In a recent poll in Veterinary Voices UK 73% of veterinary professionals had experienced owners who had stopped or refused treatment with NSAIDs citing safety concerns as the reason why - this is partly due to a huge amount of misinformation surrounding NSAIDs in animals - to put is plainly NSAIDs have huge benefits to our patients as are actually very very safe!
What are NSAIDs?
NSAID stands for nonsteroidal anti-inflammatory drug.
The World Small Animal Veterinary Association (WSAVA), an association that aims to advance the quality and availability of small animal medicine by creating a unified standard of care for the benefit of animals, states that NSAIDs are drugs that exert an antipyretic (they reduce fevers), anti-inflammatory and analgesic (pain relieving) effect. NSAIDs are the mainstays of relief from mild-to-moderate pain.
The WSAVA states that NSAIDs are effective analgesics, and offer significant benefit across the spectrum of pain intensities and are administered in chronic pain states such as osteoarthritis.
Canine Arthritis Management has a fantastic members zone that provides endless information on canine arthritis management - including a hand out that helps dispell the common myths surrounding the use of NSAIDs. Because
Are NSAIDs safe?
Brennen McKenzie, also known as the Skeptvet, has a critical eye for analysing evidence-based medicine and was past president of the Evidence Based Veterinary Medicine Association.
Brennen acknowledges that NSAIDs do have potential risks, but these are outweighed by their effectiveness in quickly controlling pain.
Fear mongering is blowing the risks out of proportion which is just as harmful as offering an unrealistic assessment of their benefits. While many pets take NSAIDs safely, find great relief from pain, and experience an improved quality of life, unfortunately there are some animals that have experienced negative side effects. These cases are often widely circulated and can generate excessive fear in pet owners. This can result in their dogs being denied the pain relief they need.
Anecdotes are very powerful but are not based on evidence.
What side effects are seen?
The body is a complex system with innumerable interactions, and anything that has a beneficial effect on one element of the system will have effects on other systems as well.
The risk of serious adverse effects from NSAID use is very low.
The same conclusion reached by the authors of a new, rigorous systematic review of the literature concerning NSAID side effects in dogs. The authors critically appraised a whopping 64 studies that looked at the use of 14 different NSAIDs. On first glance, the likelihood of adverse effects seems high, with rates from 0% to 37.5% of dogs. However, when the highest quality studies were considered (randomised, placebo-controlled clinical trials), no difference in adverse effects was detected between dogs receiving NSAIDs and those on placebo. It is clear that side effects do occur in some dogs on NSAIDs, however this study suggests that the widespread worries about common and severe harm from these medications can be balanced.
Will my dog get renal failure?
(Spoiler alert: probably not)
Gastrointestinal upset, such as vomiting and diarrhoea, are the most common adverse events reported in the studies. These are generally transient and self-limiting when the medication is stopped. It is commonly noted by many vets that reintroduction of the same NSAID at a later date does not lead to the same side effects so please don't rule out all NSAIDs because one didn't agree with your pet.
More serious side effects, involving liver and kidney problems, are only detected very rarely, and liver problems seem to only occur in dogs with pre-existing liver abnormalities. The study mentioned above adds to the existing evidence base to suggest that NSAID side effects are not common, apart from mild gastrointestinal symptoms, and serious injury is extremely rare.
CAM suggests that a balanced decision based on the rates of these problems being extremely low, against the life-limiting pain caused by arthritis. NSAIDs are very effective pain controlling drugs, and denying their benefits without a realistic assessment of the risks may lead to animals being left in pain with a significantly reduced quality of life.
NSAIDs are effective and improve quality of life
In studies and reviews of arthritis treatment for dogs NSAIDs are extremely effective. They are commonly used as a benchmark to compare new innovations. Numerous clinical trials show unequivocal efficacy. Most subjective measures by owners or veterinarians show improvement of pain in dogs by up to 90%, and when objective measures are used, NSAIDs almost always show clear benefit.
What about cats?
Pain in cats has many negative effects, both physiological and emotional. Chronic pain can be regarded as pain that has persisted for more than 2–3 weeks however it often persists months and years, and may continue beyond the anticipated healing time. It is something that we should be treating to improve our cats quality of life, and one of the most common foundations of treatment may be NSAIDs - should you be worried about long term medication?
Chronic pain can become dissociated from the inciting cause and be maladaptive (provides no apparent protective or recuperative benefits), such that the degree of pain does not necessarily correlate with the pathology observed - what this means is that there may not be a lot to see clinically on examination or diagnostic tests such as X- rays but that the degree your cat is experiencing pain can still be moderate to severe despite clinical exam not suggesting the issue should be that painful. So pain relief and other interventions are needed, but are they safe?
Interestingly, some NSAIDs are even safe in cats with chronic renal disease, and if chronic pain is managed well may even encourage more mobility. Increased mobility and less pain can result in a better quality of life, maintenance of musculature, more playfulness, less lethargy and more frequent visits to food and water areas.
It has been discussed that a number of these recent studies have demonstrated that NSAIDs (meloxicam or robenacoxib) can be administered safely to cats with stable International Renal Interest Society (IRIS) stage I and II CKD.
One study found that there was no clinical indication of damage to the gastrointestinal tract, kidney or liver.
The ISFM AND AAFP CONSENSUS GUIDELINES stated:
To date, published studies of the medium- to long-term use of the COX-1 sparing drug meloxicam in older cats and cats with chronic kidney disease provide encouraging data that these drugs can be used safely and should be used to relieve pain when needed.
While further data are needed, and would undoubtedly lead to refinement of the guidelines presented here, the panel hope that these recommendations will encourage rational and safe long-term use of NSAIDs in cats, thereby improving patients’ quality of life in the face of painful disease conditions.
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