Monday, March 10, 2014

Little dog, Big problems

"She's a very sweet dog - when she's not biting us."

And so began our most recent conversation with Dr. Dodman and his staff. I'm sure they think Jan and I are absolutely batty.

As with any appointment with Dr. D and his staff, we completed our multi-paged pre-consultation paperwork, and the meeting always begins with a review of it: What brings us there today? What was the original diagnosis? What steps were recommended and how have closely have those steps been followed? Have there been any changes in the household? Any physical changes to the dog? Any new injuries or illnesses?

One of the things I noticed when completing the paperwork was that we had gone off-course with Bella's low-protein diet. With so many cooks in our dog's healthcare kitchen, it is easy to lose track of who said what and when and how and why we should be treating her.

In this case, even Dr. Dodman's staff was surprised to discover that, while Hill's Prescription Diet w/d was a low protein option at 19.2%, the r/d version prescribed for her to help settle her colitis, at 34.6%, was not.

So it was noted that in late July we had switched Bella to a high protein diet and by September, she had bitten Jan again.

Note to self: You alone are responsible for knowing what Bella is eating and managing her protein intake regardless of who is advising you at any given time.
Action item #1: Switch her back to a low protein diet. Add fiber via pumpkin or Metamucil to achieve the higher fiber content which was the aim of the prescription dog food.
I hear  you talking about my food. 
Next up was the discussion of what happened between me and Bella in December. I covered this last week so won't go into again here but it was acknowledged that, while I missed her signals, Bella still shouldn't fly off the handle over such trivial offenses.

We talked about her shoulder pain and stomach upset and how that can wear on one's nerves over time. If Metacam is making her sick, there are other medications we could try to help ease the pain while not upsetting her stomach.
Treatment option #1: Consider a different pain reliever. If Metacam upsets her stomach, find another and get her off this never-ending roller-coaster of ick.
We then went on to talk about the possibility that Bella is suffering from PTSD (post-traumatic stress disorder) which could stem from her less-than-positive puppyhood on the streets of Puerto Rico or, rather surprisingly, could be associated with when I broke my arm and Bella was left alone for several hours afterwards.
Action item #2: Increase Bella's Fluoxetine dosage. We had never been successful in getting Bella up to the recommended dose of "Prozac" which Dr. Dodman prescribes specifically for aggression issues but is also used routinely to treat PTSD. He recommended now that she has been on it for a while, she may take to an increased dose better than she did when we tried previously.
The conversation moved on to how Bella responds during these incidents which is to say, she doesn't. I mentioned in our intake sheet that Bella seems to "disappear" during these episodes and it takes some effort and an external force to stop her. We also noted that these bouts go on more than just a couple of seconds lasting upwards of 15 or 20 seconds.

Dr. Dodman noted that this particular behavior was not common in 'ordinary' cases of owner-directed aggression and could in fact, indicate partial complex frontal lobe seizures. Huh. I did not see that coming.
Treatment option #2: Consider the anti-convulsant medication Zonisamide. While some of the symptoms Bella is displaying seem indicative of behavioral seizures, not everything aligns perfectly. Adding an anti-convulsant medication could help but it could be months before we'd really know whether or not that was the right diagnosis.
Finally, almost as an aside, I mentioned Bella's quirky little episodes of apparent reaction to unknown pain that I've been telling everyone who will listen about for as long as I can remember. I was taken aback when Dr. Dodman, instead of trivializing my concerns, actually took note and questioned me further about this.

What everyone else had dismissed as "probably" just static electricity, Dr. D took seriously. And on top of that, he gave us suggestions about why it could be involved in Bella's outbursts and what we could do to possibly treat it. He thought it could be nerve pain.
Treatment option #3: Consider adding Gabapentin (Neurontin) to Bella's current medication regimen. Gabapentin has both pain-relieving and anti-convulsant properties. This could potentially help manage both the shoulder pain as well as the possibility of partial seizures with a very notable side benefit being that it would also address any neurogenic pain she has that we have yet to identify.
PTSD, you say?
I can't imagine why.
To summarize, we were left with a number of possible diagnoses:
  1. Post-traumatic stress disorder which could be separate from or associated with
  2. Frontal lobe, complex partial seizures, and/or
  3. Un-diagnosed nerve damage/trauma.
After much discussion, we went home with a prescription of Gabapentin.

