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Pain management advice after 10 days, when Rx runs out
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Member Since:
16 September 2023
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25 September 2023 - 7:48 pm
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Hi! 

First, just want to say how thankful I've been for this community in recent months, weeks, and days as I've navigated this decision, surgery, and recovery. 

My 14.5-year-old goldendoodle girl (Huckle) had a rear leg amputated 10 days ago due to what docs think was a soft-tissue sarcoma. (Still awaiting the necropsy/histiopathy.) Thanks to this board, I had a pretty good sense of what to expect and knew to be ready, positive, patient, and slowww, with a lot of rest and care. It's hard, as I knew it would be, but we've both been doing pretty well so far. She's eating, drinking, peeing, pooping, wagging, and even doing some very heartening hopping. 

Right now, I have three main things I'm keeping an eye on: 

1. One small area toward the center of her incision is a little bit open. I sent a photo to the surgery department and they had me bring her back in. They put in two little staples (ugh), gave her some antibiotics, and some cleanser and ointment. In early post-surgery days, she seemed more comfortable lying down incision-side-down, but in more recent days that seems to cause her more discomfort. From looking around on these boards, it seems that's not all that unusual, and I'm not surprised it hurts her, given both the staples and the fact that the incision isn't totally closed-up yet. So: staples, antibiotics, cleanser, ointment, lots of rest, and fingers crossed. 

2. If she overdoes it in any given day, that magical back leg does get a bit stiff. This seems like it will be a long-term thing we'll just need to keep ahead of with PT, pain relief, maybe chiropractor. No surprises here, as she learns the mechanics of her new body and gait. 

3. But here's the reason I finally decided to post instead of just reading and learning. The meds they sent her home post-surgery with are: (1) 2mg Hydromorphone every 8 hours and (2) 150 mg Gabapentin every 8-12 hours. (Before the surgery, she weighed about 37 pounds.) We're at day 10 now, and just about out of the Hydromorphone. Because she's been waking up every night about 7 hours after her nighttime dose, seeming uncomfortable (she sits up, pants, licks her feet), I thought I'd skip her daytime dose today so I could save one up to give her at bedtime. Already just 2-3 hours later, she was restless, panting, having a hard time getting comfortable anywhere she sat. This is new. It seems clear to me that the Hydromorphone is still really helping her with pain control. I submitted a refill request to her vet, but they said she should be fine now since 10 days have passed and they don't typically refill controlled substances, and to let them know if she's having pain. So I've written back and said, yeah, she's having pain. In the meantime, we're a half a pill from being all out and their refill times are often "at least 72 hours." So I'm scrambling. Because she was on Gabapentin before the surgery, I do have a back-up of those so I can continue those for a while. I also have some Previcox in the house and also (from an ER visit just a couple of days before the surgery, though we didn't use them) some Trazodone, though I can see on these boards that it may not be everyone's favorite. 

Finally, to the question. I know you guys aren't vets, but many of you have some really helpful experience with making sure your dogs aren't in pain. If the surgery department still says they're unwilling to refill the Hydromorphone, does anyone know if it would be okay for me to shift her back onto the Previcox, at least until the end of the week when she goes back for her suture check? She was on Gabapentin/Previcox combo before the surgery, so I know there aren't interactions between those two, but I don't want to mess her up by adding Previcox into her system if she's already got so many things in there. I saw someone mentioning a wash-out period when transitioning from one medication to another. Is that only for one NSAID to another or would that apply here if I transitioned her from Hydromorphone to Previcox? 

I'm sorry this is so long. Thank you to anyone who has thoughts. I'm so grateful. 

Molly & Huckle 

The Rainbow Bridge



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25 September 2023 - 8:13 pm
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Hi Molly,

I am in the Tripawds Chat for a few more minutes if you want to talk. Back in a sec with some thoughts.

