Osteo Thread Part Vi

[4My2Greys]

I would give him 200mg (3X) a day if it were me. Nadir takes 300mg (2x) a day for bladder pain and it doesn't make him the least bit wonky. In fact he's livelier and plays more because he's not in pain. I would add an additional pill about every 2 to 3 days so he has time to adjust to the dosage.

[RaineysMom]

Ben Update:

 

Sunday was rough. I guess it was just too much standing for him at the vet's and not being able to lay down. In the evening he managed to get on the love seat but when he laid down his leg was in the wrong position and he couldn't change position and cried. Scott had to lift his pelvis to make him in an okay position.

 

Today he was better. I wanted to cut him down on the tramadol to increase the gabapentin so today he had his prilosec and rimadyl and two tramadol in the morning. In the afternoon, one gabapentin and one tramadol instead of two, and tonight gabapentin and two tramadol. He was doing a little heavy breathing earlier but it stopped before dinner. He is starting to eat less and not use the back leg a little (turning the foot backward sometimes).

 

I know I need to increase the gabapentin but by how many do you think?

 

Today for the first time my thoughts went to too soon rather than too late but I don't feel he's/I'm ready to give up.

 

Oh, I didn't tell you.....he's dug this huge hole in the back yard and when it's sunny, goes over to it and lays down like it's his private room to enjoy the outside. Priceless.

I haven't posted here for a long time, since we lost Nube.

 

I just want to tell you our experience with GT, our regular vet ,and meds. I was concerned about over medicating Nube as well. He was on just 100 mg of Gaba 3 x day and 1.5 Tramadols 3 x day, as well as 75 mg Rimadyl 2 x day. I could tell he was not doing well. I asked the good folks here and they suggested upping both the Tram and the Gaba - but I was SO afraid to, without talking to my vet. After a couple of days of seeing him not doing well, I bit the bullet and upped it myself (this goes against my grain of listening to my vets!). After starting with the oncologist, she ABSOLUTELY said 300 mg was the minimum he should be on. I think a lot of "regular" vets (and I LOVE mine) just aren't as familiar with the real dosing as they should be.

 

It was SO the right thing to do and I can't thank the experienced people here for helping me. Osteo is SO painful. It is MUCH easier to keep them in good pain management than to try to bring them back if they aren't getting enough and the pain pops through before the next dose. Pain is pain. Why let them suffer at all if they don't have to. Hell, I would have rather so severely over medicated Nube (which this is not!) and had him pass that way (which would be VERY unusual!) then let him spend a minute in such severe pain, knowing it was killing him anyway.

 

Nube was on (for most of the 2 months of pain management) 3 50mg Tram 3 x day, 300 mg Gaba 3 x day and the 75 mg Rimadyl 2 x day. At the end it was 4 50mg Trams 3 x day. I know many have given even more of the Gaba (like 900mg per dose). I'm glad you are able (as I was) to give the meds 3 x day as they wear off by the end of 8 hours (or sooner).

 

Please don't hold back on the meds, especially the Tram. It is a safe med and he should be on at LEAST 2 50mg 3 x day if not more. I would up the Gaba to 200 mg 3 x day and up to 300mg if he is still in pain (panting,etc.). You may want to up the Gaba over 2 days or so, so there aren't any "wonky" issues (Nube had none, didn't even phase him)

 

sending many prayers, BTDT and know how it is. Just don't be afraid to keep him over comfortable.

 

PS. Your AWOL Pinky was one of the hardest and most hearbreaking GAA pups I followed. I'm so very sorry you're going through this as well. Sending MANY hugs. Kim

Edited March 5, 2013 by RaineysMom

[4My2Greys]

I want to add also, I don't know if your vet will do it for you, it certainly couldn't hurt to ask, but my vet gets me a bottle of 500 count 100mg capsules from his distributor and gives it to me at his cost of $30 a bottle. If s/he is willing to write a prescription s/he might be willing to do this.

[KF_in_Georgia]

I'd get him up to two gabapentin, three times a day, by adding one gabapentin a day until you reach that total. Leave the tramadol dosage where it is until you get the gabapentin doses up. Then you can start to step back on the tramadol, if you like.

[JJNg]

I wanted to cut him down on the tramadol to increase the gabapentin

 

I agree with what the others have said about increasing the gabapentin to 200-300 mg 3X/day. Also, there's no reason to cut down on the tramadol to increase the gabapentin. If he needs to stay on high doses of both, that's fine. If you see a dramatic improvement on higher doses of gabapentin, you can try to decrease the tramadol at that point if you wanted to. But I wouldn't change the tramadol dose until after he's doing better.

