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Dr. Melina Zimmerman on Postoperative Pain Control At Home - Part 1
452 Plays8 months ago
In this episode, we're focusing on a critical aspect of post-surgical care: creating a plan to control postoperative pain once our canine or feline patients leave the hospital. We know that managing pain effectively during this period is vital for the recovery and well-being of our patients. With so many medications to choose from, costs to consider, and non-compliance to worry about, how can we optimize our patients pain control at home when there are so many variables to balance? In this episode, we're thrilled to have Dr. Melina Zimmerman lead us through this important discussion. As a veterinary anesthesiologist with additional training in companion animal rehabilitation, Dr. Zimmerman specializes in pain management for surgical and non-surgical conditions at her clinic, The Doggy Gym. In the first part of this two-part episode, we will focus our discussion on opioids and NSAIDs, with an emphasis on ancillary medications and non-pharmaceutical treatment options in our next episode. Have you ever wondered: What oral opioid options do we know are effective analgesics for dogs and cats? Is buprenorphine a great opioid or the greatest opioid? How do you get a fentanyl patch to stick? What’s with all this hype about Galliprant and Tylenol for dogs? If you’re curious about leveling up your analgesia game, we hope you give this episode a listen.
References are made in this episode to analgesic and sedative agents from previous NAVAS episodes. Check out our episode on Zenalpha and Zorbium for more information.
If you like what you hear, we have a couple of favors to ask of you:
Become a member of NAVAS for access to more anesthesia and analgesia educational and RACE-approved CE content.
Spread the word. Share our podcast on your socials or a discussion forum. That would really help us achieve our mission: Reduce mortality and morbidity in veterinary patients undergoing sedation, anesthesia, and analgesia through high-quality, peer-reviewed education.
As a reminder, the ACVAA Annual Meeting is happening in Denver, CO from September 25-27 later this year. Registration rates are discounted for NAVAS members. We hope to see you there! Sign up today!
Thank you to our sponsor, Dechra - learn more about the pharmaceutical products Dechra has to offer veterinary professionals, such as Zenalpha.
If you have questions about this episode or want to suggest topics for future episodes, reach out to the producers at education@mynavas.org.
All opinions stated by the host and their guests are theirs alone and do not represent the thoughts or opinions of any corporation, university, or other business or governmental entity.
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Transcript
Introduction and Sponsorship
00:00:06
Speaker
Hello, fellow gas passers. I'm so glad you're here with me for another episode of the North American Veterinary Anesthesia Society podcast. I am your host and proud self-declared gas passer, Dr. Bonnie Gatson. As I always say, our goal with this episode is to help veterinary professionals and caregivers like you advance and improve the safe administration of anesthesia and analgesia to all animals. And this episode is no exception to that goal, as we'll be discussing the various ways we can provide effective pain relief at home in the days following a surgical procedure for our canine and feline friends. But first, some general announcements and shoutouts with our big first shoutout going to our sponsor, Decra.
00:00:55
Speaker
They have a great line of veterinary anesthesia products, including zenalfa, which we have a whole entire episode on in our archives. And a link to that episode will be in our show notes. So check it out. Visit www.decra-us s dot.com and see what Decra can do to help your clinic optimize anesthesia and sedation at your practice.
Veterinary Conference Announcement
00:01:19
Speaker
Second, I want to see all your faces and mingle with my fellow gas passers at the meeting for the American College of Veterinary Anesthesia and Analgesia taking place in Denver this year from September 25th to the 27th.
00:01:35
Speaker
If you want to hang with a great group of nerds like me while soaking in a bunch of the latest and greatest information about anesthesia and getting those much needed CE credits, visit www.acva.org and register for the conference today.
Post-Surgery Pain Relief Discussion
00:01:53
Speaker
Navas members get a discount on registration, so don't delay. So back to the episode. I'm so over the moon about what we're going to talk about because not only is it so obviously relevant to daily practice, but I also feel like there is so much controversy and flim flam about analgesic agents out there. And we want to try to trim the fat and bring you the facts.
00:02:17
Speaker
What are the best options out there for providing pain relief for dogs and cats in the days following a surgical procedure? What options are actually practical from both a cost and a compliance perspective for owners to administer at home? What kind of non-pharmaceutical options have actual factual evidence that they help our patients in the long term?
Opioids vs NSAIDs in Pain Management
00:02:43
Speaker
Joining us is the esteemed Dr. Melina Zimmerman, a veterinary anesthesiologist and the brilliant mind behind the doggy gym, a clinic focused on pain management and rehabilitation of companion animals for both surgical and non-surgical conditions.
00:03:00
Speaker
Dr. Zimmerman has a wealth of experience in both pharmaceutical and non-pharmaceutical methods for pain relief, and she has given many lectures about just this topic all around the country, making her the perfect guest to help us explore this critical topic. And because my mom never taught me how to stop running my mouth, this episode is going to be a two-parter In the first episode, we're going to focus mostly on opioids and NSAIDs. So you're going to have to put up with a lot of gushing over buprenorphine, as well as a really great discussion on oral analgesic options with a focus mostly on opioids and NSAIDs for our furry friends.
00:03:41
Speaker
In our next episode coming out later next month, we'll finish up our discussion on oral analgesic options with a lot of time focusing on gabapentin and pre-gabalin, and then we're going to dive into our non-pharmaceutical options in that episode. So without further ado, let's start the first part of this very insightful discussion on the best ways to keep our furry friends comfortable, filled with valuable information you won't want to miss right here on the Nav-Ass Podcast.
Dr. Zimmerman's Background
00:04:18
Speaker
Thank you so much for coming on the podcast today. Can you start by telling us a little bit about yourself? Sure. Well, thank you so much for having me on the podcast. I think this podcast is absolutely fantastic. My name is Melina Zimmerman and I am a board certified specialist in veterinary anesthesia and analgesia. I have also completed additional certification in pain management through IVAPM, medical acupuncture through CuraCore, and canine rehabilitation from the University of Tennessee. I am currently the owner and veterinarian at the Doggy Gym in Belmar, New Jersey, which is a standalone pain management and physical rehabilitation practice.
00:05:01
Speaker
And I also do some anesthesia continuing education and consulting through another company that I started called Elevate Anesthesia. So I ask all of my guests this, but what drew you to stunning anesthesia in the first place? I've actually always been fascinated with anesthesia. Like ever since I was a little kid, I always thought that anesthesia was just the coolest thing, especially with pediatrics. And over the years, you know, my love of pharmacology, anatomy, physiology, and how it all applies to the delivery of anesthesia and pain management, I think is just really cool and fascinating. So what drew you to your current role related to animal rehabilitation and pain management? Like what happened with the career shift there?
00:05:46
Speaker
Yeah. So prior to opening the doggy gym, I was actually at a large, very busy specialty hospital for about eight years. And there, you know, I gained so much experience with complex anesthesia cases. I had the opportunity to do a lot of pain management and really saw how much good pain management and physical rehabilitation could make such a positive improvement in the overall patient care, patient outcome.
Acute vs Chronic Pain in Animals
00:06:11
Speaker
And so at the doggy gym, I'm able to completely focus on the patient, the owner, making that bond more strong and connected and just making patients overall more healthy and able to do their lives.