The Rainbow Bridge



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25 September 2023 - 8:24 pm
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No need to apologize over the length of your post, that's why we are here. I'm glad that Huckle is doing pretty well!

RE: the Hydromorphone. Yeah, it's a controlled substance and vets really struggle with refills because of DEA requirements and the god-awful truth that some people with addiction issues will keep it for themselves. Grr. Regardless, it's not uncommon for a vet to be reluctant about refilling it.

Chances are, any pain control will help her right now, whether it's an opioid or not. Since you have the Gabapentin, it's probably OK to continue. But instead of every 8-12 hours, many people find that giving Gabapentin closer to 3x daily is a better way to go for consistent pain relief. Not a vet as you know, but that's our experience here.

Previcox is an NSAID that reduces inflammation. You don't need a washout to go from Hydromorphone to an NSAID (two totally different kinds of pain control that work differently in the body), but I wouldn't re-introduce that until you clear it with your vet. 

they said she should be fine now since 10 days have passed

All dogs are different, what works for one isn't guaranteed to work for another. smiley7I'd like to challenge anyone who says that, by asking "How long would YOU need pain control if you had your leg cut off? Would you be back to your usual self in 10 days?" Hah! Humans are on it for much, much longer after amp surgery. OK I'm off my soapbox.

We see that most dogs are on pain meds from 10 to 14 days, sometimes longer. So, now's the time to really advocate for her. You can do it!

Make a very thorough list of her symptoms, get video, and take it to the clinic if they're not able to take your call in the morning.

If their refill lead times are 3 days, then kindly ask them to call in additional Gabapentin (and the Hydro, if they are willing) to a Walmart or other pharmacy, where you can pick it up in 30 minutes. Even better, see if they can give it to you in 100 mg increments so you can fine tune the dosage for her.

I hope this helps! Gotta run so I'm leaving the chat, but I'll be there again tomorrow during business hours. 

Keep us posted.

New England
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26 September 2023 - 5:13 am
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If she overdoes it in any given day, that magical back leg does get a bit stiff. This seems like it will be a long-term thing we'll just need to keep ahead of with PT, pain relief, maybe chiropractor. No surprises here, as she learns the mechanics of her new body and gait. 

Have you tried massaging your dog at all?  I've found my tripawd (also a rear amp) really enjoys it.  Loki can be sensitive to having her remaining back leg touched, but I've found if I do a full body massage and save the rear leg for last, she's so relaxed she just goes with it.  I've also found she prefers to be massaged while laying with her back leg down, so I have to slide one hand under her to get the outer thigh.  Start slow and keep an eye on your dog's body language.  If you think she's had enough, stop.  Try again another time.  Massage can be uncomfortable before it gets relaxing.

Pennsylvania


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26 September 2023 - 6:19 am
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Hey there, just wanted to pop in and say my pup Juno was 37lbs pre-amp and we found that 100mg gabapentin 3x per day plus half of a 75mg carprofen (also an NSAID like yours) in the day and a quarter at night worked really well for her pain. We kept her on these post op for three weeks. Of course your dog is an individual and may need more or less or different things in the end, but perhaps this plan for the same size dog may give you a place to start.

If your vets agree to the gaba & NSAID plan those should be easy to prescribe as they don’t have all the issues opioids do. This should be a reasonable ask, and if they still resist you could go to your primary vet for them (but that feels like a last resort as you really do want the input and cooperation of your surgical team.)

Natalie & Juno (aka June)

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26 September 2023 - 4:40 pm
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Hi Jerry, 

Thank you so much for your response. I definitely understand about the caution around opioids, though I also agree about the "she should not be feeling any pain now that 10 days has passed" seeming a little subjective! Huckle had a hard night. She kept waking up, trying to change positions, getting "frozen" (you know what I mean?) - I could tell she was hurting. At 5am, out of desperation, I finally gave her a dose of Previcox and 25 minutes later, she was finally cozy and sound asleep. So there's that. 

