Metoclopramide -- A Different Perspective

[krsbunny]

First, I want to say how much I appreciate the information on thisforum ... especially when it is different from what I have heard in other groups! The perspective here on misuse/overuse of motility drugs has caused me to adjust my thinking. But when I see posts like Dotty's mom hating to admit that she had allowed a shot of metoclopramide, Ifelt the need to post about mypositive experiences with these drugs.

I wish years ago when Murray was first having GI problems that I had been exposed to more than one viewpoint on “proper” diet. It is in his memory that I am offering my recent positive experience(s) with metoclopromide.

About three weeks ago on a Saturday night my bunny girl (Princess Pandora) ignored the announcement that Dr. Allan was going on vacation and no one was to need a vet for the next week. She was just slightly off her salad, acting fine otherwise. Sunday she seemed gassy so I took her temp (in her only other GI episode she had crashed fast) ... it was fine. Gave simethicone. She still didn't seem interested in food, so I gave fluids and a dose of pain meds just before bed.

Next morning she seemed better but not great, so we were off to a new vet (highly recommended by local friends). GI felt and sounded good. One tooth looked suspect, so molars were done under anesthesia. There was a small laceration on her tongue from the one visible spur. I asked about injectible metoclopramidebecause it has helped so many of my bunnies (beginning with HRH King Murray) bounce back more quickly from dentals (Dr. Allan and I suspect Murray – and some of the others he has sent here for dental care – suffer mild post-anesthesia nausea). Dr. Diehl did not think she would need it, prefers (as I do) to do x-rays before giving these drugs, and didn't want to stress her more with x-rays.

My "gut" told me Pandora might be one of the bunnies who would need a “boost”, but I decided to wait and see. She nibbled a bit Monday afternoon (yes, she had me out picking what little green grass is available in Missouri in February). Tuesday she seemed more “off” and gave me that “Why am I still not feeling good?” look. I called Dr. Diehl and he OK’d giving her metoclopramide – we agreed on a lower dose than she had during her previous GI episode. After the first dose she seemed to feel better and nibbled a bit. After the second dose she was munching on hay. By Wednesday evening she was eating almost normally and playing more than normal. By Thursday she was back to her normal bratty self.

Would Pandora have been OK without the metoclopramide? Probably. Would she have recovered as quickly? Possibly. It could be a coincidence that she started to turn around within a couple of hours of the first injection.

In my personal experience, I have not seen injectible metoclopramide (cannot speak for oral, as I don’t use it) either cause or increase GI pain. (Note: I don’t argue that others here may have had different experiences.) Because pain usually accompanies GI episodes, the vets here generally give Banamine with the first couple of doses of metoclopramide. Again, in my personal experience, Banamine is the best medication for GI pain in rabbits and is well-tolerated as long as the rabbit is properly hydrated.

Personally, I never give – or recommend giving – motility drugs without consulting a vet first and in most cases I ask for x-rays before giving them. The one exception to the second part of that statement, for me, is when the vet visit has identified an underlying physical ailment (in my house, almost always teeth) that explains the appetite change. I do not always give it after a dental – but don’t hesitate if the bunny is “off” the next day.

Motility drugs are not always the answer. I agree that if they are used inappropriately the results can be fatal. I also agree that rabbits can become dependent on them. Murray was. I did not know that at the time, but I know it now. I use these drugs more cautiously now (even before hearing this forum’s perspective). But I honestly think they allowed Murray to live as long as he did.

Note: I am more cautious about using cisapride now, but that is because it is only available in compounded form … and I have personally seen more side effects with compounded drugs (“inactive” ingredients are not always).

 

[Maureen Las]

This is sort of like blowing my mind away...

At this point we need to have a person describe thespecific physiologic action of these drugs on all systems of a rabbit under all conditions in order to say whether they are beneficial or whether a person using them is just lucky.
We have 2 very knowlegeable people with opposing viewpoints on this forum but neither person is actually stating the science behind their position.

