14 year-old Shih Tzu With Recent Cushing's Diagnosis

[jmac]

Thanks everyone! I found some of the same information and then Dr. Bruyette says it is fine. Here is the sentence he used:
Tramadol does not work in a similar manner to other narcotic pain relievers so I would not be concerned.

I am also a worrier, so that is why I am not thrilled about experimenting to see what might happen to Hannah.

Glynda-she is not on Rimadyl and never has been. She was on Metacam for a week (which I know would be the same concern) but I talked with 4 different vets: my regular vet, and IM specialist, the ER vet when Hannah went in, and now the acupuncture vet. They all say that for some reason the NATURAL steroid in combination with an NSAID does not produce the same things as for example, prednisone would with an NSAID.

After hearing it from four of them and knowing Hannah was in a really bad place at that time, we gave the Metacam with no issues. I asked what to look for, read about it online and in the insert, and remembered what Glynda had told me could happen. The Metacam did seem to help her.

Hannah is a pretty stoic dog. I only knew something was really wrong last week because she was moving SO slowly and her back end seemed to sway a little.

Now I don't really know how bad the pain is. She just seemed better before the acupuncture treatment on Thurs. and was a lot slower and sort of out of it yesterday. I read that dogs can seem a little worse initially after acupuncture and the vet told me she could be sleepy afterward, but I assumed it would be that night--not the next day. Yesterday she was walking really slowly when I took her for her super-short walk (like three houses down) to get her to poop and just moved more slowly in the house. She was almost back to a little "trot" when following me in the house on Wed. So, my only guess, was that maybe she is in pain.

At the acupuncture appointment on Thurs. she did not show tensing when he palpitated her abdomen and she DID the previous week at the first appointment, so we took that as a good sign that something was a little better. She still did a little yelp when he put in a needle in the main area that is sore. She did the same thing the first time. These are the ONLY times I have ever heard Hannah indicate she was in pain. Even at the ER vet she just breathed a little louder when they felt the sore area. She's sort of tough to figure out. I wish she could TALK to me!

At this point, I'm scared of Anipryl and Tramadol. I gave her Anipryl already this morning. Anyone know how long she should be off of it to take Tramadol? I think I'll call the vet (or both) and ask. I guess I should hold off today. I hope she'll just improve a little on her own.

Again, thank you SO MUCH for all of your help! I sincerely appreciate it and get so much information from here. I am the one bringing things to my vet much of the time, and it is usually from stuff I found out from all of you.

Keep your suggestions coming, PLEASE!

-Julie & Hannah

[Cyn719]

Hi Julie - yup worry is my middle name to - thats why I gave you that link last nigth and said I dont know how reliable it is - every vet has his opinion - so if you trust in your vet then I would listen to him -it is really hard to know what to do and what not to do -- How is Hannah today?? Thinking of both of you always

[jmac]

Thanks for the link, Cindy. Like I said, I found similar info. online. I talked to the acupuncture vet office this morning and they said the same thing-in their books it says it can be in an issue in humans. She told me that if Hannah seems to be in pain I should give HALF of the amount they recommend to give her a little boost and they felt that would be safe. It is just so hard to know if she is in pain or how much pain she is in. She is walking around the house and is wagging her tail a normal amount of the time. She is eating, waiting patiently for some bacon to fall on the floor as my husband eats breakfast....some of the normal things she does. She is just slower. Maybe that is a sign for me to hold off until she seems really slow or worse. The vet said they don't want her to be in pain so if I think she is to give the Tramadol. I don't like going off of what I "think" when she is sometimes hard to read. And being an anxious person, I may think it is worse than it is. That's why I'm going to kind of watch for today and then see where we're at. I guess 1/8 of a 50 mg Tramadol probably won't put her at major risk of some complication with Anipryl. With so many issues it's just tough to know what to do sometimes! I know you all can relate to that!

-Julie & Hannah

[Cyn719]

OMG Julie you are so right!!! Yup I can relate especially after her episode last week - it was easier for me cause she was in severe pain - loud groans - pushing her body into wall - doing the weird mouth things (they think that was she was in so much pain she felt sick to her stomach) but like I said I got my answers when we put her back on the Rimadyl and tramadol - she was 90 percent better! So I know what she needs - last night she took a tramadol and sleep but stll go up during the night to go to the bathroom - so it doesnt put her out cold - that was 50 mg (82lbs) so starting at 1/8 should be fine - let me know how it goes -- Penny is sending HUGS and KISSES to Hannah! That little face is just so cute!!!!!!!!!!!!

