Vet P.O.V. On Metacam, Rimadyl, and their NSAID-ish side-effects

For today’s post I’d like to share the contents of a reader’s email for your consideration. This is Catherine Shaffer’s story, one she and I believe is worth sharing with other Dolittler readers. My comments will follow.

Dr. Khuly,

In 2006, we had a ten year old English mastiff named Nala. In October, she seemed to suddenly develop a lot of back pain. She'd been increasingly arthritic, but otherwise in excellent health--ideal weight, etc. The vet ran a metabolic panel, and even commented that all of her enzymes were perfect,whereas normally with a dog that age they see some values drifting out of whack. The vet put her on Metacam (meloxicam) for the pain.

I think Nala had injured herself somehow, we never knew exactly what happened. She began a slow recovery and we dosed her as directed with Metacam hoping she would regain her mobility. Although her injury did seem to heal, and she started moving around more, she also sometimes seemed to be in a lot of pain and was drinking a lot of water and peeing a lot.

I knew that was a bad sign, but at that point, with her age, we were trying to be minimally invasive with treatments, and so we continued to treat her pain. The drinking and peeing symptoms seemed to abate, and a few weeks later I left for an out of state business trip. Everything seemed normal.

A day or so later, my husband called to tell me that Nala had vomited up a tremendous amount of blood (it turned out to be half her blood volume) on the living room floor and he took her to emergency. Ordinarily, we would probably have euthanized her immediately, but I was out of state and horribly distraught, so we agreed to let the vet give her two units of blood and treat her.

By the time I got home, days later, we'd spent $4000 trying to save her. The final diagnosis was liver toxicity from the Metacam, confirmed by necropsy. The drug company (Boeringer-Ingelheim) ended up reimbursing us $1100 for the diagnostics that they added to their post-market reporting, and they also apologized.

I'm a pharma/biotech writer by trade an have a master's degree in biochemistry, with experience working in pharma research. I know that idiosyncratic drug toxicity happens. But when I researched liver toxicity in dogs and cats, I was surprised to find that the rate of toxicity and death seems much higher than would be tolerated in humans (and this isn't even considering the fact that most pet owners would have followed our first impulse, which was to euthanize and not pursue things further--the true rate of toxicity may never be known).

Also, unlike in humans, the NSAIDs seem to universally cause some stomach irritation, and I have seen recommendations that dogs should be treated proactively for stomach ulcers when they are on NSAIDs, so I suspect that some animals may be more sensitive to COX inhibitors than humans, and that problem is compounded by the fact that they can't tell us they have a stomach ache, not a back ache, when they begin to have symptoms.

Our vet was really shaken by the whole incident, and she shared with me some uncertainty about using Metacam in her practice. I think ultimately she and most vets come down on the side of feeling that the benefits outweigh the risks, but personally, ever since then I won't give an NSAID to any of my pets. Our kitty had a bladder infection a couple of years ago and we were offered Metacam along with antibiotics. I politely declined, and the kitty did just fine.

I still feel horrible that I did not get Nala into the vet when we noticed the issue with the water and peeing. It was our only real clue that something was dreadfully wrong. I honestly feel that if not for the Metacam, she'd have had another year or two of decent quality of life. Although she was ancient for a mastiff, she was an extremely small and lean one, never more than 105 pounds, and until that accident in October, still enjoyed her daily walk.

Best,

Catherine Shaffer

In response to Catherine’s story, and many others I’ve received before hers, I extend my deepest sympathies. Indeed, there’s nothing that seems more senseless than a preventable death.

An explanation is subsequently in order:

NSAIDs (non-steroidal anti-inflammatory drugs) are the go-to medications for pain in dogs––much less so in cats. Though Metacam is approved for use in cats as a one-time, pain-relieving injection, it is the only NSAID available for them. For dogs, Rimadyl, Deramaxx, Previcox, Metacam and others have been approved by the FDA.

These drugs do work. They work so well that a several hundred million dollar industry is built around them. Hundreds of thousands of dogs and cats receive millions of doses of these meds every year for pain relief after surgery, following traumatic events, and to manage chronic pain.

But as with any drug, there are side-effects. Liver and gastrointestinal issues are by far the most common unwanted findings, yet these are considered “minor” by the drug manufacturers and the FDA.

While veterinarians who have seen first-hand the damage NSAIDs can do in no way consider them minor, it’s nonetheless true that our worst horror stories seem minuscule in comparison to the life-saving capacity of these drugs. In fact, the longevity of our large breed canine patients has skyrocketed since they’ve become available.

Of course, that’s no consolation to those who’ve suffered a devastating NSAID-related death or lengthy medical complication secondary to their use. I hear you all. Which is why your cautionary tales are critical. The more you speak out, the more likely we are to counsel our clients on the down-side of these drugs. We’ll more carefully detail what side effects look like so that we can intervene earlier in severe side-effect cases.

I’m especially interested in Catherine’s story because she raises some very interesting points about liver toxicity, gastrointestinal side-effects of medications, and the difference in how we manage our human and animal patients.

In response to her observation: Yes, it’s clear that pet medications, just like pet foods, must leap far fewer hurdles than the human variety. Why else is Celebrex the subject of multi-million dollar class action suits while the owners of Rimadyl side-effect casualties continue to see the drug manufacturers raking it in on these drugs?

It’s because the acceptable risk for pets is far lower than for humans. Which means there’s even more of an onus on responsible veterinarians to explain these well. No excuses.

March 26th, 2009

Add Comment138 Comments

I did a lot of research before deciding to put Zack on Deramaxx. I knew that it could have some nasty side effects, especially liver related. He came to me with hip problems at an unknown but probably middle age. we managed him with supplements for years, but he has progressively become more painfull. After he almost fell down the stairs a few times (he seems to run out of "steam" towards the top) we decided to try pain meds. After weighing the risks and benifits, it seemed to be time. I know it might fry his liver, but I don't want him in pain, or to fall down the steps, so at this point it seemed worth it to me.

