STEOARTHRITIS CASE STUDY LIFE ALTERING BENEFITS OF...

OSTEOARTHRITIS CASE STUDY:

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OSTEOARTHRITIS CASE STUDY:LIFE-ALTERING BENEFITS OF TREATMENT

FINDING THE RIGHT DRUG TO MANAGE OSTEO-ARTHRITIS PAIN OFTEN TAKES TRIAL AND ERROR.BUT YOUR PERSEVERANCE WILL BE WORTH ITWHEN YOUR PATIENTS BEHAVE LIKE PUPPIES AGAIN. We wish it could be simpler, but not all nonsteroidal anti-inflammatorydrugs (NSAIDs) are effective for alldogs. It often takes several tries before you isolate the drug that bestmanages a dog’s osteoarthritis pain and inflammation.The road to findingthe right one takes patience—and notjust yours.

Chronic joint-related conditions aretrying on family members. Frustrationand noncompliance can sneak in whenpet owners don’t see results fast enough,and owners are often faced with ago-nizing decisions about their pet’s com-fort and long-term health. But Rocky’sstory illustrates that the pay-off is wellworth the struggle.

Presentation and historyRocky, a 12-year-old neutered malegolden retriever, has been a patient ofWarren Briggs, DVM, at the OceanCounty Veterinary Hospital (OCVH) inLakewood, N.J., since October 1999.

October 1999: Rocky, who lives withhis family in Brick, N.J., was born onOct. 22, 1994. Rocky first presented toOCVH with signs of lameness at age 5.Danielle Visser, Rocky’s owner, noticedthat he began limping around this time,though it wasn’t severe. She and herhusband, Kevin, thought it might bethe result of a pool-related injury.

Rocky was not overweight at 68 lbs.Nothing unusual was noted in his

Warren Briggs, DVM, examinesRocky during a March 2007examination while DanielleVisser looks on.

OSTEOARTHRITIS CASE STUDY

medical history. Rocky showed signs of pain in his left hind leg during thephysical examination. Dr. Briggs, whohas been with the practice since gradu-ating from the Ontario Veterinary College in 1992, took radiographs thatindicated Rocky had osteoarthritis in his hips secondary to hip dysplasia. He prescribed a two-week course of a veterinary-approved NSAID, and thelimping seemed to improve initially.

Visser did not refill the drug afterthe trial because Rocky continued tolimp and his temperament changed.“The limping didn’t go away, andRocky seemed reserved and lessactive,” Visser says. Because Rockydidn’t seem like his old self, shestopped giving him the drug excepton an intermittent, as-needed basisduring the colder months.

June 2004: Visser brought Rocky(now age 9) to see Dr. Briggs becauseof lameness observed primarily in hisright front leg. She reported thatRocky was still relatively active, but helimped frequently and showed signs ofsoreness and discomfort.“We couldtell that Rocky wanted to run, but hecouldn’t anymore. He used to tearthrough the yard, but now, after twoFrisbee throws, he would go lie down.Even my parents and neighbors com-mented about his limp,” she says.

At this time, Rocky was a little heavy,weighing 78 lbs with a body conditionscore of six (on a nine-point scale). Dr.Briggs did not palpate any abnormalitiesin the right front leg and decided not totake radiographs. He prescribed anotherdose of the same NSAID, and Visserindicated that, again, Rocky’s lamenessimproved somewhat with the drug.

July 2004:About a month later, onJuly 15,Visser returned to the hospital

with Rocky because his forelimblameness and pain seemed substantiallyworse. Dr. Briggs took radiographsthat indicated that Rocky had severeosteoarthritis and degenerative jointdisease in the right elbow and shoul-der (Figures 1 to 3). At this time, Dr.Briggs opted to try a different NSAIDto help manage Rocky’s joint painand inflammation.

Visser reported that Rocky showedno problems with the drug on July 21,so she refilled it. But Rocky was stilllimping and obsessively licking hisjoints, and he had trouble with stairs.“Eventually we tapered the medicationdown because we worried about hislong-term health,” Visser says.

In November 2004, Dr. Briggs addeda nutraceutical that contains glucosa-mine sulfate to Rocky’s regimen. Dr.Briggs now prescribes nutraceuticalsconcurrently with NSAID therapy forall of his osteoarthritic patients.

