Pain Guidelines 2015 Epstein 251 72

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S P EC I A L A R T I C L E

Journal of Feline Medicine and Surgery (2015) 17, 251272

2015 AAHA/AAFP Pain

Management Guidelines

for Dogs and Cats

JFMS CLINICAL PRACTICE 251Doi: 10.1177/1098612X15572062 iSFM and AAFP 2015

Rationale: The robust advances in pain management for companion animals underlie the

decision of the American Animal Hospital Association (AAHA) and American Association

of Feline Practitioners (AAFP) to expand on the information provided in the 2007

AAHA/AAFP Pain Management Guidelines. The 2015 Guidelines summarize and offer

a discriminating review of much of this new knowledge.

Relevance: Pain management is central to veterinary practice, alleviating pain, improving

patient outcomes, and enhancing both quality of life and the veterinarianclientpatient relationship.These Guidelines support veterinarians in incorporating pain management into practice, improving

patient care.

Approaches: The management of pain requires a continuum of care that includes anticipation, early

intervention, and evaluation of response on an individual patient basis. A team-oriented approach, including

the owner, is essential for maximizing the recognition, prevention and treatment of pain in animals.

Evidence base: The Guidelines include both pharmacologic and non-pharmacologic modalities

to manage pain; they are evidence-based insofar as possible and otherwise represent a consensus

of expert opinion. Behavioral changes are currently the principal indicator of pain and its course of

improvement or progression, and the basis for recently validated pain scores. Post-surgical pain is

eminently predictable but a strong body of evidence exists supporting strategies to mitigate adaptive

as well as maladaptive forms. Chronic pain is dominated by degenerative joint disease (DJD), which is

one of the most significant and under-diagnosed diseases of cats and dogs. DJD is ubiquitous, found

in pets of all ages, and inevitably progresses over time; evidence-based strategies for management

are established in dogs, and emerging in cats.

Introduction

Pan management s central t veternarypractce, nt adjunctve. Allevatng pan s ntnly a prfessnal blgatn (recall the vet-ernarans pledge t the relef f anmal panand sufferng) but als a key cntrbutr tsuccessful case utcmes and enhancementf the veternaranclentpatent relatnshp.A cmmtment t pan management dentfesa practce as ne that s cmmtted t cmpas-snate care; ptmum recvery frm llness,njury r surgery; and enhanced qualty f lfe.

These Gudelnes cntnue the trend n allbranches f medcne tward evdence-basedcnsensus statements that address key ssuesn clncal practce. Althugh nt a revewartcle, ths cmplatn s a frce multplerfr the busy practtner, cnsldatng n a

Mark E EpsteinDVM DABVP (Canine/Feline) CVPP

Co-Chair

TotalBond Veterinary Hospitals PC,3200 Union Road,

Gastonia, NC 28056, USAEmail: [email protected]

Ilona RodanDVM DABVP (Feline)

Co-Chair

Cat Care Clinic and Feline-FriendlyConsultations, 322 Junction Road,

Madison, WI 53717, USAEmail: [email protected]

Gregg GriffenhagenDVM MS

Colorado State University Schoolof Veterinary Medicine,

300 West Drake Road, Fort Collins,CO 80523, USA

Jamie Kadrlik

CVTPet Crossing Animal Hospital

and Dental Clinic,10861 Bloomington Ferry Road,Bloomington, MN 55438, USA

Michael C PettyDVM MAV CCRT CVPP DAAPMArbor Pointe Veterinary Hospital/

Animal Pain Center, 42043 Ford Road,Canton, MI 48187, USA

Sheilah A RobertsonBVMS PhD DACVAA MRCVS DECVAA

Department of Small Animal ClinicalSciences, College of Veterinary Medicine,Michigan State University, East Lansing,

MI 48824, USA

Wendy SimpsonDVM

Morrisville Cat Hospital, 100 Keybridge

Drive, Suite A, Morrisville, NC 27560, USA

The AAFP and AAHA

welcome endorsement of these

Guidelines by the International

Society of Feline Medicine

(ISFM) and the International

Veterinary Academy of Pain

Management (IVAPM).

sngle place current recmmendatns andnsghts frm experts n pan management.These Gudelnes are the prduct f acllabratve effrt by the Amercan AnmalHsptal Asscatn (AAHA) and theAmercan Asscatn f Felne Pract-tners (AAFP). The recmmendatns fthe Gudelnes Task Frce are evdence

based nsfar as pssble and therwserepresent a cnsensus f expert pnn.

These Gudelnes are desgned t expandn the nfrmatn cntaned n the 2007AAHA/AAFP Pan Management Gude-lnes fr Dgs and Cats.1,2 The 2015Gudelnes dffer frm the earler versn nseveral ways. The frst sectns are generalcncepts desgned t set the stage fr theremanng, mre specfc cntent. The 2015Gudelnes als dscuss the mprtance f

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an ntegrated apprach t managng pan thatdes nt rely strctly n analgesc drugs.Because pan assessment n anmals hasbecme mre scentfcally grunded n recentyears, varus clncally valdated nstrumentsfr scrng pan n bth dgs and cats aredescrbed. The extensve lst f publshed ref-erences ncludes numerus studes publshed

wthn the past 3 years, reflectng the rapdpace f advances n managng pan fr cm-pann anmals. The 2015 Gudelnes summa-rze and ffer a dscrmnatng revew f muchf ths new knwledge.

252 JFMS CLINICAL PRACTICE

Types of pain

All types f tssue njury can be generatrsf pan. occasnally, pan may ccur n theabsence f thse causatve factrs. Under-standng the mechansms f pan s the key tts successful preventn and treatment. Thepan respnse s unque t each ndvdual

and nvlves tw cmpnents: The sensry cmpnent s nociception,whch s the neural prcessng f nxusstmul; The affectve cmpnent s painperception, whch s the unpleasant sensryand emtnal experence asscated wthether actual r ptental tssue damage.

Pan s the endpnt f ncceptve nputand can nly ccur n a cnscus anmal.Hwever, there s als nvlvement f aut-nmc pathways and deeper centers f thebran nvlved wth emtn and memry.Hence, pan s a multdmensnal experence;t s nt just what yu feel but als hw tmakes yu feel.3

Acute pan has been defned as pan thatexsts durng the expected tme f nflamma-tn and healng after njury (up t 3 mnths),and chrnc pan s defned as that whchexsts beynd the expected duratn asscat-ed wth acute pan. Therapy shuld be fcusedn the underlyng cause f pan (ncceptve,nflammatry r pathlgcal), rather than narbtrary labels based n duratn.4

Nociceptive pain ccurs when perpheralneural receptrs are actvated by nxus

stmul (eg, surgcal ncsns, trauma, heatr cld). Inflammatory pain results gradually frmactvatn f the mmune system n respnset njury r nfectn. Pathological pain, als called maladaptvepan, ccurs when pan s amplfed andsustaned by mlecular, cellular andmcranatmc changes, cllectvely termedperpheral and central hypersenstzatn.

Pathlgcal pan s characterzed by hyper-algesa (exaggerated respnse t nxusstmulus), alldyna (panful respnse t nn-nxus stmul, such as tuch r pressure),expansn f the panful feld beynd ts rg-nal bundares, and pan prtracted beyndthe expected tme f nflammatn andhealng. Under sme cndtns, genmc,phentypc changes ccur that create the cn-dtn knwn as neurpathc pan, wherebypan can be cnsdered a dsease f the centralnervus system. Thse changes are nt neces-sarly chrnlgc. Maladaptve pan, r thersk fr t, can ccur wthn a matter f mn-utes f certan acute pan cndtns (eg, nervenjury, severe tssue trauma, r presence fpre-exstng nflammatn).

SPEC IAL ART ICLE /2015 AAHA/AAFP pain management guidelines

CONTENTS page

Introduction 251

Types of pain 252

Continuum of care 253

Its not just about drugs 253

Recognition and assessment of pain 253

Acute pain: characteristics and causes 254

Practical approach to postoperative pain assessment 254

Chronic pain: characteristics and causes 255

Pharmacologic intervention of pain 256

Opioids 256

Non-steroidal anti-inflammatory drugs 256

Local anesthetics 258

-2 Adrenergic agonists 258

Ketamine 258

Systemic lidocaine 259

Tramadol 259

Gabapentin 259

Amantadine 259

Tricyclic antidepressants 259

Selective serotonin (norepinephrine) reuptake inhibitors 259

Acetaminophen 259

Maropitant 260

Bisphosphonates 260

Corticosteroids 260

Polysulfated glycosaminoglycans 260

Nutraceuticals and other oral supplements 260

Non-pharmacologic modalities for pain management 260

Weight optimization 260

Acupuncture 260

Physical rehabilitation 261 Nutrition management 261

Thermal modification 261

Environmental modifications 261

Chiropractic care 261

Homeopathy 261

Gentle handling techniques 262

Managing surgical pain 262

Managing pain associated with DJD 263

When pain persists: hospice and palliative care 265

A team approach and client education: creating an environment

for success 266

Summary points 268



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JFMS CLINICAL PRACTICE 253


Its not just about drugs

Classc veternary medcal educatn places astrng emphass n treatment f dseasethrugh pharmaclgy and surgery, the es-terc sklls that are the dman f the traned

clncan. increasngly, evdence-based dataand emprcal experence justfy a strng rlefr nn-pharmaclgc mdaltes fr panmanagement. A number f thse shuld becnsdered manstream ptns and anntegral part f a balanced, ndvdualzedtreatment plan.

