Steven Budsberg, DVM, MS, Dipl. ACVS, is the director of clinical research at the University of Georgia College of Veterinary Medicine and professor of orthopedic surgery, with extensive research experience in OA in animals. He spoke with DVM Newsmagazine about the challenges of treating OA, especially in the older dog.
DVM: What is it about a diagnosis of OA that makes it such a challenge?
Budsberg: When you see a geriatric patient with OA, the first thing in your mind is what caused it. I think it's a very important point that dogs don't just get OA. There is usually a causative situation, a problem with that joint at some point in its life. The classic example is the overweight Labrador who's about 6 years old with significant degeneration in the elbows. This OA is a sequela of a problem in the elbows the dog probably had at 6 months. So now that the dog is older and overweight, clinical signs of OA begin to manifest.
DVM: What signs should veterinarians be looking for?
Budsberg: Dogs start not doing things they used to do, and it's usually the owner who will pick up on it.
You might hear comments like: "My dog is slowing down." "He's limping a little bit." Or even, "He's just getting old." During the annual check-up, the veterinarian is able to say, "You know, the dog really does hurt in his elbows, his knees, his hips. Have you noticed anything?" If they haven't, it is within the veterinarian's purview to say, "We need to really look at this."
It can be a hard thing to tell the owner, "Your animal does hurt and you just don't know it," but often you have to step in and actually do that.
DVM: When an animal presents in acute distress, what are the first things that the veterinarian should consider when initiating treatment?
Budsberg: Many times animals are brought in for what's called the OA flare. In other words, the dog has had OA for years, but it comes in one day limping acutely. The dog is lame, and it hurts. We need to be aggressive to get that acute flare under control — the two-, three- or four-day pain that really hurts needs to be managed with rest and pharmaceutical therapy.
For us the acute flare is managed with non-steroidal anti-inflammatory drugs (NSAIDS). It is very important to use an FDA-approved drug since we have so many to choose from. These drugs have gone through extensive efficacy and safety testing at the recommended dosage regimens.
If the animal is in extreme pain, we can use narcotics such as fentanyl patches or injectable products. There's a lot we can use in this acute period. Once you get the flare under control, then you need to address its chronic problem.
DVM: Discuss approaches that may be considered when planning long-term care for the animal. How can the owner be brought into this plan to achieve the best outcome for the animal?
Budsberg: There's an informal checklist people should go through. The first thing to ask is the dog overweight? The vast majority of my patients are overweight, so that's the first thing you usually deal with. Obesity is bad for geriatric patients in general, but it is absolutely terrible for patients with OA.
Then you go down the list. What is the activity level of the animal? Does it get regular exercise? Is it a weekend warrior or a couch potato? What are the owner's and the animal's expectation of activity? We know with OA patients, humans and animals, consistent low-impact exercise is much better than high-impact exercise. If they can swim, take walks, if the owners can massage them — there are a lot of activities that are very good.
And then you ask what kind of therapies are we going to include — nutritional, physical therapy, drugs or a combination of these. We're starting to see some clinical data that supports the use of high omega-3, low omega-6 fatty-acid diets. The concept behind them is that changing the types of polyunsaturated fatty acids that go into the animal changes the lipids in the cell membranes, which actually changes the inflammatory response in the body.
There is no doubt that physical therapy as part of the management of OA is a very positive thing. Hot and cold packing, stretching, water exercises, underwater treadmill — all are really helpful.
NSAIDs can be used intermittently or for long periods. I think we err on the side of too little for too little time. Studies on NSAIDs funded by drug companies and pet-food studies have shown not only the improvement you would expect in the first 10 to 14 days but continued improvement over pretty much the life of the study, whether 21, 42, 60 days. With the continued relief of pain, this allows the animal to rehabilitate itself.
Then you've got a whole cornucopia of things that people have tried and, to be brutally honest, without much data behind them. The glucosamine/chondroitin combinations are tough because there is no doubt that in the experimental models glucosamines and chondroitins have positive effects. The problem is, how much do you give, how often do you give, to whom do you give. Everyone has an opinion but there's not a lot of support data.
And then there's the alternative therapies — herbal therapies, acupuncture, gold beads. When you have clients with animals that hurt, you're probably going to try all of the different things that are out there. There's excellent data in the human side and some of the same in the veterinary side that educating the OA client is one of the most effective things you can do; in other words, education about the process, about all the different sides of it, that you can't just give a pill and it all goes away. This is 30 to 45 minutes of going over this with them. If you do, you and your client will be much more successful and everything will work a lot better.
DVM: What part does surgery play in the care of these animals? What other treatment measures can we look forward to in the future?
Budsberg: Surgery for OA is really a salvage procedure unless you can treat the initial problem surgically.
When you perform surgery for OA, basically, you destroy the joint or the functionality of the joint.
You can fuse the joint, but arthrodeses above the ankle and the carpus are less reliable for a positive outcome. They can cause a large change in the gait and loss of functionality of the joint, along with other problems.
The second choice is removal of the joint. The only joint this is effective for is the hip, a femoral head and neck excision — where you take out the ball and socket and build up a false joint.
The third option is replacement surgery. Total hip replacements have been common for 30 years and more total knee replacements are now being done. Furthermore, total elbow replacements are starting to be performed and will increase in frequency in the very near future.
Also in the future, either transplanting or regrowing cartilage could become the the Holy Grail of OA treatment. But we're not there yet.
Wetzel is a freelance writer in Cleveland, Ohio.