It’s getting towards the end of the year. That means lots of top ten lists and product reccs in advance of the holidays. This list, over at FastCompany magazine’s website, took things a little further by including whiz-bang veterinary products and services along with pricey niceties like GPS collars and pet-dedicated flights. Nestled among these was Vet-Stem’s product: stem cell therapy for the dog that has everything...even osteoarthritis.

It seems stem cell therapy for ailing pets continues to gain momentum as as way to treat painful joints not amenable to surgical intervention or when surgery is deemed too invasive or stressful. Its success in the equine world for the same indications means that there’s reason to believe it’ll work for pets. Problem is, the literature is still sketchy.

Part of the problem is that we have only a very rudimentary understanding of how stem cells––harvested from a patient’s own fat and injected back into joints––can help reduce the pain and swelling located there. It makes some sense from a 30,000 foot vantage point...but not so much at the nit-picky cellular level.

But the larger problem lies in the lack of evidence on behalf of the product's efficacy. While a reasonable cluster of these exists for the equine community, only two canine studies have thus far been conducted. And I’m less than impressed. Though peer-reviewed, both were undertaken by the company that holds the patent on the process (Vet-Stem): One on the efficacy of the procedure in canine elbows included only 14 patients, while the hip disease study boasted little better with a sample size of 21. Each found the statistics as favoring the procedure...but not by a wide margin.

And still clients clamor for it. Even upon learning that stem cell therapy is an expensive, hit-or-miss prospect with very little research to back up its success in dog joints, they demand it.

And why shouldn’t they? If the alternatives don’t sound appetizing and the risk of the procedure (a two-step anesthetic process for fat collection and subsequent joint injection) seems more about their wallets than its inherent dangers to their pets, I can see why Fluffy’s owners might prefer it to a full-on hip replacement. But then, we know a whole lot more about hip replacements than we do about stem cells.

Which gets me to wondering...why is the state of veterinary research in such sad shape that we have to rely on companies to fund their own studies? I understand the economics that lie beneath, but I can’t help think there has to be a better way.

For example: With as many canine patients receiving stem cell therapy for their joints, how is it that they’ve not been tracked and monitored and their anonymous data compiled by an independent source? After all, owner reluctance would almost certainly prove no barrier.

While I certainly understand the high price of conducting prospective studies, it would seem that veterinarians, owners and the company would all have a stake in furthering research and share the burden to varying degrees. I mean, how hard is it to creatively organize a decent trial...with a reasonable sample sizes...with acceptable control groups (e.g., dogs who receive NSAIDs instead of stem cells)?

It’s a problem that dogs human medicine along with our side of things. And yet it’s rare that creative solutions arise to tackle even the seemingly simple task of compiling outcome data retrospectively. And why? In my opinion it’s largely because medicine prefers to outsource the study of emerging therapies like this one to the capitalist projects perceived to have most to gain from their outcome. But this represents a catch-22, doesn’t it? Who among us would wholly respect clinical data when it’s compiled by the most financially invested party?

In Vet-Stem’s case it’s their downfall in my eyes. But it needn’t be their undoing. What would it take to require that company-certified (yet independent) clinicians collect key data points in exchange for certification? That’s how Penn-HIP works. That’s the kind of initiative some vaccine companies take before they widely distribute their biologicals.

To my way of seeing things, our veterinary research needs to get lots more creative before we can get to where we’re going with a minimum of R&D outlays that serve only to raise the price of the product at the expense of the data’s credibility. Maybe what the veterinary industry needs is the occasional workings of a practical brain to dot their DVM/VMD ranks with a dash of simple strategic thinking. Maybe then veterinarians like me would be more willing to recommend the potentially masterful bit of veterinary innovation Vet-Stem offers.

This is not a “testimonial” intended for the commercial betterment of any one brand. It juts so happens that the only version of polysulfated glycosaminoglycans (PSGAG) in the veterinary marketplace is Adequan®. And it works.

Poly what?? OK, so it doesn’t really matter to me that you can’t pronounce this alphabet-soupy injectable drug. It’s enough for me that you know what it does so you can ask your veterinarian about it the next time your cat or dog suffers conditions for which it might prove beneficial.