[lulusmom]

Hi Julie,

Please see my comments in blue below:

Thanks everyone! I found some of the same information and then Dr. Bruyette says it is fine. Here is the sentence he used:
Tramadol does not work in a similar manner to other narcotic pain relievers so I would not be concerned.

I am also a worrier, so that is why I am not thrilled about experimenting to see what might happen to Hannah.

I don't blame you at all, especially if you aren't for sure that Hannah really needs it.

Glynda-she is not on Rimadyl and never has been. She was on Metacam for a week (which I know would be the same concern) but I talked with 4 different vets: my regular vet, and IM specialist, the ER vet when Hannah went in, and now the acupuncture vet. They all say that for some reason the NATURAL steroid in combination with an NSAID does not produce the same things as for example, prednisone would with an NSAID.
Hi Julie,

After hearing it from four of them and knowing Hannah was in a really bad place at that time, we gave the Metacam with no issues. I asked what to look for, read about it online and in the insert, and remembered what Glynda had told me could happen. The Metacam did seem to help her.

Sorry I get my NSAID's mixed up. Of the four vets you talked to about Metacam, did any of them mention that dogs with high cortisol don't usually need an NSAID? It is when cortisol has been brought down to a normal level (normal for a cushdog) that the aches and pains of arthritis are usually unmasked. Were any of them curious about Hannah's cortisol levels or are they all assuming that since Hannah is in pain Anipryl must be effectively controlling Hannah's cortisol? I'm very confused about this but then, I am easily confused.

Hannah is a pretty stoic dog. I only knew something was really wrong last week because she was moving SO slowly and her back end seemed to sway a little.

Now I don't really know how bad the pain is. She just seemed better before the acupuncture treatment on Thurs. and was a lot slower and sort of out of it yesterday. I read that dogs can seem a little worse initially after acupuncture and the vet told me she could be sleepy afterward, but I assumed it would be that night--not the next day. Yesterday she was walking really slowly when I took her for her super-short walk (like three houses down) to get her to poop and just moved more slowly in the house. She was almost back to a little "trot" when following me in the house on Wed. So, my only guess, was that maybe she is in pain.

Are your vet(s) suggesting pain meds because you are guessing Hannah is in pain or has she been formally diagnosed with arthritis, dysplasia or spinal problems? Can you remind me if Hannah had Xrays that showed any abnormalities? I do remember that one of the vets manipulated her and she did not appear to be in any discomfort and the IMS said Hannah may possibly be in pain but didn't appear to be based on her behavior during the appointment and your description of her at home. Do your vet(s) know for sure that Hannah's issues are not due to muscle wasting caused by excess cortisol? Muscle wasting makes a dog weak but it doesn't cause pain per se. If it did, my wimpy Jojo would have been yelping in pain constantly.

At the acupuncture appointment on Thurs. she did not show tensing when he palpitated her abdomen and she DID the previous week at the first appointment, so we took that as a good sign that something was a little better. She still did a little yelp when he put in a needle in the main area that is sore. She did the same thing the first time. These are the ONLY times I have ever heard Hannah indicate she was in pain. Even at the ER vet she just breathed a little louder when they felt the sore area. She's sort of tough to figure out. I wish she could TALK to me!

This takes me back to the xrays. What is the main area of soreness and was this area xrayed to try to figure out what is going on? I wish I had nickel for everytime one of us said "if only they could talk". I honestly believe if they could talk, a lot of them would tell us to take a chill pill and go to bed because we are depressing them. I also believe that if our cushdogs felt every ache or pain we think they feel and if they suffered from the angst that gives us knots in our stomachs, they'd be big old hypochondriacs.

At this point, I'm scared of Anipryl and Tramadol. I gave her Anipryl already this morning. Anyone know how long she should be off of it to take Tramadol? I think I'll call the vet (or both) and ask. I guess I should hold off today. I hope she'll just improve a little on her own.

I don't have an answer to that question but if Hannah truly does have joint or spinal problems and Anipryl has actually decreased her cortisol, then you should see some improvement as cortisol goes up after discontinuing the dosing. If that is the case, you wouldn't have to worry about Tramadol.

