Good afternoon everyone. My name is Charlotte, and thank you for joining us for today's lunchtime webinar, Pain Management in Rabbits, More Than Just Oxycon, presented by Sophie Jenkins. Today's webinar has been kindly sponsored by the Rabbit Welfare Association, so a big thank you to the Rabbit Welfare Association for today for making today possible.

So, a bit about our speaker today. Doctor Sophie Jenkins is an advanced practitioner in zoological medicine, is a veterinary surgeon based in South Wales in Cardiff. Sophie graduated from the Royal Veterinary College in 2008.

She went on to follow her passion for exotic animals and gained a general practitioner certificate in exotic animal practise in 2011. In 2016, Sophie completed a postgraduate certificate in exotic animal studies and was subsequently granted status as advanced practitioner in zoological medicine. Sophie gives CPD talks and lectures to vets and nurses on exotic medicine and surgery.

Sophie is a gold member of the Rabbit Welfare Association and fund. Sophie Sophie was recently awarded the Burgess XL winner of Rabbit Vet of the Year in 2020. Rabbit owns and runs Origin Vets clinic in Cardiff, and Sophie offers 1st and 2nd veterinary opinion, as well as referrals for reptiles, small animals, rabbits.

Birds, amphibians, and fish. Sophie's exotic work covers rabbits to rhinos, sugar gliders to skunks, chameleons to camels, as well as birds such as African greys, owls, and also amphibians, fish and inverts. Sophie has over 25 years' experience of keeping a Breeding various reptiles including bearded dragons, multiple species of chameleons, and several species of geckos.

Sophie has 1 cat and a dog, 2 large fish tanks, including a discus setup and a guami setup, a rescue horse-billed tortoise, and rescue bearded dragon. Sophie also has a big soft hot spot for rabbits and currently has 4 rescue lion heads. So we're in good hands today to talk about pain management in rabbits.

I wish to let everyone know that today's session will be recorded and available on playback, and you'll all receive a certificate for today's attendance. Please use the Q&A box for any questions you may have for Sophie throughout the presentation. And at the end of today's session, we'll see if we can answer any of these questions you may have.

If we run out of time with the questions submitted, we will email any responses to you in the next few days. So with no further ado, I'd like to now hand over to Sophie to start today's session. Thank you.

Thank you, Charlotte. Thank you very much for the welfare, er Rabbit Welfare Association fund for sponsoring this this as well. So we're gonna talk about pain management in rabbits today.

It's often overlooked, I think, because, partly because they're a prey species, so they don't always show obvious signs of pain. So we're going to understand why that can occur, and the signs of the pain in rabbits. We're gonna look at interpretting those signs to try and locate the pain.

We're gonna go with the medications that we can be used, roots and doses, in clinic and at home. And we're gonna look at sort of other treatments that we can use, including adaption of environments for chronic pain by these things like arthritis or those that need pain relief longer, for example, after fracture repairs. So I'm gonna give you a little case to think about whilst we're going through this.

This is Mara, a two year old French lap, single entire female that we saw in May 2021. Originally saw in April with abscesses on the face, not seeming to be dental related, a bit unusual. She is fully vaccinated, and she had a sudden onset of lethargy, hi and anorexia when she was brought into the clinic.

So there she is on the right hand side. So as we're going through this webinar, just bear her case in mind, and just, ensure that, you're understanding like where everything's coming from regarding her treatment as well. Any questions on her case, we can discuss right at the end, so I'm gonna run through the case, in a bit more depth.

OK, so why do we want to go through understanding pain and, and protection from it? Well, it used to be called the the sort of five freedoms. It's now more more known as the five domains, but included in that is freedom from pain, injury and disease, including freedom from discomfort.

Hunger and thirst, and to be able to express normal behaviour, and sort of prevent things like fear and distress. And all pain sort of comes into all of those, particularly in rabbits, because a painful rabbit will often develop quite quickly onto gut stasis, and then you've got the sort of nutrition aspect coming in, mental state, they're getting, distress from that gut stasis as well as then the pain that they were originally in. It does apply to all animals, including the owner and carers, including the veterinary practises, as well.

So prey species, just very quickly to remember that a prey species is an animal that's hunted or killed by another animal. So in this situation with a rabbit, we've got the European rabbit and, and the lynx. Therefore, if a rabbit showed if it was unwell, it was injured, it'd be an easy target for its, predator.

So rabbits and other prey species will often mask obvious signs of, being unwell or in pain and therefore weak. So we're going to discuss what those signs are as we go through this webinar. So why is it important to know that?

. They are species that have a different natural activity time compared to cats and dogs. The rabbits generally are crepuscular, as are many other rodents as well. Some of them can be nocturnal as well, or a combination.

That does mean it's quite difficult to visualise the pain, from an owner point of view. We're quite lucky at our clinic. We've got some very hot owners in regards to what they are monitoring, so that a lot of them will have CCTV, so they can pick up on this earlier, changes, sort of masking behaviours of of being unwell.

It's something to consider in practise, to, to sort of look at CCTV as well, for your hospitalisation setup so that you can monitor the pain score as the animals are in with you. Uncontrolled pain is unnecessary suffering. It unfortunately things like traumas do cause pain and part of that is, is to enable healing process.

However, if it pain is left uncontrolled, it can quickly lead, particularly in rabbits, and other hindgut fermenters as well, onto gut stasis. It will also cause a wind up pain, so ideally for analgesia, we want to preempt it. We want to ideally put pain relief on board before the pain happens because once it is already wound up, it's harder to bring it back under the control.

If it's left uncontrolled, it will worsen the primary, condition. So wounds won't heal very effectively, the, if the animal's left in too much pain. It can lead to a stressed immune system.

They can become weak and therefore they not as effective in how they actually respond to that illness or any other illnesses as well. And unfortunately, going back to our first point of gut stasis, particularly in rabbits and other hindgut fermenters like guinea pigs and chinchillas, it can lead very quickly onto death, and we'll briefly touch on this now as well. So if a rabbit isn't pinged, it's stressed, catechi amines are released when they are stressed, and that will decrease gut mortality.

