Analgesia following GI ulceration

RE: Analgesia following GI ulceration

KMurphy — Sun, 12 Jun 2016 10:42:11 GMT

Thanks all for the advice. Eddie is clinically much better now, good appetite, formed stools but he's still very slow at walking. His bloods show a persistent leukocytosis and he's also developed hypoalbuminaemia. As yet there are no signs related to the low albumin but I'm watching him closely! Colloids at the ready at home! I've booked him in for a scan +/- endoscopy at the beginning of the week.

I've switched him over to omeprazole and started a low dose of paracetamol (10mg/kg TID). I'm being a bit cautious with the dose given the low albumin.

[quote user="Dan Holden"]Misoprostol is not very effective at treating established ulceration[/quote]

I've always thought that misoprostol was the drug of choice for NSAID related ulceration so that's interesting to hear about its use in established ulceration.

Of course, maybe Eddie's isn't NSAID related at all... Fingers and toes crossed for a good outcome.

[quote user="Dan Holden"]he's an elderly bull terrier[/quote]

Noooo - he's still just a pup in our eyes :)

RE: Analgesia following GI ulceration

Dan Holden — Sat, 11 Jun 2016 00:20:10 GMT

I would personally avoid NSAIDS altogether in this patient until you are absolutely happy that no GI ulceration is present (this might involve endoscopy). Coxibs in particular have been shown to delay healing of experimentally-induced ulcers in dogs. For further analgesia I would go with paracetamol first (zero anti-inflammatory activity but useful analgesia at proper doses around 20mg/kg TID and kind to the gut). Try tramadol as well - you can go up to 10mg/kg TID but he might get fairly stoned. If this is an issue then try gabapentin - start low at 10-20mg/kg daily in divided doses.

For gastroprotection I would use omeprazole 1-2mg/kg once or twice daily. Misoprostol is not very effective at treating established ulceration and ranitidine is not much better.

If everything settles down and there's no evidence of ulceration or further bleeding then you could reintroduce NSAIDS. There is no evidence whatsoever to show that any one NSAID is any "safer" than another, so I would go with meloxicam again. If he vomits again or the melena persists I'd scope him - he's an elderly bull terrier.

RE: Analgesia following GI ulceration

Martin Atkinson — Fri, 10 Jun 2016 20:21:54 GMT

We're in danger of going off on a tangent here Virginia. Have you tried homeopathy or reike?

RE: Analgesia following GI ulceration

Virginia Campbell — Fri, 10 Jun 2016 19:23:39 GMT

We had this situation last year with a three legged arthritic Labrador (staff member's pet). She'd been doing really well on Trocoxil for a couple of years but then got severe GIT upset (I think unrelated to the NSAID as GIT upset occurred when she was nearly due trocoxil, not after) and was vomiting and anorexic for days. Opioids flattened her so badly that we were going to euthanase her thinking that she was lying at the back of the kennel refusing to get up from a mixture of weakness and pain, till we worked out that it was the opioids. She revived off them - but had seized up to a standstill from being more or less immobile. We reverted to just Pardale and I got our excellent physio vet to come and do "emergency" physio and acupuncture, which really helped (physio said that the twist involved in lying for long periods with front end in sternal and back end in lateral really, really annoys the muscles round the thoracolumbar spine and you can see why). We also used heat packs on her back - I guess you could try them on his back and stifles. Can't remember if we tried tramadol - at least it has a short half life so if it doesn't work or makes him weird or pukey or anorexic you can pull it and the side effects should go away fairly quickly.

If memory serves correctly we also added pred (gasp!) once the GIT signs had completely resolved and appetite had been reliably good for a few days. I had considered PLTs but my boss was dubious about the cincophen with GIT history so we went with plain pred - 10mg sid for a fairly big lab I think. Tapered that down really slowly, kept the Zantac and omeprazole going for aaaaages, kept going with physio and acupuncture. Once off pred I think we reintroduced the trocoxil at half dose to begin with, as she'd always been fine on it. Was doing well last time I heard.

RE: Analgesia following GI ulceration

Stuart Jackson — Fri, 10 Jun 2016 17:21:34 GMT

[quote user="Martin Atkinson"]

[quote user="sajackson"]To give with food doesn't provide gastro-protection[/quote]The point is not that, it is to ensure the animal is not anorexic and therefore already starting to show GI signs.

[/quote]

Good point, just checkin!

RE: Analgesia following GI ulceration

Martin Atkinson — Fri, 10 Jun 2016 17:07:53 GMT

[quote user="sajackson"]To give with food doesn't provide gastro-protection[/quote]The point is not that, it is to ensure the animal is not anorexic and therefore already starting to show GI signs.

RE: Analgesia following GI ulceration

Stuart Jackson — Fri, 10 Jun 2016 16:58:27 GMT

[quote user="Martin Atkinson"]

: 'Give with food

[/quote]

To give with food doesn't provide gastro-protection

RE: Analgesia following GI ulceration

Martin Atkinson — Fri, 10 Jun 2016 15:45:46 GMT

I've had this situation and it was managed by being far more careful with the dosing of NSAID related to feeding times. One case was better with meloxicam than carprofen, another better with Onsior that meloxicam. I also manage them with ongoing rantitidine. I keep forgetting about Pardale but its worth a try and Carprofen injections may be a thought but obvioulsy not until you're sure there's no bleeding.

In the end it comes down to a risk benefit ratio and the client needs to be in on that as well as making sure they are giving the medication responsibly. All my labels for NSAIDs are printed with the instructions: 'Give with food, do not give if anorexic, stop if there is vomiting or severe diarrhoea' but even then they don't listen and one of the worst offenders was a doctor!