But - because her kidney levels are elevated (she's been on a lot of antibiotics and pain killers pre-surgery), they're not excited about putting her back on Previcox. They suggested instead that we just boost the Gabapentin dosage to 200mg 3x a day. So I'm going to give that a whirl and see if that does it. She's got a suture/staple re-check on Friday. Fingers crossed. 

Thank you again, so much, for leaping in on this one. She's doing so well in so many ways, it's hard to see pain peeking through when I know it's not necessary! If all goes REALLY well, the incision will close up soon, cellulitis will resolve itself, and she'll be able to be off pain meds altogether, for the first time in quite a while. Something to hope for.

 

Thank you! Fingers crossed! 

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26 September 2023 - 4:43 pm
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Oh, this is good thinking. I have done some massage with her but mostly when she's overdone it on that back leg and ends up a little stiff. I do her back, neck, leg muscles, and she really loves it - leans into the pressure. So comforting to see her enjoying it. I hadn't thought to do it as an element of pain relief, though. Let me see what I can do. Thank you for the idea!

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26 September 2023 - 4:49 pm
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Hi Natalie, 

Oh, this is really helpful - thank you so much!

You can see more details in my response to Jerry, above, but it looks like our surgery team would like us to avoid NSAIDs if possible, for kidney reasons. A bummer because the Previcox worked like a charm in the night, but obviously don't want to mess with kidneys!. They're suggesting we just up the gabapentin dosage for now, so I'm gonna give that a whirl and see if that'll do it. I'm really hoping that, like with Juno, three weeks will give her body enough time to get over this post-surgical hump and past the need for too many pain relief interventions. She's 14 years old, so I don't expect she'll spring back quite as quickly as a younger dog would. If a 100-year-old grandma had her leg removed 10 days ago, I would definitely let her stay on pain relievers for a little while longer if she was still a little achey! 🙂 

 

Anyway thank you so much for piping in, this is great and very useful to know what worked for a dog with the same rough dimensions. 😉

 

Molly

Pennsylvania


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26 September 2023 - 5:46 pm
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Eeek - wow, yeah.😳 That’s a good reason to avoid NSAIDs! So glad you got clarity on that.

Tough to be caught in such a hard place, and especially because of a human addiction problem. Never imagined that would influence a pet’s pain treatment!

Keep us posted on how the increased gaba goes. 

Cheering you both on - sp_hearticon2

Natalie & Juno (aka June)

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27 September 2023 - 6:52 am
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It really is tough! I think 14 days instead of 10 would have been reasonable, but here we are. 

Just gave her the double gaba (200) and everything else is officially worn off (the math says so but I can also tell), so here's hoping for a more comfortable dog in 3...2...1... Fingers crossed. I'll update.

The Rainbow Bridge



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27 September 2023 - 10:52 am
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Molly how is she doing today? Appetite good? Did she enjoy the massage sessions?

I think that upping the Gaba is reasonable. When they say no NSAIDs did they mention anything about Galliprant, an NSAID alternative? Or the new Librela we just wrote about today? See:

https://tripawd.....edication/

Pain relief can take multiple approaches. Does your vet team work with a rehab therapist? She could certainly benefit from seeing one. If they haven't referred you, we can help you find one. Rehab experts can often troubleshoot pain when general practitioners are stumped and treat it with additional means like acupuncture, shockwave therapy, etc. Plus, the Tripawds Foundation can pay for your first rehab visit so you've got nothing to loose!

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27 September 2023 - 11:02 am
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Morning, Jerry! Thanks for checking in. 

Still watching today to see how the higher Gaba dosage goes. Only a couple of hours in, so I don't have much to report yet except to say that her pain seems to be under control, so that's good! Suture check got moved to tomorrow afternoon, so I'll be sure to ask about Galliprant and Librela - thanks for the suggestion. 

