Supplementary information
Which NSAID? An NSAID or an anti-NGF mAb?
• Pain
A primary consideration in all dogs with clinical OA.
• Inflammation
May be a more significant contributor in earlier stages of the disease.
• Sensitization
As a driver of heightened levels of pain may be a greater consideration in more severely affected dogs.
INTERNATIONAL CONSENSUS TREATMENT GUIDELINES
Canine Osteoarthritis
THIS HANDBOOK: THE PURPOSE
This handbook is intended as a simple reference guide, summarizing the key points of the COAST International Consensus Guidelines for the Treatment of Canine Osteoarthritis.
FULL PUBLICATION https://doi.org/10.3389/fvets.2023.1137888
The treatment guidelines describe the recommendations of the COAST Development Group for reducing the risk of osteoarthritis (OA) in dogs, as well as managing and treating dogs clinically affected by the disease.
• Flexibility in dosing can enable faster adjustments to care plans if needed (e.g., new or complex cases).
• Convenience and compliance can be of greater importance if the disease is stable.
Manual Therapy
Cryotherapy/ Thermotherapy
Massage
Myofascial release/ trigger point therapy
Range of motion (assisted)
Range of motion (passive)
Movement & Exercise
Hydrotherapy
It is currently unknown if the anti-NGF mAb can be used safely together with an NSAID for the long-term treatment of dogs with OA In human medicine, the longer-term, combined use of a human anti-NGF mAb with an NSAID further increased the risk of developing rapidly progressive osteoarthris (RPOA) above that seen with the use of the human anti-NGF mAb alone. RPOA has not been described or recognized in dogs to date, but neither has OA progression been extensively evaluated in this species.
Machinery or instrument applied
Acupuncture/ Electroacupuncture
Proprioceptive Exercise Electrical Nerve Stimulation
Therapeutic Exercise
Treadmill
Extracorporeal Shockwave Therapy
Photobiomodulation
Pulsed Electromagnetic Field Therapy
Traction Ultrasound
Handbook
This handbook was made possible by
The result is a practical, evidence- and clinical experienceinformed, OA-stage appropriate record of recommendations to support clinicians building patient-specific management plans for dogs with OA.
The development group
A geographically diverse group of nine international veterinarians actively working in small animal orthopedics, anesthesia, and pain research and management.
Service de chirurgie, Campus vétérinaire de Lyon VetAgro-Sup, Marcy l’Etoile, France
Herrgårdskliniken Aneby, Sweden
Movement Veterinary Referrals, Preston Brook, Runcorn, Cheshire, UK
Comparative Pain Research and Education Centre, Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
Thibaut Cachon Ole Frykman John Innes
Department of Veterinary Clinical Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
Hospital Veterinari Montjuic - Vetpartners, Barcelona, Spain
Section of Veterinary Clinicas and Animal Production, D.E.O.T., ‘Aldo Moro’ University of Bari, Bari, Italy
Masahiro Okumura
Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint Hyacinthe, QC, Canada
JCC, City University of Hong Kong
Paulo Steagall Pedro Sousa Bernadette Van Ryssen
Department of Medical Imaging and Small Animal Orthopedics, Faculty of Veterinary Medicine, Ghent University, Belgium
Clinically normal, no OA risk factors Clinically normal but OA risk factors present Clinical signs of mild OA Clinical signs of severe OA Clinical signs of moderate OA 2 3 4 1 *Only after professional consultation Professional guidance recommended. Treatment modalities have different levels of evidence to support use. Manual Therapy or Exercise Professional administered or supervised techniques Treatment modalities considered under the term ‘rehabilitation/physical therapy’ (alphabetical order) At home treatment modalities* Hot/cold therapy Massage Passive range of motion Therapeutic exercise © 2023 Elanco or its affiliates. Elanco and the diagonal bar logo are trademarks of Elanco or its affiliates. EM-DK-24-0022 02 2024 B. Duncan Lascelles Francesco Staffieri Cachon,T., Frykman, O. et al. 2023.“COAST
10:1137888 doi: 10.3389/fvets.2023.1137888 Cachon T et al. Front. Vet. Sci. 2023; 10:1137888
Development Group’s international consensus guidelines for the treatment of canine osteoarthritis” Front. Vet. Sci.
