OSTEOARTHRITIS AND CHRONIC PAIN
My father is nearly 80. When he gets up in the morning, and throughout parts of the day, things are not as easy for him as they were. His grip isn't what it used to be during his golf-heavy middle years, and his shoulders often ache. He also has some trouble with his mobility. He sees a few doctors to manage the handful of conditions that he, like many of us, deals with. Yet, none of his doctors have ever said, "Oh, you're just old and slowing down." If they did, I am sure he would find a new doctor.
Yet, with my patients, I hear this frequently. I know it is not said with malice or lack of interest in their well-being. But, instead, I think it comes from one simple place: Our pets don't complain. They are tougher than us, yes, but they still hurt. And, in reality, they
do complain, they just don't do it in a way that we are used to. The reason no doctor would ever say that to my father is because they know that A) it's just not true and B) he would give them an earful. Therefore, part of the 'art', alongside the science, of veterinary medicine is recognizing the subtle ways our pets tell us they hurt.
When a pet is slow to rise, takes a while to get going, or doesn't do the stairs so quickly or so well anymore, it's usually because they hurt. When they have trouble getting up into the car, or perhaps up on the bed or down from the couch, it's usually because they hurt. Sometimes they may sleep a little more. Sometimes they may change how they interact with us. But rarely, and I want to highlight this, do they ever stop eating. They can, but this is uncommon, so it is a poor indicator of their general state. Most animals, with most conditions, will continue to eat well past the point we would even think about food. It's how they are wired. But they still hurt.
Osteoarthritis (OA) is the most common orthopedic disease we see in animals. It is estimated, and likely
underestimated, that about 20% of dogs suffer from this. OA is pain, rooted in inflammation, that is chronic. It does not go away, it will get worse, and it does negatively impact quality of life every single day. Therefore, we must be able to recognize it and treat it effectively. Fortunately, there are many great options.
The most important part of diagnosing arthritis is the physical exam and history taking that occurs as a part of that. The changes with arthritis are often subtle and usually best documented from rest, only causing problems during activity later in the progress of the disease. Marrying the things that owners see at home with what I find on exam is the biggest clue that we may be dealing with chronic pain.
From there, one of the first tests I like to consider is acquiring radiographs ("x-rays") of the problem joint(s). While this can help us track any changes related to OA in the joint, I use it primarily to make sure nothing outside of arthritis is happening that could cause similar problems or represent much worse disease.
Once we have our baseline established, the focus from there is on managing the disease. Arthritis is not curable and, unfortunately, it will get worse. So, it is our duty to slow it down as much as we can, manage their discomfort and try to maintain their strength as much as possible. This will include activity regimens and weight loss for many patients (most arthritics are also overweight at the time of diagnosis). Most studies agree that few things have a more positive impact on the management of OA than getting to and maintaining ideal weight.
But, a big part of our goal is pain management. There are many pain medications that one can utilize and many patients will be on more than one, as each attacks pain from a different angle. The non-steroidal anti-inflammatory drug (NSAID) drug class is the most common "first line" choice. It targets the inflammation at the heart of OA as a core mechanism to manage pain. In addition to that, many others may be utilized including drugs like gabapentin or amantadine. Some of these, especially NSAIDs, require periodic blood monitoring and your vet can help you determine when that should be done. Keeping up that monitoring is an important part in managing the medication regimen.
It is critical to understand that we will never be off these medications. The dose may change, or we may shift from one drug to another for any number of reasons, but the pain must always be managed. If we fail to do this, then the body will start to lead us down a road whereby it has an inappropriate relationship with pain. Eventually, this leads to a state whereby even non-painful stimuli will be interpreted as painful by the body. This can be difficult to reverse, therefore it is imperative that we stop that process from ever really getting a foothold.
There are other supplemental options that can also help out. Things like fatty acids (from an animal source at
very high doses) and supplemental products (Dasuquin is a popular brand) are shown to have some mild benefit in many patients. There are also food options that can be a real benefit (a food called J/D is generally shown to have the best results). But none of these can take the place of regular pain management. They are helpful, and I use most all of them, but they are supplemental and do not stand on their own as a means for pain control.
So if you think your pet is at all slowing down or can't do all that they used to, please talk to your vet and have them evaluated. They may very likely be hurting. Fortunately, as we discussed, there are a lot of options to help them out.