I used motility drugs several times before coming on this forum without incident. I never thought about it twice. I now think of them as horrible.
We need more than just stating "they are safe or unsafe "

we need an explanation as to "why"
, the mechanism of action etc
someone needs to do a study on the effects of motility drugs on rabbits

otherwise it is just 2 people disagreeing
and the rest of us left not knowing

 

[Maureen Las]

wikipedia is not very legit in terms of science but it does describe this drug

http://en.wikipedia.org/wiki/Metoclopramide

I guess I want to get a good discussion going

this drug does have some horrible side effect with chronic use



like tardive dyskinesia which is seen in psych patients on psychotrophics (thorazine,stelazine ,haldol etc)

 

[krsbunny]

Yup, now you know how I felt when I came onto this forum and started reading the perspective on motility drugs. Totally blown away.

Safety when it comes to drugs is always a "relative" term. Very fewof themfall into the "always/never" category. There are always risks and benefits. Also, it has only been very recently that drug studies in humans have shown that individual "body chemistry" plays a role in both safety and efficacy. Consider, also, that there can be risk in NOT doing something.

Kathy (who has really opened a can of worms here)

 

[Maureen Las]

krsbunny wrote:

Yup, now you know how I felt when I came onto this forum and started reading the perspective on motility drugs. Totally blown away.

Safety when it comes to drugs is always a "relative" term. Very fewof themfall into the "always/never" category. There are always risks and benefits. Also, it has only been very recently that drug studies in humans have shown that individual "body chemistry" plays a role in both safety and efficacy. Consider, also, that there can be risk in NOT doing something.

Kathy (who has really opened a can of worms here)

You're certainly a courageous soul!!!!

 

[Maureen Las]

I think most of us think of motility drugs as a risky easy fix.


In other words that if a rabbit is in stasis that it requires a lot of time and effort to get the rabbit out of it using oral hydration or sub q fluids , probiotics , pineapple juice ,water etc until the stasis resolves over time.

taking a motility drug is like taking harsh laxative (this ismy mind"s picture )

I agree that all drugs have side -effects sopossibly a motilty drug could be used cautiously ..

maybe :expressionless

I have to think about it awhile...:?
but if it is a necessary drug and most of us don't use them (or use them infrequently) then why are our rabbits not dying from stasis all the time

We really should do a poll on people who have used the drugs with positive effects and people who have used the drugs with negative effects

 

[Pipp]

angieluv wrote:

We need more than just stating "they are safe or unsafe "

we need an explanation as to "why", the mechanism of action etc
someone needs to do a study on the effects of motility drugs on rabbits

angieluv wrote:

We really should do a poll on people who have used the drugs with positive effects and people who have used the drugs with negative effects

Nothing is black and white so neither 'safe' nor 'unsafe' can be used without qualification, so it would be good to collect the qualifications.

Nobody will argue that without a proper diagnosis that the drugs are dangerous -- they can cause a rupture that can kill a rabbit suffering from a blockage.

I did an informal study with info here and on Etherbun last year and I've opted generally not to use them.

Rami at Etherbun/MediRabbit tries to avoid them but will use them under certain conditions. Kim, another prolific poster on there for medical questions, does not use them at all because her vet is adamantly opposed.

My vet used to hand them out at the drop of a hat. Now he'll still prescribe them but he's very cautious.

I'll round up the various comments and conditions I collected and post them soon (hopefully).

EDIT: Ignore the first version of this post if you saw it, it was missing a paragraph or two and I appeared to be responding to something I wasn't responding to. :rollseyes:

sas :bunnydance:

 

[Pipp]

Here are some of Rami's comments. I had a direct exchange with him on this subject, but I can't find it. I'll put my favorite one first, although keep in mind English isn't his first language, when he says 'they can help more or less', he means they can make it better or worse.

