Effects of preoperative administration of ketoprofen on whole blood platelet aggregation, buccal mucosal bleeding time, and hematologic indices in dogs undergoing elective ovariohysterectomy

The Multifaceted Effects of Non-Steroidal and Non-Opioid Anti-Inflammatory and Analgesic Drugs on Platelets: Current Knowledge, Limitations, and Future Perspectives

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most widely utilized pharmaceuticals worldwide. Besides their recognized anti-inflammatory effects, these drugs exhibit various other pleiotropic effects in several cells, including platelets. Within this article, the multifaceted properties of NSAIDs on platelet functions, activation and viability, as well as their interaction(s) with established antiplatelet medications, by hindering several platelet agonists' pathways and receptors, are thoroughly reviewed. The efficacy and safety of NSAIDs as adjunctive therapies for conditions involving inflammation and platelet activation are also discussed. Emphasis is given to the antiplatelet potential of commonly administered NSAIDs medications, such as ibuprofen, diclofenac, naproxen and ketoprofen, alongside non-opioid analgesic and antipyretic medications like paracetamol. This article delves into their mechanisms of action against different pathways of platelet activation, aggregation and overall platelet functions, highlighting additional health-promoting properties of these anti-inflammatory and analgesic agents, without neglecting the induced by these drugs' side-effects on platelets' functionality and thrombocytopenia. Environmental issues emerging from the ever-increased subscription of these drugs are also discussed, along with the need for novel water treatment methodologies for their appropriate elimination from water and wastewater samples. Despite being efficiently eliminated during wastewater treatment processes on occasion, NSAIDs remain prevalent and are found at significant concentrations in water bodies that receive effluents from wastewater treatment plants (WWTPs), since there is no one-size-fits-all solution for removing all contaminants from wastewater, depending on the specific characteristics of the wastewater. Several novel methods have been studied, with adsorption being proposed as a cost-effective and environmentally friendly method for wastewater purification from such drugs. This article also presents limitations and future prospects regarding the observed antiplatelet effects of NSAIDs, as well as the potential of novel derivatives of these compounds, with benefits in other important platelet functions.

Abnormal platelet activity in dogs and cats - impact and measurement

Abnormal platelet activity can either lead to bleeding tendencies or inappropriate thrombus formation and can occur secondarily to a wide variety of disease processes, with a range of clinical consequences and severity. This article will discuss the pathophysiology of platelet function abnormalities and consider a logical diagnostic approach applicable to veterinary practice. Recent advances in platelet function testing will then be discussed, with regards to detection of platelet dysfunction and tailoring of pharmacological manipulation. Although many of these tests are still confined to research or academic institutions, techniques for indirectly assessing platelet function are starting to become more widely available. Although we still require further research to develop guidelines for the use of these tests in clinical decision-making, the recent advances in this field are an exciting step forward in being able to detect and manage platelet dysfunction in both primary care and referral practice.

Effects of clopidogrel and prednisone on platelet function in healthy dogs

Background

Glucocorticoids cause hypercoagulability, but it is unknown if they counteract clopidogrel's antiplatelet effects.

Hypothesis/Objectives

Determine the effects of clopidogrel and prednisone on platelet function.

Animals

Twenty‐four healthy dogs.

Methods

Double‐blinded, placebo‐controlled randomized trial. Platelet function was evaluated using a platelet function analyzer and impedance aggregometry (days 0, 14, and 28) for dogs treated with placebo, clopidogrel (2‐3 mg/kg/d), prednisone (2 mg/kg/d), or prednisone with clopidogrel PO for 28 days. Results were categorized as nonresponder versus responder (platelet function analyzer), and inadequate, ideal, or excessive response (aggregometry). Results were compared using mixed model, split‐plot repeated measures analysis of variance and generalized estimating equation proportional odds models. P < .05 was considered significant.

