Multimodal treatment of canine osteoarthritis (Sponsored by Hill's and Novartis)

Dr. I. Craig Prior: I'd like to welcome each of our participants to this panel discussion on multimodal management of canine osteoarthritis. The foundational pieces of this treatment should include:

• nonsteroidal anti-inflammatory drugs (NSAIDs)

• a pet food rich in eicosapentaenoic acid (EPA)

• chondroprotective injectable polysulfated glycosaminoglycan (PSGAG).

The ultimate goal of a multimodal approach is to provide the maximum quality of extended life with a minimal effective dose of pharmacologics. The optimal multimodal approach is an overlapping of medical and nonmedical management.

NSAID ADMINISTRATION

Dr. Steve Fox: A common challenge in treating dogs with osteoarthritis is deciding where to start. Do you start with an NSAID? Do you start with pet food? Almost all treatments, except maybe the NSAID, will take three to four weeks before we will see a clinical response. But the owner typically wants to see a response within 48 hours. In reality, you need to start with all aspects of treatment simultaneously to improve the animal's comfort and slow the progression of the disease. It's also important that the owner feels the pet received appropriate care.

The cornerstone of managing osteoarthritis is NSAID therapy. I do not see any pharmacologic agent taking the place of NSAIDs for quite some time. The aging animal may have compromised renal and hepatic function, so you strive to administer a drug that is not going to further compromise those physiologic functions. One tenet of a multimodal approach is administering the minimal effective dose of the most effective NSAID.

Dr. Robin Downing: If the patient is a candidate for an NSAID, I think most of us would start with the FDA-approved dose, and move down from there. We want to implement multiple treatment strategies so that over time we can reduce drug doses. In our practice, we do not have a target dose. Our goal is to use the minimal amount of the most effective drug to get and keep a patient comfortable.

Dr. Robin Downing

Dr. Michael Reems: Start the dog on the drug as early as possible. I see many patients that have been diagnosed with an osteoarthritic condition and have chronic lameness and discomfort, but are only on a nutraceutical. Owners may fail to perceive the persistent lameness as pain, veterinarians may not be aggressive enough with treatment, and there may be failure to follow up. The sooner the pain is under control, the sooner you can start physical rehabilitation and continue with other modalities that will help reduce the NSAID dose. On the other hand, I think discontinuing an NSAID without appropriate follow up gait and orthopedic evaluation is less than ideal.

Dr. Darryl Millis: Nearly all pharmacokinetic studies on approved NSAIDs have been done on animals that are 1 year of age or less. In practice, however, veterinarians are frequently faced with geriatric patients with osteoarthritis. With this kind of patient, you have to factor in changes in liver function, renal function, and gastrointestinal absorption—all of which deteriorate with age. I start with the label dose for a middle-aged or younger patient. If a patient is already compromised, I adjust the dose based on liver function and renal tests.

We typically think an NSAID yields its response within five to seven days, but in one trial improvement continued throughout the six week study. If we reduce the dosage too early, we may not see a maximal effect. Once we have the maximum effect, I slowly decrease the daily dose as opposed to changing the dosing interval. It makes more sense to avoid the fluctuations seen with every-other-day dosing.

Prior: According to a JAVMA article on the use of NSAIDs and adverse drug events, 93 percent of such adverse events are iatrogenic and due to irresponsible use.1 I have strict protocols in my practice: All animals undergo blood work before they receive an NSAID, two weeks after beginning NSAID treatment, and every six months thereafter. Patients do not get refills unless this happens. Also, I take several steps to ensure that patients are not given multiple NSAIDs, steroids, or aspirin at the same time.

Key points

Fox: We tend to be cavalier about the administration of NSAIDs, which are powerful drugs. Many veterinarians add other drugs to an NSAID, with no evidence on which to base that decision. A perfect example is sending a dog home on tramadol and an NSAID when we know nothing about the kinetics, safety, or efficacy of a tramadol/NSAID combination. Responsible use means being aware of the interaction of drugs you are using with NSAIDs.

Millis: We rarely discuss adverse events that occur with the extralabel use of drugs. When veterinarians combine extralabel drugs with FDA-approved drugs and an adverse event occurs, the blame is frequently placed on the FDA-approved drug.

Dr. Mark Epstein: We know from informal surveys that 30 to 40 percent of owners give their dogs over-the-counter aspirin from time to time. Dr. Millis' studies at University of Tennessee demonstrate that it can be effective in an experimental model of stifle osteoarthritis,2 but serious complications can arise when the veterinarian is not aware that a dog is taking aspirin and then recommends an NSAID.3,4 It is up to us to ensure that the patient has not been, or ever will be, on aspirin, glucocorticoids, or any other over-the-counter product that has COX-inhibiting activity (and there are several) when prescribing one of the veterinary NSAIDs.

