494 Canine Sports Medicine and Rehabilitation
Other non‐cancer chronic pain
Many non‐OA, non‐cancer chronic pain con-
ditions exist in dogs, and most cause, or are
likely to cause, neuropathic pain (Mathews,
2008). These include central nervous system
lesions of any type (including trauma,
intervertebral disc disease, congenital defects,
meningoencephalitides); peripheral nerve
injury (trauma, amputation, fractures); as
well as inflammatory bowel disease and
pancreatitis.
As inflammation is a component of the
underlying pathology activating nociceptive
pathways, NSAIDs can be considered first‐line
drugs. However, in a neuropathic state, NSAIDs
may be expected to contribute a less robust
analgesic effect, leaving room for other classes
of pain‐modifying drugs to occupy a more cen-
tral treatment role.
Systematic reviews of neuropathic pain in
humans (Finnerup et al., 2015) recommend a
treatment algorithm, regardless of etiology, that
includes as first choice drugs: TCAs, SNRIs,Case Study 19.2 Older patient with mild hip dysplasia and previous surgery for left cranial cruciate
ligament deficiency with advancing stifle and hip osteoarthritisSignalment: 12‐y.o. F/S, 40 kg Labrador Retriever w/
BCS 7/9 bilateral hip dysplasia, unilateral stifle injury
and clinical signs of mild OA in hips and moderate to
severe OA in left stifle.Management:
First 30 days:(1) Traditional veterinary NSAID or Galliprant®
(non‐COX‐inhibiting EP4 receptor antagonist)
(2) Weight loss diet/program
(3) Adequan® s.c. (off–label route) induction
period: Twice weekly × 4 weeks
(4) Implement at‐home therapeutic exercise
program
(5) Acupuncture and/or physical modality if
available and client consents
(6) Consider intra‐articular injection of biological
product (e.g., platelet‐rich plasma, stem cell
transplantation) at least for stifle.Day 30: Re‐evaluate and:(1) Consider attempting modest (25%) reduction
of NSAID or Galliprant® dose (efficacy or util-
ity to minimize ADEs unknown)
(2) Continue with weight loss diet/program
(3) Taper frequency of Adequan® (off‐label),
targeting once monthly
(4) If patient making inadequate progress,
consider addition of:
(a) Adjunctive pain‐modifying analgesic
drugs (PMADs): gabapentin (200 mg p.o.
b.i.d.) or amantadine (200 mg p.o. s.i.d.)
(b) Proceed with intra‐articular injection of bio-
logical agent (stifle at least, hips if possible)
(c) Referral if available to certified canine reha-
bilitation therapist (CCRT) or practitioner(CCRP) for formal rehabilitation/strength-
ening program
(d) Oral neutraceuticals (that include avo-
cado soy unsaponifiables (ASU), methyl-
sulfonylmethane (MSM), etc.).Days 60–90: Re‐evaluate and:(1) If weight optimized, switch to eicosapentae-
noic acid (EPA)‐rich diet
(2) Can consider attempting another 25% dose
reduction of NSAID, or decrease frequency to
every other day (efficacy or utility to minimize
ADEs unknown)
(3) Further taper Adequan® to frequency based
on patient’s needs
(4) Continue oral neutraceuticals and adjunctive
PMAD medication but dose/schedule
adjustments:
(a) Amantadine: attempt frequency decrease
to EOD
(b) Gabapentin: may need to taper to dose
upward to target of 300–600 mg p.o. b.i.d.Day 90+: If patient has responded well:(1) Continue EPA‐rich diet
(2) Continue Adequan® on lowest‐frequency
basis:
(a) Continue oral neutraceuticals and adjunc-
tive PMAD medications but dose/sched-
ule adjustments
(b) Amantadine: attempt frequency decrease
to EOD
(c) Gabapentin: can attempt dose or fre-
quency reduction
(3) NSAID: Can attempt another dose reduction,
or attempt to trial EOD, prn, or withdrawal.