CBD treatment

[AlexH]

Hi, my whippet boy was diagnosed with IMPA a few months ago. He's on prednisone but not doing well on it. E might be considering azathropine but my specialist has warned against severe side effects and seems reluctant to do it. I've been looking into CBD oil and wondered if anyone has used it and has experience and advice to offer. I know that it can inhibit certain medications and requires research but he's going downhill and I'm desperate!

[Jo CIMDA]

Hi
I am sorry your Whippet has IMPA.  This AI disease responds extremely well to immunosuppressive drug regimen with prednsiolone, so may I ask, what protocol has your boy been on e.g., dosages and duration etc? 

CBD oil may have some benefits, but it  will not contribute to bringing this disease under control.  The only way to do this is with a good immunosuppressive drug regimen.

Jo

[AlexH]

He's currently on 25mg per day. We started at the beginning of February and started with 50mg per day but he couldn't tolerate it. So we've never been able to higher the dose enough to suppress the immune system. It's improved mobility and there's no swelling in the joints but he's lethargic and not interested in going for walks. He's certainly not back to his old self. He's eating but losing weight. He's lost all his muscle.
We're considering Azathioprine but my vet seems reluctant and has warned me of the side effects and that it needs more closely monitoring than prednisone. I just don't know what to do! He has weekly blood tests and the losers we've got the WBC to is 19 and neutrophils to 16.
He had a full set of bloods 3 weeks ago and nothing concerning was picked up - we were looking for possible lymphoma due to white loss. Enzymes were higher than usual but they put that down to the preds.
I've read so many stories where this illness can be managed and controlled so they can live a more or less normal life. We just need to find a drug that works with him.

[Jo CIMDA]

HI

I presume your Whippet weighs 15+kg.  I am not surprised he couldn't tolerate 50mg a day but 25mg a day is not an immunosuppressive dose for a dog of this weight.

IMPA has an excellent prognosis but the dosage of prednsiolone has to be immunosuppressive for the dog to achieve remission, so if your boy hasn't been on a prednsiolone immunosuppressive drug regimen then this is why he is not in remission.

The best protocol I have come across is by Prof M J Day - see below:

Example: Reduction Protocol for prednisolone:
Clinical Immunology of the Dog & Cat , 2nd Edition,  by Michael J Day
Professor Michael Day BSc, BVMS(Hons), PhD, DSc, DiplECVP, FASM, FRCPath, FRCVS 

Professor of Veterinary Pathology, University of Bristol, UK and WSAVA - Chairman of Scientific Advisory Committee.
This example is based on a dog receiving an induction dose of 1.0mg/kg/q 12hrs (q = every)
Dose                           Duration (based on clinical effect)
1.0mg/kg/q 12h                          10-28 days
0.75mg/kg/q 12h                       10-28 days
0.5mg/kg/q 12h                         10-28 days
0.25mg/kg/q 12h                        10-28 days
0.25mg/kg/q 24h                        10-28 days
0.25-0.5mg/kg EOD                    at least 21 days
0.25-0.5 mg/kg every third day      at least 21 days

Every reduction is made after consideration to improvement of clinical signs, blood results and side effects of the drugs.

Prednisolone:  "Doses above 2.2mg/kg/day do not give more immunosuppression but do cause more side effects. Many internists believe that prednisolone doses should not exceed 80mg per day, regardless of the dog's weight."  Plumb's Veterinary Drug Handbook Eight Edition.

The problem you have now is your boy has been on a relatively high (although not immunosuppressive) daily dose of prednsiolone since February.  The side effects of prednsiolone will have built up within his body, but they have not suppressed the immune system sufficiently enough to achieve remission.  The only option you have is to introduce a 'combination' drug to enable the attacking  immune cells to be significantly suppressed.  This will allow his body to return to normal function and start producing good synovial fluid within the joints which will give pain relief. At the moment all you are doing is tempering the problem not resolving it.  Once the new drug is having good effect you can start to reduce the prednsiolone.  This is important, because a dog can only remain on prednsiolone for a period of time before it starts to produce debilitating side effects.  The good news is when the prednisolone is at a low, every other day dose, or weaned off altogether, the body will start to recover and the dog can lead a normal life again.  Whippets, as opposed to other breeds, often lose weight when on prednsiolone. 

