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7/23/2019 Pain Guidelines 2015 Epstein 251 72
1/22
S P EC I A L A R T I C L E
Journal of Feline Medicine and Surgery (2015) 17, 251272
2015 AAHA/AAFP Pain
Management Guidelines
for Dogs and Cats
JFMS CLINICAL PRACTICE 251Doi: 10.1177/1098612X15572062 iSFM and AAFP 2015
Rationale: The robust advances in pain management for companion animals underlie the
decision of the American Animal Hospital Association (AAHA) and American Association
of Feline Practitioners (AAFP) to expand on the information provided in the 2007
AAHA/AAFP Pain Management Guidelines. The 2015 Guidelines summarize and offer
a discriminating review of much of this new knowledge.
Relevance: Pain management is central to veterinary practice, alleviating pain, improving
patient outcomes, and enhancing both quality of life and the veterinarianclientpatient relationship.These Guidelines support veterinarians in incorporating pain management into practice, improving
patient care.
Approaches: The management of pain requires a continuum of care that includes anticipation, early
intervention, and evaluation of response on an individual patient basis. A team-oriented approach, including
the owner, is essential for maximizing the recognition, prevention and treatment of pain in animals.
Evidence base: The Guidelines include both pharmacologic and non-pharmacologic modalities
to manage pain; they are evidence-based insofar as possible and otherwise represent a consensus
of expert opinion. Behavioral changes are currently the principal indicator of pain and its course of
improvement or progression, and the basis for recently validated pain scores. Post-surgical pain is
eminently predictable but a strong body of evidence exists supporting strategies to mitigate adaptive
as well as maladaptive forms. Chronic pain is dominated by degenerative joint disease (DJD), which is
one of the most significant and under-diagnosed diseases of cats and dogs. DJD is ubiquitous, found
in pets of all ages, and inevitably progresses over time; evidence-based strategies for management
are established in dogs, and emerging in cats.
Introduction
Pan management s central t veternarypractce, nt adjunctve. Allevatng pan s ntnly a prfessnal blgatn (recall the vet-ernarans pledge t the relef f anmal panand sufferng) but als a key cntrbutr tsuccessful case utcmes and enhancementf the veternaranclentpatent relatnshp.A cmmtment t pan management dentfesa practce as ne that s cmmtted t cmpas-snate care; ptmum recvery frm llness,njury r surgery; and enhanced qualty f lfe.
These Gudelnes cntnue the trend n allbranches f medcne tward evdence-basedcnsensus statements that address key ssuesn clncal practce. Althugh nt a revewartcle, ths cmplatn s a frce multplerfr the busy practtner, cnsldatng n a
Mark E EpsteinDVM DABVP (Canine/Feline) CVPP
Co-Chair
TotalBond Veterinary Hospitals PC,3200 Union Road,
Gastonia, NC 28056, USAEmail: [email protected]
Ilona RodanDVM DABVP (Feline)
Co-Chair
Cat Care Clinic and Feline-FriendlyConsultations, 322 Junction Road,
Madison, WI 53717, USAEmail: [email protected]
Gregg GriffenhagenDVM MS
Colorado State University Schoolof Veterinary Medicine,
300 West Drake Road, Fort Collins,CO 80523, USA
Jamie Kadrlik
CVTPet Crossing Animal Hospital
and Dental Clinic,10861 Bloomington Ferry Road,Bloomington, MN 55438, USA
Michael C PettyDVM MAV CCRT CVPP DAAPMArbor Pointe Veterinary Hospital/
Animal Pain Center, 42043 Ford Road,Canton, MI 48187, USA
Sheilah A RobertsonBVMS PhD DACVAA MRCVS DECVAA
Department of Small Animal ClinicalSciences, College of Veterinary Medicine,Michigan State University, East Lansing,
MI 48824, USA
Wendy SimpsonDVM
Morrisville Cat Hospital, 100 Keybridge
Drive, Suite A, Morrisville, NC 27560, USA
The AAFP and AAHA
welcome endorsement of these
Guidelines by the International
Society of Feline Medicine
(ISFM) and the International
Veterinary Academy of Pain
Management (IVAPM).
sngle place current recmmendatns andnsghts frm experts n pan management.These Gudelnes are the prduct f acllabratve effrt by the Amercan AnmalHsptal Asscatn (AAHA) and theAmercan Asscatn f Felne Pract-tners (AAFP). The recmmendatns fthe Gudelnes Task Frce are evdence
based nsfar as pssble and therwserepresent a cnsensus f expert pnn.
These Gudelnes are desgned t expandn the nfrmatn cntaned n the 2007AAHA/AAFP Pan Management Gude-lnes fr Dgs and Cats.1,2 The 2015Gudelnes dffer frm the earler versn nseveral ways. The frst sectns are generalcncepts desgned t set the stage fr theremanng, mre specfc cntent. The 2015Gudelnes als dscuss the mprtance f
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an ntegrated apprach t managng pan thatdes nt rely strctly n analgesc drugs.Because pan assessment n anmals hasbecme mre scentfcally grunded n recentyears, varus clncally valdated nstrumentsfr scrng pan n bth dgs and cats aredescrbed. The extensve lst f publshed ref-erences ncludes numerus studes publshed
wthn the past 3 years, reflectng the rapdpace f advances n managng pan fr cm-pann anmals. The 2015 Gudelnes summa-rze and ffer a dscrmnatng revew f muchf ths new knwledge.
252 JFMS CLINICAL PRACTICE
Types of pain
All types f tssue njury can be generatrsf pan. occasnally, pan may ccur n theabsence f thse causatve factrs. Under-standng the mechansms f pan s the key tts successful preventn and treatment. Thepan respnse s unque t each ndvdual
and nvlves tw cmpnents: The sensry cmpnent s nociception,whch s the neural prcessng f nxusstmul; The affectve cmpnent s painperception, whch s the unpleasant sensryand emtnal experence asscated wthether actual r ptental tssue damage.
Pan s the endpnt f ncceptve nputand can nly ccur n a cnscus anmal.Hwever, there s als nvlvement f aut-nmc pathways and deeper centers f thebran nvlved wth emtn and memry.Hence, pan s a multdmensnal experence;t s nt just what yu feel but als hw tmakes yu feel.3
Acute pan has been defned as pan thatexsts durng the expected tme f nflamma-tn and healng after njury (up t 3 mnths),and chrnc pan s defned as that whchexsts beynd the expected duratn asscat-ed wth acute pan. Therapy shuld be fcusedn the underlyng cause f pan (ncceptve,nflammatry r pathlgcal), rather than narbtrary labels based n duratn.4
Nociceptive pain ccurs when perpheralneural receptrs are actvated by nxus
stmul (eg, surgcal ncsns, trauma, heatr cld). Inflammatory pain results gradually frmactvatn f the mmune system n respnset njury r nfectn. Pathological pain, als called maladaptvepan, ccurs when pan s amplfed andsustaned by mlecular, cellular andmcranatmc changes, cllectvely termedperpheral and central hypersenstzatn.
Pathlgcal pan s characterzed by hyper-algesa (exaggerated respnse t nxusstmulus), alldyna (panful respnse t nn-nxus stmul, such as tuch r pressure),expansn f the panful feld beynd ts rg-nal bundares, and pan prtracted beyndthe expected tme f nflammatn andhealng. Under sme cndtns, genmc,phentypc changes ccur that create the cn-dtn knwn as neurpathc pan, wherebypan can be cnsdered a dsease f the centralnervus system. Thse changes are nt neces-sarly chrnlgc. Maladaptve pan, r thersk fr t, can ccur wthn a matter f mn-utes f certan acute pan cndtns (eg, nervenjury, severe tssue trauma, r presence fpre-exstng nflammatn).
SPEC IAL ART ICLE /2015 AAHA/AAFP pain management guidelines
CONTENTS page
Introduction 251
Types of pain 252
Continuum of care 253
Its not just about drugs 253
Recognition and assessment of pain 253
Acute pain: characteristics and causes 254
Practical approach to postoperative pain assessment 254
Chronic pain: characteristics and causes 255
Pharmacologic intervention of pain 256
Opioids 256
Non-steroidal anti-inflammatory drugs 256
Local anesthetics 258
-2 Adrenergic agonists 258
Ketamine 258
Systemic lidocaine 259
Tramadol 259
Gabapentin 259
Amantadine 259
Tricyclic antidepressants 259
Selective serotonin (norepinephrine) reuptake inhibitors 259
Acetaminophen 259
Maropitant 260
Bisphosphonates 260
Corticosteroids 260
Polysulfated glycosaminoglycans 260
Nutraceuticals and other oral supplements 260
Non-pharmacologic modalities for pain management 260
Weight optimization 260
Acupuncture 260
Physical rehabilitation 261 Nutrition management 261
Thermal modification 261
Environmental modifications 261
Chiropractic care 261
Homeopathy 261
Gentle handling techniques 262
Managing surgical pain 262
Managing pain associated with DJD 263
When pain persists: hospice and palliative care 265
A team approach and client education: creating an environment
for success 266
Summary points 268
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JFMS CLINICAL PRACTICE 253
SPEC IAL ART ICLE /2015 AAHA/AAFP pain management guidelines
Its not just about drugs
Classc veternary medcal educatn places astrng emphass n treatment f dseasethrugh pharmaclgy and surgery, the es-terc sklls that are the dman f the traned
clncan. increasngly, evdence-based dataand emprcal experence justfy a strng rlefr nn-pharmaclgc mdaltes fr panmanagement. A number f thse shuld becnsdered manstream ptns and anntegral part f a balanced, ndvdualzedtreatment plan.
