T's Rambo 7/30 relpse conservative — Shiba Inu GRAD 9/24

Welcome to Dodgerslist. My name's Marjorie - what's yours? So glad you’ve joined us all. 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's most important that you immediately advise the vet of the worsening of neuro condition if you haven't already. The vet may want to switch Rambo from a NSAID (Rimadyl) to the more powerful anti-inflammatory which is the steroid Prednisone. Such a switch usually requires a 4-7 day washout period but such a switch can be made without a washout period by adding BOTH Pepcid AC and Sucralfate. Please let us know what the vet says about the worsening of neuro function.

Even if a switch to a steroid is not made, stomach protection must be given any time a dog is taking an anti-inflammatory. 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). canigivemydog.com/wp-content/uploads/2011/10/can-i-give-my-dog-pepcid-ac-300x300.jpg 
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

Gabapentin has a short half life and works most efficiently when given every 8 hours (3x/day). Since the vet has OK'd giving it 3x/day, please do give it that often. If there is still pain, Tramadol as a general pain med and/or Methocarbamol for muscle spasm pain can be added.

Signs of pain to be aware of: ☐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 dose to dose. If not in control your vet needs to know asap to adjust meds.

What was the date you saw the vet for CONSERVATIVE treatment of meds and started crate rest?
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.

Carry to and from the recovery suite to the potty place and then allow a very few limited footsteps. Using a sling (long winter scarf, ace bandage, belt) will save your back and help to keep a wobbly dog’s back aligned and butt from tipping over. A harness and 6 foot leash is to control speed and keep footsteps to minimum as you stand in one spot. An ex-pen in the grass is an excellent alternative to minimizing footsteps with the physical and visual to indicate there will be no sniff festing going on! www.dodgerslist.com/literature/slingwalk.jpg  LARGE DOGS: If your dog is too big to carry, it is still important that the amount of movement to the potty place be minimized. Try a pee pad right outside the crate. Add caster wheels to a wire crate and wheel down ramp over steps to outside.

Is the vet a general DVM or a specialist surgeon: ACVIM neurology or ACVS ortho?

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 your ability to learn - 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
 follow all the links in the next days to become the IVDD savvy pet parent your dog needs. Use the “search box” to easily locate topics over at our Main www.Dodgerslist.com website: www.dodgerslist.com/index/searchBOX.jpg

Healing prayers for Rambo. Please let us know what the vet says after speaking to them this morning.

T, loosing neuro function is an emergency thing. Moving to the most powerful of anti-inflammatory drugs (a steroid such as prednisone) quickly can help to save damage to the nerve cells. I hope your vet will recognize this fact and not delay in getting an Rx for pred and sucralfate plus your getting Pepcid AC into him quickly as possible. Hours matter when there is neuro loss to prevent it from being possibly permanent.

As damage to the spinal cord increases, there is a predictable stepwise deterioration of functions. When nerve healing begins, often it follows the reverse order.
1. Pain caused by the tearing disc & inflammation in the spinal cord
2. Wobbly walking, legs cross
3. Nails/toes scuffing floor
4. Paws knuckle under
5. Weak/little leg movement, can't move up into a stand
6. Legs do not work at all (paralysis, dog is down)
7. Bladder control is lost. Leaks on you when lifted. Can no longer sniff and then pee on that old urine spot outdoors.
8. Tail wagging with joy is lost
9. Deep pain sensation, the last neuro function, a critical indicator for nerves to be able to self heal after surgery or with conservative treatment. If surgery is not an option (for whatever reason) then the best option is conservative therapy.
              Surgery can still be successful in the window of 12-24 hours after loss of deep pain sensation. Even after that window of time, there can still be a good outcome. Each hour that passes decreases that chance. Precious hours can be lost with a vet that gets DPS wrong. Trust only the word of a neuro (ACVIM) or ortho (ACVS) surgeon about DPS. 
               A quick overview of conservative treatment vs. a surgery: www.dodgerslist.com/literature/healingsurgery.htm#surgeryVSconservative

Yes, with three stomach protectors on board today, the switch from Rimadyl to Prednisone can and SHOULD be made today. Otherwise, Rambo will have nothing working on the inflammation tonight or tomorrow morning and he's already showing additional signs of neuro loss. He needs the Prednisone ASAP.

