Joint health: A roundtable discussion (Sponsored by Nutramax Laboratories)

The clinical signs

Dr. Sherman O. Canapp: What are the classic signs of joint health problems in dogs and cats, and what is your take on this issue?

Sherman O. Canapp, Jr., DVM, MS, CCRT, DACVS, DACVSMR, Veterinary Orthopedic and Sports Medicine Group, Annapolis Junction, Md.

Dr. Darryl L. Millis: In the past, a lot of us have waited for animals to come in with a lameness problem or for an owner complaint of a pet's having difficulty rising or going up and down stairs. Certainly those things are still important, but it has become evident that we need to address the joint before it becomes clinically affected.

Darryl L. Millis, DVM, MS, DACVS, College of Veterinary Medicine, The University of Tennessee, Knoxville, Tenn.

What that means for veterinarians is that we have to be more proactive, especially with examination of young dogs, focusing on hips and elbows. Then as the animals reach middle age, particularly in large and giant breeds, paying close attention to those joints but also the knees. The key to maintaining good joint health is early diagnosis and recognition of a problem before it becomes a bone-on-bone and a pain management issue. We need to do some detective work before it gets to that point to try to salvage the joint as best we can.

Dr. Paul Fox: In a general practice, one needs to be aware of the animals that are at risk for having joint problems, as puppies or later in life, especially large-breed dogs and overweight dogs. Some of Dr. Lascelles' research shows that of cats over 12 years of age, 90% have arthritic changes in their joints. These changes don't necessarily mean that the cats will be lame or even in pain, but it bears to question the under-diagnosis of arthritis in cats. The discussion of osteoarthritis with clients needs to happen much earlier in pets' lives than I think we are accustomed.

Paul Fox, DVM, Mount Carmel Animal Hospital, Monkton, Md.

Dr. Dana K. Juillerat: In younger animals, it is important to notice different stances and standing positions. The animals will often stand with their knees turned outward, kind of bowlegged. Also, recognize soft tissue injuries. It is not always an orthopedic problem that is going on. Of course, lameness, changes in behavior, and a decreased willingness to jump up on the sofa are more classic signs. Clients often say, "My cat used to jump up on the top of the fridge, and it's never on top of the fridge anymore." A lot of behavioral changes go along with joint disease.

Dana K. Juillerat, DVM, MS, Tri-County Animal Hospital, Fort Pierce, Fla.

Dr. Duncan X. Lascelles: We realize that joint disease is common and that it impacts quality of life. We need to broaden our outlook and not just use a fire brigade of analgesics, but think about a multimodality approach. It is all about lifestyle decisions, and that takes it back to the early ages.

Duncan X. Lascelles, BSc, BVSc, PhD, CertVA, DSAS(ST), DECVS, DACVS, College of Veterinary Medicine, North Carolina State University, Raleigh, N.C.

We need to educate our clients as to what decisions to make to provide the best lifestyle for their pets. These early decisions will impact joint health in the long run. Starting from an early age, everything, including nutrition, supplementation, exercise, and surgical decisions, can impact joint health. The field has changed a lot. In just the past fourteen years we have made a dramatic move from a reactive approach to a more proactive, preventive approach.

Canapp: With more dogs at a younger age becoming active in sporting type activities, such as agility events, hunt tests, and field trials, owners are starting these dogs earlier and earlier in training. We are seeing some joint conditions earlier in life in the canine athlete not seen before simply because the sporting industry has become so huge. We need to educate and encourage owners to take a prophylactic, or preventive, approach and possibly start their dogs on supplements at an earlier stage, before there are signs of joint disease.

Dr. Lascelles, you have done so much work with the feline patient. Do you see a big difference between what you commonly find as far as history, physical size, or differences in joint problems with cats than you see with dogs?

Lascelles: There is a big difference. We are at the early stages of understanding what joint disease in cats is all about. The biggest difference at the moment is in the way we are diagnosing it. Dogs are taken for walks, and owners have a fairly good idea of what lameness or a mobility abnormality is. Then there are the other mobility activity perturbations that are seen: not jumping into the car, not wanting to climb up or down steps or stairs.

