Results are back .... pretty severe malformation and syrinx

[Reptigirl]

Just giving her the gabapentin and tramadol now... Holding off on prednisone and omaprazole until Pat weighs in. I can tell that gabapentin is wearing off by morning. Not sure why he has her on it just twice a day. Other folks seem to be giving it every 8 hours. But just these 2 meds alone gave us a great day ... Best in weeks. She was actuaaly playful last night for a long time. That has been gone for a few weeks. And her eyes are happier. Was afraid these would make her dopey but not bad. Giving her full dose of tramadol at night only...half dose in morning.

Our neuro had Flash on Lyrica 2X a day to start with... When I talked to her after 2 weeks of "evaluating" how the meds worked I told her that it seemed to wear off mid-day and she bumped him up to 3X a day. I think they are looking for the lowest dose possible to keep them comfortable.

[Holly]

I had asked that question in a previous thread... if Gabapentin is known to wear out of the system in 8 or so hours, why would anyone prescribe it only 2/day?? It almost seems cruel to me to give them some relief, let it wear off for too long so pain is felt, then give relief again. I can tell when it's starting to wear off with Scarlett bc she will start scratching or bunny-hopping. I try to be really vigilant so it doesn't get to this point. Occasionally, depending on the timing, she will end up getting 4 Gabapentin in a 24-hour period. Both neurologists I have seen said Gabapentin is pretty safe and it's ok to give her more, if needed.

I had a dogsitter a few weeks ago when I was ot of town who told me that Scarlett was having a lot of issues while I was gone-- hiding under chairs, scratching, etc... I almost died when I looked at her pill box and realized that both days, she had completely missed her mid-day Gabapentin!!! So poor Scarlett was only getting her Gabapentin in the am and evening. I hate that that happened, but it sure is a testament to how well the meds work for her.

In my opinion, after dealing with this for a couple of years, I think it's good that you're thinking hard about the Pred and trying the other meds first to see how much relief it gives her. I am saving Pred as a "Big Gun" if other things stop being effective.

[Pat]

Just giving her the gabapentin and tramadol now... Holding off on prednisone and omaprazole until Pat weighs in. I can tell that gabapentin is wearing off by morning. Not sure why he has her on it just twice a day. Other folks seem to be giving it every 8 hours. But just these 2 meds alone gave us a great day ... Best in weeks. She was actuaaly playful last night for a long time. That has been gone for a few weeks. And her eyes are happier. Was afraid these would make her dopey but not bad. Giving her full dose of tramadol at night only...half dose in morning.

I'll do a series of posts instead of one long one......This first post may sound like a lecture, but it is directed at all of us not just to you! It's just an opportunity to make an important point.

First of all - the comment that you were waiting for me to weigh in scared the you-know-what out of me! No one should make medical decisions based only on what someone says on an internet message board. Here is a good approach, especially when dealing with a clinician with whom you don't have an established relationship. This is what I do to establish credibility and get to a relationship where the clinician and I are part of a treatment "team":

1. Print out any and all valid veterinary resources to read, highlight, and use for a discussion. In this case, I'd print Clare's treatment algorithm for vets and also pages from Plumb's Veterinary Drug Handbook on all of the various drugs that you want to discuss - prednisone, gabapentin, tramadol, any NSAIDs, omeprazole, etc.

2. If there are questions that you have from reading message board input/feedback, I'd list them on paper to ask the clinician. But be very careful - when you start a sentence with "I read this on the internet" you almost immediately "turn off" a medical professional and put him/her on the defensive. So you want the clinician to understand that your main sources are valid veterinary references but that you also have feedback from folks with dogs with the same problem. That 360 vet website is an excellent source for material by the way. There is crap on the internet and there is valid information on the internet - you want to immediately establish that you are smart enough to know the difference!

3. IF you do not follow discharge instructions you MUST inform the clinician what you are doing and why and give feedback on the results. The fastest way to destroy a relationship is to not follow instructions and not inform the clinician until later. If you aren't able to have a phone discussion or in person discussion with the clinician, I've found it useful to send a carefully written fax or email, being careful to cite sources. My cardiologist has commented to me how helpful it is when I do that in between appointments, because he can ponder the situation and then phone me for a discussion. He says that this is a very efficient use of time.

4. If you establish a relationship of respect and partnership, with full disclosure of what you are doing and why, there should not be a problem if you choose to not exactly follow the clinician's recommendations. This (deciding a treatment course other than what was recommended) very rarely happens with me and any of my vet team, but if it does, the clinician knows that I have made an informed decision and that I accept responsibility for the consequences. I am a member of the treatment team, but I'm also the coordinator and I am the final decision-maker.

I'll do a second post with feedback.

Pat

[Pat]

Next - Plumb's Veterinary Drug Handbook - I highly recommend that everyone with a dog, esp. with a chronic illness, purchase a copy of this. This is (in the US anyway) the "Bible" that all vets and specialists use in their practice. A new one comes out every few years.

