Dena's Nutmeg 3/6 Conservative

Welcome to Dodgerslist, Dena!  Everyone here has a dog with IVDD so you have come to the right place. We’ve got valuable information we’ve gleaned from the vets Dodgerslist consults with and our own experiences with IVDD since 2002 to share with you!

It is important to know that disc disease is not a death sentence! Struggling with quality of life questions for your dog? Re-think things:
www.dodgerslist.com/index/SDUNCANquality.htm

The most important thing you can do for Nutmeg now is to start Strict crate rest right away. The hallmark component of conservative treatment is the very STRICT crate rest part (no PT, little movement). With little blood supply discs are much slower to form good scar tissue than it takes a blood rich broken bone to heal. Those weeks of a cast for a broken arm to heal is similar to the recovery suite being a kind of cast for the disc. 100% STRICT crate rest 24/7 for 8 weeks provides limited movement to allow good strong scar tissue to form.

Super tried and true tips for setting up the recovery suite, the mattress and more! —> www.dodgerslist.com/literature/CrateRRP.htm

STRICT means:
◼︎no laps
◼︎no couches
◼︎no baths
◼︎no sleeping with you
◼︎no chiro therapy whys: www.dodgerslist.com/literature/chiropractic.htm
◼︎no dragging or meandering at potty times.
◼︎no PT for conservative dogs during 8 weeks to heal disc
◼︎At home laser or acupuncture for severe neuro damage is best. Transports are always a risk to the disc of too much movement. Vet visits must be weighed risk vs. benefit for dogs with little to mild neuro diminishment.

It will help us work together with you and avoid offering ideas that could cause harm or lead the discussion in the wrong direction delaying help for your dog — please share a bit more detail with us:

Is Nutmeg currently showing signs of pain? ☐shivering, trembling ☐yelping when picked up or moved ☐reluctant to move much in crate such as shift positions or slow to move ☐tight tense tummy ☐can’t find a comfortable position ☐Arched back ☐ Holding front or back leg flamingo style not wanting to bear weight ☐head held high or nose to the ground ☐Not their normal perky selves? Full pain relief is expected in 1 hour and stays that way between doses. If not in control your vet needs to know right away to adjust meds.

Please list the exact names of all meds currently given, their doses in mgs and how many times a day they are given..  

A dog with IVDD is likely to produce excess stomach acid. This is especially true for dogs on an anti-inflammatory. To prevent the excess stomach acid from causing serious stomach damage Pepcid AC can be used. Ask the vet if Stella has any health issues to prevent use of Pepcid AC (famotidine)? (doesn’t need it, we wait til there is problem…are NOT answers to your question!) If you get a “no health” issues answer, then go to the grocery store to purchase over the counter Pepcid AC containing one single active ingredient (famotidine).

Doxie weight dogs: 5mg Pepcid AC (famotidine) every 12 hours. NOTE: Pepcid AC (famotidine) for dogs is 0.44mg per pound, 30 mins before the anti-inflammatory and thereafter every 12 hours for as long as your dog is on the anti-inflammatory. www.1800petmeds.com/Famotidine-prod11171.html

Is Nutmeg  showing any signs of GI Tract problems? —Eating and drinking OK? No nausea/not eating, no vomit? —Poops OK? Normal firmness & color -no dark black or bright red blood indicating bleeding ulcers? No diarrhea?

Since Nutmeg has lost bladder control, please review this  video then if needed  get another hands-on-top-of-your-hands expressing lesson if you need to, many find more than one lesson to be helpful.    www.dodgerslist.com/literature/Expressing.htm

Knowledge is the power to fight the IVDD enemy and win!! The very best thing you can do for YOU, the caregiver, and for your dog is to get up to speed on IVDD soonest possible. Begin absorbing the must-have overall sense of meds, care and how the treatment works. Your dog will be depending on you! - excellent video series here:
www.dodgerslist.com/literature/theater.htm

--PRINT OUT this link and tape to your fridge:
www.dodgerslist.com/literature/healingpage.htm

--use the printout as your roadmap to avoid dangerous detours in your dog’s care

--make notes/highlight to keep yourself on track

Keep reading to become the IVDD savvy pet parent that Nutmeg needs..  
We are here to help you and Nutmeg!!  Healing thoughts and prayers!