July 2005: Visser reported to Dr.Briggs that Rocky (now age 10) hadproblems going up stairs. She and herhusband reported that Rocky’s jointdegradation seemed to be accelerating.Given the fact that veterinarians todayhave an abundance of veterinary-approved NSAIDs to choose from,coupled with the realization thatdifferent animals can respond variablyto alternate drugs on the market, Dr.Briggs prescribed a two-week trial of adifferent NSAID. Visser reported thattheir experience with this drug wassimilar to that with the others: Rocky’slameness seemed to improve slightly,but not enough to offset their worriesabout his long-term health.

August 2006: Rocky’s blood-panelfindings in early August revealed thathe was at risk for liver disease. His

Figures 1 to 3: Radiographstaken in July 2004 showedsevere osteoarthritis in Rocky’sright elbow and a joint mouse/osteophyte in his right shoulder.(Radiographs courtesy Dr. Briggs)

Figure 2

Figure 3

Figure 1

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Now, more than ever, pets are treated like familymembers. Dogs sleep on their owners’ 400-thread-count sheets and receive Christmas gifts in theirvery own stockings. When a disease like osteo-arthritis affects a dog, the whole family suffers.

The Visser family of Brick, N.J., was no excep-tion. Danielle Visser recounts how Rocky’s dis-comfort and decreased mobility became nearlyintolerable. But as much as the Vissers wantedtheir fun-loving golden retriever back, theystruggled with concerns about the long-termNSAID side effects. Losing Rocky seemed muchscarier than seeing him prone on the kitchenfloor. Here she shares some thoughts onRocky’s struggle—and eventual triumph—overosteoarthritis pain:

“Rocky was always so active. He ran every-where. Then one day, around age 5, he beganlimping. Everyone noticed. And from that point,things just got worse and worse, no matter whatdrug he was taking.

“We knew Rocky was getting older and for along time, we attributed his decline in activity toaging. But Rocky seemed to go downhill quickly.We had young children who adored him, and youcould see in his face how much he wanted toplay with them. It was heartbreaking to see himslip and fall on the tile floor and try to stand up.

“After Rocky started PREVICOX® (firocoxib),we realized just how much he had deteriorated.We were accustomed to his depressed state.But PREVICOX changed everything. WhenRocky was younger (he’s 12 now), he liked to nipat my husband’s and older son’s pants near theirankles in a game of chase. He hadn’t done thatin years until he started doing it again last week!

“He is not as robust as he was in his youth,but to see him happy again made us realize thatRocky was dealing with pain for years—it wasn’tjust old age setting in. PREVICOX showed usthat. Now we have our playful Rocky back. Hehops and prances again when he’s excited orwants a treat. He gets to be a puppy again!”

As a class, cyclooxygenase inhibitory NSAIDsmay be associated with gastrointestinal, kidney,or liver side effects. These are usually mild, butmay be serious. Pet owners should discontinuetherapy and contact their veterinarian immedi-ately if side effects occur. Evaluation for pre-existing conditions and regular monitoring arerecommended for pets on any medication,including PREVICOX. Use with other NSAIDs,corticosteroids or nephrotoxic medication shouldbe avoided. Refer to the prescribing informationfor complete details or visit www.previcox.com.

OSTEOARTHRITIS—FROM THE FAMILY’S PERSPECTIVE

LIFE-ALTERING BENEFITS OF TREATMENT

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cholesterol was 384 mg/dl, and hisalkaline phosphatase activity was 902U/L.The Visser family had not admin-istered the prescribed NSAID consis-tently over the last year. Dr. Briggsrecommended an additional nutraceu-tical, which contained milk-thistleextract, B vitamins, and alphalipoicacid to help promote normal liverfunction.A laparoscopic biopsy inSeptember determined that Rocky hadnodular hyperplasia of the liver, whichis not an uncommon finding in olderdogs.The Vissers opted to withdrawRocky from all NSAID therapy.

“At this time Rocky not only struggled to rise from the floor, he hadtrouble lying down.We were alsoforced to carry him up and down thestairs to our bedroom, where he insistson sleeping. He also took a few tum-bles down the stairs, which broke ourhearts,”Visser says.“It was very dif-ficult to decide between Rocky’scomfort and his liver health, but atthat point, we were concerned aboutNSAID use.”

January 2007:Visser reported to Dr.Briggs that Rocky wasn’t gettingaround much at all anymore.Thewhole family had traveled to SouthCarolina over the holidays, and it hadbeen a difficult trip for everyone.

Rocky’s owners also reported that hislegs began trembling, and because ofearly evidence of postural difficulties, Dr.Briggs was concerned that Rocky mayhave degenerative myelopathy. He sug-gested they try a newer NSAID, a COX-2-selective inhibitor, PREVICOX®.

