Selection of an appropriate perioperative pain management plan can seem daunting. How can you select the right combination of medications that will relieve pain and minimize potential negative side effects? It may be straightforward in some cases and complex in others, but it is imperative for our patients. A balanced perioperative pain management plan requires knowledge of the individual patient, as well as the specific surgery to be completed. A routine castration in a juvenile patient likely benefits from a different analgesic plan than an amputation in a mature patient. Just because juvenile castration is a simple procedure performed frequently does not mean this patient does not benefit from appropriate postoperative analgesics. A multi-modal approach allows balanced analgesia and can minimize potential side effects of the medications. Non-steroidal anti-inflammatory drugs (NSAIDs) can be invaluable for pain management, especially with orthopedic procedures. Patient selection, dosing frequency, cost, and potential side effects should be considered prior to starting this class of medication for your patient. Injection of a long-acting local anesthetic at the surgery site helps with pain control and may lessen the need for oral medications once the patient is discharged from the hospital. Photo courtesy Dr. Kendra Freeman Patient assessment Prior to any surgical procedure, a thorough assessment of the patient is critical. Is the patient a young, healthy pet presenting for a routine ovariohysterectomy? Is the patient middle-aged, overweight, and presenting for a femoral head and neck excision? Is your patient presenting for a tibia plateau leveling osteotomy (TPLO), receiving maintenance anti-inflammatories prior to surgery? Will this change/alter the medications prescribed after surgery, since additional pain will be caused by the surgery? A complete physical exam, as well as assessment of any co-morbidities, previous anesthetic events, patient temperament, and pre-anesthetic diagnostics, can help not only develop an anesthesia plan but also a post-operative pain management plan. Anesthetic plan Development of an appropriate anesthetic plan is outside the scope of this discussion; however, this may affect the postoperative pain management plan. Are there nerve blocks or regional anesthesia planned for this procedure that may still have effects in the early recovery period? Are there injectable opioids planned that may last into the early recovery period (hydromorphone vs. fentanyl constant rate infusion)? Was an injection of an NSAID administered? If so, will the injection last 12 hours or 24 hours? Postoperative pain management When planning aftercare instructions and pain management for your patient, consider the patient’s temperament, co-morbidities, and any perioperative pain management treatments that may have a lasting effect. Local blocks Local blocks completed with bupivacaine may help mitigate pain for three to eight hours.1 Using a combination of lidocaine or bupivacaine with either an opioid or alpha-2 agonist can prolong the duration of effect of the anesthesia/analgesia.1,2,3 Using liposomal bupivacaine can numb or dull the pain at the incision site for up to 72 hours (Nocita).4 Having local, long-acting pain control at the surgical site can reduce the number of oral medications prescribed to patients. The bulk of postoperative pain management occurs in the form of oral medications. Again, multimodal analgesia is best for our patients. Gabapentin and pregabalin Gabapentin acts on calcium channels to decrease the transmission of excitatory neurotransmitters. It is rapidly absorbed in dogs after oral administration, but is also rapidly metabolized, requiring frequent dosing to maintain its effectiveness.5 Pregabalin is also well absorbed and maintains plasma concentrations longer than gabapentin, requiring less frequent dosing.6 This medication can be cost-prohibitive for some clients. NSAIDs NSAIDs inhibit prostaglandins, specifically targeting cyclooxygenase enzymes to target pain, pyrexia, and inflammation. NSAIDs that are more COX-2 specific (COX-1 sparing) are likely to have fewer negative side effects than non-specific NSAIDS, such as aspirin.7 Current U.S. Food and Drug Administration (FDA)-approved NSAIDS that are COX-2 selective are deracoxib, firocoxib, meloxicam, and robenacoxib. Carprofen has been shown to be well-tolerated with minimal side effects after two months of administration and less gastrointestinal upset compared to Meloxicam. 