Dena, advocate for the vet prescribing the max analgesic dose of tramadol.  The current dose is like not giving any tramadol!  She is in pain.  call first thing in the am to advocate.  YOu would be expected the vet to Rx something more like a full 50 mg tablet every 8 hrs.  Do not self prescribe, the vet's job is to prescribe. Your job is to be his eyes and ears at home and alert him if the Rx needs adjusting.


she could take a whole 10mg Pepcid AC (famtoidine) tablet 2x/day.

What color blood- red or black tarry blood. Blood in the poop (GI TRACT damage) or blood in the urine (Urinary tract infection)?

In ANY event...UTI or if red blood in poop, Pepcid AC really, really NEEDS to be on board.

North Carolina U. recognizes the high incidence of GI irritation in dogs with disc problems. The reasons are that pain and body changes are stresses. Just as humans can experience ulcers when under stress. NCU and 11+ hospitals working with NCU prescribe a GI protectant. Dogs presented to NCU with IVDD often develop GI upset whether they are given steroid medications or not.
www.cvm.ncsu.edu/vhc/tc/clinical_services/neuro/acute_disc.html

STOMACH PROTECTION
Dogs don't speak up at first signs of trouble like a person would. By the time we notice black or red blood in the stools, things can quickly go from bleeding ulcers to a life threatening perforated stomach.
Ask if your dog has any health issues to prevent use of Pepcid AC (famotidine)? (doesn’t need it, we wait til there is problem…are NOT answers to your question!) If you get a “no health issues” answer, then go to the grocery store to purchase over the counter Pepcid AC containing one single active ingredient (famotidine).


The usual dose during a disc episode is Pepcid AC (famotidine) for dogs is 0.44mg per pound 30 mins before the anti-inflammatory and thereafter every 12 hours. Give the anti-inflammatory with a meal as added protection. www.1800petmeds.com/Famotidine-prod11171.html
Smallest size tablet Pepcid AC comes in is 10mgs



When pain med are right for Nutmeg, then pain would be in control within the hr and stay that way round the clock, dose to dose.

Please be more specific. Red blood is in the urine? Then she will need an antibiotic likely for the bladder infection (UTI)

TRAMADOL:
The usual in controlling pain is to Rx at the higher end of the mg range AND promptly every 8 hours.

The following information is not for you to self prescribe. It is for you to bring to the table and advocate on Nutmeg's behalf. The vet's job and training is to prescribe.

1. Plumb's is considered the "drug bible" of the veterinary world.
Tramadol dosing in dogs varies, ranging from 2 to 5 mg/kg every 8-12 hours. The highest dose for maximum analgesic effect in dogs is 10 mg/kg every 8 hours. “Tramadol”. Plumb DC. In Plumb DC (ed): Plumb’s Veterinary Drug Handbook, 7th ed—Ames: Wiley-Blackwell, 2011, pp 1002-1004.

2. Veterinary pharmacologist Bruce KuKanich, DVM, PhD, DACVCP: "Tramadol is rapidly eliminated from dogs after oral administration. Recent studies are suggestive the bioavailability of tramadol in dogs is lower than originally determined and the dose of tramadol needs to be increased with dosages from 5 - 10 mg/kg PO q 8 hours-12 hours in dogs to maintain similar plasma drug concentrations as those in humans." New developments in opioids: old drugs and some future directions (Proceedings)" DVM360. Nov 01, 2009
By Butch KuKanich, DVM, PhD, DACVCP veterinarycalendar.dvm360.com/new-developments-opioids-old-drugs-and-some-future-directions-proceedings Last accessed 3/18/16

Dena you have an emergency to deal with three issues right now asap!!!!l

#1.  Call the vet alert him to blood in URINE!!! urinary tract infection (UTI). Usual is to Rx a broad spectrum antibiotic as a shotgut approach to target the bacteria.

