Jack's Coco 10/14rlapse conserv.-NECK Doberman; GRAD 12/9

Wow, so much great info. I will get back with answers as best as I can soon to all your questions. Thanks

Thanks again. Here are most answers to the questions, in no particular order:

GI Tract: No current negative signs now. The only episode was around 9/29/22 after coco was released from her first 2 day stint at the ER hospital. It could have been due to too short a wash out period (i.e., I was giving her Rimadyl (100mg split over 2 doses a day) prior to going to the ER, and I think I recall them saying they were waiting a full day or two to switch over to the steroid. That may not have been long enough). Because of the episode (they didn't fully blame the short wash out period), they cut out Omeprazole and cut the Dexamethasone dose down from 2X a day to 1X a day (.75mg tabs).

Recent increased pain: Coco had improved nicely from about 10/1 (second release from ER vomiting /diarreah episode) to 10/13 (2 days after her first follow up at the ER). Increase in pain was not due to steroid tapering. Most likely it was increased movement (i.e., I had started giving her small walks and her crate/room space was not confined enough and once she bumped her head on a door). Date of 5 minute walk was about 10/13. Pain increase was likely that night into following morning.

Left Paw: It's the front left paw that she holds out flamingo style and puts very little pressure on it. She will routinely lick this paw right after eating. And, with the paw as described, she certainly limps.

Conservative treatment: I was mostly on board with everything. My faults were sleeping in same space and allowing some extra movement (short walks). That will be no more.

Current Meds line-up: After reaching the ER vet by phone and local visit to my primary vet,
▲tramadol is now 2 pills (100mg total) every 6 hours, vs. every 8 hours. Note, while she was doing well from 10/1 to 10/13, I was only giving 1 Tramadol pill per day.
▲Gabapentin from 200mg 3X a day (every 8 hours) to now 200mg 4X a day (every 6 hours). Steroid: After the 9/29 vomiting/etc.
▲Dexamethasone was taken down from 2 pills per day at .75mg to 1 pill per day at .75mg. Now, it was adjusted upward as of 10/14 back to the 2X per day dosing.

[ MED LIST/HISTORY- Moderator's Note. Please do not edit 
55 lbs 9 y.o.
MRI 9/25
Rimadyl as of  9/21: 50 mgs 2x/day for 4 days; stop date 9/25. No 5-7 day washout causes 9/27-9/29 diarrhea! No double GI protection of Omeprazole & Sucralfate given!)
dexamethasone 0.75mg tab , ER vet 
          as of   9/27:  0.75 mgs 2x/day for 2 days; 9/29 taper doses due to diarrhea
          as of 10/14:  0.75 mgs 2x/day for ? days; then a test taper for _pain/ _neuro
10/13-14 +5-min walks
10/14 flamingo front left paw pain surfaces
traMADol 100mgs ▲4x/day
gabapentin 200 mgs ▲4x/day
Omeprazole stopped 9/27
Pepcid AC  20mgs 1x/day
10/11 Follow up exam: improvement of pain ] 

So far, this increased frequency (every 6 hours) and higher dosage has at least cut down most of coco's vocalizing pain and she is getting decent sleep (only being interrupted when she wets her wee wee pads).

MRI Report: Quote THIS MRI WAS DONE ON 9/25/22

Thanks again Paula:

Answers are:

1) Rimadyl prescribed on 9/21 and stopped by me on ~9/25 when coco first brought to ER. I was giving two 50mg doses a day (basically split the 100mg big pill in half).

2) DEXAMETHASONE: Each whole tab is .75mg

History of Dexa:
On first release from ER, I gave two .75 tabs per day (1.5mg total) on the days of approx 9/27 and 9/28. Then she was rushed in to the vet on 9/29 for the vomiting/etc. episode. On this second release from the ER on ~10/1, we cut back Dexa to one .75 whole tab per day as doc thought that may be contributing to stomach upset. Then on 10/14, when more pain came back, Dexa was bumped back up to two .75 tabs per day (1.5mg total).

Dexa tablets weren't split up.

▲Pepcid:
I now give two 20mg tabs per day, timed 30 minutes before the dexa dose.