As pet owners, we owe it to our pets to research what we are putting into their bodies and discuss the risks and benefits with our vets. I research any meds my doctor prescribes me, why wouldn't i do it for my pets.

Now - if only they made reasonable priced pain meds for dogs...........

Teri March 26th, 2009 01:18:22 PM

My 2 cents. Although a pre-treatment panel was performed and was certainly indicated, this is no guarantee of what will happen post-treatment. Was there a post-treatment panel run? (I do one 2 weeks after starting NSAIDS). Were radiographs performed to try to further diagnose the problem? Were less toxic alternatives (I love tramadol and Adequan) tried first?

Hobson March 26th, 2009 01:24:13 PM

I'd be curious to know how long it takes for Metacam to do damage. My dog Frankie , a small terrier mix, injured his back and was on the medication for about a week, and then took muscle relaxers and recovered with rest. A month or so later, he began drinking a lot and sure enough, he was diagnosed with diabetes. He wasn't overweight, and he's always been on a healthy diet.

My vet looked at Frankie's records and said "Well, he wasn't on Metacam very long so it's probably not related." This was the first I heard of any potential side effects. Now that I read your piece, I wonder....

Edie March 26th, 2009 01:24:56 PM

Thanks for sharing this story, there has been plenty of discussion about NSAIDs in Jerry's Tripawd Discussion Forums. I think what makes the topic of toxicity so difficult to address is that all dogs seem to handle each drug differently.

We had a vet who put Jerry on Rimadyl as a pup for displaysia and he almost immediately started vomitting. So we immediately stopped giving it to him! Later in life, when the same vet insisted he had arthritis and put him on Prevacox, Jerry presented with runny, bloody stool within a couple days. We did some research online and discovered many dogs had serious gastrointenstinal issues or even died from Prevacox.

After his osteosarcoma amputation, however, Jerry received Metacam daily for nearly two years without showing any adverse effects. Compared to poor Nala's story, it's aparrent that all dogs are indeed different. Could any of these reactions be breed-specific?

tripawds.com March 26th, 2009 01:36:25 PM

It truly is a question of what your particular dog can tolerate. My bulldog was on Rimadyl for years without bad effects. My vet ran periodic blood panels to check her out, and they were always normal.

We tried metacam, and within a day she had bloody stool. I gave it another day to make sure it wasn't a one-time thing, and it wasn't. So I stopped the metacam, and the vet put her back on Rimadyl.

There you go.

Susan March 26th, 2009 01:50:28 PM

We thought my dog's cancer wasn't very deep, so I chose to have it cut out. We were wrong. The vet told me rimadyl was a very good pain reliever, and she wouldn't be dopey, but that if used long-term, there was a good chance it would have bad side effects. But then he told me she wouldn't be on them long enough to suffer the side effects, so he recommended her taking them. They weren't quite strong enough to cover her immediate post-op pain, so I called in for some doggie vicodin after he said she could take both. She only needed both for a few days, then I only gave her rimadyl until she didn't show signs of pain anymore.

When her aggressive cancer returned, I called in for more rimadyl, and we shared a few more weeks together until it was time for me to stop her from hurting.

A few years later, my other dog started suffering from arthritis. I remembered the rimadyl, but also the vet's warnings. I gave that dog aspirin (after looking up dosage for his weight), and luckily it made him more comfortable until the arthritis cleared up.

After my vet's warnings, and reading about them here, I would only consider doggie nsaids as a last resort. But if nothing else worked (including alternatives), and they were suffering, I would consider trying a doggie nsaid, but with monitoring.

Sherri March 26th, 2009 02:30:38 PM

Dr K, I've heard about more and more vets using Tramadol (a pain reliever prescribed for humans) for pain relief in animals. Is this a viable alternative to these NSAIDs?

Stephanie March 26th, 2009 02:39:22 PM

Wow. My dog was just on Rimadryl last week for pain relief after a tooth extraction. It was only a 4-day dose, but I recall just accepting my vet's direction without any question about the medication. What do I know, right? He did send me home with the information sheet, and it was a short duration on the meds, but my dog has had a ridiculous amount of gastrointestinal problems in her life. Not saying the vet should have done anything differently, but good grief - I should have had more curiosity about what I was putting into her body. That's on me.

Shasta March 26th, 2009 02:42:43 PM

Stephanie: I use industrial quantities of Tramadol in my patients. Though it often isn't enough for most of my severe osteoarthritis patients, using the Tramadol with the NSAIDs helps me reduce their dose, hence fewer side-effects.

And, like Hobson, I love using Adequan for osteoarthrits pain. Definitely helps.

Dr. Patty Khuly March 26th, 2009 03:05:29 PM

I've noticed a correlation between severe or fatal NSAID reactions, and the dog having recently been under the newer type of gas anaesthesia -- every case that's been brought to my attention has had those two factors in common, and all were previously-healthy dogs (no problems noted in pre-surgery workups, etc.) I think it's worth looking into.

The older type of gas anaesthesia doesn't seem to be a problem, far as the cases I've been told about.

The Scarlet Pimpernel March 26th, 2009 03:07:48 PM

When I read a story like this, I become sick inside. NASIDS are prescribed like candy and most pet-owner's don't give it a thought.

What I perceive as the real problem is how little warning of damage before it is serious and life-threatening in a lot of pets.

I have a friend that took a cholesterol drug for 10 years, had blood checks,and one day suddenly found herself in liver failure and nearly blind. It was a long and scary hospital stay, and eventually her sight returned.

Surely there has to be safe pain relief to prescribe for surgery, if not the Fentanyl patch (low dose).

I had my old dog on such a miniscule amount, and it worked fine. That's the other thing, often NASIDS are prescribed in dosages higher than need be.

I feel bad for these affected pets and can imagine what a horrible death they endure!

