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Post by Heidi & Misty on Mar 11, 2021 22:49:16 GMT -7
Hi there, my name is Heidi and my dog Misty is a chihuahua doxie mix. She is 5 years old. She weighs 9lbs. Misty previously had IVDD surgery in June 2020. At that time, she was fully paralyzed in her hind legs and we decided that surgery was the best option. She made a lot of progress after surgery and even regained the ability to go on short walks (although a bit wobbly at times). On 2/12, Misty jumped off the couch and we noticed that she seemed to be in pain over the next few days (e.g. lethargic, loss of appetite). On 2/18, we took her into the ER. The vet said that she did not need an MRI because she still had all of her motor functions, but was just exhibiting back pain. She had a shot of Methadone and we were told to put her strict create rest for 4-6 weeks and to give her the medications listed below. She is currently taking:
Methocarbomal 0.5 ml three times daily Gabapentin 0.9 ml three times daily Trazodone quarter of 50 mg tablet once or twice daily Famotadine 0.25 ml twice daily Prednisone 0.1 ml twice daily -- She started taking this on 3/5. Note that on 2/18, she was originally prescribed Metacam. However, we told the vet that she was still in a ton of pain, especially whenever we picked her up for bathroom breaks. The vet suggested that we switch to Predisone after a 4-day washout period. She did vomit one time a few days after we switched over to Predisone, but has not had any other stomach issues, so I'm hoping it's not a big deal.
[Moderator's note: please do not edit 9 lbs. Metacam - stopped on 2/28 Prednisone as of 3/5: ??mg 2x/day for ??days ,then test taper for:_pain/_neuro Methocarbomal ??mg 3x/day Gabapentin ??mg 3x/day Trazodone 12.5mg 1-2x/day Famotadine ??mg 2x/day]
We have been confining Misty to strict crate rest, but occasionally (maybe once every couple of days), when she shifts the wrong way in her bed or when we pick her up to go to the bathroom or when she gets too excited by food, she will let out a cry of pain. Does this mean she should be on even more medication? Or is it ok to continue at the current type of medication and dosage?
I know that you recommend strict crate rest for 8 weeks, but I'm also really worried because it has been almost 4 weeks and I'm still not sure if she is getting better. Luckily I am able to care for her at all hours since I am working from home, but it causes me so much stress whenever she shows signs of pain that I can barely focus on my work.
Any advice would be greatly appreciated!
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Marjorie
Moderator~
Member since 2011. Surgery & Conservative
Posts: 5,722
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Post by Marjorie on Mar 12, 2021 7:55:40 GMT -7
Welcome to Dodgerslist, Heidi. 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. Know more about us and how we team up with veterinarians: dodgerslist.com/about-team-dodgerslist/Disc disease is not a death sentence! Struggling with quality of life questions? Re-think things: dodgerslist.com/2020/04/18/hope-quality-life/You need to speak to the vet ASAP this morning about adjusting the pain meds. Often IVDD requires three pain meds to address the different types of pain - Tramadol as a general pain med, Methocarbamol for the pain of muscle spasms and Gabapentin for nerve pain. Please speak to the vet about adding Tramadol. Unfortunately, we do not have the info we need in order to advise you as to the dosage of the Methocarbamol and Gabapentin. Please check the bottles and let us know how many mgs are in one ml of the Prednisone, Methocarbamol, Gabapentin and Famotidine so we can determine if the dosages are sufficient for Misty's weight. Please also let us know when the taper of the Prednisone will start. Yes, a full 8 weeks of strict crate rest is necessary to heal a damaged disc and allow it to form secure scar tissue. The swelling pressing on the nerves of the spine can take up to 30 days to resolve and sometimes even more and until the swelling is gone, an anti-inflammatory and pain meds are needed. Misty has been on strict crate rest for 21 days and there were four days when she didn't have an anti-inflammatory. The reason you feel that Misty is not getting better is that the vet has not as yet gotten her pain completely under control. That