September 19, 2017

Monitoring Companion Animals on Pain Medication

Panelists B. Duncan X. Lascelles, BVSc, PhD, DACVS; Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR; Mark Epstein, DVM, DABVP, CVPP; and Sheilah Robertson, BVMS, PhD, DACVAA, DACAW, provide insight on monitoring companion animals on pain medication and identify timelines for follow-up.


B. Duncan X. Lascelles, BVSc, PhD, DACVS: Regardless of what we use now or in the future, going back to monitoring these patients and the comments about maybe dose reduction or increasing the dosing interval, how often would you get these patients back into your practice to evaluate them? What is appropriate monitoring for adverse events, and what is appropriate monitoring for efficacy? How frequently should we be seeing these young patients?

Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: I don’t know that we have the answer.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: We need an answer. We need the answer, Bryan.

Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: Yes, yes, yes.

Mark Epstein, DVM, DABVP, CVPP: I think the answer is, probably more than we do.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: More than we do?

Mark Epstein, DVM, DABVP, CVPP: Yes, I think that’s reasonable. I think it’s probably a case-by-case basis. But, certainly, if you have these young patients that you’re starting off on therapy on, in the beginning you’re going to want to see them more frequently than once they’re well managed and established. And by the time they’re in the more geriatric age, you’re probably going to want to see them more frequently than you did when they were cruising along in their middle ages.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Let’s say you diagnose and start treating a young dog. When should you first see that patient back?

Mark Epstein, DVM, DABVP, CVPP: A young dog?

B. Duncan X. Lascelles, BVSc, PhD, DACVS: A young dog, and we’re talking about a practical combination of assessments.

Mark Epstein, DVM, DABVP, CVPP: So, we’ve just seen the dog, and have just started, maybe, on some nonsteroidals?

B. Duncan X. Lascelles, BVSc, PhD, DACVS: Assessing for side effects, assessing for efficacy.

Mark Epstein, DVM, DABVP, CVPP: We know from looking at the data with nonsteroidals in dogs with demonstrable OA that it can take up to 2, 3, sometimes 4 weeks in a given patient for the nonsteroidal to exert its maximum effect, or any effect, really. And that’s because some of these dogs have a central and peripheral sensitization component that has to wind down, if you will, before the clinical effect is really seen.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: And maybe even a learned component?

Mark Epstein, DVM, DABVP, CVPP: And a learned component, right. So, they’re avoiding certain behaviors, correct? I think a month is probably a good target time period. The drug trial actually lasts at least that time, and that is a good target time to see them back and continue the dialogue with the owner going forward. In the meantime, you should also be considering introducing other modalities. The polysulfated glycosaminoglycans would be very, very high on my list. The EPA-rich diets are very, very high on my list. Weight optimization is at the top of the list, besides the nonsteroidals.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: You’re saying to see them back for the first time at a month?

Mark Epstein, DVM, DABVP, CVPP: That would be a reasonable target.

B. Duncan X. Lascelles, BVSc, PhD, DACVS: And then, how often after that in a young dog?

Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: That’s a good question. Maybe in 3 months again, then at 6 months, and then see them at their yearly exam. Maybe that’s a good target. I don’t know that we have a set thing. I think you probably have to take that on a case-by-case basis. But, I think we’re going to find a lot of others appreciate that type of early management and investment in them and their patient—investment of our time, and our interest, and our concern about how we can effect a change later in life.

Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: I think something that always needs to be brought up is that it would be nice to see them more, but there also has to be the discussion on if you’re going to start all this in a very young dog, there’s a financial investment by the owner. And that is not always something that every owner can absorb. And so, I think that the economics of these diseases for the owner are of concern. They have other things in their life that need to be paid for. The dog or cat could be extremely important, but the financial investment in this disease, for the owner, can be quite extensive and challenging.

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