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rubles
19th December 2012, 02:23 AM
Charlie not having a good day.
His normally well fitting collar is snug and his neck feels swollen so I've removed it.
He's grumpy and has spent a lot of time growling. He's been licking the air as well as the patio door.
He's on gabapentin three times a day taking 1.0, .08 and .08 over a 24-hour period. He's also taken Tramadol. The air pressure has dropped. I don't think Tramadol is accomplishing anything.
Currently he's sleeping next to me on the chair in an almost vertical position leaning into the corner between me and the chair.
Would cimitidine be better than Tramadol--a pain killer.
He's been on gabapentin for 11 months and the dose quantity is steadily increasing.
Is there anything else I can do for him?

MomObvious
19th December 2012, 02:31 AM
Oh man I'm so sorry Charlie is having a really bad day. I would call the Nero, vet maybe there is something......... good luck sending happy thoughts.

rubles
19th December 2012, 02:45 AM
Thanks Melissa

Sydneys Mom
19th December 2012, 02:57 AM
The air licking and grumpiness sound like they may be SM related. Not sure about the swollen neck, an allergy maybe? Have you changed any food or treats recently? I also think that a call to the vet or neuro is called for. They may adjust his medication to help him feel better.

Karlin
19th December 2012, 11:19 AM
There are a lot of options for trying various medications. Lyrica is a more recent form of gabapentin and works much better for many dogs (but is expensive). I would definitely also get him on omeprazole or cimetidine (different CSF inhibitors work for different dogs).

If you actually think his neck is swollen I would get him to the vet immediately. He could be feeling worse because somethinng else is going on that is contributing to SM pain.

Best of luck, :flwr:

rubles
19th December 2012, 03:12 PM
Many thanks for your help. I'm looking into it now.
Sandra

rubles
21st December 2012, 01:23 PM
There are a lot of options for trying various medications. Lyrica is a more recent form of gabapentin and works much better for many dogs (but is expensive). I would definitely also get him on omeprazole or cimetidine (different CSF inhibitors work for different dogs).

If you actually think his neck is swollen I would get him to the vet immediately. He could be feeling worse because somethinng else is going on that is contributing to SM pain.

Best of luck, :flwr:
Thanks Karlin
Charlie's neck not swollen the following morning. I now have some 200 mg tablets of Cimitidine. Should he have all 200 mgs at x 1 daily? His gabapentin has been increase to 100 x 3 per day.

Karlin
21st December 2012, 01:53 PM
Have you spoken to your vet or neurologist? They should be advising on medications and be informed if anything is being added to what he is already taking. Dogs on these meds also need annual blood tests as per Clare Rusbridge's treatment algorithm available on her website.

Dogs take 50mg 2x or 3x of cimetidine generally. Definitely do not give 200mg in one dose.

Glas his neck is OK today! :)

rubles
21st December 2012, 11:59 PM
Thank yo for all your help and guidance.
Before we close though what does this drug do to alleviate the symptoms of SM?
I thoght it was generic omeprazole and it's not.

Karlin
22nd December 2012, 12:03 AM
Omeprazole is a completely different drug. It is another CSF inhibitor -- group of drugs which helps to relieve some of the pressure of the CSF circulating around the brian and down the spine.

www.cavalierhealth.org has explanations on all these drugs.

It is important to work with a vet/neuro on managing the meds for a dog -- they can answer all these questions and help find the right mix and dosage of meds -- something that shouldn't be done experimentally except with expert help as there are limits to the dosage and frequency of these drugs -- also cimetidine generally needs to be given 2 hours before or after gabapentin.

