ABSTRACT OF THE WEEK

Australian veterinary journal
Volume 101 | Issue 3 (March 2023)

Acute kidney injury in 18 cats after subcutaneous meloxicam and an update on non-steroidal anti-inflammatory drug usage in feline patients in Australia.

Aust Vet J. March 2023;101(3):90 - 98.

M K Wun¹, E Leister², T King³, R Korman⁴, R Malik⁵

¹ Veterinary Specialist Services, Underwood, Australia.; ² Pet Intensive Care Unit, Underwood, Australia.; ³ Veterinary Specialist Services, Underwood, Australia.; ⁴ Veterinary Specialist Services, Underwood, Australia.; ⁵ Centre for Veterinary Education, B22, The University of Sydney, Camperdown, Australia.

Abstract

OBJECTIVES:Acute kidney injury (AKI) is a well-known but poorly documented adverse effect of non-steroidal anti-inflammatory drugs (NSAIDs) in cats. We aimed to describe instances of NSAID-associated AKI in cats and survey Australian veterinarians on NSAID use in acute settings.

METHODS:Medical records of cats that developed an AKI subsequent to the administration of meloxicam were obtained by searching the databases of seven practices in Queensland, as well as by contemporaneously contacting select veterinary colleagues of the authors in both general and specialist small animal practice. An online questionnaire was created for the survey, and the URL distributed to Australian practitioners.

RESULTS:A total of 18 cases were retrieved, all of which received injectable meloxicam. The indication(s) for its use and the dosage prescribed were within the manufacturer's recommendations for Australian veterinarians. The majority of cases (13/18 cats) received the label dose of 0.3 mg/kg subcutaneously (SC) on the day of the procedure. In 12/18 cats, the injection was given in association with general anaesthesia or sedation. Fourteen cats survived to hospital discharge. Of 187 survey respondees, 89% routinely administered NSAIDs for surgery-related analgesia, with 98% prescribing meloxicam and 84% of these giving it SC. Ninety percent of respondees routinely administered NSAIDs for non-surgical-related analgesia, with 99% prescribing meloxicam and 35% of those giving it SC.

CONCLUSIONS AND RELEVANCE:We strongly recommend that practitioners avoid prescribing meloxicam SC in cats. This recommendation is emphatic in situations where concurrent dehydration and/or hypotension are possible.

Companion Notes

Retrospective report on acute kidney injury in 18 cats after subcutaneous meloxicam

Introduction on non-steroidal anti-inflammatory drug (NSAID) use in the cat

- NSAIDs act via inhibition of cyclo-oxygenase (COX) enzymes

- inhibiting the production of prostaglandins and leukotrienes

(those involved in the inflammatory response)

- COX inhibition also inhibits the production of homeostatic prostaglandins

- such as those responsible for the following:

- normal platelet function

- maintenance of adequate renal perfusion

- cyto-protective effects at the gastric mucosa

- COX-2 is predominantly involved in the inflammatory response

- it’s upregulated (ie inducible) at sites of inflammation

- COX-1 is expressed in most tissues

- mainly involved in homeostatic mechanisms

(ie constitutive)

- COX1 has some inducible expression and COX2 has some constitutive expression

- therefore, adverse effects can still occur with newer generation NSAIDs

(including the coxibs)

- which have a negligible effect on COX-1

- in feline medicine

- risk of adverse effects is considered low using prudent prescribing guidelines

- guidelines such as the following:

- withholding therapy during states of the following:

- hypovolemia

- hypotension

- anorexia

- avoid concurrent administration of other potential nephrotoxins

(so-called, ‘double whammy’)

- angiotensin-converting enzyme (ACE) inhibitors

- angiotensin receptor blockers

- diuretics including spironolactone

- perioperative NSAID use has traditionally been discouraged

- due to potential for reduced renal perfusion during anesthesia

- however, recent anesthesia guidelines advocate some use of NSAIDs

- prior to anesthesia (for pre-emptive analgesia)

- during recovery (as part of a balanced multi-modal analgesic plan)

- “evidence base for this altered recommendation is questionable”