Examples f nn-pharmaclgc treatmentssupprted by strng evdence nclude, but arent lmted t, cld cmpressn, weghtptmzatn and therapeutc exercse.Treatment ptns ganng ncreasng accept-ance nclude acupuncture, physcal rehablta-tn, myfascal trgger pnt therapyand therapeutc laser, amng ther mdalteswhch are dscussed later n these Gudelnes.in addtn, nn-pharmaclgc adjunctvetreatment ncludes an apprecatn fmprved nursng care, gentle handlng, care-gver nvlvement, mprved hme envrn-ment, and hspce care. Thse methds havethe crtcal advantages f ncreased care-gverclncan nteractn and a strengthen-ng f the humanpet bnd. That sharedrespnsblty prmtes a team apprach andleads t a mre cmplete and ratnal bass frpan management decsns.5

Recognition and assessmentof pain

The patients behavior is keyBecause anmals are nn-verbal and canntself-reprt the presence f pan, the burden f

pan assumptn, recgntn and assessmentles wth veternary prfessnals. it s nwaccepted that the mst accurate methd frevaluatng pan n anmals s nt by physlg-cal parameters but by bservatns f behav-r. Pan assessment shuld be a rutne cm-pnent f every physcal examnatn, and apan scre s cnsdered the furth vtal sgn,after temperature, pulse and respratn.1,2,6obtanng a thrugh patent hstry frm thewner can help determne abnrmal behavrpatterns that may be pan related. Pet wnersshuld be educated n bservng any prblem-atc behavral changes n ther pet and tcntact ther veternaran n such cases.

Pet wners and practtners shuld havean awareness f behavr types that are rele-vant t pan assessment. Thse nclude theanmals ablty t mantan nrmal behavr,lss f nrmal behavr, and develpment fnew behavrs that emerge ether as anadaptn t pan r a respnse t pan relef(Fgure 2). Because behavral sgns f panare ften verlked r mstaken fr therprblems, the healthcare team must be vg-lant n recgnzng thse anmales n thettal patent assessment.

Appropriate pain management requires a contin-

uum of care based on a well thought out plan

that includes anticipation, early intervention and

evaluation of response on an individual patient

basis. It should be noted that response to therapy

is a legitimate pain assessment tool. Continuous

management is required for chronically painful

conditions, and for acute conditions until pain is

resolved.

The acronym PLATTER has been devised to

describe the continuum of care loop for managing

pain. The components of the PLATTER algorithm

for pain management are PLan, Anticipate, TreaT,

Evaluate and Return (Figure 1). The approach

provides individualized pain management for any

patient and is devised not on a static basis but

according to a continuous cycle of plantreateval-

uate based on the patients response.

Figure 1: PLATTER approach to pain management

PLan Every case should start with a patient-specific pain assessment and treatment plan

Anticipate The patients pain management needs should be anticipated whenever possible so

that either preventive analgesia can be provided or, in the case of pre-existing pain,

it can be treated as soon as possible

TreaT Appropriate treatment should be provided that is commensurate with the type,

severity and duration of pain that is expected

Evaluate The efficacy and appropriateness of treatment should be evaluated; in many cases,

using either a client questionnaire or an in-clinic scoring system

Return Arguably the most important step, this action takes us back to the patient where

the treatment is either modified or discontinued based on an evaluation of the

patients response

C o n t i n u u m o f c a r e

Figure 2:

Behavioral keys

to painassessment

When assessing an

animal for pain, the

following behavioral

keys should be con-

sidered:

Maintenance of

normal behaviors

Loss of normal

behaviors

Development of

new behaviors

Appropriate

pain

management

requires a

continuum

of care.



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SPEC IAL ART ICLE / 2015 AAHA/AAFP pain management guidelines


Pain scoring toolsAlthugh there s currently n gld standardmethd fr assessng pan n dgs and cats, theGudelnes Task Frce strngly recmmendsutlzng pan scrng tls bth fr acute andchrnc pan. it shuld be nted that thsetls have varyng degrees f valdatn, acuteand chrnc pan scales are nt nterchange-able, and canne and felne scales are nt nter-changeable. The use f pan scrng tls candecrease subjectvty and bas by bservers,resultng n mre effectve pan management,whch ultmately leads t better patent care.

Acute pain: characteristics andcauses

Acute pan nvlves bth ncceptve and

nflammatry cmpnents and can be causedby trauma, surgery and medcal cndtnsr dseases. These Gudelnes wll fcus nrecgntn, preventn and treatment f pst-surgcal pan.

Multifactorial clinical measurement

instruments for acute postsurgical painFr dgs, a valdated, wdely used, multfac-tral clncal measurement nstrument (CMi)fr acute pan s the Glasgw Shrt FrmCmpste Measure Pan Scre. The 4AVet santher cmpste measure pan scre frdgs, reprtedly wth mre nterbservervarablty than the Glasgw shrt frm, butless based by sedatn.7,8 Smple, nlne, prac-tce-frendly numercal ratng scales (0 t 4)fr acute canne and felne pan have beendevelped (but nt yet valdated) byClrad State Unversty. in cats, a currentlyvaldated assessment tl s the UNESP-Btucatu Multdmensnal Cmpste PanScale.9,10 That scale and vde examples fhw t s appled n clncal practce can beaccessed nlne, and a descrptn f ClradStates acute pan scales are ncluded nTable 1.

Practical approach topostoperative pain assessment

Valdated CMis are the fundatn f ratnalpan assessment. Thse assessment tls pr-vde a smplfed apprach that encuragesregular use by all healthcare members and arebased n the fllwng features: observng the patent wthut nteractn(e, the patents rentatn n the cage,psture, mvement, facal expressn, actvtylevel and atttude; images 1 and 2). observng the patent whle nteractngwth a care-gver (eg, what ccurs when thecage dr s pened r an anmal s caxedt mve).

Resource Internet address Content

Colorado State University CanineAcute Pain Scale

www.csuanimalcancercenter.org/assets/files/csu_acute_pain_scale_canine.pdf

Psychological and behavioral indicators of pain Response to palpation

Colorado State University FelineAcute Pain Scale

csuanimalcancercenter.org/assets/files/csu_acute_pain_scale_feline.pdf

Same as above

University of Glasgow Short FormComposite Measure Pain Score

www.newmetrica.com/cmps Clinical decision-making tool for dogsin acute pain

Indicator of analgesic requirement Includes 30 descriptors and six behavioral

indicators of pain

UNESP-Botucatu MultidimensionalComposite Pain Scale

www.animalpain.com.br/en-us/avaliacao-da-dor-em-gatos.php

Assesses postoperative pain in cats Includes 10 indicators of pain ranked numerically

Table 1 Acute postoperative pain scales

A pain score

is considered

the fourth

vital sign, after

temperature,

pulse and

respiration.

Image 2 Cats normallysleep in a curled-up position,as seen in this patient, whenprovided with adequateanalgesia. Courtesy ofSheilah Robertson

Image 1 (a,b) Signs of acute pain include squinting, and a hunched or tucked-up position

instead of sleeping in a normal curled-up position (see Image 2). Images courtesy of SheilahRobertson

a b



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observng thepatents respnse tpalpatn f the surgcalste (image 3). Assgnng a numercalscre usng a dynamcnteractve vsual analgscale (eg, frm 0 fr n

pan t 10 fr the wrstpssble pan fr thatprcedure).

The re-evaluatnnterval wll depend nthe prcedure, expectedduratn f the chsennterventn, and prev-us pan scre. Varablty by dfferentbservers can be mnmzed by havng thesame team member assess the patentthrughut the evaluatn perd. ideally,the ndvdual patents nrmal temperamentshuld be knwn fr the purpses fcmparsn wth pstsurgcal appearance andbehavr.

