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Question Posted June 29, 2005
If someone can think of other treatment options for a 12 year old lab patient of mine named Jacque, I would appreciate it. He weighs 57#.
His diagnosis at OSU included the following larygeal paralysis, degenerative arthritis of elbows with decreased range of motion, moderate to severe arthritis of hips, chronic compression of C6-7, T13-L1.
He walks like he hurts but is happy in all other ways but coughs due to larygeal paralysis. His bloodwork is unremarkable. His owner wants to do what is best for Jacque so she is willing to pursue surgery to fix the larygeal paralysis so he can exercise.
This combination of meds has helped the most but now he is not responding as well.
Does not tolerate NSAIDS.(Metacam, Deramax, ..)
100 mg gabapentin
50 mg tramadol BID-TID
4mg Medrol BID
Glucosamine, Omega 3
Duralactin
I am starting him in in rehab, underwater treadmill, estim, ROM, ice, heat....low level laser and acupuncture...next week.
Please advise about better drug combinations and any other things that may help.
Tami Shearer
Response 1
How about adding amantadine as an NMDA receptor (wind-up pain) antagonist?
4.4-8.8mg/kg sid, or
2.2-4.4mg/kg bid
Some of the anesthesia gurus suggest a day or so, in hospital on a CRI drip (ketamine or morphine, etc) to get the pain under control. Good sight for CRI's, and other stuff is www.VASG.org . As, well as the gurus, here.
Kathy Morris-Stilwell
Response 2
What is Duralactin?
Craig Maloney
Response 3
Having seen a dog just like this recently, at our hospital, this dog would be getting at least 100 - 150 mg tramadol TID (that's 4 - 6 mg/kg) and I would be using 200 mg BID of gabapentin.
Our "n" of using these meds together at these dosages (usually we also have an NSAID on board - the duralactin should fill that slot nicely) is about 50 over the past year and our results are positive and reproducible.
Best wishes with this case!
Robin Downing
Response 4
Duralactin is a microlactin which is a dried milk protein. Studies show it helps with chronic inflammation and is considered an immuno-nutritional. I do not remember the study but it was a double blind well documented.
Tami Shearer
Response 5
What kind of exercises for a dog with those four major orthopaedic and neurosurgical conditions would have? What kind of exercise should a dog suffering four major orthopedic-neurosurgical conditions, have?
George M. Kazakos
Response 6
Merial now has Previcox approved which in trials has tended to have fewer GI side effects than other NSAIDS. Similar pain relief with Deramaxx.
Bill B. Moore
Response 7
As a food animal vet I have to say my first reaction was why. Thinking of it further as a dog owner I am now thinking how.
I look forward to the responses as I have to say your recommended therapies caught this old pet vet many years and attitudes of clients removed off guard.Looking forward to the pain and therapy related dialogue.This one caught me emotionally off guard.
Mike Sheridan
Response 8
In response to George's email: I have a rehab practice and deal with this all the time. There are many exercises the dog can do. However, the laryngeal paralysis (until repaired) will pose the biggest problem. I will not exercise a dog i suspect to have laryngeal paralysis until a surgeon gives me the ok. My rehab practice is not equipped to deal with the hypoxic animal and certainly don't want a dog to die in my underwater treadmill. however, underwater treadmill or land treadmill, sit to stands, weight shifting, balance boards, trunk stabilizations, active and passive cervical ROM, dancing (depending upon how sore his hips are), manual unloading of limbs, cone weaving, cavalletti's, etc. Are all good for this dog, plus acupuncture, therapeutic ultrasound, possibly TENS or NMES, PST, etc.
Kim Danoff
Response 9
I would consider titrating tramadol and gabapentin doses upward. Adding amantadine may prove helpful. Some older dogs do not tolerate high doses of tramadol; methadone is a reasonable alternative (and venlafaxine can be titrated in to provide norepinephrine & serotonin reuptake inhibition, if needed).
Intra-articular injections of hyaluronan followed by regular IM dosing of PSGAG (e.g. Adequan) can be very effective in some of these chronic arthritic cases.
Michael Tomasic
Response 10
I agree with Michael's comments regarding tramadol, gabapentin and
amantadine, and also Adequan. One comment on methadone: here at NCSU, we (Butch KuKanich, myself and Mark Papich) started to evaluate the kinetics and efficacy of oral methadone in dogs, but could not measure it in the plasma (with an assay sensitive enough to detect levels well below that usually found in humans, see details of assay: Kukanich B, Lascelles BDX, Papich M. (2005) Validation of a high pressure liquid chromatography and florescence polarization immunoassay for the determination of methadone in canine plasma. Therapeutic Drug Monitoring 27: 389-392).
