Antinociceptive effects of epidural buprenorphine or medetomidine, or the combination, in conscious cats

2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats

PRACTICAL RELEVANCE

Increases in cat ownership worldwide mean more cats are requiring veterinary care. Illness, trauma and surgery can result in acute pain, and effective management of pain is required for optimal feline welfare (ie, physical health and mental wellbeing). Validated pain assessment tools are available and pain management plans for the individual patient should incorporate pharmacological and non-pharmacological therapy. Preventive and multimodal analgesia, including local anaesthesia, are important principles of pain management, and the choice of analgesic drugs should take into account the type, severity and duration of pain, presence of comorbidities and avoidance of adverse effects. Nursing care, environmental modifications and cat friendly handling are likewise pivotal to the pain management plan, as is a team approach, involving the cat carer.

CLINICAL CHALLENGES

Pain has traditionally been under-recognised in cats. Pain assessment tools are not widely implemented, and signs of pain in this species may be subtle. The unique challenges of feline metabolism and comorbidities may lead to undertreatment of pain and the development of peripheral and central sensitisation. Lack of availability or experience with various analgesic drugs may compromise effective pain management.

EVIDENCE BASE

These Guidelines have been created by a panel of experts and the International Society of Feline Medicine (ISFM) based on the available literature and the authors' experience. They are aimed at general practitioners to assist in the assessment, prevention and management of acute pain in feline patients, and to provide a practical guide to selection and dosing of effective analgesic agents.

Pharmacokinetics of low-dose and high-dose buprenorphine in cats after rectal administration of different formulations

OBJECTIVES

A prospective experimental study was performed in nine young healthy cats to investigate a pharmacokinetic profile and the clinical relevance of rectally administered buprenorphine. Rectal pH value was measured in all nine cats.

METHODS

Blood was collected 15, 30, 60, 90, 120, 240 and 480 mins and 24 h after the rectal administration of a suppository and a gel at doses between 0.02 mg/kg and 0.1 mg/kg buprenorphine to determine the plasma concentration of buprenorphine. Rectal pH was measured with pH paper.

RESULTS

Upon pharmacokinetic non-compartment analysis of high-dose buprenorphine (0.1 mg/kg), average maximal plasma concentration was found to be 1.13 ng/ml, time to maximal plasma concentration was 45 mins and area under the plasma concentration-time curve was 94.19 ng*min/ml, representing low but potential bioavailability. Mean residual time was 152.2 mins and the half-life was 92.6 mins. A wide range of plasma concentrations within the cohort was measured and two of the cats had to be excluded from statistical analysis owing to incomplete uptake. Vital parameters of all cats were considered to be normal but three of the cats showed mydriasis up to 8 h after application. After the administration of a low-dose suppository or a rectal gel (0.02 mg/kg) within pilot studies, no buprenorphine was detected in cat plasma. Rectal pH in all cats was between 7.7 and 8.

CONCLUSIONS AND RELEVANCE

The rectal application of buprenorphine at a dose of 0.1 mg/kg revealed a potential but weak uptake in cats. Regarding effective concentrations in previous pharmacokinetic investigations, rectal administration is currently not recommended for good provision of opioid analgesia in cats. Pharmacological investigations of formulation and galenics in order to improve the rectal bioavailability of buprenorphine remain to be clarified before further dose-finding and pharmacokinetic/pharmacodynamic studies are performed.

An Update on Drugs Used for Lumbosacral Epidural Anesthesia and Analgesia in Dogs

This review aims to report an update on drugs administered into the epidural space for anesthesia and analgesia in dogs, describing their potential advantages and disadvantages in the clinical setting. Databases searched include Pubmed, Google scholar, and CAB abstracts. Benefits of administering local anesthetics, opioids, and alpha₂ agonists into the epidural space include the use of lower doses of general anesthetics (anesthetic “sparing” effect), perioperative analgesia, and reduced side effects associated with systemic administration of drugs. However, the potential for cardiorespiratory compromise, neurotoxicity, and other adverse effects should be considered when using the epidural route of administration. When these variables are considered, the epidural technique is useful as a complementary method of anesthesia for preventive and postoperative analgesia and/or as part of a balanced anesthesia technique.

Systematic review of the behavioural assessment of pain in cats

Objectives

The objectives were to review systematically the range of assessment tools used in cats to detect the behavioural expression of pain and the evidence of their quality; and to examine behavioural metrics (considering both the sensory and affective domains) used to assess pain.

Methods

A search of PubMed and ScienceDirect, alongside articles known to the authors, from 2000 onwards, for papers in English was performed. This was followed by a manual search of the references within the primary data sources. Only peer-reviewed publications that provided information on the assessment tool used to evaluate the behavioural expression of pain in cats, in conscious animals (not anaesthetised cats), were included.

Results

No previous systematic reviews were identified. One hundred papers were included in the final assessment. Studies were primarily related to the assessment of pain in relation to surgical procedures, and no clear distinction was made concerning the onset of acute and chronic pain. Ten broad types of instrument to assess pain were identified, and generally the quality of evidence to support the use of the various instruments was poor. Only one specific instrument (UNESP-Botucatu scale) had published evidence of validity, reliability and sensitivity at the level of a randomised control trial, but with a positive rather than placebo control, and limited to its use in the ovariohysterectomy situation. The metrics used within the tools appeared to focus primarily on the sensory aspect of pain, with no study clearly discriminating between the sensory and affective components of pain.

Conclusions and relevance

Further studies are required to provide a higher quality of evidence for methods used to assess pain in cats. Furthermore, a consistent definition for acute and chronic pain is needed. Tools need to be validated that can detect pain in a range of conditions and by different evaluators (veterinary surgeons and owners), which consider both the sensory and emotional aspects of pain.