00:06:24
Speaker
We have a huge topic to discuss today and I think you're just the right person to do that because we're going to focus our conversation today about how do we manage our patient's pain in the immediate post-operative period. A lot of the pain management topics that we've covered on this podcast have been really related to chronic pain and I think this will be one of our first pain management talks is going to be really focused on acute pain. And so for that reason alone, I think a really good jumping off point is to start by talking a little bit about different types of pain that animals can experience and how we categorize that. So why don't you start by talking a little bit about how do we describe the type of pain an animal experiences
00:07:21
Speaker
after surgery and maybe how this is a little bit different from more long-term or chronic pain states. Yeah, and I think it is so important because as much as we talk about chronic pain and all of the patients that are in chronic pain, we can't forget that treating acute pain properly is going to help prevent so many of those chronic pain syndromes from taking place. So acute pain typically caused by surgical incisions and surgical procedures is generally considered no-susceptive or physiologic pain.
00:07:55
Speaker
So that means that it's usually localized, it's typically transient, so not lasting more than the expected recovery process, which in all honesty can be anywhere between usually two and 14 days. We do have to remember that some animals are experiencing pain prior to surgeries, so they may already have a component of chronic pain that can complicate the situation, and that makes that whole neurophysiologic response to acute pain either more exaggerated or potentially more difficult to treat.
00:08:26
Speaker
So when we think then about chronic pain, this is a pathologic pain. So there's nothing good or protective about chronic pain. When acute pain is persisting beyond what that expected course of healing is, it technically is now going to be unclassified as a chronic pain. So with chronic pain, whether it's caused by tissue damage causing inflammatory pain or nerve injury causing neuropathic pain, we can get changes within peripheral nociceptors that's going to overall create a reduction in the threshold to continued nociceptive stimulation.
Managing Pain: Acute vs Chronic Approaches
00:09:04
Speaker
and that's what we consider peripheral sensitization. This is then going to lead to symptoms such as hyperalgesia, which is an exaggerated pain response to noxious stimuli, or something what we consider calling allodynia, which is a pain response to normally non- noxious stimuli. So then I think it's important to note that all of those changes within the peripheral nociceptors are going to then lead to changes within the central nervous system, specifically within the dorsal horn of the spinal cord. This is now going to lead to what we call central sensitization, which can actually change the entire way the nervous system responds to pain in more of a negative way. So I think you did an amazing job talking about the neurophysiology
00:09:50
Speaker
between acute pain and chronic pain. So let's pull that back to the clinical patient. So generally speaking, how are the approaches to pain management difference between an animal experiencing an acutely painful event, which from my understanding is like a physiologically normal pain response that occurs in an animal, versus when you have all those neurophysiologic changes that create a chronic pain state, How do we approach pain management differently between those two patients?
00:10:22
Speaker
I think, you know, whether we're treating acute pain, chronic pain, I'm always approaching pain from a multimodal angle. So really trying to find the best options for the specific patient rather than using like a certain protocol for a specific case that I'm doing. And so I think the big difference between treating acute and chronic pain is really going to be the pathways that I'm trying to effect and the length of time I'm going to treat them for. For surgery, what are the specific modalities that you're going to be using as opposed to like with arthritis, for example? So what are you specifically trying to target? Maybe that might be differently with with like ah acute surgical pain.
00:11:06
Speaker
I think taking that multimodal approach, you know, it starts before the procedure even starts because we know that patients that have heightened anxiety, heightened fear are already going to be at heightened states of experiencing their pain. So I think starting from before they even come in the building with sedatives that we send home with the patients, or if we didn't do that, giving them either oral or injectable sedatives when they first come in the practice. Right. I'm going to eliminate things like nausea, vomiting. I'm going to then use more acute pain management techniques such as anti-inflammatories, opioids, muscle relaxants, and then whatever the procedure calls for, then utilize things like local blocks, regional anesthesia, and then postoperatively continuing things like anti-inflammatories, opioids. continuous rate infusions, again, depending on which pathways I'm trying to affect. That's kind of the approach that I take and looking at it more from a pre, peri, and post anesthetic experience versus with something like arthritis when they come in, you know, they already have a degree of pain and inflammation going on. So now I'm kind of trying to play catch up.
00:12:22
Speaker
I'm trying to be more preemptive in my surgical cases so that I can make a more effective pain management
Preemptive Pain Management in Surgery
00:12:29
Speaker
for them. Yeah, I think you bring up something that's so important, which is that when it comes to treating acute pain, even though this topic is about treating patients after surgery, it's so important to realize that so much of acute pain management happens even before the surgery even begins. Absolutely. So generally speaking, would your approach to acute pain management be any difference for animals that also have a chronic pain condition? So maybe like a cat that's getting full mouth extractions, behestomatitis, or maybe a dog that has chronic stifle OA and they're getting a TPLO. How do you change your approach or do you change your approach at all for those patients?
00:13:12
Speaker
Absolutely. It changes my plan. So I think when there's already a chronic pain component present before a surgical procedure, again, the CNS is at a heightened
Oral Opioids Challenges in Pets
00:13:22
Speaker
state. Therefore, that need for that preemptive multimodal pain management becomes even more important than with just a general you know spay, neuter, you know, no pre-existing pain patient. Additionally, alternative drugs besides things like opioids, local anesthetics and NSAIDs become a lot more beneficial in these cases. So one example is ketamine is one of the drugs that's very important when we're already dealing with chronic pain because we have patients that have NMDA receptors within their central nervous system. that are upregulated and so we can utilize drugs like ketamine to help to down regulate some of those receptors and help with that chronic or neuropathic pain that's already present in those patients.
00:14:08
Speaker
Let's start talking a little bit about some of our pharmaceutical drugs that we have in our arsenal to help patients postoperatively. As you mentioned earlier, we are really trying to, for acute pain, try to preemptively treat those patients for pain, which will really help our patients in the postoperative period. And usually during the immediate perioperative period, animals are going to receive some kind of injectable pain medication, maybe opioids, maybe local aesthetics, maybe an NSAID. But once the animal leaves the hospital, we've got to try transition them to some kind of oral medication.
00:14:50
Speaker
So I want to start by discussing oral pain medication options and their advantages or disadvantages, any evidence we have for the efficacy of these medications that we're going to use for treating acute surgical pain. And we're going to start that conversation with opioids because they're the mainstay for acute pain management in small animals. So, we know they're effective at providing analgesia when we give them intravenously or intramuscularly, especially our fulmu agonists. However, you know, how effective are opioids in general at providing analgesia when we administer them orally for dogs? We can also talk about cats as well.
00:15:32
Speaker
And let's start with that. Yeah, you know, unfortunately, we do not have good evidence that oral opioids are beneficial as standalone analgesics in animals, whether we're talking dogs, cats, you know, or rabbits or ferrets. We just don't have that good evidence. The main issue is that oral opioids in small animals end up having a low bioavailability. That being said, there are active metabolites that are made from some of these oral opioids that may be analgesic, and some of the strongest evidence that we have with oral opioids comes from combining oral opioids with other drugs such as acetaminophen,
00:16:12
Speaker
and codeine We know in the last few years we've seen some evidence that combining oral opioids with pharmacokinetic enhancers could be a promising way to enhance bioavailability. So this has been recently shown with methadone and fluconazole. And hopefully we do have some better options moving forward in the future. But right now, you know ways of getting around low bioavailability of oral opioids is potentially to give them the oral transmucosal route. We do know that buprenorphine, oral transmucosally in cats, has a bioavailability of about 100%. Whereas in dogs, it's really only about 38% or 40%. But that's still significantly better than the maybe 3% to 5% of most oral opioids.