The conditions? Officially, the menu is a short one as it’s currently approved only for use in dogs and horses “for the treatment of noninfectious degenerative and/or traumatic arthritis and associated lameness of canine and equine synovial joints.” So says my Plumb’s Online Veterinary Drug Handbook (courtesy of VIN).

Unofficially, however, this drug is used safely in cats for the same indication––joint pain. Increasingly, veterinarians are turning to it for felines as a result of our extremely limited arsenal of pain-relieving drugs for this species. We’re not about to wait for approval when we all know our cats receive a pittance of the research funds dogs do. Might as well use it “off label”...if it’s safe. And we think it is.

Though Adequan is labeled as a drug, most veterinarians don’t tend to think of it in these terms. That’s because it’s derived from cow tracheas and only slightly modified in a laboratory to make it more stable. As such, it’s more like a nutraceutical (think glucosamine and chondroitin sulfate, which this drug more closely resembles than any NSAID we may use for pain relief).

While it’s considered way safer than NSAIDs (Rimadyl, Metacam et. al.), make no mistake: it’s not a 100% safe product. Toxicology studies have found that when megadoses are administered, liver and kidney changes are observed. Even in moderately over-large doses, platelet numbers are reduced and blood clotting problems may result. Furthermore, a small percentage of these overdosed dogs showed pain at their injection sites.

Yes, Adequan’s delivered as an injection. It goes in the muscle. For horses, it’s also approved for injection inside the joint. (I don’t know anyone using it this way in dogs, but I’m sure someone out there does.) And it’s only available by prescription through your veterinarian. Luckily, most vets I know are willing to show you how to give it––that is, if you’re brave enough to want to learn.

OK, so enough about Adequan’s gruesome origins, side-effects and delivery options. How does this stuff work? Though the mechanism by which Adequan makes joints feel better isn’t well understood, its action is an anti-inflammatory, cartilage-protecting one. We believe it acts by inhibiting enzymes that break down the cartilage within joints and by increasing the thickness of joint fluid.

But that’s not enough to completely explain how it reduces inflammation. Given that Adequan also seems to work to reduce swelling in the bladder and help repair corneas, it’s clear there’s more going on with this drug than meets the eye (pardon the pun).

Though it’s not been approved for use in these conditions and research is pending to prove this efficacy is more than anecdotal, feline veterinarians have been using it for the dreaded kitty condition known as interstitial cystitis (AKA, feline idiopathic cystitis) while horse vets in Brazil tested it out on indolent corneal ulcers and found that their patients' eye lesions healed much faster than their control subject counterparts.

I’ve never tried it out on eyes and I’m waiting for more of a consensus on that front before mixing it into eye drops myself (though a quick search on VIN showed that vets out there are using it with some success). I do, however, use it in my feline patients to manage their arthritis and to reduce the symptoms associated with many urinary conditions. I’ve been using it for years in this way and always thought it made at least a slight difference. In fact, some cats experienced such a tremendous benefit I’ve taken to trying it out on all of my arthritic kitties and inflamed feline urinary tracts.

For dogs and cats alike, my basic approach has been the same as of a few months ago: eight shots over four weeks (I used to use a longer course with less frequent dosing). I use it less often at a slightly lower dose for those whose kidneys and liver are in some way compromised and I always lower (or eliminate) the NSAID or steroid dose for those who are also taking these or any other drugs that have the possibility of inhibiting platelet function or “thinning the blood.”

But don’t just take my word for it. Consider that veterinarians everywhere are starting to get in on the Adequan act. With our pets living longer, we recognize the need to more carefully manage our pain relievers. Using this less side-effect fraught, alternative approach to treating pain and inflammation may just be what your vet orders, too. So go ahead, ask.

Don’t get me wrong. Here on Dolittler we’re near-fanatical about the use of pain control measures in veterinary medicine. We also spend a significant amount of time rehashing the side effects some of these alternatives offer along the way. But that’s not what this post is about.

Nope, this post is about how the use of pain relief in pets provides a reasonable escape hatch for those who would prefer to treat pain than treat the disease that causes it. And it’s not just about hip dysplasia. We’re also talking cruciate disease, intervertebral disc disease, chronic ear disease, elbow dysplasia and any other process for which pain control measures offer a stop-gap for what ails our pets.

