Advice for Ruby?

Hi everybody!
Well, as many of you know, Ruby was diagnosed with mild SM On April 22. So far, medicine seems to be working well, and she's had no pain episodes. Here's what IS going on, and I'm wondering if any of you have any tips!
So, she gets her Prednisone 5mg and Gabapentin at 7:30 am and 7:30 pm. All day long, she's quite drowsy, takes good long naps and we go on our two good-sized walks. However, once it's bedtime for me, she's become quite the little party animal! I know the Prednisone is making her have to go out for a pee a bit more than she used to. But, around 2-3am, it never fails, she wants to play "eat mommy's slippers and run away", bark at the tree shadows on the windows, and basically get all frisky! My dog is turning into a CAT!!! Help! Anybody have any ideas how to make her sleep again at night? I don't want to make her stay awake if she needs rest during the day, but I'm at a loss here.
I love her to pieces, and am happy to see her happy, but I do like sleeping at night too...
Thanks!

Yikes it's like having a newborn in the house waking you up at all hours! First of all, 10 mg of prednisone is a lot of prednisone. I would call Ruby's neurologist and see if you could cut her back to just the 5 mg dose in the morning. That might be enough to help her sleep better at night. I give Riley her 5 mg dose with her breakfast and she sleeps soundly all night. I even have to force her out to pee before I go to bed at night. Maybe he could wean her from 10 to 7.5 and then down to 5 mg. Even when Riley has a bad day, her neuro only tells me to up her to 7.5 mg for a few days to get her over the hump.

Prednisone is a strange drug. It affects everyone differently. My daughter has scleroderma and was on it for one month when she couldn't make a fist. We were told it could make her very moody and irritable (she was 16 years old). Instead, every day she said "I'm so happy!" Part of me wanted to keep her on it forever!!! So maybe Ruby is having the same reaction my daughter had - she's just happy and raring to go and let the world know she feels GOOD!

At any rate, despite how nice it is to see her feeling good, I would really see about cutting back onher dosage. Like I said, that is a huge amount. Also make sure if she is going to stay on prednisone that she takes some type of medication to protect her liver and gets her liver enzymes checked regularly. Riley goes to the neuro every four months for bloodwork, to check her pred level and her liver enzymes. Hope you get some sleep soon! :slp:

I have no experience with SM, but I do have personal experience with prednisone. My niece was on it and was only 6 at the time (leukemia and a bone marrow transplant) and it was awful. She turned into, well, I best not say, but it wasn't good. We were so glad when her dose was reduced.

But, what I wanted to mention was melatonin. Can you check with your neurologist and see if she could be on melatonin? I know that you can use it for dogs......but with the other issues, you'd want to check. It's very reasonable in price and easy to get.

Maybe you could see if you could try the Gabapentin every 8 hours, so 3/day, and forego the Prednisone? I have an SM girl and I would want to save the Pred unless it was absolutely necessary and the Gabapentin wasn't working. As far as I know, Gabapentin is pretty safe with few side effects, whereas the Pred has more side effects. Also, my SM girl is on the Omeprazole once a day. That, in combination with the Gabapentin, really helps and I believe if you look up Clare Rusbridge's protocol, it's along those lines. She saves the steroids for last, if the other meds aren't working. Where your pup has a mild case, you may have good luck with the Gabapentin, if your neurologist agrees. Maybe you could share this diagram with your neurologist in case he/she hasn't seen it.

Here is her diagram:

http://sm.cavaliertalk.com/Treatment algorithim (Syringomyelia made simple).pdf

Good luck!

Neurologist Re-check today!

Hi!
Well, as you can imagine I was a little nervous going into the doctor with Ruby today. The last time we were there was a pretty big day. But, It went really well! :wggle:
When we got there, Ruby jumped right up into a chair in the waiting room and waited patiently for her name to be called like a good little Cavalier. (I sat next to her, she doesn't share...) She had many fans, all these people who worked there who I didn't even see last time where coming out saying "Oh! Ruby"s here!" and giving her treats. It was like she was a movie star! We got into our room and the doctor came in with her intern who was with her last time. She was SO happy to see Ruby wasn't in any pain in her face! She did some neurological tests and looked very happy. Her intern said "Wow, what a difference!" I DID tell her that Ruby has become a party animal at night, so here's our new medicine regime:
Taper way down on Prednisone, Gabapentin ONLY towards the end of the day. We'll see how that goes, if she exhibits pain symtoms again, we can add Gabapentin in the AM again. As I have stated before, her SM is mild, so hopfully she won't need too many medicines just yet. Time will tell...
Also, I think we may see more friends here on the forum! I told Dr. Kline all about Cavaliertalk and she is going to recommend it to all her Cavalier patients! Also, I showed her my For The Love Of Ollie book, and she is going to tell people about that too.
I'm very happy I have all of you to share news about Ruby. I am so thankful for this forum, it's helped so much with everything going on. Also, it's fun to see pictures of all the beautiful dogs from all around the world!
Thanks again! YAY for Ruby!!! :rah:

Hello rubys mom! So glad to hear all the good news. I love your positive energy. Good news on lowering the prednisone too! I have no experience with gabapentin only at night. I always though twice a day was the minimum but i could be wrong. Gabapentin is a way less invasive drug than prednisone ( there are many on here with dogs with more severe sm that dont take prednisone yet) so my only question wouldbe why lowering gabapentin? If i were your neuro id like to see if she manages on gabapentin alone..