00:16:57
Speaker
Methadone is another drug that, when given transmucosyly, does have better bioavailability, again, than our oral full-meo agonist opioid options. I think the major disadvantage of using oral opioids is the side effects and the potential for human abuse. So you know the main side effects are going to be nausea, constipation, inappetence, sedation. Between this and the potential for human abuse, oral opioids are definitely not my first line choice for at-home analgesia. And when I do send them home, I'm always doing so for very short periods of time. mainly for either acute pain or end of life pain management. And I also don't use them as single agents. I always utilize them as an adjunct analgesic. When I was in veterinary school, I would say the number one oral opioid that we were using pretty much for like any acute pain case that we're going to send an animal home with, it's going to be tramadol.
00:18:00
Speaker
And I have now seen, because I've been practicing a long time now, I've seen tramadol somewhat fall out of favor, but I do still see it used in some practices. So let's start by talking about tramadol. So can you briefly summarize the mechanism of action of this medication? Because I think it's pretty complicated. It is a little complicated. you know We know that tramadol is a serotonin reuptake inhibitor, and when metabolized, there are certain active metabolites of tramadol that are weak mu-opioid agonists.
00:18:38
Speaker
Hats we do know produce this weak mu-opioid agonist metabolite odesmethyl tramadol in decent amounts. Dogs really do not, meaning that the analgesia that we get from tramadol in dogs is really not as high as the sedative effects that we get from it. And we really do now have multiple studies that have shown that tramadol is not a good analgesic in dogs. And the main issue in cats is that the formulations, both pill and liquid, tend to be really unpalatable. They cause either hypersalivation, bad side effects, sedation, things like that. And also to get to more analgesic levels, we do have to use higher doses that end up leading to higher side effects.
00:19:22
Speaker
So do you personally recommend this medication for post-operative pain management or are there any scenarios where you're considering using tramadol more than others? I personally do not utilize tramadol in clinical practice. Yeah, I feel the same way. Yeah, enough said, period, end of sentence.
Hydrocodone and Codeine Efficacy in Pets
00:19:42
Speaker
Yeah, enough said, done. And I think you made a really good point about the potential for human abuse yeah with these drugs as well. We do know that humans metabolize tramadol, and this can be potentially an effective analgesic for humans. So I think in sending home any pain medications of an oral nature that especially can be used for human abuse as well,
00:20:06
Speaker
is something we need to be extremely considerate of. So let's move on to hydrocodone, because I think you didn't mention this earlier. So do we have any evidence that this drug is effective at providing post-operative pain management to dogs? You know, we actually have studies that have shown us that hydrocodone does not have an analgesic effect in dogs. And so again, just like tramadol, this is typically not an oral opioid that I recommend utilizing for practice. And is that the same in cats too? It's the same in cats, unless you have any experience of the contrary. I don't. I'm not sure of any studies whereby the pharmacokinetics of hydrocodone was worked out for cats. No. And honestly, you know, hydrocodone is metabolized into hydromorphone. So it's a synthetic opioid option. But you know, that being said, I think that any study that has looked at the pharmacokinetics of this show that the amount of bioavailability that we get is not producing
00:21:01
Speaker
enough of this to create analgesic that is comparable to parenteral dosing of it. I know that there are some oral opioid formulations, including acetaminophen, and I do know some veterinarians that prescribe these medications, and I'm wondering if we have any data on their use in dogs. We do have some very weak evidence that shows that acetaminophen and codeine could potentially be analgesic, but again, the evidence is not strong enough to recommend this as potentially a single agent use.
00:21:36
Speaker
That being said, and I think we will discuss acetaminophen in a little while, but I do think acetaminophen can be utilized a little bit more frequently in dogs, not cats, but in dog post-operative analgesia that could potentially be of more benefit than an oral opioid.
Fentanyl Patches: Application and Risks
00:21:53
Speaker
Okay, so let's move away from oral opioids since it seems like we don't have a great option for our companion animals. But let's talk about fentanyl patches because this is something that I think a lot more people have experience with. And so I'm wondering, is this drug actually effective at providing postoperative pain management dogs? Do we have any evidence about its use for and its pharmacokinetics in dogs?
00:22:15
Speaker
So, you know, we do know that fentanyl patches can be effective at providing postoperative pain management for dogs and for cats. That being said, it lasts anywhere between one and four days. The absorption rate of the fentanyl patches can be dependent on certain types of skin, skin conditions, heat in the area, you know, where we're placing them. so It's really important to follow the appropriate guidelines if we are going to be using fentanyl patches. But I personally think we should be really cautious about using fentanyl patches in our veterinary patients for a couple reasons. The main one being the potential for abuse or accidental ingestion by humans. This has been shown time and time again. There's like case reports coming out all the time showing accidental ingestion by children especially. And also the side effects specifically being dysphoria can be seen at higher patch doses. And we know with lower patch doses, they tend probably not to be as effective for a prolonged period of time. And then we also have to remember that it can take between about 12 and 20 hours
00:23:23
Speaker
for the patches to get to their peak therapeutic levels and things like heating pads, bear huggers in the recovery period can potentially speed up that fentanyl release and create more side effect and then less long efficacious you know periods. Do you ever use fentanyl patches in your practice? So we used to utilize fentanyl patches a lot more before we started doing more regional and local anesthesia and analgesia. I think that with the you know more multimodal pain management protocols, the need for postoperative opioids really decreases significantly, I think, as long as we're doing a really good job at that preemptive pain management. That being said, the main times that I personally use fentanyl patches is more for that end stage, end of life pain management. And even then I do it sparingly because a lot of those patients end up becoming dysphoric or inappetent or nauseous. And so again, i as much as I love opioids, I'm an anesthesiologist, I can't say I don't love opioids, I'm not a huge fan of them for at home use. There are a few things I want to say about fentanyl patches personally from my own experience. So the first one is that I find them to be
00:24:40
Speaker
tricky in the sense that the adhesive is not super powerful. we definitely You have the certain nurses that are just so good at putting in the fan. It's like nobody else put them on. like Just give it to that one person that knows how to put them on. Yeah. and so They can be very finicky about staying on. and There's like a bunch of different ways that you can place them. And also I have seen them being placed on all different places in the body as well. So I guess my general feeling about them is that if you're worried about adhesion, like making sure the fennel patch stays on for like two to three days or however long you want to keep them on, I find that placing them on like below the Hawk is actually usually best because you can wrap it with elastic on.