Results

Closure times differed by treatment (F [3, 20] = 10.5; P < .001), time (F [2, 40] = 14.3; P < .001), and treatment‐by‐time (F [6, 40] = 3.4; P = .01). Area under the curve (AUC) differed by treatment (F [3, 20] = 19.6; P < .001), time (F [2, 40] = 35.4; P < .001), and treatment‐by‐time (F [6, 40] = 13.5; P < .001). Based on closure times, 5/6 dogs each in the clopidogrel and prednisone/clopidogrel groups were responders. All dogs in the prednisone/clopidogrel group were overcontrolled based on AUC (days 14 and 28), whereas 5/6 (day 14) and 2/6 (day 28) dogs treated with clopidogrel were overcontrolled. Compared to clopidogrel, dogs receiving prednisone/clopidogrel were 11 times (P = .03) more likely to have an excessive response.

Conclusions and Clinical Importance

Administration of clopidogrel/prednisone increases platelet dysfunction in healthy dogs.

Effects of Aspirin and Prednisone on Platelet Function and Thromboxane Synthesis in Healthy Dogs

Glucocorticoid administration is a risk factor for thromboembolism in hypercoagulable dogs, and it is unknown if aspirin counteracts glucocorticoid-induced hypercoagulability. The objective was to determine the effects of sustained aspirin and prednisone administration on platelet function and thromboxane synthesis. Our hypothesis was that aspirin would consistently inhibit platelet function and thromboxane synthesis when administered with or without prednisone. In 24 healthy dogs, platelet aggregometry and urine 11-dehydro-thromboxane-B₂ (11-dTXB₂)-to-creatinine ratios were measured on days 0, 14, and 28. Dogs were administered placebos, aspirin (2 mg/kg/d), prednisone (2 mg/kg/d), or prednisone/aspirin combination therapy PO for 28 days in a randomized double-blinded study. Aspirin response was based on a >25% reduction in platelet aggregation compared to pre-treatment values. Results were compared using mixed model, split-plot repeated measures ANOVAs. P < 0.05 was considered significant. AUC differed significantly by time [F_(2,40) = 10.2, P < 0.001] but not treatment or treatment-by-time. On day 14, 2 dogs were aspirin responders (aspirin, 1; placebo, 1). On day 28, 3 dogs were aspirin responders (aspirin, 2; prednisone/aspirin, 1). Urine 11-dTXB₂-to-creatinine ratios differed significantly by group [F_(3,20) = 3.9, P = 0.024] and time [F_(2,40) = 8.7, P < 0.001), but not treatment-by-time. Post-hoc analysis revealed significant differences between aspirin and placebo groups (P=0.008), aspirin and prednisone/aspirin groups (P = 0.030), and placebo and prednisone groups (P = 0.030). In healthy dogs, sustained aspirin, prednisone, and combination therapy do not inhibit platelet aggregation, and when used as individual therapies, aspirin and prednisone decreased thromboxane synthesis. Additional studies using varied platelet function methodologies in hypercoagulable dogs are necessary.

Antiinflammatory Drugs

This article reviews the mechanisms of action, clinical use, and recent scientific evidence for the use of nonsteroidal antiinflammatory drugs, grapiprant, acetaminophen (paracetamol), metamizole (dipyrone), and corticosteroids in pain management. The discussion is presented with an emphasis on the treatment of acute pain.

Safety and efficacy of reduced dosage ketoprofen with or without tramadol for long-term treatment of osteoarthritis in dogs: a randomized clinical trial

BACKGROUND

This study aimed to evaluate the safety and efficacy of reduced-dosage ketoprofen with or without tramadol in dogs. Five healthy dogs receiving standard-dosage ketoprofen (2 mg/kg SC, then 1 mg/kg PO daily) comprised Group A. Twenty dogs with osteoarthritis were randomized to receive reduced-dosage ketoprofen (0.5 mg/kg SC once; 0.25 mg/kg PO daily) alone (Group B) or in combination with tramadol (5 mg/kg/day PO) (Group C). Treatments were administered for 28 days. Platelet aggregation time (PAT), gastrointestinal (GI) endoscopy and glomerular filtration rate (GFR) were performed up to 60 days after treatment initiation. Pain was scored using a validated clinical metrology instrument up to D120. Data were analyzed with general linear mixed model for repeated measures (α = 0.05).