So the decision is, what 'combination' drug to use?  There are several, and the side effects are something that has to be considered as a trade-off for getting your boy back into remission and having a full, active life again, and hopefully drug free.

Azathioprine has been used for over two decades, at least,  and has proven to be a good 'combination' drug, however it can take up to 6+ weeks to take full effect and I believe you need a drug that has a quicker onset of action because you need to start reducing the pred.

The more recent immunosuppressive drugs that have had good reports with limited side effects, and have a quick onset of action are, Leflunomide or mycophenolate mofetil.   See these articles.  This particular website is a wonderful resource for veterinary articles.

http://veterinarymedicine.dvm360.com/immunosuppressive-drugs-beyond-glucocorticoids
http://veterinarymedicine.dvm360.com/lecture-link-update-immunosuppressive-therapy

I hope the above has given you something to consider and you are able to move forward with your boy's treatment.  Is there anyway you can take him to a teaching veterinary hospital?  They have the best of clinicians who are all genned up on the lasted drugs and have a lot of experience in treating autoimmune diseases.   It is often better to go to someone who has experience.

Jo

[AlexH]

Hi Jo, thank you for that information, very useful. I was with the specialist yesterday and the plan he has come up with is azathropine and reduction of prednisone to 25mg every other day. I'm not sure of duration yet as I don't pick the medication up until Thursday (they need to order it in). He said 4 weeks before it takes effect and 6 weeks before we will see any signs of possible remission.

His results were the highest they've been since we started the preds. We did get them right down when on 50mg per day for a week. But when we dropped to 25mg they started to increase again.

I'm not aware of a teaching veterinary hospital but will look, however we are with specialists and were referred from my vet, so they do seem to know a lot about it. They started with preds as usually there's a good response and didn't want to try what they have called 'heavy artillery drugs' before we'd given the preds a chance.

I'm going to discuss the information you've shared with me, with them and see what they say.

[Jo CIMDA]

Hi

Do you live in the UK?  If so I may be able to point you in the direction of a good specialist.

Anecdotally, reducing a relatively high dose of pred  to every other day is not a good drug regimen, and especially if the idea is for the Azathioprine to be the main immunosuppressive drug when it doesn't 'kick' in for several weeks.  Aza is never used as a primary immunosuppressive drug, and is always a secondary drug to prednisolone or other immunosuppressive drugs.  The best time to introduce Aza is at the very beginning of immunosuppressive treatment, so that by the time it is having good effect you can lower the prednsiolone in a controlled manner.

In addition, a pred reduction from 25mg a day to every other day when the dog isn't in remission and with no 'secondary drug' to assist may result in a full relapse of the disease.  If this happens you would have to go back to a daily immunosuppressive dose of pred
(1mg/kg/12hours pred)  and this will contribute to the already built-up, unwanted side effects of the preds.  Alternatively, a different immunosuppressive drug, that has quick effect, can be introduced.  If the clinician doesn't have the necessary experience in immunosuppressive treatment, and more prednisolone than necessary is used over a longer period of time,  more side effects are produced without resolution of the disease.
Below is an extract from the most respected veterinary drug book.

Prednisolone:

"Goal of therapy is to use as much as is required, and as little possible for as short an amount of time as possible" * Plumb's Veterinary Drug Handbook, 8th Edition.

The only time preds should be significantly, and immediately, lowered is when the dog is suffering from serious side effects of drug induced Cushing's syndrome, and  the preds are doing more harm than good; or if the dog needs surgery and the preds have to be lowered to optimise healing.    In cases like this, the preds can be significantly reduced to a 'replacement' daily dose (approximately 0.1mg/kg once daily*).  Preds must never be stopped abruptly, but they can be significantly reduced if necessary.  This will make a considerable difference to the side effects of the preds, but if the dog isn't in remission then another 'primary' immunosuppressive drug, that has a quick onset of action, has to be introduced.

