• (revised July 2011)

    Arthritis is not a reversible condition once it develops, and it always progresses over time. Also, dogs tend to be the most stiff/painful after rest, so you are probably seeing that your dog is stiff getting up after a nap, etc. Arthritis in dogs, just like in people, is also more pronounced in cold or wet weather. Many people see that their older pet is just getting up slower or not moving around well, and just attribute it to “old age.” However, it is important to recognize that these signs are caused by pain related to arthritis in most cases. Treatment is aimed at controlling the pain, reducing the progression of the arthritis, improving mobility, and maintaining overall health.

    The recommendations that I am going to make are generally needed life-long for arthritis. As arthritis progresses, the treatment recommendations for a specific patient will change. Arthritis treatment includes 4 parts, with a 5th option.

    One important additional note. If your pet has symptoms that seem consistent with arthritis, but the symptoms come on suddenly, progress rapidly (over days to weeks, rather than months to years), are associated with loss of function of one or more legs, or are accompanied by any other systemic signs (loss of appetite, vomiting, weight loss, coughing, difficulty breathing, excessive thirst or urination, etc.), then this may not be arthritis, or there may be an additional problem present along with the arthritis. Your pet needs to be evaluated by a veterinarian when beginning a medical treatment regimen for arthritis.

    1) Moderate, low-impact exercise:

           Exercise helps keep the joints more mobile and helps to maintain muscle strength and mass (so that the muscles can help to support the arthritic joints). The less active a dog is, the more stiff he/she gets. Excessive exercise can make a pet more painful, so there should be enough exercise to keep your pet active, but not so much that the next day he/she is very painful. Exercise should be performed on a regular basis. For arthritic pets, shorter, more frequent intervals of exercise are preferable over longer, less frequent activities. An arthritic dog may not tolerate a one hour walk every few days, but might be much more comfortable with daily half hour walks.  Low impact exercises such as swimming or walking are preferable over high impact exercises such as running or jumping. The best exercise for arthritic joints, hands down (or is that paws?), is swimming. Swimming keeps the muscles toned, but doesn’t impact or stress the joints. The next best exercise is walking on a regular basis. Jogging is okay, but is a little harder on the joints. The worst exercises are those that result in irregular or side-to-side motion such as hiking over rough terrain or rock hopping, or activities that cause excessive force on the joints such as jumping to catch a ball or Frisbee.

    Another factor is weight control. Dogs that are arthritic tend to be less active. This tends to lead to weight gain, which is harder on the joints and tends to make then want to move around even less, so they gain more weight…a dangerous cycle. Exercise helps keep the weight down. In addition, we now know that there are 2 kinds of fat that develop in the body…peripheral fat (on the outside of the ribcage and other external areas) and abdominal fat (which is strictly within the abdomen). We now know that abdominal fat not only is hard on arthritic joints by increasing the weight that they must carry, but also that it is actually a chemically active organ. Abdominal fat produces chemicals called cytokines, many of which are the chemicals that the body uses in creating the chemical reaction which results in inflammation and pain. Over 20 of these chemicals have been identified, so far. Therefore, abdominal fat actually “feeds” the inflammation and pain of arthritis. Arthritic dogs often benefit from being on a low calorie diet and getting low calorie treats (or no treats), in moderation, to help keep their weight controlled.

    Situations where a dog is a chronic overeater (or owners that are chronic overfeeders) may result in a dog that is very difficult to achieve adequate weight control for. In certain circumstances, there is a medication, called Slentrol, which may be indicated to help control weight in these dogs. Ask your veterinarian if your pet may be a candidate for treatment with Slentrol.

    Rehabilitation therapy:

    As an addendum to exercise, there is a more directed form of therapy called “rehabilitation therapy.” This is akin to physical therapy in people, but just has a different name in veterinary medicine. This is a matter of educating owners in certain specific exercises that they can do with their canine companions in order to help strengthen the muscles that the body uses to support the arthritic joints.  Rehabilitation therapy has been shown to be very effective at reducing the symptoms of arthritis, if the owner is willing to be an active participant in the dog’s therapy.

    Rehabilitation therapy consultation is available at our office with Dr. Kolmstetter, who has been trained in animal rehabilitation therapy. We have a canine land treadmill and a variety of canine exercise equipment available at our Pet Physical Rehabilitation Center.  There is also a rehabilitation therapy department at the Las Vegas Veterinary Referral Center, in the southwest part of town.