RESULTS

PAT was not different between groups but was increased with time for all groups. GI lesion scores were higher in Group A than Groups B and C (day 28; P = 0.005) and were increased with time for Group A (P = 0.005). GFR was lower in Group A than Groups B and C (day 28; P < 0.01) and were decreased with time for group A (P < 0.001). Standard-dosage ketoprofen administration resulted in clinically relevant adverse effects. Pain score decreased in both treated groups (B and C) from D0 to D28. Need of rescue analgesia from D29 to D120 was higher in Group B than in Group C (P = 0.039).

CONCLUSIONS

The long-term safety profile of reduced-dosage ketoprofen is similar whether the drug is administered alone or in combination with tramadol to dogs with osteoarthritis. Analgesic efficacy of the combination looks attractive.

Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 5-Discontinuation of anticoagulant therapy in small animals

OBJECTIVES

To systematically evaluate the evidence supporting the timing and mechanisms of permanent or temporary discontinuation of antiplatelet or anticoagulant medications in small animals DESIGN: Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality (poor, fair, or good), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice.

SETTINGS

Academic and referral veterinary medical centers.

RESULTS

Databases searched included Medline via PubMed and CAB abstracts. Two specific courses of inquiry were pursued, one focused on appropriate approaches to use for small animal patients receiving antiplatelet or anticoagulant drugs and requiring temporary discontinuation of this therapy for the purposes of invasive procedures (eg, surgery), and the other aimed at decision-making for the complete discontinuation of anticoagulant medications. In addition, the most appropriate methodology for discontinuation of heparins was addressed.

CONCLUSIONS

To better define specific patient groups, a risk stratification characterization was developed. It is recommended to continue anticoagulant therapy through invasive procedures in patients at high risk for thrombosis that are receiving anticoagulant therapy, while consideration for discontinuation in patients with low to moderate risk of thrombosis is reasonable. In patients with thrombosis in whom the underlying cause for thrombosis has resolved, indefinite treatment with anticoagulant medication is not recommended. If the underlying cause is unknown or untreatable, anticoagulant medication should be continued indefinitely. Unfractionated heparin therapy should be slowly tapered rather than discontinued abruptly.

Systematic review of nonsteroidal anti-inflammatory drug-induced adverse effects in dogs

The aim of this systematic review was to identify, assess, and critically evaluate the quality of evidence of nonsteroidal anti-inflammatory drug (NSAID)-induced adverse effects in dogs. Original prospective studies published in peer-reviewed journals in English (1990-2012) that reported data on the safety of NSAIDs administration in dogs were searched. For each study, design type (I, II, III, or IV) and assessment of quality (+, Ø, -) were rated. For each drug, quantity and consistency rating (***, **, *) and strength of evidence (high, moderate, low, or extremely low) were identified and evaluated. The strength of evidence was defined in terms of how applicable and relevant the conclusions were to the target population. Sixty-four studies met the inclusion criteria. Thirty-five (55%) research studies and 29 (45%) clinical trials were identified. A high strength of evidence existed for carprofen, firocoxib, and meloxicam; moderate for deracoxib, ketoprofen, and robenacoxib; and low for etodolac. Quality and consistency rating were as follows: carprofen (***/***), deracoxib (**/***), etodolac (*/unable to rate), firocoxib (***/**), ketoprofen (**/***), meloxicam (***/***), and robenacoxib (**/**), respectively. Adverse effects were detected in 35 studies (55%) and commonly included vomiting, diarrhea, and anorexia. Three studies (5%) reported a power analysis related to adverse effects of ≥80%. In randomized, placebo-controlled, blinded studies (n = 25, 39%), the incidence of adverse effects was not statistically different between treated and control dogs. Finally, most studies were not appropriately designed to determine the safety of NSAIDs, and involved a healthy nongeriatric population of research dogs.

Evaluation of inflammatory and hemostatic surgical stress responses in male cats after castration under general anesthesia with or without local anesthesia

OBJECTIVE

To characterize acute inflammatory and hemostatic surgical stress responses following castration in cats and to evaluate whether the addition of local anesthesia to the anesthetic protocol attenuates these responses.