So any underlying illness or stress in a rabbit is a major cause of gut stasis. Now, often in first opinion practises, the rabbits are coming in in gut stasis. As I said, we're quite lucky and a lot of our rabbit owners will pick up on signs of them being unwell or in pain well before gut stasis kicks in.

However, in many cases in, in the practises, the rabbit comes in because it's in gut stasis. Now, if the rabbit's not eaten properly, we always need to do a full investigation. So we're gonna touch on that a little bit as well, but we're not gonna talk too much about gut stasis.

If you get a reduced gut fertility, this will reduce the glucose absorption. It will reduce the nutrients and fluids to the cecal microflora. It will reduce the fermentation process.

So your pH changes and you get a decrease in volatile fatty acid production, which is your primary energy source. You've already got a reduced glucose absorption as well. You then get an imbalance of Ccal microflora.

This will very quickly lead Lead on to an increase in pathogenic bacteria, in particular Clostridium. And if that occurs, then unfortunately, we can go into sepsis very, very quickly, shock, and ultimately we can go on to death, as well. And obviously we want to prevent this happening.

So anytime a rabbit is in gut stasis, we need to quickly and safely correct this, as well as find the underlying cause. OK. So signs of pain.

I love this, this post went round very recently, exotics be like normal healthy rabbit and then rabbit about to die, they look identical. And I think in a lot of cases it kind of feel like that sometimes, but they do actually show quite a lot of subtle signs, and it's just learning how to read them. So we're gonna run through that, and this might be something to have up in your practise, to have it in your waiting room so that clients can look at it.

You can download the Grimace scale, which you'll run through. And it's a really good way of owners being able to recognise at home and also pain scoring in the hospital. Whenever we look at controlling pain, we're looking at always pain scoring, reflecting on is that pain belief you've given enough?

Is it too much? Do we need to alter it, do we need to add in something else? Can we stop it?

OK, so signs of pain. I know we've got a little hamster up here, and I, I, I'm aware it's not a, a, a, a lagomorph at all. But I like this picture because on the left we've got a a hamster that's coming in just for general health check.

Lovely bright open eyes, sort of whiskers and very. Various directions, sniffing around, ears alert. On the right in comparison, you've got a little hamster with closed eyes, particularly the right one.

The whiskers are sort of pointed forward and, and they're not really out looking around. And this comes on nicely into into explaining the grimmest scale. That hamster on the right hand side actually had an incisor that was growing right up into the, into the nose and was penetrating just under the eye.

So I was in a huge amount of pain. This little rabbit on the right hand side, sorry, the lower side I saw yesterday, that was a referral for a lump on its face that was given a fortunately a subclinical dose of, of anti-inflammatories and is still presenting a lot of pain. You can see the sort of whiskers are sort of pointing forward at the front there.

The eyes are semi closed, and we'll come on to discuss the grimmer scale in a bit, in a second. So the signs of pain, you normally get facial feature changes, posture changes, so they're often hunched, rather than laying out. They don't tend to flop as a rabbit owner will describe them, he's not pinkying anymore, so they're not jumping around.

So their activity levels reduced. Eating habits have changed, so they might be dropping food, having difficulty with eating food. That may or may not be due to dental or head pain.

That could be because they've got stasis, because they're in pain for something else. Their drinking might change, they might be drinking more or less, you know, in other mammals, sort of polydipsia often is down to under laying pain, and it does happen in, in rabbits. However, if they're only offered a bowl, sorry, a, a bottle, and they have heads.

Pain, particularly dental pain, mouth pain, they often can't drink from that bottle. So the owner may notice is not drinking so much. And actually it's because it physically can't, or it's in so much pain when it's trying to.

So looking at offering bowls is really important as part of our, plan as well for management of pain. And also the demeanour, a rabbit that is not, most of them are. Full of life, often investigating cheeky little characters, but sometimes they can then be withdrawn or they can become grumpy or reclusive, and we need to bear all that in mind as a sign of pain as well.

OK, so coming onto the grimmest scale, on the normal on the left hand side and in pain on the right hand side. So normal with a score of 0 and in pain on the right here with a score of 2. It's scored 01 and 2, and I'll show you the difference between them in, in a few moments on the next slide.

But a normal upright eared rabbit, it's a bit more tricky than the lop-eared rabbit admittedly, but. An up-eared rabbit, you have the ears up, it's alert, it's looking around, it's open shape. In pain, they start to close them down and the ears will start to come towards their back.

OK, so there's an upright, the ears are coming towards the back. The eyes will change shape, so they have a nice open eye in a pain-free animal and that starts to flatten down and almost becomes slightly diamond shaped at the beginning and then closes in quite a bit when they're in pain. The cheeks start to flatten so you have nice round cheeks on the left side with the normal rabbit.

They start to suck them in and that will change the nostril shape from being a U to a V. The whiskers are often pointed out and looking around in various directions, whereas in pain they often point forward and down. So that's explaining the between the 0 and 2, and here we have a set of signs in between with a score of 1.

This is a really good poster to have, as I said, up in waiting rooms in your kennel areas and hospitalisation rooms, potentially to you know, print out and and give to to to rabbit clients. It's. By the Newcastle University and it is free to download through them as well.

I'm not going to run through it in fully depth, but if you look here, particularly the nostril shape is what I'm trying to say is this sort of flattened U shape when they're comfortable. When they start to pull those cheeks in and the eyes are starting to close, you get this more of a V shape, there as well. Equally look at the ears at the bottom, nice upright open ears at the bottom or again becoming progressively closed in and and flattened towards their back, on the bottom one there with the pain.

We also do this for mice and rats as well, so it's worth bearing that in mind to to have the small rodents. OK, so common conditions that can cause pain, there are a lot of them. So here we have Mark on the right hand side, as we discussed earlier.