Chronic pain: characteristicsand causes

Chrnc pan s usually descrbed as etherpan that perssts beynd the nrmal healngtme r pan that perssts n cndtns wherehealng has nt r wll nt ccur. in smecases, pan sgnalng perssts n the absencef grss tssue pathlgy.

The fllwng basc prncples are relevant

t chrnc pan n cmpann anmals: Pet wners may nt apprecate ther petsbehavr as beng an ndcatr f chrncpan; hwever, what they mght see sncreasngly dmnshed functn andmblty that ndcate prgressve dsablty.Examples nclude: Dmnshed exercse tlerance and generalactvty. Dffculty standng, walkng, takng stars,jumpng r gettng up. Decreased grmng (cats especally;image 4). Changes n urnatn r defecatn habts(image 5). Under-recgnzed and undermanagedchrnc pan can result n prematureeuthanasa.11 Cnversely, prper recgntnand management f chrnc pan can be aslfe preservng as any ther medcal treatmentn veternary medcne. Degeneratve jnt dsease (DJD) sthe nclusve termnlgy that ncludesstearthrts (oA). Althugh DJD and oAare ften used nterchangeably n the lteratureand n practce, the brader term, DJD, wll beused thrughut these Gudelnes.

Multifactorial clinical measurementinstruments for chronic pain

observatn r reprts (eg, n a pre-examna-tn questnnare) f behavral changes rabnrmaltes s the frst cnsderatn nrecgnzng and assessng pan. Thereafter,several standardzed, multfactral CMis frchrnc pan are avalable t veternarans, as

summarzed n Table 2. Such CMis are chrncpan ndces that prmarly utlze pet wnerbservatns and nput. ideally, patents wthchrnc pan shuld be evaluated wth ne fthe multfactral CMis.

Image 3 Followingassessment from a distance,palpation of the surgical siteis performed to furtherassess acute pain. Courtesyof Sheilah Robertson

Image 4 Lack of normal behaviors, such as reduced grooming, is commonly seen in painfulcats. Image iStock/jvoisey

Image 5 Cats may start to perform abnormalbehaviors secondary to pain, such as defecatingoutside of the litter box, either because the catcannot get downstairs to the box or it cannot jumpinto the box. Courtesy of Sheilah Robertson

Proper

recognition

and management

of chronic pain

can be aslife preserving as

any other medical

treatment in

veterinary

medicine.

Helsinki Chronic Pain Index (HCPI)

Canine Brief Pain Inventory (CBPI)

Cincinnati Orthopedic Disability Index (CODI)

Health-Related Quality of Life (HRQL)

Liverpool Osteoarthritis in Dogs (LOAD)

Feline Musculoskeletal Pain Index (FMPI)

Table 2 Multifactorial CMIs for

chronic pain assessment

in veterinary medicine



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Pharmacologic interventionof pain

Effectve pan management generally nvlvesa balanced r multmdal strategy usngseveral classes f pan-mdfyng medca-tns. The ratnale behnd ths apprach sthat t addresses targetng multple stes n

pan pathways, ptentally allwng lwerdses f each drug and mnmzng the pten-tal fr sde effects asscated wth any sngledrug. The chce f medcatn shuld bebased n antcpated pan levels and ndvd-ual patent needs. Antcpatry analgesa pr-vded prr t pan nset s mre effectvethan analgesa prvded nce pan hasccurred, cntrbutng t bth a dse- andanesthetc-sparng effect.

Opioidsopds are the mst effectve drug class frmanagng acute pan and can play a rle nmanagng chrnc pan. An mprved under-standng f neurpharmaclgy and thedevelpment f nvel frmulatns f pdsmake t ncumbent n veternarans t remanfamlar wth ther mdes f actn; the var-us subtypes wthn ths drug class; and thepreventn, recgntn and treatment fadverse effects.

Whle a cmplete dscussn f pds sbeynd the scpe f these Gudelnes, the TaskFrce makes the fllwng recmmendatnsfr usng ths class f drugs n dgs and cats: opds shuld be used as a rutne

preperatve medcant, preferentally ncmbnatn wth a tranqulzer/sedatve(eg, aceprmazne, mdazlam, dazepamr -2 adrenergc agnst such asdexmedetmdne), when the patentscndtn warrants ther use. Full agnsts elct greater and mrepredctable analgesa than partal agnstsr agnsts. in dgs, the antagnst/agnst butrphanl, n partcular, appearst prvde lmted smatc analgesa and avery shrt duratn f vsceral analgesa.12,13

in a cmparsn study, buprenrphneadmnstered befre surgery and durngwund clsure prvded adequate analgesafr 6 h fllwng varhysterectmy n cats,whereas butrphanl dd nt.14

in cats, the subcutaneus (SC) rute fpd admnstratn s nt recmmended.intramuscular (iM) and ntravenus (iV)rutes are preferred bth pre- andpstperatvely. 15 The ral transmucsalr buccal rute f admnstratn frbuprenrphne may have clncal effcacyas well.16,17

The ndvdual effect f any pd,ncludng duratn, may vary wdely frm



patent t patent. Pstperatve re-evaluatnshuld be made frequently t determnengng pd requrements. Fr a patent undergng majr surgery,whereby ngng pd admnstratn canbe antcpated, the clncan may chse frmthe fllwng strateges: Perdc readmnstratn f parenteral

pds. Cnstant r varable rate nfusn.Calculatrs can be fund nlne. Lng-actng frmulatns and technlges.Fr dgs there s a Fd and DrugAdmnstratn (FDA) apprved transdermalfentanyl prduct (Recuvyra; Elanc). Gvenths canne fentanyl prduct n the market,the Task Frce dscurages the use f humancmmercal fentanyl patches n dgs due thghly varable pharmacknetcs, and rskf ether accdental r purpseful humanexpsure, wth ptental lablty frextralabel use. There s nt an expertcnsensus regardng the utlty f fentanylpatches n cats. The FDA has mre recentlyapprved a cncentrated njectablebuprenrphne prduct fr cats (Smbadl;Abbtt), whch has been frmulated tprvde a 24 h duratn f actn whenadmnstered as drected. oral pds. Dgs exhbt a rbust frst-pass effect f ral pds. N clncal studesdcument effcacy, but pharmacknetcs fcdene and hydrcdne suggest pssbleutlty.18 N cmparable studes exst fr cats. opds are synergstc wth -2

adrenergc agnsts, allwng them t be usedn lw-dse cmbnatns, ether wth rwthut ketamne, t great effect fr bthsedatn and analgesa. opds play a sgnfcant rle n humanmedcne fr the treatment f chrnc panand may play an underapprecated rle ndgs and cats as well, especally fr cancer-related pan and n pallatve care patents.That sad, clncans must be vglant wthregard t lng-term adverse effects such ascnstpatn, drug tlerance and the ptentalfr dversn by clents.

Non-steroidal anti-inflammatory drugsThe majrty f cndtns that cause panhave an nflammatry cmpnent. Nn-sterdal ant-nflammatry drugs (NSAiDs)are a manstay fr management f chrncpan as well as fr perperatve use. NSAiDsshuld be used fr ther central and perpher-al effects n bth dgs and cats after cnsder-atn f rsk factrs. There s n ndcatn thatany ne f the veternary-apprved NSAiDss asscated wth any greater r lesser nc-dence r prevalence f adverse events.19Canne and felne veternary-apprved

Anticipatory

analgesia

provided prior

to pain onset is

more effective

than analgesia

provided once

pain has

occurred.



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NSAiDs have demnstrated acceptable safetyprfles, whch s n cntrast t nn-apprvedNSAiDs such as asprn, buprfen, naprxenand melxcam fr human use.2022 Lng-termuse f lw-dse melxcam s apprved ncats n many cuntres ther than the USA.

Adverse events related t NSAiD use ndgs and cats can be mnmzed by apprpr-ate use, as utlned n Fgure 3. Althugh theverall ncdence and prevalence f NSAiD-related txcty s unknwn, t des appear tbe very lw relatve t the number f dsesadmnstered.20

of the adverse events asscated wthNSAiDs, gastrntestnal (Gi) txcty s themst cmmn. The Gi clncal sgns asscatedwth NSAiD txcty n dgs nclude vmt-ng, darrhea and nappetence.20,2325 in cats,nappetence appears t be the mst cmmnadverse event. Althugh unlkely, t s pss-ble fr ersns and ulcers t be slent and

ccur prr t any clncal sgns.23,26 Studesndcate that NSAiDs that spare cyclxyge-nase (CoX)-1 prduce a lwer frequency f Gilesns, althugh the mre hghly CoX-2selectve nhbtrs may actually prducemre adverse events when underlyng gastrcdamage s already present.19,27

The leadng rsk factrs fr NSAiD-asscat-ed Gi perfratns are ncrrect dsng,cncurrent use wth ther NSAiDs r crtc-sterds, and cntnued use despte Gi sgnsr anrexa.20,24 Sgns f Gi txcty usuallyemerge wthn 24 weeks but can ccur at anypnt durng admnstratn.28,29 it s crtcalthat veternarans cmmuncate NSAiD txc-ty rsk factrs t pet wners (eg, prvdngclent nfrmatn that descrbes ptentalsde effects, ncludng the cmmercal crcu-lars prvded by drug manufacturers andnstructn n when t stp medcatn andcntact a veternaran).

