Pepper - cruciate ligament drug options

[BrookeR]

It's been a little while. Pep is still fighting on & we've had ups and downs. Our time is running out, but Pep is still giving her all to be here. So I'm still fighting with her for as long as she wants to fight.
We finally cleared her chronic urine infection by trying a different antibiotic that we had always had on the do not use list. It was a worrisome time but she didn't have any problems with it and it cleared the infection. Her alt went down after we cleared the infection. Her levels are still higher than they have been at this pred dose in the past though. It appears she has become more sensitive to the pred now. We have started having trouble with her skin that we believe is caused by the pred. She is loosing lots of her hair down her back and has some black heads and scabby like dry patches. Her skin is turning black when the hair comes out. We did scrapings and checked for any skin infections and she is fine at the moment. At her checkup with my vet this week to see what has started to happen to peps skin my vet realised that she has done her cruciate ligament in one knee .
Surgery is not an option and we are having trouble finding a brace that fits because she has so much muscle  wastage in the top of the leg that the slide up wetsuit braces are too loose at the top and too tight at the bottom.
We need to try to reduce her pred (& hope she doesn't relapse) it's now coming into winter here. She is normally better through winter. We are hoping the urine infection was what was previously triggering her. My vet wants us to start her on a new pain relief to go with the tramadol she is already on as we reduce the pred. She has sent me info to decide which one I want to use. Her first preference is amanatadine, then gabapentin, then codeine and then paracetamol.  Due to her liver not being the best she has put paracetamol last. Does anyone have any thoughts on these drugs? She has briefly tried gabapentin once when she relapsed and it didn't help. But now we will be using it to treat arthritic pain, not an impa relapse.

[Jo CIMDA]

Hi Brooke

Poor Pep!!!!  Yet another problem but she does soldier on and she always seems to be in control.

I have no experience of Amantadine, so I looked it up in the Plumb's Veterinary drug handbook, 8th Edition. This is the bible of veterinary drug books.

It says that Amantadine is an anti viral drug  but it can be used in small animals for treatment of chronic pain. 'It is generally used in combination  with an  NSAID, opioid or gabapentin/pregabalin.'

Pharmacological/Actions:  ....Amantadine alone is not a particularly good analgesic, but in combination with other  analgesics (e.g. opiates, NSAID's) it is thought that it may help alleviate chronic pain.......'

Doses:  Dogs/cats:  As adjunctive therapy (with another analgesic) for chronic pain, neuropathic pain or to prevent "wind-up" (extra label).
2 - 5mg/kg once daily; start at a lower end dosing range and increase slowly if needed.  Because amantadine has a significantly shorter half life in dogs and cats when compared to humans, twice daily dosing may be more effective'

Client information: When used in small animals, the drug must be given as prescribed to be effective and may take a week or more to show effect.    Gastrointestinal effects (loose stools, gas, diarrhoea)  or some agitation may occur, particularly early in treatment.  Contact the veterinarian if these become serious or persist.

gabapentin is used a lot in veterinary medicine and of course codeine.  Paracetamol is used a lot more these days than it ever was, but like you say it does affect the liver.

I think you have a choice, and at least if one doesn't help you have others you can try.

I hope Pepper feels more comfortable soon.

Jo

[BrookeR]

Thanks jo. We ended up dropping the pred By 1/4 of a 5mg tablet and then tried Adding gabapentin. She was good for the first week almost two weeks of the reduced pred and then when I added the gabapentin she began limping and continued to get worse. I stopped the gabapentin and she was still worse. So we upped that 1/4 pred again. She began to walk again. When I gave her the increased pred dose at night she was back walking in the morning. My vet said pred couldn't be that quick of a reaction. I can't see it was the gabapentin and feel it's the pred. Every time we drop the pred any amount the swelling comes back in that same front elbow she began having trouble with October last year. The one we xrayed which was missing bone. It's always this elbow that she limps on too. If it were true poly arthritis why is it always this elbow? Could it show the poly arthritis more due to it already being damaged? Or is there any other things that could cause the elbow to swell every time we drop the pred and cause limping? No pain killers seem to help only the pred because it takes the swelling down. Could it just be really bad arthritis and damage to that joint. So many questions I have no answers to.
I'm trying to think of other anti inflammatory things we could try. We can't do NSAIDs. I am wondering about trying natural ones we have been previously too scared to try eg cbd oil, turmeric, etc

