Multimodal treatment of canine osteoarthritis (Sponsored by Hill's and Novartis)
A roundtable discussion
Jul 01, 2009
CUSTOM VETERINARY MEDIA
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.
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. 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.