must be done ASAP. Pain hinders healing and Misty has been in pain for far too long. Yes, a steroid such as Prednisone is a stronger anti-inflammatory than Metacam and should work more quickly on getting the swelling down and thus resolving the pain. But the pain meds also need to be adjusted to mask the pain until the anti-inflammatory has time to do its job. The fact that Misty vomited following the switch from a NSAID to a steroid indicates that there has been damage to the GI tract. Please speak to the vet about also prescribing Sucralfate. Sucralfate works in a different way than Famotidine and will help heal the damaged area. You should not have to take Misty in to the vet for another exam. Vets who understand the importance of strict crate rest during conservative care will agree to taking phone updates and adjust meds by phone. Since pain is the only symptom of IVDD and there has been no loss of neuro function, Misty is a very good candidate for conservative care. But know that the crate rest needs to be very strict. Too much movement and the damaged disc will tear more, resulting in more pain and possibly nerve damage. 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! —> dodgerslist.com/2020/05/14/strict-rest-recovery-process/STRICT means: ◼︎no laps ◼︎no couches ◼︎no baths ◼︎no sleeping with you ◼︎no chiro therapy whys: dodgerslist.com/2020/04/22/chiropractic/ ◼︎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 a 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! dodgerslist.com/wp-content/uploads/2020/04/Potty-leash-harness400-19kb.jpgIs 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. Owner understanding ensures proper conservative treatment principals: ▶︎ 4 phases of healing, what it takes to heal each phase: dodgerslist.com/in-the-right-place▶︎ Roadmap for your fridge so the whole family is on board. Stay the course, avoid dangerous detours for the healing disc: dodgerslist.com/wp-content/uploads/2020/07/Roadmap-for-Fridge.pdf Please let us know what the vet says after speaking to them this morning. Healing prayers for Misty.
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Post by Heidi & Misty on Mar 13, 2021 12:19:36 GMT -7
We asked the vet about Tramadol, but she said that it has recently been proven to be less effective than previously thought for pain management in dogs. She suggested using Hydrocodone instead. Is this something you would recommend as well instead of Tramadol? She did not give a specific date for when we should start tapering Predisone given that we are still trying to get Misty's pain under control. The vet is a general DVM. Here are her prescriptions and dosages: Prednisone as of 3/5: 50mg/ml - We give her 0.1 2x/day Methocarbomal 120mg/ml - We give her 0.5 ml 3x/day Gabapentin 100mg/ml - We give her 0.9 ml 3x/day (The vet mentioned we can go up to 1 ml if needed) Trazodone 12.5mg 1-2x/day Famotadine 20mg/ml - We give her 0.25mg 2x/day Also, I wanted to mention that prior to her relapse, she was doing TENS therapy at home. We have been continuing this 2-3x/day during Misty's crate rest as the vet recommended it and we have the TENS machine at home. She seems to enjoy it and usually falls asleep during her session. We've otherwise stopped all other exercise/shockwave therapy/acupuncture because we don't want to risk further injury by transporting her to the vet in the car, especially because she tends to get very anxious in the car. We've cancelled our weekly appointments for the rest of March, but we weren't sure if we should cancel April too or just wait and see?
[Moderator's note: please do not edit 9 lbs. Metacam - stopped on 2/28 Prednisone as of 3/5: 5mg 2x/day for ??days ,then test taper for:_pain/_neuro Methocarbomal 60mg 3x/day Gabapentin 90mg 3x/day Trazodone 12.5mg 1-2x/day Famotidine 5mg 2x/day]
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Post by Romy & Frankie on Mar 13, 2021 14:30:49 GMT -7
Tramadol is widely prescribed for IVDD. Some vets do feel it is not that effective but anectodately at Dodgerslist we have seen tramadol provide good pain relief. This is particularly true when gabapentin is also prescribed as the two work synergistically.
The vet is right that prednisone should not be tapered if there are still pain issues. I hope the addition of an additional medication will keep Misty pain free. Was the vet willing to prescribe tramadol?
