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Question Posted June 20, 2006
At this point, I have tried a formulation of transdermal tramadol in 2
neutered male domestic cats.
Case 1:
16 y.o. NM DSH, significantly decreased mobility, decreased stretching and grooming behavior, pain on palpation of lumbar spine/lumbosacral junction, decreased range of motion in hind legs, muscle atrophy bilaterally in hind legs, abnormal vocalization at night, grouchy attitude. OA confirmed on radiographs. No significant medical history. 3 months of meloxicam therapy resulted in only slight improvement to mobility, owner avoidance, and difficulty dosing. Good response to injectable ketoprofen, but not a maintenance therapy due to concerns about renal health.
Adequan 50 mg SQ 1x week for 4 weeks. Tramadol 2 mg/kg applied to
alternating ears BID. Results: After 1 month - significantly increased mobility, (able to jump steps, sleeps in relaxed, sprawled positions on his back as he used to as a kitten), grooming improved, almost no abnormal vocalization at night, decreased pain on palpation of spine, increased attention seeking behavior and pleasant interactions with owner. Upon cessation of tramadol treatment for 2 days, vocalization at night returned, with decreased mobility.
Case 2:
14 y.o. NM DLH, decreased mobility, abnormal walking pattern (abduction of hind limbs during swing phase of pace), irritability to palpation of coxofemoral joints and tail base, grooming altered, urinating outside litterbox (UA/CBC normal), savage attitude to interactions with other cats and humans. Recent radiographs not available, radiographs from 3 years ago reveal some spinal OA. Treated for hyperthyroidism with radioactive iodine 1 year ago, perineal urethostomy 13 years previously. NSAIDs avoided due to dosing regimen problems (I need my fingers) and concerns over renal function (high normal creatinine).
Adequan 50 mg SQ 1x week for 2 weeks. Tramadol 2 mg/kg applied to
alternating ears BID. Results: Improved walking stance, using litterbox, attitude improved to other cats, attention avoiding behavior to humans (does not like application of meds, grooming not improved, resents palpation/petting of hind legs and tailbase at same level). Trial cessation of tramadol resulted in litterbox avoidance again. Have started tramadol again, may increase dose.
I think the tramadol is helping in both cases, and will probably play around with the dose a little. No dysphoria seen. It certainly has been easy to manage the application, even with the saber toothed tabby. I will happily supply the name of the local compounder here in Massachusetts if anyone has any interest - seems like a good chemist.
Also wondering if anyone has other suggestions for pain management in case number 2.
Sara Savage
Response 1
I think that it's worth considering a trial of gabapentin in cats w/ spinal or osteoarthritic pain, esp older animals which are at risk for adverse renal effects of NSAIDS. Karol Mathews & I each had a case described in the Vet Clinics North America small animal practice issue (2000?) on pain management which she edited. Both were cats w/ chronic spinal injuries. The cat I described was around 16-17yr old w/ 12yr malunion lumbar spinal fracture who had (from vet's description) what sounded like neuropathic pain in hindlegs & on defecation. Stool consistency had been optimized w/ diet. He'd tried NSAID, amitryptyline, etc w/o improvement, was reluctant to put the cat on chronic opioids due to concern about constipation. Gabapentin was increasingly being used to treat human pain patients at that time, but we had no data for treating cats & only anecdotal data for dogs from an investigator using it in dogs following global cerebral ischemia. I think the vet started the cat at gabapentin 2.5 mg/kg once or twice/day. The vet (who owned BooBoo the cat) adjusted gabapentin dose so the cat was more comfortable but not sleeping all day. At one point the dose may've been as high as 5 mg/kg BID, but later decreased. I wondered if this was related to cat's declining glomerular filtration rate as he aged. He thought that he would've had to euthanize the cat (due to pain) if not for gabapentin. BooBoo was about 19yr old when euthanized due to renal failure.