[NeylasMom]

I agree with what the others have said about increasing the gabapentin to 200-300 mg 3X/day. Also, there's no reason to cut down on the tramadol to increase the gabapentin. If he needs to stay on high doses of both, that's fine. If you see a dramatic improvement on higher doses of gabapentin, you can try to decrease the tramadol at that point if you wanted to. But I wouldn't change the tramadol dose until after he's doing better.

 

It's been said before, but there is constant pain and break through pain with osteo. It's much easier to stay ahead of the pain than try to "catch up" after the fact. Sounds like you may be in either or both situations so just increase both and see how things go. If there are no obvious side effects and he feels good, I might just leave it at that. Or you can consider trying to back down on the Tramadol very slowly. Hope Ben is feeling better soon!

[lilythetigerdog]

Hi Guys,

 

It's been a looooong time since I've posted on GT, but here I am back when I need help the most.

 

Lily was diagnoed with Osteo on Monday and confirmed via biopsy results yesterday. Origianlly we thought Lily had a soft tissue injury since her limp was so sporadic and occasionally non-existant, and then it was mis-diagnosed with a cruciate problem. This morning we started her on Tramadol. The vet prescribed 5omg 2x/day. I worry that this won't be enough.

 

I already feel horrible that this is happening and I am marinating in guilt over the fact that she has been in pain for so long and I don't want my hang ups to affect her treatment. The prescribing vet is in surgery all day and our normasl vet has the day off so I am feeling totally lost here.

 

I left the vet a message saying I needed more information on the Tramadol and I also lsaying that I needed Gabapentin and Rimadyl - his tech called back and said I should just wait and talk to him tomorrow. Well, I don't want to wait. Is 50mg 2x/day enough. A friend of mine (who has been through this more than her fair share) has told me that 3x/day is what I should be doing.

 

Gah. DH and I are so devastated and confused.

 

Here is my girl:

[lilythetigerdog]

Ahem, reading this back I realize that I forgot to ask my question; What dose of Tramadol did you all start out with and what do you think about my 50mg 2x/day dosage?

 

Also, I should have done a spell check... if I could only remember how.

[KF_in_Georgia]

How much does Lily weigh?

 

I'd probably start with 50mg, three times a day. But I have a written script for my 65-pound boy that authorizes as much as two 50mg pills, three times a day. Be advised that larger doses of tramadol have been known to leave a dog panting and acting anxious. This makes it appear that the pain meds aren't working when they are. This isn't a common reaction to the tramadol, but you just don't want to freak out if the panting occurs.

 

Other people will have to talk about Rimadyl--dosage and frequency. But you'll need to give something like pepcid (famotidine) before meals, then give the Rimadyl on top of food. Usually, give 10mg of famotidine about 30 minutes before mealtime when Rimadyl will be given. And if she doesn't eat for some reason, hold off on the Rimadyl. It's really hard on the stomach. (Most of the other meds Lily will take are not hard on the stomach, but NSAIDs can trigger ulcers.) Another option for an NSAID is metacam; the liquid version is very expensive; the pill version is hard on the stomach and more likely to trigger an ulcer.

 

Gabapentin: This one is tough because a lot of vets don't know much about it. My boy can have as much as 900mg a day, and that's been prescribed for other dogs on this forum. (Sam doesn't actually have osteo; he's got arthritis in his spine and a raft of other problems). You can get gabapentin from a people-pharmacy. 100mg capsules are ideal, since that will give you some flexibility in dosing. Gabapentin will take about a day to build up to its full effect, and you might want to start out slowly: say, 100mg three (or four) times a day for the first couple of days, then increase as needed once you see how it's being tolerated and how well it's working. Gabapentin works by disrupting pain signals to the brain and is not a narcotic. But if you decide to stop it for any reason, check with your vet for how to manage it. Gabapentin has a short half-life and works more effectively if given several times a day rather than just one or two large doses. See here and here for references about gabapentin; both references are cited in this information. The following is a quote from an earlier post in this thread:

 

**Published half life of Gabapentin in dogs (meaning the time it takes for half of the substance to have been removed) is 3-4 hours, meaning a dose of Gabapentin will be gone and no longer effective in ~6-8 hours. Additionally, research shows that half life is NOT affected by dose size (meaning a 200 mg dose will not take longer to leave the system than a 100 mg dose).
See a study published here
and straight from the Merck Veterinary Manual (also note recommended dosing is TID-QID, which is 3-4x/day)
Another reliable source that lists the half life as 2-4 hrs

 

You may need to show some or all of these links to your vet or Lily's oncologist.