Pocket's Story from New Hampshire"

Barbara A. Albright/NH March 26th, 2009 03:23:10 PM

I have to agree that while NSAIDS to carry their own risks the benefits are plentiful. Workin in the ER for many years I will say that all too often owners will "treat" a household pet with medications prescribed for another (sometimes deceased) pet. Never give "Rover's" medications to "Harry" even if they are the same breed, size and have identical symptoms. Always consult with your veterinarian before giving your pet any over the counter medication, including aspirin, even if you look up the dose. You can potentially save yourself a lot of money and anguish by avoiding a trip to the emergency vet on a weekend by using common sense.

CVT March 26th, 2009 04:17:22 PM

About asprin - it is a NSAID as well, and can cause side effects - especially GI bleeding, and can interfere with some other meds, so make sure your vet knows.

I tried tramadol with zack first, before the Deramaxx, it didn't seem to help, and it made him more stupid than usual (i love him - but not the brightest dog that ever lived). My vet said that it is because it is just a pain killer like morphine, not an anti-inflammatory, which helps his arthritis more. Much fewer side effects, and less expensive, so i wish it had worked for him.

teri March 26th, 2009 04:35:09 PM

The letter doesn't mention how long Nala was on Metacam? If there were any panels run at intervals after being started on Metacam? Were refills granted without bloodwork? Was her Metacam dosed back to LED? (Lowest Effective Dose). Dogs on Metacam can often (and should be) dosed back to about half of their starting dose. I do believe that NSAID's do their job when used properly - and followed up on properly. There are many choices and some work better for some dogs than others. Let's take a poll and see who insists Tylenol works better for them than Advil...and vice versa? On the joint health side of things - there are many, many great nutraceuticals out there that can help dose back on any NSAID, or replace using an NSAID at all.

Bob March 26th, 2009 08:00:59 PM

Hi. After I read this I decided to check what I have been giving one of my cats. She kept having symptoms of a UA but tests did not indicate anything was wrong (both a free catch and a test with urine drawn from her bladder). He said sometimes cat's bladders can get "irritated" and that we should try a medicine called Proxicam 1.5mg every other day. He said if I tried it and then stopped and the symptoms came back, she may be one of the unlucky onces that would need this medicine as "maintenance". Well I looked this medicine up after reading these posts and found that it is a NSAID!!! Now I am afraid. She doesn't seem to be having any problems with it but it has only been about 1 month. I have a "wellness" check on Saturday and I am going to ask more questions. Maybe ask if we should do bloodwork. I don't know about others, but I trust my vet and I don't ask enough questions because of that trust. I am going to start asking more questions, especially about side effects.

Jan March 26th, 2009 08:47:12 PM

I'm glad you discussed the issue of risk tolerance in pets vs. in humans. It's true that the pet medical industry and human medical industries have different levels of risk tolerance. It's interesting though to see how individual owners assess risk for their pets. I've heard the story of a heavy smoker who refused to give up smoking when his doctor told him his daughter's asthma was caused by his smoking, but did give it up when his dog developed astma. My personal story is that I am MUCH more cautious about risks to my bird and about her diet than I am about my own diet or risks. My reasoning is that I understand the risks and choose to take them, but she cannot understand them so I must reduce them as much as possible for her.

Another thing that seems strange to me is how in the human medical community the overwhelming concern is to prolong the length of life (and the credo "do no harm"), while in the animal medical community the focus is on relieving suffering. Procedures that we would routinely perform on humans - even humans incapable of understanding such as children and people with mental disabilities (whether retardation, insanity, or senility) - we would never consider performing on animals, saying that they wouldn't understand.

zandperl March 26th, 2009 09:06:52 PM

The FDA Center for Veterinary Medicine now has a NSAID page with links to a lot of good information about the veterinary NSAIDs including links to articles, labels, and their new NSAID brochure. They page may be accessed here: http://www.fda.gov/cvm/nsaids.htm It's definitely necessary reading for anyone who is considering the use of a veterinary NSAID.

Jo March 26th, 2009 09:47:09 PM

My vet prescribed Metacam for my companion. He was collapsing on his rear legs, and the vet believed he had arthritis. He was on Metacam for a month. . .long enough to make him even worse than before the Metacam administration.

Until September 07, my companion was in no pain medication, only Benazepril. The vet never warned me of any side effects, never handed to me any information sheet, and never suggested a blood test for liver values.

I don't know if Metacam, which was administered to him AGAIN after his exploratory celiotomy, deteriorated his condition and Addison's. All I know it's a killing drug and its risks outweight its benefits.

http://www.metacamkills.com/

Asproolee’s Story

Fotini March 26th, 2009 10:11:00 PM

My chocolate lab, George, had to be euthanized - he had irreversible adverse reactions to the drug Rimadyl (NSAID). That was Oct. 13, 1997 - not much has changed - more NSAIDs have reached the market - more dogs are being adversely affected, and many dog owners never have been informed about the dangers of these drugs. A class action lawsuit was brought against PFizer in 1999 (I was one of two named plaintiffs in the action). Pfizer settled in 2004 - See: http://www.dogsadversereactions.com/nsaid/lawsuitsettled.html Drug companies (Pfizer was the first) have been urged by the FDA CVM to provide "Client Information Sheets" when these drugs are prescribed. Most vets don't take the time to give them out. Shame on them. We have to do our own research! http://www.dogsadversereactions.com/nsaid/memoriallist.html Jean T. - JOhns Island, SC (Always for George - Always for the Rimadyl Dogs)

Jean March 26th, 2009 10:47:06 PM

Dr K -

I was just curious whether Tramadol has been eleveated to a controlled substance for you (or for anyone else yet). Or maybe here in IL we are catching up with everyone else; but just very recently it has now become controlled. Not that is totally a bad thing but it does potentially affect how much your prescribing, how fast your going through it, etc. I have had a few cases when we thought the owners were drug seekers and taking their pets Tramadol. I haven't seen yet whether that will affect the price or not

That being said......my feeling's about NSAIDS use in animals. I think like every drug they have their time and place and can be VERY effective. I do think it is my responsibilty to share the risks with my clients and I know I could do better than I do. I think my downfall is more in the 'short term' use. I usually discuss with owners on long term drugs the side effects and risks. It is stories like the one in this post that remind me to be diligent about sharing those risks with owners.