    2) Chondroprotective agents:

    These are not drugs. They are essentially nutritional supplements (“nutraceuticals”) for the joint. They are very safe to use, even in the presence of other medical problems. They do not control pain directly, but they do help to maintain the health of the joint cartilage, which results in reduced pain and probably slows down the progression of arthritis. The end result is a more comfortable joint. They do not start working as soon as you give them, like pain medications do. These products are meant to be used long-term, to help maintain the joint health as much as possible. Don’t be discouraged if you do not see an immediate effect. The effect may not be evident, even though it is helping the joint. There are 2 main types of chondroprotective agents:

    GLUCOSAMINE:

    Recommended product:

    Cheyenne West Animal Hospital “Joint Care DS” or “Joint Care Minis”

    Glucosamine is one of the primary building blocks of cartilage. Oral glucosamine supplements are very popular, and are beneficial for the joints. Glucosamine is often combined with other products (chondroitin, MSM, creatine, manganese, vitamin C, etc.) to enhance its effect.

    There are many products, both prescription and over-the-counter, and some foods that contain these components. Other good products include Joint Care, Cosequin, Dasuquin, Glycoflex, GLC1000, and many more.

    As glucosamine has become more commonly used, there has been an explosion of products available, in all price ranges.

    A word of caution: Glucosamine is not a drug, and is not regulated by the FDA. It is considered a nutritional supplement, and therefore has much more lenient guidelines regarding its manufacturing. In addition, companies do not have to prove that their product is consistent in its formula, or that their product is in a form that can be absorbed or used properly by the body. Many of the over-the-counter products are substandard in their formulation. The good news is that these products are rarely, if ever, harmful. The bad news is that, even though a product is much cheaper, it still may not be as beneficial for your pet as a more reputable brand. Expensive over-the-counter products are not always going to be better quality, but the cheaper the product, the higher the likelihood that it is not going to be as effective.

    That being said, it is better to use a less expensive over-the-counter product, than using nothing at all. Some is better than none.

    ADEQUAN: Arthritis does to joint fluid what your car would do to oil if you never changed the oil…it causes a breakdown of viscosity. Adequan is an injectable chondroprotective agent. It works on the joint fluid, rather than the joint cartilage. It helps to decrease some of the ongoing damage that makes the joint fluid less viscous. It is a very safe product. It is given by your veterinarian as an intramuscular injection twice weekly for a course of 6-8 injections. This is the course recommended by the manufacturer, and I find that these dogs often benefit from getting an additional “maintenance” injection every 4-8 weeks, thereafter.

    The advantage is that it can help reduce the progression of arthritis, and is very safe.

    The disadvantage is that it has to be given by injection, but we can teach you how to safely and effectively administer these injections at home.

    Conclusion: Glucosamine is beneficial to dogs with joint problems and arthritis at any stage, from very early to very advanced. Adequan is also a great additional treatment. It can be used by itself, or can be combined with glucosamine.

    A special note on diet: Some diets advertise that they contain glucosamine, chondroitin, and/or Omega-3 fatty acids. This claim is usually true, but the important factor is whether or not the diet contains an amount that is enough to have the desired positive effect on the joints. A particular diet that claims to have these ingredients should be critically evaluated as to the amount that is present.

    One diet that does have the appropriate amount of glucosamine and Omega-3 fatty acids is a prescription diet from Hill’s Called Prescription diet j/d (which stands for “joint diet”). This diet contains an appropriate amount of these ingredients, so can be fed in place of using these supplements.

    3) Omega-3 fatty acids:

                  Dose: 180mg of EPA per 10 pounds of body weight, once daily

                  Preferred product: Derma-3 liquid (used at 2 times the label dose, will provide 180mg of EPA per 10 pounds of body weight)

    Fatty acid supplements, primarily Omega-3 fatty acids, are beneficial for allergies and other conditions. These products have been used for a long time in skin conditions, and there are many products available on the market. Our knowledge of the effectiveness of these products has changed over the last few years, and we are now using 5-6 times the dosage that we used to use. This higher dosage is beneficial for inflammatory conditions such as allergies, arthritis, inflammation of the organs, and other areas. Many older products have a label dose that is far too low to be significantly beneficial.

    Omega-3 fatty acids, primarily EPA and DHA, are the primary active oils.   They are known to be protective against some of the negative effects of inflammation, and (at the proper dosage) have some anti-inflammatory action themselves. There are other fatty acid supplements out there, the ideal one is one that is has a fish oil source.

    The dose is based on the level of EPA (Eicosapentanoic acid) in the product.

    Dose: 180mg EPA per 10 pounds of body weight, once daily. This can be adjusted up or down a bit, depending upon the strength of the product that you are using.

    There are many of these products, both prescription and over-the-counter, and some foods that contain these components. There are a number of good veterinary products available, but the label dose is not always the therapeutic dose.