I wonder which one of these could be causing his pain. Or her pain, sorry, she, she's an entire female. we've got dental disease, traumas, gut stasis, which is could be primary or secondary or even tertiary.

Gastric ulcer is very, very common problem in rabbits. We'll come back onto that when it comes to using treatment with meloxicam. Encephalitis is in ciculi, very common problem.

It's very prevalent in our area in South Wales. I'm not sure what other clinicians are finding at the moment. We had a huge surge over the last 3 or 4 years of it.

It's an inflammatory condition by nature. It is very, very, painful for them when it flares up. So it's worth bearing this one in mind.

Obviously, fly strike is painful. Fly strike normally is secondary to something else underlaying. So again, it's investigating what's causing that fly strike.

Urinary conditions, so UTIs, ecicli, slather stones, nephritis, things like that. Poto dermatitis could be primary or secondary. Ocular diseases, eye disease, ear diseases.

We certainly have had a lot again of increasing middle ear disease in, in the mini lock particularly over the last 2 or 3 years. It's very painful. A lot of the owners will say they haven't noticed any changes.

It gradually occurs and this lump that appears there. And what we find is after we've done the surgery, they're suddenly saying a week or two later, oh my God, I didn't realise how much pain they were in. He's now binking around, he's jumping around and happy.

He must have been in so much pain before, I just didn't realise. So I think it can be easily underestimated how painful these ear conditions are. We've got skeletal changes such as spondylosis, a fusion of the of the spine, often rabbits that are kept in hutches and, and not allowed exercise, or just elderly rabbits.

And then you've also got osteoarthritis of various joints, including dental joints and things as well. Liver lobe torsion, this can be acute and it cause a severe acute pain, but it can also be chronic, and you get this sort of intermittent chronic gut stasis that just keeps coming back and forth, and it's, it's worth considering liver lobe torsion as an underlying problem. Coccydia, we've got, I believe, I think it's lens, different species of Coccid in rabbits, of which two are pathogenic, but, certainly coccidia that causes diarrhoea in weenlands is, is really painful condition and liver coccidia in older rabbits as well.

So I'll briefly touch on some dental pain er in regards to this because it's probably one of the most common ones, but that doesn't mean it's the primary cause of the problem. We've got drooling or wetness around the mouth, swelling, warmth and pain at the jaw or end of the jaw. So often, as you're feeling along here that you press it around and examine it, and they, they will jump, they'll be flinching because they're in pain.

You've gotta watch, you're not catching the whiskers or touching the scent glands. They may well have noticed that home changes in food preferences, hay pellets from home or preferring harder food or softer food. They may show interest in food, but difficulty eating, which may present as dental pain actually may well be gut issues.

The stages of difficulty eating, dropping that food, odours from the mouth, they might be grinding their teeth, but again, this is non-specific to dental pain. It, it definitely occurs in dental pain, but it also happens unfortunately in, when they're in pain for other conditions. You might have eye abnormalities noticed, abscesses developing.

And they may also have a sycotrophal accumulation where they physically can't be cleaning their back end properly, particularly in sizes or overgrowth. That can become painful then around the back end, they can get urine scalding, which is obviously painful as well. You may get changes in size, shape, colour, number of faecal pallets, with any of these conditions as well, and often weight loss.

And then as you mentioned at the beginning, demeanour, so they often become reclusive or grumpy and and they're just not friendly rabbits anymore, they're launching out and and biting the owners and it's becoming an unusual sort of situation for the owner to find themselves in. Just briefly touching then on spurs of, so this is a painful condition. You've got, I'm not gonna go into dental disease, it's a complex, topic, but just to remind you, if you've seen things like this, they undoubtedly almost have ulcers on their tongue.

These spurs are very elongated, they're very, very sharp, and they will catch on to either the tongue or into the mucosa of the cheek, and cause a lot of pain. This is where the tooth should be and obviously the tooth is elongated and we you can see here where the ulcers are cutting in on the tongue. So if you're seeing things like this, it might look quite superficial, but it's actually very painful for the rabbit and and anti-inflammatories and other pain relief is really warranted here.

OK, so trauma, obviously fractured limbs or spine, always been careful when we're carrying rabbits around, but certainly, child pets are quite common problems where the child's dropped the rabbit because they haven't carried it correctly. Rabbit's then either fractured its back or caused a fracture of the leg. They can fall, and sometimes they do silly things, and, leap off the stairs.

It does happen sometimes if for indoor rabbits, so they'll go off the back of a sofa, and they'll, they'll sort of fracture their paw or something. And scis are damaged, often if they're elongated, they can be pulling at the bar sometimes out of boredom, and other sort of problems, and behavioural issues. And when they do that, the incisors can become trapped and can snap, and that can cause a lot of pain.

This is Cookie on the right. This is actually one of my own rabbits. I had a, a big fallout with, she's the head rabbit, and, and, another rabbit that had been there for a year, decided she wanted to take over.

They had one massive fight. And look at the, you know, the damage, and this happened whilst I was at work by the pet, pets of the vets, hey. And, you know, she, she's in a lot of pain.

There is this full thickness, skin damage here, both sides, and she had also ripped a vulva as well. She presented to me, literally with just not coming up for her food that night when I came back from, from work. So I was like, right, what's going on here?

Checked her over, found loads of wounds, and her vulva had also been damaged quite badly by the the other the rabbit, unfortunately. And of course we've got predator attacks as well, can happen. So I, I've had cats, cat bites where a rabbit actually had both ears ripped off.

I mean, this rabbit was an agonal breathing when it came into us, you know, and it was frantic. And, I mean, the, the, the unfortunately the amount of blood lost in that rabbit, and he, he was gasping for his last breath, but the amount of pain that, that those rabbits can be in with predator attacks as well. The bottom picture here, is, you'll see a picture of the jaw later on.

The owner fell down the stairs and landed on the rabbit and fractured its jaw. So again, these are in a lot of pain. That rabbit was still eating, even with a fractured jaw, he was still desperately wanting to eat.

