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1/10/17 Top Ten Best Things In Feline
Pain Management
Ralph C. Harvey, DVM, MS,
Diplomate ACVAA, Associate Professor
Department of Small Animal Clinical Sciences
UT College of Veterinary Medicine
Knoxville, TN 37996-4544 USA
Disclosure:
Dr. Harvey - occasional speaker and
consultant for Elanco, Merial, and
Zoetis
Ralph C. Harvey, DVM, MS,
Diplomate ACVAA, Associate Professor
Department of Small Animal Clinical Sciences
UT College of Veterinary Medicine
Knoxville, TN 37996-4544 USA
1. Recognition of the Benefits
•  Reducing Fear/Stress/Pain
•  Blunts the maladaptive neuroendocrine responses
•  Balanced Anesthesia and Analgesia
•  Reduces Costs of Providing Care
•  Improves Patient Recovery
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Reducing immunosuppression
Return to feeding and nutritional balance
Improved wound healing
Speeds discharge from veterinary care
•  Reduces Client Fear, Anxiety, Apprehension, Stress
•  Improves Client Approval, Cooperation, Satisfaction
1 1/10/17 Dr. Ralph Harvey
Benefits of Pain/Stress Management
•  Reduced sympathetic stimulation
•  Better control of cardiovascular
function
•  Reduced neurologic
stimulation
(maladaptive neuro-endocrine
response)
•  Improved eating & drinking
•  Improved general well-being
•  Reduced morbidity and mortality
Dr. Ralph Harvey
Pre Medication
Post Medication
Ten Best Things About Feline
Pain Management in 2015
•  1. Recognition of the Benefits
2 1/10/17 Better Tools for Evaluation of Pain –
2. Behavioral Indices Refined and Validated
•  Feline pain assessment is challenging
•  Subtle behavioral changes
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Hunched posture, changes in facial expressions
Hiding, reluctant to interact
Protecting incision
Physiologic changes
Vocalization
•  Validated feline pain scale for assessing surgical pain
Brondani JT, et al. Am J Vet Res. 2011 Feb;72(2):174-83.
Brondani JT, et al. BMC Veterinary Research. 2013; 9:143. doi:10.1186/1746-6148-9-143.
Better Tools for Evaluation of Pain
•  Feline pain assessment is challenging:
•  Subtle behavioral changes in cats
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Hunched posture
Loss of appetite
Excessive or cessation of licking / grooming
Stiff posture / gait
Hiding, reluctant to interact
Protecting incision
Physiologic changes
Vocalization
Changes in facial expressions
Behavioral indicators of Acute Pain in Cats:
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Poor or lack of grooming
Hissing or aggression if the painful part is manipulated
Unlike dogs, a tendency to hide the painful part and look normal
Dissociation from the environment
Vocalization is rare as a sign of pain in cats
Behavioral indicators of Chronic Pain in Cats:
•  Cats – isolation, decreased grooming, cessation of eating
Ralph Harvey
3 1/10/17 Ten Best Things About Feline
Pain Management in 2015
•  1. Recognition of the Benefits
•  2. Behavioral Indices Refined and Validated
Better Tools for Evaluation of Pain –
3. Facial Grimace Pain Scale Validated
E. Holden, G. Calvo, M. Collins, A. Bell, J. Reid, E. M. Scott and A. M. Nolan. 30 OCT 2014 | DOI: 10.1111/jsap.12283
Feline Facial Grimace Pain Scale:
Combine the power of the
Feline Facial Grimace with an
Interactive Behavioral Evaluation
Feline posture: A visual dictionary. Eliz. Colleran, DVM 360
https://t.co/NvMYMUicDq #veterinary https://t.co/OXYiDUl3Nh
4 1/10/17 Ten Best Things About Feline
Pain Management in 2015
•  1. Recognition of the Benefits
•  2. Behavioral Indices Refined and Validated
•  3. Facial Grimace Pain Scale Validated
4. Gentle Handling Refined
AAFP and ISFM Feline-Friendly Handling Guidelines
With respect, admiration, and thanks to Dr. Sophia Yin
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Fear - Stress - Aggression
Separated Areas for Cats or Feline Only Facilities
Pheromone spray
Towel wraps
Remove the top and work in the cat carrier
Avoid / Minimize “scruffing” or excessive stretching
•  Gentle technique, Less is More…
•  Avoid chamber induction of anesthesia
doi: 10.1016/j.jfms.2011.03.012
Rodan, et al. Journal of Feline Medicine and Surgery. May 2011 vol. 13 no. 5 364-375
Yin S. Low Stress Handling, Restraint and Behavior Modification of Dogs & Cats. Cattle Dog Publishing. 2009.
