Treatment of Early vs Advanced OA in Companion Animals
Panelists B. Duncan X. Lascelles, BVSc, PhD, DACVS; Mark Epstein, DVM, DABVP, CVPP; Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR; Margaret Gruen, DVM, MVPH, PhD, DACVB; and Sheilah Robertson, BVMS, PhD, DACVAA, DACAW, discuss different approaches to treating dogs and cats with osteoarthritis in early versus advanced disease.
B. Duncan X. Lascelles, BVSc, PhD, DACVS: We’re talking about osteoarthritis across the age spectrum, and we’re probably talking, also, about stages of osteoarthritis, degrees of severity, and degrees of impact on a patient. But if we think about the early diagnosis of OA—that we were talking about a few minutes ago—how does your therapeutic approach differ in the early-stage animals versus those with advanced disease? Mark?
Mark Epstein, DVM, DABVP, CVPP: It will begin with weight optimization, clearly. If they’re already lean, we make sure that they’re kept lean. If they are overweight, and not necessarily obese—because when we’re putting patients on that 1-to-9 scale, we tend to cheat and we say it’s a 5, but it’s really a 6, or we say it’s a 6, but it’s really a 7—we need to more clearly classify the patients. Even in that 10% to 15% of patients, that much makes a difference. Over a period of time, humans who have excess central adipose tissue—that is abdominal fat—will double their risk for any kind of chronic pain syndrome when they’re older. So, it’s really crucial, and that is where we try to start. I’m not saying my patients are any skinnier than anybody else’s. It’s a chore, and it’s difficult. It’s hard to monetize that kind of a thing, but it is crucial. We’d be remiss if we didn’t emphasize weight optimization.
B. Duncan X. Lascelles, BVSc, PhD, DACVS: That’s something that, in the early stage of OA...
Mark Epstein, DVM, DABVP, CVPP: It’s the most important thing, and the data are clear about that in humans and in animals, as well.
B. Duncan X. Lascelles, BVSc, PhD, DACVS: How about other things? Bryan?
Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: I think about managing or adjusting things based on whether I’m managing a young versus old patient. In the young, I’m doing things that help prevent or slow the progression. So, if I find that puppy who has joint laxity and is at risk for hip dysplasia, maybe something like a JPS (juvenile pubic symphysiodesis) can help improve joint congruity and help them down the line. And then I can address other things, secondarily. But things like weight management, joint diet, keeping them thin throughout their lives, just to echo my colleagues, that’s absolutely perfect. As it gets older, it changes a little bit. A lot of times, being a referral practice, we see patients who are referred in. I haven’t managed them for their whole life, so when they present older in age for osteoarthritic pain, then I’m focusing much more heavily on what strategies I can use to relieve that pain and discomfort and get them moving again—get that muscle mass up, reduce the sarcopenia or help kind of build that muscle mass back up, get them mobile, and improve their quality of life, ultimately.
B. Duncan X. Lascelles, BVSc, PhD, DACVS: So, it sounds like many of the things you’re thinking about in these younger patients are lifestyle changes and in trying to prevent deterioration in the future?
Mark Epstein, DVM, DABVP, CVPP: Nutrition.
Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: Yes, preventative measures.
B. Duncan X. Lascelles, BVSc, PhD, DACVS: Exercise, yes. And many of the patients who I see, the young dogs, have altered body carriage or altered body position. All animals and humans are programmed to minimize work—to minimize energy expenditure. When I see these animals that are leaning, they’re bent over, leaning forward, having rounded backs, I interpret that as they’re expending a lot of energy to avoid something significant, which means significant pain. How important do you think effective pain control is in these younger patients?
Mark Epstein, DVM, DABVP, CVPP: I think it’s critical.
Bryan T. Torres, DVM, PhD, DACVS-SA, DACVSMR: Yes, I think it’s critical. I also think it is important to do things like pain assessments and include the potential for physical therapy activities that could work collectively with effective pain management to increase their muscle strength in the certain areas that may be sore or reduce joint pain. And all of those items can work really effectively together.
Margaret Gruen, DVM, MVPH, PhD, DACVB: I agree that it’s critical. The other thing that I think is important, and Sheilah can talk more about this, is to think about the whole environment. For the home environment, is accessibility controlled and thought about? Do we make every effort to make sure that these patients can remain active and mobile? Do we make it as easy as possible for them? Are there rugs if there are slick floors? Are there stairs so they can get up to that bed that they like being on? We want to make sure that we keep them moving.
Sheilah Robertson, BVMS, PhD, DACVAA, DACAW: If it was an elderly person who had mobility issues, one of the things that happens is they have an in-home assessment. They go to the home and look around the home. That is possible.
Some veterinary services offer that, but I think you need to really see pictures of the owner’s home. If you find out that the dog who is quite impaired is in this beautiful home with all hardwood floors, you’re like, “OK, so now we need to talk about buying some yoga mats or some rugs.” For cats, if you think about what is important to a cat, they like living in a 3-dimensional world. One of those 3 dimensions that’s most important is height so they can see over their territory and their domain but be in their favorite place. So, is that cat able to get up there? You can do simple things like make places that are important to the animal much more accessible. You’ll have the dog where the owner says, “Well, he doesn’t go out,” and then house soiling issues that start up. Then you ask, “How easy is it to get out of your house for that?” Consequently, you realize they have to go down stairs. They might be living in a city. They’re going down stairs. Well, it’s not easy anymore, and it takes time. You have these other issues that can be very frustrating for the owner, but it actually could be a fairly easy fix when you understand the home they’re living in and the accessibility.
And just in thinking about some of these dogs, it can be night-and-day if you just ask, “Why don’t we get one of the help-up harnesses?” Because once you get a lot of these dogs up, they’re great, they can get going. And just a simple thing of asking, “Why don’t we get a harness for your dog?” can make all the difference to that owner and the dog, of course.