Sucralfate should be given on an empty stomach, one hour before food and Prednisone so the gel coating action can begin. Pepcid should be given 30 minutes after the Sucralfate.

Most vets would not operate on a dog that can still walk. If Rambo can still walk at the end of the 8 weeks of conservative care, a gradual reintroduction to walking can be done and walking is a form of PT. So hopefully no other PT will be necessary. Nerves can take a long time to heal so it's a take it one day at a time approach.

Also, did the vet say for how many days she wants Rambo on the Prednisone before tapering? Please also let us know the mgs and times given a day for each of the stomach protectors when you get a chance.

Turmeric does help inflammation but with an IVDD episode, you need to bring in the strong meds like a steroid which you now will have on board. Turmeric can also interfere with Famotidine and increase stomach acids which you don't want to have happen. So it's not a good idea to give Turmeric at this time.
pennstatehershey.adam.com/content.aspx?productId=107&pid=33&gid=000932

Turmeric is more useful for dogs who are unable to take a NSAID or steroid due to health issues or for long term use.

Have you heard from the vet yet about starting Prednisone today? If not, please do give the office another call. It really is important to get it on board ASAP to relieve the pressure on the nerves of the spine to prevent further nerve damage.

T, sucralfate works right away and Pepcid AC works in 30 mins. When it is deemed an emergency to not do the safety of a 5-7 day washout before starting pred, double stomach protection is what vets who know IVDD and the meds do. An emergency means that hours matter. By tomorrow morning it is many, many hours of pressure on the spinal cord. Rimadyl can stay in the body for 5+ days and thus the reason for the normal 5-7 day washout. A 24hr washout is like not doing any washout!!! Nerve cells die when there is pressure to the cord. We see that death as the predictable step by step loss of neuro function. See if you can advocate for getting pred on board now, today. Your vet has subjected Rambo to danger by not doing the 5-7 days washout because she believes there is an emergency in neuro loss But has tripple protected the GI tract. Why not take advanntage and get the spinal cord protected now. Again hours matter. Tomorrow morn is too many hrs away, too much delay in starting pred the med that helps to get that inflammed tissue around the spinal cord reversed.

T, a med chart can be a useful thing with so many meds to track cause and effect, plus other things to report to the vet. D/l and print from here: www.dodgerslist.com/literature/crateRRP/medchart.pdf

Just to confirm, did the vet approve starting the Prednisone last evening? Any advice we give here on the forum is for discussion with your vet and not for your own dosing. If not, be sure to let the vet know that it was started last evening. You've done a great job advocating for getting the proper meds on board for Rambo and your vet seems quite open to listening to your input so that's a real benefit to Rambo's healing.

If you feel that Rambo may have a bit of constipation from the meds, pumpkin can help that. To loosen the stool, add equal parts water to each kibble meal along with a teaspoon of plain canned pureed pumpkin 1x a day. Note alternatives: really ripe mashed fresh pear, just take off the peel off; microwaved and mashed peeled sweet potato.

T, glad to hear no worsening of neuro functions since the start of pred yesterday evening.

LIMITED MOVEMENT ISSUES
I, too, am very worried about his behavior at potty time. Can you change up things to protect his disc?
-- How about placing a pee pad right outside his recovery suite.
-- Secure some old urine on a piece of paper towel and store in a zip lock bag til needed.
-- At potty time he would then only walk a couple of footsteps out of his suite to the adjacent potty pad.
-- On the pee pad you will have placed the urine scented papertowel on the pee pad to let him know it is OK to pee in the house on the pad. Another dog's urine would be best if you can obtain some as Rambo will mostly have a good desire to mark over it!

PAIN OBSERVED?
Can you give some detail about the meaning of pred "giving slight relief last night". Are you saying you are observing pain? If yes, then clearly one pain med (gabapentin) is insufficient. Normally it takes 3 different pain meds each to address the typical sources of pain with a disc episode.