Ten Best Things About Feline
Pain Management in 2015
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1. Recognition of the Benefits
2. Behavioral Indices Refined and Validated
3. Facial Grimace Pain Scale Validated
4. Gentle Handling Refined
5 1/10/17 5. Non-Steroidal Anti-inflammatory
Drug Therapy in Cats
•  Perioperative NSAID for inflammatory pain
•  Multi-Modal or Balanced Analgesia
•  Patient Selection
•  Changing paradigm for NSAIDs
Chronic Non-Steroidal Anti-inflammatory
Drug Therapy in Cats
•  Feline ignored for too long
•  Incidence of DJD is high in older cats
•  Behavioral and Post Mortem evidence is clear
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Extra-Label Use in United States
Use with Caution in DJD / Chronic use
Dose to Lean Body Weight
Regular laboratory testing for chronic therapy
Regular Consultation / Adjust Therapy Plan
NSAID’s for Cats - options…
Meloxicam (Metacam)
Injectable approved (US) single dose at 0.3 mg/kg - much too high
“Black Box warning” for repeated dosing
Extra-label use: Preferred dose usually 0.1 mg/kg
Injectable approved (EU) chronic use 0.05 mg/kg/day
Preferred chronic dose (always extra-label) usually 0.05 - 0.025mg/kg/d
after loading dose
Titrate meloxicam to “lowest effective dose” strategy (usually q24h)
Oral liquid allows for more precise dosing, improved compliance
AAHA/AAFP 2015 Guidelines support extra-label chronic use, with limits!
6 1/10/17 NSAID’s for Cats – Improving options…
Robenacoxib (Onsior)
Tablets approved (US) three day course of periop therapy
Rapid onset, short plasma T1/2, pKa 4, Freed from albumin at low pH
sites of injury or inflammation
Limited toxicity
Dose 1 mg/kg (1-2.4 mg/kg) up to 3 days approved in US
avoid combinations with other NSAIDS, avoid with renal disease
injectable form approved in other markets – awaiting changes
Paradigm shift in pre-op use: Oral! and NSAID!
Highly palatable (Compliance improved)
ISFM and AAFP Consensus Guidelines: Long-Term use of NSAIDs in Cats
doi: 10.1016/j.jfms.2010.05.004Journal of Feline Medicine and Surgery July 2010 vol. 12 no. 7 521-538
Ten Best Things About Feline
Pain Management in 2015
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1. Recognition of the Benefits
2. Behavioral Indices Refined and Validated
3. Facial Grimace Pain Scale Validated
4. Gentle Handling Refined
5. Non-Steroidal Anti-inflammatory Therapy
6. Long - Term Pain in Cats
Species-specific responses to chronic pain:
•  Species-specific responses of cats to Chronic Pain:
•  Cats - isolation from others in the household,
decreased grooming, and cessation of eating
•  Inappropriate behaviors
•  Inappropriate elimination
•  Pain - Stress – Fear – Aggression – Euthanasia
•  Pain management becomes “life saving”
7 1/10/17 Long - Term or “Chronic” Pain in Cats
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DJD / OA
Chronic infections
FLUTD
Oral Resorptive Lesions and Gingivitis/Stomatitis
Diabetes
Cancer
•  Value of Multi-Modal Balanced Management
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Opioids
NSAIDs
Gabapentin
Tramadol
Ketamine / Amantadine
Amitryptiline
Environmental enrichment
Exercise / Weight Management
Robinson and Lascalles. 2010. JFMS
doi:10.1016/j.jfms.2010.01.002
Ten Best Things About Feline
Pain Management in 2015
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1. Recognition of the Benefits
2. Behavioral Indices Refined and Validated
3. Facial Grimace Pain Scale Validated
4. Gentle Handling Refined
5. Non-Steroidal Anti-inflammatory Drug Therapy
6. Long-Term Pain in Cats
7. Opportunities with Opioids
Butorphanol Short-acting (<90 min)
Highly valuable for sedation
Mild transient analgesia only
Buprenorphine…(Stay tuned…)
Shafford 2013 Proceedings NAVC Small Animal
8 1/10/17 “Pure Agonist” Opioids
Hydromorphone - potential for hyperthermia
Methadone - Dual mechanism actions:
Opioid agonist & NMDA receptor antagonist
Morphine - Low doses avoid hyperactivity / dysphoria
Less effective analgesic metabolites in cats than in dogs
Oxymorphone - Effective analgesic
Potentially less hyperthermia / dysphoria
Fentanyl – infusions… yes, patches… no
Shafford 2013 Proceedings NAVC Small Animal
Better Use of Opioids
Tramadol - May act as an opioid analgesic in cats
Mu opioid receptor agonist activity - limited
Serotonin / Norepinephrine Re-Uptake Inhibition
Not palatable – resolution....