There are so many different scenarios to consider when an individual has been on an inadequate (not immunosuppressive) dose, but a relatively high dose of preds for a period of time, and the whole situation has to be taken into consideration, and this is why it is best to seek advice from an internal medicine veterinary specialist who has the necessary experience to know the correct way forward and how to reach long term remission.

I do feel you need to see someone who has more experience in the treatment of AI disease.

Jo

[Jo CIMDA]

FYI.  Taken from my seminar notes:

WHAT TO EXPECT ONCE IMMUNOSUPPRESSIVE TREATMENT HAS STARTED
If a dog has a serious autoimmune disease, then the sooner treatment commences the better chance the dog has of survival.  The main delay to starting treatment is obtaining a diagnosis or at least your vet being sure that he hasn't missed anything that could be made worse by giving high doses of steroids.  Achieving a diagnosis can be a fight against time. 
If your vet has decided that in all probabilities your dog has an autoimmune disease, then to a certain extent, which autoimmune disease your dog has, as far as treatment is concerned, is irrelevant because with the exception of a few diseases, they are all treated the same, that is, with immunosuppressive drugs.  The main objective is to 'knock out' the immune system and virtually stop it from working (or near enough) so the destruction will cease and give the body a chance to recover.  As previously stated, this treatment regime works in most cases, that is, if it has been given early enough and the dosage is correct.  All dogs are different and some can tolerate the drugs better than others. In proportion to their size, small dogs seem more able to tolerate higher doses of steroids than large ones. Some diseases are more serious than others and carry a poorer prognosis. So the initial crisis is a crucial time, however anecdotal evidence shows that many more dogs survive than die if correct treatment is administered in good time.
It is hoped that a positive response can be seen within 4-6 hours of starting treatment (depending on the disease), but in a serious, life threatening situation, the first 2-7-14 days can be a very worrying time.  Assuming the dog has stabilised he will quickly feel much better, and if he is in hospital may be allowed home within a week.
When he comes home he will probably have a 'goody bag' full of drugs.  He will be on a high dose of steroid, usually prednisolone, and he may also be on another immunosuppressive drug, such as Azathioprine.  Your dog will be weaned off in a controlled manner according to his wellness and clinical observations. 
Note: High doses of steroids must not be stopped abruptly.  Your dog could go into an adrenal crisis if the medication is withdrawn too quickly. 
In addition to immunosuppressive drugs he should have something to protect his stomach from excess acid.  The last thing your dog needs when he is feeling poorly is a bleeding stomach ulcer caused by the drugs.  Sometimes, Antepsin is given to coat and protect the stomach (but this must not be given within two hours of other medication otherwise it will stop the drugs from being absorbed).  Zantac (Ranitidine) may also be prescribed to take away the excess acid. Another gastroprotectant used is Omeprazole. To minimise irritation to the stomach it is usual for the daily dose of steroid to be split into two doses and given with food, one dose in the morning with breakfast and the other dose with his evening meal. I have known several dogs, who did not receive a gastroprotectant as a part of their treatment regime, and went on to develop anaemia. This is not autoimmune haemolytic anaemia but iron deficiency anaemia caused by bleeding stomach ulcers. Using a gastroprotectant is a good preventative measure. When the steroids have been significantly reduced to a low dose, a gastroprotectant may not be necessary.
Excess acid, produced because of the drugs, may make a dog prone to developing pancreatitis. A dog with pancreatitis will appear in pain and his back may be arched as if he can't straighten up.  He may be lethargic, seem bloated and have a tender abdomen. Dogs usually go off food and water, may vomit and look depressed.  If you suspect that your dog has pancreatitis, don't try to feed him because it will make the condition worse. Take him to the vet as soon as possible as he may require treatment or need to go on an intravenous drip to stop him dehydrating.  Again, the risk of pancreatitis should be minimal once the dog is on a lower dose of steroids.   A low fat diet is best when your dog is on high dose steroids or prone to pancreatitis. 
As your dog's immune system is being significantly suppressed, he will be more likely to pick up infections, and will not have the ability to fight against them.  As a precaution a broad spectrum antibiotic is often prescribed. Also it is sensible not to exercise him in areas where he is more likely to encounter infections, for example, a park or a popular dog walking area. 
Whilst your dog is on high dose steroids he will want to eat and drink excessively. However, this also means that he will want to urinate more and this can sometimes cause temporary incontinence.  You may have to get up to let him out during the night and if you leave the garden door open during the day, it may save some mopping up!  He cannot help it and won't like it either, so don't be too hard on him, it's only temporary. You will notice as he is weaned off the drugs the unwanted side effects will subside and he should return to normal habits and behaviour.  Urinary tract infections and/or bacterial skin pustules are not uncommon when a dog's immune system is suppressed, and this is often the reason for a dog to be off colour during this time.  Note: Always consider a urine infection if your dog seems under par.  A course of antibiotics will usually sort this out quickly.
Depending on what autoimmune disease your dog has, he will probably need to have regular blood tests.  Biochemical blood tests will also keep an eye on other body functions, such as those of the liver and kidneys, which is important at this stage.
Assuming good progress is being made, the clinical signs of his illness are diminishing and positive signs of improvement are apparent, your vet will want to start weaning him down from the high doses of steroid.  This process can take 3-6 months or more, and usually begins any time after 10 - 28 days from the start of treatment, depending on the results of his blood tests and his clinical signs.
Relapses are not uncommon, especially in diseases that are difficult to control, for example SLE.  A relapse may mean that initially, your dog needed to be on a higher dose of immunosuppressive drugs for a longer period of time, or your dog may have been weaned off a little too quickly and then the dose withdrawn too soon.
If a relapse occurs he will probably show similar clinical signs to his initial crisis.  He will have to go back on an immunosuppressive dose of prednisolone, but it may not have to be quite as high as before. A combination drug may need to be added at this stage. The weaning process will then have to start all over again. Returning to an immunosuppressive dose will mean that he has to go back on a gastroprotectant.