The place where she had the surgery is an enormous specialty center so they have a whole rehabilitation department in the basement. I was thinking I'd get her in as soon as the incision is closed up, sutures and staples out, and cellulitis resolved. She's also seen a chiropractor in the past, for a neck injury, but I think first stop should probably be the rehab center? I saw the thing about the foundation covering first visit, that's amazing!

Phew. 

The Rainbow Bridge



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30 September 2023 - 11:16 pm
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Molly I hope things have gotten better and Huckle's having a good weekend! Did the suture check go OK? Did they say anything about the other pain meds?

Sounds like a great vet hospital. I would definitely take advantage of their rehab therapy team. Most therapists like to see a dog within 10 days of surgery so make the appointment soon. And yes if you see the post about how the Foundation covers your first rehab visit we do cover it as long as it's with a credentialed practitioner. 

Hope things are good! Let us know when you can.

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1 October 2023 - 7:20 am
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Morning, Jerry! Thanks so much for checking in. We are truckin' along here!

Sutures: The night before the suture check, her incision opened a bit and started oozing. Knowing she would be triaged low in the ER, I opted to just keep her super quiet and still until her appointment the following afternoon (no fun!). They cleaned it up, put in a TON more staples (poor buddy), ran a culture ($$$), and sent us home with a renewal on the antibiotic (ugh). BUT!!! It is healing up SO MUCH BETTER now. She was VERY tender from the new staples for the first 24 hours, which felt like a setback, pain-management-wise, but she's starting to bounce now. We had a great walk yesterday (almost two blocks! - remember, she's old), lots of wagging and sniffing, saying hello to folks on the street) and here's the biggie - she slept through the night last night for the first time since the surgery. So, I think we're getting there. The incision is starting to look the way I'd hoped it would look about a week ago. They're going to leave the original sutures plus the new staples all in for an additional two weeks, so I'm hoping we'll feel pretty confident about them by the time they all come out. Fingers, as always, crossed. 

pain management : Because of the elevated kidney levels, no more Previcox. So she's on a higher dose of Gabapentin for now, which sort of does the trick but isn't quite enough for the worst of it, like the first day post-staples. Now that she seems to be steadying up, I'm hoping I can start tapering the Gaba back down, either still every 8 hours but a lower dosage and/or eventually back down to every 12 hours - and maybe eventually back to none? 

Oh! I also re-started her hemp forte and Omega oils yesterday (I'd taken her off a couple of days pre-surgery). I wonder if they had something to do with the good night's sleep?

Rehab: Yes! The place is really good. We have, unfortunately, now had to avail ourselves of their Surgery department, Neurology department, Integrative medicine department, and their ER. It's like an airport: huge and clean and tons of hustle-bustle. All of the surgeons I've spoken with have said rehab is a good idea (especially given her age) but to wait until the incision is healed up and sutures are out. We're already...let's see...16 days out so I hope I haven't put her at a disadvantage but I'll give them a call this week. Incredible about the foundation setting pups up with their first visit. If that's you, thank you! 

Molly

 

Not sure if you'll be able to see this, but here's how perky she was yesterday. You'll definitely see that that back leg could use some strengthening! But so good to see her so cheerful and energetic. 

https://www.ins....._copy_link

The Rainbow Bridge



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1 October 2023 - 4:15 pm
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Wow she looks great! I mean you can't even tell that she's been through so much, or that she's 14.5! WOW! 

What a bummer about the incision, but at least it was caught early and treated. AND she's getting some sparkle back too. What a treat smiley16

Makes sense about the Previcox, that stuff can be hard on the gut. Hard to say what the tapering should look like for the Gaba dosages but generally spacing them out as you go, and decreasing the dosage after spacing them out, seems to be what most people do. Personally I would keep the dosage the same but space the timing further apart. Not a vet, so take that for what it's worth.

I'm so happy your vets have all suggested rehab. You wouldn't believe how many do not even think of telling their clients. What a great practice you're working with. Feel free to give them a shout out in our Vet Specialists Topic!

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