These are prey species, they don't always show signs that you would expect. We briefly touched us about diarrhoea with Coxsidium and little weanlings. It's a very painful condition.

I'm not gonna over sort of divulge on it, but being aware of it, they, they need prompt treatment, supportive feeding, but pain relief is really important in these situations. Always looking at reviewing the diet, preventing stress. Most of it happens when they're moving from, the breeders into the shops.

That's, that's most common. So anyone who works with. Shops that sell rabbits, it's worth bearing this condition in mind that's a painful problem and to look at how to prevent it.

OK, so investigations of pain. We always want to do a full history, even if it's ones that you've seen multiple times before, just double check, has anything changed, including husbandry and including diet. We always want to do a full physical examination, so you can see on the right here.

I've actually put 3 pictures up examining the heads, so the underneath the top and inside the mouth, because it's such a common problem that you get dental disease which may be primary or secondary to underlay and other problems. We want to do bloods potentially, so general health profiles, inflammatory mediators, Ecicular, as you mentioned earlier. We want to look at doing imaging, SO X-rays, ultrasound scan, and potentially in-house or referral for CT or scoping if needed.

Considering urinalysis, including EC PCR, and things that culture and sensitivity, and, . Uine creatinine protein ratio and things that would cause that would be indicators of renal disease that could be causing pain and if appropriate abdominal centesis depending on the presentation signs. So when we're X-raying we wanna do the full body.

This is a pho photo. This is an x-ray that we actually did yesterday, on a, a rabbit called Herbie. This rabbiter had been seen by a vets, a week ago and referred across to us for urinary problem.

I'm saying full body, I'm hoping you will see that I'm actually missing the head in this picture. Now, the reason being is this rabbit was too big to fit on the plate and we want to do some decent head X-rays that are slightly different settings from our body X-rays anyway. But this, the reason being, I want to show you this is it was referred for a urine problem.

It was standing up and, and, with its, when it was standing to urinate, its back legs were going straight and it was really struggling to lift its back and urinating and seemed really uncomfortable. They put it on, so, so meloxicon, and the rabbit had improved, but was still struggling. When I did an in-depth husbandry with this one that I've not seen before, it turned out that the, the rabbit had lost its bonded partner six weeks prior, and that also it wasn't eating hay properly for a number of months, whereas it used to always really love hay.

So, we want to do a full body X-ray. We can see rabbits, has got urinary sludge here, so it's probably gonna be in some form of pain. We can see a huge amount of fat, in the retroperitoneal area.

This rabbit was actually overweight, so that can contribute to problems as well. But we also want to include the head. Now, I'm not gonna go in depth on head X-rays, but you can see there's some abnormalities, there's some increased, sort of bony growth coming down, on, on the, on the lateral here.

Couldn't get a true DV on this one, it just would not sit nicely. And I can see there's some lucency going on on the left hand side here as well. When I examined this rabbit, you could feel the bumps on this jaw, and he was flinching, particularly on the left hand side.

When we do all views of the head, we're now doing an oblique view. This is the left hand side of the jaw. It's got bone reabsorption, it's has potentially the abscess starting to form down the bottom here, reserved crown reabsorption of the teeth here, then a wonder this rabbit is in a huge amount of pain.

So we must always do for investigations when we're trying to diagnose what the actual problem is. Sludge doesn't occur in wild rabbits. In pet rabbits, it does occur partly down to diet and partly down to not being as mobile, not being as active for any other reason.

This rabbit, since losing its bonded partner six weeks ago, had become sort of subdued and wasn't anywhere near as active, wasn't bin in, and, but I believe the dental disease, as you can see from the X-ray, would have been in place way before. This is the fracture on the of the jaw that you saw earlier, you can see the fracture going through the mandible here. So obviously that needs to have really good quality pain relief, and we're gonna touch on, on, on pain relief shortly.

This rabbit presented a dental disease, as you can see on the left hand side, it's incisor was fully overgrown. But it also presented with gut stasis, so of course we're doing hand X-rays, seeing what's going on, horrendous dental disease here. But can anyone see what's going on this?

Give me a quick second to look. Yes, we've got gut stasis, we've got a huge amount of gas in the sum here. But did anyone spot the spondylosis in this one's spine?

This was a seven year old rabbit that had been kept in touch most of its entire life. It also had severe arthritis in its knees as well. On welfare grounds, we elected to actually euthanize this rabbit, but if you were going to keep this rabbit going long term, you absolutely have to address everything for the pain management of this rabbit.

OK. So, you must define the cause of the pain as we discussed. We need to do careful support of handling, potentially looking at bunny burritos as demonstrated in this picture, remembering that they have very fragile spines, and any form of pain can cause them to be stressed and therefore may not tolerate handling as they would normally.

We may want to examine them on the floor, particularly mocha. Moko is a very jumpy rabbit, and we want to examine on the floor. We need to look at whether it's acute pain, chronic pain, mix of that pain, whether it's pre-operatively, peri or post-operatively, and at home.

Whether it's somatic, so pain in the muscle, the skin, the bone, tendons, often a specific area to, of, of pain, and often felt on movement. Whether it's visceral, which is pain in our internal organs, that can be a little bit harder to localise. Or whether it's inflammation, which is perception of sort of effective response to no stimuli.

That can occur due to an inflammatory or an immune response. Eciculli is a classic example of this situation. We want to look at whether we're doing non-steroidal anti-inflammatories, opioids, local blocks, a continuous rate of fusion, substance P blockers or steroids.

We also need to look at fluids and, and blood if they need to be given, support a feeding, a quiet predator free hospitalisation and keep with the bonded partner. And all of those help to prevent gut stasis developing and or treat the gut stasis that may have already occurred. We must remember that the vast majority of meds we're given here are off licence, so we need to get permissions from the owner and explain the potential risks that can occur.

However, without the pain relief, it's unethical to leave that animal suffering. And we also need to look at pain scoring, using the grimmer scale, teaching our colleagues how to, how to do that, and monitoring it through the hospitalisation, through any operations we're doing, and also at home as well. We want to make sure we get accurate weights.