Side Effects of the Drugs – Iatrogenic Cushing's Syndrome
Iatrogenic Cushing's syndrome is a side effect of high dose steroids and is caused by too much corticosteroid in the body. To a lesser extent, the immediate side effects observed when the dog initially goes on steroids eg., drinking, eating and urinating excessively is a mild example of Cushing's syndrome.  Personally I like to see dogs responding to high doses of prednisolone in this way, as it means that they are responding to the drugs as they should.
Usually, Cushing's syndrome only becomes a real problem when exceptionally high doses, or prolonged high doses of steroids are administered, maybe due to a relapse, or in some cases where the vet is inexperienced in reducing steroid doses and keeps the dog on a high dose for longer than necessary; or when the dog is not responding to treatment and higher doses are necessary to control the disease.  This is where the cytotoxic drug Azathioprine is very useful. 
All drugs carry side effects and Azathioprine is no exception, but it does not carry the same side effects as prednisolone, therefore by using this drug in combination with prednisolone it reduces the risk of iatrogenic Cushing's syndrome.  As Azathioprine takes at least 10 days, and up to 6 weeks to take full effect, starting the 'combination' therapy at the beginning of treatment may enable the prednisolone to be lowered within the 10-28 day band and still maintain a good level of immunosuppression. If your dog is not responding to treatment then your vet may consider changing his treatment to other immunosuppressive drugs.

