Date
Published: 11/22/2004 10:47:00 AM
This work was originally published by Veterinary
Information
Network, Inc. (VIN) and is republished with VIN's permission.
**************************
Pain Drugs
for Dogs: Be an Informed Pet Owner
A decade ago, few drugs
were available to treat pets in pain at home. Pups were spayed or neutered
at the animal hospital, stitched up, and sent home without pain medication.
And dogs with painful arthritis limped along without drugs that were
safe and effective for long-term use.
Today, a new generation of nonsteroidal anti-inflammatory drugs
(NSAIDs) is bringing relief to millions of dogs with joint problems
or with pain after surgery.
"NSAIDs are extremely effective for controlling pain and inflammation
in dogs," says Stephen F. Sundlof, D.V.M., Ph.D., director of the Food
and Drug Administration's Center for Veterinary Medicine (CVM). "These
are very valuable drugs that help many pets live to a ripe old age."
But like any drugs, NSAIDs carry a risk of side effects, or adverse
reactions. Most adverse reactions are mild, but some may be serious,
especially if the drugs are not used according to labeled directions.
Some reactions result in permanent damage or even death.
"It's important for pet owners to be aware of the risks and benefits
of all drugs, including NSAIDs, so that they can make informed decisions
about their pets' health care," says Sundlof. "Owners who give their dog
NSAIDs need to know the side effects to watch for that indicate their
pet needs medical attention."
The most common side effects from NSAIDs include vomiting, loss
of appetite, depression, lethargy, and diarrhea. Serious side effects
include gastrointestinal bleeding, ulcers, perforations, kidney damage,
and liver problems.
"The side effects of NSAIDs are very well known and very well
documented," says Michele Sharkey, D.V.M., in the CVM's Office of New
Animal Drug Evaluation. But this information is not always getting to
the pet owner, she says. "If the pet owner can recognize a possible reaction,
stop the medication, and get veterinary help, it could mean the difference
between a good outcome and a disaster."
Safety and Effectiveness
The CVM, which regulates drugs for use in animals, has approved
some NSAIDs for use in dogs with pain from degenerative joint disease
(osteoarthritis) or with pain after surgery. These include Etogesic
(etodolac), Rimadyl (carprofen), Metacam (meloxicam), Zubrin (tepoxalin),
Deramaxx (deracoxib), Previcox (firocoxib), and Novox (generic carprofen).
NSAIDs help to control signs of arthritis, including inflammation,
swelling, stiffness, and joint pain. Inflammation--the body's response
to irritation or injury--is characterized by redness, warmth, swelling,
and pain. NSAIDs work by blocking the production of prostaglandins, the
body chemicals that cause inflammation.
The FDA considers approved NSAIDs to be safe and effective when
used according to the label and when dog owners are informed about common
NSAID adverse reactions.
And veterinarians are becoming increasingly aware of the advantages
of recognizing and controlling pain, says Charles Lemme, D.V.M., a member
of the American Veterinary Medical Association (AVMA), Clinical Practitioners
Advisory Committee. "We recognize that pets are healing better and faster
with pain control."
Lemme says that the emphasis on pain management may be partly
because of the availability of the newer NSAIDs. "The NSAIDs we have
available now are a lot safer than what we've had before and we're seeing
far fewer side effects than before."
Before the newer generation of NSAIDs came along, "people were
using NSAIDs such as aspirin in an attempt to mitigate arthritic pain,"
says Michael Andrews, D.V.M., president of the American Animal Hospital
Association (AAHA). "We saw the consequence of their use," adds Andrews,
who recalls seeing a client who gave her dog aspirin for six weeks, two
times a day. "The dog had a bleeding nose that wouldn't stop."
"NSAIDs are used in many, many dogs and the frequency of problems
is quite low," says Andrews. "The duration of use makes a difference
in safety. If used for a day or two, the risks often are much lower than
when used over long periods of time for a chronic arthritic condition."
Drugs used to control pain should be given only when necessary,
and in the smallest dose that is effective, says Sharkey. "Arthritis
waxes and wanes. Some animals get worse in cold weather. If the dog seems
to improve to the point of not needing the drug, the owner should discuss
continued use of the NSAID with a veterinarian."
An owner should never give an NSAID to a pet, or increase the
dose or frequency of a drug, without the veterinarian's instructions,
adds Sharkey. "Just like different people respond differently to a drug,
the way each dog responds to an NSAID varies." Because of this individual
response, no one NSAID is considered more effective than another, and
because every NSAID can cause adverse reactions, none is considered
safer than others.
If a pet is prescribed an NSAID, the CVM recommends that pet owners
take the following steps to make sure they are fully informed about
the drug and can make the best decision for their pet's health.
Ask Questions and Tell All
Ask your veterinarian about the benefits, risks, and side effects
of any medication, including NSAIDs. "An informed dog owner is the best
defense against serious side effects from NSAIDs," says Sharkey. "Owners
should not hesitate to ask questions and inquire about possible side effects
or signs to watch for when treating a dog."