On a final note, it has been my pleasure to write this column for a little over a year now. There are few things I like doing more than educating people on veterinary medicine and helping them understand just what is being done to help their pet out. This column has been a great outlet to do that. But, it is now time to move on and hand the reins over to my colleague Dr. Michelle Hendrickson, who has guest-written for me a few times. She is a wealth of knowledge, and I have full faith she will continue to provide great insight to you about your family members. Thanks for letting me be a part of your life, in whatever small way, this past year.
Medical Director / Managing Doctor
This month we will be focusing on another one of the most common feline diseases I see in practice every week. Hyperthyroidism is quite common and affects approximately 10% of cats over the age of 10. Cats have a pair of glands on the underside of their neck. In hyperthyroidism, these glands start to over produce the normal hormones that are needed by the body. The changes that you the owner or we the veterinarian may notice are because of the excess hormones that are circulating in the cat's body.
The most common clinical signs that a cat may show include weight loss even though they are eating a normal or even increased amount of food, increased activity, increased urination, vomiting, diarrhea, rough hair coat, increased vocalizing and changes in litter box habits. Cats can have any combination of these signs or just one or two. Owners who notice any of these changes should have their cat examined by their veterinarian. Occasionally, the thyroid glands are enlarged on exam which may make your vet suspicious of this disease. This is another reason twice yearly exams are so important for our senior cats. We can sometimes pick up subtle changes and diagnose this disease as early as possible before long term serious complications can occur. If left untreated, damage will occur to the heart, kidneys and other organs.
Diagnosing this disease is usually simple and involves a blood test that measures the level of one of the thyroid hormones in the blood. While the blood test is usually straight forward in most cats, some will need additional blood testing with a more complete hormone panel to diagnose the disease. Since this disease can affect other organ systems it is usually best to screen for other diseases at the same time, especially kidney function. Most cases of hyperthyroidism are caused by a benign (non-cancerous) overgrowth of thyroid cells called an adenoma, but rarely cats can develop the cancerous form called an adenocarcinoma.
Luckily, the benign version of this disease is very manageable and has several treatment options. Once your cat is diagnosed, your veterinarian will most likely go over the treatments available and discuss which options may be best based on each cat individually. The options that can be curative and require no long term management are radioiodine therapy and surgery. Radioiodine involves giving a small dose of radioactive iodine. The overactive thyroid tissue will absorb the iodine and destroy the tissue while the normal cells are not affected and continue to function normally. While this treatment is usually more costly up front because only a few facilities are able to isolate treated cats appropriately, it can be curative and has minimal risk of side effects. Thyroidectomy is the surgical option but is not commonly performed anymore. Many of these cats are not good candidates for anesthesia and there are risks of damage to nerves and blood vessels in the area. Also, some cats can have microscopic thyroid tissue present in other areas of the neck that may be left behind even with surgery and these cats will continue to have clinical signs of hyperthyroidism.
Management options include daily medication to block the production of thyroid hormones and nutritional therapy. Methimazole is the most common medication used to manage hyperthyroidism. It helps to prevent the overproduction of thyroid hormones. If this treatment is chosen, cats will need to be on therapy the rest of their life. This medication can also come in several forms such as tablets or a gel that can be applied to the inside of the ear for those cats that do not take oral medications well. Most cats tolerate the medication with few side effects. Because the disease can continue to progress over time, the thyroid hormone level will need to be monitored regularly while on medication. Some cats will need the dose of the medication increased over time to continue to keep the hormone level in a normal range. It is also important to monitor their kidney values regularly as well because thyroid disease can mask underlying kidney disease. Once the thyroid disease is regulated, the kidney values may start to increase on blood work and additional therapy may be needed. Nutritional management involves a special prescription diet food that is restricted in iodine. The restriction of iodine helps to limit the production of the thyroid hormones. This is a great option for indoor only and single cat households. In order for the diet to work, these cats cannot have access to any other food or treats (feline or human). If your cat has other medical concerns it also may not be the best option.
Any cat with hyperthyroidism needs to be treated. What is best for your individual cat is a conversation for you and your veterinarian to meet your cat's specific needs. No matter which option you choose, know that I have many cats that have been managed for several years after their diagnosis and are still doing well! If you have any concerns about your cat or notice any of the clinical signs I previously mentioned please make an appointment for an exam with your veterinarian. Until next time, have a fun and safe summer.