Conservative treatment requires 8 weeks of strict crate rest so any unnecessary vet visits should be postponed until the 8 weeks are up. Some vets that do acupuncture will also do home visits. I am not sure if during this time of coronavirus you could find a vet that will do a home visit, but it is worth asking.
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Post by Heidi & Misty on Mar 15, 2021 9:11:56 GMT -7
The vet did not want to prescribe tramadol. She prescribed ✙hydrocodone instead. We started it yesterday and it seems to be helping!
[Moderator's note: please do not edit 9 lbs. Metacam - stopped on 2/28 Prednisone as of 3/5: 5mg 2x/day for ? days ,then test taper for:_pain/_neuro Methocarbomal 60mg 3x/day Gabapentin 90mg 3x/day ✙Hydrocodone 1.25mg 3x/day Trazodone 12.5mg 1-2x/day Famotidine 5mg 2x/day]
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Post by Jessica on Mar 15, 2021 9:34:30 GMT -7
I'm glad to hear Misty is feeling better. What is the dosage and frequency that has been prescribed for the hydrocodone? How long has it been prescribed for?
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Post by Heidi & Misty on Mar 28, 2021 19:44:39 GMT -7
For the hydrocodone, we are giving Misty 1/4 pill of 5mg 3x per day. She is generally comfortable and alert throughout the day, but every day after eating she seems to be in pain again for about 1-2 hrs before returning to normal. This doesn’t happen when she eats treats, but only after breakfast and dinner. We don’t know what is causing this, but we feel really frustrated because she is otherwise fine throughout the day. She gets the famotidine about an hr before eating breakfast and dinner. And then she gets the prednisone with her breakfast and dinner. Do you have any ideas why this could be happening? The vet recommended adding amantidine to her medications to see if that helps, but mentioned that this is really the last medication she can think of for conservative treatment. She said that if this still does not work, she would recommend surgery. We are hesitant to bring Misty in for surgery as it is not guaranteed that she will get better and she just had her last surgery less than one year ago. She also still has her motor functions so we aren’t convinced that surgery is the only other option at this point. Please let us know if you have any thoughts!
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,493
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Post by PaulaM on Mar 28, 2021 21:09:24 GMT -7
Heidi, can you fill us in on prednisone: --- Pred started on 3/5 at 5mgs 2x/day. What date did it begin to taper (less mgs and/or less times per day dosing. THIS IS VERY IMPORTANT, ir provides volumes of information! Describe the food you feed her. Kibble, soaked or not soak in equal parts liquid, canned food, etc. Describe which you observe that make you feel she is in pain after eating: ⚙︎ shivering-trembling ⚙︎ yelping when picked up or moved ⚙︎ tight tense tummy ⚙︎ arched back, ears pinned bac ⚙︎ restless, can't find a comfortable position ⚙︎ slow or reluctant to move in suite such as shift positions ⚙︎ not their normal perky interested in life selves ◻︎ head held high/ nose to the ground ◻︎ looks up with just eyes and does not move head and neck easily. ◻︎ not eating due to painful chewing or in too much overall pain ◻︎ holds front or back leg up flamingo style not wanting to bear weight Has your vet had thoughts this may be a neck disc? Extra things you can do even if it is solely a back disc: More info here: dodgerslist.com/2020/05/05/cervical-care-tips/If, there is pain, then certainly do try Amantadine. Neuro's are finding this a good addition to the pain med cocktail. As normal, look up each of your dog's meds to be an informed owner. www.marvistavet.com/amantadine.pmlEMAIL ALERTS Please enable receiving email alerts for when someone has posted. Timely interaction/communications is needed when helping your dog. How to set up: dodgerslist.boards.net/thread/7353/register-bookmark-dogs-post-thread
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Post by Heidi & Misty on Mar 28, 2021 22:36:31 GMT -7
The vet said that we can maybe start tapering in a couple weeks, but has not set a specific date since Misty still seems to be exhibiting pain. Should we ask the vet again about tapering?
