ISFM and AAFP Consensus Guidelines Long-term use of NSAIDs in cats Clinical Practice A preprint from the Journal of Feline Medicine and Surgery Volume 12, July 2010 Journal of Feline Medicine and Surgery (2010) 12, 519 doi:10.1016/j.jfms.2010.05.003 EDITORIAL NSAIDs and cats – it’s been a long journey Although the first This issue of JFMS contains the first ever panel have covered much valuable ground: international consensus guidelines ✜ To set the scene they consider how use of NSAIDs on the long-term use of non-steroidal common chronic pain can be in cats, typically was probably anti-inflammatory drugs (NSAIDs) in cats. related to degenerative joint disease, This timely publication, which appears on idiopathic cystitis, trauma and cancer. by Hippocrates, pages 521–538 (doi:10.1016/j.jfms.2010.05.004), ✜ They then explain how and why NSAIDs is a collaborative enterprise by the International can have such positive and, potentially, it has taken until Society of Feline Medicine (ISFM) and negative actions. now for cats to American Association of Feline Practitioners ✜ They consider the best ways of enhancing (AAFP). It has been compiled by a panel of owner and cat compliance, make suggestions gain the benefit of world leaders in the understanding of pain about sensible dosing frequencies, timing of in cats and, without doubt, is essential reading medication and accuracy of dosing, and the long-term use for all small animal veterinary surgeons. emphasize the importance of always using of these drugs. It is interesting to reflect that although the ‘lowest effective dose’. They even cover the first use of NSAIDs was probably by the things that need to be considered when Hippocrates (some time between 460 BC and switching between NSAIDs. 377 BC), when he administered powder made ✜ They discuss the common concurrent from the bark and leaves of willow trees to conditions that, while not necessarily help heal headaches, pains and fevers, it has precluding the use of NSAIDs, require careful taken until now for cats to gain the benefit of consideration in terms of pros, cons the long-term use of these drugs. Although and potential complications – including NSAIDs have been available for dogs for renal disease, gastrointestinal disease, many years, there has been a reluctance to cardiovascular disease and liver disease. consider their use in cats. While it is classically ✜ They make a number of recommendations presumed that this relates to worries about relating to the importance of pre-treatment potential drug toxicity, it is also likely that it screening, and the potential for interaction stems from our inability to recognize pain in between NSAIDs and concomitant drug cats as easily as we do in dogs. This is perhaps therapy (eg, glucocorticoids and not surprising, as cats tend to hide their pain. anticoagulants). It’s a strategy that makes perfect sense ✜ They ultimately help to classify those evolutionarily, as cats are solitary hunters and patients that may have a higher risk of would have nothing to gain from showing developing side effects, and hence need pain – and plenty to lose (notably the risk of very careful monitoring during therapy. getting eaten by larger carnivores or primates). ✜ They tabulate detailed dosing information The guidelines have been produced to help for each of the NSAIDs that have so far been us all to use NSAIDs effectively and safely licensed in cats, as well as suggested in cats. In their pursuit of this ambition the monitoring protocols. Although data are still limited and NSAIDs have only recently become licensed for long- Guidelines panel members term use in cats in some countries, the panel conclude that this group of drugs has a major ✜ Andrew H Sparkes BVetMed PhD DipECVIM MRCVS, Panel Chair role to play in the management of chronic ✜ Reidun Heiene DVM PhD MRCVS pain in this species. However, they underline ✜ B Duncan X Lascelles BSc BVSc PhD MRCVS CertVA DSAS(ST) DipECVS that careful patient selection, dose titration DipACVS and ongoing monitoring for the early signs ✜ Richard Malik DVSc DipVetAn MVetClinStud PhD FACVSc FASM of toxicity are essential. ✜ Llibertat Real Sampietro DVM Danièlle Gunn-Moore BSc BVM&S PhD ✜ Sheilah Robertson BVMS (Hons) PhD CVA DACVA DECVAA MRCVS MACVSc MRCVS ✜ Margie Scherk DVM DABVP (Feline Practice) Professor of Feline Medicine, ✜ Polly Taylor MA VetMB PhD DVA MRCVS Head of Companion Animal Sciences, Royal (Dick) School of Veterinary Studies, Edinburgh, UK © 2010 Published by Elsevier Ltd on behalf of ISFM and AAFP. JFMS CLINICAL PRACTICE 519 Journal of Feline Medicine and Surgery (2010) 12, 521–538 doi:10.1016/j.jfms.2010.05.004 SPECIAL ARTICLE ISFM AND AAFP CONSENSUS GUIDELINES Long-term use of NSAIDs in cats NSAIDs and cats Non-steroidal anti-inflammatory drugs (NSAIDs) are an important class Andrew H Sparkes of drug in feline medicine, having analgesic, anti-inflammatory and antipyretic activity. While BVetMed PhD DipECVIM MRCVS Panel Chair, International Society most published data on their use in this species relate to short-term (often perioperative) of Feline Medicine