Fox: The clinical effects of all multimodal treatments should become apparent within three to four weeks of their initiation. At that point you can reduce the NSAID dosage. Though we all agree that it's important to get to the minimal effective dose, how many of us actually decrease the NSAID a month later? I think the answer is virtually no one. The concept is embraced, but the execution is lacking.

Prior: Veterinarians can get stuck on label doses. They think if a label dose is halved, it isn't going to work. In my practice, our preferred NSAID is deracoxib (Deramaxx®—Novartis Animal Health). There is a dose range on the label, so I can easily show my veterinarians that when a dog is doing well they can reduce the dose from 2 mg/kg to 1 mg/kg.

Dr. I. Craig Prior

Epstein: If you begin therapy for osteoarthritis aggressively then you may be able to taper down not just the NSAID, but any of the other treatment modalities as well. Over a long period, the patient may be well managed with increasingly less intervention, including NSAIDs. In primary care, a typical presentation may be a 70-lb, 11-year-old Labrador retriever that isn't jumping into the truck anymore. It would not be uncommon for the owner to report that the animal is not in pain; however, we as the medical professionals need to recognize from the outset that the dog is likely to be uncomfortable and weak from long-term osteoarthritis. In such cases, NSAIDs play an important first-line role.

They can prove to the owner that the osteoarthritis is there when the patient improves in a short period of time. This opens the door to other techniques that can, over time, reduce NSAID use. So we use NSAIDs as a tool to demonstrate the problem and the potential for improving it.

As safe as they are, they must be prescribed quite cautiously and carefully. They are amazing drugs and have helped many patients that we couldn't have helped 15 years ago. But they are NSAIDs and it is incumbent upon us to use them responsibly, especially in older patients, and to limit the cumulative doses that these patients receive.

Dr. James Roush: I almost always try to reduce NSAID dosages. Once a patient has been on a chondroprotectant or EPA-rich pet food for a period, then maybe we can reduce the NSAID dose and the client's cost.

Key points

Prior: Hill's Prescription Diet j/d Canine is the only therapeutic pet food clinically tested to allow veterinarians to reduce NSAIDs by 25 percent and get the same effect on pain and inflammation. As an added benefit, clinical evidence shows that the combination of NSAIDs and j/d Canine also slows cartilage loss, in comparison with using NSAIDs alone.

Roush: I tell clients that if your pet needs it, it may stay on an NSAID forever. An EPA-rich pet food might make it possible to come off the drug entirely, however.

Dr. James Roush

AN EPA-RICH PET FOOD

Prior: As mentioned, another foundation of multimodal is an EPA-rich pet food. The Prescription Diet j/d food is the only EPA-rich pet food backed by evidence-based medicine.5,6

Roush: Based on the patients I see and my research background, the first thing that I recommend when sending a patient with osteoarthritis home is an EPA-rich pet food. I use NSAIDs in the initial period, especially for dogs with acute pain, but my long-term goals are to get patients to lose weight and eat an EPA-rich pet food. I want to be able to taper the NSAIDs and other drugs down to nothing. Compliance is a big advantage of the EPA-rich pet food. I am more certain that owners will feed the food every day than remember to administer pills at the correct dosage. With older patients, I also know the food is not going to adversely affect their renal function or other vital functions.

Epstein: In fact, it may help it.

Fox: Because the popular press has heralded glucosamines and chondroitins, there is a misconception that it is the glucosamine and chondroitins that are in these foods that yield the positive results. There are virtually no data suggesting that dietary nutraceuticals other than EPA are efficacious. Glucosamine and chondroitin in commercial foods are at levels far below the level we would treat these animals. We need to educate clients about this so they don't go to a nutrition store and think they are getting a cheaper source of the wrong agent.

Key points

Epstein: EPA came on the market as an anti-inflammatory for the skin. Over the years, there has been casual use of it for all kinds of inflammatory conditions, including osteoarthritis. In people, the evidence is sound that it improves inflammatory joint pain.7 The difficulty is the amount you have to give to achieve the clinical effect. It would require giving a much larger amount of supplements daily, which is not practical. The only practical way to achieve the clinical effect with EPA (from the standpoint of cost and client ease) is through pet food.