Examples f nn-pharmaclgc treatmentssupprted by strng evdence nclude, but arent lmted t, cld cmpressn, weghtptmzatn and therapeutc exercse.Treatment ptns ganng ncreasng accept-ance nclude acupuncture, physcal rehablta-tn, myfascal trgger pnt therapyand therapeutc laser, amng ther mdalteswhch are dscussed later n these Gudelnes.in addtn, nn-pharmaclgc adjunctvetreatment ncludes an apprecatn fmprved nursng care, gentle handlng, care-gver nvlvement, mprved hme envrn-ment, and hspce care. Thse methds havethe crtcal advantages f ncreased care-gverclncan nteractn and a strengthen-ng f the humanpet bnd. That sharedrespnsblty prmtes a team apprach andleads t a mre cmplete and ratnal bass frpan management decsns.5
Recognition and assessmentof pain
The patients behavior is keyBecause anmals are nn-verbal and canntself-reprt the presence f pan, the burden f
pan assumptn, recgntn and assessmentles wth veternary prfessnals. it s nwaccepted that the mst accurate methd frevaluatng pan n anmals s nt by physlg-cal parameters but by bservatns f behav-r. Pan assessment shuld be a rutne cm-pnent f every physcal examnatn, and apan scre s cnsdered the furth vtal sgn,after temperature, pulse and respratn.1,2,6obtanng a thrugh patent hstry frm thewner can help determne abnrmal behavrpatterns that may be pan related. Pet wnersshuld be educated n bservng any prblem-atc behavral changes n ther pet and tcntact ther veternaran n such cases.
Pet wners and practtners shuld havean awareness f behavr types that are rele-vant t pan assessment. Thse nclude theanmals ablty t mantan nrmal behavr,lss f nrmal behavr, and develpment fnew behavrs that emerge ether as anadaptn t pan r a respnse t pan relef(Fgure 2). Because behavral sgns f panare ften verlked r mstaken fr therprblems, the healthcare team must be vg-lant n recgnzng thse anmales n thettal patent assessment.
Appropriate pain management requires a contin-
uum of care based on a well thought out plan
that includes anticipation, early intervention and
evaluation of response on an individual patient
basis. It should be noted that response to therapy
is a legitimate pain assessment tool. Continuous
management is required for chronically painful
conditions, and for acute conditions until pain is
resolved.
The acronym PLATTER has been devised to
describe the continuum of care loop for managing
pain. The components of the PLATTER algorithm
for pain management are PLan, Anticipate, TreaT,
Evaluate and Return (Figure 1). The approach
provides individualized pain management for any
patient and is devised not on a static basis but
according to a continuous cycle of plantreateval-
uate based on the patients response.
Figure 1: PLATTER approach to pain management
PLan Every case should start with a patient-specific pain assessment and treatment plan
Anticipate The patients pain management needs should be anticipated whenever possible so
that either preventive analgesia can be provided or, in the case of pre-existing pain,
it can be treated as soon as possible
TreaT Appropriate treatment should be provided that is commensurate with the type,
severity and duration of pain that is expected
Evaluate The efficacy and appropriateness of treatment should be evaluated; in many cases,
using either a client questionnaire or an in-clinic scoring system
Return Arguably the most important step, this action takes us back to the patient where
the treatment is either modified or discontinued based on an evaluation of the
patients response
C o n t i n u u m o f c a r e
Figure 2:
Behavioral keys
to painassessment
When assessing an
animal for pain, the
following behavioral
keys should be con-
sidered:
Maintenance of
normal behaviors
Loss of normal
behaviors
Development of
new behaviors
Appropriate
pain
management
requires a
continuum
of care.
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SPEC IAL ART ICLE / 2015 AAHA/AAFP pain management guidelines
254 JFMS CLINICAL PRACTICE
Pain scoring toolsAlthugh there s currently n gld standardmethd fr assessng pan n dgs and cats, theGudelnes Task Frce strngly recmmendsutlzng pan scrng tls bth fr acute andchrnc pan. it shuld be nted that thsetls have varyng degrees f valdatn, acuteand chrnc pan scales are nt nterchange-able, and canne and felne scales are nt nter-changeable. The use f pan scrng tls candecrease subjectvty and bas by bservers,resultng n mre effectve pan management,whch ultmately leads t better patent care.
Acute pain: characteristics andcauses
Acute pan nvlves bth ncceptve and
nflammatry cmpnents and can be causedby trauma, surgery and medcal cndtnsr dseases. These Gudelnes wll fcus nrecgntn, preventn and treatment f pst-surgcal pan.
Multifactorial clinical measurement
instruments for acute postsurgical painFr dgs, a valdated, wdely used, multfac-tral clncal measurement nstrument (CMi)fr acute pan s the Glasgw Shrt FrmCmpste Measure Pan Scre. The 4AVet santher cmpste measure pan scre frdgs, reprtedly wth mre nterbservervarablty than the Glasgw shrt frm, butless based by sedatn.7,8 Smple, nlne, prac-tce-frendly numercal ratng scales (0 t 4)fr acute canne and felne pan have beendevelped (but nt yet valdated) byClrad State Unversty. in cats, a currentlyvaldated assessment tl s the UNESP-Btucatu Multdmensnal Cmpste PanScale.9,10 That scale and vde examples fhw t s appled n clncal practce can beaccessed nlne, and a descrptn f ClradStates acute pan scales are ncluded nTable 1.
Practical approach topostoperative pain assessment
Valdated CMis are the fundatn f ratnalpan assessment. Thse assessment tls pr-vde a smplfed apprach that encuragesregular use by all healthcare members and arebased n the fllwng features: observng the patent wthut nteractn(e, the patents rentatn n the cage,psture, mvement, facal expressn, actvtylevel and atttude; images 1 and 2). observng the patent whle nteractngwth a care-gver (eg, what ccurs when thecage dr s pened r an anmal s caxedt mve).
Resource Internet address Content
Colorado State University CanineAcute Pain Scale
www.csuanimalcancercenter.org/assets/files/csu_acute_pain_scale_canine.pdf
Psychological and behavioral indicators of pain Response to palpation
Colorado State University FelineAcute Pain Scale
csuanimalcancercenter.org/assets/files/csu_acute_pain_scale_feline.pdf
Same as above
University of Glasgow Short FormComposite Measure Pain Score
www.newmetrica.com/cmps Clinical decision-making tool for dogsin acute pain
Indicator of analgesic requirement Includes 30 descriptors and six behavioral
indicators of pain
UNESP-Botucatu MultidimensionalComposite Pain Scale
www.animalpain.com.br/en-us/avaliacao-da-dor-em-gatos.php
Assesses postoperative pain in cats Includes 10 indicators of pain ranked numerically
Table 1 Acute postoperative pain scales
A pain score
is considered
the fourth
vital sign, after
temperature,
pulse and
respiration.
Image 2 Cats normallysleep in a curled-up position,as seen in this patient, whenprovided with adequateanalgesia. Courtesy ofSheilah Robertson
Image 1 (a,b) Signs of acute pain include squinting, and a hunched or tucked-up position
instead of sleeping in a normal curled-up position (see Image 2). Images courtesy of SheilahRobertson
a b
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SPEC IAL ART ICLE /2015 AAHA/AAFP pain management guidelines
JFMS CLINICAL PRACTICE 255
observng thepatents respnse tpalpatn f the surgcalste (image 3). Assgnng a numercalscre usng a dynamcnteractve vsual analgscale (eg, frm 0 fr n
pan t 10 fr the wrstpssble pan fr thatprcedure).
The re-evaluatnnterval wll depend nthe prcedure, expectedduratn f the chsennterventn, and prev-us pan scre. Varablty by dfferentbservers can be mnmzed by havng thesame team member assess the patentthrughut the evaluatn perd. ideally,the ndvdual patents nrmal temperamentshuld be knwn fr the purpses fcmparsn wth pstsurgcal appearance andbehavr.
