pain was becoming a major quality of life issue, and they were starting to think that euthanasia would need to be on the cards. As I mentioned to you, we were very fortunate in the UK that Calencia was launched well over a year ago now, and it was about this time when we were discussing these these pain issues that we became aware that Salencia was on the horizon, and the owners were very keen to try it. So he was one of the very first cats that I treated with Calencia.

And again, the nice thing with it is, is this very rapid response, very safe, very well tolerated to give in in account with all these concurrent issues and, and quick to take effect if it's going to. So this was, this was an email that the owner sent me 6 days after starting the injection. Harry had Calencia on Friday, and it was soon very clear that it was having a positive impact.

He was more free flowing when he was walking and walking faster. You saw that in those video clips. When sitting, he used to constantly shift the front leg, and he isn't doing this anywhere near as much.

When he goes to sit down, he does now put his bottom on the ground rather than hovering just above the ground. And again, you saw that hovering, not wanting to sit completely down because of the pain in the in the hips and stifles. When he would get up in the night, he would limp on one of his front legs, but I've not seen him do this once since having his injection, and you could tell that his front right leg was sore when I brushed him, and he gives no sign of this now.

So really within that very short space of time, a whole range of different signs that Harry had been showing, even despite all those other treatments that he was receiving, and a good impact on a whole range of the different clinical signs that he had been showing. Harry was a very sick cat. We knew that we were reaching the end with him and and and and sadly he did die in his sleep three months after starting treatment, but the improvement was maintained throughout those 3 months, and Harry dying quietly at home was was the option that his owners had wanted for him.

We, we may or may not agree with them, but that was what they had wanted for him and they they were at least content that that that had been achieved. And when I contacted Harry's owner to ask for permission to use him as an example in, in, in talks like this, his owner reiterated that there is no doubt in my mind that Calencia made an enormous difference for Harry. So they were very happy with that treatment, and they certainly would have, they certainly would have opted for that treatment again, in knowing what they they now know.

So Calencia is a really exciting new treatment, but let's not forget that it is only one part of the of the whole menu of treatment options that we have that we can use in cats. And again, different price bracket ranges, different, different ways of delivering the treatment, different ways in which the treatments work and many of them can be used in. Combination so that hopefully really for any cat and any owner, there is an option that we can find if we are prepared to just run through all the different options and work with owners, and I think that we can and should be doing a better job of discussing this, opening owners' minds to the problem, helping them to understand that it isn't just old age, and it is pain.

And offering them that wide menu of treatment options to encourage them to believe that there is something that they can do to improve the quality of life of their, of their older cat. So with that, thank you very much for your attention. I hope it's been useful.

I hope it's, you know, provided a little bit of food for thought, and I think we're gonna take some questions if anybody has any. Thank you.