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Post by Trisha on Jul 23, 2022 5:04:53 GMT -7
Tiki is 14.5 year old 1 6 lb shih tzu - he had surgery at age 4 after an episode in which he was completely paralyzed and made a full recovery with no issues since. He began exhibiting symptoms [7/22] yesterday morning: shivering, whimpering, uneasy to stand, crying from time to time. Emergency vet prescribed a pain med [name?] and gabapentin - predinose to start tomorrow (delay due to needing another med he takes to be out of his system). He has full pain relief for approx. 7-8 hours from medication and is able to rest. He is able to wobbly stand to pee and did poop this morning which looked healthy and normal. [MED LIST/HISTORY- Moderator's Note. Please do not edit ]
16 lbs 14.5 y.o.
7/22 neuro wobbly; pain shivering, vocalizing
Galliprant stopped 7/22 No Rx for 5-7 day washout!
Prednisone as of 7/23: ?mgs ?x/day for ? days, then a test taper for: _pain / _neuro
Pain med #1 name?: ?mg ?x/day
gabapentin ?mg ?x/day
Tiki needs TWO GI tract protectors, Pepcid AC+ Sucralfate, on board w/Pred! ] The vet diagnosed as sprain though paperwork says IVDD. is conservative treatment appropriate? We have not allowed him to move since yesterday am. The vet will not consider surgery until after full blood work and MRI ($$$) and considering his age we do not know if he would even be a candidate for surgery. He is able to rest though as soon as the dose wears off it’s very clear he’s in pain. He can start steroids tomorrow. Thank you! |
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PaulaM
Moderator. 
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,928
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Post by PaulaM on Jul 23, 2022 8:15:23 GMT -7
Trish, welcome! Registering as soon as you can enables feature of getting an email alert when you have a reply. Tmely communications are important in best helping your dog. Comment is of a general nature due to missing information. You have a pain med emergency to phone the vet asap this Saturday 7/23 morning. The pain meds are not yet correctly adjusted. Vet needs your feedback wearing off too soon. PAIN MEDS Pain meds ( traMADol-general analgesic, gabapentin- nerve pain and methocarbamol-muscle contraction pain) last in the body for about 8 hrs. Advocate that each type of pain is being covered by these three pain meds. Advocate that each pain med is Rx'd for promptly every 8 hrs. STOMACH PROTECTION Advocate that his stomach be protected from stress, from the NSAID that takes 4-7 days to clear and from the Prednisone to start. Read up so you can put your concern forward to the vet today: dodgerslist.com/2020/05/06/stomach-protection/ Pepcid AC if verified by vet Pip has no liver, kidney or heart issues. Then purchase at grocery store. MISSING INFO Please advise of these important missing details from the med list: Current NSAID name? stopped 7/22 No Rx for 5-7 day washout! Prednisone as of 7/23: ?mgs ?x/day for ? days, then a test taper for: _pain / _neuro Pain med #1 name?: ?mg ?x/day gabapentin ?mg ?x/day Tiki needs TWO GI tract protectors, Pepcid AC+ Sucralfate, on board w/Pred! With double stomach protection the Prednisone steroid could start right away TODAY. Discuss two stomach protectors and starting Pred today.MONITOR for NEURO FUNCTION 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. Tiki is a very good candidate to heal with conservative Treatment! Now is the time to understand when a surgery would be considered. She is a long way from that point. 1. 7/22 Pain caused by the intial disc tear & inflammation in the spinal cord 2. 7/22 Wobbly walking, legs cross 3. _?_ Nails/toes scuffing floor 4. _?_ Paws knuckle under 5. 7/22 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 with conservative treatment after surgery. 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: dodgerslist.com/2020/02/10/surgery-vs-conservative/ * ◼︎No laps ◼︎no couches ◼︎no baths ◼︎no sleeping with you ◼︎No chiro therapy whys: dodgerslist.com/2020/04/22/chiropractic/◼︎No 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 such as Tiki's ◼︎ Avoid dangerous detours. Follow the "Roadmap." Tape it to your fridge. D/L and print out: dodgerslist.com/wp-content/uploads/2020/07/Roadmap-for-Fridge.pdf CONSERVATIVE TREATMENT Make sure you are doing all you can at home to prevent a worsening disc further diminishing neuro function. Conservative treatment is not rocket science. Once you understand the principals and whys of limited and STRICT rest you can be committed to giving good care at home. --- Tips and ideas for making crate rest go smoothly for the next 8 weeks: dodgerslist.com/2020/05/14/strict-rest-recovery-process/--- Potty time limited movement, no walking just minimal footsteps. 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 leash/harness to minimize footsteps with a physical and a visual to indicate there will be no sniff festing going on!  **
We are anxiously awaiting news of what the vet does to adjust the meds. (name, dose in mgs and how often given. |
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Post by Trisha & Tiki on Jul 23, 2022 13:04:12 GMT -7
[NOTE: all quoted text has been removed. Moderators only want to read your words to avoid confusion. Thank you! ]Thank you so muc. MISSING INFO NSAID Galliprant stopped 7/22 Prednisone as of 7/23: 3.75 mg 2x/day for 5 days, then a test taper ▲Amantadine raised to 50 mg every 8 hours ▲gabapentin raised to 200 mg every 8 hours 5. _ 7/22_ Weak/little leg movement,
[MED LIST/HISTORY- Moderator's Note. Please do not edit ]
16 lbs 14.5 y.o.