How Can I Tell if My Dog Develops Iatrogenic Cushing's Syndrome?
Iatrogenic means 'drug induced'.  Clinical signs of Iatrogenic Cushing's syndrome are the same as primary Cushing's syndrome but can present with acute clinical signs. It reflects the level of corticosteroid in the body.
The most notable side effects are, heavy panting, some hair loss, and an increase in drinking and urinating, excessive pigmentation.  This is something everyone seems to be aware of and accepts as normal when a dog is on high dose steroids. Very often the dog will be weaned down to a low dose before any major problems arise. 
Acute Cushing's syndrome due to overdosing of corticosteroids can be very serious.  Blood results will reflect this, especially the liver enzymes which may be extremely high. Red blood cells and blood platelets may also be high and blood clotting may be a risk.
So when should you alert your vet to suspected, unacceptable level of corticosteroid?  The owner should take note when other clinical signs occur, such as: Depression, anorexia, muscle wasting and extreme weakness, continuous panting, lethargy - unwillingness to exercise, skin lesions and thinning of the skin, excessive hair loss, pot-bellied appearance and sagging back, behavioural changes (aggression).
If your dog is showing these signs it will probably mean that the dose of steroids needs to be lowered. It is important that it is not confused with a relapse of the dog's condition or an infection. The dilemma is that steroids must not be withdrawn too quickly otherwise the dog may go into an adrenal insufficiency crisis.  If the clinical signs of iatrogenic Cushing's syndrome is intolerable, it is hoped that the high dose of steroids that he has been on will have already done their job and that his autoimmune disease will be stable. As long as the steroids are lowered in a controlled manner and in time, all the symptoms of Cushing's will subside and your dog will return to normal, but extreme signs must not be ignored.

The Importance of Correct Treatment and Dosage
Iatrogenic Cushing's syndrome may also occur if the vet has initially prescribed a dose too high for the size of dog being treated.  For example:  I received an email from the owner of an Irish Setter, with AIHA.  The dog was prescribed 200mg of prednisolone each day. I called the owner, only to hear that the dog had to be put to sleep that day.  I was not surprised. The poor dog was on nearly twice the highest, recommended dose of prednisolone.  She was 9 years old and had never had a day's illness in her life.  What a terrible shock for the owners and what a lot of unnecessary suffering.  I know what it feels like because I too, have lost a dog due to prescribed overdosing of prednisolone.  The feelings of responsibility are enormous.
In contrast, some dogs are not treated with enough prednisolone.  Here's another story:
A greyhound diagnosed with immune mediated thrombocytopenia (IMTP).  Her vet gave her an initial shot of dexamethasone (a steroid which is 6 times stronger in terms of glucocorticoid activity than prednisolone).  Some vets choose to give a shot of 'Dex' as an initial therapy in autoimmune disease, especially if the patient is acutely ill.  Its effects can sometimes be seen within 6 hours and lasts for 36-72 hours.
The vet did really well and a marked improvement in her clinical signs was seen. It is usual, 24 to 48 hours after the shot of Dexamethasone for the treatment to change to an immunosuppressive dose of prednisolone tablets and for the owner to continue treatment in the usual way.  However, the vet only prescribed 5mg of prednisolone a day. The owner said they were very concerned that after a few days of improvement, she seemed to be very poorly again.  The vet couldn't understand why she was not continuing to improve.  He gave her another shot of Dexamethasone and the same improvement was seen.  I suggested to the owner that she either spoke to her vet about putting her dog on an immunosuppressive dose of prednisolone or change her vet.  They saw another vet in the practice, who was more experienced in treating autoimmune disease, and the dog was put on the correct, immunosuppressive dose of prednisolone and the treatment was successful.
These case histories demonstrate how important it is to treat promptly and correctly.

Reducing the Tablets
When significant improvement in the dog's condition is seen, usually between 10-28 days, the initial steroid dose is usually reduced by 25%. The dose is generally given for another 10 - 28 days and depending on the dog's progress and clinical signs the dose is significantly reduced once more for a further 10-28 days; and again in another 10-28 days. Anecdotal evidence has shown that if at this stage the dose is lowered more slowly, or reduced to an every other day dose over a period of months rather than weeks, relapse are less likely to occur.  It is always tempting to get your dog off steroids as soon as possible, but when treating autoimmune disease, as long as the dog is on a low, every other day dose then taking the last stage slowly seems to work best, depending, of course, on the severity of the disease and allowing for the difference in individual response - no two dogs reactions are exactly the same.  With some autoimmune diseases such as SLE, the dog is likely to be on steroids for the rest of his life. Usually an every other day dose can be achieved, but you risk a relapse if you take the dose too low.