Product attributes Pet caregiver needs Pet caregiver preferences Control of key pathophysiological processes Product mode of action Product safety profile Patient needs Patient “other considerations” Life factors Financial considerations Administration At home In clinic Ease Inflammation Pain Sensitization Piprant Coxib COX Inhibitor Anti-NGF Characteristics Class Individual product Disease severity Co-morbidities Other medications Age Newly diagnosed Stable disease Formulation Duration
of action Factors to consider when making a choice
0
Quick reference chart
Corticosteroid (IA) Difficult cases or failed treatment Difficult cases or failed treatment2
Platelet Rich Plasma (IA) Quality standards/ licensed laboratory Quality standards/ licensed laboratory
Hyaluronic acid (IA) Low molecular weight (MW) Low MW if 1st use Low & High MW if used previously
PPS/PSGAG (IM) Additional therapy Additional therapy
Tramadol (PO) Adjunct analgesic (not replacement) Adjunct analgesic (not replacement)
Amantadine, Acetaminophen (Paracetamol), Gabapentin (PO)
Stem cells (IA)
Anti-NGF mAb (SC)
Adjunct analgesic (not replacement) Show clinical benefit before addition of next
Quality standards/ licensed laboratory
Quality standards/ licensed laboratory
Use as needed. Expert experience: Often ≥ weeks ideally at RTD
Use as needed. Expert experience: Often ≥ weeks ideally at RTD
Use as needed. Expert experience: Often ≥ 12 weeks ideally at RTD
Choice: Consider mode of action & product attributes. Unknown if can be used safely together for the longer-term. Achieve and maintain required level of functional improvement
NSAIDs Piprant, coxib or other COX-inhibitor (PO)
COASTeR stage
Use as needed.
Expert experience: Often ≥ weeks ideally at RTD
Use as needed.
Expert experience: Often ≥ 8 weeks ideally at RTD
Foundational Elements Introduce osteoarthritis, COAST, and life-stage specific topics
Highlight optimization of body weight condition, nutrition, and exercise
Pet Caregiver Education OA awareness Risk factor avoidance Risk factor mitigation
Use as needed.
Expert experience: Often ≥ 12 weeks ideally at RTD
Useful information
COAST & COASTeR: Explained
COAST (the Canine OsteoArthritis Staging Tool) provides the diagnostic framework for the treatment guidelines. This instrument captures input from both the pet caregiver and the veterinary team to classify dogs as pre-clinical or clinical, and stages them according to overall disease severity. COAST includes
Evaluations by pet caregiver: Validated questionnaire (e.g., LOAD) plus dog’s level of discomfort.
Evaluations by the veterinary care team: Observational and hands-on orthopedic examination (posture, motion, joint palpation & range of movement, and radiography)
radiography of the joints. Radiography is needed for the exclusion of other pathologies and the confirmation of the OA diagnosis and is a fundamental part of the diagnostic workup of dogs with suspected OA. It is also needed for the reassessment of joints in complex cases.
Dogs are assigned to stage 0-4 as follows
The foundational elements are management recommendations applicable to dogs of all COAST(eR) stages. They are largely made up of education,
awareness and health optimization strategies and form the base of the ‘base and build’ approach to protocol development.
OPPORTUNITIES: Life Stage
Evaluation opportunities
Puppy Health check and first vaccinations
Pre-clinical
Clinically Normal. No risk factors identified. Clinically Normal. Risk factors identified. Clinical Clinical Signs. Mild Osteoarthritis
Clinical Signs. Moderate Osteoarthritis.
Clinical Signs. Severe Osteoarthritis.
Young adult Health Check
Life stage
Mature adult
OA education programs
Annual Health Check
Senior Senior/geriatric wellness
Objectives
Introduce COAST/Familiarize pet caregivers with the concept/terminology
Begin pet owner disease education about OA (reduce risk factors)
Neutering discussion (positives, negatives, and timing)
Identify any individuals that could benefit from preventive surgery
Assess COAST Stage to determine an individual baseline and open discussion about OA (e.g., at-risk breeds)
Dietary/nutrition discussions
Growth rate monitor
Body weight monitor
Determine body and muscle condition score
Exercise plan
Ongoing pet caregiver education
Pre-neuter discussion (if applicable)
Focused OA education program for pet caregivers
Assess COAST Stage
Quick evaluation for clinical signs of OA
Ongoing pet caregiver education
Recommend a follow-up COAST evaluation necessary
Increase frequency of OA evaluation visits for senior dogs. Consider breed size and average life expectancy (i.e., dogs entering the last 25% of their estimated lifespan).