I had also read trials of doxycycline being used to treat arthritis but they seemed to say it only was worth while when it was used initially when pain had not long begun, not for chronic pain that had already existed for some time.

[Jo CIMDA]

Hi Brooke

If it is just one elbow then it is not IMPA, and if it were IMPA it would need a lot more pred to make a difference.

Having said that pred can have an amazing affect within 45 minutes of having a tablet (I have seen this myself)  and this is purely the anti-inflammatory response of a low dose of pred.  Personally, unless you have to take Pep off of pred for good reason then I would keep her on the low dose because it gives her a much better quality of life than without it.  I would imagine pep's elbow problem is age related and not immune mediated, which is good news.

I am honestly not sure if the other alternative therapies work.  They might to to an individual, but not for everyone/dog who has them.  I did use Cortaflex on one of my old girls once and I believe that did make a difference but it will take a while to kick in.  It is very popular for arthritis in horses too.   

I hope she improves very soon.

Jo

[BrookeR]

Thanks jo, I really appreciate you always being there when I have needed to go over my thoughts about pep and for your advice/ knowledge to help me feel that I am making the right decisions for her.

Yes I do believe pred is fast acting, even though my vet is skeptical. I've seen it change Pep very quickly. When she first was diagnosed with impa finally after a drawn out period of no one being able to diagnose her. She went weeks before I came across and insisted they test her for impa. Anyway I gave her the pred at lunchtime, she hadn't been able to walk prior and then she was running around the yard that afternoon. There have been a number of times I've seen fast improvement in pep from pred.

We saw our vet yesterday and she hadn't seen pep in a few weeks. She said she wasn't looking good and that time is coming soon. In saying that she also said she has seen pep look terrible before and then she rally's and pulls her strength together and fights back. All her vitals are good it's just her terrible joints. She has more hair loss down her back and more black head and dark skin patches but nothing is infected or nasty looking. Ideally we would like to be able to drop the pred to stop what it's doing to her skin, muscle wastage and try prevent her from doing her other cruciate. Also my vet believed pep had more muscle wastage and said if she keeps going she eventually won't be able to walk. We have started her next 4 week round of zydax injections. So will be visiting the vet weekly for the next few weeks. Now thinking of it, it was at the time we initially had zydax (3months ago) that pep was looking terrible and my vet said we didn't have long then. She said she was going to be monitoring her closer each week while we had the zydax. Pep ended up picking up then after the injections, until now. So I'm hoping the zydax is going to give her a little more time.
As for other pain killers and supplements my vet wants to leave everything as is for now with pep and just monitor her over the next few weeks to see what the zydax does to help. I also think this is the best thing to do at this point .

I agree with you, for now I feel we need to keep her at this pred dose. It is slowly eating her away but at least she is mobile and still able to walk and wanting to be here. It seems each time we reduce she begins having more trouble and can barely walk. She likes to be able to follow me around and if she can't do that that's not a happy life for her. So I think leaving her on this dose is the best option we have at having a little more time together. Rather than drop the pred and have her not be able to walk and need to be carried everywhere. That wouldn't be fair to her.

[Jo CIMDA]

I totally agree Brooke.  Quality of life is the most important thing.  Having said that, if her vitals are good then this is a big plus and it is about controlling any pain that she has.   I hope the Zydax will do the trick and you will see and improvement in Pep very soon.

I have a feeling, as she has caught us out so many times before, it will be Pep who decides when she has had enough!  She is not one to give up easily.

Jo