Chronic pain: characteristicsand causes
Chrnc pan s usually descrbed as etherpan that perssts beynd the nrmal healngtme r pan that perssts n cndtns wherehealng has nt r wll nt ccur. in smecases, pan sgnalng perssts n the absencef grss tssue pathlgy.
The fllwng basc prncples are relevant
t chrnc pan n cmpann anmals: Pet wners may nt apprecate ther petsbehavr as beng an ndcatr f chrncpan; hwever, what they mght see sncreasngly dmnshed functn andmblty that ndcate prgressve dsablty.Examples nclude: Dmnshed exercse tlerance and generalactvty. Dffculty standng, walkng, takng stars,jumpng r gettng up. Decreased grmng (cats especally;image 4). Changes n urnatn r defecatn habts(image 5). Under-recgnzed and undermanagedchrnc pan can result n prematureeuthanasa.11 Cnversely, prper recgntnand management f chrnc pan can be aslfe preservng as any ther medcal treatmentn veternary medcne. Degeneratve jnt dsease (DJD) sthe nclusve termnlgy that ncludesstearthrts (oA). Althugh DJD and oAare ften used nterchangeably n the lteratureand n practce, the brader term, DJD, wll beused thrughut these Gudelnes.
Multifactorial clinical measurementinstruments for chronic pain
observatn r reprts (eg, n a pre-examna-tn questnnare) f behavral changes rabnrmaltes s the frst cnsderatn nrecgnzng and assessng pan. Thereafter,several standardzed, multfactral CMis frchrnc pan are avalable t veternarans, as
summarzed n Table 2. Such CMis are chrncpan ndces that prmarly utlze pet wnerbservatns and nput. ideally, patents wthchrnc pan shuld be evaluated wth ne fthe multfactral CMis.
Image 3 Followingassessment from a distance,palpation of the surgical siteis performed to furtherassess acute pain. Courtesyof Sheilah Robertson
Image 4 Lack of normal behaviors, such as reduced grooming, is commonly seen in painfulcats. Image iStock/jvoisey
Image 5 Cats may start to perform abnormalbehaviors secondary to pain, such as defecatingoutside of the litter box, either because the catcannot get downstairs to the box or it cannot jumpinto the box. Courtesy of Sheilah Robertson
Proper
recognition
and management
of chronic pain
can be aslife preserving as
any other medical
treatment in
veterinary
medicine.
Helsinki Chronic Pain Index (HCPI)
Canine Brief Pain Inventory (CBPI)
Cincinnati Orthopedic Disability Index (CODI)
Health-Related Quality of Life (HRQL)
Liverpool Osteoarthritis in Dogs (LOAD)
Feline Musculoskeletal Pain Index (FMPI)
Table 2 Multifactorial CMIs for
chronic pain assessment
in veterinary medicine
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Pharmacologic interventionof pain
Effectve pan management generally nvlvesa balanced r multmdal strategy usngseveral classes f pan-mdfyng medca-tns. The ratnale behnd ths apprach sthat t addresses targetng multple stes n
pan pathways, ptentally allwng lwerdses f each drug and mnmzng the pten-tal fr sde effects asscated wth any sngledrug. The chce f medcatn shuld bebased n antcpated pan levels and ndvd-ual patent needs. Antcpatry analgesa pr-vded prr t pan nset s mre effectvethan analgesa prvded nce pan hasccurred, cntrbutng t bth a dse- andanesthetc-sparng effect.
Opioidsopds are the mst effectve drug class frmanagng acute pan and can play a rle nmanagng chrnc pan. An mprved under-standng f neurpharmaclgy and thedevelpment f nvel frmulatns f pdsmake t ncumbent n veternarans t remanfamlar wth ther mdes f actn; the var-us subtypes wthn ths drug class; and thepreventn, recgntn and treatment fadverse effects.
Whle a cmplete dscussn f pds sbeynd the scpe f these Gudelnes, the TaskFrce makes the fllwng recmmendatnsfr usng ths class f drugs n dgs and cats: opds shuld be used as a rutne
preperatve medcant, preferentally ncmbnatn wth a tranqulzer/sedatve(eg, aceprmazne, mdazlam, dazepamr -2 adrenergc agnst such asdexmedetmdne), when the patentscndtn warrants ther use. Full agnsts elct greater and mrepredctable analgesa than partal agnstsr agnsts. in dgs, the antagnst/agnst butrphanl, n partcular, appearst prvde lmted smatc analgesa and avery shrt duratn f vsceral analgesa.12,13
in a cmparsn study, buprenrphneadmnstered befre surgery and durngwund clsure prvded adequate analgesafr 6 h fllwng varhysterectmy n cats,whereas butrphanl dd nt.14
in cats, the subcutaneus (SC) rute fpd admnstratn s nt recmmended.intramuscular (iM) and ntravenus (iV)rutes are preferred bth pre- andpstperatvely. 15 The ral transmucsalr buccal rute f admnstratn frbuprenrphne may have clncal effcacyas well.16,17
The ndvdual effect f any pd,ncludng duratn, may vary wdely frm
256 JFMS CLINICAL PRACTICE
SPEC IAL ART ICLE /2015 AAHA/AAFP pain management guidelines
patent t patent. Pstperatve re-evaluatnshuld be made frequently t determnengng pd requrements. Fr a patent undergng majr surgery,whereby ngng pd admnstratn canbe antcpated, the clncan may chse frmthe fllwng strateges: Perdc readmnstratn f parenteral
pds. Cnstant r varable rate nfusn.Calculatrs can be fund nlne. Lng-actng frmulatns and technlges.Fr dgs there s a Fd and DrugAdmnstratn (FDA) apprved transdermalfentanyl prduct (Recuvyra; Elanc). Gvenths canne fentanyl prduct n the market,the Task Frce dscurages the use f humancmmercal fentanyl patches n dgs due thghly varable pharmacknetcs, and rskf ether accdental r purpseful humanexpsure, wth ptental lablty frextralabel use. There s nt an expertcnsensus regardng the utlty f fentanylpatches n cats. The FDA has mre recentlyapprved a cncentrated njectablebuprenrphne prduct fr cats (Smbadl;Abbtt), whch has been frmulated tprvde a 24 h duratn f actn whenadmnstered as drected. oral pds. Dgs exhbt a rbust frst-pass effect f ral pds. N clncal studesdcument effcacy, but pharmacknetcs fcdene and hydrcdne suggest pssbleutlty.18 N cmparable studes exst fr cats. opds are synergstc wth -2
adrenergc agnsts, allwng them t be usedn lw-dse cmbnatns, ether wth rwthut ketamne, t great effect fr bthsedatn and analgesa. opds play a sgnfcant rle n humanmedcne fr the treatment f chrnc panand may play an underapprecated rle ndgs and cats as well, especally fr cancer-related pan and n pallatve care patents.That sad, clncans must be vglant wthregard t lng-term adverse effects such ascnstpatn, drug tlerance and the ptentalfr dversn by clents.
Non-steroidal anti-inflammatory drugsThe majrty f cndtns that cause panhave an nflammatry cmpnent. Nn-sterdal ant-nflammatry drugs (NSAiDs)are a manstay fr management f chrncpan as well as fr perperatve use. NSAiDsshuld be used fr ther central and perpher-al effects n bth dgs and cats after cnsder-atn f rsk factrs. There s n ndcatn thatany ne f the veternary-apprved NSAiDss asscated wth any greater r lesser nc-dence r prevalence f adverse events.19Canne and felne veternary-apprved
Anticipatory
analgesia
provided prior
to pain onset is
more effective
than analgesia
provided once
pain has
occurred.
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JFMS CLINICAL PRACTICE 257
SPEC IAL ART ICLE /2015 AAHA/AAFP pain management guidelines
NSAiDs have demnstrated acceptable safetyprfles, whch s n cntrast t nn-apprvedNSAiDs such as asprn, buprfen, naprxenand melxcam fr human use.2022 Lng-termuse f lw-dse melxcam s apprved ncats n many cuntres ther than the USA.