 

Also, consult with Ohio State about Lily. Links for that are in the first post in this thread. Ohio State can talk to you about potential results from amputation or palliative radiation treatments or other options.

Edited March 6, 2013 by KF_in_Georgia

[lilythetigerdog]

Hi KF,

Thanks for the quick response. Super helpful! I will definitely take the results to the vet.

 

Lily weighs 62 lbs. She will be 8 years old on May 14th.

 

Unfortunately, amputation and other treatments are not an option. Our vet told me that amputating her leg and providing additional treatment won't give her any more time with us so we chose to manage her pain as much as we can. :0(

[BauersMom]

Hi KF,

Thanks for the quick response. Super helpful! I will definitely take the results to the vet.

 

Lily weighs 62 lbs. She will be 8 years old on May 14th.

 

Unfortunately, amputation and other treatments are not an option. Our vet told me that amputating her leg and providing additional treatment won't give her any more time with us so we chose to manage her pain as much as we can. :0(

 

 

Are you seeing a general vet or a specialist/oncologist?

 

So sorry to hear of Lily's diagnosis.

[lilythetigerdog]

Are you seeing a general vet or a specialist/oncologist?

 

So sorry to hear of Lily's diagnosis.

We are seeing a general vet. I am so sad about this diagnosis too. Lily is such a good girl.

[KF_in_Georgia]

Is your vet saying the cancer has metastasized to Lily's lungs? Because if the cancer hasn't spread to her lungs, there may be options that could give you more time.

 

I'm not trying to change your mind about managing her illness. I just want to make sure your vet gave you the correct info. Yes, if Lily has mobility problems on other legs or if there's something else going on, then your vet is right, but I think I'd want a second opinion. The vets at OSU are good for that...

[lilythetigerdog]

Is your vet saying the cancer has metastasized to Lily's lungs? Because if the cancer hasn't spread to her lungs, there may be options that could give you more time.

 

I'm not trying to change your mind about managing her illness. I just want to make sure your vet gave you the correct info. Yes, if Lily has mobility problems on other legs or if there's something else going on, then your vet is right, but I think I'd want a second opinion. The vets at OSU are good for that...

We x-rayed her lungs and they are clear. I was looking at the OSU link earlier this morning. I'm not sure if a second opinion would change my mind about the treatment, but it would be nice to get confirmation from the industry leaders on this. When I talk to my vet tomorrow I am going to get him to help me with this.

[MP_the4pack]

I would be interested too in knowing why the vet said amp wasn't an option. There is someone here who just celebrated 2 yrs. While my own 12 yr old girl had 6 months post amp. There are quite a few greys that survived over a year. And they were happy.

 

But don't get me wrong. If that's your decision, remember you made it out of love for her. There is NO WRONG decision.

[lilythetigerdog]

I would be interested too in knowing why the vet said amp wasn't an option. There is someone here who just celebrated 2 yrs. While my own 12 yr old girl had 6 months post amp. There are quite a few greys that survived over a year. And they were happy.

 

But don't get me wrong. If that's your decision, remember you made it out of love for her. There is NO WRONG decision.

I have no idea why amputation is not an option. I tried calling this morning to talk to him and the best I could get was that prescription filled. He is in surgery all day and I won't get a chance to talk to him/ask questions until tomorrow. And to be quite honest, I have been so upset and surprised by this diagnosis I really didn't get an opportunity to think clearly until today.

 

Is there anything else I should be asking/doing?

 

Thanks for supporting our decision. I keep feeling like what ever I do, short of having her see her 12th birthday, I'll regret it in the end.

[KF_in_Georgia]

There are lots of valid reasons not to pursue aggressive treatment. I think I'd probably take the same path if one of mine had osteo. (My osteo girl threw a blood clot and died; it was all out of my hands.)

 

But I'd want to feel confident about my decision, and--much as I love my vet--I'd want a second opinion.

[BauersMom]

In *most* cases, amp/chemo IS an option. Will it give you more time? Sometimes yes, sometimes no. It is easier to manage their pain with the limb removed, and certainly there are cases where the dogs do live for longer.

 

That all said, if you don't think you will change your mind about treatment, then that's certainly an option too and one that many people choose.

 

Basically, with osteo - you have some options and all of them suck... in the end, it's a terminal disease. You just do what you think is right for you and your pup. There is no right or wrong.

Edited March 6, 2013 by BauersMom

[JJNg]

Here's a good article with some basic info about osteosarcoma. While there are no guarantees, there are a number of treatment options that can potentially give you more time. As others have said, there is no right or wrong decision. But I believe that everyone should be aware of all the options and make an educated decision about what is appropriate for your situation.