I will mention again that I have a cat that had a reaction to Metacam...it was post an orthopedic surgery that it was utilized. However, I do not hate Metacam and still use it almost everyday for something. I guess I look at things with the attitude that Thank God we have things avaliable that can do an amazing job. I will be surprised if we ever have a drug that does something well with NO side effects. I just don't see that happening and I need to use something to help relieve pain in the interim. Granted I don't want to use the most harmful thing and cause more problems but sometimes the muscle relaxer or Tramadol isn't enough. If the owners are educated on risks then I feel the use of NSAIDS in animals is okay

J.C. March 26th, 2009 11:10:37 PM

The thing is, it's so individual. And many many dogs have taken Metacam. It's been available elsewhere for a number of years before it was available here in the U.S.
Chris took daily Metacam for years. From around 2005 to the end of his life in fall 2008 - every single day. Never once did it bother him and it was extremely effective at relieving his inflammation. Tramadol, on the other hand, made him violently ill. Couldn't tolerate it at all.
My impression has always been that problems with NSAIDs, if they are going to occur, usually occur fairly soon after starting them. That it's kind of a thumbs up /thumbs down issue - either they are fine or they have a very bad reaction and there's not much in between. And that they don't go months doing fine and then get a reaction. I don't know if that's true or not.

Natalie March 26th, 2009 11:12:54 PM

I have been the head technician at a vet hospital for almost 12 years and have seen countless animals treated with NSAIDS. I had never seen one have a life-threatening reaction to one. I owned a 9 year old queensland heeler that I had adopted from an owner who was unable to care for her when she was less than a year old. She had been hit by a tractor and required multiple orthopedic procedures. She had many complications but finally recovered well. She was fine until about 6 months ago when she didn't want to jump on the bed anymore. It was difficult to elicit any pain response from her, but we concluded that it was her hips and lower back that must be bothering her. I started her on Deramaxx (1mg/kg), Tramadol, Adequan, gluc/chon, fish oils, and she received acupuncture daily. Her initial bloodwork was completely normal. She did not improve much. One week later, she vomited once (all food, no blood). Her bloodwork was again completely normal. The next night, she began stretching and "bowing" then she started to have diarrhea. It became progressively worse incredibly quickly, she could not control her bowels at all. When she let out the most horrendous cry I have ever heard and vomited, I took her straight to the hospital. We took radiographs, she received a fentanyl patch and MLK drip, and she got worse. We gave her barium, and something looked a little suspicious. I opted to take her to surgery for an exploratory. She had an enormous perforating gastric ulcer and I euthanized her on the surgery table. Biopsy of the tissues revealed nothing more than "acute perforation, unknown cause." I never would have believed that my dog would not be waking up from surgery that day. It was the hardest thing I have yet had to do with any of my pets, mostly because it was so unexpected. My only explanation is the Deramaxx. At my hospital, we make sure each and every animal that is prescribed an NSAID goes home with an instruction/information sheet. NSAIDS have made a huge difference in the quality of life for so many pets, but I am hoping that more research will allow us to identify the pets that may not be such great candidates for these drugs. Or, maybe we will see an altogether new class of drugs that is safer. I am as neurotic as they come about my pets, and this happened so fast that nothing I did could save her. I wouldn't and haven't ever told anyone else not to use an NSAID for their own pet, but I will certainly be looking at the alternatives if any of my other pets need pain relief in the future.

jennysb March 26th, 2009 11:17:49 PM

According to the FDA and manufacturer, NSAIDs are contraindicated for cardiac patients. I found out about this "little" detail after my companion died!

Oral NSAIDs are approved for use in dogs only. *

All dogs should undergo a thorough history and physical examination before beginning NSAID therapy. *

Appropriate blood/urine tests should be performed to establish baseline data prior to, and periodically during, administration of any NSAID. *

Veterinary NSAIDS may be associated with gastrointestinal ulcers/perforations, liver, and kidney toxicity. *

Use with other anti-inflammatory drugs, such as other NSAIDs and corticosteroids, should be avoided. *

Patients at greatest risk for kidney problems are those that are dehydrated, are on diuretic treatment, or have pre-existing kidney, heart, and/or liver problems. *

NSAIDs can cause stomach or intestinal bleeding. Do all veterinarians warn their clients about the above risks? Mine DIDN'T!!!!

Fotini March 26th, 2009 11:51:27 PM

As sad as it is that some dogs have died as a result of complications from or reactions to various NSAIDS, to me the BIGGER tragedy is all the dogs who live in dreadful pain every single day because their owners - who really do love them - have read some scary story on the Internet about someone's dog who died after taking Rimadyl, Deramaxx, Metacam etc. and now they are too scared to try anything to alleviate their pet's pain.

It's important to keep in mind that while the tragedies are real, they are also incredibly RARE. Much more rare than dogs who are euthanized because they can't/won't get up anymore to go outside, and they start soiling themselves. Rimadyl and the other NSAIDS have actually INCREASED the lifespan of our pets overall, as well as improving the quality of their lives.

Well, some of the problem is denial - many, many pet owners refuse to believe that their pet is in pain unless it is actually crying or screaming. They don't realize or don't want to realize that not wanting to get up or down; not wanting to jump in the car or on the bed; not wanting to play; excessive panting; sleeping a lot more than usual etc. are all symptoms of pain.

Do I think people should reach for a NSAID for their pet first thing? No, I don't - and I wish more vets wouldn't do that either but would be quicker to recommend Adequan, Glucosamine/Chondroitin, fish oil, Tramadol, acupuncture etc. for treatment of various kinds of pain. But sometimes, especially with arthritis, you DO need the anti-inflammatory effect of a NSAID. You just have to be aware of the risks and keep close tabs on the dog's condition. IMO it really is worth the risk if the alternative is dreadful pain or euthanasia.