    As Omega-3 fatty acids have become more popular, there has been an explosion of products available, in all price ranges.

    A word of caution…an Omega-3 fatty acid supplement is not a drug, and is not regulated by the FDA. It is considered a nutritional supplement, and therefore has much more lenient guidelines regarding its manufacturing. In addition, companies do not have to prove that their product consistently has the amount of active ingredient that the product has on the label. Nor do they have to prove that it is in a form that can be absorbed or used by the body. Many of the over-the-counter products do not have the right amount, or it is in a form that the body can’t absorb or use. Other than this concern, the products are not harmful, and don’t contain a significant amount of calories.

    That being said, I would rather have patients on an over-the-counter product, than on nothing at all.

    4) Pain medication:

    Arthritis is painful. That’s why dogs are stiff or have lameness. Dogs tolerate chronic pain very well, though, and generally don’t cry or whine, so some people are under the misconception that it doesn’t hurt. Dogs with arthritis always benefit from some level of pain medication. The first line of medication is generally a non-steroidal anti-inflammatory drug (NSAiD).

    NSAiDs help reduce both pain and inflammation, which are 2 key components of arthritis. NSAiDs are given as needed for pain. However, as noted previously, it can be very difficult to tell if a pet is in pain. Arthritis progresses to the point where dogs need an NSAiD every day, and these drugs can be given on a daily basis. In general, it is better to err on the side of giving medication even on a day when the pain is not so bad, than not giving medication on a day when the pet is particularly painful and just not showing it. Owners are often surprised by how much more active their dog is when he is taking an NSAiD even if they felt that he was not painful. This is because their pet was painful, and was just not showing it.

    NSAiDs work by blocking an enzyme in the body (cyclooxygenase) that produces chemicals that are associated with the pain response…the mechanism is beyond the scope of this discussion, right now.

    All NSAiDs have potential side effects on the liver, kidneys, and stomach (gastritis, ulcers). Each specific drug has specific potential negative effects. Also, if a dog has active liver or kidney disease, NSAiDs should probably not be given, unless the benefit outweighs the risk. Because of this, when a dog is on an NSAiD, he/she should get the liver and kidney values checked (a simple blood test), occasionally, to make sure it is still safe to continue the NSAiD. It is usually recommended to check values before starting an NSAiD, then 2-3 weeks after starting the drug, then 3 months after that, then every 6-12 months thereafter (unless they are showing signs of illness, as noted below).

    Whenever a pet is on an NSAiD, he/she needs to be monitored for side effects. Symptoms can include: excessive drooling, panting, vomiting (especially if the vomit contains granular material that looks like coffee grounds), loss of appetite, or black/tarry stools. A point to note: A dog’s stools will often turn dark or even black after a long enough exposure to light and air. The stools that are of concern are generally jet black and relatively soft when they are first produced.

    There are many NSAIDs available now. Here is a brief description of some of them. This is not intended to be a complete list of all available drugs, since new drugs are regularly introduced to the marketplace, nor is it a complete list of the possible side effects of each drug mentioned. Additional literature with more complete information is available, upon request.

    ASPIRIN (“ASCRIPTIN”): This was the original NSAiD. It is a mild to moderately good pain medication, is inexpensive, and is non-prescription. It is not nearly as strong as the prescription medications and much more likely to produce stomach ulcers or gastritis in dogs. In fact, one study showed some level of bleeding from the stomach with a single dose of aspirin in every dog in the study. Aspirin can be used, but there are many drugs that have better pain control, with less chance of causing gastritis or ulcers.

    If aspirin is used, a Maalox-coated aspirin, such as “Ascriptin” may reduce some of the stomach irritation. Avoid “enteric coated” aspirin products. They are not harmful, but they often pass through the system too quickly, and are not absorbed completely in dogs, so they don’t help as much.

    IBUPROFEN (“ADVIL”): Don’t use this!! It is comparable to aspirin, is non-prescription, and is inexpensive. However, it has a much higher chance than other drugs of causing stomach ulcers and kidney or liver problems in dogs.

    NAPROXEN (“ALEVE”): Don’t use this!! This is another alternative drug to aspirin that is non-prescription, but has a much higher chance of causing kidney problems in dogs.