- NSAID-associated renal injury in cats appears to be common

- among serious adverse animal health reports in Australia for ‘19-‘20

(to Australian Pesticides and Veterinary Medicines Authority)

- 4% were associated with meloxicam

Study design

- study population: 187 responses included in the analyses

- 18 cats that received injectable meloxicam and later had AKI were included

(AKI = acute kidney injury)

- definitive diagnosis of meloxicam-associated AKI based on the following:

- IRIS AKI Grade 3 or higher with a USG <1.040

- in cases where USG was unavailable

- presumptive diagnosis based on IRIS AKI Grade 3 or higher

- persisting despite 24 hours of IV fluids

- clinical signs consistent with AKI (lethargy, anorexia or vomiting)

- AKI noted within 9 days of NSAID administration subcutaneous (sc)

- procedure:

- databases of 7 practices in Queensland searched for data from 01/07 to 01/21

- authors contacted colleagues in both general and specialist small animal practice

- online questionnaire created for the survey

- URL distributed to Australian practitioners

Results

- history and signalment

- indication(s) for use and the dosage were within manufacturer’s recommendations

- 13 of the 18 cats received the label dose of 0.3 mg/kg subcutaneously (sc)

- on the day of the procedure

- overall median meloxicam dose: 0.3 mg/kg sc

- in 12 cats, injection was given in association with general anesthesia or sedation

- in association with general anesthesia in 11 cases

(timing of administration unrecorded in 2 cases)

- during general anesthesia, 3 cats

- during recovery (intubated but off isoflurane), 1

- after recovery (extubated and conscious), 5 cats

- 9 of 18 cats received additional meloxicam after the 1^st injection

- 5 cats were given meloxicam orally at 0.05 mg/kg per day

- starting the day following the procedure in 4 cats

- 4 cats received one additional sc administration of meloxicam

- from 0.2-0.3 mg/kg given 2-7 days after the initial injection

- domestic short-haired cat, 11 cases

- Siamese cat, 2 cases

- median age: 6 years of age with a range of 5 months to 15 years

- median weight: 5.0 kg with a range of 2.3-7.6

- median body condition score: 5/9

- reasons for prescribing meloxicam in 2 or more cases

- tooth extraction(s), 7 cases

- lameness, 2

- skin wound, 2

- treatment

- initially treatment with IV therapy

- generally Hartmann's solution with rates ranging from 3-9 mL/kg/h

- median analyte levels immediately prior to starting treatment for AKI

- serum creatinine at 1000 µmol/L with a range of 397-2810

- BUN at 43.3 mmol/L with a range of 20.8-106.4

- potassium at 5.3 mmol/L with a range of 3.1-9.0

- antiemetics (metoclopramide, maropitant and/or ondansetron), some cases

- gastroprotective agents, analgesia, amoxicillin-clavulanic acid and/or mirtazapine

- at discretion of treating veterinarian

- median duration of hospitalization: 3 days

- outcome

- 14 of the 18 cats survived to hospital discharge

- owner elected euthanasia, 4 cats

- due to marginally decreased or increased serum creatinine after 24 hours, 3 cats

- due to development of anuria, 1

- 89% (166 of 187) of responders routinely gave NSAIDs for surgery-related analgesia

- 98% (162 of 187) prescribed meloxicam and 84% of these gave it sc

- if ongoing analgesia was needed, 94% followed the injection with oral formulation

- commencing the next day in 70%

- 50% administered the drug during the recovery period

- 42% after recovery

- 90% of responds routinely administered NSAIDs for non-surgical-related analgesia

- 99% prescribed meloxicam and 35% of those gave it sc

- 37.4% reported having diagnosed AKI in a cat that had received an NSAID

- in the 2 weeks preceding this presentation

- all had received meloxicam

“When given orally and at constant low doses (0.01–0.03 mg/kg SID), it is an inexpensive and generally safe medication, even in cats with pre-existing CKD [chronic kidney disease], although it should still be used with caution due to the potential for increased proteinuria….”

Keywords

Australia; NSAIDs; acute kidney injury; meloxicam;

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Comment In Aust Vet J. 2023 Oct;101(10):411-412

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