7/22 neuro wobbly; pain shivering, vocalizing
Galliprant stopped 7/22 No Rx for 5-7 day washout!
Prednisone as of 7/23: 3.75 mgs 2x/day for 5 days, 7/28 a test taper for: _pain / _neuro
amantidine ▲50 mg 3x/day
gabapentin ▲200 mg 3x/day
Tiki needs TWO GI tract protectors, Pepcid AC+ Sucralfate, on board w/Pred!]
We are hoping to have his pain management under control for now and will get the recommended stomach protectors. The vet says there are no further pain meds they can give for now - could give a fentanyl patch but takes 48 hours to kick in.
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Post by Trisha & Tiki on Jul 23, 2022 13:23:29 GMT -7
As an update: we are heading back to emergency vet. Not happy with pain management and vet will not do anything else over the phone.
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Post by Romy & Frankie on Jul 23, 2022 13:42:37 GMT -7
Good that you were able to get the pain meds adjusted. Amantadine works well with gabapentin to help control nerve pain. This combination may work to keep Tiki pain free.
If, with this change in meds, Tiki is still showing signs of pain, please call the vet right away and let him know what you are seeing. The meds may need adjustment. Pain will only slow the healing process.
Do you know why the vet said he is unable to give further pain meds? As Paula mentioned, often a combination of meds each attacking pain differently is what works best. Maybe he wants to see how this current regimen is working before he prescribes further.
Unlike Pepcid AC, Sucralfate is prescription only. Has the vet prescribed the sucralfate yet? It is important that Tiki's stomach is double protected. Our IVDD dogs have enough to deal with without the addition of stomach problems. |
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Post by Romy & Frankie on Jul 23, 2022 13:49:34 GMT -7
Please let us know what happens at the emergency vet. We will be wanting to hear.
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Post by Trisha & Tiki on Jul 24, 2022 5:08:49 GMT -7
Good morning - Tiki stayed overnight at the hospital so they could better manage his pain and give him an opportunity to rest. He was given the fentanyl patch among some other things [?]. He is doing well though we await the doctor's rounds for a further update.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,928
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Post by PaulaM on Jul 24, 2022 5:52:31 GMT -7
So glad to hear pain is being controlled.. It is often the case a 2-3 way cocktail of pain meds is needed. Will be watching for the specifis on the at home Rx’s that will maintain pain control.
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Post by Trisha & Tiki on Jul 25, 2022 5:18:31 GMT -7
Tiki is back home and with updated meds.
Prednisone [ER vet]: 3.75 mg every 12 hours for 5 days then taper
Traumeel: 1 tablet every 8 hours will check dosage
▼ Amantidine: 25mgs every 12 hours
✙Tramadol: 25 mg every 8 hours
Gabapentin: 200 mg every 6-8 hours [which actually giving?]
[MED LIST/HISTORY- Moderator's Note. Please do not edit ]
16 lbs 14.5 y.o.
7/22 neuro wobbly; pain shivering, vocalizing
Galliprant stopped 7/22 No Rx for 5-7 day washout!
