Christy's Carly 12/24 conservative; GRAD 2/18

help us with additional info on the med list please. Parts in pink letter are missing.

weight? age?
Prednisone 5mgs 1x/day for how many days?
gabapentin 100 mgs 3x/day
methocarbamol 125 mgs 3x/day
famotidine ?mgs 2x/day

Christy, call the vet. Should be no need of a risk to the disc of a car transport in to get the OK for traMADol. Vets who know IVDD know how important STRICT REST is— limited movement of the back:  dodgerslist.com/2020/05/14/strict-rest-recovery-process/

If Tramadol is not working for Carly, then vet should Rx another opiod to do the job in lieu or sythentic opiod traMADol.

An animal would not be interested in eating if in pain.  Maybe too painful to move to go out to pee.

Do you find urine leaks in bedding because you had had given her a chance to potty ever 2-3 hrs while on prednisone.  If taken out for potty opportunity and you find urine leaks, leaks on you when lifted, then she likely has lost bladder control and needs the bladder manually expressed.  More on that:  dodgerslist.com/2020/05/05/bladder-bowel-care/   Learning how to express with lesson from the vet would then be a health benefit that would be worth the risk of a car transport in for the hands on top of your hands lesson.

traMADol
Several studies have looked tramadol after its absorption into the body, and it seems that each dog's or even breed’s metabolism of the drug is different. Therefore, the best way to determine whether your dog's dosage is appropriate is by observing your dog while you're home.

1. Robin Downing, DVM, CVA, DAAPM is one of only four veterinarians in the world to hold the Diplomate credential in the American Academy of Pain Management - the largest interdisciplinary pain management organization in human medicine: Tramadol has an exceptionally short half-life in the dog (1.7 hours) making it pretty useless unless it is given at least TID. It is not a good choice as the “sole source of pain meds”. It is quite good when it is used alongside an NSAID or in conjunction with gabapentin.

2. The 2014 Kogel study of 15 beagles has this curious sentence in the conclusion:
Different breeds of dogs might not or only poorly respond to treatment with tramadol due to low metabolism of the drug. Tapentadol and morphine which act directly on μ-opioid receptors without the need for metabolic activation are demonstrated to induce potent antinociception in the experimental model used and should also provide a reliable pain management in the clinical situation. The non-opioid mechanisms of tramadol do not provide antinociception in this experimental setting. This contrasts to many clinical situations described in the literature, where tramadol appears to provide useful analgesia in dogs for post-operative pain relief and in more chronically pain states.  www.ncbi.nlm.nih.gov/pubmed/24576316
Kögel B1, Terlinden R, Schneider J. Characterisation of tramadol, morphine and tapentadol in an acute pain model in Beagle dogs.
Vet Anaesth Analg. 2014 May;41(3):297-304.

3. Some potential limitations of controlled clinical trials include that efficacy determined for one indication may not extrapolate to other disease conditions, the dose administered may not have been correct, the evaluating methods may not have been appropriate for the study, the study may not have had enough statistical power (sample size too small) to detect a true difference, the data may not be reproducible, and a perceived improvement was caused by random variability despite achieving a significant difference. Examples include that a drug effective for relieving osteoarthritis pain may not be effective for postoperative orthopedic pain and that the dose administered may have been too low and therefore lack of effect was only caused by lack of sufficient concentrations in the body...
There are few studies assessing the effects of tramadol administration to clinical canine patients in controlled clinical trials. Only 1 study reports the effects of oral tramadol in a blinded study using positive and negative controls, and these were in patients with osteoarthritis. ....
There are some data supporting tramadol use in clinical veterinary patients, but more studies need to be conducted to confirm its efficacy and safety in dogs and cats. Dogs may benefit from tramadol administered 4 to 10 mg/kg by mouth 3 times a day. However, the long-term efficacy of tramadol may decrease with time....Other studies are needed to fully describe the potential uses of tramadol in dogs and cats. KuKanich B. Outpatient oral analgesics in dogs and cats beyond nonsteroidal antiinflammatory drugs: An evidence-based approach. Vet Clin North Am Small Anim Pract 43(5):1109-1125, 2013. www.vetsmall.theclinics.com/article/S0195-5616(13)00112-5/pdf

My vet is closed for holiday and don’t open until Monday. I really don’t want to take her back to the original ER doc due to misinformation. I feel my only option is to take her to another ER but like you said transport is risky. I will call again and see if they can increase the Pred and give ok on Tramadol.