Dr. Mark Epstein

Prior: I've advised clients that they would have to give their pets anywhere from 36 to 144 capsules to get the equivalent amount of EPA in Prescription Diet j/d, at a cost of $4 to $16 per day. I urge them that since you have to feed your dog anyway, let's feed them something the pet will enjoy with scientific evidence behind it that costs less than $1 per day for a 20-lb dog.

PSGAG ADMINISTRATION

Prior: Adequan® Canine (Novartis Animal Health) is the only FDA-approved* chondroprotective drug. Many people categorize it as a nutraceutical, but veterinarians need to strongly stand behind it as an FDA-approved drug.

Key points

Fox: One of the biggest problems with nutraceuticals is they are not regulated in terms of content, safety, and efficacy. The lack of regulation opens the door for any less-than-quality operation to enter the market. That is one of the reasons why an FDA-approved product has such great value. Although Adequan is labeled as a chondroprotectant, research suggests that the product also has pronounced analgesic qualities.8

Prior: Adequan is an important drug in my practice because it is chondroprotective. I tell clients that I am trying to save what cartilage is left.

Downing: Veterinarians have an obligation to educate their clients that we are trying to salvage tissue that exists; we cannot replace tissue that has been lost.

Reems: I like to treat acute arthritis or joint injury cases aggressively. For example, within a couple of weeks of an acute cruciate injury, there will be significant inflammation in that joint. You will see some changes in the synovial fluid, matrix, and chondrocytes, and you'll start to get cartilage lesions that could become severe with persistent arthritis. Veterinarians need to know Adequan injections can be administered as early as the problem is diagnosed, provided no contraindications exist, in addition to other modes of therapy, in order to slow progression of the disease.

Dr. Michael Reems

Millis: Don't wait to administer Adequan until the patient is severely affected. We cannot wait for end-stage cartilage disease. Adequan has excellent anti-inflammatory properties, in terms of its ability to reduce the level of metalloproteinases (MMPs), which are important in breaking down the cartilage matrix. Adequan can drop those MMP levels back to normal, in contrast to untreated animals in which those concentrations skyrocket. In addition, the degenerative process is slowed histologically. Whenever I see a fairly young patient with early hip or elbow dysplasia or an acute or even partial cruciate rupture, I recommend starting those patients on disease-modifying drugs such as Adequan instead of waiting.

Fox: Anatomically, it should not be a surprise that Adequan has analgesic properties. The synovial lining, the intima, is only two cells thick, and immediately below that are free nerve endings. In osteoarthritis, you have all kinds of MMPs in the synovial fluid, only two cells removed from free nerve endings and nociceptors. Suppress that and you have analgesia.

Key points

Millis: Canine cartilage is generally much thinner than human cartilage. We might expect dogs to show the gradual progression of arthritis we see in our own bodies, but things move along much more quickly in our patients. In a knee, for example, it may take five to 10 years to develop the same amount of osteoarthritis histologically and radiographically in a person that you would get in under a year in dogs.

To keep dogs active longer and maintain a healthy life, we need to intervene early and aggressively. In addition to altering the biochemistry of osteoarthritis, Adequan has clinical effects, improving the comfortable range of motion and reducing lameness.8

Prior: Other foundations for a multi - modal approach for canine osteoarthritis are weight control, physical rehabilitation, and adjunct medications.

WEIGHT LOSS AND CONTROL

Fox: If you put animals on restricted caloric intake, it not only decreases the progression of osteoarthritis—it extends the animal's life.

Dr. Steve Fox

Roush: We cannot overemphasize the importance of reaching a healthy weight in any animal with osteoarthritis. Many osteoarthritis patients are obese, so starting a weight loss program to achieve a healthy weight is an important treatment recommendation in regard to long-term management of the osteoarthritis patient.

Prior: With every physical exam, I would also like to see a dietary consult done and a body condition score assigned. If we could achieve that, we are going to get somewhere because now we are discussing the best therapeutic pet food for a patient. If a body condition score was done on every patient on every visit, we would also be addressing the obesity problem.

And if the pet's food isn't working, we may decide to prescribe dirlotapide (Slentrol®—Pfizer Animal Health). It is safe to use with NSAIDs and nutraceuticals do not affect its performance or safety.

We counsel clients the day animals are spayed or neutered to reduce caloric intake by 25 to 30 percent to prevent obesity.9,10

Downing: Study after study in people shows that symptoms of osteoarthritis will resolve in up to 75 percent of subjects who do nothing more than lose weight. Take the weight off and symptoms improve.