ANIMALS

39 male cats.

PROCEDURES

Cats undergoing castration were randomly assigned to 2 groups: both groups underwent surgery with general anesthesia, and 1 group additionally received a local anesthetic (lidocaine [2.0 mg/kg in total, divided intratesticularly and SC]) prior to incision. Blood samples were collected after anesthetic induction (baseline) and 1, 5, and 24 hours later. Thromboelastography and coagulation variables (activated partial thromboplastin time [aPTT] and prothrombin time [PT]) were analyzed; fibrinolysis was assessed with plasma D-dimer concentrations. The acute-phase response was evaluated via measurement of plasma fibrinogen and serum amyloid A (last time point, 28 hours) concentrations. Hematologic variables were analyzed at baseline and 1, 5, and 24 hours later.

RESULTS

Evidence of hemostatic and inflammatory activation after surgery was detected in both groups. Maximum amplitude and G (global clot strength) were significantly increased at 24 hours, and significant, but not clinically relevant, decreases were detected in aPTT at 5 and 24 hours and in PT at 24 hours, compared with baseline values. Serum amyloid A concentrations were significantly higher at 24 and 28 hours than at baseline, and plasma fibrinogen concentration was significantly increased at 24 hours; WBC and RBC counts and Hct were significantly increased at multiple time points. No differences between groups were detected for any variables.

CONCLUSIONS AND CLINICAL RELEVANCE

Castration appeared to induce hypercoagulability and an acute-phase inflammatory response in cats. Local anesthesia with lidocaine did not attenuate this response.

Analgesia for anesthetized patients

Many perioperative pain management protocols for cats and dogs are overly complex, some are ineffective, and still others expose patients to unnecessary risk. The purpose of this article is to provide clinicians with a basic understanding of the pathophysiology of perioperative pain and a working knowledge of the principles of effective therapy. First, the concept of multimodal analgesic therapy is discussed. Next, the pathophysiology of perioperative pain and the clinical pharmacology of the major classes of analgesic drugs are reviewed. And last, a simplified approach to managing perioperative pain in cats and dogs is presented.

Evaluation of the effect of ketoprofen and carprofen on platelet function in dogs studied by PFA-100 point-of-care analyser

The effect of two nonsteroidal anti-inflammatory drugs (carprofen and ketoprofen) on platelet adhesion and aggregation functions was evaluated by the PFA-100 analyser (Dade-Behring, CA, U.S.A.) using its collagen-adenosine diphosphate (ADP) and collagen-epinephrine (EPI) cartridges. The function of platelets was evaluated in 55 healthy dogs, in 7 dogs treated with ketoprofen and in 31 dogs treated with carprofen in a therapeutic dose for minimum 5 days. The therapeutic doses of carprofen had no effect on the closure time of PFA-100 (which is the marker of platelet function) but ketoprofen caused a significant increase when using collagen-EPI stimulation The closure times for both the healthy (control) and the treated dogs using EPI cartridges were often longer than the upper default cut-off point (300 sec) of the device. The PFA-100 analyser with collagen-ADP cartridges could be a useful tool for veterinary applications including the evaluation of platelet aggregation in dogs treated with NSAIDs. The upper cut-off point of PFA-100 might be extended.

Nonsteroidal antiinflammatory drugs: a review

The increasing use of nonsteroidal antiinflammatory drugs (NSAIDs) in small animals has resulted in the development of new and innovative additions to this class of drugs. Examples of NSAIDs now available for use in small animals include aspirin, etodolac, carprofen, ketoprofen, meloxicam, deracoxib, and tepoxalin. The purposes of this article are to review the pathophysiology of prostaglandin synthesis and inhibition, the mechanisms of action, pharmacokinetics, pharmacological effects, and potential adverse reactions of aspirin and the newly released NSAIDs.

Evaluation of adverse effects of long-term oral administration of carprofen, etodolac, flunixin meglumine, ketoprofen, and meloxicam in dogs

OBJECTIVE

To evaluate adverse effects of long-term oral administration of carprofen, etodolac, flunixin meglumine, ketoprofen, and meloxicam in dogs.