therapy, there is increasing evidence of the value of these drugs in treating chronic pain in Reidun Heiene cats (for example, that associated with degenerative joint disease), and some NSAIDs have DVM PhD MRCVS now become licensed for long-term use in cats in some geographies. Most of our knowledge Associate Professor, Department of Companion Animals of therapeutic mechanisms or adverse drug reactions associated with NSAIDs is extrapolated Clinical Sciences, from work in other species, and there is a paucity of published data relating to cats. Norwegian School of Veterinary Sciences, Oslo, Norway Guidelines These guidelines have been drawn together by an expert panel, which have reviewed the current literature on long-term NSAID use in cats and other species, and developed guidance on their B Duncan X Lascelles BSc BVSc PhD MRCVS CertVA use based on this information. The aim is to provide practical information for veterinarians to encourage DSAS(ST) DipECVS DipACVS appropriate NSAID therapy whenever cats will benefit from the use of these drugs. Associate Professor of Surgery, Director, Comparative Pain Research Laboratory, Director, Integrated Pain Introduction Management Service, Chronic pain can be regarded as pain that North Carolina State University has persisted for more than 2–3 weeks, often College of Veterinary Medicine, Pain in cats has many negative effects, both persists months or years, and may continue Raleigh, NC 27606, USA physiological and emotional.1,2 It is now beyond the anticipated healing time. Richard Malik DVSc DipVetAn MVetClinStud accepted that there is no such thing as ‘good Importantly, chronic pain can become dissociat- PhD FACVSc FASM pain’ following surgery and during treatment ed from the inciting cause and be maladaptive, Centre for Veterinary Education, for trauma or disease – eg, pain that inhibits such that the degree of pain does not necessar- The University of Sydney, Camperdown, NSW 2006, Australia potentially deleterious movement after sur- ily correlate with the pathology observed or Llibertat Real Sampietro gery. Pain delays recovery, impacts negatively perceived by the individual, and is not associat- DVM 12 on a patient’s wellbeing, and disturbs the bond ed with healing. Multimodal analgesia is Clinica Veterinaria Bendinat, with its owner and also the veterinary team.1,3 commonly advocated, but it is becoming Mallorca, Spain Studies have looked at the use of non- evident that NSAIDs will play a key role in Sheilah Robertson BVMS (Hons) PhD CVA DACVA steroidal anti-inflammatory drugs (NSAIDs) for managing chronic feline pain, especially mus- DECVAA MRCVS 4–7 acute, especially perioperative, pain in cats. culoskeletal pain, just as they do in humans and Section of Anesthesia and Surveys have shown clinicians were more likely dogs.10,13–16 Until quite recently, while many Pain Management, 8,9 College of Veterinary Medicine, to treat pain in dogs than cats, as a result of dif- NSAIDs have been available to treat dogs with University of Florida, Gainesville, ficulties in recognizing pain, lack of knowledge degenerative joint disease (DJD),17 only a Florida 32610, USA concerning the use of analgesics, and fear of restricted range has been licensed for short- Margie Scherk drug side effects in cats. Less has been published term (up to a few days) use in cats. At the time DVM DABVP (Feline Practice) CatsINK, Vancouver, BC, Canada on the management of chronic pain in cats, but of writing, at least one NSAID – meloxicam – Polly Taylor it is recognized that signs may be subtle and has been licensed for long-term use in cats in MA VetMB PhD DVA MRCVS include withdrawing from attention, decreased many regions of the world, transforming our Taylor Monroe, Ely, UK mobility, reduced interactions with humans and ability to manage pain in this species, and a other animals, poor appetite and aggression.10–12 second – robenacoxib – has been licensed for up STRATEGIC PARTNERS IN FELINE HEALTH AND WELFARE TOGETHER IMPROVING CATS’ LIVES WORLDWIDE Collaborating to build a future of unparallelled cat care by: ✜ Raising the profile of the cat in the veterinary clinic ✜ Creating continuing education opportunities for veterinary care professionals ✜ Developing practice guidelines to facilitate high standards of feline health care ✜ Providing tools and resources to improve veterinary skills and knowledge © 2010 Published by Elsevier Ltd on behalf of ISFM and AAFP. JFMS CLINICAL PRACTICE 521 SPECIAL ARTICLE / ISFM/AAFP guidelines on NSAIDs Pain delays recovery, impacts negatively on a patient’s wellbeing, and disturbs the bond with its owner and also the veterinary team. aa to 6 days of therapy in cats (see Table 1, page 529).* There is little doubt that others will become licensed for long-term use in the future, due to the recognition of the need and value for such NSAID therapy in this species.10,11,13–15,18 FIG 1 (a,b) Clinicians are aware of their duty to promote Degenerative joint disease of animal welfare and relieve suffering, but are the elbow in a also often reminded of Hippocrates’ advice to feline patient ‘first do no harm’.