These guys can range massively from these little Netherland dwarfs right up to giant conches which could be 10 kg. We need to know an accurate weight to dose. So analgesia, this is the absence of sensibility to pain, particularly in the relief of pain without the loss of consciousness.

So, thing, things like nonsteroidals and anti-inflammatories, they don't cause sort of lost consciousness, but they are reducing the, the sort of pain response. A true analgesia would be to block it in the first place, which would be something like our local anaesthetics. I appreciate there's a whole load of meds just gone up here.

You're welcome to take photos. These are the doses that I use. They're based on my clinical experience.

They're based on published dose rates, they're based on multiple different textbooks, and they're ones that I tend to find work really, really well. You might find that others use slightly different dosing, but finding something that's working well and, and pain scoring during the, the, the time they're on those medications is important. So Meloxicon, we're gonna go through each one relatively sort of quickly but to hopefully give you an understanding of why it's important to use multi-modal pain relief.

So we know it's a non-steroidal. Our doses ranges between 0.8 to 1.5, once to twice a day.

Higher dosing tends to be using once a day, a lower dose than twice a day. It's a very good anti-inflammatory, easy to give, especially with 1 mil syringes, and it's quite sweet. It can affect the kidneys, so it's worth if we are, using this for echiicli, as an anti-inflammatory, because it's echiicli naturally affects the kidneys as well as its main targets.

We need to check the kidney parameters first. Also, if we're gonna be on long term anti-inflammatory like this, then we need to be monitoring, our kidney liver parameters as well. We mentioned earlier about stomach ulcers and rabbits with chronic stress.

This is one to be careful of because obviously Meloxicon can cause it. But because we are giving us these two rabbits who don't normally have their stomach empty, and if they did, I'd be really, really worried. They don't tend to get the problems associated.

However, if there's a stomach ulcer already there, it can worsen the signs. So if we are getting changes, I've got a couple of rabbit owners where they notice very quickly the faeces go quite dark on the rabbits, smaller, and almost black, and we start to worry about stomach ulcers developing on meloxicam. So we give it with ranitidine, and it really does help to to protect the stomach there.

Dental care is definitely a problem in guinea pigs and chinchillas, not so much of a problem with, with rabbits, and it's to do with, the enamel that they have, and it's a bit stronger than the chinchillas and the guinea pigs, but they're about sugar and meloxicon can certainly cause problems in the other species. If we are needing to use this higher dose, it's probably worth considering additional pain relief rather than just meloxiconolone. OK, so opioids, they act on the opiate receptors, we've got the new and Cain receptors for analgesia, we have full, partial, mixed, and and the antagonists as well.

So a full agonist, most of us have access to methadone in practise now. I know some still have fentolin, and may still have morphine as well. It's really good for inpatient care, it's very potent, and it's good for intraoperatively topping up as well.

But it's not really suitable for home use, so we can't really dispense it to go home with them. It certainly is, cumulative for most of them, and we need to be careful that we don't give the higher doses continuously. So we normally need to pull it down.

It'd be most of them between 2 to 4 hours. It is questionable whether it's slow down to gut mortality. Buprenorphine doesn't tend to have that problem, but I think you've got to watch with these guys.

However, we have to have really good pain relief on board, and if it's warranting these sort of opioids, then, we can support with other things, for, for gut mortality as well. It can decrease the respiratory rate and efforts, we need to be really careful with justic patients. If there's any problems, it's worth having something like naloxone in place should you need it.

It is very frequent dosing, which means that if you happen to handle quite a bit forgiveness, then it might cause stress, with that, we need to be careful. And also it can be very strong at higher doses, so it may well cause sedative effect which we kind of don't necessarily want to have in most situations with the rabbits. Partial agonist, so buprenorphine, you can give this various, roots.

I tend to do it very slowly if I'm gonna give it IV, but you can do it, soca works really well and transmucosal. Any of them take about 40 minutes to fully kick in anyway, so there's no major benefit in doing it IV, unless you happen to have an IV in place. It's really good for moderate peropperative pain relief, but also the long term pain relief at home.

I, as I've written down the bottom, you can get sublingual doses of 0.2 and 0.8 mg per kilo from Summit.

So they are really good for some long term pain relief management at home. It takes about 40, 45 minutes for the analgesic plane and lasts 6 to 8 hours. It's metabolised by the liver like a full agonist as well.

Why might we use boots off for that, cause it's a mixed agonist. OK, well, this is actually a really good one for mild dental disease. So if we are doing, a sort of a brief dental, we're not wanting them out for too long, and it can be quite useful for them or for doing, for example, X-rays or doing minor procedures that might cause a little bit of discomfort.

It's a really, really good one. It's very rapidly acting. But it's relatively short-lived, and there's studies that it varies between 45 minutes to 4 hours, so it's not very, reliable for giving more long term relief, but it's quite good for short term, situation, and it's also metabolised for the liver as well.

OK, then we go on to synthetic opioids like tramadols. There's a bit of a various range on this from 5 to 15 mg per kilo as well, every 8 to 12 hours. You can give it a subcut as well if you've got access to that.

So it's quite good for again chronic pain management at home because you can get oral solutions which are 5 and 20 mg per mL from Summit. You can also get tablets and you'd be surprised rabbits take tablets quite well. .

It's about 45 minutes to an hour for analgesic plane to kick in. It's not an anti-inflammatory, it just helps to kind of block the pain. So, we normally need to use it in conjunction with something else, and it's also metabolised by the liver.

Gabapentin. This is a great one. I use this a lot in rabbits.

It's really good for neuropathic chronic pain, particularly in spondylosis. Seems to work quite nicely for, ear pain and dental pain as well. Bit of a varying dose.

Some use it as low as 5 mg per kilo, but I generally start at 10 and once a day and then up it to twice if we need. Or sometimes I'll start it twice a day after an operation and then titrate it down. It takes a little time to build into the system and you shouldn't suddenly stop this one.

