August 13, 2018

Current Options for Managing Canine Osteoarthritis

A host of effective modalities are available for alleviating discomfort and improving mobility in dogs with degenerative joint disease.
By American Veterinarian Editorial Staff
Intra-articular needle placement for the hip joint. The joint fluid in the hub of the needle indicates correct placement.

David Dycus, DVM, MS, CCRP, DACVS-SA, is on a mission. He wants to help his fellow veterinarians understand that managing canine osteoarthritis (OA) is not a matter of simply prescribing a pain reliever and an anti-inflammatory and sending patients on their way. Instead, he said, managing this chronic, painful condition requires a patient-specific, multipronged approach.

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“At the end of the day, it’s all about keeping patients comfortable so they can stay active, maximize range of motion, and maintain lean body weight,” said Dr. Dycus, an orthopedic staff surgeon at Veterinary Orthopedic & Sports Medicine Group in Annapolis Junction, Maryland, and cofounder/codirector of the Veterinary Sports Medicine and Rehabilitation Institute. “If our patients aren’t comfortable, they’re not going to be active.” And with inactivity, he said, comes weight gain, stiffness, and loss of range of motion.

But this vicious circle can be broken with the help of several existing and new treatment modalities. American Veterinarian® spoke with Dr. Dycus about today’s best practices for managing OA.

What is your overall approach to the patient with OA?
David Dycus, DVM, MS, CCRP, DACVS-SA: In people with OA, most of the stiffness, soreness, and pain come from the loss of range of motion, and I think the same probably applies to dogs. If we can maintain as much range of motion as possible and exercise them daily, they’re going to have less stiffness and more comfort.

It used to be that we prescribed an anti-inflammatory and there wasn’t much more we would do. What has emerged in the past decade or so is the concept of multimodal management, the idea that anti-inflammatories can be combined with other modalities to better manage the condition.

We have to come at OA from every angle, with the ultimate goal of maintaining comfort and daily exercise for the dog. Owners don’t want to think they are hurting their pets, so it’s our job to ensure they stay comfortable and exercise to maintain range of motion and ideally minimize or slow disease progression as best as possible. And exercise doesn’t mean going into the backyard and chasing squirrels. It means getting outside and going on walks. Ideally, most dogs should be able to go comfortably on at least two 20-minute leash walks on flat ground every day. Once they can achieve this, then the sky is the limit in terms of time, distance, terrain, and elevation.

To achieve that level of comfort, we combine various modalities, typically starting with pain management.
 

Evaluating and Managing Pain

How do you manage their pain?
Just as in people, dogs with OA have periods of relative calmness and then periods of flare-ups during which clinical signs are acutely exacerbated. It is during the periods of calmness where we have our “baseline [management] approach.” This includes joint supplements such as glucosamine, chondroitin, and omega-3 fatty acids. However, the most important aspect of the baseline approach is daily exercise and maintenance of a lean body weight. If a patient with OA deviates from its baseline, this can indicate a flare-up. When this happens, we take a step back and ask ourselves what we can do to get the flare-up under control so that the patient can return to its baseline. During a flare-up there is more pain and discomfort, so step 1 is getting this under control.

We may start with pharmaceuticals such as nonsteroidal anti-inflammatory drugs (NSAIDs), but the goal is to use these at the lowest dose and as infrequently possible. This means using an NSAID for 10 to 14 days during the early phases of OA knowing that at some point in the future the patient may need daily NSAID support. As a profession, we’ve got to move away from offering only an anti-inflammatory and an opioid and thinking there is nothing more we can do.

Other pharmaceuticals that can be considered are opioids such as codeine. However, it should be remembered that opioids are not designed for chronic use. Gabapentin, amantadine, and amitriptyline, among others, can be considered along with an NSAID.

Do you prescribe tramadol for pain management?
I’ve moved away from tramadol for joint pain. I think there has always been controversy over tramadol’s effectiveness, with no real clinical evidence that it was helpful, and there seems to be a consensus now that it doesn’t work very well to control joint pain. One recent study used both positive and negative controls (placebo) and found that there was no improvement in peak vertical force or vertical impulse in dogs on tramadol versus placebo.1 Rather than it being a true opioid and controlling pain, I think tramadol likely affects serotonin levels. So the patient may be a bit spaced-out, but they are probably still painful.

Is grapiprant effective?
Grapiprant (Galliprant; Elanco) is a prostaglandin-receptor antagonist that targets the EP4 receptor that’s involved in OA-associated pain and inflammation. Formulated only for dogs, grapiprant can help animals that haven’t tolerated or responded to traditional NSAIDs. It’s also associated with fewer hepatic, renal, and gastrointestinal side effects. It might be a good go-to for some of those older patients who are stuck between a rock and a hard spot because they can’t tolerate traditional anti-inflammatories.

In what other ways can pain be kept under control?
There are a lot of avenues beyond pharmaceuticals to make these patients comfortable. Other disease-modifying OA agents, such as joint supplements with glucosamine, chondroitin, omega-3 fatty acids, and polysulfated glycosaminoglycans, can be incorporated, for example.

Adding to our multimodal management approach during a flare-up is the incorporation of formal physical rehabilitation and intra-articular injections. Physical rehabilitation can be used to allow active muscle contractions while minimizing the stress being placed on the joints. In this situation we can allow a patient to remain active and thus maintain range of motion while simultaneously working to help get pain under control. Rehabilitation therapies are a great nonpharmaceutical avenue for managing pain and in many cases can help us lower the dose or frequency of pharmaceuticals.

Intra-articular injections include a variety of substances, such as steroids, hyaluronic acid, or regenerative medicine (platelet-rich plasma [PRP] and/ or mesenchymal stem cells). Intra-articular injections are a way to further reduce the inflammatory response in a more target-directed way over the oral analgesics. These products can achieve a high concentration directly at the joint.

Once they’re comfortable we get them back to their baseline. It’s important to remember that what works during one flare-up may not work for the next. We must always be evolving and taking a multimodal, patient-centered approach rather than a cookbook approach.

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