ANIMALS

36 adult dogs.

PROCEDURES

Values for CBC, urinalysis, serum biochemical urinalyses, and occult blood in feces were investigated before and 7, 30, 60, and 90 days after daily oral administration (n = 6 dogs/group) of lactose (1 mg/kg, control treatment), etodolac (15 mg/kg), meloxicam (0.1 mg/kg), carprofen (4 mg/kg), and ketoprofen (2 mg/kg for 4 days, followed by 1 mg/kg daily thereafter) or flunixin (1 mg/kg for 3 days, with 4-day intervals). Gastroscopy was performed before and after the end of treatment.

RESULTS

For serum gamma-glutamyltransferase activity, values were significantly increased at day 30 in dogs treated with lactose, etodolac, and meloxicam within groups. Bleeding time was significantly increased in dogs treated with carprofen at 30 and 90 days, compared with baseline. At 7 days, bleeding time was significantly longer in dogs treated with meloxicam, ketoprofen, and flunixin, compared with control dogs. Clotting time increased significantly in all groups except those treated with etodolac. At day 90, clotting time was significantly shorter in flunixin-treated dogs, compared with lactose-treated dogs. Gastric lesions were detected in all dogs treated with etodolac, ketoprofen, and flunixin, and 1 of 6 treated with carprofen.

CONCLUSIONS AND CLINICAL RELEVANCE

Carprofen induced the lowest frequency of gastrointestinal adverse effects, followed by meloxicam. Monitoring for adverse effects should be considered when nonsteroidal anti-inflammatory drugs are used to treat dogs with chronic pain.

Safety of reduced-dosage ketoprofen for long-term oral administration in healthy dogs

OBJECTIVE

To evaluate the safety of reduced-dosage ketoprofen (RDKET) for long-term oral administration in healthy dogs.

ANIMALS

14 healthy Beagles.

PROCEDURES

Racemic ketoprofen (0.25 mg/kg, PO) and gelatin capsules, as a drug-free placebo, were each administered to 7 dogs for 30 days. Dogs were periodically monitored via physical examination, blood analyses, endoscopic examinations, fecal occult blood tests (tetramethylbenzidine and guaiac methods), renal function tests (effective renal plasma flow and glomerular filtration rate), urinalyses, urinary enzyme indices (N-acetyl-beta-D-glucosaminidase and gamma-glutamyl-transferase), and hemostatic function tests (buccal mucosa bleeding time, cuticle bleeding time, prothrombin time, activated partial thromboplastin time, and fibrinogen concentration).

RESULTS

Pyloric antrum lesion grade was significantly higher in the RDKET group on day 28, compared with the pretreatment and control group grades. Fecal occult blood grade measured by use of the tetramethylbenzidine method was significantly higher in the RDKET group on day 30, compared with the pretreatment grade. No other significant differences were detected between treatment groups.

CONCLUSIONS AND CLINICAL RELEVANCE

RDKET induced mild to moderate gastric mucosal injuries especially in the pyloric antrum in healthy Beagles, whereas no adverse effects were observed in renal function or hemostasis. Fecal occult blood tests may be useful as screening tests for adverse gastrointestinal effects induced by RDKET in dogs.

Effects of preoperative administration of meloxicam on whole blood platelet aggregation, buccal mucosal bleeding time, and haematological indices in dogs undergoing elective ovariohysterectomy

The purpose of the study was to evaluate the effect of preoperative administration of meloxicam, a non-steroidal anti-inflammatory drug used for pain control, on primary haemostasis in dogs. Twenty healthy female dogs undergoing elective ovariohysterectomy were enrolled in the study. Sixty minutes before pre-anaesthesia, a single dose of meloxicam (0.2 mg/kg) was randomly administered intravenously (IV) to 10 dogs (treatment group) while control dogs received an equivalent volume of saline solution IV. Platelet aggregation, buccal mucosa bleeding time, platelet count and haematological indices were measured at 0, 1, 6 and 24 h after administration of meloxicam. Since significant differences between groups were not observed for any of the measured parameters, preoperative administration of meloxicam may be used for pain control before elective ovariohysterectomy in healthy dogs, without compromising primary haemostasis.