In cats, it is a very different scenario. Owners are not evaluating limbs. We, as veterinarians, can't even evaluate limbs and gait very well in cats. We need to look at behaviors that we haven't looked at before, such as changes in the level of engagement with family members and other pets as well as spontaneous activities that may be more easily defined, such as jumping up and jumping down. These less-defined behaviors are going to be a very important part of leading us to a possible diagnosis of painful joints and degenerative joint disease-associated pain. With cats, we have to rely even more on owners. We have to figure out what signs to direct the owners to, what activities, what behaviors to get them thinking about.

Diagnosing joint disease

Canapp: Dr. Millis, your thoughts regarding the diagnosis of joint disease in dogs and cats?

Millis: The way we assess lameness in dogs has begun to change. Instead of just using a typical head bob and hip hike, we are now starting to look at joint range of motion, stride length, and back motion. Spinal motion has been a focus in our laboratory in looking for ways to be more sensitive in diagnosing lameness. These types of assessments are much more sensitive than the typical head bob and hip hike. However, activity level in the home environment is the key.

Canapp: We have to get much more objective in the way we are determining these early lamenesses. Agility dogs may be knocking down bars, pulling out weave poles, or not taking tight turns. The owners perceive that something is going on from a sports performance standpoint. I agree with Dr. Millis that we have to get much more sensitive than we used to be with diagnostics.

Lascelles: We need to raise the standard of orthopedic evaluations across the board.

Juillerat: I will get radiographs. We use them as screening tools in younger animals so we have something to compare with in the future. Early identification of what you are using the pet for is extremely important. We need to know if they are couch potatoes or are going to be running a marathon every day. Their daily needs and their training are all different.

Lascelles: I put an emphasis on physical examination findings but also on the realization that not all joint disease is the same. I am starting to look more often at joint fluid and being much more complete in terms of the evaluation.

In cats, we have done a lot of work looking at radiographic appearance but also realizing that radiographic appearance is not very good for diagnosing pain-associated joint disease. The radiographic appearance really doesn't match up with the examination findings or the history of activity impairment. Radiographs are an appropriate part of the diagnostic work-up, but we need to take a more holistic approach.

Treating joint disease

Canapp: Having a definitive diagnosis for a patient before reaching for any treatment is imperative. The basics are there. Your hands are, without a doubt, your best diagnostic tool.

The Big 3: An NSAID-nutraceutical combination in dogs

Dr. Lascelles, what has changed over the last decade in how joint health is managed in small animals?

Lascelles: We now understand that joint disease is a result of lifestyle decisions made much earlier on in the younger years of those animals. We are not just focusing on what is right in front of us, but we are starting to look in a broader sense at how we get there and how we can alter that course. Probably the simplest examples are feeding, caloric intake, and obesity. We now know there is a very strong connection between the amount of degenerative joint disease that is going to be present in a dog and its caloric intake over its lifetime. It's our job to try to change those lifestyle decisions early on.

Juillerat: Addressing diet is huge, and I applaud some of the dog food companies that are starting to come up with research for breed-specific diets. I think that is one way to go. Again, early preventive care, including nutrition and supplements, is essential. I think the entire veterinary field could do better with advising on appropriate nutrition.

Fox: Fifteen years ago, we had no FDA-approved NSAIDs for dogs. Now they are the cornerstone for getting patients out of pain. We also know that these medications do nothing to slow the course of osteoarthritis. Luckily, we do have some options to help slow the progression of OA. They include polysulfated glycosaminoglycan, omega-3 fatty acids, and glucosamine/chondroitin sulfate and avocado/soybean unsaponifiables (ASU). I am finding that I can use fewer NSAIDs and that some dogs, if diagnosed early enough, can be managed without them at all.

Canapp: Dr. Millis, what are your thoughts on changes in the last decade?