rubles
22nd December 2012, 03:13 AM
This is a perplexing situation to be in.
Neuro at local vet college recommended a very low dose of gabapentin backed up with prednisone for Charlie. The dose has been increased to 100 three times a day since then.
When I learned about omeprazole, cimitidine and lyrica I contacted my local vet.
Even though none of them were/are recommended for SM she wrote a prescription for omeprazole for Charlie and checked out Clare Rusbridge's site on my urging. Charlie did well on omeprazole and it's very expensive. so I thought cimitidine, in tablet form, was the generic for omeprazole and maybe that would be less expensive than the syrup being dispensed.
It's confusing because cimitidine is over the counter in the US and doesn't need a prescription. It's for stomache ailments and I think omeprazole is as well. So the pharmacist is unable to help either.
I don't think a lot of vets are familiar with this disease there being fewer cavs here than in Britain. Worse, most breeders don't admit to having SM/CM dogs (I'm sure they have) so I'm struggling to familiarize myself with different drugs.
The neuro consult I had was not very rewarding despite the cost. I was told Charlie, because of his symptoms, probably has SM and recommended an MRI costing 1,500 dollars, wrote the prescription for gabapentin and 8 prednisone tablets. I never saw the neuro. The technician took him away and returned him to me with the diagnosis in the crowded waiting room inquiring if I had any questions. Questions! I couldn't think straight., I was left on my own and our vet isn't familiar with the disease. There you have it and maybe you will understand why I have to ask how cimitidne works on SM. Head in hands.

Karlin
22nd December 2012, 10:58 AM
Do you have Clare Rusbridge's treatment algorithm? ALL those drugs are indeed recommended for CM/SM. Prednisone is only listed as a last ditch, when other drugs are not addressing pain or for dogs with specific needs for steroids. Generally you avoid prednisone unless necessary (speaking as someone who is on daily low dose preds for a type of athritis). Personally I'd save daily predisone for when absolutely nothing else works for my dogs.

I really recommend reading Rod's information on SM, my www.smcavaliers.com site, and Clare's information for pet owners with dogs with SM as there is plenty of detail on symptoms, treatment, types of drugs, dosage, recommended order to try, blood tests needed. Clare's site also has a section on CM/SM for vets and for breeders.

I think if you have people who are not treating your dog as you wish, then (as often with SM) it really becomes the owner's duty to be as informed as possible and help make the treatment decisions and ask for changes when wanted. All of us really have found we must be very proactive.

Clare's website: http://www.veterinary-neurologist.co.uk/

SM section: http://www.veterinary-neurologist.co.uk/Syringomyelia/

You can download her SM info as well as the treatment algorithm.

I would really work to talk to your vet rather than guess and buy things over the counter without knowing what you are buying -- for Charlie's well-being and yours. This could be dangerous and counterproductive. Gving him 200mg daily in one go, for example, could have been very damaging to his health so this is really important. :flwr: You really need to be working with your vet on this.

Omeprazole is also available over the counter. Sometimes prescription costs less. Omeprazole is off patent and available as a generic OTC and on prescription.

Unfortunately this IS an expensive condition to treat -- which is why we so strongly urge all cavalier owners to immediately get pet insurance that covers genetic disease as soon as they get a cavalier. If cost is a major issue in treatment then you do have a difficult dilemma -- you cannot leave him without the correct meds to adequately treat the condition over his lifetime. I don't have any answers if that is the case but I would recommend shopping around for medications as price can vary hugely (generic gabapentin is actually pretty inexpensive now through places like Costco). Lyrica is still on patent and considerably more expensive. Charlie may not need Lyrica but need a daily painkiller and there are a range of those.

The prednisone incidentally would likely cause him to gain weight over time and make him a lot more hungry.

As noted before Rod has a list of neurologists on his website and marks those known to have managed SM so maybe it would be best to try his list and see if you can find someone in driving distance that is more knowledgable or go back and work with the one you had before, but bring Clare's algorithm and be sure you have read thoroughly on the condition as well to be able to discuss options.

rubles
22nd December 2012, 02:44 PM
Thanks Karlin
I checked with my vet prior to giving Charlie any cimitidine and she recommended 1/3 of the tablet. Hard to split into thirds but I'll try. I would never give Charlie anything without clearing it with his vet. It will be a back-up on low pressure days. Cimitidine is not available over the counter here and neither omeprazole. It came from another cav owner that had extra. When I gave Charlie the prednisone I don't think it helped at all and I didn't like the side effects. I also have a small amount of Tramadol. Theomeprazole had a two-week shelf life--syrup.
I'll look at the websites you have recommended although the vet college usually has the most expertise. Sometimes I'm quite overwhelmed by all this.