Prednisone ER as of 7/24: 3.75 mgs 2x/day for 5 days, 7/29 a test taper for: _pain / _neuro
amantidine ▼25 mg ▼2x/day
gabapentin ▲200 mg ▲4x/day
Fentanyl patch expires 7/26
✙Tramadol: 25 mg 3x/day
Tiki needs Pepcid AC, on board w/Pred!]
He also has a fentanyl patch on until Tuesday. Vet has said 50% chance he improves on meds - very stressful/confusing as they haven’t explicitly said they think he may need surgery. First would need bloodwork and MRI at cost of $3,800-5,000.
He does not seem to be in pain currently but just has a hard time getting comfortable. The prednisone I think makes him somewhat anxious (when he has taken in the past, same thing). But he is resting and eating and drinking. Back legs still extremely weak.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,928
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Post by PaulaM on Jul 25, 2022 8:44:00 GMT -7
Trisha, can you tell us with specific pain description(s) you observe if he is in pain or not. ⚙︎ 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 The test prednisone taper will start on 7/28. Pain meds which do not allow you to assess for pain are stopped or begin backing down (mgs/x/day) also 7/28. Which does your vet want?
Of course if you are seeing any hint of pain it would not be time to taper prednisone, but instead alert your vet to your pain observations and likely another 5-7day course of pred would be prescribed. It takes 7-30 days for pred to get the swelling down. Taper days are not counted. So a 5-day course is rather short and may or may not get all inflamed tissued resolved.It is good to know you have a range for gabapentin. We would like to know what you are actually giving every 6hrs or 8 hrs?Amantidine is not a pain med as such. Read about how this med works when meds are properly used at the aggressive dose and 3x/day but pain is still not fully controlled. Pain is a complicated issue. Often it will take 3 pain meds for full control (traMADol, gabapentin and methocarbamol). The Mar Vista vets explain the mysteries of amantadine www.marvistavet.com/amantadine.pml
traMADolWhen the Fentanyl patch expires on 7/26, be alert to any hint of pain increasing. For a 16lb/7.26kg dog the traMADol dose is like not giving any! Alert the vet if any sign of pain surfaces and advocate for the MAX ANALGESIC dose for tramadol The usual in controlling pain is to Rx at the max analgesic dose AND promptly every 8 hours. Plumb's is considered the "drug bible" of the veterinary world. While the legs may be weak, the critical indicator of Deep Pain Sensation (DPS) still exists. A dog with DPS can self repair their nerves. Scroll up to Jul 23 to review MONITOR for NEURO FUNCTION Is a surgery something in the future that would be an option for your family? If not, then make it clear you do not want to have surgery pushed on you. You don't need another stress to deal with. If you are open to a surgery if it is needed, then give yourself a fresh review here: A quick overview of conservative treatment vs. a surgery: dodgerslist.com/2020/02/10/surgery-vs-conservative/
Describe specifically the neuro status so we can understand better understand:
Can no longer use back leg to itch an ear?
Can no longer use back legs to reposition his body in the suite?
Can no longer move up into a stand by himself
Back paws knuckle under, or are slow to correct
6. __ Legs do not work at all (paralysis, dog is down) legs are straight and knees do not tuck in legs.
7. __ Bladder control is lost. Leaks on you when lifted.
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Post by Trisha & Tiki on Jul 25, 2022 9:06:13 GMT -7
Quoted text has been removed to avoid confusion. Instead write a word or to of reference in your full sentence. Thanks!
Thank you, to answer some questions. Currently, the only thing I am observing is restlessness, though I think it also ties into him wanting to be involved in what we are doing (he is used to being around us 24/7 but won't rest so he is in our room sometimes). He still seems quite perky and on alert for anyone eating food (normal for him).
The vet only mentioned predinsone taper, not pain meds but will check in on that and will also check in on short prednisone course.
Gabapentin we are currently giving every 6 hours. I will also f/u with vet regarding Tramdol dosage. Frustrated that the vet does not seem to be prescribing therapeutic dosages but will continue to press.
I am very unsure and stressed about the surgery. In fact, I have been through this all before in 2012 when he became paralyzed and had the surgery, then made a full recovery. However, he is now nearly 15 years old and I really don't know what to do.