Millis: I think one of the biggest things, in addition to the nutrition and the plethora of NSAIDs we now have available, are the other modalities that have come to light. For example, at The University of Tennessee we have just finished a study of extracorporeal shock wave therapy. This treatment had a beneficial effect on dogs with osteoarthritis of the elbow.

Success in managing arthritic patients does not just mean looking at overall group means. That is important information and is one measure, but we also have to look at the number of responders with a treatment versus a placebo. If they do respond, how well do they respond? All of us respond differently to a particular treatment. One person may respond exquisitely well, and another person may not—but that second person may respond to another treatment. We have to add a little art back into the management of arthritis.

Canapp: What is your multimodal approach?

Fox: I tailor treatment and management to each individual patient depending on where the dog is in life and what the problems are. My number one soapbox issue is weight management—everything starts there. We need NSAIDs to quickly relieve any pain, and I use the EPA-rich foods, Adequan®, nutraceuticals, and exercise frequently for the long term. Every modality does not work for every dog, and it is not infrequent to have to change course throughout a pet's life.

Lascelles: On my list I have dietary modulation, supplementation, weight management, and drugs, including the nonsteroidals and adjunctive drugs. The physical modalities include things like transcutaneous electrical nerve stimulation, massage, ultrasound, and exercise. Not all of those modalities are appropriate in every case. In fact, we can divide our patients into the young dog early stage, before there is obvious joint disease; the middle-aged animal; and the late stage. You reach for different combinations of modalities at different stages of life and at different stages of joint disease. Early on, dietary modulations, supplementation, and weight management are going to be critically important. Later on, there is going to be much greater reliance on nonsteroidals and adjunctive drugs as we try to relieve pain and bring back mobility.

Canapp: Dr. Millis, what are your thoughts on protocols that you may use in clinical practice?

Millis: It depends on what stage we are at. If we have an early OA case where there are minimal to no radiographic signs, I'm probably going to concentrate more on making sure that the joint alignment is good and that we don't have any underlying problems such as hip dysplasia. In a young patient, we may need to correct biomechanical or alignment problems of the limb with osteotomies or other surgical means first. Then we will concentrate on trying to protect the cartilage that is there with products such as Adequan® and nutritional supplements, particularly glucosamine/chondroitin sulfate and avocado/soybean oil derivatives.

On the other hand, if we have a patient that is geriatric with end-stage osteoarthritis, then a pain-management scheme really jumps to the top to improve function and make the patient more comfortable. In either case, improved comfort level will help rehabilitation, exercise, and weight control. They all go hand in hand. I break it down to what stage of the disease the animal is at, and then I concentrate on protecting the joint versus treating the pain and perhaps thinking about joint replacement.

Canapp: One of the problems that we run into with a multimodal approach is that you can initially have too many things going on at one time. For the geriatric patient, we are trying to maintain a decent quality of life and function for the rest of its life. We need to know what treatment is going to be the safest long term and what is going to be the most beneficial. If we throw every treatment in at the same time, we really won't know which was the best. The other concern is that often clients don't give the products or the treatment options enough time to see an effect. I don't like the word protocol, but I do like the word benchmarks. In other words, we set a certain amount of time during which a particular treatment should have taken effect, and we reassess the dog objectively. If we are not seeing that effect during that period of time then we can go ahead and add in another therapy modality or nutraceutical or change directions altogether.

I'm a big fan of being patient, setting a goal, sticking by your benchmarks, and then reassessing. You need to reassess the patient every time it comes in because things change.

Treating cats poses unique challenges. There are many limitations on the use of treatments in cats. We run into this issue frequently. Dr. Lascelles, what are your thoughts on our options for cats, and what do you reach for?