Conduct a COAST evaluation or re-evaluation
Set expectations Commitment to care Value of more complex OA plan Rapid response + end-of-life prep
Body weight/ BCS Keep optimal Discuss joint loading and metabolic contribution Management plan if body weight reduction needed
Nutritionally balanced, breed, life-stage, and lifestyle appropriate
Nutrition
Keep optimal Address if risk factor Adapt for OA requirements (Refer to diet/dietary supplements)
Exercise Breed, life-stage, and life-style appropriate
Keep optimal Address if risk factor Adapt for OA severity & management requirements 3
Physical Therapy/ Rehabilitation Awareness Minimize injury risk Conditioning Full program joint injury Patient specific OA care plan (supervised and at-home) preferably developed by a certified professional
Environmental modification If problem areas identified Comfort Facilitate access Crucial (everyday life & comfort)
Surgery (medical management) ‘Preventive’ (specific criteria) ‘Curative’ Treat initiating causes or intractable pain ‘Curative’ Treat initiating causes or intractable pain
Joint Diet Functional Food Awareness/ informed choice
Chondroitin sulphate, glucosamine, ASU, green lipped mussel Continuation at caregiver request
Undenatured Collagen Type
Awareness/informed choice
Cannabidiol Supplements Awareness/ informed choice Maladaptive pain & efficacy of meds
COASTeR (the Canine OsteoArthritis Staging Tool excluding Radiography provides the treatment & re-evaluation structure for the treatment guidelines. The COASTeR stage is simply the stage of OA once
radiography has been removed from the COAST algorithm. Use of the COASTeR stage ensures that selection of treatment and the evaluation of response is based on clinical rather than radiographic signs of OA.
QUICK REFERENCE CHART: Detailed Legend
General interpretation of this recommendation
Unanimous recommendation
Majority recommendation
Minority recommendation
Unanimous support for this management approach/treatment for dogs with the specified stage of OA.
Sufficient high-quality evidence, supported by personal experience.
The benefit: harm evaluation favors treatment use
No unanimous support for this management approach/treatment for dogs with the specified stage of OA but sufficient evidence for most of the group to recommend it as a treatment option.
The benefit: harm evaluation favors use in the opinion of the majority
No unanimous support for this management approach/treatment for dogs with the specified stage of OA
Weaker evidence-base support relative to other options, with only a minority of the group recommending it as an option.
The benefit is considered at least equal or better than the risk
Individual patient factors are likely to be a significant consideration when considering use
All ages Opportune
Quick evaluation for clinical signs of OA
Ongoing pet caregiver education (brief)
Recommend a follow-up COAST evaluation necessary
OPPORTUNITIES: Education
Focus Areas Objectives
Importance of young dog OA assessment (restricted window of opportunity for preventive surgery)
Disease awareness and common causes of OA
Pet Caregiver
Weight optimization
Basic understanding of OA risk factors & avoidance
Importance of regular assessments (in-clinic and at-home observations)
Measure and evaluate body weight, body condition score and muscle condition score relative to age, breed & lifestyle
Importance of achieving/maintaining optimal body weight
Diets balanced for life stage
Energy & protein according to breed size. Puppies: Caloric intake appropriate to rate of growth
Nutrition/Dietary discussion
Nutrient deficiency OR excess contributes to OA development (e.g., Calcium: Phosphorus imbalance joint incongruency and disturbances in skeletal development, growth & mineralization
Importance of lifelong maintenance of optimal body condition score
Benefits of exercise for musculoskeletal and general health
Strengthening (core & joints)
Appropriate exercise
Age, breed, life-stage appropriate
Regularity (daily and consistency in duration)
Avoid/minimize high impact activities, sudden loading, or excessive exercise unless conditioned
Professional guidance (appropriate exercise program) ideally from certified physiotherapist
Specific exercises to support balance, strength/tone, endurance, and flexibility
Rehabilitation/
Physical therapy
Injury prevention strategies
Mental stimulation
Pet caregiver ‘dog health advocacy’: Easy, every day at-home exercises
Foundational elements
0 1 3 2 4 13 The levels of recommendation are based on the sum of individual author’s interpretations and voting, not a group consensus on set of criteria. Voting for surgical procedure recommendations was limited to orthopedic surgeons in the group only. Unanimous recommendation Majority recommendation Minority recommendation See article forscoresvoting Clarifications by COAST: 1. Subject to regular monitoring of efficacy & tolerability and adapted for individual patient requirements as required. 2. Referral to be considered or recommended. 3. Stage 4: More rapid use of adjunct analgesics likely; comfort prior to weight, nutrition, exercise; palliative care mobility device awareness. 4. Intra-articular: To functional improvement after unanimously recommended treatments or if medical options limited. Most applicable if 1 or joints affected. RTD = Recommended Therapeutic Dose; PO = per os, SC = subcutaneous; IM = intramuscular, IA = intra-articular Cachon T et al Front. Vet. Sci. 2023; 10:1137888 Patient Evaluation Multidisciplinary team) Target 1 x/year Target 2 x/year + at risk puppy radiograph screen Target 2 to 4 x/year + blood/urine analysis Target 4 to 6 x/year + blood/urine analysis Frequent: at-home/telehealth useful + blood/urine analysis
Provision of essential fatty acids plus other potential benefits
Omega-3 EFA Awareness/ informed choice With balanced diet if preferred to functional food
II Continuation at caregiver request Awareness/informed choice
+
FIRST
FIRST LINE FIRST LINE FIRST LINE FIRST LINE FIRST LINE
LINE
Non-drug Diet & dietary supplements Pharmaceuticals and biologics Clinically normal no OA risk factors Clinically normal OA risk factor(s) Clinical signs mild OA Clinical signs moderate OA Clinical signs severe OA 0 1 2 3 4
INTRODUCTION
Osteoarthritis (OA) is a progressive, degenerative disorder of synovial joints. It is characterized by pain, low-grade chronic inflammation, and structural and functional joint deterioration.