Figure 3: Nine ways to minimize the risks of NSAIDs

Obtain a complete medication historyAvoid

or use extreme caution with concurrent or recent

use of NSAIDs and/or corticosteroids (including

some nutritional supplements that may contain

aspirin or other cyclooxygenase-inhibiting

mechanisms). Practitioners should observe the

following additional precautions due to potential

drug interactions:

Avoid with furosemide and use caution with

angiotensin-converting enzyme inhibitors.

Avoid with potentially nephrotoxic drugs

(eg, aminoglycosides, cisplatin).

Caution with use of additional multiple highly

protein-bound drugs (eg, phenobarbital, digoxin,

ciclosporin [cyclosporine], cefovecin,

chemotherapy agents).

Be discriminating in patient selection Be

cautious or avoid NSAIDs in patients with the

following existing/anticipated conditions:

Low-flow states such as dehydration,hypovolemia, congestive heart failure and

hypotension. In such cases, IV fluid support and

blood pressure monitoring should be available

for anesthetized animals.

Renal, cardiac or hepatic dysfunction.

Provide verbal and written client instructions

to avoid the medications described above and to

discontinue and alert the hospital at the first sign

of an adverse event (see below).

Recognize the earliest signs of adverse

events and withdraw NSAID treatment

immediately if those events occur, especially in

the case of any GI signs in dogs and cats with

diminished appetites.

Perform laboratory monitoring The frequency

will depend on the risk factor of the patient:

Ideally within the first month of initiating therapy

then 6 monthly thereafter in low-risk patients.

For at-risk patients, monitor every 24 months

depending on risk factor assessment.

Utilize a balanced, integrated analgesic

approach as part of NSAID-sparing strategies.

Consider washout periods Clinically relevant

washout periods remain controversial and largely

undefined. Based on pharmacokinetics,

practitioners who wish to err on the side of

caution may want to withhold meloxicam for

5 days and other NSAIDs or short-acting

corticosteroids for 7 days prior to initiating

treatment with another NSAID. In the case of

long-acting corticosteroids, a longer washout

period needs to be considered. Aspirin should

not be administered because there are safer

alternatives. If a course of treatment with aspirinhas been started in a dog, the recommended

washout period before starting an approved

veterinary NSAID is up to 10 days.

Use gastroprotectants to either treat

suspected gastropathy or prevent its

occurrence, especially if no washout period

occurs. Proton pump inhibitors, H2 antagonists,

misoprostol (the drug of choice in humans) and

sucralfate can be helpful.

Dose optimization Base dosage on lean

body weight. Although there is no definitive

evidence that NSAID dose reduction lowers

the risk of adverse events, some clinicians

recommend titrating to the lowest effective dose.

Adverse events

related to

NSAID use in

dogs and cats

can be

minimized byappropriate

use.



8/22

Anther mprtant sde effect asscatedwth NSAiDs s nephrtxcty. When admn-stered befre anesthesa n healthy dgs wthcntrlled mdest hyptensn, n adverseeffect n renal functn was detected.30,31

Hwever, because sme dgs n thse studesdd develp changes n renal parameters, themprtance f mantanng a nrmtensvestate durng anesthesa s cnsdered para-munt when utlzng preperatve NSAiDs.Preperatve admnstratn n dgs s super-r n effcacy t pstperatve use, cnsstentwth results f multple studes perfrmed nhumans.32 Smlar studes have nt beencnducted n cats undergng anesthesa, butne felne study revealed n alteratn nglmerular fltratn rate measured by hexlclearance after 5 days f ral melxcam.27if iV access s nt pssble and nrmtensncannt be acheved wth certanty, the TaskFrce recmmends lmtng the use fNSAiDs t pstsurgcal admnstratn.

idsyncratc hepatcellular necrss hasbeen reprted wth varus NSAiDs butremans exceedngly rare, at nly 1.4 cases/10,000 dgs (0.052%), usually ccurrngbetween 2 and 4 weeks after startng treat-

ment. Pre-exstng elevated lver enzymes arent a rsk factr.19 idsyncratc hepatcellularnecrss s nt a true txcss but rather anntrnsc, hertable reactn t the mleculebeng admnstered.20

Hghly CoX-2 selectve NSAiDs havecaused delayed bne healng n rabbt andrdent mdels, and ne study n dgs demn-strated delayed healng f expermental tbalstetmes fllwng lng-term NSAiDuse.33 That partcular study may nt be aclncally relevant mdel, and anther studyreprted that nrmal tssue healng s rapdlyrestred nce the NSAiD s wthdrawn.34

Further, f 299 dgs recevng deracxb,carprfen and frcxb n the FDA-apprvalprcess, nne were reprted t have delayedfracture healng r nn-unn fractures.Fnally, n clncally sgnfcant bleedngdyscrasas have been reprted wth the use fveternary NSAiDs.20

Local anestheticsThs s the nly class f drug that renderscmplete analgesa. The ttalty f evdence nhuman and anmal studes reveals the pre-dctable analgesc and anesthetc drug-sparng

effects f lcal anesthetcs. in addtn, lcalanesthetcs are reprted t be antmcrbal andmmunmdulatng, and can dmnsh pst-peratve maladaptve pan states. They d ntappear t delay tssue healng.35 Lcal anesthet-cs can be admnstered ether drectly at a sm-ple ncsn ste r at a specfc nerve t prvdeanalgesa t a large regn (r area). A dscus-

sn f the many lcregnal blcks that canbe utlzed n dgs and cats s beynd the scpef these Gudelnes, but can be fund n severalreadly accessble resurces, and mst f thseblcks can be readly learned by clncans.

Lcal anesthetcs are cnsdered safe, wthadverse events generally lmted t very hghdses r nadvertent iV admnstratn (bup-vacane especally). The Task Frce supprtsthe internatnal Veternary Academy f PanManagement pstn that, because f thersafety and sgnfcant beneft, lcal anesthetcsshuld be utlzed, nsfar as pssble, wthevery surgcal prcedure.

-2 Adrenergic agonists-2 Adrenergc receptrs are lcated wth pdreceptrs. Thus, used tgether, pds and -2adrenergc agnsts are hghly synergstc frsedatn and analgesa. -2 Agnsts have aversatle dsng prfle. That allws lw- andeven mcr-dses n cmbnatn wth pdst be clncally useful and mnmzes thecardvascular effects. Clncans shuld bemndful that cardvascular sde effects ccureven wth very lw dses f -2 adrenergcagnsts, that lwer dses wll have a shrter

duratn f effect, and that analgesc effects havea shrter duratn than the sedatve effects.

KetamineKetamne exerts a pan-mdfyng effect va tsN-methyl-D-aspartate receptr antagnstactns. Subanesthetc ketamne cnstant ratenfusn (CRi) n humans prevents panand has anthyperalgesc and antalldynceffects.36,37 Studes appear t supprt a smlarclncal effect n dgs,3840 althugh theanalgesc effect f ketamne has nt yet beenstuded n a felne surgcal mdel. Theinternatnal Veternary Academy f PanManagement has adpted a pstn that thepan-mdfyng effects and safety prfle fsubanesthetc dses f ketamne warrant ts useas part f a multmdal apprach t transper-atve pan management, especally n patentswth rsk factrs that may predspse them tether exaggerated r maladaptve pan states.



The Guidelines Task Force strongly encourages

implementation of practice systems that ensure

communication to clients of appropriate adverse

effects and risk information for any prescribed

drug, including NSAIDs.

Therapy should be focused on the underlying cause

of pain (nociceptive, inflammatory or pathological)

rather than on arbitrary labels based on duration.