00:25:27
Speaker
Yeah. And I think they stay better that way. However, you're also giving really easy access for an animal to like eat it right off. Absolutely. And do we know, and this is just a ah side question, do we know that pharmacokinetics are going to be the same when we're placing them on distal limbs versus like behind shoulder blades? Because the studies that have looked at pharmacokinetics have been between or behind shoulder blades, right? So we do know that skin thickness is different in different areas. This is just me playing devil's advocate because I've placed them in those types of areas as well. It's way easier to wrap them. But then I'm questioning myself, am I doing justice to my patient and doing a good job you know with this release of fentanyl? Question mark. You would literally took the words like right out of my mouth because I find like I agree that the strongest pharmacokinetic data comes from placing them somewhere like
00:26:19
Speaker
around the apaxial muscles. yeah And the problem with placing them on the apaxial muscles is like there's not a great way of ensuring that they actually stay on. Yeah, absolutely. Yeah, and I've seen nurses do all kinds of things to try to improve the adhesion. Some nurses, we obviously clipped the area. I've seen sometimes people swabbing the area with alcohol and drying it off. I don't know if that's actually helpful or not at all. Yeah, i I don't disagree. And yes, I think my typical protocol if I am going to place it is to clip the area, make sure it's clean and dry, place it on. I a lot of the times would then put a staple on each side of it like a skin staple on each side and then cover it with
00:27:04
Speaker
like some sort of clear, you know, ah adhesive type of bandage on top of that and then staple that on top as well. Which again, now we're doing staple removals, you know, now we're doing all of these things and then writing the date on it so that we know, you know, when we should be taking it off. That was typically my protocol to make sure that we didn't get, you know, just right in the post-operative period when they pee on themselves and then slip in their pee or something like that. you know, then it just comes right off and now you're spending another hundred or so dollars on placing another one.
00:27:36
Speaker
Yeah, I was going to hope you're going to bring out the staples because I think that's my favorite way to do it as well. I never stapled the patch itself because I was always worried about that affecting question mark. Yeah, yeah like affecting the ability of the patch to actually function appropriately. Yeah. But what I have done is I placed the patch down and then either put a piece of elastic on and tape and stapled the elastic on like I'll put in the patch like a Telfer pad. and then elasticon on top of that and then staple the elasticon on. um I also like Ayaban as well. I think Ayaban works really well. Yes, that's what I was going to say. Yes, the Ayaban. But I think of all the things that, I mean, i like making sure the patch stays is so tricky. It's stressful.
00:28:22
Speaker
That's really stressful. So hopefully, you if for those of you who are using fentanyl patches with some regularity, hopefully you got some good tips on how to get them to stick. I think the other thing that's important, so let's say you've decided a fentanyl patch is going to be something that will work for you. What are some examples of some cases whereby you might be reaching for fentanyl patches in the post-operative period? I think cases that we think are going to have pain beyond incisional inflammatory pain for the acute you know three to five day post-op period because in all honesty I really don't
00:29:00
Speaker
think fentanyl patches have a big place anymore. And I think the places where I don't like seeing them used are like in the post-op TPLOs. Because I think that when it's really just incisional pain that they're dealing with post-operatively, which is the majority of the acute pain that we're treating post-operatively in most of our patients, The side effects of the opioids that we're utilizing in recovery are outweighing the analgesic effects because they don't need that level of analgesia. So in patients that have maybe a degree of chronic pain, so patients that have cancers that have been creating discomfort, so abdominal cancers, patients that have
00:29:44
Speaker
amputations for osteosarcomas because we know that their CNS is at a heightened state of sensitivity. Those are more the patients I'd be utilizing the fentanyl patches in rather than the more routine cases that don't have a significant degree of neuropathic pain going on postoperatively. I think the fentanyl patches sometimes I agree with you that they cause a lot more post-operative complications as far as like they're not eating well, they're feeling more nauseous or they're really quiet and and sleepy and the owners might sometimes they'll bring them home and the animals just sleep for a long time and it kind of is a little jarring to the owners a bit.
00:30:27
Speaker
I also think too that older patients in general tend to be more sensitive to the kind of the dysphoria or sedative effects of fentanyl. So these animals are getting like a pretty standard dose, like ah like two mics per kilo is usually what we use for deciding on fentanyl patches. And I usually round down, so so that's that's how I dose it. i I personally have found that those are the animals that sleep a lot. They're not eating as well in the post-operative period. The young, healthy, bouncing like TPLO dog that's like five-year-old lab, they don't, they're fine.
00:31:08
Speaker
Yeah, I agree. And I think this also goes back to the fact that when we're making these pain management protocols for patients to go home with, it really becomes more about the patient and not like the case or what the surgery was, right?
Buprenorphine for Pain Management
00:31:23
Speaker
It really becomes about how the patient is in, you know, tolerating and expressing their pain and, you know, what they specifically need. So, you know, it it it really becomes more personalized rather than protocol. Yeah. And I love the idea of thinking about utilizing fentanyl patches more for animals that have a chronic component on top of their acute pain state that they're experiencing. So I really liked that idea. Yeah.
00:31:51
Speaker
So let's jump to a different opioid now that we've talked about our full muse and let's just start talking about buprenorphine. I am just going to make a blanket statement right now that I personally love buprenorphine and I think it's really underutilized in general, at least as an anesthesia, like as an anesthesiologist because we do love our full new agonist for sure. But I really like buprenorphine. i might yeah you I might be the odd personnel in in that. I'm not lying. I literally have this written down. Buprenorphine is my favorite opioid.
00:32:26
Speaker
Buprenorphine I think is slowly becoming one of my favorite opioids as well. Absolutely. So let's start talking about I think cats first because there have been some new options for administering Buprenorphine to cats. And so we're going to start with that before I guess we jump into cats actually. We've thrown out the terms like full mu agonist and things like that. So let's start by just talking about the mechanism action of buprenorphine. Why is it different from like the fentanyl patch that we were just talking about? So buprenorphine is a partial mu opioid agonist, meaning it does bind to the mu opioid receptors to create analgesia. The analgesia it creates is a moderate analgesia, just not as much analgesia as we would get with a full mu agonist opioid. such as fentanyl or hydromorphone. We also know that buprenorphine has a very high affinity for the mu opioid receptors and it does bind really tightly, so that makes it difficult to then displace it off the receptors, meaning that mu opioid antagonists such as naloxone are really not effective at reversing buprenorphine.
00:33:38
Speaker
So do we have data out there that supports the use of buprenorphine as an effective analgesic agent in the post-operative period? And since we started talking about cats, let's let's go with cat. Do we have data about its use as an analgesic agent in the post-operative period with cats? Yes. So we do have evidence in cats and dogs that show us that buprenorphine can be a very viable option for post-operative analgesia. Yeah, one of the really interesting things about buprenorphine is that we can give buprenorphine a lot of different ways, which makes it very versatile, as opposed to some of the full mew agonists that we've talked about earlier when we're talking about opioids, whereby really we just have good data on intramuscular or intravenous use.
00:34:31
Speaker
And buprenorphine I think shines a little bit with its versatility. I don't know if you agree with that. I agree completely. We need to start a Buprenorphine fan club. So let's talk about transmucosal Buprenorphine, because I think that's kind of the classic way that we've been giving Buprenorphine to animals in the post-operative period, sending animals home with syringes, Buprenorphine, to just give to cats. So I think you already mentioned this, but let's repeat it. What's the bioavailability of transmucosal Buprenorphine in cats?