#2  Not eating and drinking are VERY likely signs of GI tract damage. Take no chances. Get Pepcid AC on board right now. With the call to the vet STRONGLY advocate for #2 GI tract protector prescription be on board. SUCRALFATE. Each work in a different way and the reason for there being TWO protectors on board.

Sucralfate bandaids where the disruption in the mucous stomach lining is via gel coat.
Pepcid AC suppress stomach acids that damage the GI tract.

READ about each med so you know why you are advocating for sucralfate, its timing with food, with Pepcid AC. The Mar Vista Vet web page is my go to for reading about meds : www.marvistavet.com/pharmacy-center.pml

#3 Call the vet and strongly advocate for MAXIMUM analgesic dose for Tramadol

Blood in the urine is definitely something to be concerned about. It is a sign of a UTI. Please insist the vet check the urine for bacteria. If bacteria is found, most vets would provide a broad-spectrum antibiotic as the first response to this because broad-spectrum antibiotics can destroy a number of different types of bacteria. This is important because untreated UTI's can become more serious and lead to problems elsewhere in the body.

You are right, Pepcid AC protects the stomach and not the bladder. Pepcid AC protects from excess stomach acid which is caused by all anti-inflammatories. Nutmeg's reluctance to eat and drink may be a sign that stomach damage is beginning. At this point, Pepcid AC might not be enough. Speak to the vet about adding Sucralfate so Nutmeg will have two stomach protectors to help prevent damage.

The pain your Nutmeg is showing may be because she did not receive the tramadol on the regular schedule. Once you get her back on the regular medication schedule she should not show signs of pain between the doses. Keep a close eye on her and if she does show any signs of pain, let the vet know right away. Nutmeg should not have to suffer. Vets have many ways to address pain.

Please give you vet a call right away and talk to her about these concerns.  

Dena she is drinking little and eating little?

Do you have the acid suppressor Pepcid AC now on board. Red flag signs of GI tract damage begin with nausea, not eating or drinking well. The moves into vomit, loose stools. As the stomach lining becomes really damaged bleeding uclers happen, then red or black tarry blood in poop.

Are you pilling in this manner if the three treat method below is not working for Nutmeg
:

Three treat method
Put the pill into the well of a small mashed banana ball, a cream cheese ball, liverwurst ball or inside of a sticky small marshmallow and sealed completely so no taste is on the exterior. Tramadol and gabapentin are VERY bitter if any pill dust transfers from your fingers to the outside of the treat.
Use the three treat method. Prepare 2 treats with no meds inside PLUS the med ball. Give plain treat while holding med ball in front of eyes. The idea is your dog will be greedy after the first treat to get the 2nd. Immediately hold the 3rd plain treat so she will hurry to swallow the med ball to get to treat #3.

How often are you expressing her bladder--- every 2-3 hours?   ever 4-6 hrs??

Were her meds every  adjusted?   Not wanting to be touched IS pain!
--Prednisone what was the original dose/frequency? At 5mgs 1xday is not up at what should have been the original anti-inflammatory level, but rather a taper dose that likely is not contributing much to getting painful swelling resolved.  This is one reason she is in pain!
-- How many mgs of methocarbamol are in one mL of liquid?  Check the bottle for that info.
-- Was Tramadol adjusted to higher mgs BY THE VET?  That would be another reason for pain.

---

15.7 lbs
Prednisone as of 3/6:5mgs 1x/day for ? days, then a test taper for pain/neuro issues
Tramadol 25mgs 3x/day
gabapentin 100mg 3x/day
methocarbamol liquid mgs per mL?    200mgs 3x/day
no GI tract protector Pepcid AC on board!