Tell your veterinarian your pet's symptoms and current medications,
including prescriptions, over-the-counter drugs, vitamins, herbal supplements,
and flea control products. Giving NSAIDS and other medications together
could harm your pet. Aspirin, for instance, may be in a supplement you're
giving to your pet, says Sharkey, and should not be used in conjunction
with an NSAID.
Ask for the Client Information Sheet
Pet owners should receive a "Client Information Sheet" with every
NSAID prescription. Client Information Sheets, also called "Information
for Dog Owner Sheets," are user-friendly summaries that explain the
results to expect from using the drug, what to discuss with your veterinarian
before giving the drug, possible side effects to look for, and other important
information. The FDA has helped the pharmaceutical companies who make
NSAIDs for dogs develop these sheets for the owners, and the companies
provide them with each NSAID they ship.
Ask your veterinarian for the sheet if you do not receive one,
and read the information carefully before giving the medication to your
dog. If your veterinarian can't provide the Client Information Sheet,
you can get one by printing it from the CVM's Web site or by calling the
toll-free number of the drug company.
Bernadette Dunham, D.V.M., Ph.D., deputy director in the CVM's
Office of New Animal Drug Evaluation, explains why some veterinarians
may be unable to locate the Client Information Sheet. "They often have
the role of veterinarian and the role of pharmacist," she says. Veterinary
hospitals get shipments of drugs from the pharmaceutical companies or distributors.
Then they may repackage the drug in their hospitals' bottles, often in
smaller quantities for distributing to clients. In the repackaging process,
the Client Information Sheet, which is often printed on the package insert
for the veterinarian, may be tossed out inadvertently.
The FDA, the veterinary community, and the pharmaceutical companies
are working together to ensure that NSAIDs are used safely and responsibly
and that owners are given the Client Information Sheets.
"The pharmaceutical companies are trying to come up with creative
ideas to make it easier for busy veterinarians," says Dunham. Many companies
are making the Client Information Sheet a tear-off sheet that can be
easily separated from the drug labeling.
Some companies also are packaging drugs in smaller quantities
with the Client Information Sheet sealed inside the package. Therefore,
the veterinarian can just attach the hospital label and dosing instructions
on the drug container without repackaging the drug and inadvertently
discarding the sheet.
Through published journal articles, electronic newsletters, and
information posted on their Web sites, both the AVMA and the AAHA are
reinforcing the importance of client communication regarding NSAIDs,
including handing out the Client Information Sheets, to their veterinary
members.
Get the Recommended Tests
NSAIDs approved for use in dogs contain the following information
on their labels:
All dogs should undergo a thorough history and physical examination
before initiation of NSAID therapy. Appropriate laboratory tests to
establish baseline blood values prior to, and periodically during, the
use of any NSAID are strongly recommended.
If the veterinarian recommends a blood test before administering
an NSAID to a dog, don't decline it, advises Sharkey. "There are good
reasons for it." The knowledge gained from these tests could be critical
in deciding whether the drug is safe to use in a dog.
Testing is particularly important with long-term NSAID use, such
as to treat arthritic pain, says Andrews. "It makes sense to do some preliminary
screening blood work and periodic tests to identify any problems and
monitor how well the pet is tolerating the drug over time."
Work With Your Veterinarian to Find the Best NSAID
Many NSAID choices are available, and selecting the best NSAID
for a particular pet is important, says Sharkey. "Sometimes, the process
of finding the best one can mean changing the prescription."
Lynne Heslip of Howell, Mich., tried several NSAIDs on her 4-year-old
Irish wolfhound, O.B., who had painful hip dysplasia. "The first NSAID
did not work well," she says. "Pain relief seemed to be minimal, and she
had vomiting and wasn't interested in eating." Heslip watched her normally
outgoing dog seclude herself behind the kitchen table. "She was severely
depressed. She didn't want to interact with other animals or with people."
Working with her veterinarian, Heslip stopped the NSAID, waited
five days for the drug to clear out of the dog's system, and tried another
NSAID. "Within one week, I noticed a drastic change for the better," says
Heslip. "She was much more animated and happier." O.B. was on NSAIDs for
about three years until her death. Heslip reports that her current 6-year-old
Irish wolfhound, Isabella, is on the same NSAID, with very good results.
Bad Reaction? Stop Medication and Call a Veterinarian
If you suspect an adverse reaction to an NSAID, stop administering
the drug and contact a veterinarian immediately. Some reactions are mild
and go away after stopping the drug.
When giving a pet an NSAID, watch for these side effects, which
are listed on the Client Information Sheet and on the drug label:
Decrease or increase in appetite
Vomiting
Change in bowel movements (such as diarrhea or black, tarry, or
bloody stools)
Change in behavior (such as decreased or increased activity level,
seizure, aggression, or lack of coordination)
Yellowing of gums, skin, or whites of the eyes (jaundice)
Change in drinking habits (frequency or amount consumed)
Change in urination habits (frequency, color, or smell)
Change in skin (redness, scabs, or scratching).
These side effects are the most common. But not all possible side
effects are included on the Client Information Sheet or on the drug
label. Always contact your veterinarian if you have questions about
your dog's medication.
