… but I am.
Billy’s first exposure to Rimadyl was just over a year ago and was my fault – I left a bottle with about 10 of Jasmine’s chewable tablets on the counter after feeding time. Billy exploited the opportunity and as a result, he spent 3 days in the hospital for preventative diuresis. We were lucky and he walked away unscathed. After that, we made significant changes to the way we store the Rimadyl to avoid another accidental exposure.
We starting storing the dog food and medications on top of the fridge, with confidence that they were out of Billy’s reach. The meds we keep up there are in stainless steel water bottles with heavy screw tops. We thought that was safe – who wouldn’t? That strategy has worked fine for over a year, but it turns out that Billy’s determination far exceeds anything we could have imagined.
Day Zero: The Disaster Unfolds (Mon, 10/10/11)
At 6:00am on Monday morning, I flew to Salt Lake City for a 5-day conference, leaving Rich at home with the dogs. Sometime around noon, Billy managed to get access to the top of the fridge (there’s no counter or stool nearby, he must have just scaled the front somehow) and knocked nearly everything off onto the floor. He then took the stainless steel container of Rimadyl outside, unscrewed the top, and ate them all. I had recently refilled Jasmine’s prescription so there were around 150 tablets, an unimaginable overdose by any standards.
I chose to avoid the actual calculations until I was sure he was going to survive, but I have now determined that his exposure was ~425mg/kg. Therapeutic dosage is 4.4mg/kg, and the literature talks about renal concerns beginning at 40mg/kg. In other words, his overdose was massive – 100x therapeutic and 10x toxic.
Rich discovered the disaster around 1:30pm and had Billy at PetCare by 2pm. They began aggressive treatment immediately, which involves vomiting, activated charcoal, IV fluids for the kidneys, and meds to protect the liver and the GI tract. He somehow managed to survive the night and I flew home from Utah first thing Tuesday morning.
Days 1 to 5: To Hell and Back (Tues 10/11/11 – Sat, 10/15/11)
The vomiting subsided within a couple of days but he remained nauseous and had very little appetite. His kidneys had paid a price but appeared to have to have stabilized. Because of the massive amount he got, they opted to keep him on the fluids for an extra couple of days as a precaution. Our new concern at this point was the liver, which started to go south on Wednesday. His ALT (liver enzyme) rose dramatically from 62 on Tuesday (which is WNL) to 126 on Wed (way above NL), then 400 on Thurs. If the ALT had continued to rise at that rate into the 1000 range, we would expect acute (and potentially irreversible) liver failure to not be far behind. But it seemed to stabilize in the 400-450 range. His bilirubin (which causes jaundice) remained elevated, but was also unchanged between Wed and Thurs, which suggested it may have plateaued as well. He was definitely yellow, but his eyes seemed a little better on Thursday – I thought it might be my imagination, but the nurse said the same thing.
His clinical presentation has also improved. He began eating Thursday morning, and shows more and more real interest in food (rather than just humoring me by taking something out of my hand). By Friday morning he was seeking out the morsels that I tossed on the floor, that night he was catching them in mid-air, and on Saturday morning he actually offered simple behaviors, like sit and close. He will engage with a toy when I toss it and find the squeaker, but only once or twice. We go on short walks in the parking lot and he trots with his tail wagging, at least for a few steps at a time – he obviously fatigues very quickly and we’re keeping our visits short so he can rest.
Our schedule this week has been simple: visit at noon because that’s when they run the blood tests, stress all afternoon and evening, visit before bedtime, then try to sleep at night. The 24-hour wait between blood draws is excruciating, but we’re encouraged by the small clinical improvements we’re starting to see each time we visit. In fact, today for the first time, he tried to follow us out of the visiting room rather than going back to his cage with the nurse.
Day 7: More Signs of Hope (Mon, 10/17/11)
Saturday night’s visit was quite uplifting. His attitude had improved even from the morning and we got a glimpse of the Border Collie we know and love – catching his toy in mid-air, snatching it off the ground and shaking it, even a little light tugging, and bringing it back for more. His appetite is obviously improving, as is his willingness to “work” for food. On Sunday, the nurse was pleased to report that he was eating rice and chicken out of a bowl (“like a dog”) instead of only out of her hand. And the fact that he was interested in that sort of bland-ish food was also an improvement because we had previously only been able to entice him with “junk food” (the Dr’s term) like hot dogs, string cheese, and green tripe treats.