Lascelles: I think we are somewhat justifiably concerned about using nonsteroidals in cats because of cats' propensity for renal impairment. However, we are now starting to see data that suggest that nonsteroidals may not be such a bad thing in cats with renal impairment. That's a developing area. We also have the problem that medicating cats is more problematic in general than in dogs, and so we are often limited to one dosing chance a day or one medication per cat. There aren't that many clients who are able to give multiple medications and get them into a cat without disrupting the human-animal bond. Cats are more particular than dogs about what they are eating. They resent medications that taste bitter, and a lot of the medications we would like to use are bitter tasting. We can certainly use compounding, but some medications are very difficult to compound, and when they are compounded can lose the active ingredient.

My approach is to look at the individual. I initially concentrate on three therapeutic modalities in cats. One is dietary modulation or the addition to the diet of omega-3 fatty acids. Another is the use of nutraceuticals. Certainly there is one combination (glucosamine/chondroitin sulfate and avocado/soy unsaponifiables) that I've seen clinically make a big difference in cats. The third area to consider is drug therapy, and I'm usually reaching for nonsteroidals first and looking at whether or not I can manage the patient appropriately to minimize any risk.

Other medications might include drugs such as gabapentin. Cats differ from dogs and become almost neuropathic-like in the manifestation of pain, particularly chronic pain. Obviously, I would base any protocol on the different stages of age and disease progression. Cats certainly present a lot more challenges than do dogs.

Juillerat: Cats usually don't mind having fish oil on their food, so that's a nice, easy way to get that supplement in.

Fox: I use the Hill's® Prescription Diet® j/d®. I have excellent results with Adequan® and Dasuquin®.

Millis: In cats, we rely less on anti-inflammatories and more on supplements and polysulfated glycosaminoglycan. Because of the difficulty in finding a poly-pharmacy approach to managing cats, we rely more on modalities.

Most cats are pretty tolerant of heat therapy and stretching while they sit on the owner's lap. We've had cats that have been wonderful swimmers and actually enjoy it. Of course, they are in the minority of patients, but you have to try a little bit of everything. Just setting up an obstacle course around the house can work. If a cat likes to go to a particular bed or other place, make it so the cat has to use its joints a little bit more. For example, rather than hopping up onto a bed, alter the environment with a small stool so that it is necessary for the cat to hop on the stool first and then hop up onto the bed. Then gradually increase the distance that the cat has to hop.

Finding things the cat likes to chase, such as feathers, strings, or other toys, can also encourage exercise.

Canapp: Rehabilitation therapy is critical in cats because we are so limited in what we can administer orally. We frequently place cats in underwater treadmills. The majority have actually done quite well. Rehabilitation for a cat is a little different from that for a dog in that you have brief opportunities to work on a cat and then you must take a break and come back to it again later.

Dr. Millis, what are your thoughts on the role of nutraceuticals in managing joint health?

Millis: I think they are playing a much larger role than in the past. When nutritional supplements first came out for joint health, a lot of us looked at them with jaundiced eyes because there just wasn't the research data out there. Now I think there is a plethora of information that has come out. It is not all necessarily positive. There are a lot of studies that show negative results. The question is, what is believable and what is not. You have to look at the balance of the literature and the quality of the studies but also at the mechanisms of action.

A lot of the cell culture research that has been done, especially by companies such as Nutramax, has shown how a nutraceutical product can alter inflammatory mediators and destructive enzymes or metalloproteinases. It is difficult to say that that is how it would work in a large, complex organism, but at least mechanistically there is a reason why nutraceuticals might work.

The next thing is to look at some of the long-term data in people showing that some nutritional supplements can slow the rate of cartilage loss and be chondroprotective.

Alternative sources of omega-3 fatty acids

I think these supplements can help some patients and are very safe in terms of toxicities and adverse events. We are also now learning more about other types of supplements, for example, the avocado/soy oil derivatives (see the Related Link "Promising findings from recent in vitro research"), and there has been a flurry of activity in the human literature on MSM and SAMe. All of these supplements are beginning to show positive benefits. They are playing a much larger role today than they did just ten years ago.

Fox: I use nutraceuticals for two reasons: One is for pain control, and the other is for the chondroprotective aspect.

Canapp: Dr. Lascelles, what are your thoughts on using nutraceuticals?