[ MED LIST/HISTORY- Moderator's Note. Please do not edit
55 lbs 9 y.o.
MRI 9/25
Rimadyl as of 9/21: 50 mgs 2x/day for 4 days; stop date 9/25. No 5-7 day washout causes 9/27-9/29 diarrhea! Nor double GI protection of Omeprazole & Sucralfate given!)
dexamethasone 0.75mg tab , ER vet: 
                        as of 9/27: 0.75 mgs 2x/day for 2 days; 9/29 taper doses due to diarrhea
                        as of 10/14: 0.75 mgs 2x/day for ? days; then a test taper for _pain/ _neuro
10/13-14  5-min walks
10/14   flamingo front left paw pain surfaces
traMADol 100mgs 4x/day
gabapentin 200 mgs 4x/day
Omeprazole stopped 9/27
Pepcid AC (famotidine)  20mgs ▲2x/day]

Jack, hope to hear since you are still reporting pain, you did get a vet to help adding methocarbamol 3x/day to the med list.  What kind of vet helped?

Pain hinders healing. Be persnickety that Coco is in comfort.  Once achieved and good principals of STRICT rest, Coco has the best chance to heal the disc and with time get resolution of the painfully aggravated  C7 nerve root compression coming off of spinal cord.

Here is what a nerve root being pressured by the bad neck disc looks like. The spinal cord is a bundle of nerves (yellow). Nerve root exiting the cord going to the front leg, is being painfully pinched by escaping/bulging disc material (dark blue). 

DVM, ER DVM Vet, Specialist vet?
What kind of vet prescribed increases in traMADol & gabapentin?  
What kind of vet increased DEX back up to the anti-inflammatory dose 0.75mgs 2x/day?

The picture presented with your providing information, indicates:
-- There could well have been a disc relapse of either the C6-C7 or even the older C5-C6. Relapse meaning the disc scar tissue forming could have been disrupted allowing more material to escape.   AND/OR....
-- There could be increased pain due to the DEX tapering process started on 9/29 thru 10/14. The taper is the time to monitor for any surfacing pain and any increased/new neuro damage.  Pain/neuro indicates another course of DEX.
-- So basically there is no way to know for sure if pain surfaced due to DEX tapering or if excessive moment of 10/13-14 caused by 5-minute walks.
-- It would seem the prudent course of action is to assume the worst... excessive movement caused disc scar tissue disruption and the need to start back at square one with 8 weeks of disc healing.

The focus on the 8 weeks of rest is to get the disc to heal and form strong scar tissue. No PT, no meandering at potty time, only a few minimal "footsteps" to take care of business. Weigh the risk vs. benefit of transports into clinics.... only the most urgent of health situations that simply can not be addressed over the phone. It is especially so with large/heavy dogs, that a transport is tricky in keeping the spine with limited movement.

STOMACH PROTECTION
Anti-inflammatory drugs can be truly a wonderful aid in bringing down inflammation.  On the other hand they can cause serious damage of bleeding ulcers. Be an advocate for Coco by being in the know how anti-inflammatory drugs during a disc episode can be used in safety.
--- When an emergency switch is needed from the lessor class (NSAIDs such as Rimadyl) to the more powerful class (steroids such as Dex) a 5-7 day washout may not be reasonable. Instead vets DOUBLE PROTECT the stomach lining with:    
    • Pepcid AC (famotidine) works in 30 mins + sucralfate
    • Omeprazole takes 3-5 days to reach peak efficiency, thus not a good choice with a disc episode. Once peak has been reached, Omeprazole does a very good job.
   
Worth your while to be able to protect Coco in the future, excellent reading:  dodgerslist.com/2020/05/06/stomach-protection/
    • Since Coco has suffered DEX stomach damage, be sure to monitor the progressive signs. IF there would even be a hint of a first sign, advocate strongly that not only Pepcid AC (famotidine) be on board but also a 2nd called sucralfate, a prescription med.
     GI TRACT DAMAGE signs: lip licking nausea> not eating or drinking well> vomit> loose stool> bleeding ulcer>  red or black blood in diarrhea. 

