Night time Restlessness Might be Due to Pain or Drug Interaction
Drug Interaction?- Bailey's alternative medicine vet thought it was worth a try to discontinue the Velvet Antlers that she had suggested long ago, and that she too takes. She prescribed Velvet Antlers to help build and maintain muscle mass in Bailey, since she feels that it helped her rebuild muscle following the debilitating effects of a car accident. Bailey's back end is really skinny, probably because of his arthritis, and we were hoping the Velvet Antlers would slow further muscle deterioration. I think it worked to help maintain Bailey's muscle mass.
Last week, when I came in to Bailey's acupuncture appointment exhausted and at the end of my rope because of Bailey's increased nighttime restlessness, Dr. M. suggested that we stop the Velvet Antlers. She said that she thinks that the chemical compound may be interacting with the tramadol prescribed by Bailey's regular vet to relieve any discomfort he may have from his arthritis and the growing tumor on his left side, with the unintended side effect of causing nighttime restlessness. So, Bailey went off the Velvet Antlers, at least for now. We agreed that pain relief was more important than muscle mass at this stage in Bailey's life.
Additional Drug Changes by Bailey's Regular Vet
My next move was to call Bailey's regular vet to discuss Bailey's nighttime restlessness and my resulting exhaustion. The other Dr. M. (confusing- but I don't want to use their names without their express permission, because I am not a vet and whatever they say gets filtered through my lay brain and may be sort of distorted, as much as I try to get it right) said that he doesn't want to sedate Bailey, but that working on pain management may also have the benefit of making the nighttime restlessness less severe. He said that he'd like to try another drug in addition to the tramadol to make Bailey feel better and get better rest at night. He prescribed 100 mg gabapentin twice a day in addition to the twice a day 50 mg dose of tramadol that Bailey already takes. He suggested a 5 to 7 day trial of this drug combination, which is what he gives his own dog.
The Changes in Drug and Supplements Given to Our Senior Dog over Time
Bailey's drug and supplement therapies have gradually been shifting to reflect his changing condition. The various glucosamine and condroitin supplements used to help arthritis discomfort have been replaced by heavier drugs like Metacam as the arthritis got worse. Bailey's increasingly large tumor has required additional changes in his medications, both because of the nighttime restlessness and because of the more urgent need for pain relief at this stage in Bailey's life. Bailey's condition has changed and so have priorities in his care. His tumor is inoperable and he will be 16 years old in January so we are in more of a hospice mode now. Bailey's comfort is our primary focus.
The New Drug Lineup: Tramadol and Gabapentin
Bailey's vets know that I need to understand and research everything they tell me and they are very patient with me. They both spell things out and explain things at length and then I go home and look things up myself. So, here is my interpretation of what all of this means.
Again, this is all as I understand it from a lay point of view. Tramadol is a human drug that is being used more and more in veterinary practices for pain relief. I have read over and over that tramadol is a drug that sort of falls between the non-steroidal anti-inflammatory drugs (NSAISs) like Rimadyl that some dogs can't tolerate, and heavy duty narcotics like morphine. NSAID drugs are pain inhibiting drugs that somehow interfere with enzymes that cause pain and inflammation. Heavy duty narcotics like morphine are opiates that stimulate opiate receptors in the brain and some of these drugs have the helpful benefit of pain relief, but unfortunately can cause hallucinations, sedation and heart and respiratory difficulties.
Tramadol seems to fall somewhere between the NSAIDs and the narcotics. Tramadol stimulates "mu" receptors in the brain and somehow cause pain relief without sedation or addiction. It has side effects, but most of them are mild and rare, including sedation at high doses and constipation and nausea. Tramadol is a human drug but our regular vet stocks it and we get it at his office.
Gabapentin was originally developed as an epilepsy drug but now it's widely used for pain relief. It's a human drug that is being used by lots of vets now. Our vet doesn't stock gabapentin, so he called a prescription in to our human pharmacy. Gabapentin is often used to treat neuropathic pain. It may help to deepen sleep and reduce nighttime arousals. It may also help agitation and anxiety. Gabapentin has some side effects such as dizziness and drowsiness.
Gabapentin is being used increasingly to treat chronic pain in dogs, particularly neuropathic pain and pain associated with malignancies. It is often used in combination with other pain relievers so lower doses of both drugs can be used, presumably to minimize the side effects of both.
Bailey's Trial Period on Tramadol and Gabapentin
Bailey is on these meds twice a day, 12 hours apart. His dosage is 100 mg gabapentin and 50 mg of tramadol. Bailey weighs about 58 pounds now (we're trying hard to get high quality calories into him which is a big change from the days where we tried hard to keep him at a svelte 62 or 62 pounds to help his arthritis).
Our goal is to treat Bailey's discomfort and at the same time, reduce his nighttime restlessness. The theory is that if the restlessness is caused in part by discomfort, if Bailey is more comfortable, he will rest better. I have been told that we may have to tweak dosages and that we are hoping to make things better, but that we won't achieve perfection. So far so good. He seems less agitated and he's not waking up as much. Last time, when we tried changing the tramadol schedule to help with the nighttime restlessness, I thought the change did the trick. If it did, it only lasted a few days and then Bailey was up again at night over and over. I really hope this drug combination works better.