[jmac]

Glynda,
Thanks again for your quick response. Hannah has not had an x-ray, but there has been a new development since my initial posting about her having either rear-end or back pain. A couple of weeks ago on Tues., the 27th, Hannah was walking VERY slowly, so slowly that I knew something was wrong. She was also wobbly with her back end and it was swaying a little as she would stand. I was instantly worried about a back problem and even did the test where you turn the toes under to see if they put them back. She did, but she definitely was not right to me. We went to the ER vet right away. They were able to determine easily that she has pain in her middle back just by feeling. She was tense in her back and abdomen when the vet manipulated and also breathed harder/made a little groan when she felt that area. She said we could do x-rays, but didn't really need to, since she was absolutely sure there was pain in that area and there was some sort of disc problem. She said the only thing she would do was a CAT scan if I would at some point be interested in surgery. Since I would not do surgery, even if Hannah became paralyzed (because of her age, issues, and our financial status) we didn't do them. She was definitely showing the pain this time, but still in her own little stoic way. That's when we went on Metacam for 7 days and she had acupuncture the following day, as they recommended it as a good way to help her heal.

She also indicated she was in pain in the same area for him when he manipulated the area. It is in her middle back. She also tensed when he manipulated her abdominal area that day. She even yelped a little when he put in one of the needles in that area (as she did again this week in the same spot). Therefore, we know it is a spinal problem.

She may not have any hip or arthritis issues at all. This whole thing could have been a sore back that just got significantly worse last week. That is my guess. I also think that is why she was having difficulty defecating. Her back hurt.

So......that is why we are talking pain meds. They are relying on me to know if she is in pain, which I appreciate, but then it is hard for me to now sometimes. Of course I don't want to leave her in pain, but I don't want to jump the gun either. That's what makes it hard. She did seem better, but maybe this is another little rough spot.

Do you know if I do stop Anipryl how long it would be to get out of her system? She takes a half of a 10 mg pill once a day and has been since April.

No one seems to want to check her cortisol. They say that it is hard to know what "normal" was for her and how high is "high." I don't think they believe cortisol is being controlled by Anipryl, just the symptoms. The one thing Anipryl HAS done is bring her ALKP down from 1770 to 317 since April. That is why we decided to continue. Her symptoms don't seem to be that bad and I do think we could try going off of it to see. The IM even said I could try that to see if symptoms got worse (so I know if I want to spend $80 every 2 months). I could also see if her ALKP rises from being off, I suppose. At this point, I am more concerned about her back. She may not be here for me to worry about Cushing's if we don't get this figured out.

Does this help you out any more with where we are?

Thanks!
Julie & Hannah

[lulusmom]

Hi Julie.

I have to transport my little blind chi to his forever home and pick up a little Bichon with a broken leg at the shelter so I only have a minute. Lucky for you this is going to be one of my shorter posts so no eye strain. I did quick check online and see that Anipryl has about a nine hour half life. I have the FDA NADA number for Anipryl somewhere and will go back and check the clinical trials that were done to see if I can come up with anything else. Anipryl is not without side effects. Muscle pain and constipation is listed as a human side effects and I'm hoping to find something more about that for dogs when I have time to read. Did you happen to notice if any of Hannah's issues appeared after you started Anipryl?

Will be back later.

[jmac]

Glynda-
The straining while pooping was after Anipryl...but not immediately, and also coincided with when she stopped jumping, etc. (the back problem). I'll wait to hear more. And, for the record, I love your long notes. You are thorough, and I am too. I like that! So, thank you. I'll wait to hear more.
Julie & Hannah

[k9diabetes]

Hi Julie,

I haven't written to you before but someone asked me to take a look at your thread because we have a larger dog who has back problems and have been down a pretty thorough diagnostic road with him over the past year and a half with the last step being that we did the MRI.

Took me a while to read it all that!

My immediate thought looking at your last couple of posts was the same as my overall thought after reading the whole thing:

I would have x-rays done - a good comprehensive set by someone who really knows what they're doing.

And then I would have the vet send those x-rays to a radiologist for a review.

I'll put my reasoning in a second post cuz I want to explain our dog's history and why I think x-rays would be a worthwhile investment.