    ACETAMINOPHEN (“TYLENOL”): This drug is not an NSAiD. It is a pain medication, but does not have anti-inflammatory effects. This drug can be used, but by itself is not good for arthritis control. Acetaminophen is not an anti-inflammatory, and one of the key components of arthritis is inflammation, which this drug won’t control. It is non-prescription and inexpensive, and can be used in some circumstances where dogs cannot take an NSAiD. It has to be used with great caution, especially if liver problems are present. It has potential toxicity, and a “safe” dosage has not been determined in dogs. Typically, this drug is used only when the benefits are felt to outweight the potential risks. It can also be used for more advanced arthritis pain, in a prescription form that is combined with a narcotic drug, like codeine.

    PHENYLBUTAZONE: Don’t use this!! This is an older drug that was popular before the newer generation of NSAiDs became available. It is difficult to find the product for small animals, but is still frequently used for horses. It is a prescription drug, and is inexpensive, but the pain control is not as good as other drugs, and it has much higher potential for side effects.

    PIROXICAM (“FELDENE”): This is a prescription NSAiD. It has good pain control and is an inexpensive drug. This can be used when we want more pain control, but cost is a concern. The problem is that this drug is more likely to cause gastritis, stomach ulcers or kidney problems than most of the other available prescription drugs.

    Advantages: It only needs to be given every other day, it is inexpensive, and has good pain control.

    Disadvantages: It has a higher risk of side effects.

    This is a good drug, if the dog is monitored carefully, and if the owner is willing to accept some increased risk of side effects.

    *CARPROFEN (“RIMADYL”): This is a prescription drug made for animals. It has been around the longest of all the newer generation veterinary-specific NSAiDs.

    Advantages: Good pain control, easy to give (chewable tablets or smaller caplets), once or twice daily administration, reduced side effects.

    Disadvantages: More expensive than the drugs listed above.

    *MELOXICAM (“METACAM“): This is a prescription drug made for animals. It is similar to piroxicam, but is a safer version. It comes in a honey-flavored liquid that can be mixed with the food.

    Advantages: Good pain control, once daily administration, easy to give, reduced side effects.

    Disadvantages: More expensive than the drugs listed above.

    Other prescription NSAiDs include: Deramaxx, Previcox, Etogesic, Zubrin, and others. There are also new drugs that are in the process of being approved by the FDA, and will eventually be available.

    There are other pain medications used, that are not NSAiDs, as well.

    * “DURALACTIN: This is a prescription drug made for animals, and is an anti-inflammatory, but is not an NSAiD. This drug has a different mechanism of anti-inflammatory action. It is safe to use in an animal that has active liver or kidney disease, and is easy on the stomach. This drug is probably not quite as strong as a true NSAiD, but is safer, especially in the presence of other disease conditions. It comes in chewable tablets that can be given directly, or dissolved in milk.

    Advantages: Very safe. Good for use if other medical problems are present.

    Disadvantages: Moderately expensive and not as strong pain medication as a true NSAiD.

    TRAMADOL: This is a prescription pain medication that is not an anti-inflammatory. It is similar to narcotic drugs, but not quite as strong as the narcotics, but does not have the side effects of the narcotics. It is not a controlled substance, because it is not addictive, like the narcotics.

    Advantages: Very few side effects. Best when used as an adjunct to an anti-inflammatory drug for more advanced arthritis. It can be used if other medical problems are present, in most cases.

    Disadvantages: Expensive, tablet form.

    NARCOTIC DRUGS: Examples are morphine, hydrocodone, and codeine. These are prescription pain medications that are not anti-inflammatory. They are controlled substances, so may be a little less convenient to get. Very good pain control, but potential side effects include constipation, urine retention, nausea, drowsiness, etc. Best when used as an adjunct to an anti-inflammatory drug for more advanced arthritis. Better than tramadol for pain.

    Advantages: Very good pain control. Best when used as an adjunct to an anti-inflammatory drug for more advanced arthritis.

    Disadvantages: Some are expensive, some are not; higher level of side effects; controlled substance.

    AMANTIDINE: This drug is not specifically a pain medication. It helps to treat something called “wind-up” pain (that’s pronounced wind as in what you do to a watch, rather than the wind blowing). “Wind-up” pain is a response to chronic pain, where the pain receptors become hypersensitive to stimuli. Then, things that shouldn’t be painful, become painful. When arthritis becomes more advanced, some dogs stop responding to the NSAiDs, because of wind-up pain.

    In this case, we give amantidine once daily for 3 weeks only. It is not an ongoing drug. It basically “resets” the pain receptors. If effective, it is very likely that at some point in the future, the dog will need another 3 week course.

    Advantages: Safe drug; can enhance other pain medications if wind-up present.

    Disadvantages: There is not “test” for wind-up. If we suspect wind-up pain, we just have to give the drug and see if it works. Amantidine is not to be used by itself, because it only controls wind-up pain. It must be used with another pain medication. There is also no set dose. Dose is determined by trial and response.

