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Chronic Pain Management in Dogs and Cats

Animals experience pain and discomfort just as people do.  While it is obvious that a pet who is limping is experiencing pain, often the signs of pain are much more subtle.  These signs may include

  • restlessness
  • gait changes or shifting weight
  • decreased mobility, activity or play
  • panting or rapid breathing
  • difficulty getting up or down
  • difficulty with stairs
  • inability to jump
  • vocalization
  • behavior changes (aggression, clinginess, attention-seeking, hiding, withdrawal from the family)
  • decreased appetite
  • excessive licking, chewing or mutilation of a particular area of their body
  • lack of grooming
  • change in body posture (hunched, not curled up when sleeping, stiff, neck stretched out)
  • a change in housetraining or litter box habits.

Many of these signs are incorrectly attributed to ‘old age’.

Chronic pain may be due to osteoarthritis, cancer pain, or pain associated with any of the internal organs.  Osteoarthritis is the most common type of chronic pain.  Managing chronic pain requires a multimodal approach.  A multimodal approach uses a combination of medications, supplements, nutrition and other therapies together to achieve pain control while reducing risks of potential adverse effects.  Considerations may include the type or source of pain, efficacy of therapy, concurrent medical conditions, safety, route of administration, frequency of administration, cost and the ability to administer the therapy and/or travel for care.  We work with you to develop the best treatment plan for you and your loved one.

Pain Management Therapy

Nutrition

Nutrition is especially important for pain associated with osteoarthritis.  Maintaining a lean body mass and a good body condition score are essential in alleviating musculoskeletal pain.  We will work with you to determine a safe and manageable weight loss plan for your pet if needed.

Hill’s j/d Joint Care contains therapeutic levels of omega-3 fatty acids and is enriched with glucosamine, chondroitan sulfate, L-carnitine, and antioxidants.  It is also restricted in calories to maintain your pet’s proper body weight.  It is available for both dogs and cats.  Other options include Royal Canin Veterinary Diet Mobility Support Canine or Feline, Purina Pro Plan Veterinary Diets JM Joint Mobility Canine, and Hill’s Prescription Diet Metabolic + Mobility Canine.  At this time, no prescription diets exist for birds or small mammals.

Exercise

Exercise can be very beneficial for managing pain, but should be carefully tailored to the individual patient.  Light walking, physical rehabilitation exercises, foraging activities, and swimming or other types of aquatic exercise may be recommended.  Exercise will improve joint health, help maintain good body condition, and provide environmental enrichment for your pet.

Joint Supplements

  • Omega-3 Fatty Acids: Omega 3 fatty acids include eicosapentanoic acid (EPA) and docosahexanoic acid (DHA). These ingredients reduce the production of inflammatory prostaglandins.  Omega-3 fatty acids are recommended for the management of osteoarthritis/joint pain as well as kidney disease, cardiovascular disease, and skin conditions.  Side effects are rare, but may include vomiting, diarrhea, or appetite loss; at high doses, clotting abnormalities can occur. We recommend Welactin for dogs and cats.  The liquid suspension contains the highest concentration of both EPA and DHA and is preferred over other formulations.  Over-the-counter formulations of fish oils may also be used for dogs, though high doses are needed to achieve therapeutic results.  If you choose an over-the-counter brand, it is very important to avoid products that contain added ingredients such as Vitamins A, D, or E.
  • Dasuquin Advanced With Egg Shell Membrane: This supplement contains glucosamine hydrochloride, chondroitan sulfate, avocado/soybean unsaponifiables (ASU), hydrolyzed egg shell membrane (ESM), Boswellia serrata extract, Curcuma longa extract (turmeric), omega 3 fatty acids, decaffeinated green tea extract, manganese, alpha-lipoic acid and methylsulfonylmethane (MSM). This supplement helps to support joint cartilage matrix, inhibit cartilage breakdown, and support joint comfort.  Side effects are rare but may include vomiting or diarrhea.
  • Adequan: Adequan is a polysulfated glycosaminoglycan (PSGAG) derived from bovine cartilage. It inhibits the catabolic enzymes that degrade the components of cartilage, inhibits the inflammatory mediator prostaglandin E2 (PGE2), and may help stimulate the synthesis of protein, collagen, and hyaluronic acid, the protective compounds within the joints.  It is administered by injection every 1-4 weeks either at home or in the clinic.
  • Duralactin: This supplement contains MicroLactin, a natural milk protein that manages inflammation. It inhibits neutrophil participation, thereby decreasing inflammation.  It is available as a capsule for cats and chewable tablets for dogs.  There is limited data on this supplement, but it may be worth considering in advanced cases.