Barb March 27th, 2009 12:28:36 AM

Dr.Khuly - can you talk about what meds are good choices for CATS who have chronic osteo-arthritis pain? Seems there is little in the tool box for cats. Of course we always need to consider side effects but I'm really concerned about providing pain relief for elderly animals. My cat started a very small dose of metacam last Nov & it's like she was a changed animal. I was so happy to see the improvement in her mobility and mood. Unfortunately she's recently had a GI upset, a week of abx and sulcralate and she's better, but the metacam was halted for the duration and we're not sure about trying it again. But she's clearly in pain......

hornblower March 27th, 2009 12:57:33 AM

One of my older boys, 7, was dropped as a 12 week old puppy, 5 feet onto his elbows on a hardwood floor. He suffered a dislocated fracture of the proximal radial physis. Not good! Thankfully I know a phenomenal surgeon who did a prophylactic ulnar osteotomy and splinted the limb. The radius straightened it's self out and his elbow was saved.

We had 6 years of no problem, but now OA has set in. He is super active and utterly unconcerned for his own safety. We have done adequan and for the last 6 months, rimadyl.

I'm highly paranoid about it, so 14 days, a blood panel, then at 2 months then at 6 months. So far not a hiccup and he is enjoying himself and "levitates" from sound sleep to standing effortlessly. So we'll stay the course for now.

I have had one old girl develop liver function changes when on Rimadyl. And I know of another friends dog who nearly bled out after just a few days of Deramaxx. On the other hand, a decrepit 5 year old wreck of a rescue dog we took in went on for 7 years on an alternating cycle of Deramaxx, Rimadyl and Bufferin (regime developed by a orthopedist). She was a wonderful dog who would have died years earlier if not for the NSAIDs. Every dog is so different and I never take any of it for granted.

JenniferJ March 27th, 2009 01:10:59 AM

Dr Khuly, have you done a post re epilepsy? We had to euthanize a rescue foster on Monday. Horrid. Only three years old. My first seizure affected dog. Tried several different protocols but he deteriorated no matter what was done. While there are some decent articles out there, I found that in terms of reactions to medications etc... the information was suprisingly scant.

I frankly hope it's a long tome or never before I need to deal with this again, but any helpful pointers to really solid info would be a huge help.

JenniferJ March 27th, 2009 01:21:43 AM

@hornblower: I'm no vet but I have experience in this with both and old dog we used to have and an old cat we used to have. If it was me I would start feeding this cat a raw diet (only or in addition to regular cat food) of mostly chicken wings and chicken backs/necks. chicken cartilage is a natural source of glucosamine and chondroitin. As well I would feed your cat a glucosamine and Chondroitin supplement as there just won't be enough in the chicken. You can still feed your cat the normal food you're feeding now, just less of it. An added bonus of feeding bones is the chewing of the bones is great exercise for your cat that does not put stress on the joints like running around would and cats love it as well. I would suggest that you use one of the liquid glucosamine/Chondroitin supplements as this is easily added to either wet or dry food. Some sources claim that omega-3 fatty acids, obtained from fish are helpful in controlling chronic pain, as far as we know it is completely safe when given in moderate amounts. I would personlly not give my cat any of the drugs listed in this article, and there aren't any human pain relievers that I know if that are safe for cats like Aspirin is for dogs. If I could not solve most of the pain with diet and supplements I would seriously have to start to consider quality of life at that point. Not a good thing to have to think about I now. Anyways, I hope this helps you in some way and good luck for you and your kitty.

Chuck March 27th, 2009 01:35:23 AM

@JenniferJ

Did this rescue come in having seizures? If so did you guys have a chance to test for toxins such as Ethylene Glycol or Propylene Glycol poisoning? I remember a rescue at our local SPCA who drank a bunch of antifreeze or was fed it (who knows really) and had uncontrollable seizures. They waited probably way too long and then decided to euthanize him, as the needle was being loaded the dog died during a seizure. Just sounds a lot like what you're describing.

Chuck March 27th, 2009 01:41:47 AM

Jan: From Plumb's Veterinary Drug Handbook:

"Piroxicam has not been evaluated for use in cats. It must be used with extreme caution, if at all, in this species."

Piroxicam is an NSAID that is used specifically in cases where transitional cell carcinoma or squamous cell carcinoma has been diagnosed. It is intended for palliative use in these cases only. I suggest you ask your veterinarian about this...before you give another dose.

Dr. Patty Khuly March 27th, 2009 06:03:17 AM

J.C.: Yep. It's always been scheduled for us (far as I know, since I've always included my DEA number on the script). But I don't actually carry it in the hospital. I script it all out. In fact, we keep almost no controlled drugs for at-home use. Sometimes I'll send home buprenex or butorphanol in small course quantities but our controlled pharmacy is almost completely limited to injectables and patches. Safer that way.

I think I told the story about one of my clients' teenaged son's overdose on the dog's phenobarbital a few years back. I've been paranoid ever since.

Dr. Patty Khuly March 27th, 2009 06:09:21 AM

Hornblower: Ask your vet about Adequan. It's VERY safe in the cat. Make sure you're also giving glucosamine froma reputable laboratory (Cosequin for cats is my go-to product because i trust Nutramax and it comes in convenient "sprinkle caps." And ask about Tramadol. Also considered safe in cats, though the length of pain relief is questionable.

Dr. Patty Khuly March 27th, 2009 06:15:28 AM

My oldest dog (14), an Eskie/Lab mix, was run over by a van when just a puppy. When she got to be 10, she was showing pain in walking, elbow dysplasia (really bad), and back problems. We were told to give Bufferin, which didn't help her at all. Two years ago, a new vet suggested Zubrin, which I gave on a semi-regular basis, because I was concerned about her liver. Then, six months ago (we had bloodwork done 10 months ago and all was fine), she started slowing down, a lot. Thinking it was an increase in her pain (another dog had knocked her over several times), I started to be more regular about the Zubrin, and she got better (at least in her mobility). One month ago, she slowed down even more, and I tried adding Tramadol, but she got so sleepy and had accidents because she couldn't get up to tell me she needed to go out. Monday, I came home from work, found her on the floor, unresponsive and panting. I rushed her to the vet, but she died on the way there, struggling for breath. We did x-rays (I wanted to see spleen and liver, mostly), and it turned out her heart was huge. There was also something that maybe was a tumor near the aorta, so perhaps it'd burst, leading to blood in the pericardium, and laying down, she suffocated. Bloodwork doesn't really show much about heart function, and at her annual 10 months ago, her heartrate was strong and regular. Of course, since Zubrin (all NSAIDs) are not good for cardiac problems..... But the alternative would have been arthritis pain that would have made her miserable. I just wish I'd been able to say goodbye, instead of realizing I couldn't hear her breathing and looking in the backseat and realizing she was gone.