---

The point to expressing so that the bladder is not overflowing is twofold.
-- Reflexes are not voiding all the urine. So the part that remains very quickly in a matter of days will become a raging breeding ground for bacteria (urinary tract infection -UIT). UTI not treated with an antibiotic will move up into the kidneys where it becomes a life threatening situation.
-- The other concern with not expressing, but rather waiting til the bladder is so overstretched that triggers reflexes to release some urine. Constant over stretching of the bladder wall, will cause it to loose tone permanantly. Then when the brain can reconnect in sending message to release urine, the bladder won't work right.
-- using diapers is just continuing the two above problems of not expressing in a timely manner.
-- most dogs abhor having body waste near them trapped in a diaper.  Diapers causes rashes (urine scald for a baby and can do same for a dog. Diapers are a last resort when you are expressing in a timely manner.
-- While on pred, you will like need to express her bladder every 2-3 hrs. Place a pee pad adjacent to her crate on the floor. Express her on the pee pad and then right back in the crate.

Thought: While some UTI's do have signs we can observe, others have no signs. Since you have not been expressing her to keep her dry, then she may already have a UTI. If signs would show here are some: red blood in urine. Leaking urine. Dog hold urine in because there is a painful burning sensation when they release urine.

Both pain from a disc episode can make a dog feel awful, not wanting to eat. A UTI can so make a dog feel cruddy due to bacterial infection going on and they also may not be interested in eating.

SOMETHING NEEDS TO GIVE:
--- Get a urinalysis to prove no UTI going on or if there is a UTI-- get an antibiotic on board
--- Serious discussion with vet on going to an anti-inflammatory level of prednisone to begin the process of working on the swelling in the spinal cord area.
--- Serious discussion with the vet about moving Tramadol to the max analgesic dose in line with an almost 16lbs dog!
--- Thought about hiring another vet as a 2nd opinion vet, maybe one more comfortable in their knowledge about IVDD?  People go and get 2nd opinions all the time,  no shame to anyone for doing that.

The reason for there to be the proper pain meds on board, at the right mg and at the right frequency, it so that Nutmeg can heal her disc in comfort. And also important so that you can care for her needs without cause her pain....expressing often enough so that her bladder is not over flowing.

You are reporting that prednisone was never Rx'd at the anti-inflammatory dose of 5mgs 2x/day. This is the reason Nutmeg is having pain issues.... Since 3/6, then t here has really not been any amount of pred in her body to work on swelling. Then to top things off, tramadol is at a very low dose in mgs...not likley helping mask pain.

Methocarbamol still is not clear how many mg she is getting
--- need to know how many milligrams (mgs) of methocarbamol are in ONE mL of liquid. Could you quote from the bottle exactly as written the contents of the bottle mgs per liquid mL. 1.25mL sounds maybe like that is the dose you are to give 3x/day.

Try giving some other tiny little amount of treat she likes randomly during the day. When she takes the tiny treat, praise her. So you are basically retraining her to believe there is no med in the treat. THEN, when it comes time to take meds. Use the same treat food she's trusting you—not the food treat she had been suspicious of. Try the three treat method again.

Dena, thanks. So has the methocarbamol syrup always been given at a 1.25mL quantity? Meaning has the dose always been 250mgs NOT the 100 200mgs reported?

Dena, a bit of vocabulary so we can speak the same language and  fully under stand what you write

peeing - a dog has control to send a brain message to the bladder to release urine only when in an appropriate place.   Most dogs will not pee where they sleep, unless they have not been let out soon enough and just can no longer hold it in.
overflowing- the brain can't send a message to the bladder. The dog has lost bladder control. Reflexes can release some urine but not all of it when the bladder is in an overstretched, overly full bladder.  The dog has no control, so urines can come out at any time, any place...places a dog would not normally what to release body waste...like where they sleep.

What are you doing every 2hrs now that you see urine ending up on the pee pad adjacent to the crate?
-- Is she sniffing and then making a brain decision to let the bladder know to release urine.  
-- Is she overflowing because maybe your hands are on her tummy area and kinda  manually expressing the bladder as you set her on the pee pad?
-- Are you expressing  her bladder as your vet taught you, when you place her on the pee pad?
-- The test to find out if she has bladder control now is the sniff and pee test.  Set her on an old pee spot. Make sure your hands or sling are not supporting her near the tummy/bladder area as that would defeat the test. Support her by her thighs for this test.  Can she sniff and then make the decision to release urine on the spot...that is the proof of bladder control.

