Hello everyone and welcome to today's webinar with the webinar vet. My name's Catherine Bell and I'm delighted to be your chair for the session today, which has very kindly been sponsored by Accors Animal Health. Before we begin, I've just got a couple of housekeeping notes to run over for you.
So we're really pleased that today's presentation is being delivered live, so it means you'll have the chance to put your questions directly to our speaker at the end, . If something comes to mind as you're listening, please just pop your question into the chat box and we'll do our very best to put it to our speaker later. As always, for those of you who are wondering, CPD certificates will be available once the session has been uploaded to the webinar vet's platform, which we aim to do within 48 hours.
So back to our session today, so I'm delighted to be joined by Chris Geddis, who is marketing and technical lead at Accord Animal Health. So we're gonna hand over to Chris er very quickly and then we'll get on with the presentation today. So over to you Chris please.
Thanks Catherine, hi everyone. As Catherine says, I'm technical marketing lead for Cord Animal Health, sponsors of today's webinar. So just to let you know who we are.
Cord Animal Health are part of Accord Healthcare, which is a large human pharmaceutical company who entered the animal health sector only a couple of years ago. You may have used some of our human products yourselves or indeed you may have some on your shelves which you use under the cascade. Accord Animal Health launched our first over the counter products at London Vet show last year and we'll be launching our first prescription products at LVS this year.
So do come and see us if you're there, please. I wanted to mention one of our existing products that we have because it's relevant to today's topic. Pernicox is a joint supplement which is based on cold pressed oil of green lit mussels, and it's available as a palatable paste in a dosing syringe.
It's available from UK veterinary wholesalers, and you can find out more on our website, accord-animalhealth.com. And if you have any questions you'll find our contact details on there.
Now we're currently conducting a small user experience study, so if any vets and nurses on the call would like a free trial of Pernicoox to use on their own dogs, please scan the QR code on the screen or you can email AH Marketing at accord-healthcare.com. Or you can contact us through the website and if you don't get any of these details down, I know the recording will be available so you can pick up the, details on there.
I'm afraid for logistical reasons we're only able to offer this to vets and nurses working for UK veterinary practises. But that's it, thanks everyone for coming today and thanks to Ian for speaking on what I think is a really important topic. Thanks.
That's brilliant, Chris, thanks very much. So Ian is a Liverpool graduate and a European and RCVS specialist in veterinary anaesthesia and anaesthesia. He has worked in both private practise and at several leading universities in the UK and Ireland, including serving as head of anaesthesia at the RVC and the University of Cambridge Veterinary School, and as Reader in Veterinary anaesthesia and analgesia at the Harper Keel Vet School.
He has a particular interest in the anaesthesia of unstable patients and runs regular pain management clinics. Ian is also dedicated to teaching, mentoring veterinary undergraduates and supervising postgraduate students pursuing specialist qualifications in pain management. He is also.
So currently chair of BSAVA Education Committee, president of the ECVAA and has a strong interest in evidence-based approaches to pain treatment. So a big thank you again to our sponsors today and Ian, thanks very much for joining us live. And I'll hand over to you now for your presentation.
Thank you. Thank you very much indeed Catherine, I, I, I, I don't like all those lists of things that you do. I, I'm afraid the longer you stay in the profession, the more of those things you get to do and you just fall into them.
But I am basically a practising vet who happens to work in universities. And the reason I'm here talking about this is because pain management and pain clinics are something that I do on a daily basis, basically. So I run referral clinics for, for pain cases at Liverpool, and I see a lot of cases with uncontrolled pain and different types of pain.
So really what we'll want to focus on today is to look at all the treatment options that there are for chronic osteoarthritis pain in dogs and cats. And as you are all very much aware, this is a topic which changes almost daily. And there is such a whole range of things available out there that it's sometimes difficult to know where to even start.
So what I'm gonna give you is, is my approach. My thoughts on the drugs, my feeling, which is based not only on experience but also on evidence and also on what does and doesn't work. And dare I say, based on mistakes that I've made over the years when dealing with these cases.
I don't have really enough time to go into the much much detail as I'd like, but I'm very happy to take questions that come into the chat or to to even try and answer them after the session, and you will have a chance to look back at these slides in the recording, so if I go too fast on something, I apologise. It's cos I want to cover a lot of er of of things here. So it's worth just saying what type of pain are we dealing with when we're dealing with osteoarthritis pain, just to set the scene and and and a few slides on that.
Don't forget that acute pain is adaptive and it's very useful. It tells us there's a problem, it tells us to get our hand away from that hot fire, it tells us to run away from this lion that's trying to eat us, whatever it is, but acute pain is inflammatory and no susceptive, so it's protective, and most importantly, it's reversible. What we tend to see in a lot of cases with particularly untreated osteoarthritis, however, is that we swap and we go into this neuropathic or functional pain state.
And these states are not any use to us. They have no biological function, they're not protective, they don't allow us to escape from that pain. And while it's true that osteoarthritis is an ongoing inflammatory process, a lot of cases that I deal with haven't been adequately analgesic or the owners haven't realised that there's pain, etc.
And so those are the cases that are very tricky to deal with, and it's those that I'm going to kind of try and focus on as we go through the treatments and give you my view on, on that kind of er treatment modality. It's worth looking at the causes of osteoarthritis pain, sorry, the causes of chronic pain or long-term pain, and you can see right at the top of the list, we've got osteoarthritis, which is why we're focusing on that today. It's worth just remembering though all these other causes, dental disease is the second most common cause of chronic pain.
