March 2, 2015
Originally published in the February 2015 issue of Veterinary Practice News
There’s no shortage of ways for a veterinarian to approach the treatment of joint problems in aging pets.
For dogs in particular, a path taken from several fronts is recommended by Brenda S. Kennedy, DVM, MS, of Canine Companions for Independence.
“A multimodal approach is necessary to reduce pain and minimize further degeneration in the joints,” Dr. Kennedy said. “This is especially true for senior pets, who are more likely to be in a more advanced stage of the disease process.”
Kennedy was to speak in January at the North American Veterinary Community conference in Orlando, Fla. Her talk was titled “Canine Longevity: Strategies to Extend Healthspan.”
The multimodal therapy she refers to can include the use of nonsteroidal anti-inflammatories (NSAIDs), analgesics such as tramadol, amantadine and gabapentin, or injectable polysulfated glycosaminiglycans like Adequan, or products like oral glucosamine, chondroitin, methylsulfonylmethane (MSM), as well as omega-3 fatty acids.
Adjunct therapies like acupuncture and physical rehabilitation may also be beneficial, she added.
The basics of diet and exercise are a message that Kennedy and other experts drive home.
“Maintenance of a lean body condition along with controlled exercise to maintain muscle mass are also key components to consider when managing arthritis pain,” Kennedy said.
Diet and exercise were keyed in on by Jonathan Suber, DVM, Dipl. ACVS.
“For me, weight loss and walking are the key,” said Dr. Suber, who works with VCA Animal Specialty Center of Southern Carolina in Columbus, S.C.
Suber said many owners of the elderly pets with joint problems that he sees need to hear about one or both of the basics.
“I would say 60 to 75 percent are overweight,” Suber said of his elderly patients. “It’s very rare that I see ideal body condition.”
Suber’s approach to dealing with these cases?
He explains the basics to pet owners: Get the pet’s weight down by not overfeeding and get the pet active.
“If you have a bad joint and you’re overweight, you’re not going to want to be as active,” he tells pet owners. “Moving a bad joint is the best medicine for a bad joint.”
He tries to help clients establish some kind of routine for walking and weight loss. One step in that process is to have pet owners set a reasonable goal of walking their pets each day for a set period or distance—20 minutes or a mile.
“Most people can click off a mile in about 20 minutes,” Suber said. “I try to get people to shoot for 15 to 20 minutes. I think that most people in their day have time for that.”
Before that, however, Suber’s first step is figuring out just how much a pet should weigh so he can prescribe a diet and exercise plan, and Suber is embracing one new way to do that.
He is a fan of Hill’s Healthy Weight Protocol, developed by researchers at the University of Tennessee. The protocol provides four areas to measure on dogs and six on cats. Hill’s has a website (www.hwp.hillsvet.com) where veterinarians can input the data and get back a percentage of body fat and an ideal weight for the pet.
“We’ve been trying to get our obese patients on that just so maybe we can tailor their diets or track weight loss a little better,” Suber said, adding that it enables him to give clients realistic weight goals to shoot for. “It’s been helpful because I think it gets clients more involved.”
For pets with an immediate need for aid there are myriad therapeutic and rehabilitative products, such as DogLeggs for bracing joints.
“I think the bracing and DogLeggs products, which I consider a therapeutic article of clothing for dogs, are useful,” said Katherine Goldberg, DVM, founder of Whole Animal Veterinary Geriatrics and Hospice Services in Ithaca, N.Y. “I certainly have had some good luck with the DogLeggs.”
The only potential problem Dr. Goldberg sees products is whether the patient allows the bracing to stay on.
“The big thing with anything you’re going to put on a dog is, how sustainable is the solution?” Goldberg said.
A dog may try to remove the bracing or may be unable or unwilling to walk with it, she said. Quite often, she takes a cue from the pet’s family, who she said knows instantly whether a product will last on a dog. She also likes Pawz dog boots for dogs who tolerate having something on their feet. The product provides traction to dogs with ailing joints and prevents spills and falls, she said. Goldberg is a mobile veterinarian with a focus on geriatric patients, whom she visits at home to conduct an environmental assessment.
“Assessing the dog’s living environment is so essential,” she said.
Within that assessment activity several key questions are asked and answered. What are the floor surfaces inside the home? What are paths most traveled by the pet? What is the location of the food and water? Does the home have stairs and must the pet navigate the stairs? How does the pet get in and out of a vehicle?
This activity in daily living (ADL) assessment is another methodology being borrowed from human medicine.
“We do a really good job in human medicine in accessing in ADLs,” she said, but that’s not true for pets.
“My perspective is all the medications and supplements in the world aren’t going to make up for an environment that is inhospitable for a geriatric or painful dog,” she said.
To improve the environment, Goldberg has pet owners take steps such as put down yoga mats to give a pet a runway or use interlocking foam squares often seen in children’s playrooms. They are affordable and easily washable, and they can prevent slips and falls. If a pet does fall, the flooring softens the blow, she said.
“My patients’ houses look like a day care some times,” Goldberg said.
