Roderick's Lucy 4/2 conservative- Liver GRAD 5/28

Roderick, welcome to the Forum.  You are describing a dog in pain. It is an emergency to get in touch with the vet. Hopefully the Banfield place will have an ER vet there who has access to Lucy's file which gives him the ability to prescribe and understand the blookword regarding liver issues.  Going to any vet, such as an ER at a different clinic would require a transport. Not the safest idea if this is indeed a disc episode.

A vet needs to be alerted soonest to the many the red flag signs of pain you have written about in order to tweak the meds to meet Lucy's need to be in full comfort. When meds are correct for a disc episode there is no pain surfacing round the clock AND dose to dose.  Here is what to advocate for
--- Two pain meds (gabapentin, methocarbamol) be rx'd for every 8 hrs. These pain meds have a short life in the body and pain can surface as the level get low. That is the reason for a disc episode these pain meds are not usually Rx'd for every 12 hrs.
-- Galliprant was designed to address a particular disease....Galliprant selectively treats inflammation due to arthritis and was only tested on dogs without any other disease other than osteoarthritis. Galliprant specifically blocks the EP4 receptor, the primary cause of osteoarthritis pain and inflammation.  Galliprant Pkg insert for veterianians: www.fda.gov/animal-veterinary/animal-health-literacy/galliprant-nonsteroidal-anti-inflammatory-drug-nsaid-dogs-osteoarthritis
     Do discuss if this new NSAID product is the one for IVDD, rather than NSAIDs already on the market proven to be helpful with IVDD. CAUTION: A change to a different non-steroid (NSAID) or to prednisone (steroid) would require double stomach protection if it is deemed a pain emergency to not do the usual 5-7 days of washout.  read what the FDA says about: Galliprant

You really need to be working with the guidance of a vet when a dog has liver issues and the meds that are typically used with a disc episode.
~ Pepcid AC (famotidine) processed by the liver
~ Galliprant (grapiprant) is readily and rapidly absorbed from the gastrointestinal tract in dogs.      
     Grapiprant is mainly excreted via faeces.
~ Gabapentin and  is removed from the body via the kidneys 
~  Non steroids (NSAIDS) and steroids are processed by the liver.  Remember the NSAID Galliprant shoud not be used without a 5-7 day washout with another NSAID or with a steroid.  To do so would require double stomach protection with not just Pepcid AC (famotidine) and adding in sucralfate


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. So if surgery is an option for your family get to a neuro or ortho asap.
    A quick overview of conservative treatment vs. a surgery: www.dodgerslist.com/literature/healingsurgery.htm#surgeryVSconservative

QUESTIONS
~  Let us know you are on the same page about crate rest rest
      The centerpiece of "DISC disease" treatment is the healing of the disc via limited movement of the back via a recovery suite. Crate rest is not your dog in a cage. It's a "recovery suite" with room service!
          100% STRICT crate rest 24/7 for 8 weeks provides limited movement to allow good strong disc scar tissue to form.
           Super tried and true tips for setting up the recovery suite: www.dodgerslist.com/literature/CrateRRP.htm
           PLUS further guidance on conservative treatment on our "All Things IVDD page: www.dodgerslist.com/literature/healingpage.htm www.dodgerslist.com/healingindex.htm

STRICT means:
- no laps              - no couches
- no baths            - no sleeping with you
- no chiro therapy - no dragging or meandering at potty times.

      Carry your dog to and from the recovery suite to the potty place and then allow a very, 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!

~  Why was galliprant Rx'd on Feb 29?
~ What do you observe with repositioning the legs that are hyper extended?  Are they hard to gently reposition the knee joint into a normal position.   Or can you easily reposition the knee joints, it is just that Lucy can't maintain the proper leg position.  Paw knuckling under is another sign of nerve diminishement
~ IF at some point a surgery might be something to consider, would it be a consideration for your family?

Hi, Roderick. Please let us know if you spoke to the vet yesterday. Not wanting to move much is a sign of pain so Lucy's pain meds do need to be adjusted as Paula said in her post. Pain hinders healing so have no patience with it, plus you don't want Lucy to be in pain. Methocarbamol works best when given 3x/day and Tramadol as a general pain med can be added. Many times all three pain meds - Gabapentin (works on nerve paini), Methocarbamol (works on pain of muscle spasms) and Tramadol (general pain med and works in combo with Gabapentin) - are needed for the pain of IVDD.

In addition to an adjustment in meds, what did the vet say about adding a stomach protector, if not Pepcid AC due to liver issues, than another type of stomach protector?  