Natalie

[k9diabetes]

The main reason I would do a good set of x-rays is that it's noninvasive and relatively inexpensive and you might get good information out of them.

You might not too. But that's the risk you take with any diagnostic test.

What really concerns me is that there is a lot of medication that has a certain amount of risk being suggested for Hannah without anything like a diagnosis to go with it. How can proper medication be suggested when no one really knows what is being treated?

Cosequin, for example, would be good for arthritis in the legs and hips but isn't generally considered all that helpful for degenerative discs. And an NSAID like Metacam, which I've used in two dogs and our dog with the bad discs is taking daily, is a good medication but if inflammation isn't the problem, then you're stressing the liver and perhaps the GI tract for no good reason.

The x-rays have a chance of giving you a diagnosis.

Among the things the x-rays might show are signs of joint degeneration in her spine and/or hips, knee, ankle, inflammation from arthritis in any of those joints, bone spurs, or even that there's some entirely different issue completely unrelated to her hips or back and it only seems like it's her back that hurts.

My experience with x-rays comes from two cats, both of whom have hip dysplasia, and a dog with two degenerated disks at the thoracic/lumbar junction in the mid-back so sounds like about the same place that pain has been localized in Hannah.

In all three cases, there are signs of the problem apparent in their x-rays.

Our kitty Gus (he passed away this spring from cancer), for example, had obviously badly degenerated hip joints in his x-rays. As the last vet who saw his x-rays said, it hurt her just to look at how bad his hips were.

His sister Katie is not as badly afflicted but she was diagnosed with hip dysplasia when she was young and I can definitely see that her hips bother her more now that she's 15.

Our dog, Jack, is only four years old but started having apparent back pain in spring of 2010. The first time it happened, he seemed to recover with rest. But a few months later he was having problems again and he has had mild to moderate chronic pain since around September of 2010 and has been on daily Metacam since November of 2010.

His two bad discs - T13-L1 and L1-L2 - are clearly visible on x-ray because he has narrow irregular disc spaces there and bone spurs extending across them.

So I think there's a chance x-rays will tell you more about what - or isn't - going on with Hannah. If nothing else, they should be able to help rule out some things.

The main thing with the x-rays is to have someone really good do them.

To make sure they get all the needed views and take good pictures first. And then to provide an accurate and skilled interpretation of those pictures.

We are fortunate that our general practice vet has a particular interest in radiology and has taught radiology at the vet school. So he's particulary good at taking them and at reading them.

If he hadn't had that skill, then I might have asked to have a veterinary surgeon or radiologist do them. And even with our vet's extra experience, he sends many of the x-rays he takes out to a radiologist for review. We had x-rays done on Katie recently because she was feeling poorly and he asked a radiologist to review them to be sure that his interpretation was confirmed.

So I would also request that the x-rays be reviewed by a radiologist.

And depending what the vet does or doesn't see in them, there might be others who should review them, like a surgeon in the case of signs of soft tissue injuries, dysplasia, etc. or a neurologist if there are issues in the spinal area.

I recognize that lots of consults / reviews might not be possible. And it might not be necessary at all if the standard review shows nothing or screams something obvious.

If you can manage the comprehensive set of x-rays of the spine, hips, and full length of the legs - which in your small dog should cost less than in my 55 pound border collie! - and a radiologist review, that would, to me, be the best investment of your money at this point. And hold off buying any more medicine until they find out what they are treating!

I would honestly forget about any relationship to Cushing's and leg problem.

First because from all you've said it sounds more like a bone or connective tissue problem - or something entirely different.

And because you can spend a lot of time trying to fit symptoms into the one thing you know she has and that may actually be blinding you or the vets to the actual source of the problem.

So I would let go of all of the assumptions all of the doctors have made and do what you can to do solid diagnostic detective work to find out what the problem actually is.

I know your experience with Bailey has made this terrifying for you but it's at least as likely and probably a lot more likely that she "just" has some chronic pain that will never get any worse. Borrowing pain from the future about an outcome that probably will never happen won't help you or her.

If you can find out more about what's happening with her body, you have a chance to stop worrying about nightmare outcomes from the past. And if there is a nightmare outcome, you won't be any worse off than you are now and you will know what you are dealing with.

Sending you a big hug - I know how frustrating this can be.

Natalie