It is your right, you job to know what your dog takes.  Don't be shy to have your vet explain the dose in mgs to you.  When you report  "Methocarbamol oral susp 200mg/ml"  That means each  mL has 200mgs of methocarbamol in the liquid.  Then add 1/4  (0.25mL) of 200mgs = 50mgs of methocarbamol
  200mg (in one mL)  +  50mgs (in 1/4 of a mL) = 250 mgs in each 1.25 mL dose. 

Do let us know what the correct methocarbamol mgs are in each dose. Or if you do change to the pill form what the prescription is.

Last night she had blood in her urine. So this morning when I took her out to potty I collected a sample to take to the vet. She has a UTI. She is now taking ✙Clavamox Chew 125mg, 1 tablet orally twice daily.
The vet also changed her to ▲tramadol 50mg every 8hours. And I did get the ✙Methocarbamol in pill form.

Tonight she seems much more relaxed. And taking her potty is getting less tense. I'm still having a hard time getting her to take her meds. I've tried cheese, peanut butter pill pockets, rotisserie chicken, and wet/canned dog food. She will gladly eat anyone of these. But as soon as I put her meds in it....she won't have it! She's very stubborn in general. So this doesn't surprise me.

[Moderator's Note. Please do not edit
15.7 lbs
Prednisone as of 3/6 a taper dose! : 5mgs 1x/day
Tramadol ▲50mgs 3x/day
gabapentin 100mg 3x/day
methocarbamol tab:  250 mgs  3x/day 
Pepcid AC 5mgs 2x/day
✙Clavamox Chew 125 mg 2x/day]

Great to hear that Nutmeg is feeling better, Dena. If you still see any sign of pain, do let the vet know so the meds can be adjusted again.

What is the dosage of Methocarbamol that you now have in pill form? ?mg ?x/day?

What did the vet say after speaking to him about increasing the Prednisone to the anti-inflammatory dosage of 5mg 2x/day? It's so important to get that swelling down as quickly as possible and anything less than an anti-inflammatory dosage just won't be effective at doing that. It's that swelling pressing on the nerves of the spine that causes the pain and possible nerve damage. Once that swelling is gone, there will no longer be a need for meds.

Keep trying to express. It does take practice to learn how to completely empty the bladder. If you need another hands-on-your-hands demonstration by a vet, do get one. The bladder can slip away from you as it empties and gets smaller, sometimes go back toward the pelvic area, and you need to find it again and keeps pressing until just a dribble of urine comes out and the bladder feels flat. You'll get there.

When you express, can you feel the bladder at all? Are your hands back into the hip area? Sometimes there may be a delayed reaction before the urine comes out so you should hold the pressure for 3-6 seconds before re-positioning hands. Does Nutmeg's belly feel tense when you're expressing? She may have some pain from the UTI and may be tensing up. Hopefully the meds will start to heal the infection soon. UTIs can also cause some leaking.

If you do continue to have a problem, it would be a good idea to get another hands-on-your-hands demonstration by your vet. And please do review all the tips on our page on expressing and watch the video: www.dodgerslist.com/literature/Expressing.htm

Nutmeg may have some constipation from the meds. Pumpkin can help to loosen stools. Give one teaspoon of pumpkin for every 10 pounds of body weight per day. To loosen the stool, add equal parts water to each kibble meal along with plain canned pureed pumpkin 1x a day. Note alternatives for constipation: really ripe mashed fresh pear, just take off the peel; microwaved and mashed peeled sweet potato.

Dena, so you were able to express her bladder and express for poop! That's great...keep practicing. The goal with expressing the bladder that she stays dry session to session. Is that happening now?

Sounds like the antibiotic is the right one for the particular bacteria Nutmeg has with her UTI!! good new on clear pee... no blood.

When they start to feel good because the meds are right and infection is attended to, then they are more of a challenge to maintain strict rest. Many owners find this out. Have you checked out our "Emergency Crate Training" info for lots of good strategies: www.dodgerslist.com/literature/EmergencyCrate%20Training.htm Let us know which you are trying and how it's going.