Key points

Epstein: When it comes to implementation, however, weight loss is one of the most challenging things to accomplish. Weight-control and weight-loss programs are exceedingly difficult. But it is more imperative than ever to deal with obesity. Historically, we have had the assumption that obesity is bad for joints because of the increased mechanical load. However, within just the last few years, adipose tissue has been revealed to be the body's largest endocrine organ and to produce a constellation of proinflammatory cytokines.11 These cytokines bathe the entire body in a kind of pro-inflammatory soup, detrimental to almost every tissue, including cartilage. Therefore to treat osteoarthritis in obese patients, the weight must come off. There is simply no substitute.

Millis: In my opinion, weight loss is the primary management tool in treating osteoarthritis. The difficulty, as Dr. Epstein said, is client compliance. Administering pain medication will help the animal move better, which can help it burn calories. We know that if we simply restrict calories that the body slows metabolically and is less efficient in burning them. In our practice, we like to estimate the patient's ideal body weight based on body condition scoring charts and the calories in the pet's food, and then we break down the total recommended daily caloric intake into four equal portions. Those portions are fed throughout the day. After two of those meals, we recommend 20 to 30 minutes of low-impact exercise. One of the best activities is consistent leash walking in which the heart rate is raised and the pet enters the metabolic fat burn stage. Underwater treadmill activity is also wonderful if it's available. I think the combination of weight loss, exercise, and pain control is critical.

Dr. Darryl Millis

ADJUNCT THERAPIES

Reems: My goal is to get osteoarthritis patients that have had surgery started with physical rehabilitation as quickly as possible. It is important to be aggressive initially and apply the multimodal components of analgesia so you can do the range of motion exercises and massage a couple of days after surgery. Preemptive analgesia followed by an epidural prior to surgery, and an analgesic continuous rate infusion (CRI) during surgery is very beneficial for the patient and veterinary team postoperatively. In addition, a local joint block prior to the arthrotomy or at the end of the surgery is routine at our hospital and provides excellent analgesia. We continue the CRI for 12 to 24 hours postoperatively. Cryotherapy of the affected joint is performed to reduce inflammation and swelling and provide analgesia. Although many administer injectable NSAIDs preoperatively, if no significant hypotension existed during the procedure, we administer an injectable immediately postoperatively. Aggressive perioperative pain management is the key so that we can get the osteoarthritic patient started on rehabilitation as soon as possible.

Downing: The International Veterinary Academy of Pain Management (IVAPM) is an organization of individuals from all walks of veterinary life dedicated to pain management in veterinary patients. We hope to drive more research toward multimodal management of chronic and acute pain so that we can make good decisions. Unfortunately, we often have to extrapolate from human medicine, even though we know that dogs are not small people.

Epstein: For osteoarthritis patients in the long term, no matter what tools you might use, whether pharmacologic or non-pharmacologic, the idea is to eventually use less of them. That includes drugs like amantadine and gabapentin.

Fox: Many adjunct drugs probably will never be licensed for use in veterinary medicine. It is in nobody's commercial interest to do so. It is imperative that if you use these products you understand their mode of action and the individual animal you are treating.

Prior: And, of course, we're talking about extralabel use of these drugs, so the owners must give their informed consent.

Roush: Whether or not drugs get FDA approval, they still need to be studied. We need evidence on which to base decisions.

IDENTIFYING OSTEOARTHRITIS AND DESIGNING A TREATMENT PLAN

Roush: We need to educate our clients about clinical signs that show the animal is truly experiencing pain. And we have to convince them that animals do not slow down just because they get old.

Reems: It's very important to ask the right questions to figure out whether geriatric patients are actually having problems. Veterinarians should perform gait evaluations and orthopedic exams when they see geriatric dogs for their annual or semiannual exams.

Millis: Our ability to detect lameness visually is poor. In the rear limbs, most people can see lameness if there is a 5 to 10 percent difference in peak vertical force during weight bearing. In the forelimbs, there may be a 20 to 30 percent difference in weight bearing before there is a head bob or other visual evidence of lameness. We have to put our hands on the animal and palpate it, evaluate range of motion, and check for joint effusion and pain on motion, in addition to gait evaluation.

Downing: We need to teach our clients to think about the pet's daily activities, the pet's relationship with the family, and the family's lifestyle. Sometimes clients notice a change in stamina or a disruption in sleeping or eating patterns. We need to help change the family's perception from, "He can't go cross-country skiing with us anymore because he is old," to "He can't go cross-country skiing with us because he has developed a disability that needs to be diagnosed and treated."