What starts out as a minor problem can rapidly progress to an
emergency. An owner should be encouraged to call his or her veterinarian
with any concerns about the NSAID the dog is receiving. You may even
call the drug manufacturer's toll-free number that appears on each Client
Information Sheet. When problems are experienced with a product, the
manufacturer may have specific recommendations for your veterinarian regarding
tests and treatments.
Cindi Brinkley of Danville, Ill., rushed her dog to the veterinarian
at the first sign of a bad reaction. Maude, a cocker spaniel-collie mix,
injured herself when she was 11 months old while playing with a littermate
in the house. "She slipped on the basement floor coming out of a turn,
and both back legs splayed out," says Brinkley.
Maude was diagnosed with a deformed hip joint and scheduled for
corrective surgery. In the meantime, the veterinarian prescribed an
NSAID for pain control. "I was not told a thing about the drug other
than how to give it to her," says Brinkley.
Maude had been on the drug for a month when Brinkley came home
from work one day to find the dog bleeding from her rectum. "It was very,
very frightening," she says. "The whole back of my dog was bright red--I
thought she was bleeding to death." After treatment in the veterinary
hospital and discontinuation of the drug, Maude recovered from the incident.
Now more than 7 years old, "she has some vomiting and loose stools every
so often," says Brinkley, who suspects the digestive problems may be a
lasting effect of the drug.
Report Bad Reactions
If you or your veterinarian suspects that an adverse reaction
is related to the use of an NSAID or any drug, it should be reported
to the pharmaceutical company. Usually, the veterinarian reports it,
but if the veterinarian doesn't, the owner should. The company, by law,
has to report all adverse reactions to the FDA, which looks for signals
of increased frequency and severity of adverse reactions. The FDA works
with the pharmaceutical firms to address these events and improve the
ability of the product to be more safely used.
If unable to report problems directly to the pharmaceutical company,
veterinarians and owners are encouraged to report veterinary Adverse
Drug Experiences (ADEs) and suspected product failures to the government
agency that regulates the product. Adverse experiences with NSAIDs should
be reported to the FDA's CVM.
Medicate Under Veterinary Supervision
The FDA has approved some nonsteroidal anti-inflammatory drugs
(NSAIDs) for use in dogs. In the United States, there are no oral NSAIDs
approved for use in cats. Veterinarians can, however, legally prescribe
human drugs to animals unless it presents a risk to the public health.
This type of use is known as extralabel, or off-label, for uses not listed
on the label. Extralabel use can also mean prescribing a drug to a different
species, for a different condition, or in a different dosage than that
for which the drug was approved. For example, a veterinarian may prescribe
a lower dose of an NSAID drug approved for dogs to a cat with an inflamed
joint.
But pet owners should not give their own drugs to pets or otherwise
medicate their animals without veterinary supervision, says Michele
Sharkey, D.V.M., in the FDA's Center for Veterinary Medicine.
Different species metabolize drugs differently, she says. "You
take aspirin or Tylenol on any given day for a headache and not think
twice about it, but dogs are more sensitive to aspirin than humans, and
one Tylenol can kill a cat. Pet owners should always work with their veterinarians
to make medication decisions."
Published September 2006 by the U.S.
Food and Drug Administration.
Written by Linda Bren and Dr. Michele Sharkey at the Center for Veterinary
Medicine (FDA).
Used with permission. All rights
reserved.
This work was originally published by Veterinary Information
Network, Inc. (VIN) and is republished with VIN's permission.
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Fortunately this issue of pain management in pets has recently
been a topic of high priority within the veterinary profession. The 2001
AVMA Animal Welfare Forum was presented in October 2001, in Chicago, by
the American Veterinary Medical Association. It was attended by
over one hundred veterinarians interested in developing a better understanding
of pain management in dogs and other animals. It is through these
types of educational efforts that our canine companions will have an
improved quality of life… even though they cannot verbalize when they
are in discomfort.
“Pain is an unpleasant sensory and emotional experience associated
with actual or potential tissue damage.” Pain is very subjective
and difficult to measure. I have seen in my practice numerous occasions
where a dog will hobble in to the hospital, happily wagging its tail
as it holds up a limp and fractured limb! Another dog with the same
type of fracture might be frantically yipping and crying in extreme panic
and pain. One patient obviously needs medication but how does one
judge the pain in the stoic patient?
what type of pain management will you be providing for my dog,
Doctor?” Quite honestly, some surgery cases do not require postoperative
pain management (obviously, to perform the surgery there will be a local
or general anesthetic administered). Wart removal or minor suturing
of a laceration are examples. However, if your dog will be undergoing
major surgery, you can and should inquire about post-procedure comfort
for your dog. According to Dr. Tranquilli there is a wide spectrum
of attention given to pain management among small animal practitioners; there
are some who have consistent pain management strategies and some who do
not.
Opioids… Used for more severe pain, this class of pain relief
medication includes morphine, codeine, Demerol and other prescription
products. Used in advanced cases of cancer or severe arthritic
pain, opioids do have a place in selected cases where the quality of
life for the dog can he maintained. (Although not opioids, some
antidepressant medications such as Amitriptyline may be used to treat
severe chronic pain.)