[joejoesmom]

From time to time, OSU asks me to speak with owner's of newly diagnosed hounds about osteo from an owner's perspective. This has led to a document that I am writing. It is not finished yet, but the plan is for OSU to email it to anyone they feel would benefit. It still needs a lot of work but it might help Carrie or others currently trying to make decisions. If you PM me with your email, I will send it. It is currently about 10 pages long (needs to be edited), so not appropriate for me to paste it all here. But here is an excerpt:

 

First, let me say that osteosarcoma, the most common form of bone cancer in dogs, is a truly horrible, crappy, $%@# disease. It is almost always fatal. It is incredibly painful. You are probably feeling totally devastated and overwhelmed right now. However, if amputation is a possibility for you, it is very important that you make a quick decision, despite feeling overwhelmed. Amputation is most successful when performed as early as possible in the disease process. If you are not going to amputate, you have a little bit of time-- as long as you are adequately treating the horrific pain that comes with this disease.

 

Osteosarcoma treatment options run the range from aggressive to just medication to manage the pain. Current treatments include: amputation of the affected limb--limb sparing surgery is an option in rare cases; IV chemotherapy; radiation; a biphosphonate infusion; pain management with medication; and alternative therapies (herbal medications). These are often used in combination.

Cancer survival rates are reported as “median time of survival”. For instance, if the median time of survival is one year, this means that ½ of the dogs will die before one year and ½ will live past one year.

 

The following is a chart with the generally recognized median time of survival for various treatments. These numbers are not cast in stone. New studies are always being undertaken. New therapies are being tried. In some cases, the treatments or combinations of treatments are new enough that there are no widely recognized statistics. There are also inconsistencies between different studies. Where there are inconsistencies, I have included a range.

 

Osteosarcoma Treatment Median Time of Survival

Amputation with IV chemo 12 to 14 months

Amputation with IV chemo and metronomic protocol

Amputation alone 3 to 6 months

Radiation, biphosphonate, and chemo combination 7 months *

Pain Management with medication 4 to 8 weeks

Radiation alone

Chemo alone

Biphosphonate alone

*results from a very limited study

 

Note that the median times of survival have not been confirmed by OSU recently, but I believe them to be current.

 

AMPUTATION with IV CHEMOTHERAPY (and the option for long-term metronomic chemotherapy):

Removing the affected limb will totally get rid of the terrible pain this disease causes. This is also the only chance your dog has of beating this disease. However, this possibility is so slim (less than 10 percent) that you should not make your decision based on any expectation of eliminating osteosarcoma from your dog’s body. This combination of treatments has been shown to provide the longest median time of survival, currently at 14 months for greyhounds treated at Ohio State University. Median survival means that half the dogs receiving this treatment die before 14 months and half the dogs live past 14 months.

The most critical factors influencing the decision for amputation and chemo are:

1) Are there already visible lung metastases? If so, the median time of survival will be shorter and there is currently no chance of beating the disease.

2) Are there any orthopedic issues that would make being a tripod too difficult?

3) Is the dog in good general health? If not, how will this impact the recovery and long term outlook?

4) Can the owner afford the treatment? This typically ranges from $4000 to $10000 over the course of the treatment. I have heard quotes for the amputation alone range from $1000 to $8000. Likewise, I have heard that IV chemotherapy can cost from $1000 to $7000. I know this is a big range. Mostly, it depends on the part of the country where you live and the vet that you choose. The costs can go up if your dog has any complications and whether you choose to do a metronomic protocol.

5) Is the dog petrified of the vet? If so, can accommodations be made to mitigate this? This usually isn’t a problem during the amputation phase. Your dog will be on heavy sedation for much of his time in the hospital. It becomes more of an issue during the IV chemo phase of the treatment. Your oncologist may be willing to accommodate your dog’s special needs. You could choose to do an amputation without chemotherapy. However, this will shorten the median time of survival to 3 to 6 months.

6) Can the owner provide intensive care for the week or two after the surgery? If not, can they afford to pay the veterinary hospital to provide this service? If you have questions about this, please see the document about what to expect during amputation and recovery.

7) What is the owner’s personal philosophy of treating a dog with a terminal disease? There is more on this at the end of this document.

You will note that I have not mentioned the age of the dog. In my opinion, age alone is not an important factor.

 

This is a horrible disease. It is almost always fatal, even with aggressive treatment. There are truly no guarantees, no matter what treatment you choose. Your decision is somewhat philosophical. Do you provide aggressive treatment, no matter what the cost, to extend his good quality of life as long as possible or do you let him go soon, keeping in mind that he has no concept of time or worry about how long he will live.