>> Is there any reason she'd be getting worse on motility drugs? Shouldn't the propulsid be working?

It is to activate movement of the intestine. Depending on the problem, they can help more or less. In my experience, keeping a rabbit warm (hypothermic rabbits will not eat), gentle massage of the intestine in the direction of the anus, pain medication and lukewarm oral or SC fluids help a rabbit better than all other medication.

-------

Forced movement of the gut is not only uncomfortable, but can lead to more pain than already is. Also, depending on the location of the blockage, or forced passing of the mass through the small opening between the stomach and the duodenum (pylorus) can lead to rupture and death of the rabbit.

--------

""Cisapride (Prepulsid) works on the acetylcholine release; this one is increase which in turn will increase the motility of the GI tract (intestine). It works mainly on the lower esophageal sphincter and increases the pressure in the lower part of the esophagus, stimulates the emptying of the gastric content into the intestine; it furthermore enhances the activity of the intestine (small intestine and colon).

This drug needs to be given 30 to 15 min before a meal. When it is given together with other drugs that are absorbed in the stomach, one should keep in mind that its absorption will be decreased; the contrary for drugs to be absorbed in the intestine.

There are adverse effects: It should not be used in case of GI bleeding, total blockage or with a perforated intestine. Other effects are toxicosis with diarrhea, tremors, convulsions, etc."

------

> that is why old vet sent home metronidazole for bad bacteria..and
> reglan to keep it moving.

This is good, and right. Clostridium is an anaerobic bacterium, that can only be killed with special antibiotics. Diarrhea is always linked with a disturbance of the bacterial flora of the intestine, overgrowth of pathogen bacteria, release of toxins that attack the wall of the intestine. This cycle must be stopped, by means of antibiotics, questran to absorb the toxins, fluids to fight dehydration, pain medication. I would not necessarily use gut motility drugs, as this will prevent the proper solidification and formation of fecals. Lots of probiotics may be of help in such cases. Little bacteria will survive till reaching the intestine, but may be enough.

-------

It is sometimes suggested to use GI stimulating drugs (e.g. cisapride or metoclopramide) when a rabbit suffers from diarrhea. While both hypo- and hypermotility of the gastrointestinal tract can lead to fluid losses = diarrhea, the causes that lead to hypo or hypermotility are completely different.

Q: Re: Should bunny with Diarhea get metaclopramide?

From MediRabbit (quoted 2nd hand and not verified)

Hypomotility of the gastro-intestinal tract is observed in intestinal pseudo-obstructive syndromes, with partial anatomic obstruction that results in the intestinal blind loop syndrome. It shows pancreatic insufficiency, steatorrhea (too much fat in the stool) or bile-salt malabsorption. With decreased motility, malabsorption of nutrients leads to bacterial contamination, which results in the stimulation of secretory diarrheal fluid losses.

In other words, diarrhea due to hypomotility shows overgrowth of pathogen bacteria.

In this case, the administration of GI stimulating drugs is recommended.

Hypermotility of the gastrointestinal tract is characteristic for intestinal infections, hyperthyroidism, presence of tumors, or abuse of irritative-type laxative. It may also be the result from diminished sympathetic inhibition, due to nerve damage or destruction of the related brain center (for instance by the parasite E.cuniculi).

In this case, no GI stimulating drugs should be given to the rabbit.


PS: I don't remember why right now but I think I ended up liking Cisapride better than Reglan.

Side Note: I know of a couple of cases where Cisapride actually worked for bladder control. Bunnies needing their bladders expressed were able to void on their own with Cisapride.

 

[pamnock]

krsbunny wrote:

Safety when it comes to drugs is always a "relative" term.

This single sentence summarizes it very well.

What works in one case won't work in all cases.

There are many commonly used drugs that have saved lives as well as been the cause of the loss of life.

Each case is unique, options need to be weighed,and educated decisions need to be made on a case by case basis.

You've made some excellent points Kathy! Keep the great info coming.