Particularly in dogs, ear disease, neck pain, I see a lot of cases in the pain clinic that present with osteoarthritis pain, but actually they've got neck or lumbar sacral pain. Neoplasia, undiagnosed particularly is a problem, and let's not forget skin conditions, I think it's something that we always forget, that we can just diagnose what that pustule means, but actually it's painful and we should be thinking about analgesia for these cases as well, but we're going to focus on that top cause, which is osteoarthritis. There are different types of chronic pain as well, and this is really more for inflammation, for inflammation, sorry, that there's a slip, no susceptive or inflammatory are the top types of pain, particularly with the acute pain, but if we let it go unchecked, we get into this neuropathic pain.
But then there are various other types which have been described. I don't really think it matters too much how we describe the pain apart from if we're thinking about the gabapentinoids, and I'll come back to you later. But I do think it's important that we recognise pain is there and we do something about it.
What are the implications of long term pain, why bother? Well, number one of course is welfare, for we, we, we're interested in that, we're all here because we want to treat that pain, we want to eliminate it where possible. But in terms of the dog and the patient going through this type of pain, we've got this initial sensory ouch, that hurts pain.
Then it affects emotionally and I'm sure we've all seen dogs change behaviour with repeated pain inputs, and so we actually change the emotional state of these patients. And then we think about this cognitive pain and this is definitely based on human stuff, that the dog thinks more about the pain and may alter its behaviour to avoid it. And then the motor response, which is the response to this cognitive input, so the dog feels it's unable to jump up, which therefore limits exercise, which therefore changes life and it's a whole circle that comes back.
Essentially what we're dealing with is welfare and quality of life, and that's an important discussion to have with owners when you're, when you're dealing with osteoarthritis pain. One other thing I would mention is that many dogs come to me in a pain clinic and they don't have assessment. It's really, really important that you give owners some methods or some tool to assess pain.
There are lots, I put some up here, you, you can Google and find loads. I like the, the Helsinki, that's the one that I tend to use cos there's an element of er quality of life in there as well. But it's really important that you do this.
And I think it helps owners. To to assess how the pain treatment is going, but also really importantly, it involves owners in that process. And it's worth remembering that osteoarthritis is ongoing, it's not going to go away.
Owners must be on board with helping you as part of the team caring for the patient. So please, please, whatever you do, use some form of assessment. I don't care which one, there there's lots out there.
There's a new one from Liverpool for example, called Dogma, which is a little app you can download, all very useful and they're good at focusing the mind. I'm gonna let you come back to this slide, but if I listed all the behavioural changes associated with chronic pain in dogs and cats, all of these have been documented and written about and I think we would recognise most of these. Notice there are differences in things like sleep, and I've definitely seen patients who are more awake and yet some who will sleep more, and all of those can indicate a a painful condition, so any change in behaviour, you must listen to the owners and you must listen to what they're telling you, cos that's really telling you an awful lot.
How do I go into a pain clinic, what do I do? I, I, I take students with me and I, I brief the students about how to approach these cases. Number one, identify the owner concerns and expectations.
I remember once having a dog presented to me by a, a really big guy, you wouldn't mess with him, you he he looked like a bouncer or something like that, but he was a big chap and he was worried that his Doberman was turning into a ballet dancer. I said, what, what on earth do you mean by that? He said, well, look at how he's standing, and his back leg was turned out, it was rotated out, and he was worried about how his neighbours would perceive his dog looking like that.
That dog had pretty severe spinal pain, but the, the owner's presentation, the owner's concern was how his dog was standing, not that he had pain. So always try and identify those for you. Then find the problem.
Big tip number one, many dogs that present to me with osteoarthritis don't actually have osteoarthritis or rather uncontrolled osteoarthritis. They have spinal pain, lumbar sacral disease or sacral disease is a very common one at the moment, and also paxial thoracolumbar disease. So that's quite often where these dogs' pain is and it's not the joints which we know are not good.
We're doing a good job with the joints, but they have pain elsewhere. So identify the problem and how much pain there is. It's worth then if you, particularly if you work in a university and you're teaching students, classify those components of pain, and that can be important, how far have we gone down that that road of, of, of dealing with these patients.
Then the sources of pain and the type of pain. What do I mean by that? Do we have, for example, neck pain which might be neuropathic pain because of pressure on a, on a nerve root, that's gonna need different treatment to the right hind hip pain which is because of osteoarthritis and because of new bone formation around that joint.
And actually the treatments that we would use would be different, so it's worth thinking about that. Then it's really, really important to identify the aims of the pain management. The case of that guy I was telling you about, it was to get his dog standing straight.
In others it might be to go on longer walks, it might be to be able to go up and down the stairs. What whatever it is, it's worth involving the owners and coming up with a list of things that you want to try and get to. That helps you with the treatment plan, and that helps you then to review things.
So it's really important to keep reviewing these cases, but that's my approach in a in in a pain consult. Plat is useful, plan, anticipate, treat, evaluate, return, and then re-plan. And that's really important because don't forget that osteoarthritis is like this, it is a disease for life.
Over time, it gradually gets worse. You have to tell owners that this is happening and warn them about that. But you also need, I feel, to, to give them some form of dealing with these acute flare-ups.
We've all seen this, a dog who goes on the beach at a weekend, runs 20 miles, goes crazy, then is crippled the day after. What are the owners gonna do on a Sunday morning when you're not around, so I always try and equip my owners with flare-up options, and I'll talk about that when we talk about the drugs. Some people like this kind of approach, some it works, some it doesn't.
What we have here is a first tier and then a second tier decision making treatment. So when you first see these cases, for me, the pharmacological things would be the licenced agents like the non-steroidals or the anti-NGF antibodies. But please don't forget the non-pharmacological things, omega threes, environment, exercise, weight, etc.
