Treating canine osteoarthritis without opioids

Water treadmill treatment helps with this dog’s muscle conditioning, as well as prevents muscle atrophy caused by its hip and stifle osteoarthritis. / Photo courtesy Hayley Nash For years, veterinarians treating dogs with osteoarthritis have reached for the opioid painkiller tramadol. In the face of a growing body of evidence that both long- and short-term treatment with tramadol is not only ineffective, but actually harmful, interest in alternative treatments is on an upward trend. Tramadol became the canine arthritis treatment of choice because it was convenient. It seemed to be effective in small doses, has fewer side effects than non-steroidal anti-inflammatories, and has a lower potential for human abuse than narcotics like oxycodone. Today, most veterinarians recognize that tramadol becomes ineffective at controlling a dog’s pain after just a few days of use.1 As the U.S. struggles with an epidemic of human opioid abuse, many doctors are hesitant to send home bottles of potent painkillers. Most importantly, there is no reason to mask dogs’ arthritis pain with drugs. There are several techniques available to veterinarians that not only safely and effectively treat osteoarthritis pain, they can address its root cause: inflamed and damaged joints. Simply stated, it is time to do better for patients by taking a more holistic approach. Platelet-rich plasma and mesenchymal stem cell therapies Dogs suffering from osteoarthritis have lost or damaged articular cartilage and reduced synovial fluid, resulting in less lubrication in the joints. The resulting irritation and inflammation cause pain in the affected joints for about 20 percent of dogs under one year old and 90 percent of dogs five years and older.2 Historically, osteoarthritis treatment has focused on managing pain and preventing further joint damage. Today, doctors can actually repair some of the damage using platelet-rich plasma (PRP) and stem cell therapy. Platelet-rich plasma is gaining a lot of momentum in veterinary medicine. Recent studies have shown dogs that receive PRP therapy experience decreased pain and increased joint mobility after just a few days.3,4 Examining the cartilage of the test subjects shows dogs treated with PRP experienced significantly greater improvement than controls.3 Just one injection of PRP controlled pain due to hip osteoarthritis for up to six months4 and stifled osteoarthritis caused by cranial cruciate tears for up to three months.5 PRP aids angiogenesis and cartilage remodeling and is a potent source of growth factors and bioactive proteins that ease pain and inflammation. When injected in combination with hyaluronic acid or mesenchymal stem cells, this treatment has shown to be even more effective at treating osteoarthritis than when injected alone.3 Mesenchymal stem cell therapy is another promising treatment that promotes real cartilage repair. Arthritic dogs treated with mesenchymal stem cells in clinical studies have exhibited evidence of reduced pain and increased mobility.6 A combination of stem cell therapy and PRP has yielded promising results in the treatment of early partial cranial cruciate tears.7 Mesenchymal stem cells secrete trophic factors, recruit cells to heal the damaged tissue, and create new cartilage. All of these factors combine to restore some degree of function to the damaged joint and improve the dog’s comfort. For dogs and their owners, PRP and stem cell therapy have many advantages over opioid prescription. First and foremost, these simple in-office procedures reduce pain by repairing the damaged tissue, thereby addressing the problem at its source. Second, they protect the human-animal bond, which can be strained when owners force their dogs to routinely swallow pills. Third, benefits last for months, not hours.3-5.In both PRP and stem cell therapy, the treatment is autologous, greatly reducing the risk of side effects. Low-level laser therapy Low-level laser therapy, also known as photobiomodulation therapy, is a cost-effective treatment gaining traction in the treatment of canine osteoarthritis. This noninvasive treatment was introduced nearly 30 years ago to treat osteoarthritis in humans. Low-level laser therapy involves using pure light of a single wavelength to trigger a cellular photochemical reaction to reduce pain and stiffness. Cells absorb specific wavelengths of light, stimulating healing and reducing inflammation.8 Stem cells and progenitor cells appear to be especially sensitive to light therapy. In a small clinical study, researchers saw