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Reviewing the use of NSAIDs in cats with chronic kidney disease

Monteiro B, Steagall PVM, et al. Long-term use of non-steroidal anti-inflammatory drugs in cats with chronic kidney disease:  from controversy to optimism. J Small Anim Pract 2019;60:459-462.

Chronic pain conditions, especially osteoarthritis (OA) and chronic kidney disease (CKD) frequently coexist in cats, especially those aged 12 and up; as many of 70% of cats have both health problems.  Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most effective pharmaceuticals in relieving a number of chronic pain conditions, but concerns abound regarding adverse effects of these drugs on renal function, especially when the latter is already actually or potentially compromised.  On the other hand, quality of life and welfare concerns in animal patients with chronic pain conditions are significant and may be conducive to euthanasia when no effective options appear to be available.  In the USA in particular, no pharmaceuticals have been labeled for the treatment of chronic pain in feline patients.

In human CKD, similar controversy exists. Concurrent CKD and chronic pain conditions also are prevalent in people, especially the elderly.  Substantially larger and more numerous studies evaluating the risk of NSAID consumption in people with CKD have been performed, and the vast majority of these did not demonstrate an increased risk of chronic renal impairment with NSAID use.

In this capsule review paper published by the World Small Animal Veterinary Association’s Global Pain Council (WSAVA-GPC), the authors present information compiled from recent publications detailing the scientific evidence available on long-term use of NSAIDs in cats with both chronic pain conditions and CKD.  A number of these recent studies have demonstrated that NSAIDs (meloxicam or robenacoxib) can be administered safely to cats with stable International Renal Interest Society (IRIS) stage I and II CKD.  There is some information, but less, available regarding use of NSAIDs in cats with IRIS stage III CKD. However, careful patient selection is crucial, and not all cats with CKD will be good candidates for NSAID use.

Based on the evidence reviewed, the WSAVA-CPC recommends that NSAIDs be used in cats with chronic pain and CKD provided that care is taken to insure that the following considerations are taken into account:

1) The cat must have stable CKD—minimal changes in body weight and creatinine over a period of at least two months; concurrent conditions such as hypertension should also be controlled;

2) Cats with IRIS stage I or II CKD are most likely to be good candidates for NSAID therapy; less is known regarding NSAID use in more advanced feline CKD, but some cats in stage III CKD have been treated;

3) Maintenance of good hydration is essential for these cats: free access to multiple fresh, clean water sources and at least some wet food intake is strongly recommended;

4) Use of the lowest effective dosage of the NSAID, based on the response to therapy; response to therapy is demonstrated by increased activity levels and ability to perform activities of daily living such as grooming, jumping, and use of the litterbox,  as well as improved demeanor and reduced withdrawn behavior;

5) Appropriate management of CKD based on commonly recognized and recommended standards of care, including serum phosphorus control;

6) Owner education and involvement as a member of the cat’s healthcare team; the owner is the one with “boots on the ground” on a daily basis, administering the treatments and monitoring for both beneficial and adverse effects;

7) Ongoing clinical monitoring, including physical examinations, blood pressure monitoring, laboratory evaluation (including hematology, serum biochemical profile, and urinanalysis); however, there is no consensus on how often monitoring activities should be performed;

8)  Environmental enrichment strategies should always be implemented in the treatment of chronically painful cats, and other pain management modalities that are likely to have a pharmaceutical-sparing effect such as physical therapy, acupuncture, nutraceuticals, and chondroprotective agents, should be considered.

The paper also discusses the limitations of the currently published studies on long-term use of NSAIDs in cats with CKD, and recommends that randomized prospective clinical trials using meloxicam in cats with coexisting OA and CKD be performed. One such study, although of short duration (one month) has been performed using robenacoxib.  Long-term administration of the lowest effective dose of meloxicam or robenacoxib in cats with both chronic pain and stable CKD is recommended by the WSAVA-GPC as part of a multimodal pain management program that should include non-pharmacological therapies, unless these are contraindicated.  NSAIDs other than meloxicam or robenacoxib are not recommended for this population of feline patients unless safety data are published for these agents in cats. [PJS]

See also:

Gowan RA, Lingard A, et al.  Retrospective case-control study of the effects of long-term dosing with meloxicam on renal function in aged cats with degenerative joint disease. J Feline Med Surg 2011;13:752-761.

Marino CL, Lascelles BDX, et al.  Prevalence and classification of chronic kidney disease in cats randomly selected from four age groups and in cats recruited for degenerative joint disease studies.  J Feline Med Surg 2014;16:465-472.

Sparkes, AH, Caney S, et al.  ISFM consensus guidelines on the diagnosis and management of feline chronic kidney disease.  J Feline Med Surg 2016;18:219-239.