For how many days is the 2nd 10/14 DEX course to be given 0.75mgs 2x/day?  This is very important information for YOU and for us.
    -- On the date DEX tapering start date, you have a job at home to monitor for pain.
    -- In order to do your job, blindfolds typically come off. Pain meds (methocarbamol, gabapentin and traMADol) blindfold from correctly monitoring for pain.  Let us know your vet is on board with you monitoring for pain on the Dex taper date with the stop of pain meds same day.
    
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Jack, with pain surfacing before the next dose of the pain meds, that indicates the pain meds are not yet right as mentioned in my 10/19 morning post.  Can you/did you call asap this am to advocate for Methocarmabol?    It is well known that a combo of pain meds which cover all three sources of pain is the better way to go.  Right now only 2 out of the three sources of pain are covered with traMADol/gabapentin combo.  It is not fair that Coco is needlessly suffering when there are still options to get that pain fully in control round the clock, dose to dose of  pain meds.  DEX is going to take up to 30 days to finally resolve painful swelling/inflammation.  In the meantime Coco deserves to heal in comfort.  Pain actually hinders the healing process.

It seems that you may not be getting posts in a timely manner. Your registering can fix that problem. Registration allows you to receive an automated email when there is a reply waiting for you to read.  Let us know if there is any stumbling block we could help you with registering.

Med administration
A smaller portion of the meal could be given especially along with the anti-inflammatory DEX.
   --TraMADol and Gabapentin can be given with a meal and can be given with the anti-inflammatory DEX.  
   -- Pepcid AC is the workhorse to suppress stomach acid production. The meal is for added stomach protection with DEX. 
   -- Read up on all meds you give. If your vet did not give you the info sheet with an Rx, find that info at my favorite Mar Vista Animal Medical Center:   marvistavet.com/siteSearch/view/277964_SiteSearch.pml
      • Gabapentin is well absorbed in rats, dogs and in humans, with maximum blood levels, reached within 1-3 h after oral administration Vollmer KO, von Hodenberg A, Kölle EU. Pharmacokinetics and metabolism of gabapentin in rat, dog and man. Arzneimittelforschung. 1986 May;36(5):830-9. PMID: 3730018.
    • NOTE: Pepcid AC (famotidine) is a special kind of antihistimine that does not contain any metal salts.  Read up on famotidine: marvistavet.com/famotidine.pml
    If you take an antacid that contains aluminum or magnesium, wait at least 2 hours before taking gabapentin. Some examples of these antacids are Di-Gel®, Gaviscon®, Gelusil®, Maalox® and Mylanta®.  Mayo Clinic.  www.mayoclinic.org/drugs-supplements/gabapentin-oral-route/precautions/drg-20064011?p=1
  
QUESTIONS
   What is Coco's normal diet including what you feed currently:  Raw, dry kibble, wet dog food.
     brand? or home prepared?

Do bring us up to speed on these things:
-- What kind of vet prescribed increases in traMADol & gabapentin?
-- What kind of vet increased DEX back up to the anti-inflammatory dose 0.75mgs 2x/day?
-- For how many days is the 2nd 10/14 DEX course to be given 0.75mgs 2x/day?
-- Let us know your vet has commented about you monitoring for pain on the Dex taper date with the stop of pain meds same day.

In general, both tramadol and gabapentin can be taken with or without food. If you are concerned that Coco's meds seem to take a long time kicking in, try the smaller meal. All dogs are different. If I am understanding your post correctly, she was given the meds at 4:30, but pain did not appear until 7:30?  "...didn't seem agitated and in pain until about 7:30 am today" Since both these meds should still be effective between the 4:30 dose and the 7:30 appearance of pain, it is possible that the meds were absorbed slowly. But if this was the case, I would have expected pain to become apparent earlier rather than 3 hours later.

If your regular vet knows IVDD or is willing to educate himself, you may not need to return to the ER vet. The vet must be willing to adjust pain meds when needed and understand how anti-inflammatories are used in IVDD. As your vet was okay with the ER vet upping the dosage, he may be able to work with you through this episode. Most vets are familiar with the need to taper steroids, and your regular vet should be able to give you instructions on that.

Jack, ERs are not designed for over seeing Coco's treatment over the 8 weeks of conservative treatment. That is your local DVM vet's job. Call your local vet and and see if he will prescribe over the phone, methocarbamol.  If he has not ever seen Coco for this disc episode, he may need to first examine before prescribing.  Your local vet will also be the one to supervise the use of DEX and it's tapering doses.