Comparison of Laparoscopic Ovariohysterectomy and Ovariohysterectomy in Dogs

OBJECTIVES

To evaluate technique, complication rates, postoperative pain scores, and clinical outcomes in dogs after laparoscopic ovariohysterectomy (LOVH) or traditional ovariohysterectomy (OVH).

STUDY DESIGN

Prospective clinical trial.

ANIMALS OR SAMPLE POPULATION

Thirty-four intact female dogs, weighing 2.4-31 kg.

METHODS

LOVH (16 dogs) was performed by ligation of the uterus and ovaries with surgical wire, and then removal by an assisted laparoscopic technique. OVH was performed in 18 dogs. Subjective and objective pain scores were assigned at 0, 2, 8, and 24 hours. Surgical time, complications, and pain and incision scores were evaluated. Dogs were followed for up to 6 months.

RESULTS

The mean surgical time for LOVH (120 minutes; range, 47-175 minutes) was significantly longer than for OVH (69 minutes; range, 25-140 minutes). Significantly lower pain scores (subjective, in 2 of 10 categories; objective, in 8 of 10 categories) were identified with LOVH at 1 or more time periods. Surgical complications with LOVH were postoperative fever and anorexia (1 dog), minor splenic (3) or pedicle hemorrhage (4), intermittent vaginal hemorrhagic discharge (1), and suture reaction (3). Surgical complications with OVH were hemorrhage from an ovarian pedicle requiring reoperation (1 dog), dehiscence of the abdominal wall (1), and seroma (1). Anesthetic complications included hypotension in 8 OVH dogs and 1 LOVH dog, and hypothermia in 4 OVH and 9 LOVH dogs. The mean incision scores were lower for LOVH at all time periods.

CONCLUSION

LOVH was performed successfully in young nonparous dogs >10 kg. Surgical time and complication rates were greater; however, LOVH postoperative pain scores were < or =OVH scores.

CLINICAL RELEVANCE

LOVH is a potentially safe surgical alternative to traditional OVH in dogs. Equipment cost and necessity for more than 1 surgeon may limit its usefulness in small animal practice.

Effects of preoperative administration of ketoprofen on anesthetic requirements and signs of postoperative pain in dogs undergoing elective ovariohysterectomy

OBJECTIVE

To determine the effects of preoperative administration of ketoprofen on anesthetic requirements and signs of postoperative pain in dogs undergoing elective ovariohysterectomy.

DESIGN

Randomized, controlled clinical trial.

ANIMALS

22 clinically normal client-owned dogs.

PROCEDURE

60 minutes before induction of anesthesia, 11 dogs were given ketoprofen (2 mg/kg [0.9 mg/lb], i.m.), and the other 11 were given saline (0.9% NaCl) solution. Dogs were premedicated with glycopyrrolate, acepromazine, and butorphanol and anesthetized with thiopental; anesthesia was maintained with isoflurane. Ovariohysterectomy was performed by an experienced surgeon, and butorphanol was given 15 minutes before completion of the procedure. Objective behavioral scores and numerical pain scores at rest and with movement were recorded every 2 hours for 12 hours after surgery and then every 4 hours for an additional 12 hours.

RESULTS

Preoperative administration of ketoprofen did not reduce the dose of thiopental required to induce anesthesia or the end-tidal concentration of isoflurane required to maintain anesthesia. Activity levels and median objective behavioral scores were significantly higher 4 and 6 hours after surgery in dogs given ketoprofen than in dogs given saline solution. However, mean numerical pain scores in dogs given ketoprofen were not significantly different from scores for dogs given saline solution at any time.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that preoperative administration of ketoprofen does not reduce anesthetic requirements in dogs undergoing elective ovariohysterectomy but may reduce signs of pain after surgery. Results also suggest that the objective behavioral score may be a more sensitive measure of acute postoperative pain than traditional numerical pain scores.