I have the 5th edition from 2005 - I've been waiting for the 7th edition which just became available for purchase last week. You can get it on Amazon for about $75 - the best money you will ever spend. I'll order the 7th edition soon.

P

[GraciesMom]

Did not mean to scare you poor Pat! I am collecting info from several sources, before I call the neuro office on Monday to go over questions about meds. Sadly, neuro gave me NO info on the meds in writing and very little orally....it was like here you go, this is your stuff and go home. We had to press for info and never got clear answer on why prednisone. Definitely not impressed with him...not going to have a partnership as he will not do the surgery or followup based on our findings. When I call back tomorrow, he will be on vacation and I can talk to another neuro in the same practice (another city) that I know to be more informative on meds. Wish we felt differently but he never allowed many questions on anything. Pat, you have great points on how to approach this discussion. If needed, I will mostly cite medical treatment protocols from Dr. Rusbridge, Sandy Smith, etc. because that is where most of my concerns are coming from.

I'll do a series of posts instead of one long one......This first post may sound like a lecture, but it is directed at all of us not just to you! It's just an opportunity to make an important point.

First of all - the comment that you were waiting for me to weigh in scared the you-know-what out of me! No one should make medical decisions based only on what someone says on an internet message board. Here is a good approach, especially when dealing with a clinician with whom you don't have an established relationship. This is what I do to establish credibility and get to a relationship where the clinician and I are part of a treatment "team":

1. Print out any and all valid veterinary resources to read, highlight, and use for a discussion. In this case, I'd print Clare's treatment algorithm for vets and also pages from Plumb's Veterinary Drug Handbook on all of the various drugs that you want to discuss - prednisone, gabapentin, tramadol, any NSAIDs, omeprazole, etc.

2. If there are questions that you have from reading message board input/feedback, I'd list them on paper to ask the clinician. But be very careful - when you start a sentence with "I read this on the internet" you almost immediately "turn off" a medical professional and put him/her on the defensive. So you want the clinician to understand that your main sources are valid veterinary references but that you also have feedback from folks with dogs with the same problem. That 360 vet website is an excellent source for material by the way. There is crap on the internet and there is valid information on the internet - you want to immediately establish that you are smart enough to know the difference!

3. IF you do not follow discharge instructions you MUST inform the clinician what you are doing and why and give feedback on the results. The fastest way to destroy a relationship is to not follow instructions and not inform the clinician until later. If you aren't able to have a phone discussion or in person discussion with the clinician, I've found it useful to send a carefully written fax or email, being careful to cite sources. My cardiologist has commented to me how helpful it is when I do that in between appointments, because he can ponder the situation and then phone me for a discussion. He says that this is a very efficient use of time.

4. If you establish a relationship of respect and partnership, with full disclosure of what you are doing and why, there should not be a problem if you choose to not exactly follow the clinician's recommendations. This (deciding a treatment course other than what was recommended) very rarely happens with me and any of my vet team, but if it does, the clinician knows that I have made an informed decision and that I accept responsibility for the consequences. I am a member of the treatment team, but I'm also the coordinator and I am the final decision-maker.

I'll do a second post with feedback.

Pat

[Pat]

Crap - had almost completed a long post on all the drugs, and there was a power hiccup and my computer shut down and it was all lost. Going to compose in word so I can save along the way and I'll paste over here. It won't be as articulate because I'm so short on time. Back hopefully in a few minutes.

Pat

[GraciesMom]

She is a vet tech and has the 2007 copy. She is going to let me borrow it for a week. YAY!

[Kate H]

Debra wrote: Not sure why he has her on it just twice a day

We had a discussion about this a couple of weeks ago. 8 hours is the average time that dogs take to metabolise gabapentin - which means that some will need it more often and some less often. Clare Rusbridge advises starting on twice a day (ie 12 hours) and then adjusting it to suit the metabolism rate of the particular individual dog. Meds for SM are a matter of trial and error for a few weeks or months as you and your vet work out which drugs and which dosage control pain in your particular dog. I think all vets start low and then up dosage as required - if you start too high too quickly you run out of options sooner, and may find yourself backed into a corner with no more pain-control options. Whether a dog needs additional gabapentin can often depend on air pressure - many of us find our dogs need help when the weather is particularly stormy or hot. But as Pat says, you need to keep feeding information to your vet/neurologist and liaising with them, so that they have all the data they need to make informed decisions about adjusting medication.

Kate, Oliver and Aled

[GraciesMom]

Thanks....this makes sense. Gracie was soooooo much better already on one day of meds. We did see return of scratching this morning on her walk until we got more meds in her...

We had a discussion about this a couple of weeks ago. 8 hours is the average time that dogs take to metabolise gabapentin - which means that some will need it more often and some less often. Clare Rusbridge advises starting on twice a day (ie 12 hours) and then adjusting it to suit the metabolism rate of the particular individual dog. Meds for SM are a matter of trial and error for a few weeks or months as you and your vet work out which drugs and which dosage control pain in your particular dog. I think all vets start low and then up dosage as required - if you start too high too quickly you run out of options sooner, and may find yourself backed into a corner with no more pain-control options. Whether a dog needs additional gabapentin can often depend on air pressure - many of us find our dogs need help when the weather is particularly stormy or hot. But as Pat says, you need to keep feeding information to your vet/neurologist and liaising with them, so that they have all the data they need to make informed decisions about adjusting medication.