How Do I Know if My Dog Will Relapse?
Until you have attempted to wean your dog off of the tablets for the first time you will not know if he is likely to relapse or not.  Sometimes during the weaning off process, before you even get down to an every other day dose, he may relapse.  If this happens then the drug dosage has to be raised, probably up to the last dose before the relapse (maybe a little higher, depending on the severity of the relapse) and then start the weaning process again.  If this happens again, then you and your vet may have to settle for keeping him on a low maintenance dose to achieve a good quality of life. A low, every other day maintenance dose of prednisolone is preferred to enable the dog's liver to rest in between doses. There are many autoimmune diseases that carry a good, drug free prognosis.  The more common, serious autoimmune diseases that may not need long term steroid therapy are: primary immune-mediated polyarthritis, autoimmune haemolytic anaemia and thrombocytopenia. However, as previously stated, all dogs are different and it very much depends on the individual dog, the severity of the disease, the experience of the vet and the vigilance and compliance of its owner.
If a relapse occurs whilst the dog is still being treated then true remission has not been achieved.  If the dog has achieved remission and has enjoyed a period without drugs or is on EOD maintenance drugs, when a relapse occurs or he develops another autoimmune disease, he has encountered a 'trigger factor' which has induced this change.

[AlexH]

Yes I live in the UK. I'm now very uncertain about proceeding with what they have suggested. I'm going to email them and show them the info you have sent. It makes sense. Why reduce the preds before the aza has had chance to work.
They are orthopaedic specialists as we were referred for scans because he'd gone lame but the specialist said that wasn't required as he could clearly see the swelling in the joints, so did a tap.

Not sure they are the right people.

[AlexH]

I live in South Yorkshire near Barnsley but would willingly travel if you know of  vets that specialise in this disease

[Jo CIMDA]

Hi

Unfortunately, Autoimmune disease, even if it involves the joints, is the speciality of an internal medicine specialist and not an orthopaedic specialist. Also, it is likely that whilst your boy is on steroids the results of a joint tap will not be an accurate assessment.  Steroids mask certain tests. 

As your boy has not followed the typical drug regimen for IMPA, and there is bound to be a build up of excess glucocorticoid within his body, which is an  important factor when deciding on his new treatment,  I do feel it is best to have him looked at by someone with a lot of experience in this area.  Internal Medicine specialists will know all the options available to them and decide on the best one for your boy.  I would think that further investigations won't be necessary, and they can just treat him based on his history and current clinical signs.

I have looked within your area, and specialists are sparse, but if you are prepared to travel then how about going to  Wear Referrals. It is in Chester which will take you about 1hr 35 mins by car. 
 
http://www.wear-referrals.co.uk/profile-18.html

I have looked at their website and I am quite impressed with Rory Bell's credentials.  I think I have heard of him before. Glasgow is an incredible teaching hospital and in the past he has been Senior lecturer and Head of internal medicine there.  There are also two other internal medicine specialists at Wear Referrals.   

Another referral hospital is Liverpool Veterinary School, but this is slightly further than Wear Referrals, and I think this is a really good option so why travel further?

You will have to ask your vet for a referral to Wear, but this shouldn't be be a problem.  Don't be fobbed off with trying something that isn't likely to work. You are paying for the consultation and treatment, so you may has well go to those who know best and who have the required experience.  Things will start to improve when he is on the right path.

Good luck.
Jo

[AlexH]

Thanks Jo. I have booked an appointment with my vet for this Friday and am going to discuss all of this and ask for a referral and suggest the one in Chester. I am not going to go down a route I am now completely uncomfortable with and thanks to you and your advice am going to explore another option. I have already spent hundreds (monetary value is irrelevant compared to my boy) but I am no longer insured for this, so its coming from my monthly earnings, therefore I need to know what we're doing is the right thing! The research and info you have sent contradicts what my current specialist is advising and I'm not happy with that! So thank you, I hope it's not too late and I haven't wasted too much time and can get my boy back on track.