Lascelles: Nutraceuticals are a potential source of a mild to moderate analgesic effect. I'm very focused on pain control. If you have a degree of pain relief, then you have increased mobility. Increased mobility is going to lead to better neuromuscular function. Better neuromuscular function is going to lead to microstabilization of the joint and, maybe through that mechanism, better joint health. I am primarily focused on the potential analgesic effects.

Canapp: Absolutely. I separate the use of these products into different subgroups: prophylactic/preventive, which we use for the performance and working dogs; early intervention, which we use for dogs with evidence of early joint pathology (juvenile orthopedic conditions) or following intra-articular surgical treatments; and lastly maintenance/end-stage treatment for management of dogs with obvious osteoarthritis.

Mainly because we see so many sporting and active dogs, we want to have those products on board at the time of insult to try to mitigate the inflammatory cascade that may occur from repetitive activity. For patients that absolutely have elbow disease or hip dysplasia as juveniles, early intervention is warranted. Even with chronic end-stage bone-on-bone cases, we know biologically, as Dr. Millis mentioned, decreasing interleukins and metalloproteinases can have a positive effect, but we will need something else in addition to that because of the severe pain associated with bone-on-bone conditions. I still feel that nutraceuticals probably have a place in the chronic end-stage cases, but we have to counsel the owners that they are not going to see a dramatic effect.

Millis: At The University of Tennessee, we're studying a colony of dogs with knee arthritis; we have tested nutraceuticals and all of the NSAIDs in this same group of dogs. Interestingly, at the two-week time point the nutraceutical Dasuquin® produced as great a response in terms of increasing weight bearing, as measured by a force plate, as an average nonsteroidal (see the Related Link "Dasuquin's efficacy may be similar to that of NSAIDs in dogs"). So when you consider the fact that the safety profile is favorable for a nutritional supplement, cost-wise it is comparable to an NSAID, and if you can get similar results, then I think the nutraceutical is a valuable adjunct.

There is not a great deal of information on the use of nutritional supplements in dogs and cats, but there is a growing body of human literature looking into the use of different compounds for the management of arthritis. We can't directly compare people with dogs, but where we lack the evidence in animals we can look to some of the research in people.

Lascelles: In our study at North Carolina State, we are looking at Dasuquin® in cats with painful degenerative joint disease. We are right at the end of this blinded, placebo-controlled study. The reason we are doing this study is that we did some pilot work looking at this nutraceutical. I was surprised at the response in feline patients. Dasuquin® appeared clinically to be almost as good as what we might get with a nonsteroidal. So I'm excited about looking at these results in detail when they come out. At the moment, we are blinded to the treatment groups, as is our statistician, and it will not be until all the statistics are completed that we will be unblinded. In the pilot study, we actually saw a response within about two to three weeks. At that point, nearly 80% of the pilot animals had shown a response.

Canapp: Dr. Millis, that's very similar to what you are finding compared with the NSAID in the canine model.

Millis: Yes. Anecdotally that is what practitioners report too, and it seems like avocado/soybean oil accelerates the clinical response over that of glucosamine/chondroitin alone.

Lascelles: I'm excited about that addition to glucosamine/chondroitin sulfate. I've had a lot of patients who don't respond to glucosamine/chondroitin sulfate alone. Adding in ASU puts it into a different category. We are seeing a different level of response clinically.

Millis: And there are human data to support that observation.

Lascelles: Absolutely. There is quite strong human data on ASU to support an analgesic effect.

Canapp: Dr. Fox, for what type of cases are you reaching for nutraceuticals, and are you recommending them for short-term or long-term use?

Fox: I recommend them for long-term use only. I reach for a nutraceutical earlier rather than later because I want to preserve as much cartilage as I possibly can. It is a great base to which other modalities can build upon.

Canapp: Dr. Millis, are you selecting nutraceuticals for short-term or long-term use?

Millis: Pretty much long-term. Osteoarthritis is a lifelong problem. It's not going to be cured in the short term so we have to manage it for the lifetime of the patient.

