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27 aCUTe PaIN IN CaTS: TreaTmeNT wITh NSaIDS | May/June 2014 Today's Veterinary Practice tvpjournal.com 4. Displays Wide Safety Margins & Evidence- Based Clinical Safety First, toxicity studies of NSAIDs should demonstrate a robust and wide safety margin in healthy cats. No one has yet defined what a wide safety margin is, but vet- erinarians are encouraged to read the package inserts and Freedom of Information Summaries for the vari- ous NSAIDs. Additionally, NSAIDs should have been evaluated and deemed to be appropriately safe in normal cats undergoing elective surgeries—the most common sce- nario for use of NSAIDs in general practice. Ideally, this information should be in the form of peer-reviewed lit- erature, which gives the clinician a degree of comfort about the validity of the data. Further, it would be ideal to have safety data in other target populations that would benefit from NSAID- induced pain relief, including cats with concurrent diseases, such as chronic kidney disease or cardiomy- opathy. 5. Demonstrates Robust Clinical Efficacy For feline acute pain, there should be robust evidence of clinical efficacy for the target problems, such as peri- operative pain control. For feline chronic pain condi- tions, efficacy should be demonstrated for alleviation of prolonged, maladaptive pain associated with chron- ic disease in cats, such as degenerative joint disease, spinal pain, stomatitis, cystitis, and cancer. Until very recently, efficacy of NSAIDs was very difficult to mea- sure, and there was little evidence they provided pain relief. A recent breakthrough in clinical study design, along with a Clinical Metrology Instrument, may now allow NSAIDs to be tested for efficacy in a wide variety of chronic diseases. 15 AvAILABLE NSAIDS FOR USE IN CATS In the U.S., there are 2 FDA-approved NSAIDs for short-term use in cats: robenacoxib and meloxicam. 16 Robenacoxib Robenacoxib (Onsior, novartis.com) is FDA-approved for control of postoperative pain and inflammation associated with orthopedic surgery, ovariohysterecto- my, and castration in cats. It has high selectivity for the inhibition of COX-2, sparing COX-1. 17 The clinical benefit of sparing COX-1 in the cat has not been demonstrated; however, ben- efits associated with COX-1 sparing in other species have been described. Elegant work by Ludivig Pelligand at the Royal Vet- erinary College in the UK has demonstrated that robe- nacoxib has a very short half-life (3 hours) in the blood, yet persists, and is active, for at least 24 hours in inflamed tissue in cats, 17 which demonstrates "tis- sue selectivity." Robenacoxib is approved for short-term administra- tion (up to 3 days in the U.S.) in cats ≥ 4 months of age, weighing ≥ 5.5 lb (2.5 kg) (Table 2). 6 In the U.S., robenacoxib is available in 6-mg, yeast-flavored tab- lets that can be taken with or without food. It should not be given in conjunction with any other NSAID or corticosteroids. Meloxicam Meloxicam (Metacam, us.boehringer-ingelheim.com) is FDA-approved for use in cats as a single, SC injec- tion for postoperative pain. It is an example of a pref- erential COX-2 inhibitor that has greater inhibition of COX-2 than COX-1. Table 2 lists the recommended doses for meloxicam. Meloxicam is also considered tissue selective, but differs from robenacoxib in that it has a longer half-life and is, therefore, present in the central compartment longer. Although the oral liquid suspension of meloxicam— approved for control of pain and inflammation associ- ated with osteoarthritis in dogs—is not approved for cats, it has been used off-label for chronic pain man- agement. Table 2. Recommended Doses: NSAIDs for Acute Pain Management in Cats NSAID RECOMMENDATION SOURCE RECOMMENDED DOSE Robenacoxib recommended dose from manufacturer (FDA-approved) 1 mg/kg PO Q 24 H for 3 doses Dose range, 1–2.4 mg/kg Q 24 H Meloxicam (injection) recommended dose from manufacturer (FDA-approved) 0.3 mg/kg SC (single injection) Meloxicam (oral suspension)* recommended dose from ISFm/aaFP for daily use 14 0.1 mg/kg PO for 1 day; then 0.05 mg/kg PO Q 24 H Meloxicam (oral suspension)* Other recommendations 18 0.05 mg/kg PO every other day or 0.025 mg/kg PO Q 24 H * Not FDA approved for use in cats TVP_2014-0506_FelinePainMgmt (Part 2).indd 27 5/23/2014 11:23:09 AM