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 Summary of oral pain management medication used in canine osteoarthritis

Non-steroidal anti-inflammatory drugs (NSAIDs)

As we know, there are a wide range of NSAIDs available. Most currently on the market target the enzyme, cyclo-oxygenase 2 (COX 2). This enzyme is involved in the synthesis of prostaglandin during cell injury and inflammation. COX 1 enzyme is more involved in the ‘housekeeping’ of regulating normal physiological processes.

As well as being released at the site of inflammation, COX2 is involved in central sensitisation. Central sensitisation occurs when the nociceptive neurons in the dorsal horn of the spinal cord become sensitised by peripheral tissue damage. This is strongly implicated in chronic pain mechanisms. There is evidence to show that when central sensitisation is controlled, peripheral inflammation is reduced. This suggests that if we treat the pain this way, we can also control the disease.

As noted in practice, individual dogs respond differently to the various NSAIDs available on the market. Side-effects include nausea, gastric ulceration, hepatotoxicity and renal failure. Therefore it would be sensible to consider the alternatives in patients who already have compromised renal or hepatic function.

Tramadol hydrochloride

This agent reacts with the noradrenergic and serotonergic systems. It also binds at μ receptors giving mild opiate activity. At present there is no proof to show that Tramadol has any anti-inflammatory action. Therefore in inflammatory conditions, the use of adjunctive anti-inflammatory medication should be considered. However, caution should be taken when used in conjunction with non-steroidal anti-inflammatory drugs as Tramadol may mask early signs of gastric ulceration resulting from NSAID use. It is particularly useful in dogs whose demeanour have been adversely affected by pain.

Side effects are not well documented as this drug is not licensed in dogs. They include sedation, vomiting, nausea and diarrhoea. The dose rate is 2-5mg/kg two to three times per day.

Tramadol can be used in conjunction with NSAIDs. Its use is not advisable in conjunction with other serotonergic drugs like Amytriptiline or Monoamine Oxidase inhibitors.

Gabapentin

This is another human medication which can be used to address neuropathic pain, for example pain initiated by nerve root irritation or spinal cord compression. Central disinhibition is described as the scenario when the patient experiences diffuse pain which is not a direct effect of a pathological process or proportional to its severity. Gabapentin can be very useful in such circumstances.

The precise mechanism of action is not fully understood. It is likely that it decreases the excitability of nerve cells by blocking calcium channels.

Side effects include ataxia, stumbling, sedation, vomiting, diarrhoea and skin irritation. Its use in dogs with renal or hepatic impairment should be approached cautiously.

The recommended dose rate is 5-10mg/kg twice per day, starting with a conservative dose. Anecdotal evidence suggests it is safe to use in conjunction with Tramadol and NSAIDs.

Paracetamol

This is a very safe non-steroidal but not a potent analgesic. It should not be used in dogs with hepatic dysfunction. The recommended dose is 10mg/kg twice per day.

Amantadine

This drug can be used in cases of neuropathic pain and/or central sensitisation, preferably in combination with a non-steroidal or an opiate. It works as an NMDA receptor antagonist. It is not as commonly used at Gabapentin and Tramadol. The recommended dose rate is 2-4mg/kg once daily. Side effects include vomiting, diarrhoea and sedation

Amitryptline

This is a tricyclic antidepressant which is used in instances of neuropathic and nociceptive pain. It works as an antihistamine, via descending inhibitory pain control and anxiolysis. There has been little work into its efficacy in dogs with osteoarthritis but anecdotal evidence suggests that it can be useful as an analgesic in such circumstances. It should not be used in dogs with hepatic or renal impairment or keratoconjunctivitis sicca. It should be used with extreme caution in dogs with dysrhythmias.

Side effects include gastrointestinal signs and sedation.

When considering our choice of analgesic, it is important to remember the concepts of multimodal analgesia. This employs more than one medication, working at various levels in the nervous system. The aim is to minimise the dose of each analgesic while maximising the effect on pain.

References

1. Lindley, S. (2011) Conservative management of canine osteoarthritis- part 3. Veterinary Practice 43: 19-20.

2. Gaynor, S. & Muir, W. III (2009) Handbook of veterinary pain management. Mosby Elsevier, Missouri: pp 193-201, 265-270.

Please check back regularly for further clinical information.