YOU DON'T NEED NSAIDS TO TREAT OSTEOARTHITIS...
After a professional query, someone sent me a message yesterday that got me thinking about how I handle my chronic arthritis patients. According to this doc, one of my most trusted sources in clinical pharmacology:
“YOU DON’T NEED NSAIDS TO TREAT OSTEOARTHITIS...FYI: NSAIDS kill more dogs and cats that any single drug.”
In screaming caps, he effectively berated me for my tendency to use NSAIDs in a way he would doubtless consider indiscriminate. I felt like crawling under my laptop. (If I could’ve fit, I might’ve tried.)
For those of you who aren’t up on your medical acronyms, NSAID stands for “non-steroidal anti-inflammatory drug.” You know them as aspirin, ibuprofen, naproxen, etc. (Advil, Motrin, Aleve, etc.).
In the veterinary world we use plenty of these, too. But we can’t usually use the human versions as they tend to elicit extreme gastrointestinal problems in our dogs and major kidney and liver trouble in our cats. That’s why we’ve devised great new NSAIDs for pets that are far safer than the human kind.
Meloxicam (Metacam), etodolac (Etogesic), deracoxib (Derramax), and carprofen (Rimadyl) are some commonly prescribed NSAIDs in veterinary medicine. They’re all approved for use in dogs. Only Metacam, in its injectable form, is approved for one-time use in cats.
I’ve had cause to write about this topic plenty before because of the significant side-effects that accompany the use of these drugs. (Vomiting, diarrhea, lethargy, liver failure, kidney failure, stomach ulcers, etc.) That’s why significant care must be taken to screen our patients well for their ability to tolerate these drugs. And once prescribed, educating pet owners on the sometimes subtle symptoms that can result is an indispensable step that’s too often not undertaken.
Nonetheless, it’s always been my view that pets in arthritic pain need pain relief. Moreover, it’s clear that the advent of pet-specific NSAIDs have revolutionized our ability to treat the kind of chronic pain we see in pets with arthritis. They now live longer, more comfortable lives. And that’s no statistic––it’s what I witness daily. The kind of comfort we can offer with today’s NSAIDs is nothing short of miraculous when you considered what our dogs suffered as recently as fifteen years ago.
But the question remains: Have veterinarians like me become too complacent in their willingness to hand out Rimadyl (or another NSAID) to every osteoarthritis-afflicted dog? If I’m to take heed of my clinical pharmacologist’s advice and evaluate my medical decisions unflinchingly, the answer is an unwavering YES.
I prescribe NSAIDs more often than any other drug. Considering the chronic nature of the arthritis I treat with them, along with the fact that 20% of adult dogs suffer from arthritic pain, it makes sense that in sheer volume, more NSAID doses go out my door than antibiotics and heart medication combined (I did the math yesterday).
Yet in my defense, over the years I’ve become less willing to hand out NSAIDs like candy to my arthritis patients. Not only have my cautions become stricter and more specific (website recommendations, package inserts, pre-prescription and semi-annual blood work, etc.), I’ve been prescribing lower and lower doses.
In large part, that’s because of the ready availability and safety of opiates like tramadol. This human drug (not approved yet for pets) works so effectively in combination with NSAIDs that I can justify tapering my doses sometimes down to a quarter of what I would previously have prescribed.
The other determining factor is my growing affinity for Adequan (polysulfated gylcosaminoglycans). This dog-approved injectable nutraceutical works better than I’d previously given it credit for. It works by supporting cartilage in ways we admittedly don’t quite understand. And it’s considered very safe in a larger group of my patients, including cats (pets with serious liver and kidney disorders need not apply, despite the low risk of problematic outcomes even among these cases).
One dose of Adequan injected every week for 3 to 6 weeks has been my preferred approach lately, but I’m now considering the eight-doses-in-four-weeks approach on the advice of the ego-ripping, clin pharm guy referenced above.
Glucosamine (another nutraceutical designed to support the cartilage) is another favorite mainstay of mine, as are fatty acids. And frequent swimming is my oft-cited recommendation for muscle building.
The clin pharm guy? He’s big on Dasuquin, the Nutramax brand of glucosamine with avocado extract (which has been found to reduce the formation of inflammatory compounds). Green tea, grape seed extract (not toxic) and antioxidants like zinc, vitamin E, selenium and vitamin C can also be helpful, he says.
He’s also clued me in to the use of amantidine, gabapentin or amitriptyline for the kind of pain that comes from abnormal nerve stimulation (neuropathic pain), which is common in some arthritis sufferers. Though I’ve used these before, I’ve never felt they did as much as any NSAID. Truth is, though, they sure don’t come with the big risks NSAIDs do.
Will I stop using NSAIDs? You’ll probably have to pry them out of my cold, dead hands. But I can promise you I’ll be trying more new approaches in light of yesterday’s come-down. And my NSAID dose-count? I’m sure it’ll continue to drop. Unless my clients refuse to take on the multi-pronged approach I’ll increasingly recommend, I can’t see how it wouldn’t.
But then there are always the clients who’ll refuse to tackle a problem the way you’d like. And, for those, as for pets whose pain relief needs are not well met without NSAIDs, my ability to prescribe these drugs is golden. Despite my warnings (and sometimes my protests), they’ll continue to take their risks––and I’ll feed their habit...gladly.
Clinical pharmacologists sure do know a whole lot, but they don’t usually have to watch the pets suffer like we regular vets do. Sure, I don’t need to prescribe so many NSAIDs––and not in every case––but I can’t completely agree that I don’t need any. Still, feel free to ask me about this again in a few years. Maybe by then I'll have changed my mind.