This time, Rocky’s improvement wasdramatic.“After one dose, we didn’tneed to lift Rocky off the floor any-more! We couldn’t believe it,” Vissersays.After a two-week trial withPREVICOX,Visser reported thatRocky’s lameness continued to im-prove.“He doesn’t limp or fall downthe stairs anymore, and he can climbthe porch steps again. He can walkaround the block and even plays tug-of-war with the kids!” she says.Visserrefilled the prescription in Februarybecause Rocky continues to show aremarkable response to PREVICOX—far better than the other NSAIDs triedover the previous eight years.

Current status: At a follow-up visit inApril 2007, blood tests revealed thatalthough Rocky’s cholesterol level hadincreased slightly to 401 mg/dl, hisalkaline phosphatase activity haddecreased substantially to 398 U/L.Visser again refilled the PREVICOXprescription at this visit.“The bestnews is that Rocky seems happy again.He got his spunk back,” she says.

Four NSAIDs are kept on the shelfat the 10-doctor Ocean CountyVeterinary Hospital, but owner Dr.Briggs now reaches for PREVICOXfirst thanks to several arthritic patients,like Rocky, who have shown tremen-dous improvements in lameness anddiscomfort after starting the drug.“Like me, the doctors here are startingto witness more and more reasons toprescribe PREVICOX first forosteoarthritis,” he says. n


• Reduce pain and inflammation.

• Slow disease progression.

• Facilitate the repair of damaged tissues.

• Improve, or at least maintain, joint function andmuscle mass.

GOALS FOR OSTEOARTHRITISTREATMENT

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With one in five dogs older than 12months diagnosed with osteoarthritis,1-3

a good deal of your time will be spentcounseling families who have watchedtheir beloved companions change fromonce-spry pups to down-troddenanimals.The daily routine is upset—lifestyles are altered; no more hikes atthe lake or games of fetch in the back-yard.These unfortunate changes oftendeprive the entire family of quality timespent together as well as the physicaland psychologic benefits of exercise.

How does this shift affect the family?“Dogs who develop osteoarthritis haveoften lived with their families for 12,13, or more years, guaranteeing a strongfamily-pet bond,” says Robin Downing,DVM, CVA, DAAPM, director of theWindsor Veterinary Clinic and theDowning Center for Animal PainManagement in Windsor, Colo.“Thisbond makes it even harder for people

to watch their dogs suffer—unable todo the things they once enjoyed.”Andbecause our culture is apt to dismissosteoarthritis-related changes as part ofnormal aging, practitioners need to beproactive in educating clients aboutjoint health so treatment can begin assoon as possible.

The emotional implications of osteoarthritisIn the old days, Duke grabbed the leashat the crack of dawn and wouldn’t besatisfied until he’d lapped the park threeor four times. Nowadays, he doesn’tmuch budge from his favorite spot onthe sofa.Though Mrs. Jones observesthis change, there are obstacles that maykeep her from reporting it to you.Clients are often slow to report signs ofosteoarthritis in older dogs because theysuffer from anticipatory grief.The lossof favorite activities—even the climb

Rocky asleep on the Vissers’couch in March 2005.

Take osteoarthritis treatment beyond your doors

EMPOWER OWNERS TO TAKE CHARGE OF THEIR DOGS’OSTEOARTHRITIS—FOR THE PET AND FAMILY ALIKE.


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upstairs to sleep on the owner’s bed—reminds people that their pets won’talways be around.“If anticipatory griefis triggered, owners are more inclinedto resign themselves to a less active dogor to make excuses when Muffin snapsat the grandchildren,” Dr. Downingsays.

“But the good news is that osteo-arthritis treatment promises big emo-tional pay-offs because people havelong since accepted these changes asinevitable,” says Ernie Ward, DVM, prac-

tice management consultant andowner of Seaside Animal Care inCalabash, N.C.You can almostgive families the feeling of turn-ing back the clock, and you’llhear statements like,“Wow, wegot our puppy back!”Comprehensive osteoarthritismanagement gives you theopportunity to restore the dailyactivities that are at the heart ofthe family-pet bond.