9/22



Systemic lidocaineThere s strng evdence f the safety andbenefcal effects f iV ldcane n pan afterabdmnal surgery (althugh nt fr thersurgeres elctng smatc pan) n humansand pssbly n hrses, ncludng bth analge-sa and return f bwel functn.41 iV ld-cane s anesthetc-sparng n dgs and cats,

but current evdence fr a pan-mdfyngeffect n these speces remans ncnclusve.42

Sme nvestgatrs dscurage the use f iVldcane n cats due t negatve card-vascular effects, but successful use n clncalpractce has been anecdtally reprted.43Varus frmulatns fr a cmbnatn fmrphne, ldcane and ketamne CRis havebeen descrbed n dgs.44

Tramadolin cntrast t humans, tramadl n dgs hasa very shrt half-lfe (1.7 h) and neglgbleamunts f the pd M1 metablte areprduced.4548 Pharmacdynamc studesdemnstrate the anesthestc-sparng andpan-mdfyng effect f parenteral tramadln dgs.4953 Cnvncng evdence fr a pan-mdfyng effect f ral tramadl, hwever,remans elusve, and already lw plasma lev-els quckly dmnsh wth sequental admns-tratn.5457 one small study f ral tramadldd reprt a statstcally sgnfcant ncrease fmechancal threshld levels n dgs, but nlyat the 5 and 6 h tme pnts.48

in cntrast t dgs, cats d prduce the -agnst M1 metablte. A pan-mdfyng

effect has been demnstrated n bth a ther-mal threshld and clncal surgcal mdel.58,59There s ne case seres nvlvng the use fral tramadl n a flavred cmpunded frm(the drug s therwse qute btter). Dse ttra-tn, txcty and safety data are currentlylackng n bth dgs and cats.60

GabapentinGabapentn s an antcnvulsant wth an-algesc prpertes that may be prmarlyderved by dwn-regulatng calcum chan-nels.61 Because f ts effcacy and tlerablty,gabapentn s wdely used n humans wthneurpathc and ther maladaptve pancndtns.62 Alng wth publshed clncalcase reprts n anmals, the data suggest astrng ratnale fr usng gabapentn ndgs and cats wth smlar cndtns.63,64one canne study suggested a dsease-mdfyng effect n expermental DJD, butclncal studes are lackng.65 in cats, neunpublshed study demnstrated a beneftf gabapentn n naturally ccurrng DJD(E Trncy 2013), and ne case seres fchrnc musculskeletal pan has als beenpublshed.66

There s encuragng evdence t supprtthe use f gabapentn fr pstsurgcal pan nhumans,6772 but nt yet n dgs and cats.An 812 h dsng nterval has been suggestedbased n ne publcatn.73 The prmaryadverse effect n dgs appears t be smn-lence (als the case n humans), whch usuallyreslves wth patent acclmatn ver several

days, allwng fr a taperng-up schedule.AmantadineAmantadne exerts a pan-mdfyng effect asan N-methyl-D-aspartate receptr antagnstand remans a drug f nterest fr chrnc pan(but nt specfcally fr DJD) n humans.74 onestudy demnstrated utlty as an adjunct tNSAiDs n dgs wth refractry DJD,75 andthere s ne case reprt utlzng amantadnet treat neurpathc pan n a dg.76 Txctyand pharmacknetc studes have been per-frmed n humans and cats,77,78 but nt ndgs.

Tricyclic antidepressantsAs a class, trcyclc antdepressants (TCAs) arethe mst effectve medcatns fr selectveneurpathc pan cndtns n humans.79 indgs, there exsts nly a sngle case reprtwhere amtrptylne was used fr neurpathcmusculskeletal pan.80

Selective serotonin (norepinephrine)

reuptake inhibitorsThese cmpunds exert ther effect by ncreas-ng sertnn wth r wthut nrepnephrne

n the synaptc cleft. At least ne selectvesertnn (nrepnephrne) reuptake nhbtr(SS[N]Ri), dulxetne, has a chrnc pan labelndcatn n humans. in dgs, bavalabltys pr and clncal effcacy s lackng.81

At ths pnt n the Gudelnes, the TaskFrce wants t emphasze the fllwng:

Acetaminophen

Acetamnphen s cntrandcated n cats. indgs, several early studes revealed a pan-mdfyng effect n rthpedc surgery, andpharmacknetc data have been reprted.8284The lterature des nt appear t ndcate thatacetamnphen has a prclvty twards hepa-ttxcty n dgs.

Many drugs and compounds enhance either

monoamines or serotonin expression. Caution

should be used when such analgesic agents

are used in combination. Examples include

tramadol, TCAs (including amitriptyline and

clomipramine), SS(N)RIs, amantadine, metoclo-

pramide, selegiline, amitraz, mirtazapine and

trazodone.



10/22

MaropitantMarptant s a central antemetc ndcatedfr the treatment f acute canne and felnevmtng, whch s ften a pstsurgcalsequela and a cntrbutr t the pan burden.Marptant wrks thrugh a blckade f sub-stance-P bndng t the neurknn-1 receptr,whch s nvlved n pan prcessng. The true

pan-mdfyng effect f marptant n dgsremans uncertan despte canne studesrevealng an anesthetc-sparng effect and ann-nferr effect t mrphne n an var-hysterectmy mdel.85,86

Bisphosphonates

Admnstered by iV nfusn, ths class fdrug exerts antsteclast actvty and cancntrbute t pan relef n dgs wth bnecancer.87

CorticosteroidsCrtcsterds are nt prmarly analgescdrugs, but may exert a pan-mdfyng effectby reducng nflammatn. Ther utlty as ananalgesc therapy n dgs and cats has ntbeen reprted.8891

Polysulfated glycosaminoglycansA parenterally admnstered plysulfatedglycsamnglycan (PSGAG) prduct hasregulatry apprval fr the cntrl f sgnsasscated wth nn-nfectus degeneratveand/r traumatc arthrts f canne synvaljnts. independent studes supprt PSGAGsas safe and effectve chndrprtectants

wth pssble dsease-mdfyng effects.9294

The bavalablty and dstrbutn fPSGAGs t nflamed jnts n cats hasbeen demnstrated wth extra-label SCadmnstratn.95

Nutraceuticals and other oral

supplementsoral nutrtnal supplements represent a wdespectrum f cmpunds ether as sngle agentsr n cmbnatns. Anecdtal evdence fr apan-mdfyng effect f thse prductsremans mxed. if nutraceutcals and/rherbal supplements are made part fa treatment plan, the Task Frce suggestsmndfulness twards prduct qualty cntrl;awareness f the ptental fr drug nterac-tns wth ther medcatns (eg, sme ver-the-cunter jnt prducts and herbal mxturescntan asprn and sme may cntan herbssuch as St Jhns wrt that nterfere wth ser-tnn release r reuptake); and avdance fngredents derved frm endangered speces.

in the future, evdence fr the pan-mdfyng effect f cannabnds and/rther cmmercal drug dervatves maybecme evdent.

Non-pharmacologic modalitiesfor pain management

Weight optimization

Adpse tssue secretes a mxture f cytknesthat crculate thrughut the bdy, cntrbut-ng t the pathlgy f many dseases, nclud-ng DJD, and t the hypersenstzatn prcessn general. Ether mantanng r reganng alean bdy cndtn scre s central t thetreatment f chrnc pan.

AcupunctureThe Gudelnes Task Frce hlds thatacupuncture ffers a cmpellng and safemethd fr pan management n veternarypatents and shuld be strngly cnsderedas a part f multmdal pan managementplans.96 it s a mnmally nvasve treatmentthat, fr mst anmals, s nt uncmfrtable,ften pleasant, and can be used ether alne rn addtn t ther pan treatment mdaltes(image 6). Acupuncture has been recgnzedby the Natnal insttutes f Health snce 1998as havng applcatns n human medcne,especally pan management. There s a sldand stll grwng bdy f evdence fr the use

f acupuncture fr the treatment f pan nveternary medcne t the extent that t snw an accepted treatment mdalty frpanful anmals.97101



Image 6 Note howcomfortable cats usuallyare for acupuncture therapy.Courtesy of Sheilah Robertson

Increasingly, evidence-based data and empirical

experience justify a strong role for various non-

pharmacologic modalities for pain management.