Euphoria / dysphoria and mydriasis potential
Some human formulations contain acetaminophen
(highly toxic to cats)
Shafford 2013 Proceedings NAVC Small Animal
Ten Best Things About Feline
Pain Management in 2015
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1. Recognition of the Benefits
2. Behavioral Indices Refined and Validated
3. Facial Grimace Pain Scale Validated
4. Gentle Handling Refined
5. Non-Steroidal Anti-inflammatory Drug Therapy
6. Long-Term Pain in Cats
7. Better Use of Opioids
9 1/10/17 8. Buprenorphine – Optimized as Simbadol
Simbadol – FDA Approved for 24 hour analgesia in cats
Repeat for 72hr total
Effective and safe analgesic for cats
Our first 24 hour duration opioid analgesic for cats
•  Unique Profile in Cats
Unique Physiology, Pharmacology of Higher Dose
Excess Substrate Delays Elimination of Active Drug
•  Once Daily Surgical Pain Control
Simbadol (buprenorphine injection) Freedom of Information Summary, NADA 141-434; July 18, 2014
Steagall PVM et al. VAA, 2013; 40: 83-95
Hedges AR, et .al J Vet Pharmacol Therap, 2013; 37: 252-259.
Steagall PVM et al. VAA, 2013; 40: 83-95
Simbadol - Plateau or “ceiling effect” as buprenorphine dose increases:
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SIMBADOL™ (buprenorphine injection) Black Box Warning: Human
Safety
10 1/10/17 Case Studies 258237
•  Adenocarcinoma
•  Heart Murmur - Aortic
Regurgitation
•  Total Ear Canal Ablation (TECA)
•  Balanced Anesthesia/Analgesia
Simbadol, (Onsior), (Local)…
Dr. Ralph Harvey
Simbadol – 24 hour analgesia in cats
Analgesic Efficacy
TJ 258237
11 1/10/17 Buprenorphine – Additional Options
•  Trans Mucosal Administration of Buprenorphine
•  Oral or Nasal
•  MADTM Intranasal Mucosal Atomization Device
•  Buprenorphine-SR aqueous polymer vehicle
•  compounded product, lack of evidence, concerns limit
use
Simbadol (buprenorphine injection) Freedom of Information Summary, NADA 141-434; July 18, 2014
Steagall PVM et al. VAA, 2013; 40: 83-95
Hedges AR, et .al J Vet Pharmacol Therap, 2013; 37: 252-259.
Steagall PVM et al. VAA, 2013; 40: 83-95
Ten Best Things About Feline
Pain Management in 2015
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1. Recognition of the Benefits
2. Behavioral Indices Refined and Validated
3. Facial Grimace Pain Scale Validated
4. Gentle Handling Refined
5. Non-Steroidal Anti-inflammatory Drug Therapy
6. Long-Term Pain in Cats
7. Better Use of Opioids
8. Buprenorphine – Optimized as Simbadol
12 1/10/17 9. Transform the “Grumpy Cat”
The grouchy, fearful, angry, antisocial cat has “issues…”
Very often an unnecessary situation
Turn it around with analgesic strategies
Pharmacologic
Behavioral
Management
Strengthen the bonds
Practice - Client - Patient
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•  Facilitated exam / management / procedures
•  Caudal Epidural for blocked tomcats
•  Chronic disease states:
•  Interstitial Cystitis
•  DJD / OA - greatly under-diagnosed in older cats
•  Chronic oral disease stomatitis / gingivitis
•  Cancer pain management
•  Extension of health-span and life-span
•  Prolongation of the Human-Animal Bond
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Ten Best Things About Feline
Pain Management in 2015
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1. Recognition of the Benefits
2. Behavioral Indices Refined and Validated
3. Facial Grimace Pain Scale Validated
4. Gentle Handling Refined
5. Non-Steroidal Anti-inflammatory Drug Therapy
6. Long-Term Pain in Cats
7. Better Use of Opioids
8. Buprenorphine – Optimized
9. Transform the “Grumpy Cat”
13 1/10/17 10. Updated and Expanded 2015
AAHA AAFP Pain Management Guidelines
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Pharmacologic and non-pharmacologic modalities
Evidence-based or consensus of expert opinion
Behavioral changes – Validated pain scales
Post-surgical pain is predictable
Strategies mitigate adaptive & maladaptive pain
•  Chronic pain – DJD predominates
Prevalent, Under-diagnosed, Ubiquitous, Progressive
Evidence-based strategies emerging in cats
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2015 AAHA/AAFP
Pain Management Guidelines for Dogs and Cats
J Am Anim Hosp Assoc 2015; 51:67–84. DOI 10.5326/JAAHA-MS-7331
Epstein . J Feline Med Surg. 2015 Mar;17(3):251-72. doi: 10.1177/1098612X15572062.