Canapp: I'm sure you've all seen clients bring in their bagful of supplements. A study done by the University of Maryland in the late 1990s was eye-opening. The researchers went to local health food stores and took products off the shelf, including chondroitin sulfate, and analyzed them. They found that 82% of the products didn't meet label claims. While all products costing less than $1 per daily 1200-mg chondroitin sulfate dose contained less than 10% of label claim, even more concerning was that even a couple of the very expensive products contained less than 10%. So, buyer beware.

Millis: There is an ethical obligation to put in the product what is on the label, and to make sure the product doesn't have toxic effects. In our profession, it is necessary to educate owners about the wide variation in these products and to teach them how we choose a particular product. Independent laboratory testing of a product's purity is probably the best thing we have at our disposal to make sure the product is in the pill. One organization that does do this is a website called consumerlab.com. For a small fee, you can have access to their testing results for various vitamins and nutritional supplements. These are mainly human products, but some veterinary products are tested as well.

Fox: My feeling is that Nutramax is on the forefront of research on the ingredients in their products. By using the highest-quality ingredients, their products are the gold standard by which all other nutraceuticals should be measured.

Canapp: Dr. Lascelles, what are your feelings on quality and quality control?

Lascelles: My approach has been to go with products from companies that are transparent in terms of quality control, that appear to be interested in research, that are moving forward, and that have a history of trying to produce a better product. Also, for any particular product I try to find out where it has come from. You would be surprised how many times the trail goes cold. I feel better if I can source a product back to a company and can call the company and talk to them and review the information they have. To be honest, I've settled on one company. I'm sure a lot of good companies are producing nutraceuticals, but I've settled on one company and even had the opportunity to tour that factory and actually see what is going on. All of those things together have made me feel reasonably confident that I am directing my clients to buy something that has in it what the manufacturer says it does.

Canapp: I have found that clients who have switched from glucosamine/chondroitin sulfate products to Dasuquin® see a benefit. Has this been your experience?

Lascelles: Yes, I absolutely agree. I think the addition of the ASU is a really exciting move forward. I find myself recommending the glucosamine/chondroitin sulfate/ASU combination more strongly as I get more positive feedback about it. So, absolutely, I think there is a greater clinical response and a more predictable response with the addition of ASU.

Millis: Yes, I think there is a measurable increase in activity with the combination product. There may be a synergistic response, or perhaps one dog doesn't respond to the glucosamine but it responds to the ASU. If you put all of the compounds together, then you may have more dogs respond. I do see a better response with a combination product, and MSM on top of that may add another layer of improvement.

Canapp: You mentioned synergy. Some of the research that has been done in cell culture shows the effects of these products on inflammatory mediators and their protective effects. We see an effect with the use of glucosamine, and add chondroitin sulfate, and the effect is greater. Then with the ASU product, you see a further drop in the expression of inflammatory mediators. That further expresses the synergistic effect of these products when acting together.

Millis: The sophistication of the studies and the state of the art knowledge suggest that you are actually turning on some of the metabolic machinery to gear up the production of cartilage matrix synthesis and hyaluronic acid synthesis. More importantly, from an arthritic standpoint you are actually altering some of the inflammatory mediators. ASUs have been especially impressive in their ability to suppress some of the interleukins and the matrix metalloproteinases, known substances that not only contribute to cartilage damage but also the pain pathways associated with arthritis. For example, putting glucosamine into a cell culture media increases GAG synthesis.

Chondroitin sulfate also increases GAG synthesis, but when you add the two together you actually get not just an additive response but a synergistic response. The interaction of all these different substances and how they affect cellular metabolism and protein synthesis and suppression of inflammatory mediators is interesting.

Canapp: Dr. Lascelles, has that been your experience, looking into the literature and the studies that you have come across?

Lascelles: Absolutely. I think the in vitro work is strong, consistent and compelling (see the Related Link "Promising findings from recent in vitro research"). It is very tantalizing evidence for an explanation of why there may be an analgesic effect with these combinations. But I think we have to be careful about leaping from in vitro studies to thinking this will be the effect of the orally administered combination in the patient.