00:35:07
Speaker
And I guess we can also say dogs as well. And what's the difference? So the transmucosobuprenorphine has 100% bioavailability when given to cats. So the same if we give it transmucosally as if we give it intravenously in cats. In dogs, whereas parenterally, you know, we have 100%, when we give it oral transmucosally, that's going to be more of like that 40% bioavailability. I think the main issue with all of this is, though, that if it is not given transmucosally and it's actually given orally, the bioavailability goes down to pretty much zero. So you know it's so important to realize that you know we really need to teach owners how to do this. And again, it really comes down to patient selection, because if we have a cat that has full mouth extractions, and now we're telling the owner, here's some syringes of buprenorphine, give this trans me closely in their mouth, you know, three, four times a day, that might not go very well in that specific patient.
00:36:10
Speaker
Yeah, i I think I was going to totally reiterate that, that you have to give it either under the tongue or like in the cheek pouch or something like that. They're not supposed to eat it. Yeah, and even under the tongue, you know, I think is so, i I totally agree and that's what I tell people, but it's like even sometimes, especially if the volume now becomes larger, so if we're using it in dogs or big cats, you you know There is probably a decent amount of that that then goes orally. and i think too Yeah, and I think to remember that even though it's 100% bioavailability, dosing becomes really important because with any opioid, whether it's a FOMU agonist, partial MU agonist, the higher the dose, the longer the analgesic effect.
00:37:00
Speaker
the lower the dose, the shorter the analgesic effect. So if now we're coming and we're saying, okay, well, you're a 10-kilogram cat, so we're going to send you home with 0.01 mgs per kg of buprenorphine to give every 8 to 12 hours. Well, 0.01 mgs per kg of buprenorphine is probably only going to last that cat about like five hours, six hours, right? So there's a big period that we're missing, especially now if that is partially going orally, so they're getting even lower of a dose. So sometimes with the oral transmucosal route, I actually dose up on my buprenorphine where I normally would for an IV dose.
Cymbidol and Simadol for Analgesia
00:37:40
Speaker
Yeah. I actually really liked that idea because we haven't really talked about this very much, but buprenorphine has a pretty, in my opinion, and probably also has data that it has a very wide safety margin and also has a ceiling effect. So there's a point where, you know, you can't giving more buprenorphine. and You're not necessarily giving more analgesia, but you're also not necessarily seeing a lot of toxic side effects either. Absolutely. So it's, I i always agree about. increasing the dose of buprenorphine in general. Yeah. My typical buprenorphine doses for transmucosal for cat specifically is typically between like 0.02 and 0.06 makes per cake every eight to 12 hours.
00:38:23
Speaker
Oh, I don't think I've ever gone as high as 0.06. In smaller cats, right? If they're like really tiny, I always think about metabolic or allometric scaling. So smaller patients might need a little more, bigger patients might need a little less, but I'm typically not going below that 0.02 makes per gig if I'm dosing every eight to 12 hours. So let's talk about a different buprenorphine formulation, which is Cymbidol, which has been around for a while now. So why don't you start by just telling us a little bit about what is Cymbidol? So Cymbidol is just concentrated buprenorphine. And when we give it at the label dose, it can last
00:38:58
Speaker
up to 24 hours. And I'm using quotation marks there because the pharmacokinetics are kind of all over the place when we're using it at the label dose. So instead of giving a typical 0.02 makes for keg in like a normal presurgical dose of but buprenorphine and Simidol-labeled dose is 0.24 mgs per keg, which really, just like you said, there's a ceiling effect for that analgesia. So we're just peaking up those plasma levels of buprenorphine, and then they're gradually just falling off over a period of time.
00:39:32
Speaker
So the advantage of this is if you can't touch the patient postoperatively, if the owner is unable to medicate at home, at least they have something on board. Right. And I'm in quotations again. But the issue is that we don't know when it's going to wear off. So they're very well maybe be breakthrough pain. if that's being used as a single agent. And some other disadvantage is that because those plasma levels peak up so high, the side effects such as euphoria, dysphoria, hypersalivation, hyperthermia, possibly sedation, not as much, definitely can be seen. I think the cool thing about Cymbadol, because I'll be honest, I do not utilize Cymbadol at the label dose
00:40:17
Speaker
at all, and I have very strong feelings about that. But the cool thing about Cymbadol is that now we can use it at more normal buprenorphine doses, and that's how I tend to use it. So in both dogs and cats, whether we're giving it transmucosally, IV, IM, we can utilize it at what I would consider a regular or normal buprenorphine dose very effectively. So essentially you're using Simidol as just a standard buprenorphine, but the concentration is different. Yeah, and I like it actually for that oral transmucosal because it ends up being a smaller volume. So I think we get a more efficacious transmucosal route, if that makes sense.
00:40:59
Speaker
Absolutely. I think I have a lot of vets that complain to me about Cymbadol at the dose that it's labeled for, that a lot of cats get very hyperthermic or they get very dysphoric with it. And I think it turns some people away from it, but I do like the idea of using that formulation for like oral transmucosal use instead. Yeah, I love that they've come out with studies. You know, I think North Carolina were the first people to start coming out with studies looking at that with Simidol. And I think that was great because I don't know how you are in Florida, but I sometimes have a hard time getting regular buprenorphine up here. And so at my practice now, I have Simidol. It's a huge bottle and it's great. And so I now just utilize that, you know, for my normal buprenorphine dosing.
00:41:46
Speaker
Yeah. Well, on a business level though, you know you get more out of the bottle because if you're just if you're dosing it at your standard doses, you're getting a lot more use out of that one bottle.
Zorbium for Cats: Usage and Effects
00:41:57
Speaker
Absolutely. Even though I think it is a little bit more pricey. Yes. It can be. It actually it depends on the formulation of buprenorphine, how I was getting buprenorphine before I switched to using Cymbadol. It actually was more expensive and now I'm saving money using the Cymbadol. Not significantly, but... Yeah, I have some practices that compound... They get compounded buprenorphine, so like the classic buprenorphine is 0.3 mix per mil. There are some pharmacies that compound it higher, like 0.6. But I have no idea what the the cost difference between like a compounded buprenorphine versus Simidol would be anyway. Yeah, I'm not sure. And I think it all depends on market value and availability as well.
00:42:41
Speaker
But for our listeners might be something interesting to look into if you are trying to look for a way to save money in your practice and you're using a lot of buprenorphine. Especially if you're sending home buprenorphine for transmucosal routes, I think that having the more concentrated version is actually pretty nice. Yeah, so let's move on to like the newest formulation of buprenorphine. And for our listeners, we do have an entire episode on Zorbium. It's actually our first episode of the Navas podcast we ever produced. So we all have to belabor a lot about Zorbium, but I am curious about your experience with it because we've now had it for a few years now. So not to belabor the point, but why don't you just briefly explain to our listeners what Zorbium is.
00:43:25
Speaker
Yeah, I really like Zorbium. So Zorbium is a transdermal buprenorphine for cats, and it's administered similarly to like a topical flea or tick preventative, and it can last up to 72 hours. But unlike Cymbadol, the plasma levels don't peak up, rather it's a slow release of buprenorphine into the bloodstream. So I personally think this is a better option for cats at home that owners can't medicate like after procedures or, you know, can't touch for some reason. Zorbium is labeled, I'll say this in a as an aside, but z zorbium is labeled to be given prior to the surgical procedure. And I'm curious your opinion, but I prefer to give it after the surgical procedure or during the recovery period. so that I can control that pain management intraoperatively a little bit more effective. And also, you know, I think it's really important to say, don't forget to wear full PPE when you're administering the Zorbium. So gloves, mask and eye protection. And we don't want to touch the patient then for about an hour because we don't want to get Zorbium in our mucous membranes. That would you know be a bad day for us.