Practical use of opioids in cats: a state-of-the-art, evidence-based review

Rationale

Recent recognition of the need to improve pain management in cats has led to the investigation of the pharmacokinetics and efficacy of opioid analgesic drugs in this species. The results of these studies may be difficult to interpret because the effect of these drugs varies with dose, route of administration and the method used to assess them. As equipotency of different opioids is not known, it is hard to compare their effects. Animals do not verbalise the pain they feel and, in cats, it may be more difficult to recognise signs of pain in comparison with other species such as dogs.

Aim

This article reviews the use of opioid analgesics in cats. It must be remembered that not all drugs are licensed for use in cats, and that marketing authorisations vary between different countries.

A review of the studies using buprenorphine in cats

Pain management is a crucial component of feline medicine and surgery. This review critically evaluates studies using buprenorphine in cats and highlights the clinical application of the opioid in this species. The pharmacokinetic-pharmacodynamic (PK-PD) modeling of IV buprenorphine has been best described by a combined effect compartmental/receptor association-dissociation model with negative hysteresis. Therefore, plasma concentrations of the drug are not correlated with analgesia, and clinicians should not expect to observe pain relief immediately after drug administration. In addition, a ceiling effect has not been demonstrated after administration of clinical doses of buprenorphine in cats; dosages of up to 0.04 mg/kg have been reported. The route of administration influences the onset, duration, and magnitude of antinociception and analgesia when using this drug in cats. At clinical dosages, the SC route of administration does not appear to provide adequate antinociception and analgesia whereas the buccal route has produced inconsistent results. Intravenous or IM administration at a dosage of 0.02-0.04 mg/kg is the preferred for treatment of pain in the acute setting. A literature search found 14 clinical trials evaluating buprenorphine sedation, analgesia, or both in cats. There were 22 original research studies reporting the antinociceptive effects of buprenorphine by means of thermal threshold, mechanical threshold, or both, minimal alveolar concentration, or PK-PD. Individual variability in response to buprenorphine administration has been reported, indicating that buprenorphine may not provide sufficient analgesia in some cats. Pain assessment is important when evaluating the efficacy of buprenorphine and determining whether additional analgesic treatment is needed.

Anestesia epidural com associação medetomidina e lidocaína, em gatos pré-medicados com acepromazina e midazolam

Avaliaram-se os efeitos anestésicos promovidos pela associação medetomidina e lidocaína por via epidural, em gatos pré-tratados com acepromazina e midazolam. Foram utilizados 10 gatos adultos, machos e fêmeas, hígidos e com média de peso de 2,5±0,6kg, distribuídos em dois grupos (GM e GL) de igual número (n=5). Administraram-se, como medicação pré-anestésica, acepromazina, 0,2mg/kg, e midazolam, 0,5mg/kg, via intramuscular, e 20 minutos depois, nos animais do GM, por via epidural, lidocaína, 4,4mg/kg, associada à medetomidina, 0,02mg/kg. Os gatos do GL receberam lidocaína, 4,4mg/kg, associada à solução de NaCl a 0,9%. As avaliações ocorreram antes da pré-anestesia (MPA), 20 minutos após a MPA e antes da anestesia epidural, e aos 10, 20, 30 e 40 minutos após a anestesia epidural, respectivamente, T-20, T0, T10, T20, T30 e T40. Foram avaliados: frequência cardíaca (FC) e respiratória (FR), temperatura do corpo, saturação de oxiemoglobina, analgesia, miorrelaxamento e período de recuperação. No GM, a FC diminuiu em T20, T30 e T40 em relação ao T-20 e T10 e foi mais baixa que a FC do GL em T20, T30 e T40, respectivamente, 86, 91 e 88 bat/min e 194, 205 e 177 bat/min. A FR variou entre o T-20 e os outros momentos de avaliação nos animais do GL. Nas variáveis eletrocardiográficas, houve diferenças entre T20, T30 e T40 e T-20 e T0, valores de 235, 238 e 240ms e 156 e 161ms, respectivamente, somente no GM. Este grupo diferiu do GL nas avaliações em T20, T30 e T40, valores de 147, 132 e 150ms para os gatos do GL. Oitenta por cento dos gatos tiveram analgesia intensa, e em todos os animais ocorreu relaxamento da mandíbula e da língua. O tempo de recuperação foi de 40 e 15min no GM e no GL, respectivamente. Concluiu-se que a associação lidocaína com medetomidina promoveu plano anestésico estável com grau de anestesia e recuperação anestésica de boa qualidade.

Plasma concentrations of buprenorphine after epidural administration in conscious cats

Buprenorphine plasma concentrations were measured after administering buprenorphine (20 μg/kg) into the lumbosacral epidural space of conscious cats chronically instrumented with an epidural catheter. Blood was collected from a jugular vein before injection and 15, 30, 45 and 60 min and 2, 3, 4, 5, 6, 8, 12 and 24 h after administration. Plasma buprenorphine concentrations were measured using ELISA. Background concentration (before injection) was 1.27 ± 0.27 ng/mL (mean ± SD). Including background concentration, the mean peak plasma concentration was obtained 15 min after injection (5.82 ± 3.75 ng/mL), and ranged from 3.79 to 2.20 ng/mL (30 min-3 h), remaining between 1.93 and 1.77 ng/mL (4-12 h), and declined to 1.40 ± 0.62 ng/mL at 24h. Elimination half-life was 58.8 ± 40.2 min and clearance 56.7 ± 21.5 mL/min. Results indicate early rapid systemic uptake of buprenorphine from epidural administration with plasma concentrations similar to using buccal or IM routes by 15 min postinjection.