11/22



Physical rehabilitationCmbned mdalty therapy t decrease panand restre functn s nw cnsdered anessental apprach fr musculskeletal njuryand pstsurgcal recvery.102 in the treatmentf chrnc dsease, such as DJD r cnfrma-tnal abnrmaltes, rehabltatn shuld becnsdered an mprtant cmpnent f an

verall lng-term treatment strategy.103

The fundatn f rehabltatn s therapeu-tc exercse that ams t restre muscul -skeletal strength and functn, endurance andprprceptn, and reduce pan. Mst cm-mnly t nvlves exercse and manual thera-py, ncludng jnt mblzatns, massage andmyfascal release. Energy-based mdaltesare als ften emplyed, ncludng neurmus-cular electrcal stmulatn, transcutaneuselectrcal nerve stmulatn, crytherapy wthand wthut cmpressn, therapeutc ultra-sund, therapeutc laser and extracrprealshckwave therapy.104108

Myfascal pan syndrme (MPS) s ncreas-ngly recgnzed as an mprtant cmrbdtyn many chrnc pan cases n anmals. MPS sacknwledged fr the mprtant rle t playsn the pathlgy f DJD, repettve strannjures n perfrmance dgs, r as a sequelat rthpedc surgery. The pathphyslgyf myfascal pan s a cmplex syndrmenvlvng mtr, sensry and autnmcnerve cmpnents that s beynd the scpe fthese Gudelnes, but s well descrbed else-where.109 Treatment f MPS s ften essentalt regan full functn f the affected lmb,

regardless f the underlyng cause.110

Nutrition managementin the verweght patent, the prme nutrtn-al emphass shuld be achevng a leanerbdy cndtn. Weght cntrl dets frtfedwth mega-3 fatty acds have been shwn tbe effectve at reducng sgns asscated wthbth canne and felne DJD.111114

Thermal modificationin acute njury, ncludng surgcal areas, cldcmpressn has a demnstrable beneft nreducng pan and nflammatn, andprmtng return t functn.115 in the case fchrnc njury, heat can mprve cmfrt andfunctn thrugh a varety f mechansms.116

Environmental modificationsThere s strng evdence that the stress fhsptalzatn nhbts nrmal behavrs nanmals, ncludng eatng, grmng, sleepngand elmnatn.117 Fear, anxety, stress anddstress lead t hyperalgesa n bth humansand anmals.118121 Strateges t mtgatehyperalgesa, therefre, nclude prvdngbeddng, blankets r clthng frm hme

wth famlar scents; allwng vstatn fhsptalzed pets; separatng the dgs frmthe cats; placng cages s that anmals d ntsee each ther; usng speces-specfc synthetcphermnes; and prper handlng, especallydurng prcedures (see bx n page 262).122126

in patents wth DJD, thrw rugs and rampswll mprve mblty and abltes at hme(image 7).

Chiropractic careThe Gudelnes Task Frce has nt fund suff-cent, relable, nn-cntradctry evdence frthe use f chrpractc care fr pan manage-ment n veternary medcne at ths tme. Thatsad, chrpractc care has many well-defnedapplcatns n human medcne that havebeen supprted thrugh relable research.

Homeopathy

incntrvertble evdence that hmepathy seffectve n ether human r veternary med-cne fr the treatment f pan s lackng. Slerelance n hmepathy t treat a panful cn-dtn s, n essence, wthhldng pan treat-ment. Thus, ths Task Frce dscurages theuse f hmepathy fr the treatment f pan.

Image 7 Environmental management isneeded in addition to medical management forcats with DJD. Providing a stool (a,b), ramp orstep(s) (c) allows the cat to reach favoredareas. Pet steps are commercially available orcan be built; those pictured in (c) were built byDr Robert Wright of The Cat Doctor in PortlandME, USA. Images courtesy of Deb Givin

a

c

b

Photos included in this

Guidelines document pub-

lished in JFMS are intended to

demonstrate gentle handling tech-

niques, body positioning, behavior

and comfort practices specific to cats.



12/22

Managing surgical pain

The Task Frce suggests that pan man-agement fr dgs and cats undergng asurgcal prcedure ncludes the fllwng: preperatve pd plus atranqulzer/sedatve (eg, aceprmazneand mdazlam r dazepam anddexmedetmdne). Admnstratn f an NSAiD ether pre- rpstperatvely based n patent rsk factrsand clncan preference. lcal anesthetc.



Fr patents undergng prcedureswth rsk factrs fr mre severe, prtract-

ed r maladaptve pstperatve panstates, the fllwng nterventns r drugs

shuld be strngly cnsdered: Cld cmpressn. -2 Adrenergc agnst. Ketamne CRi. Ldcane CRi. Gabapentn. Epdural anesthetc(s).

Many cats have DJD in the spine as well as

the limbs. Scruffing can further exacerbate

the pain of thoracic or lumbar DJD. Instead

of scruffing, there are other excellent

alternatives that are actually safer for staff

as well as more comfortable for the feline

patient.

The hold depends on the cats

demeanor and comfort. For example,

some cats calmly look around or will eat

canned food or treats while venepuncture

from the medial saphenous vein is

performed (image a). For the more anxiouscat, use one to three of the middle fingers

to massage the area above the eyes (this

is also an area of acupressure to help calm

the cat), while the first and fifth digits hold

the head in place to prevent escape and

staff injury (image b).

Images courtesy ofIlona Rodan

a b

c d

For cystocentesis, a standing procedure

is often easier than stretching out the cats

legs (image c). For cystocentesis with

the cat positioned in lateral recumbency

(image d), move the legs back without

stretching them, and use either the

massage hold pictured in (b) or hold the

cat with the fingers made into a V shape

(two fingers on one side of the neck and

three on the other side).

G e n t l e h a n d l i n g t e c h n i q u e s

Detailed information

on handling feline patients

has recently been published in

the AAFP and ISFM Feline-Friendly

Handling Guidelines127 and the AAFP

and ISFM Feline-Friendly Nursing CareGuidelines.128

The importance of gentle handling of patients with either acute or chronic pain cannot be overstated, especially when working with

arthritic dogs and cats. Conscious avoidance of careless handling will ensure the patients comfort, allow for a more thorough and

effective physical examination, and avoid exacerbating anxiety in the agitated, fearful or aggressive patient. An important additional

benefit of gentle handling is that it demonstrates to the pet owner that healthcare team members are compassionate and aware of

the significance of pain in their patients.



13/22



Managing pain associatedwith DJD

Overview of DJD in companion animalsDJD, ncludng oA, s ne f the mst sgnf-cant and underdagnsed dseases f cats anddgs. DJD s clncally relevant because f tsverall prevalence and unversal ncdence n

lder anmals. Whereas dagnstc apprach-es fr canne DJD are well establshed, the besttls fr dagnss f felne DJD are stll bengdevelped.

The pan treatment cntnuum fr DJDbegns wth the nset f dsease, whch usuallystarts at a very yung age n dgs (eg, cnfr-matnal etlgy) and cats (unknwn etl-gy), and perssts thrughut the anmals lfe.Perhaps mre s than any ther pan cnd-tn, the management f DJD benefts frm anntegratn f bth pharmaclgc and nn-pharmaclgc treatments. once a dagnss smade, treatment gals, expectatns and ut-cme measures shuld be cnsdered prr tntatng any treatment. The care-gver s anessental part f any treatment prgram andshuld be cnsdered a part f the team.

Canine DJD: therapeutic considerationsBecause early nterventn can delay the nsetand severty f DJD, the Task Frce emphaszesthat chef amng all preventve and treatmentmdaltes fr canne DJD s weght ptmza-tn. Mantanng a lean bdy cndtn frm anearly age demnstrably mnmzes DJD devel-pment n predspsed breeds.129131 in ver-

weght patents, weght lss alne, even a md-est 6.18.85%, mprves clncal sgns f DJD.132There s strng evdence t supprt the use f

NSAiDs fr the management f DJD pan ndgs. Data n the safety and effcacy f lng-term NSAiD admnstratn n dgs appear tsuggest an verall beneft frm ths mdaltyfr a sustaned perd f tme at labeled dsesand ntervals, prvded the patent des nthave addtnal rsk factrs.22 NSAiD therapyshuld be talred t sut every ndvdualpatents needs. Veternary NSAiDs studed fr

chrnc use (between 28 days and 1 year)demnstrated satsfactry safety prfles ndgs, wth 9597% f dgs able t receve therNSAiD at labeled dses and ntervals wthutadverse effects fr the duratn f the study.22

There s currently n evdence that a hgher rskfr NSAiD-nduced adverse effects exsts as theduratn f treatment ncreases. Sme dgs

may requre several weeks f NSAiD treatmentbefre clncal mprvement s nted.133

in addtn t NSAiDs, there are therptns t cnsder. Frst, PSGAGs are mrelkely t have a benefcal effect when gvenearly n the dsease prcess.92 As mentnedearler, an FDA-apprved prduct wthestablshed effcacy and safety s avalable.Secndly, data supprtng analgesa and func-tnal mprvement frm therapeutc exercseare well establshed n humans and are begn-nng t accrue n dgs.134 Thrdly, a systematcrevew analyzng data frm several placeb-cntrlled blnded studes affrmed the utltyf dets rch n ecsapentaenc acd fr dgswth DJD.135 Varus ther strateges can be(and ften are) emplyed, but ther supprt-ng evdence s weak, cnflctng r altgetherlackng at present.