KateH March 27th, 2009 06:33:35 AM

KateH: What a sad story. So sorry.

Jennifer J: You know, I've never attacked the problem of seizures in a Vet 101 type of post. Though I've discussed it obliquely in a zillion, and profiled one case in a Pet Patients post, I've yet to do a thorough job of it. Thanks for the nudge.

Dr. Patty Khuly March 27th, 2009 07:43:13 AM

I realize it was not prominently enough referenced in my post so I'm repeating this link here.

This is Veterinary Partner's excellent information on the use of any NSAID in pets. For veterinarians and veterinary staff, consider printing this out every time you use NSAIDs in a patient--or at least before you intend to use long-term NSAIDs for chronic conditions.

I simply give out the URL but not every client is Internet savvy (not yet, anyhow).

Dr. Patty Khuly March 27th, 2009 07:59:34 AM

Thank you for the link to that article. Just this morning, when I was telling a neighbor why she wouldn't be seeing 'the little white dog' in my yard anymore, she told me about her niece, whose 9 yr old boxer mix is having trouble getting around. She said someone at the vet's (front desk staff) told her to use Bufferin (up to 3x a day!) - and I just shook my head. There are so many people who are told this around here. I was thrilled when my vet said to try something newer and better - which it was, mostly, except at the end. I printed out that sheet to give to her - and I'm going to be watching patients breathing more, and try to remind the vet about the heart issue, as well as liver/kidney problems from now on. And thank you for your concern. She was our 'smiley face girl' and is greatly missed.

KateH March 27th, 2009 09:15:25 AM

"School" (of life as well) is a place where your abilities (or lack thereof) are put under a microscope. And it is a place where there is a constant honing and perfecting of your lessons and technique.

The Vet should be feeling a debt of gratitude she's fears she never can repay since she wasn't sued for ever cent she has and will ever have.

Evet March 27th, 2009 10:55:58 AM

Chuck, he was a shelter dog with no history. He was in foster care with another rescuer for 6 weeks with no issues, was neutered, recovered and adopted out. he came to me after having a seizure cluster. The family had just found out they wee going from 2 jobs to none so sent him back to rescue, which I think would have occurred even without the seizures.

Blood work was done when he first seized as were follow ups. Nothing odd. He had a very very hard time getting acclimated to phenobarb but eventually did. Was seizure free with me for 6 weeks then began to seize. 3 days of intensive care and nothing could adequately stop them.

We did not do a necropsy. In an ideal world we would have but rescue funds are limited. And according to my vet and physician hubby, a standard necropsy is prety unrewarding for epilepsy unless it's a tumor or other gross anatomical cause.

JenniferJ March 27th, 2009 12:44:38 PM

I too am a fan of Adequan - I use the Equine not the canine and often wonder why more vets don't turn to Adequan ? I have also been researching Hyaluronic Acid to use in combo with Adequan haven't done it yet still reading - My experience is the Adequan is more effective than NSAIDs for joint injuries - not aware of any ill effects of Adequan ? is it because of cost more vets don't prescribe ? I haven't heard or read any criticism of Adequan, would be interested if anyone has some....

Sorry to read of Nala's reaction, sympathies to her owner and thanks for sharing her story.

LC March 27th, 2009 01:08:24 PM

These drugs have a place in veterinary medicine if used judiciously with the owner being aware of possible problems. But in my experience they are given out like candy to any dog that has even minor pain. And in most cases the owners are not aware that there can be any side effects; they are not given written information, and not instructed to do follow up blood work. That is the vets' lack of proper protocol. And in our area it is not just "one" vet but the majority of them, most of whom began prescribing these drugs when the manufacturer rep told them they were "safe" and have not changed their protocol since. I'd like to see somebody do a "mystery shopper" type survey to see what percentage of vets actually give appropriate information and warnings to owners with these drugs. I'll bet you would find that 75% of vets give these drugs with almost no information about possible side effects.

Mary March 27th, 2009 01:09:59 PM

Thanks Dr Khuly, I look forward to learning more about seizures and epilepsy. As i said, I hope to never deal with it again, but can't imagine I won't have at some point.

JenniferJ March 27th, 2009 02:49:16 PM

NSAIDs improve the quality of life for many dogs. I think the larger issue here is that many pet owners are not provided with sufficient information about their pets' prescriptions. Human pharmacies ALWAYS hand out paperwork even if you have been on the same medication for 17 years! Therapeutic drug monitoring (follow-up bloodwork etc) is also a critical step. There are numerous physiological factors that may affect drug clearance or volume of distribution. Body composition Breed effects/genetic variability Gender Age Pregnancy/lactation ***Presence of underlying disease**** Consider that the majority of drug trials for target animal safety are done in young, healthy, beagle dogs. NOT elderly, compromised, large breed mastiffs (or insert other breed here)! Pharmaceutical companies are able to conduct field effectiveness studies with client-owned animals with the owners' consent. Anyone can look up the Freedom of Information for an FDA approved drug. First, locate the NADA number of the drug. http://www.fda.gov/cvm/Green_Book/elecgbook.html You will see that Metacam has NADA number 141-213. Next, go to the Freedom of Information Summaries http://www.fda.gov/cvm/FOI/foidocs.htm and find the corresponding number. http://www.fda.gov/cvm/FOI/141-213.pdf