And the things with the target on there have high impact on this disease and can be disease modifying, and yet all of the non-pharmacological treatments, particularly in the first stage, are an owner burden, because they have to come in and and do things. Never forget the owners in this. I always make a point to ask owners how they're coping, how they're dealing with this, because quite often these are their fur babies and they're very, very upset quite often about the degree of pain, and I've had many owners, in tears and actually saying thank you for asking, because it's not something we can talk about quite very easily.
So please ask owners how they're doing. If that first tier doesn't work and we're not getting adequate control, then we have to go into the weird and wonderful world of all these other drugs and I'll talk about those shortly, but we have to continue to remember the other things like the environment, exercise, omega threes, weight loss, etc. So it's really, really important to remember that it's not just the drugs, it's not just a non-steroidal, it's a whole range of things and it can take some time to sort out.
So how do I treat pain, analgesia, body weights, control of complications, disease modification, and then exercise, so the A, B, C, D and E, in my head is what I go through, and we will start with the first of those, which is what most people think of as the treatment for osteoarthritis, which is analgesia, pain relief. If I were to list all the drugs, this is. This is a moderate list, I could actually come up with a few more, but I, I, I want to concentrate on the commonly used ones together, going through some of the myths and the good and the bad points.
You'll notice some of the drugs there are in red, I'll come back to why, some are in orange, which means we might be changing our mind about them. But there are lots of drugs and I will briefly mention them. But please don't forget the interventions on the right hand side, I don't necessarily like the word complementary, I think it's hand in hand, but I think it's really important that we do physical therapies as well, and there are a number of these which again I will just mention.
So I, I'm based in the UK so I'm gonna start off with the licenced drugs which is my first line treatments for a a naive non for a naive osteoarthritis case. NSAIDs, as we know, are the mainstay, and they're very good, very potent, very effective at treating no susceptive inflammatory pain. And basically in my hands, any dog who isn't on an NSAID will, should be on an NSAID for osteoarthritis.
These drugs are disease modifying, they can slow the process down, they are very efficacious at treating osteoarthritis pain. However, we know all about the side effects, we know all about the things that are there, so I think it's really important that we are aware of the issues alongside the traditional non-steroidals like these, and, and I'm not advocating one over the other. Quite often dogs come to me saying, Metaca doesn't work, I'll put them on Rimiel or Eure and that does work.
And there's no rhyme or reason behind it I'm afraid, no, no real way of telling ahead of time, but it is worth swapping one non-steroidal for another, leave at least a week between the two drugs and see how you get on. I'm seeing a lot more of these though, I work in referral practise and we are definitely seeing an increase in GI ulceration, not really renal disease, but definitely GI ulceration, so again, warning owners, any diarrhoea, particularly blood, any vomit with, Coffee grounds in it, they must stop and let us know straight away. Don't, don't, don't not tell them about this.
I actually have sheets with side effects, listed and what to watch out for and what to do, and I give those out with the, with the drugs. Galapr is an interesting drug, it's a Pipri class non-steroidal, and what it does is block the effect of prostaglandin E2 on the EP4 receptor, and this is probably the major receptor that moderates and up regulates inflammation and pain, but this is really only in osteoarthritis cases, there's more and more evidence coming out now that it doesn't do much for soft tissue pain, etc. No doubt it does have an effect, but really I would only use this in osteoarthritis pain, however, I'm happy to use it, it can definitely be used as a first line treatment, but you must have that diagnosis, and I'm gonna come back to this again, but a lot of the treatments that we use, you must have a diagnosis.
Flexing a hip and getting some pain doesn't mean that there's necessarily joint pain there. It is worth taking some time and if you can, try and get images, etc. To confirm the diagnosis of osteoarthritis, because muscle pain in that area can look very similar and it's very easy to be caught out between the two.
Galapent is approved for use in dogs for 9 months, yep, it, it, it's very easy to give, it's well tolerated. I do definitely see though, some dogs will develop a little bit of vomiting or diarrhoea, usually for the 1st 2 or 3 days, I just alter the foods timing with the drug and usually they'll work through it. So if I see vomiting or diarrhoea with the traditional NSAID, I will stop the drug because I'm worried about ulceration.
The Gabapentin usually work through it, and usually it will, it will, they will come through, but I keep in touch with the owners at this stage, and as you know, not for use in cats at all. Newer agents, I guess I'm gonna have to remove this title very soon because this has been around for a little while now, but what about Librella, what about Silencia, the anti-nerve growth factor, monoclonal antibodies. The original work was very interesting, this is in 2018, and again you can go and look this up.
This is an open access journal, and very interesting to actually read about the effects of it and how the drug works. If you want to know more, I'd recommend this Enimoto paper. What do I see, this is kind of a diagram of how nerve growth factor or the effects of nerve growth factor and where it binds and what it does and it has a lot of effects within the cell.
Basically though, this is another non-steroidal, sorry, this is another osteoarthritis specific drug. It only really works in cases of osteoarthritis, which is the indication for Librella. So again, I think it's really important that you have that diagnosis first.
I definitely see injection site pain when I'm using it, perhaps because the dogs have, have had multiple other things before, and a lot of owners will tell me the dogs will drink and and wee a lot more, but I'm actually wondering if that's an improvement and that they can get up to go to drink and they can get up to wee, so actually the activity is better. It said you have to give 3 months, but I, I would expect to see something almost immediately with Librella in dogs at least, and I guess about 50% of the patients I use it in will, will improve. Once again though, you must only use this with the correct diagnosis, there's some evidence that it might make neuropathic pain a little bit worse, because of the central interactions, so if you have known osteoarthritis, that's the source of the pain, then it's definitely worth considering.