In dogs, OA generally starts early in life, e.g. due to developmental joint disease such as hip dysplasia or osteochondrosis dissecans. Joint trauma is another important causative factor. Diet, obesity, genetics, age, and environment are risk factors that can influence OA development and progression. The disease is incurable, and patient care is primarily focused on minimizing the consequences related to pain, mobility impairment and decreased quality of life.
THE COAST GROUP RECOMMENDATIONS: Base and build
Canine OA patients have changing and generally expanding needs as disease severity increases, and only the consulting veterinary care team can develop a treatment plan appropriate to each dog’s specific situation. The COAST International Consensus Guidelines for Treatment of Canine OA provide a reference to evidence- and expert opinion-based OA management recommendations to support informed choice. The recommendations follow a stage-wise, simple but practical base and build approach.
Foundational elements (page 13) such as pet caregiver education and the pro-active evaluation of lifestyle factors, form the ‘base’ of the recommendations and are considered applicable to all dogs.
Recommendations by COASTeR stage are intended to expand or ‘build’ on the foundational elements in a stepwise but flexible manner, according to strength of recommendation and the specific OA management needs of the dog.
Treatment options & strength of recommendation may differ depending upon COASTeR stage:
COASTeR stage 4
BUILD
COASTeR
Additional considerations when choosing treatment options:
Age of the dog
Co-morbidities
Concurrent medications
Type of joint(s) affected
Number of joints affected
Impact of disease on the dog as a whole
Pet caregiver circumstances
Start with the foundational elements and then build according to disease severity.
If build elements are not applicable to the patient, refer to COASTeR Stage 0. Otherwise, expand on the previous stage discussions and management approaches.
Consider COASTeR stage recommendations with the strongest support and evidence (unanimous) first. Consider more weakly supported options (majority or minority) for dogs needing additional support:
• Complex or challenging cases
• Those already receiving unanimously recommended options (e.g., dogs on a plan but progressing to the next stage)
Adapt protocols according to patient-specific needs (e.g., dosage adjustments, co-morbidity considerations, product intolerances).
Note: Relatively few of the drug and non-drug treatment modalities frequently incorporated into multi-modal OA management protocols have been rigorously studied and there only a limited number of pharmaceutical /biologic products approved for use in dogs.
Info Page
The COASTeR stages can be determined by looking at the illustrations found in this material. It can also be done by filling out the COAST or COASTeR form (excluding radiography) to reach a result.
Scan the QR code to find and download these tools with a collection of relevant information - including a digital version of the guide.
This handbook provides a simple overview of the COASTeR treatment recommendations.
Please refer to the publication for full details, including voting scores and factors affecting decisions.
CONTENT
All stage Foundational elements BASE
COASTeR stage 3
COASTeR stage 2
stage 1
Adapt Plan and/or include
options Stage 0......................................................................................................................................................................... 2 Stage 1......................................................................................................................................................................... 3 Stage 2......................................................................................................................................................................... 4 Stage 3......................................................................................................................................................................... 6 Stage 4......................................................................................................................................................................... 9 Challenging scenarios.............................................................................. 12 Foundational elements.......................................................................... 13
COASTeR stage 0
additional management
Optimising health
Pet caregiver education focus
Increase awareness and understanding of OA.
Explain why continued avoidance of OA risk factors is important.
Body weight management
Introduce COAST(eR) if not already known.
Highlight the benefits of patient monitoring.
Emphasize foundational elements according to changing life stage or educational opportunities.
Nutrition
Adjust diet according to any changes in nutritional requirements. A joint diet/functional food is not recommended.
Exercise
Adapt according to breed and life stage requirements.