[AlexH]

Just to add, when the joint tap was done we hadn't started on any steroids, he had been on onsior and gabapentin. The results in terms of neutrophils were extremely high, thus the conclusion of IMPA. They then suggested preds but it seems the levels administered were incorrect and we are so far behind where we should be and have allowed a build up without any progress. We have had good weeks and bad and he has maintained weight then in a week lost 2kg which was clearly visible and distressing, yet his appetite remained consistent. He has since gained weight as I bulked his diet with pure green tripe, chicken, organic chicken and other stuff. There was a week where he had a real spring in his step again and that was on 25mg per day, but yesterday his results were terrible. Higher than when we first went there which is so destroying. As I said before, they were adamant we just went with preds, there was no discussion about a combination of az and preds. My understanding from them was preds would be enough on its own. Az was an option later down the line if preds didn't work and they have been reluctant to even administer Az!

[Jo CIMDA]

Hi

You sound much more confident, and this is really good.

I just want to add that when you see a specialist, very often it is just for an initial consultation and assessment, and thereafter the case is dealt with on a local level, and your vet will confer with the specialist at every step of the way, so you shouldn't have to return to Chester again, certainly not on a regular basis anyway.

It is common for dogs on immunosuppressive doses of steroids to put on weight.  They lose muscle tone, but gain fatty deposits. However, Whippets and Sighthounds are different to other breeds in a way that they process drugs and I just wanted to warn you that many Whippets lose weight then they are on steroids, but when the drugs are lowered everything will return to normal - thank goodness.

IMPA can reach remission with just prednsiolone, but it has to be in the correct dose and following a good protocol such as the Michael J Day one.  If the dose of preds is not adequate it will not have the desired effect, but at the same time you are building up the effect of excess corticosteroid.  This is why the drug protocol is so important.  Also, it is very important to be prepared to adjust the protocol to the individual and the clinical signs that are in front of you.

If I lived in your area and I had a dog with an AI disease, after seeing their website, I would choose to go and see  Rory Bell at Wear.

Another thing, don't ever be afraid to say you can't afford it.  Some practices will want to do so many different tests it just becomes over diagnostic. You know your boy's problem and you need advice on treatment.  Saying you can't afford it, avoids unnecessary testing which is good for the dogs, and for the pocket. 

I hope you have a good meeting with your vet on Friday.  If you feel inclined before Friday, you could telephone your vet and say you have decided to get a second opinion and could he please refer you to Rory Bell at Wear.  You are in the driving seat.

Jo

[AlexH]

Thank you so much. If I can speak to my vet before Friday I will ask for the referral. It's very very clear that the protocol re dosage has not been followed. I did question it and also asked why such a dramatic (50% increase/decrease) and asked about upping by 5mg at a time and the same for lowering but was advised this wouldn't be conducive.

Also good to know that following the initial consultation we can manage on a local level as I have been doing a long trip weekly for blood tests.

He was originally 20.1kg (a stocky strong whippet compared to his brother who is 16kg) he dropped to 18kg in a week but is now back to 19kg, however he has lost all muscle.

From what I have been told/read/researched with IMPA it can be difficult to diagnose the cause (we've had tick screenings) so I won't be considering more tests, unless absolutely necessary, I just want to be treating him with the right drugs st the right dosage to achieve the right results - that's my goal.

He went lame suddenly in June last year and we didn't get a diagnosis of IMPA until this February so it's been a long long time. I hope we can get him on the right track now and I'm going to challenge every decision to make sure that happens. It's gone on too long. We've had sleepless nights where I've been up every single hour (he suffered colitis) or through excessive thirst so up 3/4 times for a wee. He's been shattered and so have I, (I'll do whatever it takes and Altair's been exhausting and continues to be, he is our family and deserves to be given everything we can, time/effort/love and dedication - that's unquestionable). I feel I've let him down so far but that will change and I'm going to be confident that we can get him back on the road to recovery. Thanks again for all the information you have shared.

[Jo CIMDA]

HI
I am so pleased you feel more confident about going forward.  IMPA has a really good  prognosis and I have known numerous dogs who have been diagnosed and treated and have gone on to lead a normal life.  Trigger factors have to be avoided if at all possible.


Good luck
Jo