Would galliprant be better with liver issues?

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My 11 year old labrador, Tess, has osteoarthritis and a wonky gait following being hit by a car as a youngster (20 months). She first went on Metacam at the end of 2016 despite having an ALT of 198. She remained on it for six months over the winter. She went back on Metacam in late 2017 and in April 2018 her ALT was 202. The vet encouraged me to keep her on Metacam but on as low a dose as possible so she was having about a 50% dosage. In July 2018 her ALT was 273 and she was taken off Metacam to see if this would reduce. ALT was the only enzyme elevated. She had also had a leptospirosis vaccine in April (L2). Taking her off Metacam didn’t help (297 after a month off) and in September she had liver biopsies at the Cambridge vet school.   The findings were that there was little or no active hepatitis and that the fibrosis was likely to be the result of a previous ‘insult’ which had now passed. They said Metacam might have been the cause but not necessarily. The vet school strongly recommended Denamarin on an ongoing basis and said she could return to taking Metacam with close monitoring. I decided to see how she would go without the Metacam but with regular (weekly) hydrotherapy and monthly physio with laser and underwater treadmill. She was given Denamarin and ALT levels were 344 (Nov ’18), 337 (Jan ’19) and now 283 (Apr ’19).
For the past couple of months she has been quite sore on her left front leg after resting. The soreness gets worse every time she gets up from a rest during the day but is much better first thing in the morning. She is also more anxious. I feel that I would like her to be on anti-inflammatories for at least a few weeks to see if this helps her. However, my vet is now adamant that she shouldn’t have any drugs because of her liver despite the liver specialist (Penny Watson) saying it should be okay as long as bloods are taken in the first week or two and Denamarin is continued. I also asked my vet about whether galliprant might be a safer option for her liver but she hadn’t heard of it. So my question is should I push my vet to look into galliprant i.e. is it a safer option for the liver? Or should I just push her into allowing me to put Tess back on Metacam, reminding her of the specialist’s advice.
She is a good weight, all slippery surfaces are covered and she uses a ramp for the car. Sorry to be so long-winded and thank you in advance for any advice.
Amanda

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Thank you, Gwen, that’s really helpful. It’s useful to have some perspective from the vet’s point of view as well as it’s so easy to adopt an antagonistic stance when you are trying to do the best for a much-loved pet. I appreciate that vets have to make difficult decisions and that their viewpoint will be affected by their own experiences. I imagine it’s also pretty frustrating when a vet spends years qualifying and then a client, armed with all the information they’ve gleaned from the internet, questions their decisions. I think consulting a pain specialist may well be the best way forward. Thanks again, Amanda

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Hi Amanda, I would echo Lyndsey and Hannah’s comments. Galliprant works very differently to NSAIDs but they have not tested it on dogs with liver issues. It is licensed for mild OA pain and so is worth a try but may need additional pain relief alongside it.
I would also suggest you push for specialist involvement again if your vet has been given advice that there is no specific reason to avoid NSAIDs. As vets, we are daily making judgements to get the balance between risk and benefit right for each individual patient. Dogs respond differently to each other and past experiences of adverse events in our patients have a major impact on prescribing habits and the risk a clinician is prepared to take. This is the same in human medicine (I speak from personal experience as a patient who is also actively involved in patient advisory groups for research!). Furthermore, the impression that an owner is risk-averse will also put a vet off prescribing a medication that might have an unknown, albeit small, risk attached. If you read some of the anti-vet, anti-NSAID comments coming across in social media and the internet you will realise why this is a hard professional judgement to make.
Your vet could also refer your dog to a pain clinic with a veterinary specialist who has a more in-depth knowledge of pain medication options. We often see patients who cannot be given NSAIDs for a variety of reasons and here we will use combinations of other medications, often human formulations used ‘off-licence’ to gain better control of pain in dogs and cats. The strain is taken away from your own vet who can then just follow up on the specific guidance given once the dog is more stable and is ‘handed back’ to the vet.
Cambridge may well have a vet who takes pain management referrals but there are other centres in that area that I know run pain clinics.
I hope you find a suitable treatment for your dog, and keep up the good work with non-medication management options – they are the most important.
Best wishes,
Gwen

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Thank you very much, Lynsey and Hannah, for your information and thoughts. It’s really helpful to be able to get some feedback on this.

Amanda

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Hey there
I spoke to Elanco and sadly they can’t comment as the trials have been in dogs with healthy livers …no effect on liver was seen …but they can’t promise the same doesn’t apply to a damaged liver.. in theory should be fine but a monitoring sample 2-4 weeks later would be wise.
Regards
Hannah

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Hi Amanda,

I will ask one of the vets to pop in and answer this for you. My understanding of Galliprant is that is targets the EP4 pain receptors responsible for arthritic pain, and as such doesn’t affect the housekeeping prostaglandins that we see side effects from in the traditional NSAIDS. However, I think it is also marketed for earlier stages of arthritis, and so not sure if it would be of benefit to your dog specifically -however if it is your only choice I’d be tempted to trial it!
Perhaps you could ask your vet to contact the specialist to discuss this with her themselves, to clarify the situation and their advice? Hannah has told me in the past that raised liver enzymes alone are not a reason to stop using NSAIDs, and that the current view is that the liver would need to be severely affected to stop their use. Clearly Tess has had further investiagtion here, and it sounds as though she has coped well without anyway up until this point, but now her quality of life and pain indication needs to be balanced with the liver issues.

Best wishes,

Lynsey

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