Sarah March 27th, 2009 03:04:48 PM

I've had a large breed whose comfort and life were enhanced significantly through Rimadyl - my vet is strongly in favour of the minimum dose theory, and it gave the boy an extra year at least. Apart from my own fur-kids, I'm also interested in the NSAIDs as related to birds, and there is almost no reliable info on this. We use Metacam very judiciously in our wild bird patients, and vet opinion is polarised for and against. Our main avian vet does not believe in pain relief for birds at all, while our 'in-house' vet favours moderate dosing for severe injuries. Either way, use is very short-term. I'd be interested in hearing from anyone with personal knowledge of birds and NSAIDs, specifically Metacam? Email is jcat456@gmail.com

jcat March 28th, 2009 02:37:02 PM

Just to let you know, Metacam is licensed for use in cats in the UK, at one third the concentration of the dog Metacam. We're a very small clininc, so I haven't prescribed it very much and can't comment in side-effects, efficacy, etc. To add my two cents to the Rimadyl debate, I've been prescribing it for about five years and had one dog vomit on it. But I always warn about the gastric/hepatic possibiliteis!

melvet March 29th, 2009 08:13:54 AM

The real tragedy is that so many dogs and cats are placed on NSAIDs to treat "arthritic" pain that should never have been allowed to develop. Many times NSAIDs are used to cover up a painful condition that otherwise would be treatable, if not curable, with an appropriate surgery. From hip dysplasia to elbow dysplasia, luxating patellas, cruciate disease, back pain, and on and on -- all of these are very treatable conditions that respond to direct therapy. Then they would not need lifelong therapy with these drugs. There are two tragedies when a pet dies of NSAID toxicity: that they lived with unnecessary pain and they died from a drug that could have been avoided with an appropriate diagnosis and treatment.

murphy March 29th, 2009 10:00:17 AM

I'm shocked to hear such sad stories about NSAIDs. My heart goes out to you. Many years ago, my vet recommended Deramaxx as an arthritis pain management solution for my 65 lb. Lab/Shep mix. (This was during the drug's trial phase and my vet was very perscriptive in her description of the potential side effects.) Kylie was one of the fortunate ones who showed immediate relief but required higher dose than recommended. My vet insisted I have blood labs performed every 6 months and, when Deramaxx gained approval, sign a yet another disclosure doc stating I took full responsibility for the doseage I was administering, as Deramaxx had recently downsized their recommended max miligrams/day. For me, Deramaxx gave Kylie 5-6 good quality years which wouldn't have been possible without the drug. I only wish there was something less expensive. I started out paying $60/month and over a 5-6 year period it went up to almost $90/month.

Pamela March 29th, 2009 06:10:25 PM

My 12 year old Samoyed mix has a sensitive GI system, so I was leary of putting her on NSAIDs when her arthritis started to impact her quality of life. I currently have her on Adequan (we're at the end of the loading phase), tramedol (25mg am and pm), and glucosamin/chondroitin supplements. While the results haven't been dramatic, she does seem more comfortable, more willing to go up and down stairs, will "trot" alone when we walk, and jumps up and down when happy/excited. It's not cheap, but she's been cost effective up until now! I'm willing to spend a few bucks to make her golden years a little more comfortable...

Susan in Portland, OR April 3rd, 2009 08:19:00 PM

When my mother's 15 year old maltese was diagnosed by his vet with likely anal sac adenocarcinoma, she simultaneously diagnosed him with fairly advanced kidney failure. He also had longstanding arthritis. On the very day she dx'ed him with kidney failure and referred us out for further investigation of his probable tumor, she prescribed him metacam for his arthritis pain --without a single word about possible toxic side effects and without a client information sheet.

Fortunately, he was a nippy lil guy, and my mother tried but could not administer the metacam. By that time, she had called me and told me about it and I looked it up and told her not to give it to him. I couldn't believe the vet had given a dog in kidney failure metacam without a word of caution.

At the Brightheart referral hospital where they confirmed his cancer, they also emphatically said that the first vet should NOT have RXed metacam.

His cancer had metastacized but he still was feeling fairly well. At his age and with his kidney failure, our choice was not to treat the cancer, which was also the onco's recommendation. Instead, he received tramadol for pain and 75 ml of fluids 2x day, plus other kidney support. His kidney values stabilized and he remained reasonably comfortable and normal for about 6 more months; he lived 8 months after diagnosis when we finally decided the time had come.

I am convinced if we'd given him that metacam, my mother would not have had that extra time with him. It would have done his kidney's in, I feel sure. And not a word of warning from the vet.

I did not report her to the Board, but I think I could have. My mother wanted to continue going to that practice, but she switched to a different vet.

Stefani April 3rd, 2009 09:58:54 PM

When I first brought my two kittens home from the shelter, they were 8 weeks old and severely underweight. They were jumping all over the furniture when the female jumped off the couch, landed wrong and hurt her front paw. When she was still limping the next morning, we took her to the vet to make sure nothing was broken. The vet said it was just a sprain and gave me a perscription for metacam, and to give this kitten 1-2 drops by mouth each day for two weeks (which was also how long this aweful splint was supposed to stay on). On the way home I was reading the box, it said for dogs 6 months or older and the smallest dose listed was for a 30 pound dog. We called the vet to see if there had been a mistake and no one answered the phone any of the 5 times we called until they turned the phone off at closing. The next day we finally got an answer, though all they had to say was "vets prescribe off label sometimes, it's fine" I decided the risk wasn't worth it and threw the meds out. As for the splint, they had taped two popsicle type sticks directly to her fur THEN wrapped gauze and vetwrap around the outside. We ended up having to cut/shave her sore paw out of this thing. Coincidentally I only left it on two days since my confidence in the vet was gone I decided I could just re wrap it myself if she was still limping. Thankfully Melody was fine and went back to playing with her brother. If anyone who reads this lives in North Texas, avoid the "Lewisville animal hospital" like the plague, they don't seem to care in the slightest about the well being of the animals they see.

Minxie April 4th, 2009 02:06:22 AM

My 9 year old lab had an adverse reaction to Metacam. He was in severe stomach pain after being on the drug for 2 weeks - minimum dose. He ended up at emergence and 8 weeks later he is still on sulcrate and famatodine for suspected stomach ulceration. It was a very painful experience for him.