Veterinarians are increasingly turning to the injectable osteoarthritis medication Adequan to treat horses, dogs and cats.
Kennedy, with Canine Companions for Independence, credits the growing interest in such medications with emerging evidence that they help.
“Adequan is widely used by veterinarians, and its efficacy is supported by clinical studies,” Kennedy said. “It is the only FDA-approved disease-modifying osteoarthritis drug in the veterinary market.” Suber agreed.
“Out of all the nutraceuticals, Adequan has the most scientific evidence behind it,” Suber said. “For sure Adequan helps.”
While some nutraceuticals have been found to have mild pain-alleviating properties, some experts aren’t too high on all of them.
“We are constantly seeing new products promoting joint health introduced to the market and we live in a society where the idea of taking a pill to protect or improve our joints is appealing,” said Duncan X. Lascelles, BVSc., Ph.D., Dipl. ECVS, Dipl. ACVS.
“This mindset, coupled with the persuasive expectation effect or placebo effect, has made supplements very popular. Unfortunately, good clinical evidence of a supplement’s measurable effect on disease progression does not exist.”
Dr. Lascelles, a professor of small animal surgery at the North Carolina State University College of Veterinary Medicine, added, “There is some clinical evidence of a small pain-relieving effect of a few products, especially those containing omega-3 fatty acids.”
Like Kennedy, Lascelles also was scheduled to speak at NAVC. His presentation was “How and Why I Use Supplements for the Management of Joint Health in Dogs and Cats.”
When it comes to dealing with aging pets with joint issues, focus No. 1 should be on controlling pain, Lascelles believes.
“While we await the development of methods to retard joint disease, or prevent its progression, it is important to manage the pain associated with joint disease in cats and dogs,” Lascelles said.
Currently, no U.S. Food and Drug Administration products are approved for cats, and only nonsteroidal, anti-inflammatory drugs are approved for dogs, he said. However, he cautioned that NSAIDs may be associated with side effects in some patients.
Lascelles is encouraged by work at North Carolina State that he believes may offer some relief to pets suffering from joint problems. The College of Veterinary Medicine’s Comparative Pain Research Program is looking into developing novel painkillers for dogs and cats.
One study is evaluating a long-term NSAID for treatment of chronic musculoskeletal disorder, including arthritis, in cats.
Another study is a trial of a new biological compound to treat pain. The blinded, placebo-controlled pilot study will evaluate the efficacy of NV-02, an antibody to nerve growth factor, for the treatment of osteoarthritis pain in cats.
Thirty-six cats will be recruited into the study. Each will be evaluated over 11 weeks for changes in pain and mobility using various owner assessments, activity monitors, kinetic variables and veterinarian-assessed joint pain, according to a description of the study.
Researchers have gotten good results from several similar studies on dogs, Lascelles noted. “We found positive results for one product that has been developed specifically for dogs and we are optimistic we’ll find similar results for the feline-specific version of the product,” Lascelles said. “This is incredibly exciting because, if confirmed, it might mean we will have a safe, effective biological compound, specific for the dog or the cat, which following a single dose can provide many weeks of real relief for our senior pets.”
Newer treatments to treat arthritis pain, such as stem cell therapy and lasers, are what Kennedy is encouraged by.
“Additional controlled research studies are needed to fully understand the benefits of these modalities,” she added.
Kennedy said “a tremendous need” exists for continued development of effective treatments for degenerative joint disease and pain in senior dogs.
“Impairment of mobility in older dogs can have a major adverse effect on quality of life and if it cannot be managed, owners may elect euthanasia,” she said.
Platelet-rich plasma therapy, or PRP, is a modality that Suber believes holds promise.
“I’m really excited about platelet-rich plasma, PRP,” Suber said. “It’s starting to get a lot of conversation in human joint disease.”
Injecting high levels of PRP into an arthritic joint or torn tendon releases a growth factor that helps heal the joint, Suber explained.
Suber believes that more veterinarians will follow human doctors’ lead-—something he’s been doing for the past year. “I’ve been happy with it in the cases I’ve used PRP for,” Suber said. “It makes them more comfortable and gets them using their leg better.”
In fact, Suber lately has been seeing more companies marketing PRP equipment to general practitioners.
Kennedy believes there should be a greater emphasis on prevention—not just for joint disease but also for other chronic diseases that occur as a pet ages.
“The current focus is on treating the symptoms after the arthritis has already developed, and in many cases has progressed to an advanced stage,” she said.
She would like to see more research on interventions that may slow the aging process in dogs, which would increase their healthy years, or health span.
“There is very active research in the human arena addressing the question of which types of interventions can improve health span in humans, and scientists are starting to ask these questions in dogs as well,” she said. As an example she pointed to the recently established Canine Longevity Consortium, an interdisciplinary network of researchers and clinicians throughout the country with the goal of implementing a nationwide canine longitudinal aging study.
“Large-scale studies such as these are critical to further our understanding of aging and age-related diseases in dogs, so early interventions can be identified that can maximize the healthy lifespan of our canine companions,” Kennedy said.
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