It may be for Coco that a fatty meal is not the best thing. In fact during a disc episode, you do not want to be feeding your dog fatty foods. Fats/oils can cause similar symptoms of loose stool making it confusing whether a dangerous GI issue or temporary food feeding issue.

QUESTION
What is Coco's normal diet including what you feed currently: Raw, dry kibble, wet dog food.
brand? or home prepared?

Do know that once pain has ramped up it can take longer to get it back in control.  The advantage of a 3-way pain med combo (traMADol, gabapentin and methocarbamol) is that each of the three sources of pain are being addressed and less likley to have pain ramping up but able to stay on an even keel.

Jack, vets who know IVDD appreciate the need for carefully protecting the disc with limited movment. They appreciate the difficulty in doing that for large breed dogs and car transports. Vets who know IVDD, will handle things over the phone such as med adjustments, updates from you, etc.

Vet your vets! Learn as much as you can about IVDD so you can bring things to the table for discussion and determine who to hire to be on Coco' IVDD health care team.  Anyway this is what most of us have found out not all vets can know every disease for all the many species they treat (cats, dogs, farm animals, birds, etc). During the course of a day they might be a pediatrician, a dentist, a surgeon, a dermatologist, etc. With our own doctors who treat one species (the human one) they will often refer you to a specialist dermatologist, surgeon, dentist, etc.   
    Dr. Nancy Kay, DVM, ACVIM has hit it on the nail especially with IVDD. Each of us needs to be self educated so we can team up to work with our vet and if need be hire an IVDD knowledgeable vet.
It is good you got a range for gabapentin doses.  What we need to know is what are you actually dosing at?
    300mgs 3x/day  OR    300mg 4x/day

Also for how many days  is DEX to remain at anti-inflammatory level of 0.75 mgs 2x/day ?

Coco had a bad pain [10/23] night last Sunday. Since then, I was able to get script for ✙methocarbamol and ✙amantadine. Plus, we did a first session of acupuncture and laser. She seems to have stabilized well and without obviously apparent pain over last few days.

MED LIST/HISTORY- Moderator's Note. Please do not edit
55 lbs 9 y.o.
MRI 9/25
Rimadyl as of 9/21: 50 mgs 2x/day for 4 days; stop date 9/25. No 5-7 day washout causes      
                          9/27-9/29 diarrhea! No double GI protection of Omeprazole & Sucralfate given!)
10/13-14 +5-min walks
10/14 flamingo front left paw pain surfaces
10/11 Follow up exam: improvement of pain
10/23 increased pain
dexamethasone 0.75mg tab , ER vet 
                        as of 9/27: 0.75 mgs 2x/day for 2 days; 9/29 taper doses due to diarrhea
                        as of 10/14: 0.75 mgs 2x/day for ? days; then a test taper for _pain/ _neuro
traMADol ▼50mgs 4x/day
gabapentin ▼200 mgs 4x/day
✙Methocarbamol: 500 mgs 3x/day
✙Amantidine  NOT GIVEN
Pepcid AC 20mgs 2x/day]

Meds update:
▼Tramadol: decrease to 50mg and remains at 4X day dosing
▼GABA: decrease to 200mg and remains at 4X dosing
Dexa: remains at .75mg at 2x day
✙Metho: 3X day at 500mg each
✙Amantadine: I haven’t given yet. I want to see if the above covers pain before adding another med.

Hi, the ER vet prescribed the methocarbamol (after I asked). Both the ER doc and an in-home vet I called suggested the Amantadine. I did the ER doc visit via a phone consult; they weren't for this, but I demanded it saying I was not going to risk further injury by transporting her for the 70 mile drive!

Quick update on Coco: Was improving nicely all week. Last night at 2am, she [11/2] became very restless. Was in definite pain. Yelped once. Low-level whining. And repositioned herself multiple times in rapid fire fashion.

There was no physical event (running, jumping, etc.) that could explain this. The "only" difference was that she had electroacupuncture [11/2] about 12 hours prior. Could acupuncture trigger a pain episode??? This was her 2nd ever session. Last week's session she was more highly medicated, so perhaps all the meds covered any pain. This week though, she was on less meds. So, perhaps pain broke through??