The choice was obvious: Gabapentin is often used in combination with NSAIDs like the Meloxicam we had Bella on to boost their efficacy. Add in the neurogenic and anti-convulsant properties combined in one medication as well as minimal side effects and we could possibly treat all of Bella's issues whether conclusively diagnosed or not.

That "not conclusively diagnosed" still gives me pause. If Bella has un-diagnosed nerve damage, shouldn't we be looking into what that is and possible options to fix it? Could we be masking something that should be cause for concern? And what about seizures? If she's having them, should we be trying to discover the root cause and address that?

We've opted to take one step at a time.

We have made the recommended changes and we're monitoring our girl's progress. I keep a daily journal of what Bella eats, what meds she takes, how she feels and behaves. From there we can track trends and gain insight into what is really going on inside that little body (and really big brain) of hers.

Next week we'll talk about how it's been going.


14 comments:

  1. Wow - and we thought Maggie & Duke were project dogs!
    Bella is very lucky to have the 2 of you (and Dr. Dodman's team. :)

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  2. That's a lot to take in! I hope that it's been helping her!

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  3. Both Ruby and I take gabapentin for our creaky joints. Neither of us has had any negative side effects.

    Bart

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  4. That's great to know, Bart, thanks! (Sorry about your creaky joints though.)

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  5. Thanks, Carrie. It was a lot to digest but yes, we have already seen signs of relief. Not sure we've got it all figured out yet but we're getting there.

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  6. Yup, she's a handful. I can't help but think if this has all been pain related, she's got/going to be so relieved if/when we fix it once and for all.

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  7. There are times that ONE OF US, Doesn't quite catch up on posts.
    Seeing and reading all this, WOW. Have to say again, Bella is one cherished girl and how lucky she is to have you. Bella, get well soon baby and what ever it is, the real lovely you is in there. LOTS AN LOTS OF LOVE BELLA. Luvs Cat Flap Cavalier and the cat X

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  8. I found this sentence interesting "Dr. Dodman noted that this particular behavior was not common in
    'ordinary' cases of owner-directed aggression and could in fact,
    indicate partial complex frontal lobe seizures. Huh. I did not see that coming." because when you said she goes somewhere else, the first thing I thought of was rage syndrome....which I believe is also some sort of seizure.

    I'm one of those want to get to the bottom of things people too, but sometimes, unfortunately, getting to the bottom of things involves trial and error to rule things out (and to rule other things in.). This is one of those times that I so wished dogs could talk, to let us know what's going on in their minds. I do hope that the Gabapentin is helping (and lowering the protein in the food), no matter what the cause, and I'm looking forward to reading how the rest of this goes.

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  9. Bella's so lucky to have you in her corner. I hope that the adjustments help her. ((hugs))

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  10. Bella's lucky to have a concerned kitty in her corner. :)


    She surely is our little enigma. But she's such a good sweet girl when things are going terribly wrong that it's easy to fight for her. Thanks for the kind words.

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  11. Dr. D did talk about "Springer Rage". He has long thought the syndrome is associated with seizures.


    I think we had it in the back of our minds (hence our even mentioning that it's like she's not there) but we both experienced Beau's seizures and this is nothing like those were. I guess the brain is just a very complicated piece of organic machinery and we're doing our best to figure it all out.

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  12. we are sending you love a patience

    Stop on by for a visit

    Kari

    http://dogisgodinreverse.com/

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  13. Jan K, Wag N Woof PetsMarch 13, 2014 at 5:28 PM

    That is a lot to take in, but it sounds like you are dealing with it logically....one step at a time. I hope it is going well.

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  14. Oh, man... I feel for you--and for Bella. I know dogs like this: all sorts of "mysterious" medical issues, aggression, fear, unpredictability. Yes, Bella is lucky to have you, and I look forward to following her ongoing saga. Kudos, Leslie!

    P.S.--thanks for stopping over at Life In Dogs and for leaving the sweetest comment on the post about Romy and her Seven Dwarves :)

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