But as I'm sure you're all aware, there's been a lot of talk lately about the potential side effects, about fast onset or or rapidly progressive osteoarthritis, about potential neurological and renal side effects. I, I think we, we, we may see an increase in those, yes, but we see side effects with many other drugs as well. And I think let's just keep an eye on this and, and see where things go.
The, the numbers at the moment are slightly unsure one way or the other, but please be aware of the potential side effects, and they are listed now on the package inserts. In cats, we tend not to use the drug very much, I certainly don't see as many cats as I would see dogs. There's slight, a couple of problems with it, I, I definitely see skin reactions in those that I have used it, and you have to make sure that your patients are above 2.5 kg, and sometimes these older skinny arthritic cats may be less than that, which limits its use occasionally.
It can take up to 3 months though I do find that it's slower onsetting cats and those that I have used it in, have, have shown an improvement, but it has taken a little while. So again, the assessments are really important because cats are very difficult to assess, but there are tools out there, and again I would refer you to my earlier slide, it's really important to assess these patients. Let's just have a look at the other two licenced agents that we can use, that's paracetamol in the form of PdLV and Tramadol.
As you know, Pardel is approved for use, it's got a veterinary licence, it has some homoeopathic codeine in there, which really isn't doing anything at all for our patients, but I think that the doses that we're using of Pardel, about 33 mgs per gig, is a decent dose. It's only licenced for up to 5 days use though, so a maximum of 5 days, so again for the chronic cases, it's probably not worthwhile continuing at those doses because you're going off licence after about 5 days. There is an IV prep available and I'm sure most of you are using it.
It isn't licenced alone, so you do have to justify the use of paracetamol chronically, in terms of the cascade, but I will certainly use it in many dogs that have er osteoarthritis. I find it a very useful adjunct of background analgesia, and this is also what I would use as my flare-up treatment in those dogs that it's suitable for. Yes, it can be used alongside non-steroidals, yes, it can be used alongside steroids.
People worry about the liver. I don't give it to patients who have known oxidated liver disease, and that's essentially those that are acidic and yellow. Any other dogs, I'm quite happy to use it in, but we do warn the owners about potential side effects, and we do recommend a blood sampling, particularly in the early stages of treatment, just to make sure we're not causing any problems.
There are, there are so many doses out there for paracetamol, the SAVA formulary I know tended to be around about 10 mg per kg, I, I use a minimum of 20 milligrammes per kilogramme 3 times a day, and that doesn't matter if it's oral or if it's an IV preparation, but I will use 20 milligrammes per kilogramme 3 times a day. And I was talking earlier about flares and equipping owners with something, if I have a patient who's receiving paracetamol, I will very happily give 33 milligrammes per kilogramme, so almost doubling that dose, 3 times a day for up to 5 days. I asked them to let me know if they decided to do that, and only for a maximum of 5 days, usually 2 or 3 days is sufficient, but that's a really good kind of flare treatment for those cases who can, who can take paracetamol.
Obviously paracetamol is not for use in cats, as I'm, as I'm sure you're all aware, you mustn't give it to cats. Tramadol, er, tramadol, so tramadol is a licenced analgesic, chewable tablets available as Traleve, unfortunately there are some real problems with tramadol. In theory it has a weak uptake, a weak opioid action, and norepinephrine or serotonin reuptake inhibition, and it was considered originally quite useful for moderate to severe pain.
However, there is now an awful lot of evidence that tramadol is doing very little, if anything, in dogs. Only about 10 to 12% of dogs can metabolise it to the active metabolite, which is Odesmethyl tramadol, so immediately 90% of dogs can't metabolise it. There's now also some evidence that what it's doing is increasing serotonin within the brain but not actually affecting the pain pathway.
So yes, there may be a subset of dogs where we get a a a a change in behaviour, which was thought to be because of analgesia, in reality it's just changing behaviour so they can't demonstrate the pain is there. So again, a very personal opinion, but we've got a lot of evidence to back this up now, and this is the one drug that drug that I actively remove from dogs if they come to me in the pain clinic and they're receiving tramadol. It's a drug that I will take them off because I feel it can be just confusing the story and not allowing these dogs to show pain, which is a real worry for me.
I feel that they might be trapped in. Now this is very different in cats, I think in cats we have a good amount of evidence that tramadol is producing some analgesia, slightly different mechanism in cats, the big problem is they really hate the taste, and so actually getting them to take tramadol can be tricky. What I tend to do is keep it in the freezer or in the fridge, and that decreases the smell from it, and so we've got more chance of getting it in, but if you can get cats to take tramadol, it's worth doing.
But dogs, no, for me that, that's an absolute no for, for dogs. So what do we do if we've been through our licenced range of drugs and we've still got pain. Then we have to look at other things, but I make the point down at the bottom of this slide, whatever you do, change one drug at a time.
Add one in or take one away, but don't change three things because you will have no idea which was, wasn't working and which might be working going forward. Really, really important that work with the owners, explain it's gonna be a journey, but it's for the long term, very important to work out what we're doing. Let's have a look at unlicensed agents in the UK anyway, which are used under the cascade, and again this is no particular order, I'm not advocating one drug over the other, I will take each case as an individual and work through the options.
And just to remind you about the cascade. And the, the, the importance of, of following that. And I always record on the patients' notes that we have explained what drugs we're using, how, why, what the legal situation is, er and some of you may even be getting owners to, to sign to say that they understand that and that's not a bad thing as well.