    GABAPENTIN: This is a drug that is used for neuropathic pain in many circumstances, and can be a safe and effective additional medication for chronic pain, such as with arthritis. This is a prescription medication that is available in most human pharmacies. For smaller animals, this medication must be compounded into a form (liquid or capsule) that can be accurately dosed. The prescription medication for humans comes in a liquid form as well, but be aware that the liquid that is made for humans should not be used in animals, because of the artificial sweetener (xylitol) that is used in it. This sweetener is not safe for animals.

    STEROIDS: Primarily prednisone. These are very potent anti-inflammatory drugs. They are stronger than NSAiDs. The problem is that at the dose required to control arthritis pain, it has wide-ranging side effects on the body, including the liver, kidneys, bones, muscles, stomach, and intestines. It can cause high blood pressure, decreased healing ability, weight gain, stomach ulcers, and suppression of the immune system.

    Advantages: Very good anti-inflammatory drug, inexpensive.

    Disadvantages: Many side effects and can actually speed up the progression of arthritis. Only used when nothing else seems to be effective, usually as a last resort.

    5) Alternative therapies – acupuncture and chiropractic:

    Acupuncture is an ancient oriental technique that most people have heard of. There are many potential reasons why this therapy can benefit patients with arthritis, however, it is difficult or even impossible to describe in “western” terminology. This is a therapy that has been used effectively for thousands of years in people and animals, and has significant benefits, especially for chronic pain conditions.

    Acupuncture can be performed in our office by Dr. Lopez. In addition, there are holistic veterinarians in Las Vegas that we can refer you to that are specifically trained in acupuncture and other alternative therapies, such as chiropractic. Please call our office for more details.

    Chiropractic is a therapy that has been used frequently on people, and is now also being practiced on animals. We do not practice chiropractic at our office, and therefore cannot specifically advise or educate on its benefits, risks, or effectiveness. If you are interested in more information, we can refer you to a doctor that practices animal chiropractic for more information. If you are going to consider this approach, make sure that it is with a doctor that is experienced. There are a few veterinarians that practice chiropractic regularly, and there is one human chiropractor in town (Dr. Sidney Carter) that is licensed to practice chiropractic on animals.

    Conclusion:

    In early to mid-range arthritis, I recommend an NSAiD.

    Recommended products: Rimadyl or Metacam.

    If cost is a significant concern: Piroxicam (watch out for side effects). In addition, we now carry a generic form of carprofen (the active ingredient of Rimadyl), which is slightly less expensive, but only comes in caplet form (Rimadyl is a chewable tablet).

    When arthritis is more advanced, I recommend the above NSAiD plus tramadol.

    Rehabilitation therapy is beneficial at all stages of arthritis.

    If more severe pain is present, or the symptoms are non-responsive to medications, recommend NSAiD plus a trial course of amantidine. In addition, we will sometimes add a narcotic with more advanced arthritis.

    If medical problems preclude the use of NSAiDs, I recommend Duralactin, +/- tramadol or a narcotic drug. In some cases, we can use acetaminophen/narcotic combination.

    Caution:

    1) NEVER USE A STEROID AND AN NSAiD AT THE SAME TIME.

    2) NEVER USE 2 DIFFERENT NSAIDs AT THE SAME TIME.

    The above 2 circumstances can result in severe and potentially lethal side effects. If we change from one NSAiD to another or change from a steroid to an NSAiD (or vice versa), then the dog must be off of the current drug for 3-7 days before starting the drug that we are changing to. We will usually give Tramadol (which can safely be given with any of the other above drugs) to control pain during this “wash-out” period.

    Other supplements:

    Some vitamin supplements, primarily vitamin C and Vitamin E, have potential benefits for arthritic patients. They both act as antioxidants or free-radical scavengers, and therefore have some inherent ability to reduce some of the damage caused by inflammation.

    Final conclusion:

    Treatment protocol for arthritis:

    Ideally:

    – Regular, moderate exercise and weight control (special diet, and/or weight loss medication, if needed).

    – An NSAiD, as needed for pain (Rimadyl or Metacam)

    – Glucosamine supplement.

    – +/- Adequan (can be beneficial, especially for more advanced arthritis)

    – Omega-3 fatty acid supplement

    –       +/- vitamin C and/or vitamin E supplement (caution must be used, because Vitamin E can potentially enhance the negative side effects of the NSAiD drugs).

    If not controlled by above protocol

    –       Add tramadol

    If still not controlled:

    –       Trial course of amantidine

    –       +/- add narcotic drug.

    *Drugs specifically made for animals.