The smallest gabapentin capsule was 100 mg/ml, so he used a scale & divided the capsules into empty gelatin capsules to dose the cat. Although I cautioned him not to abruptly stop gabapentin, due to reports of rebound pain in humans when this is done (ie should taper off the dose), but he did it once after cat was too sleepy following a dose (10 mg/kg?) & said that cat subsequently had episode of severe pain.
Pauline Wong
Response 2
I heard at a meeting by Dr Cho(?) that published doses of tramadol for small animals is too low. He suggested 5-10mg/kg once daily. Has anyone else been using this dose? I have had excellent success with this medication
Tia Greenberg
Response 3
I have been pretty successful at causing anorexia at a 5 mg/kg po bid dose in some dogs, and I have seen clinical improvement in other dogs at a dose of 2 mg/kg po bid-tid.
Ben Brainard
Response 4
We have been using 2-4mg/kg every 6-8 hours for radiation acute effects, along with an NSAID. We generally start them at 2mg/kg before they get sore and increase as needed, and we also tend to stay at the lower end once we add a fentanyl patch.
Monique Mayer
Response 5
I just want to add my "2 cents" to Pauline's comments about gabapentin in cats - -
This has been a miracle drug for cats with OA as well as spinal pain in my practice - - I do have owners split capsules (which they are VERY happy to do...) - - I start most cats on 50mg PO BID - TID depending upon the cat's needs. It has been extremely well tolerated (our caseload is now nearing 30 cats on it middle to long term), with just one cat being a bit spacey for about 4 days (he worked through it...).
I also have used gabapentin in cats to successfully reverse what I am convinced is neuropathic/phantom pain from badly done declaws - - cats that act like 'sore feet" when they walk, but careful examination/manipulation yields no reaction. I generally use 50 mg PO BID for 8 - 12 weeks, and so far (with an "n" of 5) have had resolution to the abnormal walking in every case. These cats had their declaws 2 - 6 years prior to seeing me.
Robin Downing
Response 6
I have also had very good results with cats and gabapentin. We normally have it compounded in a cat friendly flavored liquid. It has been well tolerated - better than most analgesics in cats in my hands.
The Neurontin solution is available for about $117.97 for the 470 ml 50 mg/ml product ( http://www.drugstore.com/pharmacy/prices/drugprice.asp?ndc=00071201223&trx=1Z5006 ). Island pharmacy will make 240 ml in a flavored base for ~ 68.00. There is no generic liquid that I have been able to find.
Easterling has the smaller tablets; 100mg, 300mg, . The 100mg are around $23.00/100ct. The 300mg around $66.00/100ct. Easterling can be reached at 1-800-456-0757. Drugstore.com and Easterling have 600mg & 800mg tabs (http://www.drugstore.com/pharmacy/drugindex/rxsearch.asp?search=neurontin&expand=Gabapentin&trx=1Z5007 ). The 600mg tabs should be around $100.00/100ct. The 800mg ~ $90.00/100ct. I do try to keep a reasonably current price/source info here: http://www.vasg.org/drugs_sources_%26_costs.htm . The 100mg and 300mg tablet info has been there.
More recently we have been using gabapentin as a perioperative analgesic tool for acute inflammatory pain. The number of human references to gabapentin improving postop patient comfort while reducing opioid requirements has been impressive. This meta-analysis was recently released: http://eutils.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16701190&itool=pubmed_DocSum (I have this on file if anyone is interested). This recent study was performed on human spays where an NSAID, gabapentin, or both were used perioperatively to assist in pain management (in addition to basic analgesic strategies). Only the combined gaba/NSAID group had 100% satisfaction in their pain control: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16368826&query_hl=6&itool=pubmed_docsum . I have this full study available too. And there are many other similar references if anyone is interested.
Robert M. Stein
Response 7
Kudos for utilizing an effective regime for OA/chronic pain in cats.
My question to you may seem rudimentary but I think it bears asking:
How do you know that a cat is suffering from chronic pain? In other words, what is your criteria for rolling out pharmacologic intervention on behalf of this species?