Karlin
22nd December 2012, 04:14 PM
I know, it can seem overwhelming but it is very important to be as informed as possible as decisions made can be very significant and the condition can be very painful, leading to unwanted suffering if not treated as best as possible.

I forgot you were in Canada -- I know the laws can be different on what is OTC.

According to Clare's algorithm

http://www.veterinary-neurologist.co.uk/syringomyelia/docs/treatalgo.pdf

the usual starting dose of cimetidine is 50mg 2x or 3x unless the dog is fairly large -- it's 5-7mg per kg so a cavalier would have to be pretty big to take a third of a 200mg tablet (which is already the higher end dose -- everyone I know using this, with cavaliers of a range of sizes, gives 50mg). I use a pill cutter and cut pills into fourths. Cimetidine tends to have fewer potential side effects than omeprazole. While neither -- or ANY -- CSF inhibitor may seem to make an outward difference I think it is very important that SM-affected dogs take one as they do have an affect that will at least make syrinxes less likely to grow as fast as they might otherwise.

I think reading some background information will help a lot in understanding the condition, the treatments, and the options.

rubles
24th December 2012, 12:35 AM
According to the algorithm only NSAIDS have been licensed for SM in dogs. It's interesting to note though Clare starts with Cimitidine and progresses to gabapentin and prednisone and Charlie's vet was following the neuro's recommendation of 600 mls of gabapentin every twelve hours with prednisone as back-up if required. The cimitidine tablets I have are a longish oval so I'll split them once lengthwise and then split the halves again. Hopefully it will work. The omeprazole was a syrup with a two-week shelf life because that's how it is recommended for people. We'll get there it just takes time.

Karlin
24th December 2012, 11:06 AM
According to the algorithm only NSAIDS have been licensed for SM in dogs.

Yes that's right -- that's one reason why I noted earlier that generally, I think it really is better to work with a neurologist and not a vet when possible, because vets do not normally prescribe human drugs like gabapentin and CSF inhibitors (I feel the same about human GPs vs specialists for treating specialist conditions -- my GP is wonderful but really knows nothing about treating the kind of arthritis I have). Most vets have no idea of the role CSF inhibitors can play for example (nor do a lot of neurologists (!) who may not be all that familiar with SM nor follow the research, though! Finding a good neurologist can take time too). Clare did up the algorithm for vets, because of this and it is a great resource and so handy to print out and bring in to a vet or to use as a general reference for any owner of a CM/Sm dog. :)

Actually if you look at the diagram, the algorithm does not recommend prednisone as a backup -- it is only listed at the very bottom and as the very last resource, and suggests using it only if and when every other available medication has been tried. For some dogs, it is a godsend, but that is in very particular cases where other drugs don't work or bring too many side effects of their own, or the condition is very painful and advanced. In my opinion too many vets and neurologists leap to prescribe this medication -- probably because it provides swift relief and so owners feel like something has been done -- but it has potentially very significant and even lethal side effects over time. I've written elsewhere about prednisone -- there are many good reasons to use it, especially for short term pain relief where the drug is quickly tapered (how it is typically used, which to many people mistakenly think is risky). But if it can be avoided, I would avoid it and so would many vets/neuros. I cannot understand why any vet or neuro would give it immediately when only just beginning to try out lower doses of other SM meds.

I have those same darn ovals! -- you can do a decent split with a pill cutter. A little lopsided won;t matter too much. :) That shape sure is annoying though! If I recall the prescription ones I had over here were round; it was the OTC ones (generic) that are oval but so it the main commercial form too. Omeprazole disagrees with some dogs.