Angie had mentioned that we need to consider physiologically what is going on. In some cases, viruses cause chemical disfunctions in the gut nervous system resulting in illeus. (A problem I commonly saw in the spring/fall when I worked on a stable for retired horses). One major consideration is pain management. I also found that Nutri Cal, which is easily absorbed is very helpful in supportive treatment.

Pam

 

[naturestee]

Great discussion!

It's interesting how differently people think about gut motility drugs now. A few years ago when Iwas dealing withmy very first stasis incident, my vet (my favorite of several for rabbits) prescribed oral fluids, syringing small amounts of food, and Bene-bac.That vet (Dr. Travis, for Myheart's knowledge) told me that he rarely uses gut motility drugs because he's seen many problems from their use. I posted on Etherbun and was raked over the coals for not demanding gut motility drugs! As it was, the bun recovered in just a few hours and was certainly in no need of additional medical attention.

I have used this drug a few times now, so I figured I'd share their uses and the outcomes.

A year and a half ago, this same vet prescribed Metroclopramide (given by injection initially, I think) to Sprite who had a very severe case of sudden bloat with a full stomach, empty intestines, and no visible obstruction on xrays. She was also given sub-q fluids and pain meds. She died that night with some blood leaking from her anus and on a few poops that she had managed to pass. I didn't have a necropsy donebut I was scared that the motility drug might have forced her gut to move too much. However, reading the Wikipedia article saying that it loosens the pyloric sphincter, which may have been the issue to start with looking at the full stomach/empty intestines, Metroclopramide was probably Sprite's best hope of survival. FYI Sprite had chronic GIissuesdue to her Dwarf Hotot genetics, often called megacolon.It wasusually controllable with diet but she was alwaysworse than her sister Fey, who is still doing well.

Last spring, Loki had a bad case of stasis over the weekend that I could not pull him out of. Usually he only has a bit of gas, and only when he's molting. This time neither applied. On Monday, the vet (Dr. Bixler, notthe preferred Dr. Travis) found slight molar spurs and elongated molar roots that were probably causing the problem. Loki was kept overnight due to his poor state and given Metroclopramide (along with subq fluids and pain meds) to help get his intestines working before his molar grind the next day. His gut was moving some by the next day, and he started to eat a little after his dental work was done. FYI this vet is one that often reaches for gut motility drugs first, provided the xrays show no blockage.

And then there's Dora. My sickly little orphan baby. It's a miracle she survived everything she did. At one point when she was several weeks old, Dr. Travis found her cecum to be full of gas and not working properly when I had brought her in for yet another bout of diarrhea and gas. He tried one dose of oral Metroclopramide (plus gas meds and sub-q fluids) and wanted her brought in the next day for further evaluation. It seemed to help slightly and didn't seem to hurt, so she was put on it for a week or two and I think she may have been treated for Clostridium at the same time (have to look back at my records). Afterthose meds were done, she didn't have another relapse of diarrhea or other gut issues.

So there you have it. Personally, I won't use gut motility drugs for simple stasis issues and wasn't thrilled about Loki getting them. But in Dora's case it really did help with her chronic cecum issues.

 

[Maureen Las]

I used it on (RIP) Gabriel a long time ago and this the reason why.
Because Gabriel may have had mega-colon and had had so many medical issues going on afterI rescued him he could not be neutered until he was at least 1 yr old.

After he went through puberty he became almost like a feral domestic rabbit. He was impossible to hold (unusually strong) and bit me good and hard whenever he could. I spent months handling him with gloves and would not be around him without wearing long pants and shoes and socks ( I know this sounds hard to believe)

When he went into stasis I felt that I could not do the care required with fluids feedings etc to get him out of it. In other words I could not handle him well enough to do procedures on him
The vet put him on motility drugs (metoclopromide) after an x-ray and I thought to myself "this is the only way to go with this rabbit; I'll have to take the risk"
I used it and it worked OK without ill effects but I decided not to post it on the forum as it may have been a bad example for others although I knew that I had little choice seeing that I could not handle this rabbit well.