Is gabapentin your first-line intervention? Do you score the pain in some way?
Thanks for your perspective on the next frontier...
Mark E. Epstein
Response 8
Does gabapentin have anti-inflammatory effects? Also, when purchased from Island Pharmacy, can you purchase it for in hospital dispensing? We have been told by most compound pharmacies that when we purchase product, it must be prescribed for a particular patient. We too have been really happy w/ gabapentin in cats, although I haven't used it a lot. For the post-declaw "phantom pain" syndrome, we've used tramadol-metacam-amantadine, gradually d/c'ing the metacam. If we can purchase the liquid compounded - woo-hoo!!!!
Kathy Morris-Stilwell
Response 9
Robin if your looking for a generic try contacting Diamondback Drugs 866-646-2223. They are a great company and will do everything they can to get the drug or find someone that can.
Nancy M. Thompson
Response 10
Dr. Stein - What assurances do you have that the Internet pharmacy is in fact compounding or selling what you are paying for?
John Ludders
Response 11
For those of you with experience using gabapentin: I'm considering a gabapentin trial for chronic pain control, are there any suggestions regarding removing an animal from chronic opiod therapy prior to starting gabapentin? I assume, from what I've read, that if I am being truly cautious at the very least I wouldn't want to dose simultaneously.
Sara Savage
Response 12
We have been using longer term tramadol and gabapentin together in our cancer bone pain dogs. I am interested what others think of using them simultaneously...
Monique Mayer
Response 13
I routinely use tramadol and gabapentin or amantadine together in advanced osteoarthritis, typically also with injectable adequan and oral glucosamine.
Sharon Jensen
Response 14
"How do you know that a cat is suffering from chronic pain? In other words, what is your criteria for rolling out pharmacologic intervention on behalf of this species?"
I have a proactive investigative approach to my aged cat exams asking about changes in the patient's activity patterns/limitations that owners have noticed in addition to careful palpation - especially of the spine, emphasizing the lower lumbar/TL areas. If there is support for pain a therapeutic trial is the next step.
"Is gabapentin your first-line intervention?"
Depends. Sometimes I will start with transmucosal buprenorphine as it is so much easier to administer than most drugs, is usually well tolerated, and has an attractive duration of effect. Along with buprenorphine I use amantadine, tramadol, and amitriptyline generally working with compounded drug in flavored base. The strategy being to gain the best benefit/control with the least difficult administration routine.
"Do you score the pain in some way?"
I do not try to follow a numerical scoring system - the subjectivity of that seems so daunting in a patient unable to effectively communicate their experiences.
Bob Stein
Response 15
There is no reason to stop the opioid and, in fact, you may have better success with the two combined.
You would expect some sedative effects initially as with other anticonvulsants - influenced by dose and patient sensitivity.
Bob Stein
Response 16
Just wanted to concur with Dr. Stein's comments about identifying pain in cats, using careful manipulation and historical comments, with a couple of additional comments.
We DO use a 1 - 10 pain scale for assessing every patient (as a place to start and to provide some sort of continuity). In a small practice this
works pretty well.
And I DO use gabapentin as a first line agent in old cats I have only just met, presuming that they became painful more than just a day before they visit me. I also use acupuncture regularly in these patients with generally excellent results.
Robin Downing
Response 17
I have been reading with interest about gabapentin for cats. But what is the recommended doseage for dogs? BTW I called about the 100 mg. tablet of gabapentin, nothing is known about the efficacy or duration of action if it is broken in half.
Lorrie Clemens
Response 18
I titrate the dose up to 10mg/kg per day, but recommend divided doses to avoid the fluctuations. Dogs metabolize tramadol much faster than people, who can often tolerate qd dosing. In severe pain cases, I would lean more toward QID dosing, but generally use TID. If I have to go BID, I will increase the dose 25-50%. My own 6yo dog (that will need an THR in the near future) is at 4mg/kg BID, but no NSAIDs at present. He is more playful now than literally, ever before.