There's various tablets and also liquids from, from Summit, and obviously other suppliers as well. But they do the nice small 10 milligramme tablets, which are great for small rabbits or for, guinea pigs and things as well. Again, this is also metabolised by the liver.

So you're noticing a lot of these drugs are metabolised by the liver, and this is what we said at the beginning, it's really worth doing. Bloods to assess, for any organ changes because so many of these drugs we are given are metabolised by the liver and the rabbits. Particularly paracetamol.

This one can cause liver damage long term, and we need to be monitoring it carefully, but it's very, very good, as a substance P blocker. So it sort of stops that pain reaching the brain. We tend to use it for a lot of our apps, we use it IV, slowly, about 150 MB per kilo to start and titrate it down to 10 every 8 to 12 hours.

It's really good per-operatively but also postoperatively as well. It lasts around 8 to 12 hours, but the actual analgesic plane starts quite quickly within 10 minutes if you give it IV. You can get sugar-free solution and you can get sugar solution, .

There's no evidence at the moment out there that this sugar-free solution paracetamol, causes any problems in these species. They don't use the Xylitol anyway. So it doesn't seem to cause, cause a problem.

So I, at the moment, I'm sort of using the sugar-free solution until I find any evidence otherwise, I don't want to be given these high gut fermented excess of sugar. Coming towards the last couple, we've got prednisolone, and you might question, oh my God, used prednisolone in the rabbit. Whoa, major problem with pasturella.

And of course, if we've got a rabbit that you know has got pasturella or has had it in the past, you really probably avoid this one. However, we need to bear in mind that about 80% of rabbits carry this anyway. So we have to use it with caution.

Also, it can cause dysbiosis with the guts as well. But it's a really good, anti-inflammatory. It's so potent, it's great, particularly in Econiculli.

You can use the tablets, they take them really well, but you can also get prednisolone liquid as well, which I think is 1 mg per kilo liquid. So it's, sorry, 1 mg per mL liquid. It's a really, really good one.

You just have to bear caution with it, OK? We've got our local anaesthetics that we mentioned. So we've got lidocaine and caine, generally 1 to 2 mg per kilo, starts at the, at the lowest of dosing and being careful if you're using intrabez because bearing in mind there's lidocaine and intrabes as well.

This is the only true analgesic because it blocks the nervous system pain transport at a point of where it's happening. So the pain is just not perceived by the brain. So if you use it, effectively, it can be really, really good, inoperatively.

You have to watch for ventricular tachycardias and potentially hypertension that can occur as well. So dental nerve blocks is a great example for this one to be used, particularly, you know, if you're removing teeth, it's really, really good. The lidocaine's quite short acting, about 20 minutes, the cane takes a bit longer to kick in, but it's longer acting.

It's also useful potentially to use lidocaine as a CRI to block visceral pain. So just bearing that in mind if you're doing CRIs as well. Roppotent, quite popular at the moment.

We've had some new studies come out in the last couple of years, which sort of show it is a really good visceral pain relief. And it's anaesthetic sparing, so it doesn't cause any sort of sedation. It also has mild prokinetic effects on the guts now, noted as well the last couple of years, but potentially for that reason to maybe avoid a true obstruction.

So it's a neuroquiin, one receptor antagonist, which also has additional mild energetic, analgesic effect. Anti-anxiety effect, which is quite useful for rabbits because they get quite nervous in these situations, of being away from their usual place, and an anti-inflammatory effect. It's quite readily available, most, most practises haven't.

So if you're not using it already, it's a really good one to start adding into your pain relief management for, for rabbits. OK, so, to feed it, it's really important to remember to feed these guys, it's part of pain relief management, because if you don't, then you will develop gut stasis and potentially hepatic libidosis. The anorexic rabbit will use a free fatty acids instead of glucose and volatile fatty acids as their energy source, which results in hepato libidosis and they can die within a week.

It's really serious, so it's really important as part of our pain management to include feeding. As long as it's not blocked. This is a liver lobe torsion, my very first one I did around about 14 years ago, and we've got pain management on board with CRI going on and blood transfusion as well.

So coming on to environmental adaptions and adjunctions to analgesia, really important, especially in the elderly or disabled rabbit. Important to keep them with their bonded partners where possible at all times, including in the hospital situation. Look at using pet remedy if they're indoor bunnies or if you've got electricity outside in in setups then potentially outside as well.

We want to avoid patches which have got corners, that are sharp, and particularly with ramps, and side panels so that they can balance along the side and they know where they're going, especially if they've got eye issues. Tunnels can help mobility, it can help them find their way back to places. We mentioned before about bottles being difficult for rabbits with dental disease, so adding in water bowls.

We want to use some hanging items for foraging to encourage what I call yoga stretch, and I'll show you a picture in a minute. Foraging really helps movement, it helps mental stimulation and it helps to control pain. Very, very important.

We want to protect them from the cold, damp weather or hot days, cos if they're if they're elderly rabbits, if they're struggling to move as much, they may not be able to confirm and regulate as well, and of course prevent fly strike. So this is foraging, what I'm on about. These little stockholders are great, the underwear areas, and they, you can see here how high rabbits do stretch up, so it's important to be able to allow that.

That's really good for those with spondylosis to try and get their backs a bit more supple again. I showed you this picture because it's got a really sharp steep slope on this hatch. It's far too small anyway, but this is the angle I was trying to explain, coming down the, the slope into a corner is really bad for a rabbit anyway, but a rabbit that's got pain is gonna really struggle.

What we want is room to hop, to be keen to dig and to have weather protection and all of these examples are are great. We need to bear in mind that those that are jumping, that they can still get food or are scratching it around will really help to keep the rabbit mobile and help to prevent pain. We do use pay laser, it's a class 4 therapeutic laser, it's non-invasive and helps to promote cell function using different wavelengths of light.