 

[tonyshuman]

I agree with some of what has been said here. Basically, I would only ask for gut motility drugs as a last resort to surgical removal of a blockage, which I've read about while editing old infirmary posts. Not a good idea in the slightest!

I don't have personal experience with the drug, but I think it can be overprescribed for non-severe stasis and gas. Also, they can be prescribed without other things that are very important, like hydration.

The problem I have with them is that they may just cause more frequent and stronger contraction of all of the muscles lining the intestines, not the rhythmic contraction and relaxation needed to keep things moving. Also, with a dehydrated hairy ball of material clogging the intestines, the real issue is to get that material lubricated and moving outward, which can only be acomplished by hydration. Squeezing and squeezing on something that's stuck to the intestines because it's dry isn't going to get it going.

It may be helpful at lessening nausea post-surgery, but I would be interested to hear more about this because although wikipedia says it can be anti-emetic (emesis=vomiting) and anti-nausea, it also says it doesn't do this for post-surgery emesis or nausea.

 

[Hazel-Mom]

Here is the perspective of Dr. Dana Krempels: http://www.bio.miami.edu/hare/ileus.html
I have always thought this an excellent article on how to treat GI stasis.
She does advocate the use of motility drugs, but only when prescribed by a vet, and after propper diagnosis (I assume X-rays are part of that).

 

[krsbunny]

It's Kathy playing "Devil's Advocate" again...

While I have a great deal of respect for Dana Krempels and what she brings to the world of rabbits ... just in case anyone here is unfamiliar with her, it is important to understand that although she does have a PhD in biology, she is not a vet any more than Randy is! Lucile Moore, who invited me to co-author When Your Rabbit Needs Special Care also has a PhD in biology ... but she carefully avoids using the title "Dr." in the context of rabbit health and care.

I'm sure this article and its predecessor have saved the lives of many, many rabbits ... but I suspect they are also one of the reasons that motility drugs have been (over) used in rabbits. Many people take these articles to their vets and these articles have influenced my ideas in the past. That is one of the reasons I really do appreciatethis forum'sopposite perspective. I suspect it is no coincidence that my "muse," HRH King Murray was a gray bunny ... so I would constantly be reminded that things are rarely black or white!

The only thing I can say with 100% certainty is that I do NOT have all the answers. In fact, I'm not at all sure that I'm asking the right questions! So, please ... you are invited to challenge and question anything I say -- it does not offend me in any way. Such questions will help me examine those opinions and decide whether they are my own or someone else's. Sometimes my answers will come from my mind and other times from my intuition.

Thanks for letting me be who I am!

Kathy

 

[Pipp]

krsbunny wrote:

It's Kathy playing "Devil's Advocate" again...

Oh goody, I get to play Devil's Advocate to a Devil's Advocate... what does that make me? :biggrin2:

One thing to remember about Dana's extremely well-distributed article is that she has been continuously updating it but the updates aren't always the ones to be reproduced.

She, like the others, has become a lot more cautious as well, although she is still one to recommend it more readily than others. (I think she's been saying "and 'eventually' gut motility drugs" in her references, which is also a Rami phrase?)

I'll also add that the site we probably refer to the most -- MediRabbit -- is owned and operated by Dr. Esther Van Praag, who is also a biologist and not a vet. (For that matter, I have never heard Rami refer to himself as a vet, either). onder:

So moot point on that one.

But I will agree that when one article becomes the 'bible' so to speak, it can close the door somewhat for further advancements/opinions, etc,. because so many people 'preach' quite strongly and may not look for a good information balance.

I think all of us will question at least some parts of all sources, and so they should.