Pain Medications

  • NSAIDs: Non-steroidal anti-inflammatory drugs or NSAIDs reduce pain, inflammation, and fever by reducing the inflammatory mediators cyclooxygenase, phospholipase A2, and prostaglandins. This class of medication will likely provide the best pain relief for your pet.  Examples include Rimadyl, Novox, or Metacam. Most pets tolerate these medications well, but there is the potential for side effects in any individual.  The most common side effects are associated with the gastrointestinal tract (vomiting, diarrhea, gastrointestinal ulceration), kidneys, and liver.  Cats are more sensitive and these medications should be used with extreme caution.  Birds and small mammals tolerate Metacam well.  Blood monitoring should be performed on all pets receiving these medications long term.  Do not use these medications with other NSAIDs or with glucocorticoids/steroid medications.
  • Galliprant: Galliprant (grapiprant) is the newest anti-inflammatory medication on the market. While it is an NSAID, it was developed to specifically target the prostaglandin EP4 receptor, reducing inflammation in the joints with minimal actions on the other prostaglandin receptors in the body.  This allows us to specifically manage joint pain and inflammation while significantly reducing the gastrointestinal, kidney, and liver side effects. Side effects may include vomiting, diarrhea, decreased appetite and lethargy.  For severe pain, we have not found this to be as effective as other NSAIDs.  Blood monitoring should still be performed with long-term use.  This medication is only for use in dogs.  Do not use this medication concurrently with other NSAIDs or with glucocorticoids/steroid medications.
  • Gabapentin: Gabapentin is a pain medication that is especially beneficial for neuropathic pain. Gabapentin is an analog of gamma-aminobutyric acid (GABA) and acts on the calcium channels of the spinal cord to inhibit the release of excitatory transmitters.  It reduces hyperalgesia (exaggerated responses to pain).  Side effects may include sedation and difficulty walking, though these side effects generally improve after 3-5 days on this medication.  We commonly use this medication in dogs, cats, birds, and small mammals.
  • Tramadol: Tramadol is a synthetic centrally acting opiate-like analgesic that also inhibits the reuptake of serotonin and norepinephrine to provide pain management. This medication appears to be beneficial in only a small subset of patients.  In those patients, its beneficial effects are likely due to the increase in serotonin and norepinephrine and not due to its analgesic actions.  Side effects are rare, but may include sedation, agitation, anxiety, tremors, dizziness, lack of appetite, vomiting, or diarrhea.  It is a bitter medication and can be difficult to administer to some pets.
  • Opioids: Opioid pain medications work at the level of the opioid receptors located in the brain and spinal cord. Examples of opioid pain medications include buprenorphine, morphine, fentanyl, codeine, hydrocodone, and butorphanol.  Side effects may include sedation, vomiting, constipation, dysphoria, hallucinations, and cardiac or respiratory effects.  With the exception of buprenorphine in cats and small mammals, these medications are rarely used for chronic pain.
  • Miscellaneous: Depending on your pet’s condition, a few other medications may be discussed. Amantadine is an NMDA receptor antagonist used for neuropathic pain.  In severe cases, intravenous ketamine or other continuous rate infusions (CRI) may be used in the hospital.  Tricyclic antidepressants, bisphosphonates, lidocaine patches and maropitant may rarely be used in select conditions.

Monoclonal Antibody Therapy: Anti-Nerve Growth Factor Therapies

Solensia (frunevetmab) for cats and Librela (bedinvetmab) for dogs are injectable monoclonal antibody (mAb) therapies administered monthly to control osteoarthritis pain.  These therapies specifically target nerve growth factor (NGF), a key mediator of osteoarthritis pain.  They also limit the release of additional NGF and other pro-inflammatory mediators, lowering neurogenic inflammation.  These therapies are very effective with pet owners reporting positive results after three months or less.

Side effects are not common but may include vomiting, diarrhea, appetite changes, lethargy, dermatitis, and pain at the injection site in both dogs and cats.  In dogs, increased urination and urinary tract infections have been reported.  Less common but serious side effects in dogs include weakness, paralysis or mental changes.  These therapies should be avoided or used with extreme caution in patients with existing neurological disease.  The safe use of these therapies in conjunction with non-steroidal anti-inflammatory medications (NSAIDs) long term has not yet been established.

 

Integrative Therapies

It has become more common to see pet owners choosing non-pharmacological options for pain management before adding in drug therapy.  These treatment modalities can be excellent for managing chronic pain.  For additional information, please request our handouts on acupuncture and laser therapy.