Canapp: Dr. Juillerat, if these products actually have some sort of chondroprotective effect, then when would you recommend their use?

Juillerat: I recommend their use in younger animals to try to prevent disease in the future.

Canapp: Dr. Millis, do you have anything to add on the chondroprotective effects of these products?

Millis: In human patients, some studies have come out recently looking at cartilage thinning with hip and knee arthritis, particularly with regards to the use of glucosamine. A couple of these studies show that glucosamine, as well as ASUs, can actually reduce the rate of cartilage loss in a large series of patients. It is difficult to do those types of studies in dogs because the cartilage thickness is so thin compared with human cartilage. At least one study looking at injectable PSGAGs has suggested that it does, in fact, alter the progression of hip dysplasia in puppies bred for the disease.

Canapp: That was the premise behind our study when I was at Kansas State. Our findings were published in AJVR in 1999. We wanted to see if glucosamine/chondroitin sulfate had an early protective or chondroprotective effect. We had four groups of dogs in the study. One group was treated with glucosamine/chondroitin sulfate for 21 days; the other three groups were given placebo. At the end of the 21-day period, the dogs' right antebrachial carpal joints were injected with chymopapain to produce a mild transient synovitis. The prior treatment group then continued on glucosamine/chondroitin sulfate. We started another group of the dogs on the glucosamine/chonodroitin sulfate product, began administering a third group glucosamine/chondroitin sulfate/S-adenosylmethionine (SAMe), and a fourth group placebo. What we saw was that the dogs that had been pre-treated with the glucosamine/chondroitin sulfate product before the creation of synovitis had significantly less inflammation. We based that finding on nuclear scintigraphy, both soft tissue phase and bone phase, as well as objectively in the evaluations. So that was the basis for the premise that performance dogs or active dogs could utilize these products early on.

Dr. Juillerat, when are you recommending the use of these products in younger animals for chondroprotection?

Juillerat: Again, it is a patient-by-patient decision. Any of the small breeds that present with lameness that I know are going to develop a luxating patella I'll start on a nutraceutical. I don't see a large number of athletic canine patients, but I'll start the dogs that I know are going into competitions on it. I work with three police localities, and I probably have a total of 35 canine officers, and all of them are on nutraceuticals. I prefer to use nutraceuticals over the diets simply because I don't have any control of how much the patients are going to be getting with the diets. I feel there is more control in making a recommendation on dosage with the nutraceutical product.

Canapp: Dr. Lascelles, are you recommending the use of nutraceuticals in younger animals?

Lascelles: I am, but I'm recommending their use for pain control. So when there is any level of discomfort, that is when I start recommending their long-term use. I am not currently recommending nutraceuticals for joint health in young animals that are considered working animals.

Millis: I agree. If an animal has documented joint problems, I will recommend a nutraceutical at an early age. I know of no objective data that say nutraceuticals will prevent the aging wear and tear of osteoarthritis.

Lascelles: I think we all know there are lifestyle changes (such as weight management) that are more difficult to make but are probably going to have a much bigger impact on joint health at the end of life.

Fox: I use nutraceuticals if a dog comes in with early-diagnosed hip dysplasia, coronoid disease, or osteochondrosis. Then I use Adequan® with these nutraceuticals for pain relief and also to hopefully slow down the progression of the disease. When that young animal comes in to me it is all about weight management and getting that dog out to exercise.

Canapp: What combinations of nonsteroidals and nutraceuticals do you use, and what is your current technique?

Millis: For the patient with moderate to severe OA, I go with the big three: An NSAID for pain and anti-inflammatory control; an omega-3 fatty acid, given through either diet or supplementation; and then Dasuquin® with or without MSM. I feel that that combination addresses the major pathways that affect cartilage degeneration and also pain and has the least toxic effects. In terms of which is going to give you the most improvement clinically, probably the NSAIDs are going to work the quickest on average, although Dasuquin®, according to our research, works nearly as quickly. The effects of the omega-3 fatty acids are a bit longer. You need all three of those components to have reasonable success. Then we go from there. For example, we may consider adding SAMe or other products. Oftentimes we will also administer polysulfated glycosaminoglycans as an injection.