It's difficult for us to fully support you until we have complete medication information. Please fill in the blanks in the list below for us. The bottle of meds should have how many mg in one ml - if not, please check with the vet.

11 lbs 12.5 y.o.
Galliprant as of 2/29: 20mgs 1x/day for ? days
methocarbamol started 4/2: ?mg in 1 mL of liquiid? ?mgs (1mL dose) 2x/day
gabapentin started 4/2: ?mg in 1 mL of liquiid? ?mgs (0.5mL dose) 3x/day

Do know that crate rest with conservative care must be much more strict than after surgery.  You  mentioned that you don't go for walks and that she doesn't sleep on the sofa or your bed but do you have Lucy confined to a crate or an ex-pen or some type of recovery suite?  Think of a crate as a cast for the spine.  Too much movement and the damaged disc can tear more or rupture, leading to paralysis.  Carry Lucy in and out to potty with very, very few steps allowed to potty and then back into the crate.

Acupuncture and laser therapy can be helpful in giving nerves a jump start in healing.  Be sure the holistic vet does NOT do any chiropractic treatments - here's why:  www.dodgerslist.com/literature/chiropractic.htm
However, transport to a vet involves the risk of too much movement of the spine with possible increased damage to the spine.  If you can get an acupuncturist to come to your home, that would be best.  All vet visits during conservative treatment need to outweigh the risk of being out of the crate, transport in the car, etc.  Transport to a vet for acupuncture is usually recommended only when a dog is severely injured and cannot move legs.  From what you've told us, Lucy can walk, only doesn't want to (most likely due to pain) and is knuckling.  Acupuncture can help with pain but only if an aggressive course of pain meds does not work, which has not been done in Lucy's case.  Acupuncture benefits wear off whereas consistent aggressive pain meds keep pain under control.  If Lucy must be taken to a vet for absolutely necessary visits, be sure to secure her crate well in the car and pad her crate well with rolled up towels/blankets to prevent her from jostling when you turn or stop the car.

Healing prayers for Lucy.

Roderick, keep up the good work of protecting her early healing disc by being so attentive to very, very limited footsteps at potty time!

QUESTIONS
~ Did you get a hold of a vet, an ER vet via a phone call yesterday about the pain?  Were pain meds adjusted?
~ Is Lucy still in pain this am with reluctance to move. hind legs slow in moving?
~ has there been any increased neuro dimishment beyond knuckling?
~ Would you clarify about the formula written on each bottle. The numbers given seem off:
       83mg of methocarbamol contained in one mL of liquid?
       250 mg of gabapentin contained in one mL of liquid?

Roderick what date did the vet say to increase gabapentin from 2x/day to 3x/day?

Hate to assume anything about medications. Double check with vet if the gabapentin solution is 250mgs gaba per ONE mL of solution. "250mgs solution" may be understood to be 250mg/1 mL but again hate to guess.

Vets who know IVDD, understand the critical need to limit movement to the back. They are open to phone call updates especially when things are improving in the treatment they prescribed. Also when there is still pain, then a phone update alerts them to tweak meds. You report good things! So this naturally questions how the the risk of a car transport would be worthwhile and just what benefit Lucy would get at the visit not able to get via a phone call?
- Pain - She is not in pain. So appears no need to tweak meds
- neuro - Her hind legs are stronger. Alway best to be specific though in what you actually observe. You are the eyes and ears for the vet and for us on the Forum.

What exactly did you observe that makes you say stronger legs? for example could be:
== could not push up to stand with back legs after squatting to pee, and now almost can?
== was wobbly walking and now she walks with more steadiness?
== was knuckling back paw(s) and now rarely or not at all?
== NOTE: nerve healing is not normally expected during the short 8 weeks it takes for the disc to heal. If you are seeing betterment (healing) of nerve function, that is VERY good at this point in time. All the more reason not to risk a setback with too much movement.

When things can be handled over the phone with the vet, that ensures the early healing disc will not suffer with too much movement during risky a vehicle transport. Too much movement can cause a relapse of a tear to the early forming scar tissue on the outside of the disc. When there are things that simply can't be handled over the phone and require the valuable benefit of a vet visit, then:
Pad out the crate with a rolled up blanket snug around Lucy's body. This will prevent her back/neck from shifting as you take a corner or come to a stop.

Roderick, I'm confused by your statement "her blood work doesn't show any illness, but nothing seems to work". Please clarify that for us.

What medication did the vet give Lucy for the UTI?

What are the names of the herbs that the holistic vet prescribed? One thing to note is that herbs and natural medicines still have side effects and can have contraindications with other meds. It is vital that you research everything you give your dog in depth. Know the intended effects, appropriate dosing, side effects and interactions with other herbs/medications.