Sadly, vets show little interest in the condition, either. Board member Pat B attended the session on SM at a recent annual national vet conference --the biggest -- and hardly anyone went to that session. :( Many breeder and pet owners are way ahead of vets in understanding the significance and impact of CM/SM. But if vets don't educate themselves, many dogs will remain undiagnosed or misdiagnosed and will be poorly treated. Honestly, at this point the average cavalier owner will know far more than their vet simply by reading a few things widely available on the net. Maybe too many vets hardly ever use google either, but I have lost count of the number of cases where they could have helped a dog far sooner if they'd done what most of us do -- go to Google, list the symptoms and breed, click search and top of the list, up will come SM (with clear indications to eliminate other options first...).

Nicki
31st December 2012, 09:46 PM
Glad to hear that Charlie's neck has gone down. Had he been vaccinated or anything?



-- also cimetidine generally needs to be given 2 hours before or after gabapentin.

Karlin, there was a lengthy discussion about this some time ago, Pat in Atlanta did a considerable amount of research into this and posted that it was not necessary to give Cimetidine two hours apart from Gabapentin.

It's in this thread http://www.cavaliertalk.com/forums/showthread.php?39554-Daisy-and-Her-Medication&highlight=noah+compendium

Pat:


I read the pages in Plumb's Veterinary Drug Handbook on cimetidine, and it's a little more complex than what has been said - which is not to give with any other drugs without a two hour window. Basically - the effect of SOME drugs taken with cimetidine is ENHANCED, and the effect of some OTHER types of drugs taken with cimetidine is DIMINISHED. There is a list of these drugs in Plumb's, and there is more extensive info in Plumb's than in the NOAH compendium, but here is a cut and paste from NOAH:

"Due to inhibition of cytochrome P-450 activity by cimetidine, the metabolism and elimination of some drugs can be reduced. Clinically relevant interactions may occur with compounds having a narrow therapeutic index, e.g. beta-blockers, calcium channel blockers, benzodiazepines, barbiturates, phenytoin, theophylline, aminophylline, warfarin and lidocaine. Doses of such drugs may need to be reduced when administered concomitantly with cimetidine. The increased gastric pH resulting from cimetidine administration may lead to reduced absorption of drugs requiring an acid medium for absorption. It is recommended that at least 2 hours should elapse between administration of cimetidine and aluminium or magnesium hydroxide, metoclopramide, digoxin or ketoconazole when possible."

Note that there is no mention of gabapentin or pregabalin type drugs in the above list. Also note that the more common problem is that drug effect is ENHANCED, not diminished. From what I've read, I don't see a problem giving gabapentin and cimetidine at the same time and it seems to be an over-generalization to say not to give ANY other drug at the same time. If I had an SM dog on these meds, I'd want to specifically read and understand where the problem is in Plumb's or another drug handbook. Also, I would consider the option of using one of the other H2 receptor antagonists such as omeprazole, ranitidine or famotidine.


Also I posted
the British National Formulary http://bnf.org/bnf/bnf/current/41001i744.htm

Like Plumb's, it shows interaction information and Gabapentin and Pregablin are NOT mentioned.

rubles
1st January 2013, 12:32 AM
Charlie had his vaccinations last spring.

ByFloSin
1st January 2013, 09:19 AM
I don't have the experience to contribute anything new to this thread, but I do have a dog with CM/CM and yes, I did have an innexperienced vet to deal with, and a neurologist too far away by public transport to consult unless as a last resort.

I did carefully read and print down a couple of copies of the algorythym, one of which I gave to my vet. One great advantage was that Rebel had had two scans, 18 months or so apart, so my vet could easily see how far the disease had progressed.

It did take some time for my vet to persuade her senior partner in the practice to allow her to prescribe medicines not yet licensed for use on dogs, but the conservative treatments that were started made a huge difference to Rebel's pain levels and quality of life. Since then the senior partner has been persuaded to take a more liberal stance and my vet has liaised with the neurologist when she hasn't been sure how to progress.