 

I chose to do aggressive treatment. I got another 20 months of incredible quality time with my sweet Joey. I don't regret my decision at all. Did Joe realize that I bought him this extra time with me? No he didn't. Did he have a great year and a half? Absolutely. I made my decision as much for me (perhaps even more for me) than for Joe. There really isn't anything wrong with that, because Joe had an excellent quality of life. As soon as he didn't, I let him go.

 

Based on what I have read from others, it seems that most people are content with the decision they made -- whether it was amputation/chemo or palliative care. There really is no right and wrong decision. Others have said this, and I believe it: "There is no wrong decision. Whatever decision you make will be out of your love for your dog and the needs of your family."

[45MPHK9]

I keep feeling like what ever I do, short of having her see her 12th birthday, I'll regret it in the end.

I really hope that this isn't case for you.

 

We had no regrets about opting for palliative care for Bee Wiseman when she was diagnosed with osteo. She lived eight weeks with the cancer. We always felt like we were in control of and ahead of her pain. In the last couple of days, when we couldn't get ahead of her pain, we were ready to release her from the awful pain that the drugs could no longer control.

 

I've written this here before. If an amputation could have cured Bee of the cancer, we would have gone that route. It couldn't, so we didn't even try it. We have no regrets about this. We never felt like we didn't do everything possible for her given the diagnosis. We had eight great weeks with her. We said goodbye to her peacefully.

 

I hate this godforsaken cancer for taking her away at 10 years old, but we managed the disease on her behalf. It was, for us, the best possible outcome given the awful circumstances.

 

I'm sorry for the diagnosis.

[Charlies_Dad]

First off, I am very sorry that Lily has been diagnosed with Osteo. We are all here to support you in any way we can. Already you have received good advice and unfortunately in the end there is no 'right choice' other than what you feel is right for Lily. As for your vet, well I'll be blunt and say that he/she needs to provide you with all the options up front. Without knowing Lily's past health record, it's difficult to know where he/she is coming from however all options should be discussed immediately with possible outcomes for each. Jane, aka joejoesmom, has outlined them well and this is what a good vet will do for their patients. Obtaining a second opinion is always a good thing and leveraging OSU's assistance to me personally is top priority in a case like this. As for the options, well personally I cannot handle a dog in pain and that is what Osteo introduces and the worst kind. Palliative care does not 'manage the pain' but rather masks it for a while until it gets to a point that you have little choice. It is the path to take if you choose to at least give your pup a little more time to enjoy life and make memories as time will be short for most pups however there are exceptions like FedX who's Mom battled with him for I believe just over 16 months which is an incredible feat. I know she pursued several options with the exception of amputation and she may chime in on what she has done and she has also written in past posts in this thread or the previous Osteo threads. The other approach is amputation and chemo which is the best approach for relieving the pain however the surgery and recovery can take 2-4 weeks depending on the pup. There are also financial considerations to take into account as it's not cheap but then again some of the palliative care options can certainly be costly as well. We chose the latter with our angel Charlie and it was the right one for him and us. He lived a happy 21 mths post diagnosis which is very good but he did not see his 10th birthday even with this run. There are others on this board who have pups that have surpassed that by months so some pups do live a long time after amputation but they are few, not the majority. Choosing this option, one has to look at 12 mths as a decent amount of time with anything over that being a real bonus (IMHO).

 

Please give your Lily a hug from me and we will be here for you both.

[Guest dmt]

So sorry to hear about Lily's diagnosis. Sending hugs and prayers.

[Jackandgrey]

Carrie there is absolutely no reason that Lily is not a candidate for amp/chemo. I am suspecting the vet just believes it is not of benefit in the long run. She is otherwise healthy and has no limb problems. Amputation alone will absolutely not buy you more time. I know how confusing this is. there is so much information to absorb. Whatever decision you make is the right one, trust me. I know how much you love her and no has her interests at heart more than you do. There is no guilt attached to whatever choice you make. You know my number. Call it anytime.

 

As for palliative care, I did it with three of mine, there is no way in hell they EVER suffered the "worst kind of pain". Their lives were of varying lengths after diagnosis but their days were good. That was the deal we made.

Edited March 7, 2013 by Jackandgrey

[BauersMom]

Osteo is extremely painful, and arguably one of the worst kinds of pain - I think the point is if you are going the palliative route you HAVE to be willing to medicate and not hold back on pain medications, which often means you are going against the recommended medication options given by some vets. Palliative is managing the pain as best you can. I don't think there was any knock on someone deciding that route, but that is absolutely the reality of osteo.

Edited March 7, 2013 by BauersMom