This afternoon, we got good news from his first urinalysis – no urinary casts. These casts, if present, are positive indicators of kidney tubular damage. Absence doesn’t necessarily mean no damage, but it’s still very encouraging. He’s also not spilling protein into his urine. Plus his bilirubin level has dropped significantly and he’s noticeably less jaundiced today. Liver and kidney blood values still not what we’d like them to be, but he continues to eat and play and his stamina is improving. And my friend Sarah is quick to remind me (after her first-hand experience with Rav’s acute failure of both liver and kidneys as a puppy), “look at the dog, not the numbers”.
Following the good results from the urinalysis, they started tapering his fluids in anticipation of sending him home soon.
Day 8: Homecoming! (Tues, 10/18/11)
I’m beyond thrilled to report that 8 days after admission, Billy is home from the hospital! I picked him up on my way home from work and here we are.
Clinically, he’s getting better every day. Today when I visited him at lunchtime, he ran full-speed across the parking lot to chase a squirrel on top of the fence. He obviously has some reconditioning to do after 8 days of lying around in a cage (and more recently a 5’x5′ “room”), but I’m sure that will come back quickly once he’s released to run freely on the back hill. I’m keeping him confined for a day or two while we re-introduce him and Zack, and also I’m going to be a lot more compulsive about daily mushroom checks. It’s that time of year, and even a small insult that wouldn’t normally be a problem could be real trouble now.
Chemically and medically, we definitely have some fallout. His liver numbers are far from perfect, but the Dr. is optimistic that those will recover over time – the liver is very resilient and can regenerate. However, his kidneys have almost certainly sustained some level of permanent damage and we’ll probably have to manage chronic kidney disease throughout his lifetime. Based on his current chemistry, he’s labeled as Stage 2 (out of 4).
Next steps include nutritional research and consultation, guidance from an internist (preferably one who understands what it is that we do), and careful monitoring of blood work and hydration.
How do we protect him in the future?
We may not be able to. Dietary indiscretion is no joke, and neither is his drive to exploit vulnerabilities. We can’t put him in a bubble, so all we can do is continue to make adjustments and hope for the best.
We started by buying a new storage cabinet, which now houses all of the food, medications, and garbage containers. It includes a shelf at about the right height that now serves as our food and medication prep center (instead of the kitchen counter). The cabinet doors have hasp loops that will always be secured with a carabiner, and we have fabricated a nylon crossbar that inserts into the door handles for further security when we’re not here. And finally, the cabinet will be secured to the wall so he can’t pull it over.
I am sticking with the metal stainless steel water bottles, but I have purchased smaller 12-oz ones and will only store a limited number of meds (i.e. less toxic overdose potential) in the cabinet. The remainder will be stored safely somewhere else.
The other significant change is that Jasmine no longer gets tasty chewable Rimadyl tablets. I replenished her prescription with boring caplets. She won’t mind because she still likes Pill Pockets, which I buy by the case anyway, and which are also now secured in the new cabinet.
Soap Box: Don’t buy chewable Rimadyl
On the day Billy went to the hospital, there were three other dogs admitted for Rimadyl toxicity. One of them got it from its owner’s purse after having just been prescribed it therapeutically that day. Four dogs in one day in one hospital? Something is definitely wrong with this picture, and what’s wrong is packaging a toxic medication as a tasty treat.
Finally, I can breathe again
Last Monday night when I was alone in my hotel in Utah, I was certain I was going to lose my boy and I grieved. And my mood on Thursday night, after his liver went south, was equally dark or maybe even worse because I had let my guard down. But now he’s home, he’s hungry, he’s back to his happy playful joyful self, and he has no activity restrictions. I fully expect him to return to his agility training soon and hopefully he’ll lead a relatively normal life.
Life is good!