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Thread: Luka's SM Update

  1. #11
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    I think it would help you to see Clare's website http://www.veterinary-neurologist.co.uk/

    At the top there is a tab called Syringomyelia, the bottom tab is downloadable PDFs - you want the treatment algorithm one.
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  2. #12
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    in a way it made me feel better to know this illness can be managed.
    But this is the point (not that the word disability has any negative context): many of us find SM really isn't usually an illness that can be managed very well at all once you start to get any significant level of symptoms, and whatever the level to start with, you live in constant, justifiable worry that it will progress to the point where it isn't manageable. That is exactly what I mean about the word being misleading. Progression is unfortunately the norm for SM, and managing with meds requires increased dosages in almost every case I know plus regular revision of the cocktail of drugs, meaning lots of trial and error and neurologist visits. On Luka's meds right now: many neurologists would also have a dog on some kind of CSF reducer -- it is one of the only drugs that actually is known to be able to slow (and in very early cases of small pre-syrinxes, even to halt) progression. You will see it is one of the first things listed on Clare's treatment algorithm.

    You might consider a second opinion. Each neurologist has their own approach, but the level of damage to Luka's spine already indicates the disease has progressed very rapidly.

    It isn't that there is anything wrong about opting for medications, but in such a context I find it especially hard t see how medications could be described to be managing a disability; the risk is that with continued progression they would only be able to provide palliative care and a closing window may exist in which surgery can do anything, if it was to be considered an option. Acupuncture does sometimes help to manage pain but again will not halt progression and as Nicki says, it is adviseable to find an acupuncturist familiar with SM.

    There are indeed dogs with SM that can be managed on medications alone for a normal or close to normal lifetime; but these tend to be dogs with small narrow centrally positioned syrinxes with few symptoms.
    Karlin
    Cavaliers: Jaspar Leo Lily Tansy Libby (foster) Mindy (foster)
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  3. #13
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    Quote Originally Posted by goda View Post
    Luka's Gabapentin has been increased to 4 times a day and he gets codeine 3 times a day.
    I'm curious because I don't think I've heard of anyone using codeine for SM. Is it uncommon to use this drug for SM? When my mom was in my home at the end of her life and we were working with Hospice, I remember that the drug was pretty strictly controlled though we did use it.

    Pat
    Pat B
    Atlanta, GA

  4. #14
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    From Clare's website; maybe these will help?:

    So if a syrinx is detected either by screening or because of investigation of another disease do I need to be concerned?
    Syrinxes can progressively expand and a dog which is asymptomatic in early life may eventually become painful. However a narrow symmetrical (less than 3 millimetres wide) syrinx or central canal dilation is unlikely to develop a pain syndrome. Some owners opt for intermittent neurological examination or even repeat MRI to assess for progression. The real significance of asymptomatic dogs is that their offspring appear to have a higher chance of being affected and more chance of being symptomatic. For this reason breeders are advised to MRI screen their breeding animals.
    Pain is positively correlated with syrinx width and symmetry i.e. dogs with a wider asymmetrical syrinx are more likely to experience discomfort, and dogs with a narrow syrinx may be asymptomatic, especially if the syrinx is symmetrical. Dogs with a wide syrinx may also scratch, typically on one side only, while the dog is walking and often without making skin contact. Such behaviour is often referred to as an “air guitar” or “phantom” scratching. Dogs with a wide syrinx are also more likely to havescoliosis (curvature of the spine).yringomyelia may also result in other neurological deficits such as weakness and poor coordination and slow correction of abnormal limb position.
    What drugs are used to treat syringomyelia?
    Medical management of syringomyelia is based on anecdotal reports as there has only been one clinical trial assessing the effectiveness of a novel neurogenic painkiller and results from this trial are still being analysed.
    Typically the first drugs used for treatment of CM/SM are (unlicensed) drugs that reduce CSF pressure e.g. furosemide, cimetidine or omeprazole. The principle of this therapy is that reducing CSF pressure reduces the driving force contributing to the syringomyelia. Some owners report a reduction in signs of apparent pain.
    If the pet is in pain then a non steroidal anti-inflammatory drug (NSAID) is often prescribed e.g. firocoxib, carprofen or meloxicam. This may be in addition to one of the drugs above.
    For dogs with signs of neuropathic pain (e.g. severe pain; increased sensitivity to normally non painful sensation such as touch; and scratching behaviour) an (unlicensed) neurogenic painkiller is more likely to be effective for example gabapentin orpregabalin.
    Corticosteroids are an option if pain persists or where available finances prohibit the use of other drugs however as these drugs can have more long term side effects the author prefers to avoid them if possible.
    Are there any alternative therapy options?
    Anecdotally, acupuncture and ultrasonic treatments have been reported to be useful adjunctive therapy in some cases. In some cases chartered physiotherapists are able to help alleviate signs. www.acpat.org, acpat@calra.net . Care should be taken however as the response to these treatments is very individual and some dogs may actually be more painful afterwards. Spinal manipulation is contraindicated.
    What is the prognosis for my dog?
    Unlike mitral valve disease, CM/SM is rarely fatal however this does not diminish the importance of this painful disease and a significant number of dogs are eventually euthanatized as a consequence of uncontrolled pain. This is more likely in dogs with a wide syrinx and/or with first clinical signs before 4 years of age. Study of a small case series (14 Cavaliers) managed conservatively (eg with medications) for neuropathic pain suggested that 36% were eventually euthanatized as a consequence of uncontrolled pain. However 43% of the group survived to be greater than 9 years of age (average life expectancy for a Cavalier is 10.7 years). Most dogs retain the ability to walk although some may be significantly tetraparetic and ataxic.
    Karlin
    Cavaliers: Jaspar Leo Lily Tansy Libby (foster) Mindy (foster)
    In memory: Lucy
    Cavalier SM Infosite:www.smcavaliers.com

