It’s 2 a.m. on a recent Saturday. It had been an impossibly busy week in the hospital and, by all rights, I should be hours into a deep sleep. But here I stand over an open abdomen. Technicians are bustling about the operating theater and the anesthetist, Christine, with whom I had started the previous day at 8 a.m., was at her post, closely monitoring the patient. It was the week that refused to end.
The patient was an 11-month-old boxer named Cookie. She had been spayed six weeks earlier, and her GI problems began shortly after. Her appetite had been inconsistent, and she had intermittent episodes of nausea and vomiting. She had been treated with anti-ulcer and anti-nausea medications, antibiotics and appetite stimulants.
Response to treatment was short-lived and incomplete, but this bout was different. She had spiked a high fever and her abdomen was painfully distended with fluid.
Shortly after admission, an ultrasound and examination of the fluid confirmed that Cookie had life-threatening septic peritonitis. This means she had an infection in her abdomen, usually due to a leak in the gastrointestinal tract. Only about 50 percent of patients with this condition actually survive. And one more thing. The mom informed me that Cookie was her 5-year-old daughter’s best friend. No pressure there.
As we prepared for surgery, Christine postulated that the cause was anti-inflammatory drugs. I said that was reasonable, but this dog was young and healthy, and was not taking anti-inflammatories.
She referred to what was given after spay surgery. The record showed Cookie received an injection of an anti-inflammatory called Ketoprofen, and two doses of another anti-inflammatory called Previcox.
Although it’s a dangerous practice to mix these drugs, it was six weeks earlier. Surely she would have been worse then, and would have either improved or died by now. And she had been treated for ulcers since then. Christine has been with me for 11 years, and I have learned not to bet against her intuition.
Upon entering the abdomen, it was immediately apparent that the problem was a perforated ulcer in the stomach. The only likely suspect in this case was the post-surgical doses of anti-inflammatory drugs.
Anti-inflammatories come in two varieties: steroidal and nonsteroidal anti-inflammatory drugs, or NSAIDS. Due to the harmful effects of long-term steroid administration, they are seldom an appropriate first-line treatment of osteoarthritis.
NSAIDS are used quite commonly for this but they, too, can have serious, even life-threatening, side effects.
Basically, inflammation is triggered by a series of chemical reactions in the body. These reactions result in the formation of compounds known as prostaglandins. Block the formation of certain prostaglandins and you will reduce inflammation. However, you will also block the formation of prostaglandins that do good things, like ensuring a nice protective layer of mucus in your stomach.
The newer generation of NSAIDS are meant to only block production of the inflammatory prostaglandins, while allowing the others to continue their duties, like protecting the stomach and providing the kidneys with a healthy blood supply. These are called COX-2 specific drugs, named for the specific pathway they block.
There are four such drugs currently approved by the FDA for use in dogs. These go by trade names such as Deramaxx, Rimadyl, Previcox, Metacam and a host of other generic labels.
Though, in theory, these drugs are safer, they are not without risk. Severe damage to the liver, kidneys and gastrointestinal tract are possible. These risks can be managed with some simple precautions. I try and establish the lowest effective dose.
These drugs should be discontinued at the first sign of GI upset. Antacids may be administered along with NSAIDS if your pet is sensitive to them. NSAIDS should never be given concurrently with other NSAIDS or steroids.
In the past year, a new class of anti-inflammatory has emerged called piprants. The FDA recently approved a veterinary drug marketed under the trade name Galliprant. This class of drug is theoretically safer because it only blocks one very specific, pro-inflammatory prostaglandin receptor site while not interfering with the production of prostaglandins, or their function in other areas.
It is still a little early in the game for this drug. Anecdotally, I have heard mixed reports of effectiveness compared with conventional COX-2 drugs, and it seems to be a frequent cause of gastrointestinal upset. I have not heard reports of anything life-threatening, so this drug may at least represent an alternative tool to manage arthritic pain, especially in dogs who cannot tolerate other NSAIDS.
As for Cookie, surgery involved resecting the lesion, closing the hole in her stomach, and flushing out her abdomen, followed by aggressive medical support. Cookie fought hard and rallied to a relatively early discharge from hospital. It was as if she knew she was needed elsewhere. Cookie is now well on the way to a complete recovery and, of equal importance a little girl has her best friend back. (Dr. Henri Bianucci)
Dr. Henri Bianucci and Dr. Perry Jameson are with Veterinary Specialty Care LLC. Send questions to firstname.lastname@example.org.