Whatever you use though, we tend to use evidence based veterinary medicine, and I think that using the evidence is really, really important, not just, oh let's try that, it's, let's look and see if there is evidence for this drug in this condition er and see how that works, and that is a very sensible way forward er and a very good way of justifying your, your treatment options. I want to talk about a man scene and the man scene. These are NMDA receptor antagonists, so they break that cycle of chronic upregulation of spinal cord, sensitization of development of chronic or pathological, this cognitive and functional pain states.
I find them really useful for opioid tolerant patients and they are synergistic with opioids, so, definitely can be used in the acute situation as well. I put some amantadine's suggested doses down there. Just be careful in cavvies, and I, I'll be intrigued to know if anybody else has experienced this, but I have given amantadine to 2 or 3 patients in the past who are cavaliers with syringomyelia, and they developed pretty horrendous itching, so much so that they have rubbed themselves raw around the back of the head, round the ears, and had to go on steroids, etc.
So just be aware of that, I don't know if that was just me being unlucky, but it's definitely something that I have seen a few times now. Throw a spanner in the works and I realise that many of you might be using amantadine, and I definitely see patients come to me in the pain clinic who are receiving amantadine. Since 2022, there has been an EU ban on the use of amantadine in animals because amantadine's a human antiviral and there's increasing evidence of resistance in the human field to this drug.
So there has been this ban. I think because we have come out of the EU then there is some confusion over this, etc. But definitely I know don't use amantadine and I will use other drugs in place because I don't want to contribute to this pool of resistant viruses, which, you know, if we had another pandemic, who, who knows what effect that would have.
So Amanstine is banned in the EU as an animal medication. So what do we have instead? Well, we've got two things really, memantine.
Memantine I find quite useful, and I find it less sedating and less nausea inducing, which amantadine certainly used to be. And this is a very good oral, really inexpensive NMDA receptor antagonist. No clinical trials as yet, doses there, I usually start about 0.5 mg per gig once a day, but we'll happily go up to twice a day and then increase the dose as well.
Slow onset, that's the trouble, it can take 3 to 4 weeks, as did amantadine, to be fair, transient GI signs may or may not lower seizure threshold, I, I'm not convinced about that, I've definitely not seen that as a problem, but these are all reported issues. If we don't have amantadine, sorry, memantine, what else could we use? Well, obviously ketamine is the other drug, which is an MDA receptor antagonist.
It's a pity you're not all in a room with me, because I'd ask for a show of hands, how many of you are using subcut ketamine for treatment of chronic pain or to initiate treatment of chronic pain. There is a recent survey and that says that about 50% of people are using it. So that's quite a high number.
And that comes from a number of sources and one for example, you might know zero pain philosophy, a friend of mine, Matt Gurney, who runs this, and definitely he and I kind of agree that we do see some response to ketamine subcutaneously at about 0.5 mgs per kg. I will quite Often use ketamine as a, as a trial drug to see if memantine's going to work, so if they respond to ketamine, if we see a change documented using a scale with subcu ketamine, then these are dogs that I'm quite happy to start with memantine, knowing that it will help.
Subcut it tends to last anywhere between 3 days and a week, it can be a little bit variable, and I, I tend not to go higher, I once gave 1 Migba kick to a bulldog who, who actually belonged to one of the veterinary nurses I work with, and this dog was totally spaced for the next hour. So for me I now just use half a Migba kick and see if there's a response. Gabapentin and pregabalin, the gabapentino's not licenced again, we don't really know how they work, it's not acting on GABA channels, but these are indicated for neuropathic pain.
That's fine, but what is neuropathic pain, and sometimes that's very, very difficult to work out, we know we have spinal cord disc compression, etc. Then yes, I will start patients on one of these two drugs. However, they are quite sedative, and they can be quite expensive, particularly pregabalin, but please remember that with gabapentin, if you're going to use that, it has to be 3 times a day, or these patients will have periods when they're not covered for neuropathic pain.
There is some concern though, which is increasing now over their appropriate use. I see an awful lot of patients who will come and be referred for various conditions, and so many of them are receiving already gabapentin, and we don't always know why. Sometimes they're just used as sedative agents to calm the patients coming through into the hospital.
So there is some evidence or or some concern that what we're doing with these drugs, particularly in the early stages, is just sedating rather than actually analgesic. So again, I make the point I would only use when I know there's neuropathic pain there. In terms of evidence, there's only one paper looking at gabapentin alongside non-steroidals in osteoarthritis, and again that was, that was two drugs together, and there was some evidence that it did decrease pain scores, but only one paper, that's all the evidence that we've got.
Amitriptyline is a drug that I use quite a bit now, again not licenced in veterinary species, it's a TCA tricyclic antidepressant, and again, neuropathic pain but also central spinal cord pain can be quite useful, it acts as a central opioid receptor, etc. A serotonin norepinephrine reuptake inhibitor, so don't use it with other drugs like tramadol or pethidine that might do the same thing. It's reported it might cause cardiac arrhythmias, but I have never seen that.
But I, I just warn you that it is out there, I, I'm not sure how true that is. You will see cats doing this, it's like tramadol, this horrible ropy saliva cos they hate the taste of it. But I do find it particularly useful, particularly as a behavioural component to the pain.
And, and just so that you know, I often refer to, and I'm lucky that I work with physiotherapists and behaviourists, and I will quite often refer painful patients to behaviourists because I feel it's actually a behavioural problem rather than a pain problem once we've eliminated pain. But definitely things like tail pull injuries in in dogs and cats where they are sore and they're constantly going at the back end and it becomes a habit rather than the pain driving that. I do find amitriptyline can be quite useful, a useful add-in to other things particularly.
What about some of the other things that are out there, I, I've just mentioned them, Tapentadol, which is a benzanoid opioid. This has got a good safety profile and a good, pharmacokinetic profile. So this is a controlled drug, it's Schedule 2, whether we should be giving it out to owners or not has to be your decision, but sometimes they do in palliative care cases.