I wasn't very clear, sorry! Yes, the Prednisone is going to be tapered down to the point of being no more. It looks like here (on my directions paper) it will take a little over a month to do so. The Gabapentin is making her a baby zombie all day, so she thought of cutting it back to nighttime only.
It's still the whole trial and error phase I think.
Oh man, she's doing laps from the kitchen to my bed right now! I'd better get going on breakfast time! (dang it, prednisone!!!)


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Lol. Thanks for clarifying. Gabapentin can take 3 weeks to adjust to but lethargy should go away!! Good luck!!

I am confused by your neurologist's approach. None of this is usually the approach for mild SM -- you give preds for very serious pain -- eg severe SM pain that hasn;t been handled by anything else effectively; you also typically try other far milder things before trying even gabapentin for 'mild' SM. How are you defining mild? If she is having pain, then it is more than mild; mild generally means scratching only, perhaps a few times a week at most. If she needs preds for pain, that is moderate to severe.

Prednisone is generally the drug of last resort. Gabapentin is pretty useless used only once a day. Even at twice a day, many dogs don;t seem to do well for long and the drug most typically seems to be used every 8 hours, eg 3x. It is IMHO a MUCH better option than prednisone for lifetime, and yes, 10mg is pretty high for a dog. That would be considered a moderate dose even for an adult human (I have to take prednisone for a while, so am getting pretty experienced with preds :lol. Short term it can definitely be a miracle drug with great pain relief, but it won't tell you a lot about how other medications will work til she is entirely off the preds. (Just for others who have posted -- many people have no side effects from prednisone even long term. Most side effects come from initial very high doses and cease as the drug is tapered.)

As you can see here,

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

(same diagram Holly linked to, but ashamed to say, more up to date -- I haven't uploaded the new diagram yet)

there are quite a lot of alternatives to go through that tend to handle SM well for most dogs, before you get to prednisone. After prednisone the only option is surgery (or euthanasia). For some dogs there are specific reasons for using prednisone -- eg other drugs cease to help, or disagree with the dog, etc. But I don;t know why anyone would start with this as a treatment approach except for emergency pain treatment to give fast relief. In that case you'd taper the dog off the drug entirely (gradually though as serious medical problems can ensue if anyone or any animal just stops taking a dose as high as 10mg daily). I see you are saying this is the approach but the recommended dose for SM is 0.5mg per kg so only about 5mg for even a large cavalier. So don't understand why she blasted Ruby with such a high dose as the taper is much longer, if all that was being attempted was to remove some pain -- why not one of the many other things that would be tried first? And as noted, while she is on preds you will have no realistic way to gauge whether anything else works so will have to start all over with trial and error once she is off.

I'd want to try gabapentin 2x or 3x along with frusemide and if that isn;t enough, up the gabapentin dose and/or add in an analgesic; if that doesn't work, try pregabalin (Lyrica) as per the protocol above; and only if THAT doesn't work, introduce low level preds at 5mg daily and then taper if possible and maintain on some other combo of drugs.

You cannot give melatonin and prednisone at the same time -- one boosts the immune system and one suppresses it -- you could remove the helpful effect of prednisone.

Dogs (and people) tend to adjust to gabapentin and the lethargy goes. However prednisone can ALSO cause lethargy AND more liveliness (believe me!!) so it may well be the preds causing the lethargy especially if it is in the hours following the dose.

PS -- Most people take prednisone only in the morning for just the reasons you note -- it causes insomnia with a lot of people. The morning is when the body releases natural cortisol, which prednisone replaces at a far higher dose.

I'm wondering if maybe the reason for prednisone was for the additional spine issues? Her spinal fluid was very "imflamed". This was treated with 2 weeks of Antirobe also.
I'll re-write what I have here:
MRI shows a cervical Syrinx, and the total protein count was elevated on her cerebrospinal fluid analysis. (this is why she had antibiotics) Mild COMS, protrusion of C2-C3 intervertebral disk.
I do know the plan/goal is to stop the prednisone hopefully...
I'm so new to this and I'm afraid to tell/say to her doctor I think she should try something different. How can I phrase this so I don't seem pushy? We are going back for recheck in 4 weeks, and will be calling in one week.
Oh, also it says here: "as long as Ruby isn't painful, we can stop the prednisone." Hmmmm, well, if she's on Gabapentin, maybe she won't hurt at all? Argh! So confusing!!!
Thanks Blondiemonster and Karlin!