It improves world healing time, reduces pain and increases circulation, and we use it for a big va variety of cases, those who want evidence-based medicine, they are producing loads of references that you can get and it's all on their website, OK, but that's only for the class for therapeutic, any other class, and there isn't any evidence based medicine out there that I'm aware of. OK, so we've pretty much gone through everything. I'm gonna bring all together now and try and discuss mocha.

So, so, as we said, so last year, the sudden onset lethargy and anorexia. We did a full examination and I found a narrowed eye, flattened ears, and withdrawn in a cell. A mouth exam was OK.

No sign of head pain noted. She had an increased heart rate, and the gut sounds were there but reduced, and palpation was normal. And I found crepitus in her left stifle and pain on palpation of her distal femur.

So I'm hoping that you're all thinking about what we need to do, which is put on some pain relief, but also to support the gut stasis as well. And this is what we gave her a combination of opioids, paracetamol, some neuroppotent and non-steroidals, and sort of gut support meds. We also put her on fluids and we started a support feeding.

Once we were happy that she was picking up and her pain signs were reducing, we then went on to x-ray her. So you can see she's got a fractured, distal femur here. And we need to do this under repair, but obviously what we want to do is get the gut status controlled.

So there's no point going straight into surgery on this today. We can find her space, so she was unable to move too far around and gave a really good pain relief. Got her back on track with eating, and 36 hours later did the fracture repair.

So obviously we needed to measure the gaps, and I'll come on to a postoperative X-ray later. So we've done the perioperative period, we've got her back on track, she's now eating, we've got her on fluids. We now need to look at perioperatively as we're going through the operation.

On board we've got non-steroidals, opioids, paracetamol and neuropants, we've got fluids. Pre-anesthetic, we had an anallitic with midazolam. We induced with ketamine and then onto alfaxone a little bit later, she went on to a ventilator and we maintained her with isofluoride oxygen.

She had methadone, through the operation at a slightly lower dose, to continue, her every two hours. We gave a local anaesthetic block with lidocaine at 2 per kilo, and we had rescue analgesia plan if needed, for ketamine as well. So this is the postoperative picture, sorry, X-ray, and you can see the slag screws have been fitted in place.

She had K laser, upon recovery, to aid healing and also of the wound and also for the muscle and bone. So postoperatively, we got the immediate postoperative period in the hospital where she was stayed for 48 hours. She maintained on fluids and on various medication.

We started to reduce the methadone down after 24 hours to buprenorphine. And we had other things on board, such as, aliropipant, paracetamol, meloxicam, and thatloxmide to continue. We did laser therapy each day and she had pain scoring done every day.

Within a few hours of the op, she was alert, she was up head up, eating really well and passing normal shaped faeces in colour, texture and size. OK, so after 3 36 hours we were happy, she's on buprenorphine, she stayed on that in hospital for another 12 hours, she went home the next day. She went home to continue on buprenorphine for 10 days, Meloxicam for 4 weeks, paracetamol for 7 days, and gabapentin for 4 weeks.

She had Kalaser twice a week. We taught the owner to do physio at home, and we taught the owner to do pain scoring so that we knew when we reduce these meds and when we reducing them, we're doing them at different days. Note that the paracetamol was at 7 days, the buprenorphine was at 10 days, and then we continued the anti-inflammatories and gabapentin for longer.

Once she fully healed, we went back to the original her history. She was a a neutered female, so we neutered her on a postoperative x-ray about 8 weeks later, and then around 4 or 5 weeks after that, we then bonded her to a neutered male at home. So in summary, prey species can mask pain really well, we need to be very aware of of the pain that can occur and the signs that come with that.

Full investigations are required, including full physical examination. If in any doubt, analgesia. Multimodal is always potentially best and local where you're able to as well.

Pain scoring in-house and at home is really important to do and don't forget your adjunctive therapy. Thank you all for listening. I think we've rocked in at around about 50 minutes, so we have got time for, questions, and I hope you've all enjoyed and, and, feel a bit better about analgesia and rabbits.

Thank you, Sophie. I think we also have a, poll, so we'd like to just pop up. So if we could just have some feedback, that would be amazing, thank you.

OK, so I think we've got a couple of questions. Do you want me to go through them, Charlotte? I can see a couple popping up.

Yes, that's not a problem. I can do that now as well. So we did have one just a second ago that was just in relation to the slides that you had up.

Where did I find it? . Do do do.

While you're finding that one, I'm just gonna answer another one, lots to come for dogs or cats, Georgina's asked, . It doesn't actually matter. Neither are licenced.

If you're going to go down technically licence and route, the moxon for cats is licenced for guinea pigs, rabbits are closest to guinea pigs than they are to dogs and therefore technically, On a licencing route, the cat one, which is 0.5 mg per mL, would be the one to use. However, that's a huge amount of drug to be given to, to the, to the rabbits, and, and I use the the dog one.

It doesn't really matter as long as the owner's aware it's off licence and you calculate the correct Migs per mil dose. Lovely, we've had some questions where people are trying to find out where ranitidine is sourced. We get ouritidine from Summit.

I'm not sponsored by Summit, believe me, I don't have any shares, and then they just do a lot of the good, good drugs for rabbits. Thank you. Next one we've got is, once a rabbit develops and it in sizes of overgrowth, how frequent would we should we be intervening in oral treatment, so is it like every two months or something?

Sorry, I missed that then, Charlotte. Sorry, that's OK. So if a rabbit has an overgrown incisor, how frequently should we be intervening in oral treatments, sort of every two months?

Over going in sizes, we'd always remove them. Lovely. What is your preferred, anaesthesia sedation protocol for rabbit X-rays?

I think you might have gone over this a bit, all of the talk. It depends on what we're doing afterwards if we're going into any other procedures, but most of our rabbits, we would give them some midazolam, and I, and, I tend to do a lot of them just off midazolam and just careful positioning, very, sort of gently positioning, and, and they, they will lay there. If you need to, then tour books really well as a sedative, that we mentioned earlier, it gives some pain relief if you're doing it, anything that might be painful.

