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Pain Management Using Metacam

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by Arnold Plotnick MS, DVM, ACVIM, ABVP

Veterinarians currently employ two main strategies for managing pain in companion animals.  The first strategy is pre-emptive analgesia.  This involves giving pain medication before the patient is exposed to the painful procedure.  The second strategy is multi-modality therapy.  As the name implies, this strategy takes advantage of the fact that various classes of analgesic drugs have additive or synergistic effects when administered together.  The rationale is to combine drugs that disrupt the development of pain at the various individual steps along the pain pathway.

There are several pharmacologic classes of drugs available to treat pain.  Opioids, alpha-2 agonists, non-steroidal anti-inflammatory drugs, local anesthetics, and adjuvant analgesic agents have all been employed in controlling animal pain. One particular class of drugs, the non-steroidal anti-inflammatory drugs (NSAIDS), is very effective in controlling post-surgical pain as well as pain and inflammation due to arthritis.  Unfortunately, cats are particularly susceptible to exhibiting adverse effects from this class of drugs, which includes aspirin and acetaminophen, both of which can be harmful, and even lethal, to cats.

How NSAIDs work

The NSAIDs control pain by inhibiting an enzyme called cyclo-oxygenase (COX).  Several years ago, it was discovered that there were two forms of this enzyme, COX-1 and COX-2.  We now know that the COX-1 enzyme is continuously produced by the body and is mostly responsible for generating compounds that are beneficial, such as maintaining blood flow to the kidneys and protecting the stomach lining.  COX-2, on the other hand, is mainly responsible for generating compounds that contribute to pain and inflammation.  The traditional NSAIDs, such as aspirin, inhibit both COX-1 (the “good” enzyme) and COX-2 (the “bad” enzyme).  The newer NSAIDs are designed to inhibit the bad one, COX-2, while having minimal effect on COX-1.  In the past few years, several COX-2 specific drugs have been marketed for people and for dogs, but very few have been  suitable for cats.

New drug

The U.S Food and Drug Administration initially approved meloxicam (brand name: Metacam; manufactured by Merial, Ltd.), for control of pain and inflammation associated with canine arthritis.  The drug had been used in many other countries, however, in an off-label manner to treat pain in cats as well.  It no longer needs to be used off-label.  Injectable meloxicam is now approved for use in cats in the U.S.

Advantages

Meloxicam is not the only NSAID that can be given to cats.  Others, such as aspirin, carprofen, ketoprofen, and piroxicam have been given to cats, with varying degrees of success, and more importantly, with varying complications.  Some of these NSAIDs cause gastric upset (aspirin, piroxicam), some exist primarily as injectable formulations and cannot be given orally.  Except for aspirin, these NSAIDs are not intended for long-term use. A major advantage of meloxicam is that it comes as an oral formulation and can be given long term to manage post-surgical pain, inflammation and discomfort due to arthritis, and pain associated with cancer. 

Poor Little Louie

Louie is a 5 year-old Maine Coon owned by Louise Roussin.  Louie has a painful oral condition called lymphoplasmacytic gingivitis.  This is an auto-immune disorder in which the gums become extremely inflamed, tender, and painful.  When medical management with antibiotics and steroids can no longer control the condition, extraction of all the teeth behind the canines is recommended.

Louie was losing his battle with this disease.  Oral pain was affecting his ability to eat and his demeanor.  I gave him a ketoprofen injection several hours before the procedure (pre-emptive analgesia) and an injection of a narcotic pain reliever at the end of the procedure and again four hours later (multi-modality therapy).  That evening, Louie’s face was a little swollen, and of course he had no interest in food.  The following morning, Louie was feeling great.  He was affectionate, rubbing his face against the cage and demanding attention from me and my staff.  I gave him another injection of ketoprofen and sent him home that evening. 

Ms. Roussin called two days later.  Louie was eating softened food, although he was acting sluggish and aloof, and this was very unusual.  Concerned that oral discomfort from the multiple extractions might be affecting his demeanor, I prescribed meloxicam once daily for the following three days.  Ms. Roussin called on day 3 to tell me that Louie immediately returned to his sweet, affectionate self as soon as the medication was administered.  This was my first experience using meloxicam, and I now dispense one dose of meloxicam after every dental procedure, and additional doses if any extractions were performed.

Conclusion

It is now recognized that animals perceive pain much the same way that humans do, and that we have a moral obligation to protect pets from pain and suffering.  This increased understanding has driven the need to develop more effective methods of controlling feline pain, and veterinarians should now be able to control pain in virtually all feline patients.

       

Updated 2/9/06