We notice that she whimpers when she tries to reposition herself. She is reluctant to move and only moves her eyes. Her body is tense. Her ears are pinned back. Again, this lasts about 2 hrs after meals before she returns to normal. We usually feed her pumpkin puree, sweet potatoes, and chicken/other wet dog food for protein. She was having a bit of trouble going to the bathroom before, which is why we incorporated the pumpkin and sweet potatoes. We also add a bit of water to to her food. She urinates and defecates about twice a day. She doesn’t have trouble eating since the pain usually arises after meals.
[Moderator's note: please do not edit 9 lbs. Metacam - stopped on 2/28 Prednisone as of 3/5: 5mg 2x/day for 25+ days ,then test taper for:_pain/_neuro Methocarbomal 60mg 3x/day Gabapentin 90mg 3x/day Hydrocodone 1.25mg 3x/day Trazodone 12.5mg 1-2x/day Famotidine 5mg 2x/day]
The vet has not mentioned the possibility of it being a neck disc. Her last surgery was for a disc that ruptured on her back and the vet believes this relapse is related to that.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,493
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Post by PaulaM on Mar 29, 2021 7:25:09 GMT -7
Heidi, the signs you mention are suspiciously of a neck disc: only moves her eyes and the issue of pain after eating. Has the vet observed only moving her eyes rather than turn head to look at things? A neck disc can also have a neuro effect on the rear limbs. Here are the extra things you can do for a neck disc that are ok if this is truly only a back discs: dodgerslist.com/2020/05/05/cervical-care-tips/Misty's body is dealing with many repair jobs. The full nutrition of minerals, vitamins, protein her wet dog food are needed. You can put a teaspoon of crumbled chicken on top of the wet dog food, that will not unbalance the dog food. If Misty still has some constipation (is that what is meant with "having trouble going to the bathroom")?, then give 1/2 teaspoon ONCE a day of either pumpkin puree or mashed sweet potato. Both pumpkin and sweet potato are high in fiber. Too much fiber can cause constipation, firmer stool and what is desired. So you are saying that Misty has been on pred since March 5th at 5mgs every 12 hours? That she has been on pred at the anti-inflammatory dose for a straight 25 days now?
Would a surgery be an option for your family to take into consideration at some point? dodgerslist.com/2020/02/10/surgery-vs-conservative/
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Post by Heidi & Misty on Mar 29, 2021 8:07:37 GMT -7
The vet has not seen her recently so she has not observed this in person, but these signs of pain only arise for 1-2 hrs after eating and then goes away. We already prop up her food and water bowl so that she does not have to bend down to eat and drink.
We will adjust her food to only pumpkin or sweet potato once per day.
That’s correct regarding the prednisone. We have not changed her dosage [since 3/5] since she’s been prescribed that medication and the vet has not instructed us to taper. Should we ask her again even though Misty’s pain isn’t fully under control?
We’d really like to avoid surgery if possible. She just had surgery less than a year ago and we don’t have pet insurance. We are also optimistic that she will get better with crate rest since she still has all of her motor functions (vs last time her hind legs were completely paralyzed).
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Post by Jessica on Mar 29, 2021 11:13:19 GMT -7
Hi Heidi - Just a thought to consider discussing with your vet: I had a hard time getting my dog's pain under control. He had a neck episode and we made a switch from gabapentin to pregabalin (Lyrica®). Pregabalin is stronger, and also more expensive, but it seemed to help. More information on pregabalin can be found here: www.wedgewoodpharmacy.com/learning-center/professional-monographs/pregabalin-for-veterinary-use.htmlAs Paula mentions, it may be worth giving the Amantadine a try too. In addition to propping up food/water bowls and softening food, I found switching to a shallow dish worked well. This way they can avoid anything touching their faces while eating. If your bowls don't have high rims it may not be necessary. However, it may be an easy thing to try to help avoid excess aggravation after meals.