Epstein: There are a number of different disability indexes and scoring systems for evaluating patients. If we could, as a profession, begin to use them systematically, we could assign semiquantitative values to our patients' disability, which would allow us to track cases. If we recognize a problem in the exam room, we know that we have only about 15 minutes of client contact time to talk about so many issues with these older patients. This means that you need to have many conversations about osteoarthritis over time instead of just a few moments at one visit. We need to educate the client that treatment is a marathon and not a sprint. The pet is will have this problem for the rest of its life.

Reems: There are more dogs suffering from elbow or hip dysplasia than are recognized. Maybe we should implement a program so that dogs get an orthopedic exam routinely.

Prior: That is what prompted me to change to semi-annual examinations rather than annual exams. We have one exam for a thorough physical examination, annual immunizations, heartworm testing, etc. The other semiannual exam is for not only another physical, but spending more time rechecking teeth and talking about dental care, diet, and exercise, but also doing a thorough orthopedic exam, which some of us have forgotten how to do.

Downing: In our practice, our technicians capture the preliminary data on travel sheets. We need to do a complete thorough physical exam as well as a metabolic profile because we need to come up with an accurate and a complete diagnosis. Once we have done that, then it is time to make a plan and to put the plan in writing. The written plan becomes part of the medical record so that any other doctor in our practice can pick it up and know our intentions. The client also gets a copy to take home. We know from research that clients remember only about 10 percent of what we tell them in the exam room, and there's no predicting which 10 percent will be retained. So a written plan is important. Also, we schedule the first recheck before the client leaves the practice. We know that we have done our best to get that patient back in and reassessed. Then we're able to do the three Rs of orthopedic pain management (Recheck, Reassess, and Revise).

Prior: So we have a consensus that we start off with a thorough physical exam, and minimum data base. If everything looks good, we start off with an Deramaxx, Prescription Diet j/d, Adequan, and weight loss/control if appropriate.

For better mobility results, take the multimodal approach

EXAMINATION AND FOLLOW UP

Reems: After the treatment plan is initiated, you want to keep recheck intervals relatively short. We usually ask the owner to return in two weeks. We give the owner things to do at home, such as taking the pet on short, frequent leash walks. Then we'll see them in two weeks and start teaching them more rehabilitation techniques.

Prior: At the two-week follow-up visit, you can recheck laboratory work to make sure the dog is tolerating the NSAID. By then the EPA-rich pet food should also be exerting its effect. It takes three weeks before we see improvement from Adequan. You can schedule the next recheck a month from the two-week visit.

Downing: I typically don't begin tapering a drug dose until after four to six weeks because I want the Adequan and EPA-rich pet food to have a chance to work. For a patient that is fairly comfortable, I want to do the first recheck at 10 to 14 days. We schedule weigh-ins in our hospital as no-charge appointments. They are conducted by a receptionist or technician. Those patients don't fall off the radar screen, and it costs me almost nothing. You reward the behaviors you want repeated. That personal contact and attention helps keep them on track.

PHYSICAL REHABILITATION

Epstein: When we treat patients with lameness, we treat them for pain, but the goal of rehabilitation is more broad. We want to treat their disability and return their abilities and mobility to them.

Fox: The term "rehabilitation" has a negative connotation. It suggests the dog has a deficiency. A lot of physical rehabilitation is actually routine activity to ensure normal maintenance of musculoskeletal structures.

Reems: Rehabilitation should be discussed during the initial consultation. Expectations for rehabilitation can be included in the initial estimate or treatment plan in order to improve compliance.

Downing: Rehabilitation is one of the first discussions we have, so clients should not be surprised when we bring it up in more detail the next time they come in.

Prior: When do you like to add in physical rehabilitation?

Downing: As soon as the animal is less painful, from three days to two weeks after the initial treatment. Painful tissues are unhealthy tissues and "working" them can actually create problems. We need to avoid being too enthusiastic with our physical modalities. We tell the client that we are going to break the maladaptive pain and inflammatory cycle and we are going to start the dog on a path to better function and comfort that can be sustained because we are going to build strength as well.

Millis: Physical rehabilitation can encompass a huge range of nonpharmacologic management, from therapeutic exercise all the way to modalities such as heat and cold application.

Exercises need to be split into two areas—joint motion exercises and limb use exercises. Joint motion exercises include passive range of motion or stretching exercises. Joint mobilization exercises such as stepping over the rungs of a ladder and going up and down stairs will target specific joints. The limb use exercises can be broken down into three areas: stamina development for severely affected patients, cardiovascular training, and strength and power training.