Otherwise, you can add a bit of dorm in there as well. Then you can reverse that really quickly. But that is a, it is a complex, talk that one itself.

Thank you. I think you have also answered this one already. What is the role of paracetamol in pain control and dosage?

What was the what, sorry? What is the role of paracetamol in pain control and what's the dosage? The dosage of paracetamol is 10 to 15 mg per kg every 8 to 12 hours, but you, it is reported, you can use it a lot higher, as well, but I just, I that would be more of a short term if you're using it that high.

I generally give it IV if it's in-house or perros if it's at home. And it, it's a substance P blocker, so it blocks the pain, transmission to the brain itself, which is a little bit how mirropotin also works as well. Lovely, and that sort of goes on to our next question because I've got substance P blocker question mark as well, so I guess that sort of answers that.

Also, what about Cerenia, especially in gut stasis? Assurenium is the miropotent. So, that, yeah, yeah, it's useful in gut status for the reasons we mentioned in the slides today.

And on the same topic as well, do you see a difference in the incidence of gut status when rabbits are kept as house rabbits? Well, an increase in, in gutta house rabbits just says a difference in the incidence. So I'm assuming there would be an increase.

I, I wouldn't particularly say like a lot of our rabbits that we do have are, house rabbits. You gotta bear in mind that stress can cause gut stasis, and houses are particularly warm, compared to what the rabbit would be used to. So an ideal rabbit temperature is 14 to 19 degrees outside, but most houses are 21 and particularly you can get quite hot, in the summer.

But also in winter, people will turn the heating on, so it goes hot in the summer, then it goes cool in autumn. So the rabbits build up a bit of fat, and they moult their winter coats and their summer coat, get a winter coat, and then they turn the heating on. So rabbits can, can, can have gut stasis just literally from, from that.

Thank you. I've noticed someone's asked to check it, put it in because I'm not sure if we've gone through it, but someone's asked if we give the buprenorphine IV at home. No, the bin morphine that was given to mocha and to any animals that we send home is always given sublingually.

Perfect, thank you. That was the one I was just trying to find. what was the next one, We tend to use cisapride rather than metoclopidine.

Do you have any specific doses to try at all? I used to pride as well, but when we weren't talking about gut stasis specifically today, er, so I, I use both, it depends on what the situation that that I'm using that I'm using them for. Thank you.

It's pretty much the same answer as that one. Everyone's saying thank you. It's very meaning forward informative so far.

Someone's asked about using paracetamol longer term for older rabbits with tramadol and Metaca. Yes, I certainly have used paracetamol long term. We just monitor, you know, parameters and things and make sure that the, the, the rabbit's not getting any major side effects from that.

Lovely, is there any benefit using lactate measurements and gut status? Lactate measurements, you can do, anything that's certainly above, I think it's above 1.5 is, it is quite severe, .

Someone's asked about analgesia where liver and kidneys are affected. Obviously if they're both affected, you have to look at why they're affected, and, and how the rabbit's doing at home. Pain scoring is really important.

The welfare of the animal has to be, most important. So if the animal is in pain, you have to give pain relief or euthanize it to relieve that. And so if the livers and kidneys are affected to the point that you can't give adequate pain relief, you need to look about whether that's a welfare compromise.

However, I, I do use all those meds as above with liver and kidneys affected, but we, we use combination, lower doses, and we also do a lot of, owner, education about monitoring at home and, and, and sort of adaptations as well. Cheers, I've got one. How did you administer local anaesthesia to mocha, epidural or nerve block, and how did you localise?

We did a nerve block and also a local splash around as well. Someone's asked about the carcinogenic effects of ranitidine. This is in human medicine that was found, it's never been found in rabbits that I'm aware, so it was withdrawn from the human market ranitidine for a long time, and, it's now back into the human market.

It seems to be, not much of a, not a problem in, in, in rabbits, and I've I've been using the best part of 20 years and, and I never had a carcinogenic problem that I'm aware of from using ranitidine. Omeprazole works differently and I, and I don't believe that there's any major benefit of using omeprazole in, in rabbits. Ranitidine also has a prokinetic effect on the guts as well, so it's really good to help the guts moving through and using combination of metoclopramide, it's a nice gut stimulant.

I've got one, if you've got suspicion of gastric ulcers, I'm guessing what would you use?itidine, yeah, OK. .

Yeah, I have used sucrophate in in rabbits before. I didn't seem to be very well tolerated. I had a couple that sort of seem to be drooling a lot on the succophate.

I haven't done any studies on it though. And that was just literally one of the questions as well, do you have experience with it? So they've got no fentanyl either, so she was looking at something for a local anaesthesia doing surgery for abdominal wall.

Is it, do you have any recommendations? Sorry, she's looking for what, sorry? So she doesn't, they don't have any ranitidine in the in their country, what can she use instead?

Do you have experience with the, so fentanyl, no fentanyl here? Do you use local analgesia during surgery for abdominal wall? A couple of questions there.

So, the ranitidine, if, it depends on what you want to to use it for. If you're not having it, if, if it's not got it in the, in the country, then it depends on, on what you're, what you're looking for. If it's for, for gut sort of support, then there's the other drugs you've got cystified metoclopramide that you can utilise instead.

So that'd be fine. In regards to local analgesia for abdominal wall, I'm assuming they meaning for. Exploratory surgeries or spades and yeah, we use local blocks prior to to incision into our skin.

Fabulous, thank you. I think we might have to wrap it up there, guys. We have, got a few questions remaining.

So we will, submit those through to Sophie, and the Rabbit Welfare Association to get back to everyone, and we'll email that those responses that when we can get through them. But I'd like to thank you again, Sophie, for an informative session. And we obviously always enjoy your sessions with all the questions that we do get, and the amount that does do that do join us.

I'd like to say thank you again to the Rabbit Welfare Association for sponsoring today's session. We hope everyone enjoyed today's webinar, and thank you all for joining us. Thank you very much.

Take care now. Take care.