I am telling you all this to highlight that although most vets have little or no experience of SM it is possible to work well with the owner, the matrix and neurologists to enhance the sufferer's quality of life and indeed expectation of life especially when the dog is elderly like my Rebel when the symptoms first show. My experience is that once a relationship of trust and the sharing of knowledge and expertise is achieved, then the right level of treatment for that particular dog is more easily found, so keep working for that rubles so that all your efforts will show results and Charlie will look and feel much better.

Karlin
1st January 2013, 01:21 PM
I am telling you all this to highlight that although most vets have little or no experience of SM it is possible to work well with the owner, the matrix and neurologists to enhance the sufferer's quality of life and indeed expectation of life especially when the dog is elderly like my Rebel when the symptoms first show. My experience is that once a relationship of trust and the sharing of knowledge and expertise is achieved, then the right level of treatment for that particular dog is more easily found, so keep working for that rubles so that all your efforts will show results and Charlie will look and feel much better.

This is a helpful and realistic contribution to the discussion -- thanks for adding it! :) It's a good reminder that we as owners are part of a partnership of care and we can inform ourselves and gently push to get the partnership we feel is best for our dog's care. An informed owner is really so important.

Pat
26th January 2013, 04:56 PM
Just want to be clear that I did not say that "it is not necessary to give cimetidine and gabapentin two hours apart" but rather I said that I did a lot of research, and I can't FIND anything in the literature that indicates that giving the drugs together is a problem. I certainly don't want to be on record here as disagreeing with something that a neurologist tells a client about drug administration.

Since I don't have a dog on SM meds, I've not had a conversation about this with a neurologist. If I were a client and was instructed to not give the drugs together, I'd respectfully ask for the source material/reason for this recommendation. It would be important to me because of my schedule which would make compliance more difficult. Here again is my original quote, and thanks, Nicki, for including my quote!


"From what I've read, I don't see a problem giving gabapentin and cimetidine at the same time and it seems to be an over-generalization to say not to give ANY other drug at the same time. If I had an SM dog on these meds, I'd want to specifically read and understand where the problem is in Plumb's or another drug handbook (added now - or other reference material). Also, I would consider the option of using one of the other H2 receptor antagonists such as omeprazole, ranitidine or famotidine."

Pat

rubles
28th January 2013, 01:01 AM
I chose to administer Charlie's Gabapentin and cimitidine at least two hours apart ensuring there would not be a problem, just in case, not carved in stone.:thmbsup:

Kate H
28th January 2013, 10:11 AM
Clare tweaks her algorithm from time to time in the light of more experience, but the 2 hour gap for cimetadine is still in place. The only technical information for the compatability of cimetadine with other drugs is for humans, since it is not licensed for use with dogs. So it may be that Clare's experience is that there is some incompatability when it is used with other drugs for dogs - even if this is only true for some, not all, dogs. I'm not sure that you can automatically assume that a drug that works in one way for humans will necessarily work in exactly the same way for dogs, with identical side effects. Don't think it's that easy!

Kate, Oliver and Aled

Karlin
28th January 2013, 12:15 PM
Hi Pat -- I am of the same opinion. I know from direct conversation, that Clare has not been entirely sure of whether there's any actual, significant, interference in the past, but clearly she accepts documentation that there is evidence that cimetidine slows absorption of other drugs and thus includes the recommendation of giving them apart, as evidenced in her algorithm. BUT it is not even clear that this makes much difference in humans, as far as I understand. Let me see if I can find the original citation -- I think Rod has it on Cavalierhealth.org somewhere.

My own experience is that not only has it never made any difference to give them together but I actually think Leo does better when they are given together. He seems a lot more restless when they are given 2 hours apart. It also makes it easy to forget to give the cimetidine. A lot of neurologists do not feel you need to give them apart. Clare is being especially safe on this one, is my sense -- just in case it does make a difference for the given dog.