00:44:33
Speaker
What's your experience? I really like Zorbium so far. To say my experience more so is actually cats. I mean, they look comfortable. They're not necessarily super euphoric, maybe slightly, but in at least in the hospital, I think if the animals are truly uncomfortable in some way that I think Zorbium does a really nice job. What I'm trying to say is like, Zorbium, I think the labeled use, it might not be the labeled use, but a lot of the clinical data coming from it was for cats that were undergoing spays and neuters. Yeah. And I personally feel like for a neuter, I feel like 72 hours of pain relief is kind of overkill for those patients.
00:45:20
Speaker
And so those are the cats I find that are getting like really dysphoric on Zorbium. Absolutely. And I think it again, highlights this fact, just like with the fentanyl patches, the ones that are showing the side effects are the ones that don't need the analgesia as much typically, right? So yeah it's not that ongoing. So that's why it's so important. Treat the patient, not the procedure, right? So really think about what pain is this patient going to be going through, not like, oh, I did a neuter because maybe you did a neuter, but maybe it was a three-year-old cat that, you know, you had to do some more dissection or maybe it was cryptorchid or maybe it was, you know, whatever the case may be, right? So, treat the actual patient. But if we feel, I don't disagree, I think Zorbian might be
00:46:06
Speaker
a little overkill for a typical six-month-old cat neuter, right? yeah And those are the ones that I definitely agree are more dysphoric. But if it's like full mouth extractions, by all means, I think Zorbium becomes such a nice option you know for that. Yeah. My largest experience using Zorbium so far is actually in dentistry patients. And so I have a lot of clinics, we're actually just using buprenorphine as our opioid of choice, even for the perioperative period. And so we're combining buprenorphine with like full mouth extractions and maybe like ketamine CRI during the procedure. So I think most animals on that combination that we use for our dentistry cases are doing really well perioperatively. That being said, if we're anticipating
00:46:55
Speaker
a large amount of extractions for that cat or that we know that cat has stomatitis already because we've done an exam. Yeah. Yeah. If we know we're we're going to be doing a lot of work in that mouth, we've been using Zorbium beforehand as our, because we're going to give that cat buprenorphine anyway, so we're just going to use Zorbium. Are you taking any precautions with like heating pads or like with anything like that or like wet wetness? like I know after about an hour, it's a mo you know you're supposed to be able to do it. I'm just curious from a because I personally just haven't used it that way. Yeah. so We wait about an hour before we start the procedure. and so According to Alanco, after about an hour, that product should be completely absorbed. and so Using heating pads,
00:47:42
Speaker
or anything like that is a moot point, at least according to Olenco. And I personally have not had any issues with that as long as you're like waiting like the hour between where you get started. I also like it because you know a lot of those cats with stomatitis, they're uncomfortable. And so I really like the idea. like When they walk in the hospital door, we pop sorbium on them right away. And so even if they're going like later on in the day, we're at least providing them with analgesia even while they're waiting for their procedure to happen. I think that's great. Yeah. Yeah. So I've been very pleased with sorbium personally. I think the biggest side effect I have seen with it so far has been hyperthermia. Yeah. And I have seen some cats get very hyperthermic with sorbium personally, but I have not seen any long-term issues or complications as a result.
00:48:34
Speaker
Yeah, I typically, I don't know how you feel about opioid induced hyperthermia, but I don't treat it as a pathologic hyperthermia. Yeah, I don't either. When people ask me what to do about it, I usually tell them stop taking the temperature.
00:48:56
Speaker
actually That's my rule of thumb. Yeah, I've recommended sometimes if they're not also using an NSAID that that might be helpful even though it's not necessarily like the mechanism is necessarily going to break the hyperthermia associated with opioids. but and said our way to treat pyrexia. So potentially sometimes that helps. And there's like general cooling things like maybe stick a fan in front of their cage. The other thing I found too, and this is a little anecdotal, but I have started advising people to even an obese cats where they might
00:49:32
Speaker
technically qualify to get the larger cat dose, abs absorbium. I usually still tell people to give the small cat dose. Got it. Just because I think that dosing off, i'm either again, completely anecdotal, and this is not based off of any kind of data at all, so it's important for listeners to know. But I do find that dosing on lean body weight when it comes to sorbium or buprenorphine in general, I think is probably a good idea to avoid some of those side effects. And I think the biggest side effect of buprenorphine that bothers people the most is going to be the the hypothermia.
00:50:09
Speaker
Yeah, I agree. And i you know yes, off-label, all of those things.
Transdermal and Transmucosal Buprenorphine
00:50:14
Speaker
But for any analgesic or anesthetic drug, I almost always dose on either lean body weight or I dose reduce. So I think one way or another is fine. But just be consistent with what you do with that. Is there any good buprenorphine option for dogs, in your opinion? Like in the post-operative period? We do know that there are transdermal buprenorphine patches that have been shown to have some decent pharmacokinetics in dogs. That being said, I haven't personally utilized them. Have you ever utilized buprenorphine patches in dogs?
00:50:50
Speaker
No. you know it It would be interesting to see how that goes. It would also be interesting. Have you used sorbium on any dogs? Off label? I have not. I have not either, but I'm kind of curious to see some studies come out about that. I hope that there's something in the works, you know, looking at some transdermal buprenorphine options for dogs as well, because I think they're just as deserving as getting transdermal buprenorphine as cats are. That being said, I think that transmucosal buprenorphine is something that I will sometimes utilize in dogs. and just parenteral types of options. In your opinion, what are the best practices for veterinarians to judiciously and responsibly prescribe opioids for our patients? What is our role in this?
00:51:33
Speaker
I think the most important thing is not to give more than a three-day prescription for acute pain and to really critically evaluate the benefit of them for chronic long-term pain management from an abuse potential, from a side effect, and really from an efficacy standpoint. You know, are these really helping our patients? Are we doing something good in these situations? I get so many dogs that come in to see me, especially, that have been on tramadol for like 10 years or something, you know three times a day tramadol for like 10 years at like two makes per keg. And I'm like, is this really efficacious for this patient? you know it's It's typically one of the first drugs that I wean them off of and very often find that that long-term management on that tramadol or oral opioid or XYZ type of ah opioid that they're on is not giving them efficacy. So I think really reevaluating those patients, the chronic ones, making sure that we're being really patient and case-selective about which ones we're sending home with oral opioids.
NSAIDs in Post-Op Pain Management
00:52:42
Speaker
So we're gonna jump into NSAIDs now because it's arguably one of the most effective oral analgesics for our companion animals. But we do know this class of drugs comes with some side effects. So first question I have for you is, what are the advantages to including an NSAID in the post-operative analgesic plan? Well, first of all, I love NSAIDs. That being said, it is all about patient selection and really about client education to make sure we're using them as safe as we can. I think the main advantage of using NSAIDs in the acute postoperative analgesic plan is that they are potent anti-inflammatories and a majority of the pain from soft tissue surgeries is inflammatory in nature.