Bianca Shaw
Response 19
Has anyone had any problems with tramadol causing seizures in dogs? I am aware that it can lower the seizure threshold of dogs already seizure patients. I tried to start a 9 yo Weim on Tramadol and twice it appeared to initiate seizure activity. The dog had no history of this.
Christine Makowski
Response 20
Since you seem to have a lot of experience with gabapentin, what is the dosage range for dogs and what are signs of overdosage?
I am treating a 10 year old Boxer who has a severe malalignment at C6 and is 3 legged lame. She will bear weight on her left front leg but will not walk on it. This has been slowly progessing for 2 years. Unfortunaly the owners will not go for an MRI. She cannot tolerate pred. I am not sure if she is painful, the x-rays are her joints are clean. But in case she has nerve root impingement I wanted to try the gabapentin. I am seeing only moderate relief with rimadyl and tramadol.
Lorrie Clemens
Response 21
I use gabapentin quite aggressively in my practice for many pain patients -- particularly those who have been painful over time - - dogs and cats. My dosing varies with the patient and the level of pain that my examination and manipulations suggest they are experiencing. Generally, I start my patients at a dose of 4 - 5 mgs/kg PO BID and go up from there. My experience tells me that this is a fairly conservative place to start.
For a moderately to severely painful patient, I will start dosing at 8 - 10mg/kg PO BID - TID and go up from there.
Sedation is the most common side effect I have seen, and there appears to be quite a bit of patient variation in this occurring. Only a few times have I had pet owners report sedation, and in those cases we dropped the dose and/or frequency and the signs resolved (and the pain issues were resolved despite the lower dose). Most individuals develop tolerance quickly and can handle increasing doses well. I recheck these patients fairly frequently in order to increase doses as needed to control pain. In an earlier discussion about gabapentin, one practitioner spoke of a really accelerated dosing regimen to get patients out of pain quickly - - accelerated enough that they really made their patients sedate, knowing the symptoms would most probably resolve within a few days.
I have heard reports of inappetance in patients new to gabapentin, but I have not yet seen it.
I cannot speak about whether or not gabapentin will help this particular patient, but if she were my patient I would certainly give it a try. I would start her at 300mg PO TID (mostly because I stock 100mg and 300mg capsules in my pharmacy :-) ). I would assess very frequently and begin adding mg's - - 300mg QID if the owners can schedule 4 doses - - otherwise, incrementing up 300mg at a time at approximately weekly intervals. If you get into the range of 50 - 70 mg/kg/day divided with no effect, then this is probably not a tool that will make a difference for her. I have had several hospice patients who needed @ 60 mg/kg/day to stay comfortable (and their mentation was normal and they engaged in their normal activities of daily living).
I commonly use gabapentin in conjunction with NSAIDs and tramadol.
I hope this helps you and your patient, Lorrie. These are such difficult cases to witness, and we are often ineffective in our efforts. Thank heaven this dog has you in her corner advocating on her behalf!
Robin Downing
Response 22
Dr. Downing stated "I commonly use gabapentin in conjunction with NSAIDs and tramadol."
Amantadine is also a consideration, w/ the above combination, I believe. Especially w/ chronic pain.
Kathy Morris-Stilwell
Response 23
We stock liquid Neurotin (50mg/ml) in our hospital. We buy the 500ml (I think) bottle from Wal-Mart, costs about $220. We use it mostly in house for our smaller patients, but also script it out to our smaller patients as needed. We've found that most pharmacies will only sell the huge bottle, they will not sell portions of it. And for the smaller patients, the bottle is the same size as them!!! so owners don't want to buy the whole thing from the pharmacy so they buy portions of it from us.
The liquid that we carry smells really good, but don't be fooled it has the absolute worst taste!! It's 100 times worse than any cough medicine, in my opinion!! so we only use the liquid in small patients when their dose is only a small amount.
Lori Fuehrer