I called again and they refused bc the doc who evaluated her is not there now….so new doc needs to see her to provide tramadol.

Christy, could the other ER vet access Carly's file and prescribe adjustment to meds? How is Carly today? Legs, bladder control?

Christy, kudos to you for getting adjustments to meds.

Just a few comments to consider.
traMADol
-- If there is still pain, it is because for a 24 pound dog traMADol 25mgs 3x/day is low.  Veterinary Pharmacist KuKanich: "Dogs may benefit from tramadol administered 4 to 10 mg/kg by mouth 3 times a day." 
       24lbs/10.89kg Carly X 10 mgs traMADol = 100mgs dose 3x/day
At minimum traMADol whole 50mgs tablet 3x/day. With option to go 100mgs 3x/day if still pain surfacing.

What is the effect of dosing traMADol 25mgs 3x/day.
-- Did it relieve pain
-- Did pain surface before next doses of the three pain meds?

PREDNISONE
What date did you begin using the pills from the the 7-day course 5mgs 2x/day of prednisone? 12/26 or 12/27?

If you were carrying her and pressuring her tummy area, then YOU were expressing her in a way. The ONLY proof of bladder control is:
     1.  You set her down on an old pee spot when you know she should have to go.
     2. Make sure the sling is relaxed and not pressuring the tummy area.
    3. What for her to sniff an old pee spot. Does she attempt to circle?  You know the stuff dogs do when they are about to pee on their own.
    4. Then if you see urine released, that would indicate head level smelling and then proof message went from brain down to bladder muscles to release urine. Proof of bladder control

PILL NAME
What is the name of the pill, mgs dose, frequency?
 
--If she is still in pain, that could be a reason to not want to eat.
--If the famotidine along is not enough to suppress acids, as it normally is, then the pill should be SUCRALFATE.  Most dogs do well with famotidine alone. Some need sucralfate (a 2nd protector).  Please read up on sucralfate in case you need to phone in and advocate.
-- It is important to get to the root cause of why not eating so one knows which treatment.  The idea is not to induce hunger, but get rid of source of pain or get rid of too many stomach acids which can lead to bleeding ulcers.

Signs of Progression due to acid damage to stomach lining.
Nausea such as lip licking> not wanting to eat> vomit>  loose stool> bleeding ulcer>  red or black blood in diarrhea> perforated stomach lining

Christy, good to hear she is back to eating so likely famotidine is doing a good job of suppressing acids for her.

 FYI: not wanting to eat can be a sign of pain, could be a sign of  stomach damage, etc. It is your job to be a detective for the vet with your eyes and ears.  Reporting your observations helps a vet to determine what the correct treatment approach should be.

Curious: What is the name of the pill the vet suggested for not wanting to eat? 

PREDNISONE
Please clarify the dates for the two courses of prednisone.

Prednisone as of 12/24: 5mgs 1x/day for 3 days, 12/27 taper test: _pain/_neuro
                        as of 12/26? 5mgs 2x/day for 7 days, then 1/7? TEST taper: _pain/_neuro

-- 1st course 5mgs 1x/day was started on 12/24 for 3 days, taper on 12/27, is this CORRECT?
-- 2nd course 5mgs 2x/day for 7 days was started on what date?

PAIN
--- If there is currently pain when moving or when nearing the next dose of  pain meds, THEN you would alert your vet to see if meds can be adjusted, added, etc.  
--- If pain is now being fully managed round the clock, when having to move and nearing the next dose of pain meds, then would not seem there is any need to adjust meds.

Being able to sniff (head level) an old pee spot and then observing the dog release urine is proof a dog has bladder control.
   Leaking on you when lifted is a sign of lack of bladder control.