Kate, Oliver and Aled

[Pat]

Sigh……my lost post was good and I don’t know if I can reconstruct.

These are my thoughts based only on my research, extensive reading, and experience, and this may or may not be in alignment with other pet owners and with vets/neuros. I have no problem with others disagreeing!

My strong preference is not to start treatment for any condition with a cocktail of meds. You cannot assess positive results or side effects when starting with a cocktail – how do you know what to attribute to which drug? How do you know that you need all of the drugs if you start them all at the same time, especially considering that the goal of treatment is to use the lowest effective dose and least amount of medications. I realize that with an acute and/or serious condition, you may not have a choice. This is one reason that I start treatment for acquired valvular disease before onset of acute CHF. I also realize that effective treatment for many conditions is the synergy between medications and that monotherapy is usually not possible with these chronic conditions. Still, if I can add in a new drug every week or so, that is my preference.

Gabapentin appears to be a very safe drug. This would be MY preferred first line drug for CM/SM pain. Because of the nature of CM/SM pain, I would probably start at three times per day to assess the effectiveness in order to achieve continuous and controlled pain relief rather than “up and down” pain control. The dosage could be raised rather than the frequency of dose if there is insufficient pain relief. If an every 8 hour dosing schedule was difficult for me, I’d start with pregabalin at a twice a day dosage. (I did see Kate’s comment and it does make sense; I still think I’d start on a lower dose three times per day.)

I would absolutely use a proton pump inhibitor because of research that I’ve done. I would want to read more on potential GI side effects if I were to use one of these drugs. I read a bit on the SM yahoo list about three weeks on/one week off dosage for omeprazole to protect the GI tract so I’d want to explore those ramifications before making a final decision. My personal preference would be not to use long term furosemide – this is because of a good deal of experience with the drug and understanding the side effects, particularly on kidney function. (Obviously I’ve used furosemide for CHF and will use it again.) I’d want to add a proton pump inhibitor pretty soon after starting gabapentin – a week or so after I was comfortable that there were no side effects from gabapentin. Holly, I can find no reference that omeprazole can’t be used with prednisone. If you look at Clare’s chart, you can see that these two drugs can be used together. It does appear that she recommends discontinuing NSAIDS if steroids are started.

Tramadol also in my experience and research appears to be a pretty safe drug. I’d want to have that on hand for added relief if the gabapentin was not sufficient and/or for special instances (storms, grooming, stress, etc.). I’d not want to start gabapentin and tramadol together initially unless I saw that gabapentin alone was not enough to control pain on a routine basis. I’ve used this drug long term for geriatric dogs for other medical conditions with no problems. There is the potential for addiction, but that does not concern me for a dog with a chronic illness. Note that Tramadol is not an NSAID. It is an incredibly inexpensive drug.

NSAIDS – my PERSONAL prejudice is that I just will not use NSAIDS at any time for any situation. The only situation that would change my mind is for a medical condition where I couldn’t achieve pain relief with any other treatment and for which euthanasia was the only alternative. This is because of what I know about potential for major organ (kidney and liver) failure as a result of NSAID use. Others disagree with my view, and vets happily prescribe NSAIDS routinely.

Prednisone – there are 8 pages in Plumb’s on steroids and it’s just too long to try to summarize here. The most serious potential side effects are Cushings disease, diabetes, pancreatitis, GI ulceration, behavioral changes, etc. It is a powerful medication with a lot of potential consequences. I have used prednisone in the past for various conditions including allergies and cancer. Tucker is currently on a temporary low dose for flea bite allergy. If I used pred for a long term, I’d do my very best to move to alternate day therapy. There is more potential danger of problems on an immunosuppressive dose which is 1-3 mg (can’t remember if per lb or per kg and don’t have time to find reference). I would consider it in a case like Bev’s Riley, but this would be a consideration only if all other treatments were insufficient. I’d personally prefer low dose pred to NSAIDS, but that’s my prejudice.

On a final note, I strongly disagree with the minimum recommended monitoring parameters for many of these drugs. If my dog were taking these drugs, particularly furosemide, prednisone and/or NSAIDS, I’d do full blood chemistry including CBC and urinalysis every three months or so. Every 12 months is just not often enough to catch major organ damage BEFORE there are symptoms and when you have a reasonable chance of turning organ failure around and saving your dog, particularly when first starting these drugs or when changing dosage. Again, this is my personal prejudice based on experience. I’d also never add potassium supplements UNLESS blood chemistry indicated low potassium – this is unclear on the chart. There are consequences to high serum potassium levels, including fatal arrhythmias. Also, particularly with a senior dog, I would run full blood chemistry and urinalysis BEFORE starting furosemide, prednisone or NSAIDS to establish baseline organ function before starting the meds. This should also be done before starting meds for heart disease.

Pat