Adverse events related t NSAiD use ndgs and cats can be mnmzed by apprpr-ate use, as utlned n Fgure 3. Althugh theverall ncdence and prevalence f NSAiD-related txcty s unknwn, t des appear tbe very lw relatve t the number f dsesadmnstered.20
of the adverse events asscated wthNSAiDs, gastrntestnal (Gi) txcty s themst cmmn. The Gi clncal sgns asscatedwth NSAiD txcty n dgs nclude vmt-ng, darrhea and nappetence.20,2325 in cats,nappetence appears t be the mst cmmnadverse event. Althugh unlkely, t s pss-ble fr ersns and ulcers t be slent and
ccur prr t any clncal sgns.23,26 Studesndcate that NSAiDs that spare cyclxyge-nase (CoX)-1 prduce a lwer frequency f Gilesns, althugh the mre hghly CoX-2selectve nhbtrs may actually prducemre adverse events when underlyng gastrcdamage s already present.19,27
The leadng rsk factrs fr NSAiD-asscat-ed Gi perfratns are ncrrect dsng,cncurrent use wth ther NSAiDs r crtc-sterds, and cntnued use despte Gi sgnsr anrexa.20,24 Sgns f Gi txcty usuallyemerge wthn 24 weeks but can ccur at anypnt durng admnstratn.28,29 it s crtcalthat veternarans cmmuncate NSAiD txc-ty rsk factrs t pet wners (eg, prvdngclent nfrmatn that descrbes ptentalsde effects, ncludng the cmmercal crcu-lars prvded by drug manufacturers andnstructn n when t stp medcatn andcntact a veternaran).
Figure 3: Nine ways to minimize the risks of NSAIDs
Obtain a complete medication historyAvoid
or use extreme caution with concurrent or recent
use of NSAIDs and/or corticosteroids (including
some nutritional supplements that may contain
aspirin or other cyclooxygenase-inhibiting
mechanisms). Practitioners should observe the
following additional precautions due to potential
drug interactions:
Avoid with furosemide and use caution with
angiotensin-converting enzyme inhibitors.
Avoid with potentially nephrotoxic drugs
(eg, aminoglycosides, cisplatin).
Caution with use of additional multiple highly
protein-bound drugs (eg, phenobarbital, digoxin,
ciclosporin [cyclosporine], cefovecin,
chemotherapy agents).
Be discriminating in patient selection Be
cautious or avoid NSAIDs in patients with the
following existing/anticipated conditions:
Low-flow states such as dehydration,hypovolemia, congestive heart failure and
hypotension. In such cases, IV fluid support and
blood pressure monitoring should be available
for anesthetized animals.
Renal, cardiac or hepatic dysfunction.
Provide verbal and written client instructions
to avoid the medications described above and to
discontinue and alert the hospital at the first sign
of an adverse event (see below).
Recognize the earliest signs of adverse
events and withdraw NSAID treatment
immediately if those events occur, especially in
the case of any GI signs in dogs and cats with
diminished appetites.
Perform laboratory monitoring The frequency
will depend on the risk factor of the patient:
Ideally within the first month of initiating therapy
then 6 monthly thereafter in low-risk patients.
For at-risk patients, monitor every 24 months
depending on risk factor assessment.
Utilize a balanced, integrated analgesic
approach as part of NSAID-sparing strategies.
Consider washout periods Clinically relevant
washout periods remain controversial and largely
undefined. Based on pharmacokinetics,
practitioners who wish to err on the side of
caution may want to withhold meloxicam for
5 days and other NSAIDs or short-acting
corticosteroids for 7 days prior to initiating
treatment with another NSAID. In the case of
long-acting corticosteroids, a longer washout
period needs to be considered. Aspirin should
not be administered because there are safer
alternatives. If a course of treatment with aspirinhas been started in a dog, the recommended
washout period before starting an approved
veterinary NSAID is up to 10 days.
Use gastroprotectants to either treat
suspected gastropathy or prevent its
occurrence, especially if no washout period
occurs. Proton pump inhibitors, H2 antagonists,
misoprostol (the drug of choice in humans) and
sucralfate can be helpful.
Dose optimization Base dosage on lean
body weight. Although there is no definitive
evidence that NSAID dose reduction lowers
the risk of adverse events, some clinicians
recommend titrating to the lowest effective dose.
Adverse events
related to
NSAID use in
dogs and cats
can be
minimized byappropriate
use.
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Anther mprtant sde effect asscatedwth NSAiDs s nephrtxcty. When admn-stered befre anesthesa n healthy dgs wthcntrlled mdest hyptensn, n adverseeffect n renal functn was detected.30,31
Hwever, because sme dgs n thse studesdd develp changes n renal parameters, themprtance f mantanng a nrmtensvestate durng anesthesa s cnsdered para-munt when utlzng preperatve NSAiDs.Preperatve admnstratn n dgs s super-r n effcacy t pstperatve use, cnsstentwth results f multple studes perfrmed nhumans.32 Smlar studes have nt beencnducted n cats undergng anesthesa, butne felne study revealed n alteratn nglmerular fltratn rate measured by hexlclearance after 5 days f ral melxcam.27if iV access s nt pssble and nrmtensncannt be acheved wth certanty, the TaskFrce recmmends lmtng the use fNSAiDs t pstsurgcal admnstratn.
idsyncratc hepatcellular necrss hasbeen reprted wth varus NSAiDs butremans exceedngly rare, at nly 1.4 cases/10,000 dgs (0.052%), usually ccurrngbetween 2 and 4 weeks after startng treat-
ment. Pre-exstng elevated lver enzymes arent a rsk factr.19 idsyncratc hepatcellularnecrss s nt a true txcss but rather anntrnsc, hertable reactn t the mleculebeng admnstered.20
Hghly CoX-2 selectve NSAiDs havecaused delayed bne healng n rabbt andrdent mdels, and ne study n dgs demn-strated delayed healng f expermental tbalstetmes fllwng lng-term NSAiDuse.33 That partcular study may nt be aclncally relevant mdel, and anther studyreprted that nrmal tssue healng s rapdlyrestred nce the NSAiD s wthdrawn.34
Further, f 299 dgs recevng deracxb,carprfen and frcxb n the FDA-apprvalprcess, nne were reprted t have delayedfracture healng r nn-unn fractures.Fnally, n clncally sgnfcant bleedngdyscrasas have been reprted wth the use fveternary NSAiDs.20
Local anestheticsThs s the nly class f drug that renderscmplete analgesa. The ttalty f evdence nhuman and anmal studes reveals the pre-dctable analgesc and anesthetc drug-sparng
effects f lcal anesthetcs. in addtn, lcalanesthetcs are reprted t be antmcrbal andmmunmdulatng, and can dmnsh pst-peratve maladaptve pan states. They d ntappear t delay tssue healng.35 Lcal anesthet-cs can be admnstered ether drectly at a sm-ple ncsn ste r at a specfc nerve t prvdeanalgesa t a large regn (r area). A dscus-
sn f the many lcregnal blcks that canbe utlzed n dgs and cats s beynd the scpef these Gudelnes, but can be fund n severalreadly accessble resurces, and mst f thseblcks can be readly learned by clncans.
Lcal anesthetcs are cnsdered safe, wthadverse events generally lmted t very hghdses r nadvertent iV admnstratn (bup-vacane especally). The Task Frce supprtsthe internatnal Veternary Academy f PanManagement pstn that, because f thersafety and sgnfcant beneft, lcal anesthetcsshuld be utlzed, nsfar as pssble, wthevery surgcal prcedure.
-2 Adrenergic agonists-2 Adrenergc receptrs are lcated wth pdreceptrs. Thus, used tgether, pds and -2adrenergc agnsts are hghly synergstc frsedatn and analgesa. -2 Agnsts have aversatle dsng prfle. That allws lw- andeven mcr-dses n cmbnatn wth pdst be clncally useful and mnmzes thecardvascular effects. Clncans shuld bemndful that cardvascular sde effects ccureven wth very lw dses f -2 adrenergcagnsts, that lwer dses wll have a shrter
duratn f effect, and that analgesc effects havea shrter duratn than the sedatve effects.
KetamineKetamne exerts a pan-mdfyng effect va tsN-methyl-D-aspartate receptr antagnstactns. Subanesthetc ketamne cnstant ratenfusn (CRi) n humans prevents panand has anthyperalgesc and antalldynceffects.36,37 Studes appear t supprt a smlarclncal effect n dgs,3840 althugh theanalgesc effect f ketamne has nt yet beenstuded n a felne surgcal mdel. Theinternatnal Veternary Academy f PanManagement has adpted a pstn that thepan-mdfyng effects and safety prfle fsubanesthetc dses f ketamne warrant ts useas part f a multmdal apprach t transper-atve pan management, especally n patentswth rsk factrs that may predspse them tether exaggerated r maladaptve pan states.
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The Guidelines Task Force strongly encourages
implementation of practice systems that ensure
communication to clients of appropriate adverse
effects and risk information for any prescribed
drug, including NSAIDs.
Therapy should be focused on the underlying cause
of pain (nociceptive, inflammatory or pathological)
rather than on arbitrary labels based on duration.