Karlin
28th January 2013, 12:32 PM
Some info:

Drugs.com lists no known, cited interactions between Lyrica (pregabalin, same family of drug as gabapentin) and cimetidine: http://www.drugs.com/drug-interactions/cimetidine-with-lyrica-669-0-1937-2171.html

There is a 'minor' interaction that MAY occur between gabapentin and cimetidine noted there, which is not believed to be clinically significant:
Cimetidine may decrease the clearance of gabapentin by about 14%. The creatinine clearance has also been reported to be decreased by about 10% when cimetidine and gabapentin are coadministered. The mechanism of this interaction is unknown. This interaction is probably not clinically significant.. The site notes for consumers:

Consumer information for this minor interaction is not currently available. Some minor drug interactions may not be clinically relevant in all patients. Minor drug interactions do not usually cause harm or require a change in therapy. However, your healthcare provider can determine if adjustments to your medications are needed

Here again, the interaction is not considered of clinical importance (eg people would not be required to avoid taking these drugs together): http://www.druglib.com/druginfo/neurontin/interactions_overdosage_contraindications/

Here is one study of a form of long-release gabapentin which clearly states NO NEED to administer separately from cimetidine:

http://www.ncbi.nlm.nih.gov/pubmed/20573085


No gabapentin enacarbil dose adjustment is needed with co-administration of naproxen or cimetidine.

The widely used MIMS website -- which provides drug info to medical practitioners -- also clearly states the same info -- the interaction is not considered clinically significant (scroll down near end to interactions):

http://www.mims.com/USA/drug/info/Gabapentin%20Tablet/?type=full

I will ask Clare again if she feels this is a hard and fast rule but my understanding is that this is really a case of being ultra cautious given the tiny possibility that there might be an affect for some dogs, in the absence of any definitive data.

Pat
28th January 2013, 01:18 PM
The only technical information for the compatability of cimetadine with other drugs is for humans, since it is not licensed for use with dogs. So it may be that Clare's experience is that there is some incompatability when it is used with other drugs for dogs - even if this is only true for some, not all, dogs. I'm not sure that you can automatically assume that a drug that works in one way for humans will necessarily work in exactly the same way for dogs, with identical side effects.

Kate, Oliver and Aled

I agree with this - which is why I try not to use sources for humans when seeking information on drugs for veterinary use. But....it's not true that there is no technical information for drugs used in veterinary medicine that are not licensed for use with animals. Plumb's Veterinary Drug Handbook is the US "Bible" for drugs used in veterinary medicine, and it covers ALL drugs used off-label for animals. These drugs are not licensed for use in animals. The dosages, side effects, indications, interactions with food and other drugs, etc. in Plumb's are all for animals, not for humans. It also lists information specifically for dogs, cats, or other animals because the information is not the same for all animals. You can also find information on drugs used off label in the various veterinary textbooks, including indications for use, dosages, side effects, etc. There are many, many drugs used for companion animals that are not licensed for use in animals.

Pat

rubles
28th January 2013, 01:32 PM
This has evolved into a very useful, informative discussion and I've learned a lot since my initial post.

The more I read, the more this reminds me of warfarin sodium, an anti-coagulant. This drug requires careful monitoring, can interact with other medications and to a lesser degree food. Unfortunately medical personnel lack a basic philosophical knowledge in its use. A patient needs to recognize bad advice and unfortunately the worst, for me, was given in a hospital.

I've been lucky though with a cooperative vet and primary care physician both open to discussion of a different point of view.

The Internet has proven its worth with excellent forums on both subjects and I was lucky to find both of them.

Karlin
28th January 2013, 03:05 PM
I do not think it is the case that Clare has any indication that there is evidence that dogs have any issues with the two being given together, but I will ask. My understanding from her in the past was that she was simply erring on the side of great caution.

My own experience from giving the two drugs for years now, is that there is no difference -- or a difference to the detriment of NOT giving them together -- perhaps because that means there's no cimetidine in the system for two hours.