This might also help:
This might also help:
And also here a vet notes he has never heard of gabapentin causing seizures or being likely to have led to a vestibular episode:
Note that dog has obvious ear infections, and some serious problems.
I'm so confused. I read that ataxia (imbalance) can be an uncommon side-effect of neurontin. But he was on it when he was young with no problems. While I read your post, I actually heard him groaning in the hall, so I went and gave him 100mg gabapentin. He got his 5mg of prednisone last night. I don't know if I should add more prednisone tonight or not, or wait to talk to the vet in the morning.
Karlin, do you think it's possible for him to be on both regular prednisone and gabapentin? In the past, gabapentin alone wasn't enough. Now it's looking like prednisone alone isn't enough (unless a higher or daily dose helps and he tolerates it). Are the two ever used together, if only to buy time?
I've tried lyrica in the past by the way and it had surprisingly little effect.
I did also try gabapentin on its own again last year. He had surgery on his tail to remove a tumor, so he had to be taken off prednisone to heal and was put on gabapentin instead. The tail turned out to be a nightmare to heal anyway, compounded by the fact that the gabapentin wasn't enough for his headaches.
It's the combination of all the things you saw that would suggest vestibular and not a neurontin side affect, I think. A high dose of neurontin (gabapentin) could cause ataxia, but not that shifting of eyes which is considered probably THE defining symptom for vestibular episodes. Ataxia with neurontin is more due to being groggy.
That's why I'd give the regular gabapentin dose.
You can give gabapentin and steroids.
Lyrica didn't work for my Leo either at the starting dose but now he is on 50mg 2x (he weights 16 lbs) and is much better than when he was on 200mg or even 300 mg of gabapentin 3x. It may be that adjusting the dose would help. It may be too that a CSF inhibitor, if nopt being given, would really help (eg cimetidine).
I woud definitely NOT increase prednisone without medical advice. Steroids have significant side effect risks in their own right and at higher doses can cause more serious diseases (eg diabetes, Cushings, etc) and also will have stronger basic side effects like hunger, insomnia, thinning hair.skin, increased bruising. I'd only opt for steroids when all other options are depleted but they can give significant support and quality of life when appropriate. :) (I know -- I have been on them for a severe form of muscular arthritis that is now in remission and hopefully won't recur).
How much does he weigh?
Thank you! I'll keep up the gabapentin then and wait for the blood tests and my regular vet's opinion tomorrow regarding prednisone. Prednisone has been a miracle drug for him. He went from hanging-in-there to normal dog status within a week and has mostly stayed that way for years. He did have to be switched from 2.5mg daily to 5mg every other day though after a couple of years due to a worrying blood count (which resolved itself on the every other day dose). His coat is dry and a bit thinner and he is food-crazy, but those have been the only side-effects. I haven't done a prednisone related blood count now in a year though (there's been so much else to worry about with the tail... and mvd), so tomorrow's tests will be important.
He is about 10kg. He's a big cavalier, not over-weight at all.
I did ask the emergency vet if she thought putting him on antibiotics was a good idea just in case it is an infection. She thought not, since they are very strong. I hope they have some way tomorrow of telling if there is an infection (preferably other than a long train trip to Helsinki for a 1000e MRI).
Btw, is cimetidine more helpful than omeprazole? He was on omeprazole for a few months when he was young and I didn't notice a difference. When prednisone resolved everything, omeprazole was dropped - also because the vet thought it should only be prescribed short term.
I'll definitely think about trying Lyrica again. I got the impression from your post that its effects are cumulative? Gapabentin seemed to work more like a great short term pain reliever when he was young (he was better for a few hours and then bad again). Lyrica had no such immediately noticeable effects (I think he was on 25mg twice a day, along with weaning off prednisone).
Different dogs respond to different CSF inhibitors... some notice a huge difference with them, and cimetidine has far fewer possible side effects than omeprazole (though omeprazole works fine for many dogs and sometimes, better than the other options). To be honest I have never seen any major difference with CSF drugs BUT there is compelling evidence that they do potentially slow progression regardless of whether there's an obvious visible benefit so I think any dog with CM/SM should be on one, myself.
Many drugs need time to build up in the system. However I saw an immediate affect with gabapentin and also with the higher dose of Lyrica. At 25mg Lyrica had no affect for Leo and he was actually worse than on gabapentin. I decided to try it again at a higher dose and it has been much better for him than gabapentin, at a lower dose given less frequently.