Also, strengthening is the key to rehabilitation because osteoarthritis is a disease of the entire joint and not just the articular cartilage. The muscles surrounding joints are important to provide strength and stability and act as shock absorbers. It is vital to rebuild muscle mass in these patients.

Epstein: In primary care situations, if I were to say your pet needs physical rehabilitation, the implication is that the pet needs to be referred to a place where someone is certified in that specialty and that there are no alternatives. In reality, there are activities that are very simple to do for clients who are willing to do them. If you know from the beginning a client is not willing or able to take the dog for a walk, you won't bug him about it. Most clients will agree that rehabilitation is good for the pet if you explain how to go about doing it. With some training and basic equipment of your own, you can implement some appropriate fundamental exercise physiology in your primary care facility—and charge for it.

Downing: How do we prevent primary care providers from thinking they cannot do rehabilitation because they are not certified rehabilitation practitioners and don't have specialized equipment such as an underwater treadmill? Dr. Millis is co-author of a technical text book, Essential Facts of Physiotherapy Rehabilitation and Pain Management. It also has a companion DVD that demonstrates exercises. Practitioners can look at this and say, "This is something I can do, or this is something I can teach my client to do."

Prior: Novartis has a CD-ROM available called, "An Animated Guide to the Multimodal Management of Canine Osteoarthritis." It contains rehabilitation forms and instructions for exercises. I uploaded it onto my server, and my staff can access it from any computer in the practice. They can print out specific exercises for a pet to do at home. What other tools should we be using?

Reems: The Novartis book, An Illustrated Guide to Orthopedic Conditions is a great tool. I use it every day to educate clients.

Prior: Two books written by a couple of our panelists might also be helpful: Multimodal Management of Pain in Osteoarthritis by Dr. Fox and Dr. Millis and Chronic Pain in Small Animal Medicine by Dr. Fox.

The IVAPM also has a website that is worth spending time exploring (www.ivapm.org). It has a wonderful list serve, which is a members-only area to share information and answer others' questions. It also provides a wealth of information and contains up-to-date information on all of these issues.

Epstein: IVAPM is a multi-disciplinary organization and membership is open to technical and nursing staff, as well as DVMs. By joining IVAPM, a world of information will be open to you. There is also a certification process, in addition to membership, so you'll join like-minded people who are knowledgeable and able to help. This is a resource that is unparalleled in our field. It is a great place to get started and stay in tune, not only for you but also for your entire staff.

CLIENT AND SUPPORT STAFF EDUCATION

Prior: Once we recognize that a patient has a disability, we need to start educating the client. In the exam room, we have to make recommendations. What are some client communication points that you think are key to initiating successful patient treatment?

Reems: Owners frequently don't recognize that lameness indicates pain. We have to get that message across to implement a program that results in a healthier patient with a better quality of life.

Prior: To help drive early diagnosis, Novartis Animal Health and Hill's Pet Nutrition have launched a new website, www.TreatDogArthritis.com, which promotes client education and awareness of the signs of arthritis. The site also provides a printable arthritis assessment to accompany clients on their next clinic visit.

Downing: When you manage patients with chronic pain it takes ongoing client education, specific protocols, and monitoring procedures. We need to create a client expectation that there are particular steps that we will go through in treating and managing a pet long term. Some of the key components include reassessments and monitoring, which are not negotiable because they are in the pet's best interest.

Millis: At our rehabilitation clinic at the University of Tennessee, we have an arthritis education room for owners to use. We have models of joints and DVDs about osteoarthritis. We also give owners a three-page list of 19 different treatments for osteoarthritis. We ask them which treatments particularly interest them. We also ask things such as does the pet have difficulty getting up and down stairs. We also ask them to score the severity of that disability and to list the three things that are most troubling for the pet. Those give us some goals to work toward. Although it does take time, this approach to education increases compliance greatly, especially if you keep those rechecks frequent enough to keep them motivated.

Prior: Hill's Pet Nutrition and Novartis Animal Health have also compiled a kit called "The Hill's/Novartis Multimodal Osteoarthritis Program Kit" for veterinary health care teams with useful materials. The kit contains educational interactive tools designed for the entire veterinary health care team, pet owner materials, plus high-value rebates teams can use to help pet owners give their canine companions treatments that will improve quality of life.