Feline DJD: therapeutic considerationsUntl the early 2000s, lttle attentn was padt DJD n cats; hwever, estmates frm pub-lshed studes suggest that 4092% f all catsmay have sme clncal sgns asscated wthDJD.136 Felne DJD s nw recgnzed as a ser-us welfare prblem, partcularly n lder cats,

whch s a rapdly grwng demgraphc.136,137

The mst frequently affected jnts appear tbe the hp, stfle, tarsus, elbw, thraclumbarand lumbsacral area.137 Fr each 1 yearncrease n a cats age, the expected ttalDJD scre ncreases by an estmated 13.6%.Mrever, there s a dramatc ncrease n theprevalence and burden f DJD at abut 10years f age. A dagnss f felne DJD s basedn a thrugh hstry reflectng changes nbehavr and lfestyle, physcal exam fndngs(image 8), and pssble radgraphc evdence.

Image 8 (a) Muscle wastingover affected legs is acommon sign of DJD, asseen in this orange tabby.(b) Close-up of the frontlimbs of the cat, showingdeformities secondary toDJD. Images courtesy ofIlona Rodan

Perhaps more

so than any

other pain

condition, the

management

of DJD benefits

from an

integration

of both

pharmacologic

and non-

pharmacologictreatments.

a b



14/22



Behavral changes are the mst cmmnsgns f DJD-asscated pan n cats. FelneDJD s usually blateral s, althugh catsrarely lmp, they are lkely t be stff, have aless flud gat, becme less actve (especally atnght) and exhbt decreased jumpng frequen-cy r jumpng heght.138 owners ften ntethat ther cats are very stff gng up r dwnstars. The cat may resst handlng, pettng, rstrkng f the back r lmbs. Shwng thewner a lst f the cmmn pan-related

behavrs caused by DJD s helpful n makngthe dagnss (Table 3).it shuld be assumed that a senr cat has

sme DJD, and every effrt shuld be madet ncrprate gentle handlng technques(images 9 and 10) and padded surfaces fr thecat t le n durng the exam. A pstveclncal respnse t analgescs wll als nd-cate the presence f DJD. The frst valdatedclncal metrlgy tl fr the evaluatn ffelne musculskeletal pan has nw beenprduced and s avalable fr use n practces(see Table 2).139,140

NSAiDs are the manstay f pharmaclgctreatment fr DJD n ther speces, and there scnsderable evdence t supprt ther effec-tveness n cats as well.141145 in the USA, hw-ever, NSAiDs are nt apprved fr lng-termuse n cats, and the ptental sde effects ftendeter many clncans frm rutnely usngthem n cats. Renal txcty s always a cnsd-eratn wth the use f NSAiDs; hwever, neretrspectve study fund that lng-term usef melxcam dd nt reduce the lfespan fcats >7 years f age wth pre-exstng, stablechrnc kdney dsease (CKD) cmpared wthcats wthut CKD.146

Lw-dse melxcam (e, 0.010.03 mg/kgrally q24h) s effectve n treatng arthrtccats and s well tlerated, even n cats wthCKD prvded ther clncal status s stable.145Melxcam s effectve when admnsterednce q24h and s palatable fr mst patents,makng t easy t admnster. in Eurpe,Australasa and many cuntres, melxcam s

apprved fr lng-term use n cats at a dse f0.05 mg/kg q24h. The ral rute f admns-tratn and lng-term use f melxcam ncats reman ff-label n the USA.

Rbenacxb s a CoX-2 selectve NSAiDapprved fr surgcal pan n cats. it has ntbeen studed fr ether felne DJD r n ldercats but there are lng-term safety data nyung cats (e, 5 x the recmmended dsagefr 6 mnths and 10 x the recmmendeddsage fr 6 weeks).147,148

Dsng n lean bdy weght, clse mntr-ng f clncal status (especally appette), reg-ular labratry mntrng, and apprpratelymdfyng the treatment plan are recm-mended fr cats recevng NSAiDs.149 NSAiDsshuld be used wth cautn n a case-by-casebass n cats wth DJD, and cat wners shuldbe advsed that, n the USA, use f NSAiDsfr felne DJD s an extra-label treatment.

Behavioral component Indicators of DJD

Interaction withothers

Withdrawal, hiding, increased clinginess, irritabilitywhen touched, aggression toward other cats or humans

Appetite Declines but cat continues to eat

Posture Hunched, head lowered, sitting or lying abnormally,

squinting, facial expression indicating discomfortGrooming Declines, matting of fur, over-grooming of painful area

Litter box use Decline in bowel movements, house soiling, inability toget into box

Play Reduced overall, reduced jumping

Vocalization Increased but decreased greeting and other pleasantvocalizations, hissing if touched on painful area, squintingif acute pain

Mobility Not jumping as often or as high, hesitant to jump, difficultygoing up or down stairs, stiffness, less active, difficultygetting into or out of litter box, sleeping in more easilyaccessible locations

Table 3 Signs of degenerative joint disease (DJD) in cats

Image 9 Since DJD isubiquitous, can occur in catsof all ages, and can bedifficult to detect, everyeffort should be made toincorporate gentle handlingtechniques for all cats. Forexample, gently pushing thefront leg forward frombehind the humerus, insteadof pulling on the front foot,will help to prevent elbowpain. Courtesy of Ilona Rodan

Image 10 Instead ofstretching and pulling hindlegs back tightly, gentlyplace one or more fingersbetween the hind feet andhold without stretching.This prevents exacerbationof lumbar, lumbosacral, kneeand hip pain. Courtesy ofIlona Rodan

It should be assumed that a senior cat

has some DJD, and every effort should be made

to incorporate gentle handling techniques.



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Treatment f DJD n cats shuld fcus nenvrnmental mdfcatn (images 11 and12) n addtn t pharmaclgc therapy. inaddtn t steps and ramps t facltate accesst favrte elevated areas, addtnal ltterbxes wth at least ne lw sde wll makeaccess easer. owners can als prvde phys-cal therapy by mplementng play tmesusng favrte tys t ncrease exercse andmblty.

When pain persists: hospiceand palliative care

Hspce s desgned t prvde cmpassnatecmfrt and care t patents at the end fther lves and t supprt ther famles nthe bereavement prcess. Hspce care frtermnally ll patents s recmmended when

lfe expectancy s less than 6 mnths.Pallatve care s the actve, ttal care fpatents wth dsease that s nt respnsve tcuratve treatment, wth pan cntrl bengthe paramunt feature. The gal s acheve-ment f the best qualty f lfe (QL) frpatents and ther famles. Ths assumesngng assessment f QL n the termnallyll patent. User-frendly QL assessmentscales are avalable t help veternarans, vet-ernary staff and wners make prper assess-ments and decsns at the end f a patentslfe.150 it s generally agreed that the petscare-gver s best suted t evaluate QL, buta team apprach (dscussed n page 266)emphaszng regular cmmuncatn smprtant t prvde empathetc supprtwhen end-f-lfe decsns are made.

An ntegrated apprach that ncludes nn-pharmaclgc mdaltes s typcally bestfr pallatve care and hspce patents wthcancer because ther dsease s ften asscat-ed wth features f bth acute and chrncpan. in cases f pallatve radatn, ether asmaller number r lwer dses f radatncan make treatment prtcls mre tlerablefr the patent and agreeable t the wner.

Image 12 The gray and white cat in (a) is seen as gregarious and is choosing to climb to higherlocations. Image (b) shows the same cat with DJD and the inability to jump. Provision of a stepallows the cat in image (c) to perch in a favored place. Images courtesy of Sheilah Robertson

Image 11 (a) Note this catsuncomfortable stance whileeating caused by DJD.(b) Raising the food ontoa low shelf allows the catto sit normally and eatcomfortably. Images courtesyof Margie Scherk

Envrnmental mdfcatn, physcal therapy(eg, massage, acupuncture and therapeutclaser) r ultrasund can be useful addtns tthe pan management plan. Prvdng nutr-tnal supprt va feedng tube can be helpfulwhere eatng s therwse dffcult r panful.

in cases nvlvng hspce and pallatvecare, t s mprtant t encurage clents thave realstc expectatns f the utcmesnvlvng ther pets. As well as explanatnsf prbable utcmes, ths nvlves prvdngthe clent wth end-f-lfe chces nvlvngthe pet. Euthanasa s an ptn that relevespan and sufferng and shuld be dscussed asa reasnable and humane alternatve at anapprprate pnt. Euthanasa may be a tpcthat the veternary team ntates f the petwner des nt.

Euthanasia is an option that relieves pain and

suffering and should be discussed as a reasonable

and humane alternative at an appropriate point.

a b

cba



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A team approach and clienteducation: creating anenvironment for success

Primary care practices should be committedto educating the healthcare team and itsclients about prevention, recognition, assess-ment and treatment of pain. A team approach

and consistent pain management messagesdirected at clients will help ensure patientcomfort at all stages of treatment. The client isoften considered the most important memberof the healthcare team.