And obviously there's a an explosion in the use of trazodone at the moment. This is a tetracyclic antidepressant. We don't know if it has analgesic effects or not.
And again, I think we're gonna have to keep a very close eye on this to make sure that what we're not doing is just sedating the patient. Having said that, pain has an emotional component, and perhaps we're just treating that emotional component, that would be fine as well. Transdermal lidocaine can be useful, I use this insurgical patients post-op.
Obviously unfortunately because most of our patients are hairy, it's not that easy to get the lidocaine across the skin, so we would have to er er clip patches, etc. Which is not wonderful, and the big concern is patients eating these patches, however, there is some evidence that those are quite useful, and there is some research into their use. Methocarbamol, I don't know if any of you have used this, it's a centrally acting muscle relaxant, so again these back dogs who are getting horrible spasmy type pain and non-steroidals aren't really touching it, it can be quite useful for this spinal abdominal gripy type pain, I tend to use it though in hospitalised patients, cos we're still as yet a bit unsure about some of the side effects.
Bisphosphonates, I don't know if any of you are treating, osteosarcoma cases where owners have refused to, you know, have an amputation for example, then for palliation, I do find particularly alendronic acid really useful, I do find it a great analgesic. It is however associated with decreased life expectancy in humans, although obviously if we're dealing with osteosarchic patients then that that becomes less of a concern, and I think the pain control and the palliation becomes much more important. Don't forget, if you have a patient who you can't control the pain in, getting them in, giving them IV infusions, giving them opioids can be a good way of resetting that pain threshold, and this is something that I will quite often do, might even include, for example, doing an epidural with steroids for lumbosacral disease.
But follow that up with a ketamine depot to break that cycle, it can be quite a useful technique, so don't forget that that is a possibility as well, to actually hospitalising to treat the pain and then resetting that pain threshold. And there is various recipes, as I know you're aware for MLK infusions, in all the formularies, that's the one that I use, but er it's just an example, and again the numbers are there for you to come and have a look at later. Couple of other things from the States, no SETA, which is 48 hours of buppivocaine, for soft tissue surgery, we don't yet have that in this country, but hopefully we will get a a a a go at that soon.
And then of course there's the cannabinoids. Very mixed evidence about whether they're doing anything or whether they're not. They may or they may not.
We need large controlled trials on these, but in a recent survey of patients who were coming to my pain clinic, about, about 60% of the owners had tried CBD oil in their dogs particularly. So this is something we need to be aware of, we know it's out there, evidence at the moment is limited and I'm not recommending it until I see better evidence. I, I might change though, I might change as evidence comes through.
One thing that's really important, and why I don't want it going underground is that a lot of the CBD products, for example, that were on sale in the States 4 years ago, actually had half, at least only half of the amount of CBD that they stated on the, on the actual label. So they must come with a full certificate of analysis. Really important that people are using the proper stuff from reputable pharmacy stores.
And then Capsaicin is is something used in people, er not gonna go into that, I don't know if we'll ever be using it, but it's an interesting treatment particularly for rheumatoid arthritis. So some of those other methods apart from the drugs, acupuncture, I use it quite a bit, these are some dogs that I acupuncture, and NICE for example in the UK recommend it for chronic lower back pain, migraines, stifle osteoarthritis, so the evidence is there that it works. We have limited veterinary clinical studies, it's virtually impossible to sham acupuncture a patient to control something, which is the problem that we've always had.
I find about 80% of patients who we acupuncture with musculoskeletal pain or muscular pain in these cases, the apraxial muscles on the back, about 80% of patients respond very nicely, and we can withdraw or decrease at least some of the other analgesic agents we're giving, and well tolerated in patients, worth learning how to do if you're interested in pain management for sure. Physiotherapy, I'm not gonna go into physiotherapy cos I don't know enough about it, but our physiotherapists do an amazing job, and one thing I would shout out for, please don't forget preconditioning. Sometimes some of the older dogs that you're going to do surgery on that might already have osteoarthritis, it is worth doing some pre-surgery physiotherapy on them to try and precondition them so that they don't get crippled with the osteoarthritis because they're lying in the same position on a hard table for 2 or 3 hours.
It is worth remembering that, and always with anaesthetized patients, passively move the limbs around now and again as much as possible, just to keep everything flowing properly. Hydrotherapy similarly thoroughly recommend it, and one of my dogs has had hydro, er a a really good technique and definitely something to think about. People ask me a lot about laser therapy, we've got limited evidence for it, so it's not something that I actually do, some people like it, and definitely what's really important is the contact with the patient, the physical side of things, moving them around, that's really an important part of physical therapies, so I have no problems with that aspect of it, but again I think the evidence for it is, It is a little bit confusing at the moment, I, I'd like to see some larger trials used, but definitely it's a possibility, together with things like shock wave therapy, etc.
There's some evidence for them, but not every, every study is saying the same thing. Tents is really useful, but the problem is we have furry dogs. So actually getting that contact between the skin and the electrical stimulation pads is really difficult.
If we have a shaved patient, for example, then yes, it can be quite useful. And tends it does tend to work quite nicely, particularly in our hospitalised patients. It might just mean that we're stimulating the muscles and getting blood flowing, etc.
But whatever it's doing, it seems to be doing a good job, but I do find it very difficult for it to be effective in very furry patients. We just can't get that contact. And then finally we have things like palliative radiotherapy, and this is our radiotherapy unit at at Liverpool, so obviously we will do this quite a bit, and there is some evidence that this is very effective for canine osteoarthritis.