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Systemic lidocaineThere s strng evdence f the safety andbenefcal effects f iV ldcane n pan afterabdmnal surgery (althugh nt fr thersurgeres elctng smatc pan) n humansand pssbly n hrses, ncludng bth analge-sa and return f bwel functn.41 iV ld-cane s anesthetc-sparng n dgs and cats,
but current evdence fr a pan-mdfyngeffect n these speces remans ncnclusve.42
Sme nvestgatrs dscurage the use f iVldcane n cats due t negatve card-vascular effects, but successful use n clncalpractce has been anecdtally reprted.43Varus frmulatns fr a cmbnatn fmrphne, ldcane and ketamne CRis havebeen descrbed n dgs.44
Tramadolin cntrast t humans, tramadl n dgs hasa very shrt half-lfe (1.7 h) and neglgbleamunts f the pd M1 metablte areprduced.4548 Pharmacdynamc studesdemnstrate the anesthestc-sparng andpan-mdfyng effect f parenteral tramadln dgs.4953 Cnvncng evdence fr a pan-mdfyng effect f ral tramadl, hwever,remans elusve, and already lw plasma lev-els quckly dmnsh wth sequental admns-tratn.5457 one small study f ral tramadldd reprt a statstcally sgnfcant ncrease fmechancal threshld levels n dgs, but nlyat the 5 and 6 h tme pnts.48
in cntrast t dgs, cats d prduce the -agnst M1 metablte. A pan-mdfyng
effect has been demnstrated n bth a ther-mal threshld and clncal surgcal mdel.58,59There s ne case seres nvlvng the use fral tramadl n a flavred cmpunded frm(the drug s therwse qute btter). Dse ttra-tn, txcty and safety data are currentlylackng n bth dgs and cats.60
GabapentinGabapentn s an antcnvulsant wth an-algesc prpertes that may be prmarlyderved by dwn-regulatng calcum chan-nels.61 Because f ts effcacy and tlerablty,gabapentn s wdely used n humans wthneurpathc and ther maladaptve pancndtns.62 Alng wth publshed clncalcase reprts n anmals, the data suggest astrng ratnale fr usng gabapentn ndgs and cats wth smlar cndtns.63,64one canne study suggested a dsease-mdfyng effect n expermental DJD, butclncal studes are lackng.65 in cats, neunpublshed study demnstrated a beneftf gabapentn n naturally ccurrng DJD(E Trncy 2013), and ne case seres fchrnc musculskeletal pan has als beenpublshed.66
There s encuragng evdence t supprtthe use f gabapentn fr pstsurgcal pan nhumans,6772 but nt yet n dgs and cats.An 812 h dsng nterval has been suggestedbased n ne publcatn.73 The prmaryadverse effect n dgs appears t be smn-lence (als the case n humans), whch usuallyreslves wth patent acclmatn ver several
days, allwng fr a taperng-up schedule.AmantadineAmantadne exerts a pan-mdfyng effect asan N-methyl-D-aspartate receptr antagnstand remans a drug f nterest fr chrnc pan(but nt specfcally fr DJD) n humans.74 onestudy demnstrated utlty as an adjunct tNSAiDs n dgs wth refractry DJD,75 andthere s ne case reprt utlzng amantadnet treat neurpathc pan n a dg.76 Txctyand pharmacknetc studes have been per-frmed n humans and cats,77,78 but nt ndgs.
Tricyclic antidepressantsAs a class, trcyclc antdepressants (TCAs) arethe mst effectve medcatns fr selectveneurpathc pan cndtns n humans.79 indgs, there exsts nly a sngle case reprtwhere amtrptylne was used fr neurpathcmusculskeletal pan.80
Selective serotonin (norepinephrine)
reuptake inhibitorsThese cmpunds exert ther effect by ncreas-ng sertnn wth r wthut nrepnephrne
n the synaptc cleft. At least ne selectvesertnn (nrepnephrne) reuptake nhbtr(SS[N]Ri), dulxetne, has a chrnc pan labelndcatn n humans. in dgs, bavalabltys pr and clncal effcacy s lackng.81
At ths pnt n the Gudelnes, the TaskFrce wants t emphasze the fllwng:
Acetaminophen
Acetamnphen s cntrandcated n cats. indgs, several early studes revealed a pan-mdfyng effect n rthpedc surgery, andpharmacknetc data have been reprted.8284The lterature des nt appear t ndcate thatacetamnphen has a prclvty twards hepa-ttxcty n dgs.
Many drugs and compounds enhance either
monoamines or serotonin expression. Caution
should be used when such analgesic agents
are used in combination. Examples include
tramadol, TCAs (including amitriptyline and
clomipramine), SS(N)RIs, amantadine, metoclo-
pramide, selegiline, amitraz, mirtazapine and
trazodone.
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MaropitantMarptant s a central antemetc ndcatedfr the treatment f acute canne and felnevmtng, whch s ften a pstsurgcalsequela and a cntrbutr t the pan burden.Marptant wrks thrugh a blckade f sub-stance-P bndng t the neurknn-1 receptr,whch s nvlved n pan prcessng. The true
pan-mdfyng effect f marptant n dgsremans uncertan despte canne studesrevealng an anesthetc-sparng effect and ann-nferr effect t mrphne n an var-hysterectmy mdel.85,86
Bisphosphonates
Admnstered by iV nfusn, ths class fdrug exerts antsteclast actvty and cancntrbute t pan relef n dgs wth bnecancer.87
CorticosteroidsCrtcsterds are nt prmarly analgescdrugs, but may exert a pan-mdfyng effectby reducng nflammatn. Ther utlty as ananalgesc therapy n dgs and cats has ntbeen reprted.8891
Polysulfated glycosaminoglycansA parenterally admnstered plysulfatedglycsamnglycan (PSGAG) prduct hasregulatry apprval fr the cntrl f sgnsasscated wth nn-nfectus degeneratveand/r traumatc arthrts f canne synvaljnts. independent studes supprt PSGAGsas safe and effectve chndrprtectants
wth pssble dsease-mdfyng effects.9294
The bavalablty and dstrbutn fPSGAGs t nflamed jnts n cats hasbeen demnstrated wth extra-label SCadmnstratn.95
Nutraceuticals and other oral
supplementsoral nutrtnal supplements represent a wdespectrum f cmpunds ether as sngle agentsr n cmbnatns. Anecdtal evdence fr apan-mdfyng effect f thse prductsremans mxed. if nutraceutcals and/rherbal supplements are made part fa treatment plan, the Task Frce suggestsmndfulness twards prduct qualty cntrl;awareness f the ptental fr drug nterac-tns wth ther medcatns (eg, sme ver-the-cunter jnt prducts and herbal mxturescntan asprn and sme may cntan herbssuch as St Jhns wrt that nterfere wth ser-tnn release r reuptake); and avdance fngredents derved frm endangered speces.
in the future, evdence fr the pan-mdfyng effect f cannabnds and/rther cmmercal drug dervatves maybecme evdent.
Non-pharmacologic modalitiesfor pain management
Weight optimization
Adpse tssue secretes a mxture f cytknesthat crculate thrughut the bdy, cntrbut-ng t the pathlgy f many dseases, nclud-ng DJD, and t the hypersenstzatn prcessn general. Ether mantanng r reganng alean bdy cndtn scre s central t thetreatment f chrnc pan.
AcupunctureThe Gudelnes Task Frce hlds thatacupuncture ffers a cmpellng and safemethd fr pan management n veternarypatents and shuld be strngly cnsderedas a part f multmdal pan managementplans.96 it s a mnmally nvasve treatmentthat, fr mst anmals, s nt uncmfrtable,ften pleasant, and can be used ether alne rn addtn t ther pan treatment mdaltes(image 6). Acupuncture has been recgnzedby the Natnal insttutes f Health snce 1998as havng applcatns n human medcne,especally pan management. There s a sldand stll grwng bdy f evdence fr the use
f acupuncture fr the treatment f pan nveternary medcne t the extent that t snw an accepted treatment mdalty frpanful anmals.97101
260 JFMS CLINICAL PRACTICE
SPEC IAL ART ICLE /2015 AAHA/AAFP pain management guidelines
Image 6 Note howcomfortable cats usuallyare for acupuncture therapy.Courtesy of Sheilah Robertson
Increasingly, evidence-based data and empirical
experience justify a strong role for various non-
pharmacologic modalities for pain management.