I think Pam still brought up an extremely important point about not losing sight of the individual rabbit. There is no one answer for all.


sas :bunnydance:

 

[krsbunny]

Thanks for reminding me of the other thing I wanted to say! I think Gabriel's story was an excellent example of how important it is to take into account "patient preferences" when deciding how to proceed with treatment. It has been easy for me keep that perspective with a diagnosis of cancer ... but not as easy in conditions that have more proven treatment protocols. My rabbit Dante (whose story ends the Interspecies Communication chapter of the Special Care book) taught me a huge lesson when he let me know -- in no uncertain terms -- that he would rather die than continue treatment for an ear abscess. Many bunnies bond deeply with us during intensive care ... but that will not be true for everybun. There are no "one size fits all" answers!

Kathy

 

[Maureen Las]

krsbunny wrote:

It's Kathy playing "Devil's Advocate" again...

While I have a great deal of respect for Dana Krempels and what she brings to the world of rabbits ... just in case anyone here is unfamiliar with her, it is important to understand that although she does have a PhD in biology, she is not a vet any more than Randy is! Lucile Moore, who invited me to co-author When Your Rabbit Needs Special Care also has a PhD in biology ... but she carefully avoids using the title "Dr." in the context of rabbit health and care.



Kathy

I just want to jump in here and and say what I feel re. Randy's background in contrast to someone witha PHD in biology.
Randy is a licenced wild-life rehabber in the state of NC and owns his own rescue. His main speciality and interest is cottontail rabbits which would of course requires extraordinary knowledge of the anatomy and physiology of both domestic and wild rabbits in addition to other species ofmammals including birds and other wildlife. His knowledge base is way beyond what is required by the state to be a rehabber.Heis dealing with animals underextreme and emergency conditions ; he is involved in surgeries .I do believe that Randy has the education, knowledge and experience to treat rabbits under almost any conditions. He is not working alone so his perspective on gut motility drugs and other issues is influenced and shaped by the vets that he works with on a daily basis. It is not just Randy's voice on this forumbut it is the also the voice of the vet group behind him
Since Randy is also dealing withother animalsI think that this alsogives him a unique perspective. maybe his teams knowledge of motility drugs is based on more than just its action on a domestic rabbit.

I am not brilliant but I am able to recognize it in others and Randy is brilliant .Every now and then someone comes along with apassion for something, and if you get the passion , the intelligence, the experience and the creativity to take that knowledge to another leveland put it all together that is a unique person.

Randy teaches veterinary interns . Now that in itself says something. I am sure that no one at Sabrina's is walking around saying that Randy is not a vet so that is reason to discount him .

He knows his stuff and it shows

I would hand over any one of my rabbits to Randy and his team for care and then I would RELAX becauseI would know that they would be in the best hands.

Maureen

 

[Pipp]

I don't think Kathy was at all being negative about Dana Krempels or Randy, she was just pointing out (as was I) that experts come in all packages.

Personally I'd be just as happy taking advice from a biologist bunny slave than a vet who has never been owned by a rabbit.


PS: Gray is my favourite colour.

sas :bunnydance:

 

[krsbunny]

No, I was not saying anything negative about either Dana or Randy! Both are experts in their own way. I very much appreciate that Randy is skilled and experienced and knowledgeable -- and that he points out in every post I've read that he is NOT a vet. (Yes, that may be partly for his protection, but I still appreciate it.) Most people who have been in rabbits are familiar with Dana Krempels and her articles -- and that she also is not a vet. However, although she has certainly earned the title Dr., in a post on rabbit health where she is introduced as Dr. Krempels someone unfamiliar with her might wrongly "assume" vet and place extra weight on her words. That was what I was qualifying. Since Dana is also involved with rescue, both she and Randy have more hands on experience with more bunnies than I have. I am neither vet nor rescuer... I am more researcher and analyst <gr>. My experience is either personal (hence my catchphrase "This is just my personal experience/opinion") OR what I've learned from the vets I've worked with or experiences of others (including heads of many large rescues around the country). Kathy