...I'm seriously considering giving Ruby her Gabapentin 2x's a day anyways right now.

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Jessie, you are lucky Karlin posted so extensively on this as she is usually (if not always) right. The cool thing about Karlin is that she is always brutally honest and says what nobody else wants to say, or doesn't have the knowledge too, and I know it's not always what you want to hear. There IS a good changce she will manange on Gabapentin alone, but as Karlin said you'd have to taper her of the pred completely to find out.
Maybe the pred was given for the inflammation.. Truthfully, I don't know, but I surely would address this with your neuro. She would be far better of on Gabapetin 3 times a day. I'm glad I read Karlins post because I learned several things about prednisone that I did not know. One thing that Dr. West told me is that prednisone does "artificially" make one better as opposed to Gabapentin which just works on the pain.
I am going in myself in a month since Blondie's trial period on Gabapentin (of 3 months) is almost over. Since I have a hard time with her symptoms (which on the surface often seem not to bad which doesn't always mean there is no pain!!! ) so the only way to tell is by clinical check ups by Dr. West. I am keeping my fingers crossed for our next check-up hoping that he will allow her to remain on Gabapentin.

Wow. I was shocked about 10mg of prednisone. Karlin gave good advice but ella was on 2.5 mg every other day. She was severly effected though.

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Hopefully not too brutally honest. :lol:

I forgot about the disk protrusion and those inflammatory markers; yes that may well be why she thought to use preds. Still seems high to me but maybe that is the correct approach with that level of inflammation. It is true that many health issues would be permanently fixed by prednisalone IF it were possible to easily stay on it for a long time. Unfortunately it tends to have side effects above a certain dose (generally over 20mg in people) used more than 4 months. Some of these can be very serious. But some people/animals have no other medical option. When first used in the 40s or 50s at the Mayo Clinic they thought they HAD discovered a miracle drug -- until the side effects started to show up. This gives a good explanation of how it works:

http://www.marvistavet.com/html/body_prednisone.html

Because it has potentially serious side effects (and some distressing ones for people, like weight gain and 'moon face') after high doses/longterm use, (in part because the immune system is depressed by the drug which is why it works so well on autoimmune conditions/inflammation) people incorrectly assume this is a drug that should always be avoided. But short term it is extremely effective at reducing pain and inflammation and gives very fast, 'miraculous' relief. I am using it at a moderate dose, tapering to low maintenance dose for some time, and it literally got rid of every single other ache and pain I had -- it is like rolling back to your pre-injury teens or 20s! You can see why people thought it was a miracle.

Jessie, on talking to your neurologist -- I would just print out and bring in Clare's diagram and ask about starting with something like frusemide and metacam, or frusemide and low-dose gabapentin (whatever Clare's starting dose is -- though most cavaliers seem to need around 100mg to start. I'd ask her to explain what the prednisone is for -- almost surely the inflammation and disk, but if for the SM, I'd ask if once it is discontinued, if you can then start at the beginning of the treatment diagram and work your way through.

I have two cavaliers with mild SM and for a long time they didn't take anything and now take cimetidine (a variation on using frusemide -- frusemide made them pee all the time and cimetidine was easier). Neither takes anything else. The moderate dog needs cimetidine and gabapentin sometimes supplemented on a bad day (often a changeable day) with a bit of metacam. He does not need this daily. He still scratches daily but it is well controlled on 200mg gabapentin 2x. Lyrica didn't really seem to work for him. If you give cimetidine, omeprazole etc (a CSF inhibitor) they need to get it two hours apart from the gabapentin as it conflicts with the gabapentin.

Neurologists can have very different opinions on how to treat SM and they all have their own preferred drugs. I always ask for explanations until I understand what I am being given and why and often will ask my vets about alternative approaches I may have read about -- the same as I do with my own health. Because your neurologist is taking a somewhat different approach -- which she likely has her own reasons for doing -- I would just ask to have that approach explained. And I'd suggest once she is off preds, trying Clare's approach as it has been developed over a decade of treating the breed for this sad problem. You can always bring back in low dose preds and taper again.

One question I'd have for her is: is she sure the issue is SM and not that protruding disk? A dog can have a syrinx yet have some other problem causing pain. Perhaps she has aimed initial treatment at the disk. Disk disease is common in the breed and can be hard to distinguish from SM pain. Is the syrinx mild and the pain mild? If so, why use preds? The syrinx can be small and the pain significant depending on the shape and width of the syrinx.