He is now on Adequan and Tramadol to control his elbow and wrist arthritis. I too, wonder why Adequan isn't prescribed more readily. I used on my horse for years. No side effects and it really helped her and prevented further cartilage degeneration. It saved her life because she was literally a new horse on it.

I know that many dogs have been helped by NSAIDs. I just think that owners should be coached on what to look for if their is a negative reaction. Even the slight reactions should be noted as very serious. My dog just looked uncomfortable in his tummy area. No diarreah and slight vomiting. That was one day. The next day he went to emergency.

Chase April 16th, 2009 10:13:28 AM

In October of 2008 my female cat aged 13 was diagnosed by ultrasound with inoperable transitional cell carcinoma on the bladder wall growing down into the urethra. The onc vet gave her 2 months to live and prescribed metacam. She has been getting .2mls. orally every 3rd day (0.5mg/mL oral suspension) for over 6 months. (I also teated her homeopathically for 4 months.) In january she was diagnosed additionally with restrictive cardiomyopathy. A few weeks ago I read that metacam should not be given to animals with heart problems. My vet said that the metacam may be inhibiting the tumor growth and to continue its use. I have done so, but 5 days ago, there was blood in the urine for 2 days and then it was "normal" again. There has been no decrease in urine output. I'm feeling nervous about the metacam. I would very much appreciate your input. She also receives 12.5 Mg. of lasix daily to help prevent build-up of fluid in the pleural sacs. A bout of fluid build-up in January led to an echocardiogram and the heart diagnosis.

Maria May 4th, 2009 03:31:14 PM

I wish I had known or even been told the potential side effects of Metacam. My cat was hit by a car 12 days ago and, although luckily nothing was broken, he was in shock and in pain. He was admitted to an emergency vet (it was a Saturday evening) who gave him Metacam injections and released him wih instructions to dose him with Metacam orally twice a day. We did not give the dose as we knew he wasn't well- he tried to eat but kept spitting it out, then threw up- which he has never done before. We took him to his usual vet who then did loads of tests ( at great expense) to see if he had broken or chipped a bone. They also gave him Metacam injections despite me having informed them he had thrown up. He then declined rapidly and the vet said he was anaemic and the anaemia was a result of either flea bite giving a virus or a serious autoimmune disease. I told him both were unlikely as I use proper flea treatment monthly and it seemed too coincidental to suddenly develop an autoimmune anaemia( I am English so spell anaemia the English way!). At no stage did the vet mention a gastric ulcer as a cause of the anaemia. 7 days ago he called to say that our cat needed an emergency blood transfusion within the next hour or he would die. He could not get hold of the blood and could not even establish whether the cat was type A or B and our only option would be to drive 60 miles away to a specialist cat hospital ( the Royal Vet College in Hertfordshire). As England is a crowded island with too many cars we had a very slow moving and traumatic car ride through traffic jams and a 50 mile journey took 2 hours. cut long story short- he received the blood transfusion and perked up- went downhill the next day- discovered fluid in abdomen which was infected and he had peritonitis- operation followed and, sure enough, it was a gastric ulcer which had caused the anaemia and the peritonitis. To visit our cat has been almost impossible as we have to drive 2 hors there, 2 hours back and fit in an hour with him, and work and see to our children. We've seen him every other day and today he was moved out of intensive care. I would hate to think of the choices we would have had to make if we were not insured ( the bill so far is £5,900- that's about $10,000 and counting!). I will be telling every cat owner I know about Metacam!!!!!

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adsf June 1st, 2009 03:06:47 AM

Dear Dr K,

Thanks very much for your informative article.

My approximately 5-year old rescue female Rott suddenly limped quite heavily last night. Something was wrong with her front right leg, but I could find no thorn/lacerations/etc on her paw, felt nothing unusual in her joints. I took her to the vet this morning, and she was given a Metacam injection, with Metacam medication to be taken orally once a day for the next 7 days.

Well, it's been almost 12 hours since she had her Metacam jab this morning and she's still limping (and obviously in some sort of pain as she doesn't walk around the apartment as much). My heart goes out to her. So far, she has no adverse side effects/reactions to Metacam, but I am wondering, how long does it take for Metacam to 'kick in'? I am afraid it may not be arthritis that is afflicting her, that it may be something worse, although the vet did say it was either that, or soft tissue injury. In any case, Metacam would help.

I can only hope that Metacam works on her soon.

DL June 3rd, 2009 09:21:26 AM

My dog was put on Rimadyl a couple years back - she was limping - the vet said it would help her shoulder - it almost killed her - made her loose her bladder function - and made her extremely sick - of course we stopped it after she became sick but she has never been the same since - she ended up getting Addison's disease and I'm sure it was actually caused by the Rimadyl. I would never use a NSAID - since then I have heard of many dogs dying through being on Rimadyl :(:( - One vet has told me that vets can get points for prescribing it - the pharmacuedical company or whatever gives them points that add up so they can get iPods and stuff - that's why some vert prescribe it :(

Joanne July 1st, 2009 01:23:54 AM

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ثثث July 3rd, 2009 09:33:55 AM

My dog was prescibed Rimadyl today by the vet. I asked him outright if there was any type of side effects I should be aware of or on the look out for and he said no. She is also taking an anti biotic.

She had to get staples today to close a wound caused by another one of our dogs, my new boy, who is quite large, got into her food bowl and she picked a fight with him, his tooth caught her side and left quite a deep wound. The wound before going to the vet didn't seem to bother her, but now she is dopey as all get out, not even recognizing us until we get right up to her, and she seemed to be in a bit of pain before I gave her her dose for the evening.

I think tomorrow I may not give her any of the pain meds, unless she really seems to need them and if I do give her any it will be half the dose they told me to give.

I'm glad that I checked on line to see what type of side effects this medication can cause...I'm off to research the anti biotic as well.

My deepest condolences to those who lost their pets.

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