  5. #15
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    Quote Originally Posted by Pat View Post
    I'm curious because I don't think I've heard of anyone using codeine for SM. Is it uncommon to use this drug for SM? When my mom was in my home at the end of her life and we were working with Hospice, I remember that the drug was pretty strictly controlled though we did use it.

    Pat
    Here in the states they put codeine in over the counter cough syrup. In people they give codeine easier than vicadin and percocet. Tylenol 2, is codeine and acetaminophen and usually drug of choice for dentist patients. So it's controlled but not as controlled as class 2 narcotic such as percocet. (oxycodone) It's just an all around pain med, and I don't think it's ever given long term??? (meaning several years) as I think tolerance builds up fast!!
    Mom of Blondie aka The Monster, my furry daughter and loyal friend!!!!!!!!

  6. #16
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    Um...Atlanta, GA is in the states! But you know what, I was actually thinking of morphine when I wrote that post rather than codeine - morphine is what was so controlled when used for end of life palliative care, and that is the drug that was given to my mother. I did read up on both codeine and morphine in Plumb's Veterinary Drug Handbook.

    But again - I don't think I've ever seen codeine or morphine listed as drugs used for SM - and I'm curious whether anyone else has had their neurologists prescribe these opiates. I've seen gabapentin and pregabalin used of course, a whole host of NSAIDS, steroids and Tramadol - and I think that's it. Have others used codeine or morphine for SM pain?

    Pat
    Pat B
    Atlanta, GA

  7. #17
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    Quote Originally Posted by Pat View Post
    Um...Atlanta, GA is in the states! But you know what, I was actually thinking of morphine when I wrote that post rather than codeine - morphine is what was so controlled when used for end of life palliative care, and that is the drug that was given to my mother. I did read up on both codeine and morphine in Plumb's Veterinary Drug Handbook.

    But again - I don't think I've ever seen codeine or morphine listed as drugs used for SM - and I'm curious whether anyone else has had their neurologists prescribe these opiates. I've seen gabapentin and pregabalin used of course, a whole host of NSAIDS, steroids and Tramadol - and I think that's it. Have others used codeine or morphine for SM pain?

    Pat
    Pat, I was thinking the same thing when I read codeine. Actually tramadol is controlled but that's not my question because I've never heard of codeine being prescribed.

    Ella took tramadol everyday, which some say is only prescribed after surgery. I asked her neurologist and vet about long term on tramadol because of some concern, but I wonder if codeine is newly being prescribed?

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    Anne Proud mother of Elton 5 and Angel Ella

  8. #18
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    I'm having trouble with the forum and posting long responses. Just wanted to say Karlin explained how exactly I felt and most others. Its a roller coaster and I'm getting tears thinking of it. Its so new to you and like Karlin said, there are always changes, questions about are you doing the right thing.

    Just to hear disability concerned me. Karlin said it best. Also what are your expectations with acupuncture? Are you thinking instead of surgery?

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    Anne Proud mother of Elton 5 and Angel Ella

  9. #19
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    Quote Originally Posted by Pat View Post
    I'm curious because I don't think I've heard of anyone using codeine for SM. Is it uncommon to use this drug for SM? When my mom was in my home at the end of her life and we were working with Hospice, I remember that the drug was pretty strictly controlled though we did use it.

    Pat
    It's a painkiller and FDA controlled.

  10. #20
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    Quote Originally Posted by Blondiemonster View Post
    Here in the states they put codeine in over the counter cough syrup. In people they give codeine easier than vicadin and percocet. Tylenol 2, is codeine and acetaminophen and usually drug of choice for dentist patients. So it's controlled but not as controlled as class 2 narcotic such as percocet. (oxycodone) It's just an all around pain med, and I don't think it's ever given long term??? (meaning several years) as I think tolerance builds up fast!!
    I think you are mistaken, codeine in cough syrup is not over the counter in the United States. Every form of codeine is subject to FDA regulations.

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