significant improvement in dogs suffering from osteoarthritis after six weekly laser treatments. After just one session, clinicians and owners observed the dogs appeared to be in significantly less pain. In three-quarters of cases, clinicians were able to reduce the amount of analgesic medication prescribed to the dogs after week two. The dogs’ pain continued to noticeably decrease throughout the six-week study, with no laser-related side effects.9 More alternative treatments Opioids were never really a good option for treating dogs’ chronic pain. They mask pain rather than resolve it. As a result, using them to treat chronic conditions like arthritis means either never-ending drug therapy or alternating periods of treatment with periods of pain. Hyperbaric therapy is widely used in human medicine, and over the last decade its use in animal medicine has grown. Dogs are placed in a hyperbaric chamber filled with oxygen at a pressure from one and a half to three times normal atmospheric pressure. Duration and frequency of treatment varies. Hyperbaric therapy is safe and well tolerated.10 Hyperbaric therapy effectively reduces inflammation and improves circulation. Studies on its effectiveness in treating osteoarthritis have been inconclusive, but it is a viable option for candidates with mild to moderate symptoms. Nuclear magnetic resonance therapy is a relatively new treatment that combines a magnetic field with an interfering radio frequency signal to stimulate cell growth. The effectiveness of this therapy in treating canine osteoarthritis is inconclusive, but some dogs seem to benefit. There are enough positive indicators of its effectiveness that this treatment bears further study.11 Acupuncture is a centuries-old pain-relief treatment that may be beneficial to dogs, particularly in treating post-operative pain. In treating the pain of osteoarthritis, acupuncture’s effectiveness is difficult to measure, but owners of dogs who receive acupuncture report seeing some improvement in their dogs’ activity levels and behavior.12 Physical therapy can provide a boost to all other treatments. Spanish researchers recently found when physical therapy is combined with PRP to treat osteoarthritis, the exercise kept dogs comfortable longer between PRP injections.13-15 The increased physical activity can also help prevent obesity, a key risk factor in osteoarthritis. Physical therapy, such as stability work on a table, can be an alternative to resolve osteoarthritis issues in a more substantial way than medication. / Photo courtesy Hayley Nash An ounce of prevention The best way to shield a pet from arthritis pain is to protect joints before they are damaged. Veterinarians should broach the subject of osteoarthritis with dog owners—particularly the owners of large breeds prone to joint ailments—as early as the dog’s first birthday. A study of more than 100,000 dogs¹6 found some purebred dogs have a higher incidence of degenerative joint disease than other breeds or mixed-breed dogs. Labrador retrievers seem especially susceptible to joint ailments when compared to mixed breeds. Many factors, including breed and age, may play a role in a dog’s predilection toward osteoarthritis. The rising rate of osteoarthritis in dogs, however, is commonly accepted to be the result of rising rates of obesity. A report suggested 55.8 percent of American dogs are overweight.17 This excess weight puts additional strain on a dog’s joints. Obesity is often associated with increased inflammation, which can aggravate tissue damage. Veterinarians have an obligation to discuss weight management diet and in-house physical therapy options during every wellness visit. As overweight pets become the norm, dogs at a healthy weight may appear thin to their owners. It is a veterinarian’s responsibility to measure a dog’s weight and body fat at every appointment and educate owners on the ideal weight range for their dog. A healthy lifestyle that includes a high-quality diet, weight management, and nutraceutical supplements can build strong joints and delay the onset of osteoarthritis.18,19 Treating arthritis through nutrition Foods and dietary supplements formulated for joint health have both anti-inflammatory effects to address the pet’s pain and protective effects to slow and reduce tissue degeneration. Ingredients commonly found in therapeutic diets include omega-3 fatty acids, green-lipped mussel, glucosamine, and chondroitin sulfate. Fatty acids and green-lipped mussel have been shown to reduce inflammation throughout the body. Glucosamine and chondroitin sulfate work