8,9 Generic forms are available, which may help with client costs. The availability of injectable and oral formulations of nonsteroidal anti-inflammatory medications can streamline perioperative medication selection. The availability of generic options can help in cost-conscious cases. Photo courtesy Dr. Kendra Freeman Some NSAIDs (meloxicam, carprofen, robenacoxib) are available in an injectable formulation. This allows for injections during or at the completion of the procedure and provides analgesia before the patient is able to take oral medications. NSAIDs, such as meloxicam, deracoxib, and reobenacoxib are labeled for once daily doses. This may increase client compliance. Grapiprant is a more recent addition to the veterinary oral NSAID arsenal. This medication is an EP4 prostaglandin receptor antagonist. It can improve symptoms of osteoarthritis with a wide safety margin.10 There is some evidence that grapiprant may be effective in acute pain relief following ovariohysterectomy.11 Acetaminophen Acetaminophen (paracetamol) is a centrally acting medication that has analgesic properties and can decrease fevers. Acetaminophen has no significant anti-inflammatory effects and is not classified as a true NSAID. Because of these differences, acetaminophen and a true NSAID may be used concurrently in postoperative patients. Injectable paracetamol is not approved by the FDA. While the oral formulation is used off-label in the U.S., we must remember this medication is extremely toxic to cats. Acetaminophen is also available as a combination with various opioids in oral formulations, although oral opioid absorption in dogs is variable. Additional treatments that may be beneficial in addition to traditional analgesics are cold laser, massage, acupuncture, and cold compress application. Evidence to support the beneficial effects of low-level laser therapy is conflicting.12,13 Physical therapy may help patients return to function sooner for more complex recoveries. This reduces stress on the joints and muscles throughout the body, thus improving comfort. Balanced perioperative analgesia does not need to be overly complicated. Knowledge of the specific procedure and the basic pharmacology of available medications are the basis for developing a plan. The patient will be best served by addressing pain from multiple sources, allowing maximum pain relief while minimizing the side effects of individual medications. Kendra Freeman, DVM, MS, DACVS (Large Animal/Small Animal), is a graduate of Colorado State University and maintains dual certification with the American College of Veterinary Surgeons. Dr. Freeman is an associate surgeon in Albuquerque, N.Mex. Her case load consists of orthopedics, general soft tissue, and sports medicine cases with the occasional return to her roots in large animal lameness and surgery. References Read, Matt R., Luis Campoy, and Berit Fischer, eds. Small animal regional anesthesia and analgesia. John Wiley & Sons, 2024. Martin-Flores, M. and Lorenzutti, A. (2024) ‘Local Anesthetic Pharmacology’, in Small Animal Regional Anesthesia and Analgesia . Second. Hoboken, NJ: Wiley Blackwell, pp. 35–41. Cital, Stephen Niño, Tasha McNerney, and Darci Palmer, eds. Pain Management for Veterinary Technicians and Nurses. John Wiley & Sons, 2025. Nocita (Bupivacine Liuposmal Injectable Suspension) [Package Insert} In: Aratana Therapeutics, Inc; 2018. Kukanich B, Cohen RL. Pharmacokinetics of oral gabapentin in greyhound dogs. Vet J. 2011 Jan;187(1):133-5. Salazar V, Dewey CW, Schwark W, Badgley BL, Gleed RD, Horne W, Ludders JW. Pharmacokinetics of single-dose oral pregabalin administration in normal dogs. Vet Anaesth Analg. 2009 Nov;36(6):574-80. Sennello KA, Leib MS. Effects of deracoxib or buffered aspirin on the gastric mucosa of healthy dogs. J Vet Intern Med. 2006 Nov-Dec;20(6):1291-6. Raekallio MR, Hielm-Björkman AK, Kejonen J, Salonen HM, Sankari SM. Evaluation of adverse effects of long-term orally administered carprofen in dogs. J Am Vet Med Assoc. 2006 Mar 15;228(6):876-80. Luna SP, Basílio AC, Steagall PV, Machado LP, Moutinho FQ, Takahira RK, Brandão CV. Evaluation of adverse effects of long-term oral administration of carprofen, etodolac, flunixin meglumine, ketoprofen, and meloxicam in dogs. Am J Vet Res. 2007 Mar;68(3):258-64. Rausch-Derra L, Huebner M, Wofford J, Rhodes L. A Prospective, Randomized, Masked, Placebo-Controlled Multisite Clinical Study of Grapiprant, an EP4 Prostaglandin Receptor Antagonist (PRA), in Dogs with Osteoarthritis. J Vet Intern Med. 2016 May; 30(3):756-63. Southern BL, Long SM, Barnes DN, Enomoto H, Messenger KM. Preliminary evaluation of the effects of grapiprant compared with carprofen on acute pain and inflammation following ovariohysterectomy in dogs. Am J Vet Res. 2022 May 28;83(7) Luna SP, Basílio AC, Steagall PV, Machado LP, Moutinho FQ, Takahira RK, Brandão CV. Evaluation of adverse effects of long-term oral administration of carprofen, etodolac, flunixin meglumine, ketoprofen, and meloxicam in dogs. Am J Vet Res. 2007 Mar;68(3):258-64. Tumilty, S., Munn, J., McDonough, S., Hurley, D. A., Basford, J. R., & Baxter, G. D. (2010). Low level laser treatment of tendinopathy: a systematic review with meta-analysis. Photomedicine and laser surgery, 28(1).