Obviously the, the price precludes it and the fact that they need a general anaesthetic and several fractions of treatment, means that it's not going to be a practical treatment, but, but occasionally, alongside other things we will use this. Body weight, so I'm gonna just quickly whiz through the next couple, body weight, really important, 10% body weight loss can reduce pain scores and improve quality of life with osteoarthritis. Please don't forget this aspect, and that's a very difficult aspect to approach with owners, I appreciate that, but please don't forget this aspect of the osteoarthritis pain management.
Control of complications, common sense comfort, I know I'm speaking to the converted here, you know about owner compliance and how important that is, involve them in the process, involve them, don't be afraid to tell them about the complications, because then they're involved in that process. Teaching massage techniques really useful, again it's improving that, that touch, that, that feel and that connection with the, with the patient, and between the owners and their pets, they really like that. And then obviously environmental modifications, raising dog bowls for example, I, my dogs eat now from a raised bowl because of neck pain, things that go up and down into the car, ramps, etc.
Hiding places for cats, all of these things, they're feeling sore, they're feeling miserable, they want to hide. Let's not, let's not stop that behaviour, let's help them, but also treat and, and, and, and work together with all our patients. So, you, you know about the common sense stuff, but I spend a lot of time going through owner with owners about this, and many are, haven't thought about it.
They all say as well, by the way, that slippy floors are really bad for osteoarthritis patients. Just a quick shout to have a little bit of slippy floor somewhere because I find a lot of dogs will want to go and lie on a cool, hard floor to ease the, the, the pain. Pain in their joints and this is something I find pretty consistently.
They like to sleep on something and walk on something that's nice and fluffy, but sometimes they'll just want to go and stretch out on a, on a cold, cool floor. So that can be really helpful as well together with cool mats. Disease modification, I just want to talk about as well, it is really important that we have the correct diagnosis so that we know how to treat, OK, really important, we want to be treating the right disease and not what we think is the right disease.
So there are specific things such as corticosteroids for immune mediated polyarthritis. Surgical intervention, we, we do a lot of hip replacements for example at Liverpool, so these are, following the correct diagnosis, surgical. Then there's things like the polysulfate, glycosamine, the glycans, inconsistent results I would suggest with those, so I tend not to bother with those.
If owners want to use those, that's fine, I, it's not something that I would ever use. I do think there were an awful lot about feeding, about nutraceuticals as we call them, and definitely for me the omega 3 fatty acids in cold pressed green lit mussel is the one that there is consistent and good evidence for, and it's the one supplement that I will actually tell owners to go and, and, and look for and seek out and and put their dogs on. And both of my dogs, you know, I, I do what I say, both of my dogs are on cold lip green er cold pressed green lip mussel extract.
There was one paper looking at elk, velvet antler as well, yeah, I, I, I don't know either, but apparently that was quite good. Things like glucosamine, chondroitin, turmeric, even the big Cochrane reviews in people say that there's no evidence for them, so I think it's really important that we look at the evidence, but again it's that green lipped muscle which definitely has a, has a difference, and there's various papers that will look at this, er er and lots out there, you can go onto Google Scholar and find most of these. Finally exercised.
Exercise is really important. We only use strict rest for acute conditions, as you know, post-surgical flare-ups, etc. Exercise is really useful, weight loss, muscle strengthening, it has this emotive component, it's really important that dogs are kept interested.
The ones that I can't treat very well in the pain clinic are those that come in that have given up. Those that want to do things, but the pain is stopping them doing things, those are relatively easy to treat, but the ones that have given up are the really tricky ones. So it's really important to keep their minds focused.
Ask owners to video what they're doing and you can quite often pick up clues for what's happening there, harnesses, for example, modification of exercise, scent training, all these are good. Little and often, as you know, is in theory the best. I ask owners to say how long before your dog wants to stop and doesn't want to do any more.
If that's 20 minutes, then the walk should be 10 to 15 minutes, so just before we reach that. Point, don't let them get to that point where they don't want to go on anymore. They really must not get to that stage.
That's when they do some damage and the, the mental side kicks in and they, they start to not like walks. So it's really important to keep them interested. Just very briefly, I think I've got a couple of minutes, case discussion.
This is a, a, a case that I saw in the, in the pain clinic, pretty typical 1114 year old, pretty large Labrador, severe fall in osteoarthritis pain, it was both elbows. Elevated liver enzymes, not dramatically, occasional vomiting, would that worry you? I think it tends to be the inflammatory state that we see in these Labradors, yeah, for sure we were checking bloods, but there was no significant disease, no tumours, etc.
Is receiving meloxicam. But the owners thought it had reduced efficacy. I think it's instead we've got progression of osteoarthritis or we've got something else going on.
So the first thing here to do is to check pain, once we're happy that the liver, kidneys, etc. Are functioning, then we check everything else. We put this dog on paracetamol, 20 mgs per kick, 3 times a day and did a quality of life assessment.
Some people would be worried about paracetamol because of the raised liver enzymes, in this case I wasn't. We had a functioning liver, we just had a liver that was wearing out, but we've also got a dog in extreme pain, so we had a lot of discussions with the owner about the quality of life versus potential side effects. And I have never had an owner saying I'd rather my dog live longer in pain than slightly shorter but pain free, so you do have to have those conversations I'm afraid.
Occasional flares though, what would you do in those cases, what would your approach be? How would you equip these owners and what would you try going forward? Added in pregabalin at that stage because I was pretty convinced that we had severe neuropathic pain.