Dogs coming off gabapentin (and I would guess Lyrica too as it is related) need to have the dose gradually reduced (a lot of people and vets do not realise this).
If gabapentin was only working for a few hours then probably meds needed adjusting. Most of us with SM dogs find, I think, that we need to regularly tweak the dose and/or the mix of meds the dog is taking.
At 10 kg, only 150mg 3x would be a modest dose of gabapentin -- he'd have room to go up on that and possibly come down on the steroids.
Steroids are a miracle drug in that they can immediately address inflammation and related pain but unfortunately one with a huge amount of side effects. They should only be used with caution. They often are absolutely the right thing often for short term reductions from a high dose to stabilise inflammation and pain, and also for long term use when nothing else works, but always at the lowest possible dose.
I would not hesitate to use them when there are no other choices, but there are generally some trade offs over time.
One issue is that many vets and neurologists opt for them right away as they give fast, easy results that make clients happy. But their use has many possible health implications and over time they can cause quite serious health problems. For a really painful dog that cannot be managed in other ways, the it is the right choice. But I would always recommend looking for alternatives first (as would, I know, Dr Rusbridge).
Bev is an example of a dog owner who does need to be using steroids and it sounds like you are too -- though I would wonder whether the steroids could be reduced or eliminated with a higher gabapentin dose (you could easily go up to 300mg 3x) or to Lyrica. I'd wonder if he'd do well on 200mg 3x for example and perhaps a painkiller as recommended on Clare's treatment algorithm, plus a CSF inhibitor, and enable you to get him off steroids. Or at least reduce the steroids. Though you need careful management of any NSAID painkiller given with a steroid.
Thank you for such comprehensive answers!
I will try Lyrica again at a higher dose. Is 50mg x 2 the maximum?
I have worried sometimes about whether I switched to prednisone too soon. I was a student at the time and gabapentin had to be made up especially in liquid form for Sammy and sent from Helsinki in 50e tiny bottles. I think 200mg per dose was the highest I ever gave him. Since his condition fluctuated so much on it anyway, prednisone seemed like a god send. Thankfully he has tolerated it really well so far. I know that many dogs don't.
At this point I'm more worried about whether permanent damage has been done to his vestibular system and whether this is now a chronic symptom that cannot be masked with drugs. But I suppose I will just have to wait and see in that regard!
Edit (forgot to mention): in the very beginning he was on Metacam which did absolutely nothing for him, so I haven't given NSAIDs another thought since. But maybe it could help in combination.
Terrible news from the vet today. His eyes are now oscillating upwards in a pattern which she says indicates he has central brain damage and not vestibular damage. Blood tests and x-rays show a damaged liver (it was difficult to tell how damaged from the picture) and an enlarged heart. We almost decided to end this struggle there and then, for his sake. But I brought him home anyway on the off-chance that his brain symptoms will improve with cimetidine and that his liver will improve with tapering off prednisone. I am distraught, especially at the thought that I might have spared him liver damage if I had kept trying other drug combinations. I am also scared that the brain damage is somehow related to the liver empairment. He was doing so well in previous blood tests and apart from dry fur and a strong appetite, there were no other side-effects.
So the medications he will be on now are cimetidine, lyrica, furosemide and tapering off prednisone. He also has tramal in case of intense pain. I don't know if I'm doing the right thing keeping it going. He is walking better every day. But his eyes look really sad and his head is pulled down to the right.
Oh, no Laura, that's a lot to deal with.
Some of these things are really expert areas -- have you been able at any time to work with a neurologist just to confirm this diagnosis on upward movement of eyes?
Is he on frusimide for his heart or SM? If for SM, it has been removed for some time from Clare's treatment algorithm because of potential issues in giving it to dogs before actual heart disease.
Cimetidine is rarely known for problems with liver toxicity, as noted on Clare's algorithm. At the same time a lot of cavaliers seem to have liver problems. Nicki is generally good on this so hopefully she wlll see this post and have some comments.
Most cavaliers will xray with a slightly large-appearing heart so this may not be anything at all to be concerned about. It depends on whether it is definitely connected to the start of heart failure -- but many of us have cavaliers live many years with heart disease.
I would think your main concern will remain the neurological signs you are seeing. Could your vet contact Clare Rusbridge or another neurologist for some advice?
I'd pull him off cimetidine under the circumstances and would not have him on frusimide unless it is was for heart conditions. Omeprazole and some other meds do the same CSF action.
I hope some others might have some comments too.