Avoid high impact activities/sudden changes in direction in unconditioned dogs.
Rehabilitation/Physical therapy
Programs focused on building strength and tone, and minimizing injury risk can be beneficial.
Discuss activity associated risk of injury and OA in conditioned dogs.
Risk factor mitigation
Refer to, and build on, previous stage instructions.
Pet caregiver education focus
Focus on disease progression and importance of mitigating identified risk factors.
Patient evaluations
Increase awareness of non-identified risk factors.
More frequent evaluations for all at-risk dogs (breed, lifestyle, age, developmental disorder, etc.). Frequency determined by management objectives (e.g., weight monitor). As a guide:
Dogs < 1 year of age: 2-3 visits during the dog’s growth phase.
Radiographic screening is encouraged.
Body weight management
Discuss the contribution of excess weight to joint loading and inflammation.
Nutrition
Enable a nutritionally balanced, breed, and life-stage appropriate diet.
For dogs that have reached adulthood, a joint diet or omega-3 fatty acid supplement may be considered, but they are not unanimously recommended.
Exercise
Adapt the exercise program to address OA risk factors.
Dogs > 1 year of age:
Regular assessment (every 6 months).
Pet caregiver to complete client-reported outcome measure (e.g., LOAD).
Stress the importance of achieving and maintaining optimal bodyweight.
Help understanding of joint diets and Omega-3 supplements for informed choice.
Diet
Focus on minimizing any deleterious effects on joints.
Rehabilitation/Physical therapy
Consider developing a program in partnership with a certified rehabilitation/ physical therapist.
Encourage a full rehabilitation program if a joint injury (current or previous) is identified.
Puppies: Identify individuals that could benefit from preventive surgery (e.g., Juvenile Pubic Symphysis)
Curative surgery (e.g., Total Hip Replacement) later in life is an alternative option.
Referral is alwaysoptionan
2
COASTeR stage COASTeR stage
1 0
No clinical signs of OA One or more risk factors No clinical signs of OA No risk factors
3
joint disease Joint trauma
bodyweight
predisposition (breed, conformation)
Degenerative
Excess
Genetic
(e.g. unlimited feeding, Ca:P imbalance)
(higher risk in neutered dogs)
(senior dogs)
(working & sporting dogs)
Gender
Age
Environment
OA risk factors
Non-drug Surgical Non-drug
Clinical signs of mild OA 2
“Regular re-evaluation of patients is important”
Commitment to care
Refer to, and build on, previous stage instructions.
Pet caregiver education focus
Set expectations from the first visit:
• OA is a life-long progressive disease that can be managed.
• Commitment to a long-term care plan including re-evaluations.
Patient evaluations
Check-ups: Average of 2 to 4 times/year.
• Evaluate response to treatment and check for drug tolerability.
• Fewer re-visits once optimal function achieved.
• Value of nurse/technician and multidisciplinary led appointments.
Body weight management
Discuss the contribution of excess weight to joint loading and inflammation.
Nutrition
A nutritionally balanced diet is essential.
Omega-3 EFA supplements can be given if preferred, although the additional benefits (e.g., calorie control) of a functional food should be considered.
Dietary supplements
Consider singularly or as a combination product:
• Chondroitin sulphate
• Glucosamine
• Avocado-soybean unsaponifiables (ASU)
Focus on optimal early management.
Mitigate OA progression factors or any new / unaddressed risk factors.
Exercise
Adapt exercise according to clinical OA management requirements.
Rehabilitation/Physical therapy
Involve or refer to a certified physical therapist/rehabilitation specialist, if possible.
Recommend exercises to support balance, strength, endurance and flexibility.
Include supervised in-clinic and at-home exercises.
Treatment modalities (e.g., manual or machinery applied) selected according to individual patient needs.
Environmental modifications
Blood work is recommended especially if there are risk factors to treatment (comorbidities, concurrent treatment, etc.).
“Suggested minimum of 4 weeks duration of use, ideally at the recommended dose for COASTeR Stage 2 dogs”*
Stress the importance of achieving and maintaining optimal bodyweight.
For adult dogs, recommend a functional food/joint diet (refer to manufacturers feeding recommendations).
Combined EPA/DHA Dosage (BW in kg): Minimum 75-100 mg/kg/day.
Potential to increase to 310*BW 0.75 (Upper safe limit = 370*BW 0.75)
• Undenatured Collagen Type II (UCII)
• Green lipped mussel
A clinical benefit is unlikely if the patient is receiving a joint diet containing the same or similar ingredients.
“It is unknown if the anti-NGF mAb can be used safely together with an NSAID for the long term” See back page
Develop plan with a certified physical therapist/rehabilitation specialist whenever possible (see below).