Christy, it would be very helpful to always use the date. Please clarify the conflicting information. We calculate when the pred taper starts dependent on the start date.

What was the start date for prednisone pills 5mgs 2x/day?
FYI: Date in brackets and italics is our calculated date based on info given.

STOMACH PROTECTION MEDS:
Pepcid works to suppress acids.  Sucralfate works to bandaid and help with stomach lining healing when Pepcid alone had not been sufficient protection. 
    SUCRALFATE– Carafate® is a prescription product. Any sign of GI tract damage, advocate for this to be added to Pepcid AC. Most dogs do fine with Pepcid alone. A small number of dogs, however, may show stomach damage signs starting where sucralfate is AN ADDITION to the Pepcid AC doses.
        Progression of SIGNS: Nausea such as lip licking> not wanting to eat> vomit> loose stool> bleeding ulcer> red or black blood in diarrhea> perforated stomach lining
    Learn more about the stomach protectors here:  dodgerslist.com/2020/05/06/stomach-protection/

Do let us know how the discussion goes with your vet if there is not eating due to pain or if he suspects there may be beginning signs of GI damage due to prednisone.  And he decides that sucralfate is needed.

Christy, Sucralfate is for stomach ulcerations.  If you search for SUCRALFATE on the forum you will see neuros and general DVM vets will prescribe when a dog is showing the early warning signs listed for you in last post.  Vets who know IVDD are not wanting to take a chance of adding an ulcer situation on top of a disc episode.

Since Carly is on a prednisone which is known to cause GI problems, most vets would want to attack the most likely cause of too much acids causing not wanting to eat.  So if you have ruled out she is not in pain, it could be likely stomach acids.  We are  not vets. We can't exam your dog. We can give you some background information, links, etc. to aid you in presenting your concerns and why you are advocating for XYZ.

Does traMADol 50mgs 3x/day   improve her wanting to eat?

What kind of vet is the "she" who won't Rx sucralfate--- er vet, your own vet?

If your own DVM vet, how about calling back the ER vet or the one now on ER duty who can access Carly's file at ER clinic and Rx sucralfate.

Look at our member's Directory for recommendations for a vet:  dodgerslist.boards.net/board/13/member-reported-surgery-costs-recommendations

Christy good job done on two fronts!!
   •  You successfully advocated for traMADol 3x/day.
   •  You monitored and observed Carly interested in eating again. So that rules out "not eating" wasn't due to stomach problems.

We don't know enough information about the tapering that is scheduled to start on Tues Jan 3. Anytime you mention a med change to make any sense at all it must include "name of med"  "dose in mgs"   "how often given"
We would like to follow along by knowing the vet's taper schedule
--- as of 12/27 5mgs 2x/day for 7 days, then 1/3 TEST taper for: _pain/_neuro
    -- 1/3 taper doses pred ?mgs 1x/day for 7 days
    -- 1/10 taper doses pred ?mgs 1 dose every other day (EOD) for ? days

As long as there are pain meds on board, you, naturally, will not be able to quickly and accurately monitor pain! 
    • All three of the pain meds block pain the pain signs you would be monitoring!  
    • Check with your vet about stopping each of the 3 pain meds on Jan 3 along with the pred tapering start date.

 Have a Plan B worked out with your vet should the prednisone taper reveal pain surfacing when she is closed.
    • You will expect pred would go back to the original anti-inflammatory level 5mgs 2x/day dose for a bit longer.
    • You need your vet's confirmation and enough pills on hand should you see pain or neuro diminishment surfacing on the prednisone taper til you can contact her by phone to report things.

Christy, fingers crossed for a good taper (no pain, no new/increased neuro diminishment!

Hope no signs will surface indicating a need for another course of pred and pain meds back on board.

Please keep us posted as the tapers progresses.

Christy, you are right!  Stay the course to complete all 8 weeks to allow the disc to heal.

The meds took care of the painful swelling is seems. You will know for sure with the final dose of pred.

Mark your calendar for graduation day on Feb 18.  Then we will have lots of tips and ideas for safely and gradually transitioning Carly back to family life and activity.