Do call your vet IF, you are observing any pain, pain nearing next dose of gabapentin (for nerve pain), or when he has to move. Advocate for the other two pain meds be prescribed:
-- tramadol as the general analgesic 3x/day
-- methocarbamol for typical muscle contraction pain 3x/day
◻︎ not their normal perky selves  

GI PROTECTION
Just checking to make sure of optimal GI Tract protection with the dosing order:
   Sucralfate requires stomach acid in order to form its protective gel coat over any damaged area.
   ~Ideally give Sucralfate on an empty tummy at least 1 hour before feeding or 2 hours after feeding
   ~If possible, sucralfate should be given 30+ minutes prior to the administration of Pepcid AC and Prilosec.
   ~Give Pepcid AC/Prilosec 30minutes before Prednisone
   ~Give prednisone with a meal. Pred could be given along with pain meds IF also due at that time.
resource: www.marvistavet.com/sucralfate.pml

TEST PRED TAPER on Fri 6/28
  With the taper scheduled to begin, you will want to be up to speed on what the pred taper is all about to be in the best position to ask questions, be part any discussions with your vet.  Good info for you to read:  www.dodgerslist.com/literature/healingsweling.htm
 --- Let us know what your and your vet's Plan B is.
 --- Let us know if your vet is amenable to a phone update on Friday to avoid risky transports in with things than can be addressed by phone.  Transport to a vet involves risk of too much movement of the spine with potential to then damage the early healing disc, especially with a large dog and one who thrashes around being picked up! The benefits of the treatment need to be weighed against the risk of too much movement.   It is not until the taper starts that pain/neuro might be revealed that day or some days after as pred begins to be lowered in the body. So Friday may or may not be too early to know if pred has fully done it's job or not.
 --- Let us know which your vet wants on the begin of the Fri 6/28 pred taper test (backing off all pain meds or the full stop of them.)  This is done to determine if the swelling in the spinal cord is really all gone. It is this swelling that causes the pain and neuro deficits. If the dog is still taking pain meds it will mask the pain that indicates the swelling is still there. If the anti-inflammatory and pain meds are both stopped and no pain surfaces the swelling is gone and only the remaining period of crate rest is needed. If pain returns when these meds are stopped, more time on all meds is needed.  Prednisone's job is only to get the swelling around the spinal cord resolved.  It is mother nature and Rambo's body which will do the job of self repairing nerves with time.

Thrashing when picked up is normal behavior for him? In that case it doesn't sound like he is showing any signs of pain. The problem with the thrashing is it is too much movement for an IVDD dog. The pee pad with another dog's urine on it worked well for Frankie when he was on crate rest. Until I put the paper towel with the other dog's urine on it, he wouldn't use it.

Your schedule with the Sucralfate is fine. Is it a similar schedule at night?

For the tramadol, if he is not showing signs of pain, it isn't necessary to add it. It may be that the gabapentin alone is controlling the pain.

T, sometimes we can not know for sure if the dog is suffering with pain.  You could try an experiment to add in tramadol and see if the suspicious pain panting, lowered tail subsides.

The usual pain meds used wtih a disc episode have a short half life. That means these drugs begin leaving the body at less than effective level after 8 hrs. Thus vets who know IVDD and the pain it can cause, prescribe these pain meds to be given promptly every 8 hrs.  It will take about an hour or less to get pain in control and should remain fully in control when pain meds are dosed promptly every 8 hrs. (tramadol, gabapentin and methocarbamol).  

Sucralfate requires stomach acid in order to form its protective gel coating.
— "Ideally" give Sucralfate every 8 hrs at 6am, 2pm and 10pm on an empty tummy 1 hour before feeding
— Give Pepcid AC and Prilosec at 6:30am and 6:30pm at 30 mins after sucralfate
— 1 hr after sucralfate dose at 7am and 7pm, feed a meal. Also give prednisone every 12 hrs
— Give pain meds (gabapentin, tramadol) promptly every 8 hrs at 7am, 3pm and 11pm 

Are you using a med chart, very helpful in figuring out the maze of every 8hrs, 12hrs dosing schedules? Handy place to make note of times of panting, tail down, etc. in relation to dose times to see a pattern.   