Adapt programs to pet caregiver circumstances if required (e.g., homemade equipment).
“Effective pain control facilitates rehabilitation programs, as well as improving comfort and QoL”
Discuss modifications if problem areas are identified (e.g., hard, slippery flooring).
NSAIDs
A piprant, coxib or other COX-inhibitor as a management option for OA pain and inflammation.
Refer to product information for individual product details.
Treat until functional improvement is optimal with a product that is well-tolerated.
• Sufficient duration
• Efficacious dosage
• Regular re-evaluation (e.g., 7 to 14 days, 1 month, then monthly, then as required for monitoring purposes)
Anti-NGF monoclonal antibody
Anti-NGF as a management option for OA pain. Refer to product information for product details. Treat until functional improvement is optimal, if product is well tolerated.
• Sufficient duration
• Efficacious dosage
• Regular re-evaluation (e.g., monthly prior to injections plus consider more frequent intervals for monitoring purposes)
Other treatments
Pentosan polysulphate IM Polysulphated glycosaminoglycan IM
All COAST group members consider NSAIDs as a first-line therapy option for this stage of OA.
A majority (6 out of 9) of COAST group members consider antiNGF as a first-line therapy option for this stage of OA.
* Based on expert experience. Required level of improvement may be seen before or after suggested period of use. Product choice, dose and duration of use is according to individual patient requirements. The recommended therapeutic dose has the strongest evidence of efficacy. Confirm that the product is well-tolerated and adjust protocols for specific needs.
Consider surgery if OA pain cannot be managed well enough with medical + non-drug options.
Specialist advice should be sought prior to surgery.
The need for surgery directed at initiating causes of secondary OA is usually clear. COASTeR
Low molecular weight hyaluronic acid IA Pharmaceuticals and biologics
Refer productto information
“Consider additional information to support informed treatment choicesee back page”
4 5 Surgical
stage
Non-drug
Non-drug
Clinical signs of moderate OA 3
Increasing Complexity
“Importance of a multi-disciplinary team”
Refer to, and build on, previous stage instructions.
Pet caregiver education focus
Help them understand the benefits of a multi-modal approach.
• Explain that adjustments to established plans may be needed.
Patient evaluations
Increase support and monitoring.
• Check-ups: Average 4 to 6 times/year.
• Most frequent visits when assessing response to new treatment(s).
• The inclusion of engaging educational tools is important.
Nurse/technician led appointments and a multi-disciplinary team approach is strongly encouraged.
Body weight management
Reset outcome expectations if necessary.
The COAST Group endorses all forms of patient check-ups but recommends a hands-on evaluation at least 2 to 3 x/year.
Exercise
Modify exercise plan according to capabilities and needs of the patient.
Align with the physical therapy/ rehabilitation program.
Blood work of increased importance (likelihood of co-morbidities and use of multiple medications).
“Regular ongoing assessments, capturing pet caregiver and veterinary team observations, are needed to minimize the risk of sub-optimal pain relief. Use validated tools when possible”
Continue to highlight the need to achieve and maintain an optimal bodyweight, and why it is important.
Nutrition
For adult dogs, a nutritionally balanced, functional food is recommended for Omega-3 EFA content, calorie control and potential to support cartilage health (Refer to manufacturer feeding recommendations).
Dietary supplements
Consider singularly or as a combination product:
• Chondroitin sulphate
• Glucosamine
• Avocado-soybean unsaponifiables (ASU)
Omega-3 EFA supplements if preferred.
Combined EPA/DHA dosage
(BW in kg):
Minimum 75-100 mg (kg/day).
Potential to increase to 310*BW 0.75 (Upper safe limit = 370*BW 0.75)
Consider additional benefits of functional food.
Rehabilitation/Physical therapy
Place greater emphasis on benefits of referral to a certified physical therapist/ rehabilitation specialist.
Environmental modifications
Focus areas:
Comfort
• Beds
• Rest areas
Consider the potential benefits of machinery applied techniques.
Continue to implement individually tailored programs, ideally incorporating in-clinic and at-home approaches, to support balance, strength, endurance, and flexibility, and to address any specific needs.
• Undenatured Collagen Type II (UCII)
• Green-lipped mussel
• Cannabidiol (CBD)
A clinical benefit is unlikely if the patient is receiving a joint diet containing the same or similar ingredients.
Access
• Non-slip flooring
• Ramps or steps
(Facilitate movement between areas of different heights)
As for the previous stage, seek specialist advice and consider surgical options, if OA pain cannot be managed well enough with a multi-modal approach. The increased demands of the more complex medical management protocols may influence decision making more strongly.