  • Acupuncture: Acupuncture has been practiced in China in both humans and animals for thousands of years. It involves the insertion of small, thin, sterile needles into specific points in the body to cause a therapeutic change to occur.  These points are called acupoints.  Over thousands of years, we have created a map of 359 transpositional acupoints and 77 classical acupoints in humans and animals; we routinely use 173 acupoints in veterinary medicine.  Research shows that these points are located in areas with a high density of free nerve endings, mast cells/immune cells, small blood vessels, and lymphatic vessels.  Stimulation of these points leads to a cascade of changes in the body including an increase in blood flow to the area, an increase in local immune response, and release of beta-endorphins, serotonin, and other neurotransmitters to reduce pain.  In addition to dry needling with thin needles, electroacupuncture, aquapuncture, and acupressure may also be used at these specific points.
  • Chinese Herbal Therapy: Herbal therapy is another branch of Traditional Chinese Veterinary Medicine (TCVM). The choice of herbal therapy depends on the patient’s disease condition and TCVM pattern; we cannot prescribe herbal therapy without a consultation with a TCVM practitioner.  Many options for therapy exist depending on the patient.  Body Sore is a great example of a balanced herbal therapy for pain management in dogs and cats.  From a TCVM approach, this formula resolves Qi and Blood Stagnation and alleviates generalized pain, lameness or stiffness.  Its active ingredients include Ligusticum, Notopterygium, Angelica, Epimedium, Cyathula, Cuscuta, Corydalis, Paeonia, Eucommia, Psoralea, Myrrh, Olibanum, Millettia, Persica, and Carthamus.  Side effects may include vomiting, diarrhea, or lack of appetite.  It is important to inform your veterinarian of all of the herbal therapy or supplements that you are giving to your pet as some therapies can have adverse effects together.
  • Laser Therapy: Laser therapy uses specific wavelengths of light to induce a therapeutic effect in the body. In general, laser therapy is used to reduce pain, reduce inflammation, and increase healing in an area.  Laser therapy increases circulation, leading to increased oxygen and nutrient delivery.  This creates an optimum environment for healing including a reduction in pain, stiffness, muscle fatigue, swelling, and inflammation.  Laser therapy is a great modality to alleviate pain in birds and small mammals as well.
  • Massage Therapy: Massage therapy is beneficial, especially for aging animals. The aging process can lead to circulation issues that may affect efficiency of movement.  Concurrent arthritis or other painful conditions can cause muscle tension, stiffness, and discomfort.  There are many benefits to massage therapy including increased circulation, improved range of motion, decreased muscle tension, improvement in pain, reduction of inflammation, reduced anxiety and increased activity level.
  • Assisi Loop/PEMF: The Assisi Loop is targeted Pulsed Electromagnetic Field Therapy (PEMF) that can be used at home to reduce pain and inflammation at a focal site. Pulsed electromagnetic field therapy affects the voltage-dependent binding of calcium to calmodulin.  When binding occurs, nitric oxide, an anti-inflammatory molecule, is produced.  Nitric oxide reduces pain, improves blood flow, and reduces edema.  This cascade further triggers additional positive effects such as new blood vessel formation, tissue regeneration, and tissue remodeling.
  • Chiropractic: Animal chiropractic care is a gentle and kind way to achieve pain reduction. When the body isn’t moving as much as it used to, the brain’s perception of pain becomes amplified.  When the brain senses motion, the perception of pain is down-regulated.  Restoring even the smallest amount of motion, like the type that occurs along the spinal column, can provide a measure of comfort and pain relief.  To learn more about chiropractic care for your pet, please contact Chiropractic for EveryBody: http://chiropracticforeverybody.com or call 952-484-5460.
  • Physical Rehabilitation: There are several excellent rehabilitation opportunities in the Twin Cities including Twin Cities Animal Rehabilitation + Sports Medicine Clinic, K-9 In Motion, and the University of Minnesota. Therapy may include aquatic therapy, underwater treadmill, physical manipulation, and rehabilitation exercises.  In addition, we can discuss specific modifications to your pet’s environment to help with mobility and to ease pain and discomfort.

 

As you can see, we now have many tools available to help manage chronic pain in pets.  For some patients, one or two of these therapies are sufficient.  For others, we’re using nearly all of these modalities together.  If your pet is experiencing chronic pain, contact us today at (651) 645-2808 or group@stfrancisabh.com.  We’ll work with you to develop a plan that is best for both you and your loved one.

 

Content prepared by St. Francis Animal Hospital, 1227 Larpenteur Ave. West, Roseville MN. 55113