He typically does not [scratch ear] do this, so hard to observe.
He is able to move himself in the suite if needed and does stand occasionally.
He is able to stand.
He is not knuckling under but is wobbly somewhat (back leg weakness).
Not currently [paralyzed].
Is able to urinate and defecate outside - we are supporting with harness.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,928
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Post by PaulaM on Jul 25, 2022 9:21:58 GMT -7
Fingers crossed on the begin of the pred taper Thurs 7/28, you won't see any pain surface. Tiki has a good chance to heal his disc during the 8 weeks. Nerve healing may or may not come back in that short of time. Nerve healing should be thought of in terms of months rather than days/weeks whether after a surgery or for conservative treatment.
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Post by Trisha & Tiki on Aug 1, 2022 6:38:31 GMT -7
Hello!
Tiko has been doing well over the last week, comfortable and resting in his pen and has seemed in very good spirits/back to himself. We have been very consistent with meds, no movement, and a sling for bathroom.
We have begun pred taper [7/29] Friday (not Thursday) and he has run out of his Traumel.
[MED LIST/HISTORY- Moderator's Note. Please do not edit ]
16 lbs 14.5 y.o.
7/22 neuro wobbly; pain shivering, vocalizing
Galliprant stopped 7/22 No Rx for 5-7 day washout!
Prednisone ER as of 7/24: 3.75 mgs 2x/day for 5 days, 7/29 a test taper for: _pain / _neuro
amantidine 25 mg 2x/day
gabapentin 200 mg 4x/day
Tramadol: 25 mg 3x/day
Tiki needs Pepcid AC, on board w/Pred!]
Today, for the first time, he has begun panting [8/1] again and I'm wondering if it is a sign pain has started back up. We have vet appointment at 5:30 pm today - do you think I should be pushing for a longer round of pred?
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,928
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Post by PaulaM on Aug 1, 2022 8:18:10 GMT -7
Trisha, it is amazing how much understanding is gained when having both the current med list PLUS the observations you report. Can you fill us in on the current med list part? -- How were the 3 pain meds handled at the start of the 7/29 taper of anti-inflammatory prednisone? Pain meds block true and accurate assessments about existence of painful inflammation. 1. 3 pain meds backed down in frequency and mgs? or.... 2. full stop of all 3 pain meds? If you observe two or more signs of pain, it helps to confirm pain. Some signs such as shivers, panting for example can also be due to being chilled or for panting too warm. With the panting today did you observe any other of these typical signs of disc episode pain?
SIGNS OF PAIN:
⚙︎ shivering-trembling ⚙︎ yelping when picked up or moved ⚙︎ tight tense tummy ⚙︎ arched back, ears pinned back ⚙︎ 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
It can take in the range of 7 to 30 days on the original anti-inflammatory level prednisone dose before all painful inflammation is gone. Taper days, at a lower dose, are not counted in that 7-30 days.
Tiki's 5-day prednisone course was short. Some dogs can get the swelling down in 5 days. Many dogs end up needing a 2nd or even a 3rd prednisone course to fully resolve painful swelling/inflammation.
Vets who know IVDD understand the importance of STRICT rest at home to avoid disrupting the disc scar tissue forming. Often things like med adjustments, updates can be handled over the phone. When there is an emergency/urgent matter of health, etc. the risk to the disc of too much movement is overweighed by the vet visit to receive urgent medical help.
THINGS TO CONSIDER
-- Call the vet to update him. And IF you have clear observable pain sign evidence surfacing during the taper of prednisone, advocate for another course of prednisone (3.75 mgs 2x/day). Remember having pain meds on board limits your ability to accurately assess for pain.
-- IF there is any new or increased neuro diminishment, describe what you observed to the vet.
• more wobbly, back paws knuckle under or are slow to self correct.
• no longer able to move up into a stand
-- Prednisone should be accompanied by an acid reducer (Pepcid AC) for the duration. EXCEPT if vet says Tiko has a health issue!