in tandem; glucosamine reduces inflammation and contributes to cartilage repair, while chondroitin sulfate increases the elasticity of cartilage and reduces joint swelling. A 2019 Italian study found after 90 days of treatment with a nutraceutical blend that included glucosamine and chondroitin sulfate, as well as more experimental nutraceuticals like krill oil and shiitake, dogs suffering from osteoarthritis experienced improved mobility, lessened pain, and improved levels of cholesterol and triglycerides.20Omega-3 fatty acids decrease pain and inflammation associated with osteoarthritis and suppress pro-inflammatory mediators.18 Another recent study showed reduced osteoarthritis pain in 93.5 percent of dogs after one month of supplementing their diet.21 Once arthritis begins to appear, it can often be managed in its early stages through nutraceuticals and physical therapy. As the disease progresses, PRP, stem cell treatment, and other drug-free therapies intended to repair damaged joints can be introduced. If you must prescribe a pill… When pain is acute, a veterinarian may still want a prescription to provide immediate relief until other treatments take effect. If a pill is called for, grapiprant has several advantages over opioids. Approved in 2016, grapiprant is a relative newcomer on the veterinary pain relief scene. Grapiprant is a nonsteroidal anti-inflammatory drug (NSAID), a category of drugs that has been reliably used for years to effectively manage pain and improve mobility.3,13 Unfortunately, long-term use of traditional NSAIDs can have deleterious side effects, including accelerated cartilage degeneration and damage to the liver, kidneys, and stomach.22 Grapiprant works farther down the arachidonic acid cascade than traditional NSAIDs, reducing painful inflammation without these negative side effects.22 How effectively it treats osteoarthritis pain is still a matter of debate, but in cases where a pill for immediate relief is desired, it is the safest and gentlest option available to veterinarians. Any drug therapy should be viewed as a short-term, secondary therapy in treating osteoarthritis. A good primary therapy addresses the cause of the inflammation. Drug therapy is best viewed as a short-term bridge to keep the dog comfortable while rehabilitating. This may be necessary when the primary therapy is something like a weight loss and nutrition regimen, which takes time before showing tangible benefits. Before prescribing pills, remember that owners will probably not fill the prescription at the veterinarian’s office. Instead, they are likely to bargain hunt online and get the prescription from a third-party seller. Veterinarians who are relying on the owner to obtain the right medication and give the pills on schedule, and also trusting the dog not to spit them out, may not get the desired outcomes. In short, this approach abdicates a lot of control over how a veterinarian’s prescribed treatment plan is carried out. A look ahead The future of pain management for osteoarthritis in human medicine is moving in the direction of drug delivery systems like liposomes, nanoparticles, hydrogels, and drug conjugates23. Although these newer technologies are yet to be tested in dogs, procedures such as PRP and stem cell therapy are less risky and more effective than any pill and are delivered in-office by trained staff, not sent through the mail by a third party, which is a win-win for all. Deepan K. Kishore BVSc, AH, MS, ABVP (canine/feline) serves as the director of research at the Neel Veterinary Hospital in Oklahoma City, Oklahoma. Dr. Kishore performs several soft-tissue, orthopedic, and minimally invasive surgeries. Dr. Kishore integrates physical rehabilitation, acupuncture, and hyperbaric oxygen therapy for post-surgical management of orthopedic and spinal decompression surgeries. Dr. Kishore also performs platelet-rich plasma therapy and stem cell therapy for management of osteoarthritis. You can contact Dr. Kishore at deepankishore@icloud.com Hayley Nash RVT, CCRP is a registered veterinary technician and a certified canine rehabilitation practitioner. Nash is the head technician for rehabilitation at Neel Veterinary Hospital in Oklahoma City and also performs physical rehabilitation and hyperbaric therapy at Neel Veterinary Hospital. References Steven C. Budsberg, Bryan T. Torres, Stephanie A. Kleine, et al. Lack of effectiveness of tramadol hydrochloride for the treatment of pain and joint dysfunction in dogs with chronic osteoarthritis 2018; 252:4, 427-432 Roush JK, Dodd CE, Fritsch DA, et al. Multicenter veterinary practice assessment of the effects of omega-3 fatty acids on osteoarthritis in dogs. J Am Vet Med Assoc. 