Dr. I. Craig Prior: I'd like to welcome each of our participants to this panel discussion on multimodal management of canine osteoarthritis. The
foundational pieces of this treatment should include:
- nonsteroidal anti-inflammatory drugs (NSAIDs)
- a pet food rich in eicosapentaenoic acid (EPA)
- chondroprotective injectable polysulfated glycosaminoglycan (PSGAG).
The ultimate goal of a multimodal approach is to provide the maximum quality of extended life with a minimal effective dose
of pharmacologics. The optimal multimodal approach is an overlapping of medical and nonmedical management.
Dr. Steve Fox: A common challenge in treating dogs with osteoarthritis is deciding where to start. Do you start with an NSAID? Do you start
with pet food? Almost all treatments, except maybe the NSAID, will take three to four weeks before we will see a clinical
response. But the owner typically wants to see a response within 48 hours. In reality, you need to start with all aspects
of treatment simultaneously to improve the animal's comfort and slow the progression of the disease. It's also important that
the owner feels the pet received appropriate care.
The cornerstone of managing osteoarthritis is NSAID therapy. I do not see any pharmacologic agent taking the place of NSAIDs
for quite some time. The aging animal may have compromised renal and hepatic function, so you strive to administer a drug
that is not going to further compromise those physiologic functions. One tenet of a multimodal approach is administering the
minimal effective dose of the most effective NSAID.
Dr. Robin Downing: If the patient is a candidate for an NSAID, I think most of us would start with the FDA-approved dose, and move down from
there. We want to implement multiple treatment strategies so that over time we can reduce drug doses. In our practice, we
do not have a target dose. Our goal is to use the minimal amount of the most effective drug to get and keep a patient comfortable.
Dr. Robin Downing
Dr. Michael Reems: Start the dog on the drug as early as possible. I see many patients that have been diagnosed with an osteoarthritic condition
and have chronic lameness and discomfort, but are only on a nutraceutical. Owners may fail to perceive the persistent lameness
as pain, veterinarians may not be aggressive enough with treatment, and there may be failure to follow up. The sooner the
pain is under control, the sooner you can start physical rehabilitation and continue with other modalities that will help
reduce the NSAID dose. On the other hand, I think discontinuing an NSAID without appropriate follow up gait and orthopedic
evaluation is less than ideal.
Dr. Darryl Millis: Nearly all pharmacokinetic studies on approved NSAIDs have been done on animals that are 1 year of age or less. In practice,
however, veterinarians are frequently faced with geriatric patients with osteoarthritis. With this kind of patient, you have
to factor in changes in liver function, renal function, and gastrointestinal absorption—all of which deteriorate with age.
I start with the label dose for a middle-aged or younger patient. If a patient is already compromised, I adjust the dose based
on liver function and renal tests.
We typically think an NSAID yields its response within five to seven days, but in one trial improvement continued throughout
the six week study. If we reduce the dosage too early, we may not see a maximal effect. Once we have the maximum effect, I
slowly decrease the daily dose as opposed to changing the dosing interval. It makes more sense to avoid the fluctuations seen
with every-other-day dosing.