This dog also had neck pain which hadn't been picked up before. So we're gonna make the point when these dogs come to you with known osteoarthritis, don't assume that that's their pain, please look elsewhere as well. We use paracetamol for flares, as I described before, the owner were the owners were quite happy to use this on bad days, and actually we use Lidoderm derm patches because the orthopods had taken lots of samples from this dog's joints to check for immune mediated problems, because there was a slight concern over that at one stage, and so we could put some lidocaine directly onto the joints and that helped as well for the flares.
Then actually responded really well to acupuncture. We tried acupuncture after changing the drugs and seeing where we were up to, we thought we weren't quite there enough, and there was definitely this secondary back and neck pain, which is musculoskeletal pain. So we, we got pretty good quality of life for this dog in the end.
It didn't live very long, but it's a 114 year old Labrador unfortunately, but what, what life it did have was, was very good in the end. So I think I've managed to get through everything pretty OK, sorry it was a bit of a rush. Just a few points.
There is not ever going to be a magic bullet for osteoarthritis pain. Pain assessment tools possible, we're going to be able to target and treat that pain effectively, but please remember osteoarthritis is dynamic, it changes over time, expect flare-ups, pre-plan for them and give the owners something to do, get the owners on board, and finally, a mistake that I've made a few times, never assume any new pain is osteoarthritis, there might be other sources of pain that you need to know about. So thank you very much, that's me.
I'm gonna stop sharing my screen now and hopefully we'll, I've left enough time for a couple of questions with that are already come through. Oh, that's brilliant. Thanks so much Ian.
That was a really interesting and thorough presentation, you covered an awful lot of ground there, so thank you, that was great. And 3 minutes to spare, so well done, you didn't run out of time either. I know Chris has got a slide that he's just gonna pop up again for anybody who missed it earlier.
That's great, thank you, Chris. So there's the QR code there if anybody would like to scan it before the session ends, please do so now. If you have any questions for Ian, please pop them into the Q&A box, I can see that some have come through, so shall we do some quick ones now, Ian, is that OK?
Yes, I can, I can start at the top, I can see a couple of them. How do you determine which issue they have, whether it's osteoarthritis or something else? Yeah, really good question, it's a thorough exam.
You have to go over the patient, you have to examine each joint, ideally you have to take images as well, but quite often I'm finding there's muscular pain, neck, thoracolumbar, and axial, kind of, lumbosacral pain, so that that's quite often where I will find the pain as well. Don't forget palpate the abdomen, palpate the kidneys as well, I'm afraid it's just doing a thorough exam which can be quite difficult cos there's more than one source of pain quite often. From the paracetamol, can you buy paracetamol in the store instead of a veterinary practise once prescribed?
I, I refuse to answer that. I, I tell owners what I would use if I were going to give my patients, paracetamol. I think I always start them on tramadol, sorry, on tramadol, on, Parel.
But because it's only licenced for 5 days, I'm quickly going to go off that, so, many patients that come to me are already receiving human paracetamol, however, that, you know, we perhaps shouldn't be doing that. Librella, negative experience owners have reported, have you had reports of adverse? Yes, we do see adverse reactions, but we see adverse reactions in any particular drugs.
So I, I think that can be a problem. There is now a warning and an FDA warning about the side effects, and please, please, please, if you do see side effects, report them, otherwise we won't know about them. So please do report them.
I haven't seen any severe side effects, no, none of the neurological ones, but there are reports of that. is it OK to keep tramadol in a fridge or freezer, storing temp is room temperature, I absolutely agree. I tend to store them at room temperature, put them in the fridge freezer for a short time before trying to give them to the cat.
I don't find that that's reducing the efficacy, I find that it is still working, but I do find it occasionally easier for the cats to take it. So yes, thank you for saying that, but I think store as according to the, to the package. Best pain management for dog and cats with CKD grade 30, that, that's another hour I'm afraid.
Unfortunately, there was a very nice study that showed that cats are receiving meloxicam in chronic kidney disease, live longer than those who weren't receiving meloxicam. So again, it's a discussion with the owner, an open and frank discussion about the side effects and a discussion. About pain, quality of life versus potentially worsening of a disease.
So I don't think there is a best, but I do think it's really important to be open with the owners about that, and I do give non-steroidals to cats who have chronic kidney disease, but that's the clinical decision on each case. How often do blood test for non-steroidals as you get older? Again, clinical exams are really important, don't use bloods as, as a substitute for clinical exam, but I recommend twice a year unless there are signs of renal or hepatic disease, so vomiting, diarrhoea, off food, anything like that, then we will get them in sooner and check.
But as a routine, I recommend every 6 months to my cases. Silencia, can we give it every a month? Do you have advice for it?
Follow the package inserts, I think, follow the, follow what's said from the drug manufacturer. I think it's really important that we don't, go off that, particularly with the side effects reported. So I, I would just use what it says in the on the label, and that's definitely what I would do.
Fantastic, oh that's great Ian. Thank you very, very much again for that great presentation and for taking the time to answer some questions as well, we really appreciate it, thank you. I'd also just like to say a big thank you to Accords Animal Health for supporting this er session today.
Er Chris's slide is still there, so if you do want to scan the QR code to get some more information from his team, please do so now. I also just want to really quickly mention. As well that this is the 2nd webinar that we have done with Accord.
We did one a couple of months ago and we've already had over 700 people view the last webinar. It was a fantastic webinar, so please do go and check that one out as well if you've not seen it already. I know Bec's gonna pop that in the chat box.
Just a quick reminder as well, because I know we'll get asked. Recording of this session and your CPD certificate will be available on the webinar vets platform within 48 hours. As always, we will email you once it's ready and your CPD records will automatically be uploaded as well.
And that's it, all that's left to say is just thank you very much everybody for joining us. Thank you Ian, and enjoy the rest of your day. Thanks again, thanks everyone.