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Physical rehabilitationCmbned mdalty therapy t decrease panand restre functn s nw cnsdered anessental apprach fr musculskeletal njuryand pstsurgcal recvery.102 in the treatmentf chrnc dsease, such as DJD r cnfrma-tnal abnrmaltes, rehabltatn shuld becnsdered an mprtant cmpnent f an
verall lng-term treatment strategy.103
The fundatn f rehabltatn s therapeu-tc exercse that ams t restre muscul -skeletal strength and functn, endurance andprprceptn, and reduce pan. Mst cm-mnly t nvlves exercse and manual thera-py, ncludng jnt mblzatns, massage andmyfascal release. Energy-based mdaltesare als ften emplyed, ncludng neurmus-cular electrcal stmulatn, transcutaneuselectrcal nerve stmulatn, crytherapy wthand wthut cmpressn, therapeutc ultra-sund, therapeutc laser and extracrprealshckwave therapy.104108
Myfascal pan syndrme (MPS) s ncreas-ngly recgnzed as an mprtant cmrbdtyn many chrnc pan cases n anmals. MPS sacknwledged fr the mprtant rle t playsn the pathlgy f DJD, repettve strannjures n perfrmance dgs, r as a sequelat rthpedc surgery. The pathphyslgyf myfascal pan s a cmplex syndrmenvlvng mtr, sensry and autnmcnerve cmpnents that s beynd the scpe fthese Gudelnes, but s well descrbed else-where.109 Treatment f MPS s ften essentalt regan full functn f the affected lmb,
regardless f the underlyng cause.110
Nutrition managementin the verweght patent, the prme nutrtn-al emphass shuld be achevng a leanerbdy cndtn. Weght cntrl dets frtfedwth mega-3 fatty acds have been shwn tbe effectve at reducng sgns asscated wthbth canne and felne DJD.111114
Thermal modificationin acute njury, ncludng surgcal areas, cldcmpressn has a demnstrable beneft nreducng pan and nflammatn, andprmtng return t functn.115 in the case fchrnc njury, heat can mprve cmfrt andfunctn thrugh a varety f mechansms.116
Environmental modificationsThere s strng evdence that the stress fhsptalzatn nhbts nrmal behavrs nanmals, ncludng eatng, grmng, sleepngand elmnatn.117 Fear, anxety, stress anddstress lead t hyperalgesa n bth humansand anmals.118121 Strateges t mtgatehyperalgesa, therefre, nclude prvdngbeddng, blankets r clthng frm hme
wth famlar scents; allwng vstatn fhsptalzed pets; separatng the dgs frmthe cats; placng cages s that anmals d ntsee each ther; usng speces-specfc synthetcphermnes; and prper handlng, especallydurng prcedures (see bx n page 262).122126
in patents wth DJD, thrw rugs and rampswll mprve mblty and abltes at hme(image 7).
Chiropractic careThe Gudelnes Task Frce has nt fund suff-cent, relable, nn-cntradctry evdence frthe use f chrpractc care fr pan manage-ment n veternary medcne at ths tme. Thatsad, chrpractc care has many well-defnedapplcatns n human medcne that havebeen supprted thrugh relable research.
Homeopathy
incntrvertble evdence that hmepathy seffectve n ether human r veternary med-cne fr the treatment f pan s lackng. Slerelance n hmepathy t treat a panful cn-dtn s, n essence, wthhldng pan treat-ment. Thus, ths Task Frce dscurages theuse f hmepathy fr the treatment f pan.
Image 7 Environmental management isneeded in addition to medical management forcats with DJD. Providing a stool (a,b), ramp orstep(s) (c) allows the cat to reach favoredareas. Pet steps are commercially available orcan be built; those pictured in (c) were built byDr Robert Wright of The Cat Doctor in PortlandME, USA. Images courtesy of Deb Givin
a
c
b
Photos included in this
Guidelines document pub-
lished in JFMS are intended to
demonstrate gentle handling tech-
niques, body positioning, behavior
and comfort practices specific to cats.
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Managing surgical pain
The Task Frce suggests that pan man-agement fr dgs and cats undergng asurgcal prcedure ncludes the fllwng: preperatve pd plus atranqulzer/sedatve (eg, aceprmazneand mdazlam r dazepam anddexmedetmdne). Admnstratn f an NSAiD ether pre- rpstperatvely based n patent rsk factrsand clncan preference. lcal anesthetc.
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Fr patents undergng prcedureswth rsk factrs fr mre severe, prtract-
ed r maladaptve pstperatve panstates, the fllwng nterventns r drugs
shuld be strngly cnsdered: Cld cmpressn. -2 Adrenergc agnst. Ketamne CRi. Ldcane CRi. Gabapentn. Epdural anesthetc(s).
Many cats have DJD in the spine as well as
the limbs. Scruffing can further exacerbate
the pain of thoracic or lumbar DJD. Instead
of scruffing, there are other excellent
alternatives that are actually safer for staff
as well as more comfortable for the feline
patient.
The hold depends on the cats
demeanor and comfort. For example,
some cats calmly look around or will eat
canned food or treats while venepuncture
from the medial saphenous vein is
performed (image a). For the more anxiouscat, use one to three of the middle fingers
to massage the area above the eyes (this
is also an area of acupressure to help calm
the cat), while the first and fifth digits hold
the head in place to prevent escape and
staff injury (image b).
Images courtesy ofIlona Rodan
a b
c d
For cystocentesis, a standing procedure
is often easier than stretching out the cats
legs (image c). For cystocentesis with
the cat positioned in lateral recumbency
(image d), move the legs back without
stretching them, and use either the
massage hold pictured in (b) or hold the
cat with the fingers made into a V shape
(two fingers on one side of the neck and
three on the other side).
G e n t l e h a n d l i n g t e c h n i q u e s
Detailed information
on handling feline patients
has recently been published in
the AAFP and ISFM Feline-Friendly
Handling Guidelines127 and the AAFP
and ISFM Feline-Friendly Nursing CareGuidelines.128
The importance of gentle handling of patients with either acute or chronic pain cannot be overstated, especially when working with
arthritic dogs and cats. Conscious avoidance of careless handling will ensure the patients comfort, allow for a more thorough and
effective physical examination, and avoid exacerbating anxiety in the agitated, fearful or aggressive patient. An important additional
benefit of gentle handling is that it demonstrates to the pet owner that healthcare team members are compassionate and aware of
the significance of pain in their patients.
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Managing pain associatedwith DJD
Overview of DJD in companion animalsDJD, ncludng oA, s ne f the mst sgnf-cant and underdagnsed dseases f cats anddgs. DJD s clncally relevant because f tsverall prevalence and unversal ncdence n
lder anmals. Whereas dagnstc apprach-es fr canne DJD are well establshed, the besttls fr dagnss f felne DJD are stll bengdevelped.
The pan treatment cntnuum fr DJDbegns wth the nset f dsease, whch usuallystarts at a very yung age n dgs (eg, cnfr-matnal etlgy) and cats (unknwn etl-gy), and perssts thrughut the anmals lfe.Perhaps mre s than any ther pan cnd-tn, the management f DJD benefts frm anntegratn f bth pharmaclgc and nn-pharmaclgc treatments. once a dagnss smade, treatment gals, expectatns and ut-cme measures shuld be cnsdered prr tntatng any treatment. The care-gver s anessental part f any treatment prgram andshuld be cnsdered a part f the team.
Canine DJD: therapeutic considerationsBecause early nterventn can delay the nsetand severty f DJD, the Task Frce emphaszesthat chef amng all preventve and treatmentmdaltes fr canne DJD s weght ptmza-tn. Mantanng a lean bdy cndtn frm anearly age demnstrably mnmzes DJD devel-pment n predspsed breeds.129131 in ver-
weght patents, weght lss alne, even a md-est 6.18.85%, mprves clncal sgns f DJD.132There s strng evdence t supprt the use f
NSAiDs fr the management f DJD pan ndgs. Data n the safety and effcacy f lng-term NSAiD admnstratn n dgs appear tsuggest an verall beneft frm ths mdaltyfr a sustaned perd f tme at labeled dsesand ntervals, prvded the patent des nthave addtnal rsk factrs.22 NSAiD therapyshuld be talred t sut every ndvdualpatents needs. Veternary NSAiDs studed fr
chrnc use (between 28 days and 1 year)demnstrated satsfactry safety prfles ndgs, wth 9597% f dgs able t receve therNSAiD at labeled dses and ntervals wthutadverse effects fr the duratn f the study.22
There s currently n evdence that a hgher rskfr NSAiD-nduced adverse effects exsts as theduratn f treatment ncreases. Sme dgs
may requre several weeks f NSAiD treatmentbefre clncal mprvement s nted.133
in addtn t NSAiDs, there are therptns t cnsder. Frst, PSGAGs are mrelkely t have a benefcal effect when gvenearly n the dsease prcess.92 As mentnedearler, an FDA-apprved prduct wthestablshed effcacy and safety s avalable.Secndly, data supprtng analgesa and func-tnal mprvement frm therapeutc exercseare well establshed n humans and are begn-nng t accrue n dgs.134 Thrdly, a systematcrevew analyzng data frm several placeb-cntrlled blnded studes affrmed the utltyf dets rch n ecsapentaenc acd fr dgswth DJD.135 Varus ther strateges can be(and ften are) emplyed, but ther supprt-ng evdence s weak, cnflctng r altgetherlackng at present.
