Master’s student: Mette Malmstedt Bindslev
Specialisation: Internal Medicine
Master's project: Efficiency and safety of pharmaceutical treatment of chronic pain in dogs or cats with chronic kidney disease (CKD). A scoping review to inform decision making in clinical practice.

Abstract

Background

Chronic Kidney Disease (CKD) and degenerative joint disease (DJD) are common diseases in dogs and cats, especially in geriatric patients where they often coexist. Management of chronic pain is important in relation to quality-of-life but also quantity of life. Attention to safety of drugs used to manage chronic pain are therefore necessary and sometimes challenging, as non-steroidal anti-inflammatory drugs (NSAIDs) are most used, and kidney disease is listed as a contraindication or warning on all NSAID data sheets.

Objective

The aim of this review is to map available evidence in pharmaceutical management of chronic pain in cats and dogs diagnosed with CKD, to promote evidence-based decisions regarding the safety and choice of drugs, and to identify any deficits in the research in this area.

Study design

The review was performed as a scoping review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

Results

The search revealed 3123 records after duplicates were removed. Seven studies evaluating NSAIDs in CKD cats(six) and dogs(one), were included in the qualitative synthesis. Study designs: Retrospective case-control, prospective, double-blinded control, prospective, randomized, blinded, placebo-controlled clinical trial, prospective placebo-controlled crossover clinical trial and prospective clinical trial. All studies included cats and dogs in IRIS stage 2 or 3. NSAIDs studied: Meloxicam, piroxicam, robenacoxib, acetylsalicylic acid and tepoxalin. The four studies evaluating meloxicam found no statistically significant (SS) changes in creatinine due to treatment. One study found no reduction in survival time and apparently no negative effect on longevity in long-term treated cats. No SS changes in creatinine were observed in cats treated with piroxicam and acetylsalicylic acid respectively and the same was noticed for robenacoxib. Tepoxalin in dogs reported the same, no SS changes in creatinine or Urea. None of the studies reported QoL in a quantitative way or evaluated efficacy of treatment. Adverse effects (AE) were primarily associated with the gastrointestinal tract. For tepoxalin the AE were extensive and serious.

Conclusion

Lack of evidence for safe pain management in cats and dogs with CKD. Though, based on the studies in this review there are an indication that with pertinent monitoring of clinical status and biomarkers for kidney function, meloxicam and robenacoxib can be used in cats in IRIS stage 2-3 at the lowest effective doses. There is no evidence for safe administration of tepoxalin in dogs with CKD. Implications for research: Prospective randomized studies examining other types of pain medication, monitoring response to treatment on a pain scale, QoL scale and monitoring of kidney function by means of multiple biomarkers and GFR would be beneficial. Implications for Practice: A benefit versus risk assessment must be made; improved QoL vs risks of proteinuria and AE. Regular monitoring of blood kidney values and hydration is very important.