2015 AAHA AAFP Pain Management Guidelines
Managing routine surgical pain:
Preoperative opioid plus a tranquilizer/sedative
(acepromazine, midazolam, diazepam,
dexmedetomidine)
NSAID either pre- or postop - patient risk factors &
clinician preference
Local anesthetics are integral to surgical plan
.
2015 AAHA/AAFP
Pain Management Guidelines for Dogs and Cats
J Am Anim Hosp Assoc 2015; 51:67–84. DOI 10.5326/JAAHA-MS-7331
Epstein . J Feline Med Surg. 2015 Mar;17(3):251-72. doi: 10.1177/1098612X15572062.
2015 AAHA AAFP Pain Management Guidelines
Managing higher-level pain:
For more severe, protracted or maladaptive
postoperative pain:
Cold compression
Alpha-2 Adrenergic Receptor Agonist Dexmedetomidine
Ketamine CRI
Lidocaine CRI (dogs but usually not for cats)
Gabapentin
Epidural analgesia / anesthesia
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2015 AAHA/AAFP
Pain Management Guidelines for Dogs and Cats
J Am Anim Hosp Assoc 2015; 51:67–84. DOI 10.5326/JAAHA-MS-7331
Epstein . J Feline Med Surg. 2015 Mar;17(3):251-72. doi: 10.1177/1098612X15572062.
14 1/10/17 2015 AAHA AAFP Pain Management Guidelines
“Less is More”
For everyone involved
.
Ten Best Things About Feline
Pain Management in 2015
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1. Recognition of the Benefits
2. Behavioral Indices Refined and Validated
3. Facial Grimace Pain Scale Validated
4. Gentle Handling Refined
5. Non-Steroidal Anti-inflammatory Drug Therapy
6. Long-Term Pain in Cats
7. Better Use of Opioids
8. Buprenorphine – Optimized as Simbadol
9. Transform the “Grumpy Cat”
10. 2015 AAHA AAFP Pain Management Guidelines
Selected References:
Epstein . J Feline Med Surg. 2015 Mar;17(3):251-72. doi: 10.1177/1098612X15572062.
Brondani JT, et al. Am J Vet Res. 2011 Feb;72(2):174-83
Brondani JT, et al. BMC Veterinary Research. 2013;9:143. doi:10.1186/1746-6148-9-143.
E. Holden, G. Calvo, M. Collins, A. Bell, J. Reid, E. M. Scott and A. M. Nolan. 30 OCT
2014 | DOI: 10.1111/jsap.12283
Rodan, et al. Journal of Feline Medicine and Surgery. May 2011 vol. 13 no. 5 364-375
Yin S. Low Stress Handling, Restraint and Behavior Modification of Dogs & Cats. Cattle
Dog Publishing. 2009. doi: 10.1016/j.jfms.2011.03.012
ISFM and AAFP Consensus Guidelines: Long-Term use of NSAIDs in Cats
Journal of Feline Medicine and Surgery July 2010 vol. 12 no. 7 521-538. doi: 10.1016/
j.jfms.2010.05.004
Robinson and Lascalles. 2010. JFMS. doi:10.1016/j.jfms.2010.01.002
Simbadol (buprenorphine injection) Freedom of Information Summary, NADA 141-434;
July 18, 2014
Steagall PVM et al. VAA, 2013; 40: 83-95
Hedges AR, et al J Vet Pharmacol Therap, 2013; 37: 252-259.
Steagall PVM et al. VAA, 2013; 40: 83-95
Shafford 2013 Proceedings NAVC Small Animal
2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats
J Am Anim Hosp Assoc 2015; 51:67–84. DOI 10.5326/JAAHA-MS-7331
15 1/10/17 Top Ten Best Things In Feline
Pain Management
Ralph C. Harvey, DVM, MS,
Diplomate ACVAA, Associate Professor
Department of Small Animal Clinical Sciences
UT College of Veterinary Medicine
Knoxville, TN 37996-4544 USA
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