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Post by Heidi & Misty on Mar 29, 2021 11:44:22 GMT -7
Thank you both for the advice! We just placed an order for the amantidine so we will see how that goes before switching up the gabapentin. Good idea regarding the shallow food bowl. We will definitely try that as well.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,493
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Post by PaulaM on Mar 29, 2021 12:53:20 GMT -7
Heidi, while in most cases it will take 7-30 day up at the anti-inflammatory prednisone dose (excluding any tapers days) to resolve all painful swelling, there have been a few cases on this Forum where the dog was on pred for more than 30 days.
With the pain being so hard to get in control, I feel like this vet's comments on pain control rather fit Misty's case. Ask for the more stronger pregabalin in place of gabapentin and along with the amantadine. Expedite getting pain in control with a more aggressive pain med approach with stronger pregabalin PLUS amantadine now, today.
Let us know what your vet thinks, hopefully you can get a phone call in to advocate for this idea today.
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Post by Heidi & Misty on Apr 21, 2021 20:22:20 GMT -7
SURGERY 4/19 Hi! We just wanted to update everyone since we decided to move forward with surgery. We took her in for an MRI last week, which revealed that her old disc that ruptured didn’t heal properly from the prior surgery because the scar tissue was adhering to the spinal cord. Additionally, a new disc nearby had ruptured. She had her surgery on 4/19 and is now home. She seems to be pain free but is very tired and sleepy. Will keep you posted on the progress.
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Marjorie
Moderator~
Member since 2011. Surgery & Conservative
Posts: 5,722
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Post by Marjorie on Apr 22, 2021 6:14:22 GMT -7
I'm glad to hear that Misty has the surgery behind her and is home resting. I'll move your thread to the surgery board.
Please let us know what meds Misty was sent home on (name, dosage in mgs and frequency given), how many weeks of post-op crate rest has been prescribed and what PT has been recommended.
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Post by Heidi & Misty on Apr 27, 2021 8:13:41 GMT -7
Here is Misty’s current dosage: [9 lbs.] Prednisone 2.5mg 1x/day Amantidine 30mg 2x/day Gabapentin 75mg 3x/day ▲Trazodone 25mg 3x/day
We are supposed to start tapering prednisone and amantidine tomorrow. Misty had been doing completely fine in terms of pain post-op, but today she was showing minor signs of discomfort again (shivering, which thankfully stopped after her morning meds, low energy and reluctance to move) so we are worried about starting the taper tomorrow. We are checking in with the neurologist later today so we will bring this up. We are also supposed to schedule a time next week to get her staples removed. For PT, we’ve just been massaging her hind legs and doing a bit of PROM to move around her joints.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,493
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Post by PaulaM on Apr 27, 2021 8:54:58 GMT -7
Updating the surgeon let's him know how his prescriptions are working. Often it can take about 2 weeks before all the surgical caused swelling subsides. Pain nearing the next dose of med, shows meds need adjustment to provide round the clock discomfort from pain and likely extended for a bit longer.
Let us know what the surgeon says (details of mgs, frequency, days extended).
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Post by Heidi & Misty on Apr 28, 2021 20:00:24 GMT -7
The surgeon had us walk her around the room to see if she was still able to do so. Since Misty passed the test, the surgeon told us to continue with her planned tapering. Now we are down to ▼amantidine once per day and prednisone every other day. Misty hasn’t exhibited more pain since we started tapering, which seems like a good sign. [Moderator's note: please do not edit 9 lbs. Metacam - stopped on 2/28 Prednisone as of 3/5: 5mg 2x/day for 25+ days ,then test taper for:_pain/_neuro Methocarbomal 60mg 3x/day STOPPED? Gabapentin 75mg 3x/day Trazodone 25mg 3x/day Amantidine 30mg ▼1x/day Famotidine 5mg 2x/day STOPPED? ]
However, we noticed that Misty’s energy level changes throughout the day, but generally she had been lower energy than last week (sometimes it’s around her next round of meds, but not always so it’s really hard to tell). Is it normal for her to have ups and downs like this? Are we just being overly anxious?