Simple question: At early stages of acupuncture treatment, could residual effect from a treatment cause a break through pain episode in dogs?? Thanks

Thanks. I was there for the whole session (in my home) and no signs of any pain
when needles were inserted.

From my 11/1 phone consult with ER doc's office, we lowered Tramadol only. So most current meds line-up at the time of acupuncture on 11/2 was:

Tramadol: 50mg 3x day (down from 50mg 4x day) = 150mg total
Gabapentin remains at 200mg (4X a day) = 800mg total
Methocarbamol remains at 500mg (3x day) = 1500mg total
Dexamethasone remains at .75mg (2X a day) = 1.5mg total
Pepcid 20mg (2x day)

MED LIST/HISTORY- Moderator's Note. Please do not edit
55 lbs/ 24.95 kg 9 y.o.
MRI 9/25
Rimadyl as of 9/21: 50 mgs 2x/day for 4 days; stop date 9/25.
10/13-14 +5-min walks
10/14 flamingo front left paw pain surfaces
10/11 Follow up exam: improvement of pain
10/23 increased pain
11/2 at home electroacupuncture treatments
dexamethasone 0.75mg tab , ER vet
                        as of 9/27: 0.75 mgs 2x/day for 2 days; 9/29 taper doses due to diarrhea
                        as of 10/14: 0.75 mgs 2x/day for 21+? days; then a test taper for _pain/ _neuro
traMADol      50mgs ▼3x/day on 11/1 -pain 11/2
                  ▲100mgs ▼2x/day as of 11/2
gabapentin  200 mgs 4x/day
Methocarbamol: 500 mgs 3x/day
✙Amantidine  100mgs 1x/day as of 11/2
Pepcid AC 20mgs 2x/day]

I was holding off on giving the Amantadine since we were doing fine for this past week. Last night's obvious pain break through was enough for me to start ✙Amantadine (100mg 1X day). With this addition of Amantadine, the ER doc and other in-home vet indicated (if I used the Amantadine) we could look to taper (and finally get off of) the Tramadol. So, as of today, I added the Amantadine at the 1X 100mg dosage. And, on my own, I'm taking ▼Tramadol back to a 2X a day frequency at 100mg each (rather than 3X). Too early to judge, but Coco has definitely calmed down from last night's restless movements.

Yes, Tramadol may need to be boosted back up and I'm keeping close watch.

One of the biggest things now, with all the sedating meds (and the steroid) is that she is basically just leaking urine. I'm going through lots of wee wee pads. The leaking (and wetness on pads) will wake her up multiple times throughout the day/night, disturbing the good sleep.

I guess it's a balance of managing pain vs. excessive/uncontrolled urination.

Hi Paula, thanks again for all the suggestions. With the excessive/uncontrolled urination, I think I will do the decaf tea and ointment. I have been pretty diligent in cleaning coco with a wet cloth as well as unscented baby wipes.

Regarding diapers, I bought a bunch of them weeks ago, but wasn't a fan as she'd pee so much that leaking would still occur on the bedding. Plus, I was afraid they would cause skin irritation. And, you mentioned it was only a short-term fix anyway.

First things first, my meds routine (as of 11/1 - 11/3 and prior to calling ER vet office again on 11/4) was: Tramadol (50mg at ~3X day = ~150mg total), gabapentin (200mg x 4X day = 800 total), Dexamethasone (.75mg x 2X day = 1.5mg), Methocarbamol (500mg x 3X day = 1500 total), pepcid (20mg x 2X day). I had not yet administered Amantadine on my own since coco appeared out of obvious pain. (As a reminder, weeks ago we reached our highest dosages of Tramadol at 400mg total/day and gabapentin at roughly 1000mg/day with a 4X day dose schedule.)

From a week's earlier phone consult with ER doc on ~10/24, she said to keep Dexa as is (2X day) since, at that time, Coco was still having breakthrough pain episodes. At that time, she ok'd scripts for Methocarbamol and Amantadine. So, no taper of steroid yet.

We have not tapered the steroid yet. But, we did start lowering pain meds more (see reason below) and there was clear breakthrough pain.