Cost and compliance are issues we deal with a lot in veterinary practice. Owners often wonder how much multimodal treatment is going to cost them. Sometimes these people are spending hundreds of dollars a month buying nutraceuticals. When we recommend Prescription Diet j/d, they may talk about the cost. We can tell them that it's still less than buying a specialty coffee once a day and that they don't have to buy the expensive nutraceuticals. They just need to feed the dog something that works.

Downing: Focusing on the added value is where our success lies. Based on cups per day and volume per meal, we calculate what a client's retail cost is going to be per meal. That gives them a real number to think about. And we tell them this pet food will allow us to decrease reliance on other modalities. As the dog becomes skinnier, stronger, and more mobile, we may be able to eliminate some of the ancillary costs of NSAIDs.

Fox: It is incumbent on veterinarians to encourage owners to spend their money where the science is strong.

Downing: Practitioners must create a culture that encourages delivery of this information to the client. People behave how they are trained to behave. If we want our staff to support good client education on pain management, they have to be trained to do that. There are a couple of excellent tools available to us. One is the American Animal Hospital Association (AAHA) book, The Path to High Quality Care, which lays out the findings of the Hill's/ AAHA compliance study.12 To educate our teams about the role of nutrition, there is the free online training program called "VNA—Veterinary Nutritional Advocate," sponsored by Hill's. It has information on nutrition and the small business model in veterinary practice.

Epstein: Dr. Downing is right that we have to create a practice culture that values pain management and physical rehabilitation. That means that the practice leaders have to be committed to this culture, from the top. Once you have agreed on this, it is a matter of creating a consensus within the practice and creating your own protocols and guidelines.

As we've mentioned, IVAPM is a clearing house for information on pain management. If a practice wishes to become a 21st century pain management practice, the tools are out there.

Prior: Representatives from companies such as Novartis and Hill's can be a great resource for information. They also will coordinate with local veterinary medical associations to set up meetings and bring in experts like our panelists to talk about these subjects.

Fox: If total clinic education is not top-down driven, it won't be taken seriously. If the whole team is not on board it won't work. How many times does the veterinarian say, for example, "We need to put your dog on this pet food," then as the owner checks out and realizes the food is somewhat expensive, the receptionist says, "Maybe you can go down to the grocery store and buy a cheaper food." Everybody has to see the total picture. They have to be trained to support the common message.

Roush: We spend a tremendous amount of time counteracting what clients read in the lay press and on the Internet. We fight misinformation all the time. I think we need a website where veterinarians can send clients to read about topics like pain management.

Epstein: IVAPM is developing a site for pet owners as well.

CASE STUDY CONTEST

Prior: Dr. Fox, please tell us about the case study contest for which Hill's and Novartis provided $40,000 in cash awards.

Fox: The contest was opened to all veterinarians with the criteria being that they must use Hill's Prescription Diet j/d Canine, Deramaxx, and Adequan Canine in a multimodal management scheme to manage a case of canine osteoarthritis. In a nutshell, it was an attempt to look at cases that were managed by at least these three therapies. First prize was $25,000, second prize was $10,000, and third prize was $5,000. The awards will be given at the Fall 2009 American College of Veterinary Surgeons meeting.

CONCLUDING REMARKS

Fox: The multimodal approach is the strongest evidence-based, best-medicine approach to osteoarthritis.

Reems: "An Animated Guide to the Multimodal Management of Canine Osteoarthritis" CD produced by Hill's and Novartis is a great tool to convince veterinarians to get their team on board.

Downing: When treating osteoarthritis pain from a multimodal perspective, it is critical to understand that the components are synergistic. A single component is not a magic bullet, and these pieces work as well as they do because they complement one another. We need to educate clients about why a multimodal perspective is superior.

Success hinges on communication. We need to keep an open mind because pain management is a constantly changing discipline. We need to pick a pain scale for our practice to use. It doesn't matter which one, but it does matter that we train our staff to use it—and use it every day. Taking an animal that is in tremendous pain and mitigating that pain, restoring function and comfort, and restoring the pet's relationship with its family is very rewarding. Clients will tell you through their tears that you have given them their pet back.

Epstein: Under-managed pain is a criterion for euthanasia, is it not? So pain management is just as much a lifesaving process as anything that happens in an intensive care unit.

Roush: We need to steer ourselves, our staff, our students, and our clients away from the idea that pain management is a one-time occurrence. Rechecks and revision of therapy for continued pain management are important and they are practice builders. We need to use the words "disability" and "exercise therapy" to get the message across.

Millis: Osteoarthritis is lifelong and incurable, but it is a very treatable disease. Managing it is hard work and time consuming, but it is worth it.