-- IF is it determined there is a health emergency worth taking a risk of disruption of early forming disc scar tissue with a transport in, be careful with the transport! Will be watching for your update, and details of his meds, etc. |
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Post by Trisha & Tiki on Aug 1, 2022 8:43:34 GMT -7
Thank you, they did not taper pain meds at all during pred taper so all his meds have remained the same except his traumel, which he ended last night. Thus, it is difficult to know if the initial prednisone has worked. He had his gaba and aman. At 10:30 and is resting now. I am not observing other signs of pain.
It’s very difficult and frustrating to try and get call backs from the emergency vet and so we are getting in with his actual vet today. I’m not sure how at this point to find a specialized vet who better understands IVDD and who will also now take on his care.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,928
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Post by PaulaM on Aug 1, 2022 11:01:09 GMT -7
Trisha, ok now I think I see the predicament you are in. An ER vet is not the type of vet to oversee Tiki's treatment over the long term, but just on an emergency basis. Your vet can't prescribe over the phone unless he has seen Tiki for this current disc episode. This is then, I believe, is the reason you have an appt with your local vet so he can take over supervision of prednisone til proven all pain has been resolved? If your local vet has already seen Tiki for this disc episode and you were not satisfied, then it is you who needs to step up to kinda drive the treatment. You are aware of how a prednisone taper works. You have the ability to speak frankly with your vet about any concerns you have. In other words join in the discussion for Tiki's treatment and advocate for him. Anything that is discussed you do not fully understand, ask for clarification, ask "why not's" "what would it hurt to try xyz", etc. Finding a new local vet can be done. It will take yet another transport into 3rd vet. So if your local vet is willing to try some things you have learned about proving prednisone has done it's job or still has work to do, you two could make a good IVDD health care team for Tiki. Owner education makes a lot of things possible! Strategies for finding a vet comfortable with their IVDD knowledge if it comes to that: dodgerslist.com/2020/05/10/find-ivdd-vet/Board certified specialist are not just for the reason of surgery. They can also help when a local vet is not comfortable in using medications. Find an ACVIM board certified neuro surgeon: vetspecialists.com Find an ACVS board certified ortho veterinary surgeon: online.acvs.org/acvsssa/rflssareferral.query_page?P_VENDOR_TY=VETSAmantadine is not really a pain med per se as you have read in the link provided some time ago. traMADol and Gabapentin take about 8 hrs to leave the body. Do not give them again before seeing your local vet so he has some chance to properly assess for pain. Will be watching for your update after the late afternoon appt today. |
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Post by Trisha & Tiki on Aug 2, 2022 7:56:39 GMT -7
Update: tiky’s vet seemed very aware of treating IVDD. New medication plan is as follows:
Prednisone: 5mg for 7 days then begin taper
Amantadine: finish current scrip (3 more days) then stop
▼Gabapentin: 100 mg every 6 hours
✙Methocarbamol: 125 mg every 12 hours
Traumeel: 1 tablet every 8 hours
[MED LIST/HISTORY- Moderator's Note. Please do not edit ]
16 lbs 14.5 y.o.
7/22 neuro wobbly; pain shivering, vocalizing
Galliprant stopped 7/22 No Rx for 5-7 day washout!
Prednisone ER as of 7/24: 3.75 mgs 2x/day for 5 days, 7/29 a test taper for: 8/1pain / _neuro
local vet as of 8/1: 5mgs for 7 days, 8/8 test taper: _pain/_neuro
amantidine 25 mg 2x/day to stop 8/4
gabapentin ▼100 mg 4x/day
✙Methocarbamol 125mgs 2x/day
Tramadol: 25 mg 3x/day STOPPED?
Tiki needs Pepcid AC, on board w/Pred!]
Tiky seems to be resting now. We will f/u in one week.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,928
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Post by PaulaM on Aug 2, 2022 10:54:02 GMT -7
Trisha, was traMADol 25 mgs 3x/day stopped?
Hope to hear all pain continues to be in check right up to the next dose of pain meds.
At the hands on exam what did your vet say? Did he detect any discomfort or pain in addition to your reporting panting?
On the 8/8 pred taper, which does your vet want for the pain meds (gabapentin, methocarbamol, traMADol)
--- backing down on 8/8 in mgs/frequency? OR
--- full stop of all pain meds?
What is the stumbling block to get acid suppressor Pepcid AC (famotidine) on board for 16lbs Tiki: 5mgs every 12 hours?
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