6 7 Surgical
COASTeR stage
Non-drug
Non-drug
In-person Telehealth Videos Pet-owner questionnaires
“A minimum of 8 weeks duration of use is usually required to get better control of underlying processes”*
Clinical signs of moderate OA
“Use products at an efficacious dosage and for a sufficient duration, for optimal functional improvement”*
NSAIDs
A piprant, coxib, or other COX-inhibiting NSAID as a first-line option for management of OA pain & inflammation.
Refer to product information for individual product details.
As for COASTeR 2, treat optimally for functional improvement when possible.*
Regular re-evaluation after starting treatment (e.g., 7 to 14 days, 1 month, 2 months, then monthly or as required).
Anti-NGF monoclonal antibody
Anti-NGF mAb as an alternative first-line option for the management of OA pain (it is unknown if anti-NGF can be used safely together with an NSAID for the long term).
Refer to product information for product details.
As for COASTeR 2, treat optimally for functional improvement when possible.* Regular re-evaluation after starting
Adjunct analgesics
“Additional pain relief, not replacement pain relief (unless exception)”
If additional pain relief is needed, start ≥1 month after main pain management option (unless patient specific exception). Important for cases of sensitization or chronic neuropathic pain (suspected or proven).
Stop adjunct analgesic prior to reducing or ceasing use of NSAID or Anti-NGF mAb.
Stem cells (IA)
Use licensed laboratories and refer to experienced centres.
Other treatments
Low molecular weight hyaluronic acid IA◊ Pentosan polysulphate (PPS) IM
“Duration of product use is dependent upon time taken to optimize functional improvement and is subject to patient monitoring and product tolerability”*
Clinical signs of severe OA 4
COASTeR stage
Rapid response
Refer to, and build on, previous stage instructions.
Pet caregiver education focus
“Alleviation of pain is the priority”
Consider protocol adjustment once treatment goal achieved.
• Cease any adjunct analgesic first.
• Consider NSAID dosage reduction.
“Extend the administration interval in preference to lowering the dose”*
treatment (e.g., 1 and 2 months and continue monthly or as required. More frequently can be considered.
Limited knowledge of use with adjunct analgesics.
Consider protocol adjustment once treatment goal achieved.
• Cease any adjunct analgesic first.
• Currently no data to guide dosage reduction decisions.
Stepwise introduction†
• Amantadine (reserved for human use in some regions)
• Acetaminophen (paracetamol)
• Gabapentin
• Tramadol (e.g., relapsed/recurrent cases).
Regulatory policies may apply.
Polysulphated glycosaminoglycan (PSGAG) IM
Platelet-rich plasma IA◊
Refer to product information
Corticosteroids IA◊ (particularly difficult to manage cases or other options limited/failed).
* Based on expert experience. Required level of improvement may be seen before or after suggested period of use. Product choice, dose and duration of use is according to individual patient requirements. The recommended therapeutic dose has the strongest evidence of efficacy. Confirm that the product is well-tolerated and adjust protocols for specific needs. †Benefit: risk of concurrent use. ◊Consider referral to centres with IA administration experience and use licenced laboratories.
“Frequent monitoring due to:
Disease severity
Co-morbidities
Multiple medications”
Ensure that pet caregivers understand the severity of their dog’s condition.
Highlight the need for radiography/a full COAST evaluation.
Explain impact on mobility due to severe, chronic, OA pain and loss of strength.
Prepare for rapid introduction of drug and non-drug approaches (if patient overall health status and pet caregiver considerations allow).
Patient evaluations
Thorough patient assessment:
Determine how aggressive pain management protocols can be while considering patient safety. Include radiography (rule out other diseases).
Blood work is important.
Body weight management
Options may be limited if already on OA management plan. Help understand what additional approaches are available, including surgery.
Ensure commitment to frequent checkups.
Engaging educational tools and resources are crucial.
Include end-of-life preparation.
Frequent check-ups (weekly, then monthly to monitor welfare and response to treatment). Incorporate home-visits if needed/possible.
Multi-disciplinary team approach is strongly encouraged.
The contribution of excess bodyweight to joint pain & lack of mobility can be significant. Focus on patient comfort/priority care first. Weight management can be part of initial discussions if caregiver is not overloaded.
Increase the emphasis on weight control once OA pain is better controlled.
Nutrition
Focus on controlling pain/priority care first. Incorporate into protocols if caregivers have the capacity.
Dietary supplements
Cannabidiol (CBD) – Adjunct pain relief is a significant need for COASTeR Stage 4 dogs. Preliminary data indicates that CBD has the therapeutic potential to contribute to OA pain management.