00:53:29
Speaker
I do think that NSAID should be administered once or twice a day, depending on which NSAID we're using, and should always be given with a meal. The biggest side effect that we see is GI mucosal irritation. So in patients that have sensitive stomachs, I sometimes will send them home with a GI protectant, an acid reducer, or just have the owners give them after a full meal. And they definitely can be used with other analgesics, just not with things like steroids. I always tell owners if the pet is not eating, if the pet vomits, or if the pet has diarrhea, stop giving the NSAIDs, call me immediately so we can make a plan moving forward.
00:54:09
Speaker
When are some cases where you would personally avoid using an NSAID in a small amount of patient? I would avoid using NSAIDs in patients that have pre-existing GI mucosal damage. Other than that, I always weigh the pros and cons of using NSAIDs based on their history and whatever comorbidities they have. Sometimes if I have patients with coagulopathies, like Malmilla Brands disease, and sometimes I will avoid using NSAIDs in those patients or if they have like low platelet counts, things like that, do you do that as well or do you think that is a little overkill?
00:54:44
Speaker
I think it depends on their status. So if they are patients that I'm actively treating with platelets, like I'm giving platelet transfusions or I'm giving blood product to, maybe I'll wait until they're in a stable place, but then I really don't not use NSAIDs in those patients. I just wait until they're in a stable hemodynamic situation. Another common thing that I see in practice is animals with elevated liver enzymes without any other blood work findings of decreased liver function. And I do find that some veterinarians are avoiding using NSAIDs in those patients. And I'm wondering what your opinion about that is.
00:55:30
Speaker
I find a lot of veterinarians do not use NSAIDs in those situations. And I won't lie, I have a little bit of a soapbox about this because I think that it's so important to remember that elevated liver enzymes is not the same thing as hepatic dysfunction. So it really is important not to just classify those patients as liver disease patients and know that we can still very safely use NSAIDs in probably the vast majority of those patients. I think that for veterinarians that are a little bit more nervous about that, maybe starting with lower dose ranges, drugs that we can dose more on that 12-hour period rather than giving a big 24-hour dose of an NSAID,
00:56:15
Speaker
Those are kind of my guidelines and suggestions. What are your thoughts on that? Curious. No, I agree with you that the side effects we see with NSAIDs specific to hepatic adverse effects are that usually it's an idiosyncratic reaction. And so if we are going to see hepatic dysfunction, it's usually unpredictable and not necessarily related to patients that already have increased liver values. um At least that's what the data we currently have shows. So sometimes I will recommend like if if veterinarians are anxious or nervous about that, maybe a dose reduction or giving the NSAID maybe instead of like if it's a once a day NSAID maybe giving like every other day or something like that them you know to decrease their anxiety about that. Doing some kind of either dose reduction or dosing interval reduction depending on the NSAID that's being used.
00:57:13
Speaker
is at least the animal still going to like get an NSAID? Yeah, I agree. And I think, again, it just like every single thing, I sound like a broken record when I say this, but it's all about treating the patient, right? So it's about weighing the pros, weighing the cons, and trying to find the best plans for that specific patient. Okay. So let's jump into discussing some of the specific NSAIDs. And I really want to focus our conversation on galloprants because I find that this is the one drug that I have the most questions about personally. So it's not a traditional NSAID as I'm sure you're going to inform us in just a moment. So why don't you tell us a little bit about how this particular drug works?
00:57:58
Speaker
Galloprant is a non-steroidal anti-inflammatory, but it specifically blocks the EP4 prostaglandin receptors without a affecting the Cox pathways like traditional NSAIDs do. We do know that for acute post-operative pain relief, this is not the most effective choice. And we do have a couple studies in cats that have shown some off-label use, but we again don't know that it's an effective analgesic for the acute post-operative period. Since EP4 receptors are localized in the dorsal root ganglion as well as peripheral nociceptors,
00:58:37
Speaker
There technically should be less of an issue using this in patients with renal insufficiency. But again, I think we really need more data to support its use and its efficacy as we know that you know inflammatory pain is way more complex than one receptor. So, I think that's really important to note that in that acute post-operative phase, this might not be the best choice. And maybe we'll have more evidence in several years that show us differently, or we might dose it differently, you know, question mark, but right now, it's definitely not my end set of choice for acute post-operative pain.
00:59:15
Speaker
The drug's currently labeled to treat osteoarthritis pain in dogs. So a lot of patients will with orthopedic conditions will come in on this drug already, or maybe they are having going to have a surgical procedure not related to anything at all with their joints, but they're on galloprant already to to treat their arthritis. So if you have a surgical patient that's already on galloprant, Do you just continue the patient on Galloprint post that? Or do you actually recommend weaning this particular drug like off the patient? If you do recommend weaning, like how do you do that? Because there's a lot of controversy about this particular topic. A lot of people have different opinions. And I think it's just because we don't have good data about what to do.
01:00:01
Speaker
Again, I do think it depends on the patient and the surgical procedure and why they're on galloprant in the first place and why they're not on a traditional NSAID, right? So if they had a sensitivity to another NSAID, if they have a history of renal insufficiency, if they have XYZ, I might keep them on the galloprant, but my preference would be for an acute post-operative pain to switch them to like a Remedil or something equivalent. So, what I personally would do is stop the galloprant two or three days before the surgery, and as long as the procedure goes well, as long as there's no complications, no hypotension, no hypothermia, I'll start something like Remedil in recovery.
01:00:46
Speaker
And then once that patient finishes, it's course of like, let's say it's like a five day course of an NSAID or seven day course or something like that. Would you just have that patient continue Remedyl to treat its arthritis? Presumably it's on that. Or would, would you have the patient go back onto Galloprent? Or do you think that's kind of up to the owner and each dog? I think it's up to each dog. I wouldn't leave it up to an owner specifically, but I would really try and critically evaluate how that patient then does on the Remedil because I've actually seen this, I don't know if you have as well, quite a few times where a patient has been managed, and I'm in quotations again, on Galloprant for their arthritis pain. We get them on to something like Remedil for an acute surgical, you know, whatever, and then post that
01:01:34
Speaker
they're actually doing so much better with their arthritis pain than they were doing prior to the procedure, even if the procedure had nothing to do with where their arthritis is. And so in those situations, I might keep them on the Remedil, but in other situations, if I have a dog that's been well managed with their osteoarthritis pain on Galloprant, I think switching them back to Galloprant is absolutely fine.
Acetaminophen Use in Pets
01:01:56
Speaker
It really just depends on that specific patient response. And again, why they weren't on a traditional NSAID in the first place. Yeah, I think that's a good point about just asking questions about why that patient was put on galloprant in the first place. Mm-hmm. So let's switch away from galloprant. Let's talk about Tylenol, another kind of non-traditional NSAID. So how does this drug work?
01:02:21
Speaker
Yeah, so acetaminophen is going to inhibit COX-3 isoenzymes. We also know that this can also activate CB1 receptors. It can inhibit serogenergic descending pathways. And it really has been shown to have comparable analgesia to things like meloxicam and carprofen for post-operative pain in dogs. And a specific study looked at it in spays. We do know that acetaminophen does require hepatic glucuronidation for removal. So that's why cats who have a low capacity for this shouldn't get acetaminophen because it can lead to methemoglobinuria, homolysis. This can happen in dogs as well.
