Guidelines for the Long-Term Use of Nsaids in Cats

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 recognising 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 recognised 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’. This is often rightly used to b question whether an intervention will actually do more harm than good, and to withhold that intervention when doubts exist. However, we need also to recognise that withholding treat- ments such as analgesics can sometimes cause the greater harm, because we are no longer addressing the pain and suffering the animal b is enduring. In drawing up these guidelines, FIG 2 Anteroposterior the international panel of experts’ purpose has (a) and lateral (b) radiographs of the been to review the current literature on long- hock of a Scottish term NSAID use in cats, and to provide practi- fold cat with severe osteochondrodysplasia, cal guidance on their use. The overarching aim showing destruction is to encourage more widespread and appro- of joint spaces priate NSAID therapy, when cats will benefit and extensive plantar exostosis. from the use of these drugs. However, most of Courtesy of Kim Kendall our knowledge of therapeutic mechanisms or adverse drug reactions is extrapolated from work in other species, as there is a paucity of published data relating to cats. Common causes of chronic pain and inflammation in cats One of the difficulties in managing pain in cats is FIG 3 Watson, a DJD sufferer, enjoying its initial recognition. It is important, therefore, to the benefits of daily NSAID treatment be aware of common causes of pain and to have a high index of suspicion for signs and behav- iours potentially related to pain. If something is clinical disease is present many owners may painful to us, it is likely to be painful to a cat. simply assume a cat is ‘getting old’, and even educated and attentive owners may not neces- Degenerative joint disease sarily appreciate suffering associated with DJD The most common cause of chronic feline pain without veterinary observation and insight. is thought to be DJD, and this has been the sub- In the absence of medical intervention, many ject of a number of important studies in the past cats with DJD suffer pain and discomfort for 10 years.11,15,16,18–24 From these studies, it is clear years, greatly affecting their quality of life and that DJD is very common, with radio graphic the human/feline bond. It is vital that examina- changes affecting up to 60–90% of cats (Figs 1 tions of the older feline patient should specifi- and 2),18,24 that it affects both the spine and the cally address whether DJD is present, through appendicular joints, and that it occurs especial- history and physical examination and, where ly commonly in older patients.18,24 The hips, necessary, radiology and therapeutic trials. stifle, shoulder, elbow, tarsus and spine are Control of bodyweight, exercise and environ- the most common sites affected, although other mental modifications may help cats with DJD, joints can also be involved. Studies based on as may other medical therapies. However, the radiographic findings have limitations, though, dramatic responses reported to NSAIDs13,21,23 as the changes observed do not necessarily cor- indicate that there is a huge scope for safe, respond to clinical disease, or the severity of effective long-term NSAID therapy in the large clinical disease and pain. Nevertheless, where cohort of aged cats with DJD (Fig 3). 522 JFMS CLINICAL PRACTICE SPECIAL ARTICLE / ISFM/AAFP guidelines on NSAIDs Other diseases There are many other feline diseases where If something is painful to us, control of protracted inflammation and pain is it is likely to be painful to a cat. important. These include various cancers (Fig 4a), particularly where definitive treatment is not possible, or in some cases for the anti - neoplastic effect NSAIDs may offer.25–28 Other control of fever with NSAIDs may also be common conditions associated with chronic valuable in some situations. A short therapeu- pain where NSAIDs may form part of therapy tic trial of an NSAID without a definitive diag- include trauma, lymphoplasmacytic gingivo - nosis may sometimes be appropriate, using stomatitis (Fig 5),29 idiopathic cystitis,30,31 skin the response to treatment as a guide to diag- disease and uveitis (Fig 6). In the last, both nosis and further therapy.

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