Nutraceutical and dietary management of chronic pain (Proceedings)

The most common application of nutrition and nutraceuticals in the world of pet pain is among chronic, maladaptive pain patients... These are the patients who benefit the most from a multi-modal, multi-target approach to their pain relief. In order to provide the very best care for these patients so as to achieve the best outcome on their behalf, we need to adhere to a few simple strategies. I like to think about putting my pain management plan together for chronic pain patients as analogous to building a pyramid — in this case, building the pain management pyramid.

It is critical to remember to begin at the beginning with these patients, and to be careful not to overlook something important because we get distracted by some clinical sign that we perceive as disproportionately urgent. Like building a real pyramid, when we build a pain management pyramid, we must lay a frim and large foundation. It is in this foundation that we place the nutritional and nutraceutical products that can assist our patients to a place of greater comfort.

So, before we can make the best choice for a nutritional intervention on behalf of a chronic pain patient, we need to begin at the beginning with a thorough examination include a neurologic exam, soft tissue palpation, joint ROMs, and gait assessment (at walk and trot, straight line and circling to both sides). Include a metabolic profile so as not to miss important co-morbidities. Once you have completed an appropriate diagnostic plan (e.g. don't forget radiographs when indicated so as not to miss an obvious OSA and treating it as an OA), then make your treatment plan to treat the treatable — and treat ALL the treatable. Make your plan and work the plan.

Chronic pain is best addressed from a MULTIMODAL approach — it is no longer appropriate to throw an NSAID or two at the patient. As we work to break the pain cycle as quickly and effectively as possible, we can initiate our nutritional plan to begin building for the long-term. There is no one right answer, but we need to set priorities (and there may be multiples) based on the needs of each individual patient.

Most chronic pain patients are less active, and consequently are overweight! Dr. Denis Marcellin-Little does a great presentation articulating that the most important pain management strategy and physiotherapy treatment for chronic pain patients is normalizing body condition. This means diagnosing and treating hypothyroidism. It also means that we must choose a nutritional product that follows the science. In this case, a nutrient profile that is proven to facilitate not only weight loss, but the up-regulation of "lean" genes, and the down-regulation of "obesity" genes. This nutrogenomic research is very elegant and compelling. And it translates into excellent outcomes in the real-world clinical setting. For chronically painful (OA) cats, in our pain management referral practice, high protein/low carb continues to outperform all other nutrient profiles to normalize feline body condition.

Make a long-term nutritional plan right at the beginning. If a co-morbidity exists, plan for appropriate therapeutic nutrition once weight loss is achieved. For instance, you may choose to utilize a proven weight-reduction formulation to achieve optimal body condition score, and then transition to a therapeutic joint support formulation once the body condition is normalized. However, if the patient has concurrent early renal disease (persistent microalbuminuria), a better long term choice will be a therapeutic renal support nutrient profile.

Best therapeutic nutrition is best achieved with a fixed formulation and consistency of feeding, so be VERY specific about WHAT to feed, HOW MUCH to feed, and WHEN to feed (e.g. how many meals per day?) Likewise, we have an obligation to follow the science. So for the chronic pain patient withno co-morbidities, right now the very best science for nutritional joint support lies behind a canine product that has demonstrated positive outcomes in as little as 3 weeks. There is now a feline joint support formulation, also backed by solid science.

If our chronic patient has metabolic co-morbidities, we must choose a nutrient profile that is the best fit for that patient. So, the presence of chronic renal disease mandates a renal support nutrient profile. If the patient also suffers from inhalant allergies, IBC, or colitis, suggesting immune-system imbalances, then a hypo-allergenic nutrient profile may make a better choice. Diabetes mellitus creates yet another scenario for nutritional support focusing on a metabolic issue that "trumps" joint disease. The take home message here is not to overlook any metabolic issues that should influence our nutritional choices for our patients.

The literature in human pain management clearly indicates a role for omega-3 fatty acids in ramping down inflammation — particularly joint inflammation in osteoarthritis. The specific omega-3 FAs that appear to be most beneficial are EPA and DHA. It is of particular interest that earlier this year a prescription omega-3 FA capsule was approved by the FDA. The combination of EPA and DHA also appears to support immune system function as well as to have a positive effect on remission times in certain cancer cases. Among the over-the-counter omega-3's that are currently available, the company that has received the greatest attention from the human medical profession is Nordic Naturals. This company has a liquid formulation for pets that is very well-accepted by dogs and cats, and is concentrated enough to make dosing pretty straightforward. Please visit www.omega-research.com for a compilation of scientific papers about the benefits of omega-3 FAs.

Another nutraceutical that has been demonstrated to benefit animal patients with osteoarthritis pain is microlactin. Microlactin is a milk protein that has been extracted from the milk of hyperimmunized cows. In this application, it has a general anti-inflammatory effect by blocking cytokines to inhibit neutrophil participation in the inflammatory response. This reduces inflammation and helps prevent subsequent tissue damage caused by excess neutrophil infiltration with the result of stopping chronic inflammation at the cellular level and thus avoiding the inhibition of protective prostaglandin activity.

Avocado soybean unsaponifiables and low-molecular weight chondroitin also appear to have a beneficial effect on joints affected by osteoarthritis. Additional quantifiable research needs to be conducted to clarify the details of these positive effects.

Finally, it is common to see pet owners reaching for glucosamine products, or glucosamine with chondroitin. Unfortunately, there is very little data to support the idea that these compounds get into the joints. The possible exception is that low-molecular-weight chondroitin may actually get to the joint tissues. More work needs to be done. Chondroprotective products administered orally are not considered drugs, but rather are nutraceuticals. The manufacturers have not had to provide efficacy data to the FDA or other regulatory bodies. Clearly we need controlled clinical studies in animals with naturally occurring OA to determine efficacy.