Note: both tramadol and prednisone can make a dog pant.  Try a fan near but not pointed at the dog to circulate air. 

Let us know if you will be dosing tramadol 50 mgs at every 8 hrs and what you observe.

Rx is for sucralfate every 8 hrs (3x/day). 6am, 2pm and 10pm are 8 hrs apart.

Pepcid AC and Prilosec are Rx'd for every 12 hrs (2x/day) So there can not be a match in timing for all three doses of sucralfate. "IDEALLY" you would give Pepcid and Prilosec at least 30 mins after sucralfate. So that only works at the 6:30am time. The next time is actually 4.5 hrs after the 2pm sucralfate dose...just works out that way.

Read the Mar Vista link I provided for the full info. Ideally you try to give time for the sucralfate to start forming a gel coat before giving pred and giving a meal. marvistavet.com/sucralfate.pml

There's likley not enough room on the sucralfate bottle to put in all the options in timing with food and timing with Pepcid AC/Prilosec

T, do get in touch with your vet. Always describe in specifics what you observe rather than making general statements of neuro is worse. Discuss if going a bit higher on the prednisone dose for a 24lbs dog is prudent to be aggressive in getting the swelling down if she feels there is actually some degree of neuro diminishment.
   Could more effort be due to it might be a bit painful to get up?  You have not started Tramadol yet, correct?

Below reference is for you to be able to discuss things with the vet, but definately not change the pred dose yourself.  Prednisone is one med that needs to be prescribed by the vet. Pred is a hormone that has anti-inflammatory properties.

T, sounds like your excellent ability to report your observations led to a meaningful discussion in adjusting Rambo's medication therapy.  Good job on your part in being the eyes and ears for your vet and being able to join in the discussion to help Rambo.  This is the kind of teamwork we hope for each member of the Forum. 

When  pred goes back to 5mgs 2x/day on 6/29, for how many days will that be for  before the prednisone test taper begins?

Basically, when a dog can walk, can take a few footsteps at the every 4 or so hrs potty times, that should be enough to keep joints flexing and  the blood circulation up in the legs.  Always the focus during conservative treatment is limited movement to protect the scar tissue trying to form on the disc.   Feet rubbing often will cause the leg to jerk —perhaps causing too much movement to the back.  Mornings, especially after sleeping all night he might be a bit stiff?  If you can be very careful and Rambo is OK with it... these least aggressive of range of motion and massage normally reserved for paralyzed dogs when they are off of all meds and no pain exists might help with  morning arthritis stiffness.

Only the information highlighted in PINK would pertain to Rambo's stiff morning legs.
www.dodgerslist.com/literature/massagepassiveexercises.htm

Taking in senior and special needs pets is a truly wonderful thing to do.

Am I correct in thinking that Rambo is now taking 10mg prednisone in the morning and 5mg in the evening until you touch base with the vet later in the week? At that time a taper will be discussed.

It makes a huge difference when you have a vet open to discussing things with you. We pet parents are really the most important part of our dog's health care team and it is vital that the vet listens and responds to our concerns.

If Rambo is moving around a lot at night and keeping you up you could try some natural calmers. 

Try using an oral calmer in combination with a Pheromone diffuser. This seems to work best. It takes several days for these to start working - it isn't immediate. Of course ALWAYS keep your vet in the loop on all things you give your dog. Other product brands may be available in your area or on-line… just shop by the active ingredient(s) on the label and the quantity for best price.

Place a DAP pheromone diffuser at floor level where the recovery suite is. Some brands to consider:

--Adaptil (DAP) wall plug in diffuser
www.adaptil.com/us/Adaptil/Adaptil-Diffuser

Use a diffuser with one oral calmer from below:
1) ANXITANE® S chewable tabs contain 50 mg L-Theanine, an amino acid that acts neurologically to help keep dogs calm, relaxed
us.virbac.com/product/behavior/anxitane-chewable-tablets

2) Composure Soft Chews are colostrum based like calming mother's milk and contain 21 mg of L-Theanine.
www.vetriscience.com/composure-soft-dogs-MD-LD.php