Fast forwarding to yesterday (11/4 in am). I called the ER place and spoke to the vet tech. I never can just reach the doc and I really don't have full confidence in the vet tech. Anyway, I described my latest worry that, with the current meds schedule (and the recent addition of our first dose of Amantadine on 11/3), that coco's urination/incontinence/uncontrolled leaking got out of hand. She could never stay still/relax in her crate as she'd jump up (from her sleep) with every drop that leaked out. Hearing this, the vet tech suggested, to help with over-sedation/peeing, I take Tramadol down to only 100mg/day total and gaba to 400mg/day total. Well, I started out at this rate on 11/4 (which meant I didn't take our regular noontime gaba dose), but couldn't make it through the early afternoon as coco was crying a lot. Her peeing did slow down, but the pain is a worse thing than peeing, so I decided to just get her back to her normal dosing schedule (plus the addition of Amantadine). Also, on 11/4, the tech suggested only 750mg total of methocarbamol per day spread over 3 doses.

So, with this pain too unbearable to see, as of writing this reply on 11/5, I was thinking (and started) the following:
-▲ Tramadol (50mg 4X day for 200 total or possibly higher as we've once hit as high as 400)
- gaba (200mg at 4X day); perhaps up to 900mg total
- Dexa (stay the course at .75mg at 2X day)
- Methocarbamol (get right back up to 3X a day at 500mg for 1500 total)
- Amantadine (do 100mg or 120mg at 1X day)

MED LIST/HISTORY- Moderator's Note. Please do not edit
55 lbs/ 24.95 kg 9 y.o.
MRI 9/25
Rimadyl as of 9/21: 50 mgs 2x/day for 4 days; stop date 9/25.
10/13-14 +5-min walks
10/14 flamingo front left paw pain surfaces
10/11 Follow up exam: improvement of pain
10/23 increased pain
11/2 at home electroacupuncture treatments
dexamethasone 0.75mg tab , ER vet
                as of 9/27: 0.75 mgs 2x/day for 2 days; 9/29 taper doses due to diarrhea
                as of 10/14: 0.75 mgs 2x/day for 21+? days; then a test taper for _pain/ _neuro
traMADol 50mgs ▲4x/day
gabapentin 200 mgs 4x/day
Methocarbamol: 500 mgs 3x/day
Amantidine 100mgs 1x/day
Pepcid AC 20mgs 2x/day]

This is so confusing, especially as the docs are so hard to reach. I did schedule a neurologist appointment near me at another ER vet, but the waiting period was a full month and is coming up on 11/14. It's so discouraging.

Coco is in pain right now a full 100 minutes after her last dosing. I wonder if her condition is getting worse? I have been very good crating her with no activity other than quick potty breaks. These past few days, she hasn't even wanted to walk outside to pee.

The vet tech assumed that was from the over-sedation. I tended to agree, as coco will venture outside at the tail-end of the dosing window (once the meds start wearing off).

I am really upset/sad, and wonder the following... With each of these pain episodes that break through, if it's due at all to worsening of the condition, does our time clock start back at square 1?? It feels like the last 4/5 weeks of 24/7 oversight may have not counted for much if the clock starts all over again. I do hope this disc has made some progress toward healing.

Feeling kind of lost now . Appreciate your support and insight always. thanks

Thanks,  I have gone up to 100mg every 6 hours from traMADol before, so I may have to work my way towards that very soon. Her noon dose today was [▲traMADol] 100mg, so we will perhaps do that again at 6pm and midnight to get us at that level. Good suggestion about uti urine sample. Thanks!

MED LIST/HISTORY- Moderator's Note. Please do not edit
55 lbs/24.95 kg     9 y.o.
11/4 pain surfaced at lowering of sedation pain meds
dexamethasone 0.75mg tab , ER vet
            as of 9/27: 0.75 mgs 2x/day for 2 days; 9/29 taper doses due to diarrhea
            as of 10/14: 0.75 mgs 2x/day for 21+? days; then a test taper for _pain/ _neuro
traMADol ▲100mgs 4x/day
gabapentin 200 mgs 4x/day
Methocarbamol: 500 mgs 3x/day
Amantidine 100mgs 1x/day
Pepcid AC 20mgs 2x/day]