In one dog of the group, we could measure reasonable levels. Although this may not reflect the whole population of dogs, it does raise doubts as to the predictability of ORAL methadone as an analgesic in dogs.
Duncan Lascelles
Response 11
Following up on oral methadone which was a collaboration between Duncan Lascelles, Mark Papich, Katrina Mealey, myself and Anna Aman. 0/6 dogs had detectable plasma concentrations following oral administration of methadone 2 mg/kg. Only 1 dog had low plasma concentrations of methadone when pretreated with multiple doses of ketoconazole (a potent CYP3A inhibitor). This data has been published as an abstract through the Merck-Merial Scholars program (2004)and is currently in press with JVPT. Methadone like almost all of the opiates is poorly and erratically absorbed orally precluding their use. Tramadol is the only non-NSAID analgesic which has been conclusively demonstrated to be absorbed relatively well orally, but is still somehat variable.
Tramadol's effect is partly due to it's actions on serotonin receptors. Serotonin syndrome is of consequence to overstimulation of serotonin receptors (mental, autonomic, neurologic consequences, potential death), therefore tramadol should be used EXTREMELY cautiously with other serotonergic drugs (TCA's - clomipramine, etc.; SSRI's - fluoxetine, etc.; SNRI's - venlafaxine; St. Johns Wort). Additionally, tramadol should be used extremely cautiously in animals prone to seizures as it lowers the seizure threshold.
Butch KuKanich
Response 12
Duncan brings up an important point regarding drug usage. Many of the drugs used in an attempt to control pain in animals are not well studied in the treated species. It is prudent to titrate doses to effect--remembering that no drug has a single effect. Even with regard to drugs that are well studied, we probably have all experienced the sometimes significant variation in response to a given dose. Certainly some of that variation may be due to the physical status of the patient at the moment (acid-base status, adrenergic activity, cardiovascular status, etc), but some may also be due to the normal kinetics of the drug for that individual.
Michael Tomasic
Response 13
I'd be interested to know whether you believe the pain is related to the hips or to potential nerve root compression (back or neck). If the pain is severe (suggested by the subject line and variety of meds), perhaps non-medical avenues might be considered?? I certainly understand palliating an older animal, but if the pain is radicular/nerve root in origin, decompressive surgery may potentially remove the source of the problem. Any spinal pain on palpation? New hip?
Christopher L. Mariani
Response 14
Interesting PK data about methadone in dogs. Did you also do PD? If yes, any prelim results?
Louis-Philippe de Lorimier
Response 15
Adequan is a good adjunct (as has been mentioned) and I would not hesitate to add in essential fatty acids.
I guess the stupid thing to ask (since dx made at my alma mater - OSU) is: are you sure hypothyroidism is not involved with laryngeal problem?
Jeff Rhody
Response 16
We were going to perform PD studies on methadone, but since we could not get the drug into them orally we did not. PK parameters for methadone were disappointing also with a short terminal half-life (<2h) and a high clearance.
Butch KuKanich
Response 17
The dog with multiple orthopedic/neurologic problems and laryngeal paralysis. I see many dogs that have similar mobility issues that do fine in day to day life until they develop laryngeal paralysis. You would be amazed at the energy level and pain tolerance increase you find once you have restored an airway that is adequate to allow them to return to the normal abilities of a geriatric patient. My experience is that the ortho/neuro signs can be significantly more apparent in dogs that suffer from laryngeal paralysis. I would definitely address the laryngeal paralysis first (unilateral arytenoid lateralization works extremely well and recovery is very quick) and then re-evaluate the degree orthopedic and neurologic impairment 4 weeks or so post-op. There is my occasional 2 cents. Hope is helps.
Mark B. Parchman
Response 16
I don't know what you mean with 57# but if # is = kg 50 mg is lower than 1 mg/kg. I had used tramadol between 2-5 mg/kg without important side effect, at 1 mg/kg I had seen more disphoric effect and no pain control. In my practice I use 2-5 mg/kg bid or tid of tramadol plus NSAID, usually Carprofen or meloxicam at the lower dose possible. For the use of tramadol in epileptic patients: there is a study in a head trauma center in UK that show no interaction with epilepsy on an high number of patients with convulsive syndrome.
Nicola Ronchetti
Response 17
The # symbol is used in the US for "pounds", not kilos. Another little quirck with our totally illogical language.
Doug Wyler