2010; 236:59–66. [Abstract] Lee, M., Kim, J., Kwak, H. et al. A placebo-controlled study comparing the efficacy of intra-articular injections of hyaluronic acid and a novel hyaluronic acid-platelet-rich plasma conjugate in a canine model of osteoarthritis. J Orthop Surg Res. 2019; 14, 314. https://doi.org/10.1186/s13018-019-1352-1. Alves JC, Santos A, Jorge P, Lavrador C, Carreira. A report on the use of a single intra-articular administration of autologous platelet therapy in a naturally occurring canine osteoarthritis model--a preliminary study. BMC Musculoskeletal Disorders. 2020; 21:127. Venator KP, Frye C, Gamble LJ, Wakshlag. Assessment of a single intra-articular stifle injection of pure platelet rich plasma on symmetry indices in dogs with unilateral or bilateral stifle osteoarthritis from long-term medically managed cranial cruciate ligament disease. Vet Med (Auckl). 2020; 11:31-38 Sasaki A, Mizuno M, Mochizuki M, I Sekiya. Mesenchymal stem cells for cartilage regeneration in dogs. World J Stem Cells. 2019; 11 (5); 254-269 Canapp Jr SO, Leasure CS, Cox C, Ibrahim V, Carr B. Partial cranial cruciate ligament tears treated with stem cell and platelet-rich plasma combination therapy in 36 dogs: A retrospective study. Vet. Sci. Dec. 14 2016, p. 112. Looney A, Huntingford J, Blaeser L, Mann S. A randomized blind placebo-controlled trial investigating the effects of photobiomodulation therapy (PBMT) on canine elbow osteoarthritis. Can Vet J. 2018 Sep; 59(9): 959-966. Barale L, Monticelli P, Raviola M, Adami C. Preliminary clinical experience of low-level laser therapy for the treatment of canine osteoarthritis-associated pain: A retrospective investigation on 17 dogs. 2020; Vol. 10 No. 1 Birnie GL, Fry DR, Best MP. Safety and tolerability of hyperbaric oxygen therapy in cats and dogs. J Am Anim Hosp Assoc. 2018 54 (4): 188-194. Huels N, Harms O, Keim D, Rohn K, Fehr M. Treatment of the clinical symptoms of osteoarthritis in the elbow joints of dogs using nuclear magnetic resonance therapy: A randomized, double-blinded trial. Front Vet. Sci. 13 2020 p. 919. Baker-Meuten, A., Wendland, T., Shamir, S.K. et al. Evaluation of acupuncture for the treatment of pain associated with naturally-occurring osteoarthritis in dogs: a prospective, randomized, placebo-controlled, blinded clinical trial. BMC Vet Res. 2020; 16, 357. https://doi.org/10.1186/s12917-020-02567-1 Cuervo B, Monica R, Chicharro D, et al. Objective Comparison between Platelet Rich Plasma alone and in combination with physical therapy in dogs with osteoarthritis caused by hip dysplasia. 2020; 10,175. Aminkov, K.B., N.H. Mehandzhiyski, B.Y.Aminkov, N.Z.Zlateva-Panayotova. Application of platelet-rich plasma for canine osteoarthritis treatment: a clinical series. J. Vet. Med. March 23, 2020 Shaw KK, Alvarez L, Foster SA, Tomilson JE, Shaw AJ, Pozzi A. Fundamental principles of rehabilitation and musculoskeletal tissue healing. Veterinary Surgery. 2020; 49, issue 1. 22-32. O’Neill DG, Church DB, McGreevy PD, et. al. Prevalence of disorders recorded in dogs attending primary-care veterinary practices in England. PLoS One. 2014; 9:e90501 Ward E. US Pet obesity rates plateau and nutritional confusion grows. Association for Pet Obesity Prevention Annual Report. March 2019. Richardson DC, Schoenherr WD, Zicker SC. Nutritional management of osteoarthritis. Vet Clin North Am Small Anim Pract. 1997; 27:883–911 Johnson KA, Lee AH, Swanson KS. Nutrition and nutraceuticals in the changing management of osteoarthritis for dogs and cats. J Am Vet Med Assoc. 2020; 256:1335-1341. [Abstract] . Musco, N, Vassalotti, G, Mastellone, V, et al. Effects of a nutritional supplement in dogs affected by osteoarthritis.Vet Med Sci. 2019; 5: 325– 335. https://doi.org/10.1002/vms3.182 Beths T, Munn R, Bauquier SH, Mitchell P, Whittem T. A pilot study of 4CYTE Epiitalis Forte, a novel neutraceutical in the management of naturally occurring osteoarthritis in dogs. Aust Vet J. pp. 591-595. Grapiprant: An EP4 prostaglandin receptor antagonist and novel therapy for pain and inflammation. Vet Med Sci.2016; Feb;2(1): 3-9. Dejulius CR, Gulati S, Hasty KA, et al. Recent Advances in Clinical Translation of Intra-Articular Osteoarthritis in Drug Delivery Systems. Advanced Therapeutics. 2020; Sep 28.

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Treating canine osteoarthritis without opioids

How to heal the condition, not the symptom

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