Spread the wordThe first step toward helpingarthritic dogs and their families is

consistent, comprehensive joint-healtheducation. Provide clients with a joint-health checklist in written form and onyour website so they can promptlyreport discomfort and behavior changesthat may signal osteoarthritis, such as:

• Frequent or sudden fatigue• Limping or less frequent jumping,

running, or playing• Difficulty rising from the floor and

walking up stairs• Weight gain • Slower movement in cold weather• Discomfort when joints are touched • Excessive licking of the joints• Decreased appetite (which may

signal intense pain).Many dogs suffer in silence because

osteoarthritis progression can be slow,but that doesn’t mean the pain isinsignificant. Every dog manifests paindifferently.“I remind owners to lookfor subtle cues, too,” Dr.Ward says.“Observe the dog when you let herout in the backyard. Is she exploringand sniffing around as usual, or doesshe do her business and lie by thedoor to wait?”

Treatment to restore the bondThough there is presently no cure forcanine osteoarthritis, the pain andinflammation associated with it can betreated. Effective osteoarthritis manage-ment begins with a definitive diagnosisbased on radiography. If you treat thewrong disease with the wrong drug,you’re setting yourself up for failure andowner frustration.

At the Windsor clinic, Dr. Downingrecommends the following multimodalprotocol for her osteoarthritis patients:

• Break the pain-inflammation cyclewith nonsteroidal anti-inflammatorydrugs (NSAIDs).

• Use nutritional science to influencejoint health.This includes weightloss and management to achieve andsustain an appropriate body condi-tion score.

• Supplement the diet with nutraceu-ticals and chondroprotective disease-modifying drugs (e.g., injectablepolysulfated glycosaminoglycans).

• Help manage inflammation withphysiotherapy.

“Though NSAIDs have changed theway I practice veterinary medicine,osteoarthritis deserves more than just apill,” Dr. Downing says.

Make sure your team membersexplain up front what the treatmenttimeline looks like (e.g., premedicationblood and urine tests, weight loss,follow-up appointments) and what is


“Osteoarthritistreatment gives you a rare chance to influence the entire family’s health.”

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expected of the family. It’s no secretthat chronic conditions require a lot ofwork and patience. Give owners specificfeeding and exercise recommendationsif weight reduction is a goal. It’s notenough to simply recommend arestricted-calorie diet.

Follow your discussions with writtenmaterials so owners can weigh theoptions and make informed decisionson their own time. Phone the familyafter two weeks of therapy to monitorthe dog’s response—and foster externalaccountability—and schedule a follow-up appointment after the first month.

How NSAIDs help Inflammation is at the root of osteo-arthritis discomfort and pain.Theinflammatory cascade causes thecartilage in joints to deteriorate. If theinflammation is left unchecked, deg-radation accelerates.The COX-2-selective inhibitor NSAID PREVICOXinterrupts the inflammatory cascadeassociated with osteoarthritis.“Drugslike PREVICOX ultimately help dogs’joints last longer,” Dr. Downing says.

NSAID therapy helps you accomplishother goals, such as weight loss andincreased exercise.“It’s unethical to pushan arthritic dog to be more active whenhe is in pain,” Dr. Downing says. Using

PREVICOX in the first wave of treat-ment opens the door for nutrition andphysiotherapy to work, with the ulti-mate goal of reducing the dog’s relianceon drugs.And how do the owner andanimal benefit from this system? “Thedog gets to live right up to the verymoment he dies,” Dr. Downing says.

Dr.Ward offers this information tohelp you make a compelling argumentto clients: PREVICOX has been shownin several studies to specifically targetosteoarthritis pain and inflammation.“The post-launch PREVICOXExperience Trial4 provided the data andconfidence I needed to know that thisdrug works in the real world with realdisease and real clients,” he says. n

References1. Hedhammar A, Olsson SE, Andersson SA,et al. Canine hip dysplasia: study of heritabilityin 401 litters of German Shepherd dogs. J AmVet Med Assoc 1979;174:1012-1016.2. Johnson JA, Austin C, Breur GJ. Incidenceof canine appendicular musculoskeletal disor-ders in 16 veterinary teaching hospitals from1980 to 1989. Vet Comp Orth Traum 1994;7:56-69.3. Moore GE, Burkman KD, Carter MN, et al.Causes of death or reasons for euthanasia inmilitary working dogs: 927 cases (1993-1996).J Am Vet Med Assoc 2001;219:209-214.4. Ryan WG, Moldave K, Carithers D. Clinicaleffectiveness and safety of a new NSAID,firocoxib: A 1,000 dog study. Vet Ther 2006;7:119-126.


Getting arthritic dogsback on their feet

returns favorite family activities.

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