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Thread: Head shaking/Worried that the Vestibular is back with Avengence :(

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  1. #1
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    Default Head shaking/Worried that the Vestibular is back with Avengence :(

    Those of you may have seen my previous post.

    Merlin began with Vestibular Disease early August, he lost his balance, was sick, dizzy, had weak limbs, head tilt, severe head shaking, right side ear scratching, and right side facial paralysis. This was all linked to middle ear fluid, they tested this fluid and because there was no infection present, they have decided there is no need to treat this condition.

    Whilst having his MRI, they found he has Chiari Malformation. They said this could be causing the head rubbing/head shaking/ear scratching etc. (as he has no ear infection)

    His vestibular disease has calmed down, he's still a bit wobbly on his legs sometimes, his right side facial paralysis is still there and will never go (but he is drooling a lot less) and he will always have a slight head tilt.

    The neurologists have started him on Frusemide for his Chiari Malformation. We are on a trial with him ...
    Half a tablet every day for 2 weeks, then.
    Half a tablet every other day for 2 weeks, then
    No tablet for 2 weeks, to see how he responds.

    After starting the tablets he showed a great improvement, his head rubbing/head shaking/ear scratching all calmed down, and we would only see these symptoms maybe once a day, which was a huge improvement to what he was.

    We are now on the 2nd week of treatment, and he's gone down hill again, head shaking is back again, he's pawing at his face all the time, and pushing his face into/onto everything.

    Our neurologist is currently on annual leave, but the vet hospital said we need to ride it out with him, carry on the treatment for the full period and then discuss again. But I just cant see him like this, I dont know how much pain he is in, and I feel helpless.

    I can see still see signs of improvement, he's appetite is back again, he can walk longer on the fields, he wags his tail more again, does the silly crawl along the floor with is back legs spread out like frogs like (he's so cute when he does that), I offer him water to keep him hydrated, I lift his bowl for him when he eats as he seems more comfortable eating at head height, he sleeps on an old duvet to keep him comfortable, we walk him on a harness so if he falls out whilst "cocking his leg" then I have hold of him.

    I just need some support and words from someone that i'm doing the right thing with him with this "seeing how things go" advice from the vet hospital.

    Me and Merlin would appreciate your comments.
    Thanks
    Gemma & Merlin (aged 6 years, 8 months)

  2. #2
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    I think this generally sounds like the right approach -- and seems as if CM could be the issue -- but the neurologist is using out of date treatment information. Frusemide is no longer used by most due to warnings from cardiologists that it can damage the heart if used regularly in advance of heart disease, and as almost all cavaliers will eventually have heart disease, it is strongly advised to use a different CSF (cerebro-spinal fluid) inhibitor, such as cimetidine or omeprazole.

    Dr Simon Swift, the UK CKCS Club's cardiologist, has specifically advised against using frusemide for CM/SM.

    As your fellow has only been on it a short time I wouldn't worry but I'd ask your neurologist to please talk about the use of frusemide with Simon Swift and let them know it has been removed from Dr Clare Rusbridge's treatment algorithm.

    Here's a link to Clare's information including the treatment algorithm:

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

    If I were in your shoes I'd keep him back on the regular frusemide as at the start til you can discuss further with the neurologist ut not drop the dosage. You might also discuss whether gabapentin is worth trialing with Merlin. I do understand the point your vet is making but I would not leave a dog without pain relief now, if you were seeing results. Please note that this is what I would do but others may differ. I'd ask if perhaps you can give metacam or similar and see if it manages the discomfort. This is listed on Clare's algorithm which you can show them.

    There are several here with symptomatic dogs with CM only and hopefully they will see this and tell you what worked for them.
    Karlin
    Cavaliers: Jaspar Lily Tansy Libby Mindy
    In memory: Lucy Leo
    Cavalier SM Information site:www.smcavaliers.com

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    I was a bit confused about the whole "frusemide treatment. This is generally used for fluid build up and more frequently used for Syringomyelia rather then Chiari Malformation according to my local vets but the neurologist said this is the best way to start treatment for him. He already has a grade 2 heart murmur, which the neurologist knows about (he said he's not showing any signs of heart failure, and his heart is beating strong and powerful), but i'm a bit concerned about why he has chosen Frusemide for Merlin, and why his symptoms seemed to have improved and then worsened again. Thats what made me think is it the Vestibular coming back for another attack.

    I forgot to mention, Merlin is already on metacam each day for his arthritis. They found arthirits in his top spine, and lower back, and presumed when he limps/legs weaken, that this is due to arthiritis, however I think this is because of the CM. However regardless they told me to keep giving him Metacam every morning with food, to keep any leg pain at bay.

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    Quote Originally Posted by Karlin View Post
    Frusemide is no longer used by most due to warnings from cardiologists that it can damage the heart if used regularly in advance of heart disease, and as almost all cavaliers will eventually have heart disease, it is strongly advised to use a different CSF (cerebro-spinal fluid) inhibitor, such as cimetidine or omeprazole.
    Just writing to elaborate a bit on this since I'm "nutty" about precise information.

    Furosemide/Frusemide (US/UK spellings) doesn't damage the heart if used before the onset of congestive heart failure (versus heart disease), but rather it can activate the RAAS prematurely. The renin-angiotensin-aldosterone system (RAAS) is a complex hormone system that regulates blood pressure and water (fluid) balance. It is ultimately maladaptive. This is another reason that furosemide alone should not be given for CHF, but it should be given in conjunction with an ACE inhibitor like enalapril or benazepril (Fortekor) which has a positive effect on the RAAS. Another consequence of furosemide is a chronic state of overall dehydration, which can ultimately affect the kidneys. (Personal note - I've had more Cavaliers with serious consequences from kidney disease than from heart disease.) All of the above is why I've been outspoken about my concerns with furosemide in the CM/SM algorithm from the very beginning.

    http://en.wikipedia.org/wiki/Renin-angiotensin_system (although Wikipedia is not my favorite source)

    Pat
    Pat B
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    Thanks! I think frusemide has been off the algorithm for quite a while now, but still seems to get prescribed by a lot of neurologists.
    Karlin
    Cavaliers: Jaspar Lily Tansy Libby Mindy
    In memory: Lucy Leo
    Cavalier SM Information site:www.smcavaliers.com

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    I have a Cavalier with CM and SM, but his syrinx is small and most if not all of his problems are from the CM. CM starts off the problems by constricting the base of the brain and inhibiting the flow of CSF - which may eventually lead to the production of syrinxes in the spinal cord, and researchers are increasingly recognising that CM alone can cause considerable pain. Wobbly back legs are a common symptom, but confusingly many CM/SM symptoms can resemble other conditions and vice versa. If Merlin's CM is causing problems, a CSF inhibitor such as cimetidine should help, but it is a chronic (and possibly progressive) condition, so tapering off the CSF inhibitor after a few weeks to see if he can manage without it doesn't make sense. The usual basic dose of cimetidine is half a tablet (50mg) three times a day. It's also important, in view of the possible damage to the kidneys that Pat mentioned, that Merlin has a blood test every six months to check kidney and liver function. Most of the pain caused by the CM will be neurological pain (Oliver had regular headaches before we found a drug regime to deal with them) and gabapentin is the most widely used drug for this - other pain relieving drugs don't always work as well. Finding the right drugs and dosage can be very individual and it can take several months to get it right. But starting gabapentin can often make an immediate difference. Not all neurologists are very clued up about CM/SM - there are after all a great number of other canine diseases for them to specialise in! - but Clare Rusbridge's website is a great resource.

    Kate, Oliver and Aled

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