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,493
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Post by PaulaM on Apr 28, 2021 20:15:16 GMT -7
What do you observe when you report "lower energy?"
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Post by Heidi & Misty on Apr 29, 2021 6:04:27 GMT -7
She is mostly sleeping all day. And when she does get up to eat or go to the bathroom she is slow to move around. Even when we come in the room to greet her or give her treats she doesn’t pop up that quickly, which seems off to us.
In addition to the above, she is still on: Gabapentin 75mg 3x/day Trazodone 25mg 3x/day
[Moderator's note: please do not edit 9 lbs. Metacam -STOPPED on 2/28 Prednisone as of 3/5: 5mg 2x/day for 25+ day; 4/27 taper Methocarbomal 60mg 3x/day STOPPED? Gabapentin 75mg 3x/day Trazodone 25mg 3x/day Amantidine 30mg ▼1x/day Famotidine 5mg 2x/day ]
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,493
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Post by PaulaM on Apr 29, 2021 9:58:52 GMT -7
Heidi, reluctance to move IS pain. I would relay what you observe to the surgeon. Often it can take 14 days before all the surgical caused painful swelling is gone. It has only been 10 days since surgery. Let us know what your surgeon says about adjusting pain meds.
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Post by Heidi & Misty on May 3, 2021 20:14:42 GMT -7
We brought Misty in for her follow-up [5/3] today to get her stitches removed so the surgeon did a neurological exam on her as well. The surgeon didn’t think her pain meds needed to be adjusted, which was a bit surprising to us since we communicated the signs that we were noticing. On the whole, we agree with the surgeon they Misty has been improving since her surgery, but sometimes she has good days and sometimes she has bad days. The surgeon said that we can actually stop amantidine tomorrow and see how Misty reacts. If there are no adverse reactions after a few days, then we can start tapering gabapentin as well. We also stopped prednisone and famotidine over the weekend and have not noticed any adverse reactions so far.
[Moderator's note: please do not edit 9 lbs. Metacam - stopped on 2/28 Prednisone as of 3/5: 5mg 2x/day, STOPPED 5/1 Gabapentin 90mg 3x/day TBA 5/6ish taper Trazodone 25mg 3x/day]
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,493
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Post by PaulaM on May 4, 2021 8:03:27 GMT -7
Heidi, is she still taking methocarbamol. Does she still have "good" and "bad" days (your observations for those words would be helpful). Maybe from 4/20 til 5/3 all the pain had been resolved so that the surgeon observe no signs of pain.
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Post by Heidi & Misty on May 4, 2021 8:29:38 GMT -7
No she stopped taking [methocarbamol] that after surgery. She is currently taking 25mg trazadone 3x/day (not 12.5), but the surgeon said that we can decrease that as needed. On the bad days, she’s very lethargic, slow to move and unenthusiastic to eat, but I guess the surgeon didn’t observe any signs of pain when we brought her in.
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Post by Romy & Frankie on May 4, 2021 14:12:55 GMT -7
Trazadone is an anti-anxiety medication and may make her more lethargic. When you are comfortable cutting back on that, she may regain some of her energy.
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Post by Heidi & Misty on May 4, 2021 16:42:33 GMT -7
That is helpful to know! I wonder if that’s a factor... we may try to cut back slowly since we feel like she is generally pretty relaxed at home and doesn’t mind crate rest. Do you feel like her current dosage is pretty high for her weight? It’s about double what we were giving her pre surgery.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,493
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Post by PaulaM on May 4, 2021 20:50:04 GMT -7
It would be best to check in with the Neuro. Post-op may have a certain reason for using the higher end of the traZODone range for her weight. Read more about traZODone: www.marvistavet.com/trazodone.pmlIs there a pattern for "bad days"? Certain time of the day, an activity? How often do you see "bad days"?
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