Feline DJD: therapeutic considerationsUntl the early 2000s, lttle attentn was padt DJD n cats; hwever, estmates frm pub-lshed studes suggest that 4092% f all catsmay have sme clncal sgns asscated wthDJD.136 Felne DJD s nw recgnzed as a ser-us welfare prblem, partcularly n lder cats,
whch s a rapdly grwng demgraphc.136,137
The mst frequently affected jnts appear tbe the hp, stfle, tarsus, elbw, thraclumbarand lumbsacral area.137 Fr each 1 yearncrease n a cats age, the expected ttalDJD scre ncreases by an estmated 13.6%.Mrever, there s a dramatc ncrease n theprevalence and burden f DJD at abut 10years f age. A dagnss f felne DJD s basedn a thrugh hstry reflectng changes nbehavr and lfestyle, physcal exam fndngs(image 8), and pssble radgraphc evdence.
Image 8 (a) Muscle wastingover affected legs is acommon sign of DJD, asseen in this orange tabby.(b) Close-up of the frontlimbs of the cat, showingdeformities secondary toDJD. Images courtesy ofIlona Rodan
Perhaps more
so than any
other pain
condition, the
management
of DJD benefits
from an
integration
of both
pharmacologic
and non-
pharmacologictreatments.
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Behavral changes are the mst cmmnsgns f DJD-asscated pan n cats. FelneDJD s usually blateral s, althugh catsrarely lmp, they are lkely t be stff, have aless flud gat, becme less actve (especally atnght) and exhbt decreased jumpng frequen-cy r jumpng heght.138 owners ften ntethat ther cats are very stff gng up r dwnstars. The cat may resst handlng, pettng, rstrkng f the back r lmbs. Shwng thewner a lst f the cmmn pan-related
behavrs caused by DJD s helpful n makngthe dagnss (Table 3).it shuld be assumed that a senr cat has
sme DJD, and every effrt shuld be madet ncrprate gentle handlng technques(images 9 and 10) and padded surfaces fr thecat t le n durng the exam. A pstveclncal respnse t analgescs wll als nd-cate the presence f DJD. The frst valdatedclncal metrlgy tl fr the evaluatn ffelne musculskeletal pan has nw beenprduced and s avalable fr use n practces(see Table 2).139,140
NSAiDs are the manstay f pharmaclgctreatment fr DJD n ther speces, and there scnsderable evdence t supprt ther effec-tveness n cats as well.141145 in the USA, hw-ever, NSAiDs are nt apprved fr lng-termuse n cats, and the ptental sde effects ftendeter many clncans frm rutnely usngthem n cats. Renal txcty s always a cnsd-eratn wth the use f NSAiDs; hwever, neretrspectve study fund that lng-term usef melxcam dd nt reduce the lfespan fcats >7 years f age wth pre-exstng, stablechrnc kdney dsease (CKD) cmpared wthcats wthut CKD.146
Lw-dse melxcam (e, 0.010.03 mg/kgrally q24h) s effectve n treatng arthrtccats and s well tlerated, even n cats wthCKD prvded ther clncal status s stable.145Melxcam s effectve when admnsterednce q24h and s palatable fr mst patents,makng t easy t admnster. in Eurpe,Australasa and many cuntres, melxcam s
apprved fr lng-term use n cats at a dse f0.05 mg/kg q24h. The ral rute f admns-tratn and lng-term use f melxcam ncats reman ff-label n the USA.
Rbenacxb s a CoX-2 selectve NSAiDapprved fr surgcal pan n cats. it has ntbeen studed fr ether felne DJD r n ldercats but there are lng-term safety data nyung cats (e, 5 x the recmmended dsagefr 6 mnths and 10 x the recmmendeddsage fr 6 weeks).147,148
Dsng n lean bdy weght, clse mntr-ng f clncal status (especally appette), reg-ular labratry mntrng, and apprpratelymdfyng the treatment plan are recm-mended fr cats recevng NSAiDs.149 NSAiDsshuld be used wth cautn n a case-by-casebass n cats wth DJD, and cat wners shuldbe advsed that, n the USA, use f NSAiDsfr felne DJD s an extra-label treatment.
Behavioral component Indicators of DJD
Interaction withothers
Withdrawal, hiding, increased clinginess, irritabilitywhen touched, aggression toward other cats or humans
Appetite Declines but cat continues to eat
Posture Hunched, head lowered, sitting or lying abnormally,
squinting, facial expression indicating discomfortGrooming Declines, matting of fur, over-grooming of painful area
Litter box use Decline in bowel movements, house soiling, inability toget into box
Play Reduced overall, reduced jumping
Vocalization Increased but decreased greeting and other pleasantvocalizations, hissing if touched on painful area, squintingif acute pain
Mobility Not jumping as often or as high, hesitant to jump, difficultygoing up or down stairs, stiffness, less active, difficultygetting into or out of litter box, sleeping in more easilyaccessible locations
Table 3 Signs of degenerative joint disease (DJD) in cats
Image 9 Since DJD isubiquitous, can occur in catsof all ages, and can bedifficult to detect, everyeffort should be made toincorporate gentle handlingtechniques for all cats. Forexample, gently pushing thefront leg forward frombehind the humerus, insteadof pulling on the front foot,will help to prevent elbowpain. Courtesy of Ilona Rodan
Image 10 Instead ofstretching and pulling hindlegs back tightly, gentlyplace one or more fingersbetween the hind feet andhold without stretching.This prevents exacerbationof lumbar, lumbosacral, kneeand hip pain. Courtesy ofIlona Rodan
It should be assumed that a senior cat
has some DJD, and every effort should be made
to incorporate gentle handling techniques.
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Treatment f DJD n cats shuld fcus nenvrnmental mdfcatn (images 11 and12) n addtn t pharmaclgc therapy. inaddtn t steps and ramps t facltate accesst favrte elevated areas, addtnal ltterbxes wth at least ne lw sde wll makeaccess easer. owners can als prvde phys-cal therapy by mplementng play tmesusng favrte tys t ncrease exercse andmblty.
When pain persists: hospiceand palliative care
Hspce s desgned t prvde cmpassnatecmfrt and care t patents at the end fther lves and t supprt ther famles nthe bereavement prcess. Hspce care frtermnally ll patents s recmmended when
lfe expectancy s less than 6 mnths.Pallatve care s the actve, ttal care fpatents wth dsease that s nt respnsve tcuratve treatment, wth pan cntrl bengthe paramunt feature. The gal s acheve-ment f the best qualty f lfe (QL) frpatents and ther famles. Ths assumesngng assessment f QL n the termnallyll patent. User-frendly QL assessmentscales are avalable t help veternarans, vet-ernary staff and wners make prper assess-ments and decsns at the end f a patentslfe.150 it s generally agreed that the petscare-gver s best suted t evaluate QL, buta team apprach (dscussed n page 266)emphaszng regular cmmuncatn smprtant t prvde empathetc supprtwhen end-f-lfe decsns are made.
An ntegrated apprach that ncludes nn-pharmaclgc mdaltes s typcally bestfr pallatve care and hspce patents wthcancer because ther dsease s ften asscat-ed wth features f bth acute and chrncpan. in cases f pallatve radatn, ether asmaller number r lwer dses f radatncan make treatment prtcls mre tlerablefr the patent and agreeable t the wner.
Image 12 The gray and white cat in (a) is seen as gregarious and is choosing to climb to higherlocations. Image (b) shows the same cat with DJD and the inability to jump. Provision of a stepallows the cat in image (c) to perch in a favored place. Images courtesy of Sheilah Robertson
Image 11 (a) Note this catsuncomfortable stance whileeating caused by DJD.(b) Raising the food ontoa low shelf allows the catto sit normally and eatcomfortably. Images courtesyof Margie Scherk
Envrnmental mdfcatn, physcal therapy(eg, massage, acupuncture and therapeutclaser) r ultrasund can be useful addtns tthe pan management plan. Prvdng nutr-tnal supprt va feedng tube can be helpfulwhere eatng s therwse dffcult r panful.
in cases nvlvng hspce and pallatvecare, t s mprtant t encurage clents thave realstc expectatns f the utcmesnvlvng ther pets. As well as explanatnsf prbable utcmes, ths nvlves prvdngthe clent wth end-f-lfe chces nvlvngthe pet. Euthanasa s an ptn that relevespan and sufferng and shuld be dscussed asa reasnable and humane alternatve at anapprprate pnt. Euthanasa may be a tpcthat the veternary team ntates f the petwner des nt.
Euthanasia is an option that relieves pain and
suffering and should be discussed as a reasonable
and humane alternative at an appropriate point.