Each healthcare team member should beable to recognize pain-associated behavior inanimals, as described earlier in theseGuidelines, and know how to respond appro-priately. Table 4 provides examples of howhealthcare team members should respond topatients experiencing pain.

Staff training and education

Ideally, every healthcare team member shouldhave a defined role in managing animal pain.Staff and client education should address con-ditions associated with pain; its preventionand treatment; and appropriate interaction,handling and nursing care involving thepatient. Medical rounds and staff meetings areeffective tools in making sure that all staffmembers are aware of the individualized painmanagement needs of every hospitalizedpatient. Having a patient advocate for eachhospitalized animal will enable a highly accu-rate and individualized evaluation of the

patient and ensure successful treatment.Recall that Table 1 lists pain indices relyingon observation and input by clinical person-nel. Those assessment tools complement thepain-scoring instruments based on ownerobservation and input, which are listed inTable 2.

Client education and instructionsWith each pain management plan, it is impor-tant that the client be given specific instruc-tions, both verbally and in writing. Potentialadverse drug effects and action to be takenshould be emphasized. It is advisable to

provide a hands-on demonstration of how toadminister medications and handle the pet athome. To reinforce verbal information aboutpain assessment, provide handouts that dis-cuss general information about animal painand any side effects of medications.Compliance will improve if the pet ownerunderstands the treatment schedule and ademonstration of how to administer oral med-ications is given. Clients should be encour-aged to address their concerns about the petscondition and treatment plan via e-mail,phone or follow-up consultations.

Acknowledgements

These Guidelines were prepared by a TaskForce of experts convened by the AmericanAnimal Hospital Association and theAmerican Associationof Feline Practitioners.TheAAHAsecuredsponsorship ofan educa-tional grant in accordance withtheir policiesfrom Abbott Animal Health, ElancoCompanion Animal Health, Merial, NovartisAnimal Health and Zoetis. This report wassubjected to review in accordance with bothAAFP and AAHA policies.

Funding

These Guidelineswere supportedby an edu-cational grantto AAHA from Abbott AnimalHealth, Elanco Companion Animal Health,Merial, NovartisAnimalHealthand Zoetis.

Conflict of interest

Mark Epstein has previously consulted forAbbott, Elancoand Merial. Sheilah Robertsonis a key opinion leader for Novartis AnimalHealth.

Ideally, everyhealthcare

team member

should have

a defined role

in managing

animal pain.

Veterinarian

Assess pain in every patient regardless of appointment type(eg, wellness, sick, follow-up)

Develop standard operating procedures for the practice to prevent pain,including the following: Weight optimization and prevention of dental disease Handling and hospitalization to prevent fear and pain

PLATTER (see Figure 1) to follow up and modify plan

Provide staff education on: Effective client communication and education Preventive pain strategies Recognition and assessment of pain Drug interactions and adverse effects

Technician

Obtain medication history

Anticipate painful procedures

Recognize signs of pain and alert veterinarian

Treat as directed by a veterinarian and update records

Assess postoperative patients and record pain score

Assess chronic pain patients and record pain score

Maintain effective client communication and education

Patient-care

personnel

Prior to examination: Note possible causes of pain Note any patient behavioral changes

During the examination: Proper handling Other stress/anxiety-relieving techniques

Following the examination: Monitor patients behavior Contact client about questions or concerns Set follow-up appointment

Housing should be stress/anxiety-relieving

Table 4 Healthcare team member responsibilities for

pain management



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ApprovedNSAIDs

Otheranalgesicdrugs

Opioidpremedtra

nquilizer/sedative

Localand/orregionalanesthetic

Chondroprotectants

(GAGs)

Acupuncture

Therapeuticjointdie

ts

Therapeuticexercise

Weightmanagement

Lifestyle/environmen

talchange

Optimalsurgicaltec

hnique

Patientwarmingper

ioperative

Othernon-pharmainterventions

Comments/details

DJD dog X X X (1) X X X X X X X

DJD cat (with CKD) X (2) X X (1) X X X X X X X

Soft tissue abdominalsurgery

X X (3) X X X X X X

Dental surgery X X (3) X X X X X X

Orthopedic procedure X X X X X (4) X X (4) X (4) X (4) X (4) X X XHospital procedures:

IV catheterization X (5) X (8) X (6) X Consider localanesthetic cream

Urinary catheterization X X (9) X (10) X (6) X X

Bone marrow aspiration X X (9) X X (6) X X Consider generalanesthesia

Radiography (painfuland/or arthritic patient)

X (9) X

Anal sac expression X (9)

Ear cleaning X (7) X (7) X (7) X Consider generalanesthesia for deepear cleaning

Thoracocentesis and/orabdominocentesis

X X (9) X X (6) X

Notes:1 Local or regional analgesia may be useful in localization of pain and short term relief of significant DJD pain2 See discussion on pages 256258 concerning the use of non-steroidal anti-inflammatory drugs (NSAIDs) in cats3 The addition of other analgesic drugs will depend on patient characteristics and extent of the procedure4 These interventions will be helpful pre- and postoperatively for the relief and/or prevention of postoperative and chronic pain5 Ideally premedications should precede other preparations for general anesthesia such as placement of an IV catheter6 These are invasive procedures and should be treated as such to optimize patient care and minimize trauma/tissue damage and post-procedural pain7 The level of intervention will be tailored to the invasiveness of the procedure. Deep ear cleaning will require more significant intervention than

superficial cleaning in most cases8 In non-emergency settings (eg, routine pre-surgical application)9 Chemical restraint in lieu of manual restraint when patient is fractious, distressed or otherwise intolerant of the procedure10 Sterile lidocaine lubricant; caution in cases of urethral or bladder mucosal damageGAGs = glycosaminoglycans, CKD = chronic kidney disease, DJD = degenerative joint disease

Summary of appropriate interventions for pain in dogs and catsTable 5

Abbreviations used in the GuidelinesAAHA American Animal Hospital Association

AAFP American Association of Feline Practitioners

CKD Chronic kidney disease

CMI Clinical measurement instrument

CRI Constant rate infusion

COX Cyclooxygenase

DJD Degenerative joint disease

GAGs Glycosaminoglycans

GI Gastrointestinal

IM Intramuscular

IV Intravenous

MPS Myofascial pain syndrome

NSAID Non-steroidal anti-inflammatory drug

OA Osteoarthritis

PSGAG Polysulfated glycosaminoglycan

SS(N)RI Selective serotonin (norepinephrine) reuptake inhibitor

SC Subcutaneous

TCA Tricyclic antidepressant

QoL Quality of life



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Effective pain management is an essential component of companion animal medicine. It reduces

disease morbidity, facilitates recovery, enhances quality of life, and solidifies the relationship between

the veterinarian, client and pet.

Behavioral changes are the principal indicator of pain and its resolution, for which there are now several validated

clinical scoring instruments.

Pain is not an isolated event but instead exists either as a continuum of causation, progression and resolution or as a chronic

condition. Thus, treatment of pain should consist of a continuum of care in the form of anticipatory analgesia through the

anticipated pain period followed by longer term or even chronic treatment that relies on periodic reassessment of the

patients response.

Effective pain management is integrative in two respects. First, it does not rely solely on pharmacologic methods but also

uses a variety of non-pharmacologic modalities; not least of those is gentle handling and nursing care of the patient in the

context of a stress-free physical environment. When considering either non-pharmacologic methods or hospice care that may

be outside the immediate skills or services provided by the primary practice, the veterinarian should have a list of experts for

referral in place. A second aspect of integrative pain management is the multimodal use of medications that either block or

modify multiple pain pathways. A multimodal approach also reduces reliance on any single agent, minimizing the potential

for adverse drug events.

Pain management in clinical practice is a team effort, with the pet owner functioning as an integral part of the team.

All healthcare team members should have a defined role in the practices approach to providing compassionate care to

its patients. That enables the practice to speak with one voice and in a consistent manner in the implementation of pain

management protocols.

Client education is a key component that enables the pet owner to manage pain in the home setting. Direct involvement

of the client in pain management efforts is consistent with the continuum of care concept and a demonstration of the

practices commitment to the pets quality of life.

A fully integrated approach to pain management, involving recognition and systematic assessment, pharmacologic and

non-pharmacologic methods, and including both healthcare team members and the pet owner, ensures that everything

possible has been done to relieve a patients pain once it enters the practices care.

SUMMARYPOINTS

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Pain Guidelines 2015 Epstein 251 72

Documents