One of the most important tenets of holistic medicine is managing pain in cancer patients. All cancers cause inflammation which leads to chronic pain ranging from mild to severe. Regardless of whether conventional or alternative modalities are employed, all cancer patients must be treated for pain. I firmly believe this is the time and place when pharmaceuticals should be employed. Numerous studies have shown the earlier these drugs are used, the better the patient will do. This is true of people and animal patients—PAIN MUST BE TREATED EARLY! NSAIDS, or non-steroidal anti-inflammatory drugs, are utilized first to combat pain and inflammation. These are prescription drugs ( such as Rimadyl, Deramaxx, or Metacam(Meloxicam)) pets take daily in pill or liquid form on a long term basis. If NSAIDS are not controlling pain well enough, then analgesics, such as gabapentin and amantadine, are added to the pain treatment protocol. Both of these analgesics work on neurological receptors to control maladaptive pain. They have been extensively used to help people battle chronic pain and are showing much promise for our animal friends as well. Tramadol, a synthetic opioid, can be used for acute flare-up of pain or break-through pain.
I will be writing more about alternative pain medications for dogs who cannot tolerate NSAIDs in the near future, but there are times when an NSAID really is the best choice for pain control. This might be because other types of pain medication don't fully control the pain, or because the animal is sensitive to other medications as well.
There are things you can do to make NSAIDs easier on the dog's GI tract, although they will not always be enough for every dog. To understand how some of these might work, it's important to understand what NSAIDs are, and how they function to control pain.
NSAIDs are anti-inflammatory drugs that inhibit an enzyme called cyclooxygenase (COX for short). Cyclooxygenase is a substance in the body that causes it to produce prostaglandins, which cause pain and swelling. The problem is, prostaglandins do all sorts of beneficial things in the body, too, like maintain and repair the intestinal lining, control the body's hormonal systems, and regulate kidney function. There are, in fact, few body systems that do not rely, at least in part, on prostaglandins, so inhibiting them clearly has the potential to cause as many problems as it solves, or more.
Most people know that non-steroidal anti-inflammatory drugs (NSAIDs) such as Rimadyl, Metacam/Meloxicam, Previcox, Deramaxx, Etogesic, and others can irritate the digestive system and cause ulcers of the GI tract. They do this because COX enzymes and prostaglandins are necessary to repair and maintain the intestinal lining. In fact, while kidney damage and death do occur as a result of these drugs and get most of the hype, the main reason dogs are removed from NSAID therapy is because of the damage to their GI tract, including nausea, vomiting, diarrhea, ulcers, and bloody stool.
There are different kinds of COX, and they serve slightly different functions. It was once believed that COX-2 was the "bad" COX, and COX-1 was the "good" COX, and so the newer generation NSAIDs have been developed to be more and more COX-2 specific, but that is not turning out to be the case. It seems that COX-2 does have a protective effect on the gastrointestinal lining, and older generation NSAIDs like aspirin, which tend to inhibit COX-1 more so, or equally to, COX-2, actually have some GI-protectant benefits that help make up for the damage they cause.
So, if your dog has osteoarthritis or some other form of chronic pain, and really needs to take NSAIDs to maintain quality of life, there are a number of things you can do to prevent gastrointestinal problems.
First, make sure you are using multi-modal pain control. If you aren't relying exclusively on the NSAID for total pain control, you'll be able to use a lower dose, or even skip a day every few days and give the gut a chance to heal. Drugs such as Tramadol, amantadine, gabapentin, and narcotics can be used in combination with NSAIDs, or instead of NSAIDs, to control the pain of cancer or osteoarthritis. If your veterinarian isn't familiar with these drugs or is unsure of how to use them, ask for a referral to, or ask your vet to consult with, a veterinary anesthesiologist, or with the Analgesia/Anesthesia consultants on the Veterinary Information Network if they are a member. There is also a great deal of valuable veterinary information on the website of the Veterinary Anesthesia Support Group.
Second, consider alternatives to be used in combination with, or instead of, NSAIDs. Fish oil capsules, glucosamine-chondroiton, Adequan injections, and acupuncture are among the main available alternative therapies that have shown benefit in many cases of osteoarthritis and inflammation. (And of course, keep your dog lean!)
Third, ask your veterinarian about misoprostol. Misoprostol is a prostaglandin analog, and by taking it orally along with NSAIDs, you can help mitigate some of the effect of COX inhibition on the intestinal lining. While misoprostol can cause upset stomach and diarrhea on its own in some dogs, if your dog tolerates it, it's well worth considering as an adjunct to NSAIDs.
Another useful drug is Sucralfate.
Stomach ulceration in humans is a prominent medical condition and there has long been pressure to develop effective and convenient ways to address this problem. Until relatively recently, we relied on simply neutralizing stomach acid by pouring alkaline solutions (i.e., Alka Seltzer, Tums, Rolaids etc.) into the stomach. In fact, ulceration is a complicate process and there are many ways to address it.
Sucralfate was developed as an adjunctive treatment for stomach ulcers in humans. Sucralfate is a sucrose aluminum hydroxide compound that forms a gel-like webbing over ulcerated or eroded tissues thus serving as a sort of a bandage. It is effective in the upper GI tract: stomach, duodenum (upper small intestine), and esophagus.
Sucralfate not only “bandages” the ulcer but accumulates healing tissue factors in its bandage; it not only protects the ulcer but actively assists in the healing process. Because Sucralfate is a locally acting medication and is not absorbed into the body it has very limited side effects potential.
How about antacids like Pepcid (famotidine) and acid controllers like Prilosec (omeprazole)? While they might reduce the symptoms of GI ulcers in dogs on NSAIDs, they don't appear to have any benefit at all in actually reducing the ulcers once they occurred. So despite their widespread use with NSAIDs, they may actually mask an ongoing problem. Misoprostol actually has some acid regulating properties itself, but more than that, it acts to restore the intestinal lining naturally, to prevent the formation of ulcers and help heal those that have already formed. In addition, the use of antacids can be contraindicated with both misoprostol and sucralfate.
The herb slippery elm might also be worth considering, although it's not clear if it actually helps heal the gut, simply provides some protection to the intestinal lining, or only serves to make the dog feel better. Slippery elm, the inner bark of ulmus fulva, is a soothing, gelatinous substance that has traditionally been used for the treatment of ulcers. It is also used for sore throats and skin irritations. Slippery elm is an extremely safe herb and is actually used as a food. It is sold in bulk in health food stores, as well as in capsules and as a tincture. It's slightly sweet so most dogs will eat it readily, but it can be given in capsule form or as a tincture if necessary. A veterinary product exists called Phytomucil.
Of course, the side effects of NSAIDs are not limited to the GI tract, so it's important to work with your veterinarian to monitor your pet's kidney and liver function as well.