Fox: The NSAID that I feel most comfortable with is Deramaxx® because of its flexible dose schedule. I also use Rimadyl® and meloxicam. With nutraceuticals, I stick with the brand names, the Nutramax product Dasuquin®. Again, weight control is incredibly important. All these things are done in concert to decrease the amount of NSAIDs I use.

Lascelles: I'll use any of the approved nonsteroidals. I think of the nonsteroidal as my base analgesic. I'll also use steroids, but obviously not at the same time as NSAIDs. After having chosen the base analgesic, I use nutraceuticals. I tend to stick with Dasuquin® specifically. I tend to use those treatments long-term and then try to taper the nonsteroidal dose downward. I've moved away from short-term or pulse therapy to long-term treatment. I find that after a reasonably long period of nonsteroidal administration you can taper the dose. I continue with a nutraceutical while I'm doing that.

Canapp: Dr. Millis, do you find that there is some point in these multimodal types of regimens that you can lower or come off the nonsteroidals altogether?

Millis: Yes. If you look at the FDA data from some of the NSAIDs, particularly Deramaxx®, the improvement in weight bearing measured by force plate was continual throughout that six-week trial. I try to go for six weeks with everything full-bore to try to maximize the effect and then taper down from there. A lot of owners are justifiably concerned about potential adverse events, and it does make sense, especially in a geriatric patient. Rather than go to every-other-day dosing, I would rather decrease the daily amount of product. This approach avoids the wild shifts in pharmacokinetics, and it becomes a habit for the owner to give something every day rather than trying to remember to give it one day and then not the next.

Canapp: There are more veterinary studies coming out recently on the use of omega-3 for supplementation and nutraceuticals for osteoarthritis treatment in dogs. A recent study that came out in JAVMA looked at the use of the j/d® diet over time and compared that to a regularly available control dog food. The study showed that there was significant improvement in the supplemented dogs by using objective gait analysis or force plate analysis. Do you reach for omega-3s?

Lascelles: I do use omega-3 fatty acids. I promote their use on the basis that it is probably rebalancing the diet or helping to rebalance the diet and potentially promoting the production of less proinflammatory or some anti-inflammatory eicosanoids.

Juillerat: I also use omega-3 fatty acids. I don't go straight to the diets. I like to be able to know how much is actually going into the animal.

Fox: I happen to use the j/d® diet because I think it is hard to supplement the amount of omega-3 fatty acids that you need to reduce pain and slow the progression of arthritis. It is very palatable, and it is not another thing for the client to give. It is not uncommon for one of my patients to go home with j/d®, Adequan®, and Dasuquin® or a combination thereof.

Canapp: We have so much in our arsenal we can reach for. Since we are such a rehabilitation therapy-heavy practice, we reach for a lot of manual therapy modalities—acupuncture and chiropractic and all those types of modalities—in addition to the products we have already discussed.

Juillerat: At my practice, the Dasuquin® product with MSM is our primary recommendation, with the soft chews becoming increasingly more popular.

Lascelles: We have a lot of modalities available to us, and I tend to focus on modalities and nutraceuticals backed by a body of evidence that shows we are going to get some benefit. I will use glucosamine/chondroitin sulfate and ASU.

There are many other natural products that can have very powerful pharmaceutical effects. Just because these products are labeled natural, we cannot dismiss the fact that they may be associated with toxic side effects, particularly in combination with other drugs. We have to be cautious and go where the weight of evidence takes us, and then keep an open mind that other modalities and other treatments may work.

Canapp: We need to reach for products that have been proven to be safe and that we know contain the product the label claims to. And we need to look out for our clients' financial well-being as well as our patients' health.