01:03:04
Speaker
but it's much less common with therapeutic doses. It still should be potentially avoided or used in caution with dogs with actual hepatic dysfunction or advanced kidney disease, not just elevated kidney or liver enzymes. You know, I definitely like Tylenol. I think that it's one of the underutilized analgesics in veterinary medicine for sure. And it's typically a drug that I'll use a lot of the time for my chronic arthritis patients for breakthrough pain. So when they're having flare-ups, you know, and they're already on a traditional NSAID, I might have them use acetaminophen for a period of time, or if they're on a steroid, I might have them use acetaminophen for a period of time just to help kind of with that analgesia. How do you dose it, dogs? I typically dose somewhere between 10 and 20 mgs per kg. It depends, again, metabolic or allometric scaling, you know, becomes important in that as well.
01:03:56
Speaker
How many times a day? I do it every eight to 12 hours. Okay. Typically 12 hours. Okay. If you're doing lower doses, you know, every eight hours is fine. um Is there a specific formulation of acetaminophen that you recommend to clients because there's so many variations of Tylenol and and shit yeah yeah, out there. So I wonder if there's a combination you're using. Yeah, paracetamol is actually used more in the UK and it's actually much more widely utilized than Tylenol is utilized in the US. I think it's really important to make sure that if you're using like a liquid, there's no xylitol or other additives. I'm not using like Tylenol PM in these patients. you know We need to make sure that we're being you know specific about what kind of Tylenol we're using, but even generic acetaminophen I've used absolutely in dogs.
01:04:48
Speaker
Let's talk about NSAIDs and CATS. What are your recommendations for what kind of NSAIDs to use, how often you're using them, at least in the acute post-operative period? I personally really like robinococci when it comes to CATS NSAIDs. That's probably the one that I utilize the most. And I think one really important thing that I see a lot of veterinarians doing is they're only sending it for a three-day period because that's technically what the label dose is. But just like we do for probably 75 plus percent of the things in veterinary medicine, right, we're using it as an off-label dose.
01:05:27
Speaker
So I think it's important to remember that we can utilize rabbinicoxib for longer periods of time. I've actually had cats on it for years, potentially, right? I think for me personally, and this is a very controversial topic among veterinarians, but I am very much a lowest effective dose of NSAID for my chronic patients. So you know I think that using it off label for longer periods of time, but then dose reducing is usually what I'll do. and then increasing the dose if they're having flares, decreasing the dose if they're in their, you know, more normal periods or potentially using it on that as needed basis. You know, I think especially preemptively, like before activities or, you know, exercise and things like that is absolutely appropriate. But for that acute postoperative period, you know, treating the acute pain, remember, it's going to last somewhere between three and 14 days. So typically seven to 14 days is what I recommend with soft tissue surgeries. sending home and sending cats, typically. So, rabbinicoxib is labeled for three days. it's Okay. So, is your recommendation to use that off-label for seven to 14 days or something like that, depending on the soft tissue injury? Yes. Okay. What about meloxicam? What's your opinion about its use because it's labeled very specifically in the United States?
01:06:51
Speaker
And it's, I believe the oral formulation is not labeled for using cats. So I'm just curious what your opinion on that is. I use it for sure. So I think meloxicam is a very effective NSAID in cats. I think we have studies that show us that it's a very effective NSAID in cats. And I think that the label dose you know is of many different drugs often ends up being you know a little higher than what we actually need clinically to produce analgesia.
Conclusion and Future Episodes
01:07:19
Speaker
So, typically if I'm giving like an injection of either meloxicam or rabbinicoxib to a cat postoperatively, I'll use meloxicam at about 0.1 makes per keg, you know, subcutaneous, and then I'll use rabbinicoxib at the two make per keg label dose subcutaneous, and then the next day I'll send them home typically with either the one make per keg of robinococcib or 0.1 makes per keg of meloxicam, but after about a week or so, I might half that dose for that second week and then have them just kind of wean off it that way. So we're not just abruptly stopping the NSAID. Okay. I think it's important to note just to make sure that you're using either meloxicam or robinococcib, but it sounds like you favor robinococcib over meloxicam. I personally do, yes, in in my practice, but yes, it's either or I'm not using them together.
01:08:09
Speaker
Yeah, and it sounds like you are advocating for their off label use if that's correct. Correct. Absolutely. Okay. Well, so what I'm going to do now is I think that we have a lot more pharmaceutical and non-pharmaceutical options to talk about when it comes to post-operative analgesia including things like Gabapentin, pre-Gabalin, we haven't really talked about local anesthetics yet. So there's still a lot more to talk about. So I'm hoping you would be willing to come back on the podcast and talk to us for maybe like a part two about this because it's a really big but very important topic. Yeah, I would love to. And I think, you know, this really is a really important topic. And just because we're trying to highlight some of the things here, you know, again, it really comes down to that overall multimodal analgesic protocol.
01:08:56
Speaker
and trying to come up with the best options for the specific patient. So if there's questions off the podcast, you know I'm very available and I know you are as well to answer those questions, but you know pain management is an art for sure. It's not a set and forget and we always have to be ready to kind of jump to the next option when we're having breakthrough pain or what our plan was isn't necessarily enough or the right plan. So yeah, I'm excited to talk more about other options that we have too. Awesome. Well, we will look forward to part two with Dr. Zimmerman next time on the NAVAS podcast. Thank you.
01:09:39
Speaker
If you like what you've heard today, I encourage you to check out NABAS and consider becoming a member. As a member of the North American Veterinary Anesthesia Society, you get tons of benefits, including access to CE events, focusing on anesthesia and pain management, blog posts, fireside chats with board and anesthesiologists, as well as specialty technicians, and just so much more. Visit www.mynabas.org to advance your anesthesia journey today. If you have been enjoying the content of this podcast, I would sincerely appreciate it if you would give us a like or subscribe to our podcast. Write a review or simply spread the word about this podcast to your friends and coworkers. We appreciate any and all listener support. If you have any questions about this week's episode or the Navas podcast in general, or if you want to suggest topics for future episodes, please reach out to us at education at mynavas.org.
01:10:36
Speaker
We would love to hear from all of you. Also, a huge thank you to our sponsor, Decra, without whom this podcast would not be possible. Visit their website, www.decra-us.com to learn more about their line of veterinary anesthesia products. This podcast was produced by Maria Bridges, edited by Chris Webster of Chris Webster Productions, and technical support was provided by Saul Jimenez. I want to thank our guest, Dr. Melina Zimmerman, for this wonderful discussion on post-operative pain management. We look forward to having her on the next episode to finish up this discussion. And lastly, a huge thank you to all the gas pastors out there who choose to spend their time with me today on the North American Veterinary Anesthesia Society podcast.
01:11:23
Speaker
Becoming a skilled anesthetist is a lifelong journey of learning and self-discovery, so I hope you consider listening in the future. I'm your host, Dr. Bonnie Gatson, and thank you for listening. See you next month with another episode of the Nav-Ass Podcast.