Prior: There are so many products available and varied recommendations available that practitioners often feel lost and don't have a clear roadmap of how to proceed. It is good to be able to pull together a concise plan and a list of resources we can use to get these animals on the right path and improve their quality of life.

REFERENCES

1. Lascelles BD. Blikslager AT, Fox SM, et al. Gastrointestinal tract perforation in dogs treated with a selective cyclooxygenase-2 inhibitor: 29 cases (2002-2003). J Am Vet Med Assoc 2005;227:1112-1117.

2. Millis DL. Nonsteroidal anti-inflammatory drugs, disease-modifying drugs, and osteoarthritis, in Proceedings. A multimodal approach to treating osteoarthritis 2006; 9-19.

3. Wallace JL, Zamuner SR, McKnight W, et al. Aspirin, but not NO-releasing aspirin (NCX-4016), interacts with selective COX-2 inhibitors to aggravate gastric damage and inflammation. Am J Physiol Gastrointest Liver Physiol 2004;286:76-81.

4. Fiorucci S, Santucci L, Gresele P, et al. Gastro intestinal safety of NO-aspirin (NCX-4016) in healthy human volunteers: a proof of concept endoscopic study. Gastroenterology 2003;124:600-607.

5. Roush JK, Dodd CE, Fritsch DA, et al. A multicenter veterinary practice assessment of the effects of omega-3 fatty acids on canine osteoarthritis. J Am Vet Med Assoc 2009: in press.

6. Roush JK, Cross AR, Renberg WC et al. Effects of feeding omega-3 fatty acids on force platform gait analysis and serum fatty acid profiles in dogs with osteoarthritis. J Am Vet Med Assoc 2009: in press.

7. Goldberg RJ, Katz J. A meta-analysis of the analgesic effects of omega-3 polyunsaturated fatty acid supplementation for inflammatory joint pain. Pain 2007;129:210-223.

8. Millis D, Korvick D, Dean D, et al. Modu lation of cartilage injury with growth hormone and/or polysulfated glycosaminoglycans in a canine model of osteoarthritis, in Proceedings 45th Annu Meet Orthop Res Soc 1999;792.

9. Kealy RD, Lawler DF, Ballam JM, et al. Effects of diet restriction on life span and age-related changes in dogs. J Am Vet Med Assoc 2002;220:1315-1320.

10. Kustriz MV. Determining the optimal age for gonadectomy of dogs and cats. J Am Vet Med Assoc 2007;231:1665-1675.

11. Lago R, Gomez R, Otero M, et al. A new player in cartilage homeostasis: adiponectin induces nitric oxide synthase type II and pro-inflammatory cytokines in chondrocytes. Osteoarthritis Cartilage 2008;16:1101-1109.

12. American Animal Hospital Association (AAHA). The Path to High-Quality Care: Practical Tips for Improving Compliance. Lakewood, Colo. AAHA Press, 2003.

To learn more about the International Veterinary Academy of Pain Management (IVAPM), visit www.ivapm.org

For more on Hill's® line of EPA-rich pet food, visit www.jumpfordogs.com

For more on Hill's® Prescription Diet® j/d® Canine, please contact your Hill's representative or Hill's Veterinary Consultation Service at 1-800-548-VETS.

Side effects of Deramaxx (deracoxib) include those involving the digestive system, kidneys, or liver. These are normally mild, but may be serious. Pet owners should discontinue therapy and contact their veterinarian immediately if side effects occur. Evaluation for pre-existing conditions and regular monitoring are recommended for pets on any medication, including DERAMAXX. Use with other NSAIDs or corticosteroids should be avoided. Refer to full product information located in this publication. For more on Deramaxx, please contact your Novartis Animal Health representative or visit www.deramaxx.com

Adequan Canine (polysulfated glycosaminoglycan or PSGAG) should not be used in dogs who are hypersensitive to PSGAG or who have a known or suspected bleeding disorder. It should be used with caution in dogs with renal or hepatic impairment. Possible side effects (pain at injection site, diarrhea and abnormal bleeding) were mild, transient and self-limiting. Safety studies of PSGAG in breeding, pregnant or lactating dogs have not been conducted. Refer to full product information located in this publication. For more on Adequan, please contact your Novartis Animal Health representative or visit www.adequancanine.us

© 2009 Hill's Pet Nutrition, Inc. and Novartis Animal Health Inc. All rights reserved. The views in this publication represent those of the participants and do not necessarily reflect those of Hill's Pet Nutrition Inc. or Novartis Animal Health Inc. To view this publication online, visit www.dvm360.com/c71