In the case of elbows, it recently came to pass that a new patient presented with his owner in tow. The five year-old dog had been suffering pain in one elbow since he was a six month-old puppy. His previous veterinarian had passed on recommending an orthopedic consultation with a specialist:

“There’s nothing to be done about bad elbows,” he’d claimed. And that’s true...IF the disease is advanced enough...IF there’s not a huge hunk of stuff floating in the elbow area that’s realistically amenable to surgical excision.

Long story short: The dog should have been offered an orthopedic surgery at six months of age. It may have kept him near pain-free for life. It would almost certainly heve prevented this degree of degeneration. Instead, the effectiveness of the pain relievers had granted him a reasonable degree of comfort. No long walks, no major exercise, no normal dog stuff, but a modicum of comfort, nonetheless.

Dog moves to Miami at middle age and sees a new veterinarian. Off he goes to the specialist and finally gets a surgery to alleviate what’s evolved into a horrible problem. One he needn’t have suffered so seriously in the first place.

Now, it’s true that if this owner hadn’t had the financial means to undertake a major surgery early on the dog would still be in the same boat. But that wasn’t the case, it seems. And nothing irks me more than a client who wants to do the right thing and doesn’t get the chance––much less a patient whose suffering could have been largely prevented.

But let’s take the vet-bashing off the table. We all know there are great vets, good vets, well-meaning but not-so-up-to-date vets and then there are the serious losers. No industry, no profession, no job is devoid of its bottom-of-the-barrel bunch so let’s not belabor the point.

The more relevant issue here is the existence of pain relief protocols that work so well we can often manage diseases that sometimes deserve another approach.

It’s a double-edged sword, for sure. Pain relievers are keeping a number of my large dog patients living well into their fifteenth year. Most of these are dogs who would have succumbed years ago to the “can’t get up” syndrome old dog owners know so well. In fact, that’s how many of them came to me:

“Doc, it’s time to put him down. He just can’t get up.” After a round of X-rays, discussion of options and a side-effects lecture, most of these owners took home a bottle of pills in place of surgical alternatives. And I couldn’t necessarily disagree with them. One day you think your dog is dead, the next day he’s running around “like a puppy again, Doc.” Would you go for the surgery after that kind of success? Maybe not if the surgery goes for $3,000.

But it’s one thing to treat a geriatric pet in that manner, quite another to allow a younger pet with plenty of time on his ticker to forgo more definitive alternatives. Still, it’s understandable that the price may not be right––not when a client is faced with a bird in the hand solution in the guise of an Rx.

Yet this oh-so-effective approach is not always so perfectly safe––less so when it comes to the long term use of drugs. And it’s also not so inexpensive as it may appear at first blush. Sure, you can find deals on the Internet, but even then, most of my chronic pain-treating clients pay at least $30 every month for their pain-relieving meds (though it’s usually closer to $60). So let’s do the math on a sample patient:

A ten year-old dog with cruciate disease in his knee will pay $30 (best case scenario) every month until he’s thirteen, at which time the meds can no longer power through the pain and weakness. That’s $1,080. Add the necessary labwork every six months (required to safely remain on the meds) and that’s another $100 a pop (at least). So now we’re at $1,680 for three years...for a painful solution that could have been repaired for $2,000.

Sure, that’s a simplistic scenario that portrays the height of frugality. But I see this kind faulty thinking based on the power of meds play out day after day in my practice. Because surgery is scary. Because it’s a one-time hit below the belt. Because the medicine works.

Now let’s take this one step further: Is the use of pain-relieving medication at all responsible for the continued presence of hip disease in our canine population? I’d argue it’s inevitable. If the use of NSAIDs and other pain relievers makes it easier to accept that dogs will all suffer pain as they age, does it not stand to reason that assiduous breeding for best hip conformation might take a breather? I wonder.

In any case, it’s all too clear that pain relieving methods, for all the good they do, are only as good as the industry that supplies it, the docs who deliver it and the owners who choose to wield this weapon––judiciously or not.