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Managing Osteoarthritis Beyond the NSAID: Part Three

Matt Brunke, DVM, CCRP, CVPP, CVA
Diplomate, American College of Veterinary Sports Medicine and Rehabilitation

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Management
- Those that had a primary problem and now suffer from OA
- Ex: The typical “OA Consult”
- Joint Supplements/Omega-3 FA
- Adequan (cats too)
- Daily Exercise/Rehab
- Manage weight
- NSAIDS (flare-ups)
- Analgesia

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What OA Management is Not!!!
“Here is your NSAID and tramadol and that’s all we can do”
-WE CAN DO BETTER!!
- NSAIDS – lowest dose possible as infrequently as possible
- Opioids – not designed for chronic use!
- Tramadol – likely no benefit1
- Recheck them
- 4-6 weeks
- 12 weeks
- Then every 4-6 months thereafter

1. Budsberg et al. JAVMA 427-432, 2018

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No Tramadol

Lack of Effectiveness of Tramadol Hydrochloride for the Treatment of Pain and Joint Dysfunction in Dogs With Chronic Osteoarthritis

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Polysulfated Glycosaminoglycan
- FDA approved, disease modifying osteoarthritis drugs; for dogs and horses; water-based, for intramuscular Injection
- Dosage: 2 mg/lb body weight, IM, twice weekly for up to 4 weeks (maximum of 8 injections)
- MOA: specific is not known; in vitro studies show;
- Inhibit serine proteinases; PGE2 synthesis; metalloproteases, hyaluronidases and others
- Stimulate synthesis of protein, collagen, proteoglycans, and hyaluronic
acid
- Anecdotally “maintenance” injections monthly
- Off label SQ usage
- Off label feline SQ usage

Adequan prescribing information. NADA 141038, Novartis Animal Health, US, INC

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Adjunct Analgesics
- Use in addition to or as a replacement for NSAIDS
- Amantadine – only drug studied to treat canine osteoarthritis
- In dogs with osteoarthritic pain refractory to an NSAIDs, addition of amantadine improved physical activity
- Might be a useful adjunct therapy for the clinical management of canine osteoarthritic pain.
- 3-5mg/kg SID-BID, cats too
- Gabapentin – Calcium channel modulator – cats and dogs
- 5-10-20mg/kg BID-TID
- Amitriptyline – SSRI – norepinephrine - cats and dogs
- 0.5-1.0mg/kg SID-BID

Lascelles BDX, et al. J Vet Intern Med. 22(1):53-9, 2008

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Adjunct Analgesics
- Acetaminophen – dogs, not cats
- 10-15mg/kg TID
- Codeine
- 1-2mg/kg BID-TID
- Grapiprant
- Still an NSAID.
- Needs to be given daily, permanently
- On an empty stomach
- 9 cases of ARF on ACVIM list-serv

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PEMF Pulsed Electromagnetic Field Therapy

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PEMF Pulsed Electromagnetic Field Therapy

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MOA – Upregulates Nitric Oxide

PEMF strongly enhances NO production
- Effect HSP cellular chaperones & activate immune defense
- A potent driver of the anti- inflammatory process
- In standard model of inflammation
-PEMF comparable to NSAIDs

PEMF effects in human & veterinary clinical trials correlated with anti- inflammatory activity, pain reduction & ~ 50% reduced opioid intake

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PEMF Research - Human

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PEMF Research - Dog

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PEMF Research - Dog

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PEMF Research - Dog

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Intra-articular Injections
- Triamcinolone or Methylprednisone
- Combine with HA
- Platelet rich plasma (PRP)
- Combine with HA
- BMAC/PRP or Adipose
- Cells IA, not IV
- Aseptic technique
- 22g needle
- Sedated, outpatient
- Blind or fluoroscopic guided

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Intra-articular Injections

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Synovetin
- Tin-117m – conversion electron therapy
- Approved for dogs in US for elbows
- Up to one year improvement from one injection

The optimal-sized (~2-20 microns) particles are small enough to be engulfed by macrophages, but large enough to remain in the joint space.

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Synovetin OA
Instability

- Synovitis
- Overproduction of macrophages and synoviocyte with synovial hyperplasia
- Macrophages overproduce proinflammatory
- Inflammatory mediators move into and out of cartilage and synovial lining
- Initiates and drives cartilage destruction
- Chronic pain, inflammation and disability

The cycle of inflammation causes progressive joint damage

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Upcoming Treatments
- Molecular Driven Therapy:
- Ranevetmab (NV-01) for dogs and Frunevetmab (NV- 02) for cats (Nexvet)
- Anti-nerve growth factor (NGF) monoclonal antibody
- NGF is a key regulator of nociceptive pain in OA by increasing nerve fiber excitability and the sprouting of new nerve fibers into inflamed tissues.
- Injectable with 4 week efficacy1-2 in the canine and 7 days in the feline3

1.Lascelles BDX, et al. BMC Vet Res 2015;11:101-113. DOI 10.1186/s12917-015-0413-xs. 2.Webster RP, et al. AM J Vet Res 2014;75(6):532-535.
3. Gearing DP, et al. J Vet Inter Med 2016;30:1129-1137.

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What techniques do I use?
- All of the ones we just mentioned!
- I adjust to my patient’s needs, client’s needs/wants
- I offer what I would do if it was my pet.
- Or my mom’s!

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Summary
- Treat early – be proactive, not reactive
- Don’t wait until severe cartilage damage
- Weight loss and exercise are crucial in all stages
- Multimodal approach
- Include pain management

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Updated Guidelines

2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats

-https://www.aaha.org/public_documents/professional/guidelines/2015_aaha_aafp_pain_management_g uidelines_for_dogs_and_cats.pdf

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Thank You
- Matt Brunke, DVM, CCRP, CVPP, CVA Diplomate, ACVSMR
DrMattBrunke@gmail.com
DrBrunke.wordpress.com