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A team approach and clienteducation: creating anenvironment for success
Primary care practices should be committedto educating the healthcare team and itsclients about prevention, recognition, assess-ment and treatment of pain. A team approach
and consistent pain management messagesdirected at clients will help ensure patientcomfort at all stages of treatment. The client isoften considered the most important memberof the healthcare team.
Each healthcare team member should beable to recognize pain-associated behavior inanimals, as described earlier in theseGuidelines, and know how to respond appro-priately. Table 4 provides examples of howhealthcare team members should respond topatients experiencing pain.
Staff training and education
Ideally, every healthcare team member shouldhave a defined role in managing animal pain.Staff and client education should address con-ditions associated with pain; its preventionand treatment; and appropriate interaction,handling and nursing care involving thepatient. Medical rounds and staff meetings areeffective tools in making sure that all staffmembers are aware of the individualized painmanagement needs of every hospitalizedpatient. Having a patient advocate for eachhospitalized animal will enable a highly accu-rate and individualized evaluation of the
patient and ensure successful treatment.Recall that Table 1 lists pain indices relyingon observation and input by clinical person-nel. Those assessment tools complement thepain-scoring instruments based on ownerobservation and input, which are listed inTable 2.
Client education and instructionsWith each pain management plan, it is impor-tant that the client be given specific instruc-tions, both verbally and in writing. Potentialadverse drug effects and action to be takenshould be emphasized. It is advisable to
provide a hands-on demonstration of how toadminister medications and handle the pet athome. To reinforce verbal information aboutpain assessment, provide handouts that dis-cuss general information about animal painand any side effects of medications.Compliance will improve if the pet ownerunderstands the treatment schedule and ademonstration of how to administer oral med-ications is given. Clients should be encour-aged to address their concerns about the petscondition and treatment plan via e-mail,phone or follow-up consultations.
Acknowledgements
These Guidelines were prepared by a TaskForce of experts convened by the AmericanAnimal Hospital Association and theAmerican Associationof Feline Practitioners.TheAAHAsecuredsponsorship ofan educa-tional grant in accordance withtheir policiesfrom Abbott Animal Health, ElancoCompanion Animal Health, Merial, NovartisAnimal Health and Zoetis. This report wassubjected to review in accordance with bothAAFP and AAHA policies.
Funding
These Guidelineswere supportedby an edu-cational grantto AAHA from Abbott AnimalHealth, Elanco Companion Animal Health,Merial, NovartisAnimalHealthand Zoetis.
Conflict of interest
Mark Epstein has previously consulted forAbbott, Elancoand Merial. Sheilah Robertsonis a key opinion leader for Novartis AnimalHealth.
Ideally, everyhealthcare
team member
should have
a defined role
in managing
animal pain.
Veterinarian
Assess pain in every patient regardless of appointment type(eg, wellness, sick, follow-up)
Develop standard operating procedures for the practice to prevent pain,including the following: Weight optimization and prevention of dental disease Handling and hospitalization to prevent fear and pain
PLATTER (see Figure 1) to follow up and modify plan
Provide staff education on: Effective client communication and education Preventive pain strategies Recognition and assessment of pain Drug interactions and adverse effects
Technician
Obtain medication history
Anticipate painful procedures
Recognize signs of pain and alert veterinarian
Treat as directed by a veterinarian and update records
Assess postoperative patients and record pain score
Assess chronic pain patients and record pain score
Maintain effective client communication and education
Patient-care
personnel
Prior to examination: Note possible causes of pain Note any patient behavioral changes
During the examination: Proper handling Other stress/anxiety-relieving techniques
Following the examination: Monitor patients behavior Contact client about questions or concerns Set follow-up appointment
Housing should be stress/anxiety-relieving
Table 4 Healthcare team member responsibilities for
pain management
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ApprovedNSAIDs
Otheranalgesicdrugs
Opioidpremedtra
nquilizer/sedative
Localand/orregionalanesthetic
Chondroprotectants
(GAGs)
Acupuncture
Therapeuticjointdie
ts
Therapeuticexercise
Weightmanagement
Lifestyle/environmen
talchange
Optimalsurgicaltec
hnique
Patientwarmingper
ioperative
Othernon-pharmainterventions
Comments/details
DJD dog X X X (1) X X X X X X X
DJD cat (with CKD) X (2) X X (1) X X X X X X X
Soft tissue abdominalsurgery
X X (3) X X X X X X
Dental surgery X X (3) X X X X X X
Orthopedic procedure X X X X X (4) X X (4) X (4) X (4) X (4) X X XHospital procedures:
IV catheterization X (5) X (8) X (6) X Consider localanesthetic cream
Urinary catheterization X X (9) X (10) X (6) X X
Bone marrow aspiration X X (9) X X (6) X X Consider generalanesthesia
Radiography (painfuland/or arthritic patient)
X (9) X
Anal sac expression X (9)
Ear cleaning X (7) X (7) X (7) X Consider generalanesthesia for deepear cleaning
Thoracocentesis and/orabdominocentesis
X X (9) X X (6) X
Notes:1 Local or regional analgesia may be useful in localization of pain and short term relief of significant DJD pain2 See discussion on pages 256258 concerning the use of non-steroidal anti-inflammatory drugs (NSAIDs) in cats3 The addition of other analgesic drugs will depend on patient characteristics and extent of the procedure4 These interventions will be helpful pre- and postoperatively for the relief and/or prevention of postoperative and chronic pain5 Ideally premedications should precede other preparations for general anesthesia such as placement of an IV catheter6 These are invasive procedures and should be treated as such to optimize patient care and minimize trauma/tissue damage and post-procedural pain7 The level of intervention will be tailored to the invasiveness of the procedure. Deep ear cleaning will require more significant intervention than
superficial cleaning in most cases8 In non-emergency settings (eg, routine pre-surgical application)9 Chemical restraint in lieu of manual restraint when patient is fractious, distressed or otherwise intolerant of the procedure10 Sterile lidocaine lubricant; caution in cases of urethral or bladder mucosal damageGAGs = glycosaminoglycans, CKD = chronic kidney disease, DJD = degenerative joint disease
Summary of appropriate interventions for pain in dogs and catsTable 5
Abbreviations used in the GuidelinesAAHA American Animal Hospital Association
AAFP American Association of Feline Practitioners
CKD Chronic kidney disease
CMI Clinical measurement instrument
CRI Constant rate infusion
COX Cyclooxygenase
DJD Degenerative joint disease
GAGs Glycosaminoglycans
GI Gastrointestinal
IM Intramuscular
IV Intravenous
MPS Myofascial pain syndrome
NSAID Non-steroidal anti-inflammatory drug
OA Osteoarthritis
PSGAG Polysulfated glycosaminoglycan
SS(N)RI Selective serotonin (norepinephrine) reuptake inhibitor
SC Subcutaneous
TCA Tricyclic antidepressant
QoL Quality of life
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Effective pain management is an essential component of companion animal medicine. It reduces
disease morbidity, facilitates recovery, enhances quality of life, and solidifies the relationship between
the veterinarian, client and pet.
Behavioral changes are the principal indicator of pain and its resolution, for which there are now several validated
clinical scoring instruments.
Pain is not an isolated event but instead exists either as a continuum of causation, progression and resolution or as a chronic
condition. Thus, treatment of pain should consist of a continuum of care in the form of anticipatory analgesia through the
anticipated pain period followed by longer term or even chronic treatment that relies on periodic reassessment of the
patients response.
Effective pain management is integrative in two respects. First, it does not rely solely on pharmacologic methods but also
uses a variety of non-pharmacologic modalities; not least of those is gentle handling and nursing care of the patient in the
context of a stress-free physical environment. When considering either non-pharmacologic methods or hospice care that may
be outside the immediate skills or services provided by the primary practice, the veterinarian should have a list of experts for
referral in place. A second aspect of integrative pain management is the multimodal use of medications that either block or
modify multiple pain pathways. A multimodal approach also reduces reliance on any single agent, minimizing the potential
for adverse drug events.
Pain management in clinical practice is a team effort, with the pet owner functioning as an integral part of the team.
All healthcare team members should have a defined role in the practices approach to providing compassionate care to
its patients. That enables the practice to speak with one voice and in a consistent manner in the implementation of pain
management protocols.
Client education is a key component that enables the pet owner to manage pain in the home setting. Direct involvement
of the client in pain management efforts is consistent with the continuum of care concept and a demonstration of the
practices commitment to the pets quality of life.
A fully integrated approach to pain management, involving recognition and systematic assessment, pharmacologic and
non-pharmacologic methods, and including both healthcare team members and the pet owner, ensures that everything
possible has been done to relieve a patients pain once it enters the practices care.
SUMMARYPOINTS
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