Likely that dogs progressing from COASTeR Stage 3 will be receiving a functional food or Omega-3 EFA supplement.
Take into account that patients are receiving multiple, important drugs at this stage.
Nutritional supplements (chondroitin sulphate, glucosamine, ASU, UC II, Green lipped mussel), are of lesser importance but may be considered.
8 9
Non-drug COASTeR stage
3 +
Pharmaceuticals and biologics
Clinical signs of severe OA
Exercise
Exercise will be significantly impacted but there will be a range in physical ability.
Rehabilitation/Physical therapy
Emphasize benefits of tailored therapeutic exercise by a certified physical therapist/rehabilitation specialist
Ensure it is part of a comprehensive multi-modal approach.
Environmental modifications
Crucial at this stage
• Reduce distance and effort needed to move to important areas (food, rest, toilet)
• Comfortable beds and resting areas
• Non-slip flooring
• Ramps and steps to facilitate access
Mobility Assistance Devices
Determining an exercise goal appropriate for each individual patient is important.
“A minimum of 12 weeks duration of use is usually required to get better control of underlying processes”*
The choice of options makes these programs particularly suitable for complex cases e.g., focus on at-home support if transportation is initially impossible / challenging.
Provide information about mobility assistance devices so that pet caregivers can make an informed choice.
For palliative care and end of life management: see page 12
For management of severe break-through pain: see page 12
Need to change NSAID? see page 12
Extensively explore medical management options and seek specialist advice prior to surgery.
Poor physical condition and factors such as co-morbidities may influence decision making.
“COASTeR Stage 4: Aggressive use of analgesics and a more rapid introduction of pharmacological adjuncts is likely to be required” *
NSAIDs
A piprant, coxib, or other COX-inhibiting NSAID as a first-line option for management of OA pain & inflammation.
Refer to product information for individual product details.
As for COASTeR 3, treat optimally for functional improvement when possible.
• Regularly re-evaluate after starting treatment.
• 1-, 2- and 3-month efficacy re-checks are preferably ’hands-on’.
• Include more frequent general follow-ups.
The requirement for an NSAID is often lifelong (Cessation of NSAID is unlikely).
Anti-NGF monoclonal antibody
Dosage reduction may be possible with care but is not an expectation.
Consider the more rapid introductions of adjunct analgesics if required (Benefit: risk).
Consider other analgesic options if no clinical improvement or further deterioration.
“It is unknown if the anti-NGF mAb and an NSAID can be used safely together for the long term, but consideration of concurrent use is more likely due to pain severity” * (benefit: risk)
Anti-NGF mAb as an alternative first-line option for the management of canine OA pain. Disease severity will influence benefit: risk evaluation of concurrent use with an NSAID. Refer to product information.
As for COASTeR 3, treat optimally for functional improvement when possible.
• Patient evaluation after 1 month (continue, adjust or stop treatment)
• 1-, 2- and 3-month efficacy re-checks are preferably ’hands-on’.
• Include more frequent general follow-ups.
Cessation of mAb is unlikely.
Stem cells (IA)
Referral to centers with experience of this approach advised.
+
“At this stage, IA options are a key consideration if only one or two joints affected”◊
Adjunct analgesics
Introduce in a stepwise manner.†
• Amantadine (reserved for human use in some regions)
• Gabapentin
• Acetaminophen (paracetamol)
• Tramadol
Other treatments
Corticosteroids IA◊ (concomitant use with NSAIDs is contraindicated)
Platelet-rich plasma IA◊
Hyaluronic acid IA◊
• Low molecular weight HA if first use
Dosage reduction may be possible with care but is not an expectation. Consider the more rapid introductions of adjunct analgesics if required (Benefit: risk).
Consider other analgesic options if no clinical improvement or further deterioration.
Pharmaceuticals and biologics
Regulatory policies may apply. High quality standards mandatory.
Patients likely to require more than one/ multiple adjunct analgesics. Re-evaluation is important to check tolerability.
• Consider both low and high molecular weight HA if low MW HA has been used previously
Pentosan polysulphate (PPS) IM Polysulphated glycosaminoglycan (PSGAG) IM
* Based on expert experience. Required level of improvement may be seen before or after suggested period of use. Product choice, dose and duration of use is according to individual patient requirements. The recommended therapeutic dose has the strongest evidence of efficacy. Confirm that the product is well-tolerated and adjust protocols for specific needs. †Benefit: risk of concurrent use. ◊ Consider referral to centers with IA administration experience and use licensed laboratories.
10 11 COASTeR stage 4
Non-drug Surgical