UTIs are common with IVDD dogs but are usually seen when a dog doesn't have bladder control or only partial bladder control. Are you finding any wet bedding or does Lucy leak on you when picked up? Is she only releasing urine when you take her outside? Be sure to take Lucy outside often enough as urine lying for too long in the bladder can cause UTIs.

Roderick, your vet is correct about being very wary of going against the Galliprant package insert of not switching to another NSAID or switching to a steroid.

Here are additional reasons that now at this point in time (6 days/144 hours) after the disc episode happened it may not be a good idea to pursue a risky to the stomach switch.
---Pain report pain is in control
--- Neuro report. No new or increased nerve diminishment beyond knuckling
--- LIver issues. A vet would be the person to determine if the blood work re: liver was too severe and not prudent to use a different stronger brand NSAID or a steroid. You are not reporting any issues that a vet needs to consider this anyway

The SINGLE most important care you can do for Lucy right now is the 100% STRICT rest. Stricter rest than for after a surgery) That means
--  not out of the crate for anything but potty times.  And supervised for very, very fewest of footsteps to take care of business.
--- for a dog like Lucy who has relatively mild nerve diminishment  you WOULD NOT be taking her into a vet for acupuncture.  However getting her UTI confirmed and getting an antibiotic on board was a very good reason to go in for a vet visit!  Good job!


QUESTIONS
-- What is the name of the herb Rx'd. As Marjorie explained there is great concern to have herbs in use when the big gun meds used with IVDD are on board.
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Roderick, since you last wrote, there seems to be some missing information.

"Back on prednisone" Could you tell us what previous date she started pred? at what dose and teims a day. The dose you reported of every other day, is the end part of the prednisone taper. IT is a must to do the end taper schedule as that is what signals the body to start making its own steroid hormone. Give the pred exactly as directed by your vet.

When did Galliprant stop?


Has the methocarbamol been stopped. if not why not?
Has the gabapentin been stopped, if not why not

If you don't see any sign of pain, Roderick, then there would be no reason to give her the Methocarbamol. Having any pain meds on board will mask any sign of pain that you need to be aware of so you know that the swelling has not yet resolved and the original dosage of the Prednisone is still needed. At this point, since you don't give the Methocarbamol every day and no sign of pain has arisen, it's likely that Lucy no longer needs Methocarbamol.

This is all a very good indication that the swelling has resolved, that the taper of the Prednisone can continue until finished and that Methocarbamol is no longer needed. Good news! Please continue to look for any sign of pain until all meds are finished. Pain = swelling = more time on original dosages of all meds.

Roderick, Lucy has graduated from 8 weeks of STRICT restricted movement rest.

With 8 weeks of rest the disc has healed
With no pain meds on board, there is proof no existence of spinal cord swelling.
Thus graduated!

You may have observed some nerve healing. Do know there is still time for more nerve healing to take place.  Nerves can be very slow to heal depending on how much damage there is.

Knuckling nerve damage

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Nerve damage of inability to position legs as they should be when sitting.

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With having graduated crate rest NOW is the time to begin a slow reintrodution back to family life and physical therapy.

GRADUATION, A SLOW INTRODUCTION

Determining how you are going to ease back into more normal activity at graduation. The idea is to gradually give more freedom under controlled conditions. Not free reign of the house and yard immediately! LOL Take a look at our information and then come up with a plan to gradually increase activity over about a month's time following the end of crate rest.

There is a sample schedule to slowly introduce your dog back to family life and physical activity: dodgerslist.com/2020/06/15/back-friendly/

Back friendly fun things: dodgerslist.com/2020/06/16/have-fun-nose-work/

Make some home modifications so that you can reduce the stress on the spine in the future. No more stairs, ramps to slide down from  furniture: 
Ramps: dodgerslist.boards.net/thread/867/ramps
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You will want to consider how you will prevent rug burns from scooting and protecting bacteria from entering the bladder. Females have a very short path into the bladder and the use of a garment will protect against urinary tract infection (UTI). Here are some sew and no-sew options:
 dodgerslist.com/2020/06/13/garment-skin-uti-protection/ 

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PT THERAPY AT CLINIC or HOME
Water therapy:  dodgerslist.com/2020/05/28/surgery-dog-water-therapy

At home daily massage and range of motion. Appropriate physical therapy can help maintain the muscles with lost nerve connection. Therapy keeps muscles in optimal condition while in wait to receive regenerating axon terminals.


Please stay in touch and let us know how Lucy is doing with the after rest PT. We LOVE updates!