Elsie/11 month whippet / relapse

[Erica]

Thanks Jo. I wondered more if her dose should be increased if her weight does. I am fighting a bit of a battle with the vets today about her steroid protocol going forward. :-(

[Jo CIMDA]

No Erica, the dose per kg stays the same.

Jo

[Erica]

Hi Jo,
Elsie update.
Elsie managed 3 weeks on 25mg of steroids. Surprisingly she coped better than expected. My treating vet isn't convinced that she relapsed because her CRP results at the time were normal. I saw an emergency vet at the time. Her symptoms were - trembling, respiratory rate 44 per min, temp at home 38.6 but at the vets 39.4.
Can CRP be normal in a relapsed dog?
Because of the above, the vet wants to reduce her steroids every ten days to 10mg. Elsie is now on 15mg/day.
At the practice there is a vet who attended lectures by Prof. Day at Bristol University. I saw her at Elsie's initial diagnosis.
What is the importance of taking longer with the lower doses? My treating vet says that by then the doses are so low that they are doing anything..
Is there a adrenal gland issue? So, does the body have to learn to produce it's own corticosteroids again?
Thanks. I just want my ducks in a row.

[Jo CIMDA]

Hi Erica

"Can CRP levels be normal in a relapsed dog"

I suppose it depends on how quickly you respond to the clinical signs and start treatment. In Elsie's case she really did respond well to the increase in pred.

Below is from a human site:

https://www.healthnavigator.org.nz/health-a-z/c/c-reactive-protein-test/

The CRP test measures the level of a protein in your blood called C-reactive protein (CRP). The level of CRP increases when you have certain autoimmune diseases that cause inflammation, such as arthritis, inflammatory bowel disease (such as Crohn's disease or ulcerative colitis), or if you have an infection such as pneumonia.

The serum CRP level in a

[Jo CIMDA]

Hi Erica

I wrote a lengthy reply and it cut a lot of it off.  I don't know why.  I will look into it.  Meanwhile, please email me at cimda@aslog.co.uk and I will send you the reply via email.
Sorry about this.

Jo

[Erica]

Elsie update.
She is now on 5mg per day. She is extremely well with plenty of energy, eating well and happy.
When we get to the stage of reducing from 5mg, is it better to give 5mg every other day or 2.5mg per day. (Last time the vet gave me 1mg tablets and we went from 5mg to 3mg per day).

[Jo CIMDA]

This is great news Erica. 

I am so pleased that Elsie is doing well.  When you get to a very low dose of pred there are several ways that you can reduce and I do think that taking it slower, although it is not suppressing the immune system, helps to maintain homoeostasis and it is less of a shock to the system.

Personally, dropping to a low daily dose, as you did last time, and then going every other day for a couple of weeks, and then every third day for another couple of weeks, before leaving it off altogether is a nice gentle easing off of steroids, and it does no harm too.  You can go as slow as you feel is right.

Well done.  Let us know how it goes.

Jo

[Erica]

Thank you. X

[Erica]

A quick update. Elsie is now down to a reduced dose of 4mg per day. From 5mg to nil, we are taking a few months. My current vet studied under Prof. Day at Bristol Uni.
I asked a month a so ago about CRP tests and their usefulness at predicting relapses. I found a paper by E.Beidermann, A Tippled and T.Flegel. It states ' SRMA is a common inflammatory central nervous system disease in dogs that can be treated effectively although relapses are common and should be expected in 1/3 of dogs. There is currently no identified indicator for relapse-free successful therapy. Nevertheless, elevated CRP serum levels or elevated NCC on CSF analysis at re-check appointments should warrant further therapy, whereas normal CRP levels are less helpful since they do not exclude relapses.'

[Jo CIMDA]

This is such good news Erica.  I am so pleased for Elsie and of course you.

A dog with a genetic predisposition to autoimmunity can only achieve 'long term' remission because there is always the possibility of meeting a 'trigger' which may cause a relapse, or of course a trigger that could cause a different AI disease. 

Relapses are not uncommon but anecdotally, dogs that I have known to have SRMA are very often young and although a relapse may occur, and usually after the initial diagnosis, the prognosis is very promising because many do go on to achieve long term remission and never have another relapse. Correct treatment and weaning down of the steroids is crucial to the outcome but there are no guarantees that a relapse won't occur.  Potential triggers must be avoided but, from my experience,  I also feel that when a dog gets this sort of AI disease when they are very young they can often achieve lifetime remission, as can children with juvenile arthritis.  They seem to be very similar processes and outcomes. 

As for CRP markers, I think you are more likely to see clinical signs of a relapse before CRP markers rise.
Interesting quote though.  It can take up to 48 hours for CRP markers to rise after clinical signs.

Limiting triggers is so important, so no more vaccines etc., and only treat for worms and fleas if there is evidence.

I am so pleased that Elsie is making such good progress.
Jo
 


 

[Erica]

A little update about Elsie.
She is currently on 2mg per day.
She had a bit of a freak accident 10 days ago when she ran into a sharp branch in the garden and had a nice cut that required stitches under GA. She coped well and has remained okay. Her white cell count was on the low side of normal so she was given a short antibiotic course.
On top of that my 9 year old whippet, Pip, has just been diagnosed with a grade 3 heart murmur, enlarged heart, leaky valve. :-((. She has been given pimobendan.
I do think that it is time pedigree dogs has some outcrosses to widen the genetic pools.

[Jo CIMDA]

A little update about Elsie.
She is currently on 2mg per day.
She had a bit of a freak accident 10 days ago when she ran into a sharp branch in the garden and had a nice cut that required stitches under GA. She coped well and has remained okay. Her white cell count was on the low side of normal so she was given a short antibiotic course.
On top of that my 9 year old whippet, Pip, has just been diagnosed with a grade 3 heart murmur, enlarged heart, leaky valve. :-((. She has been given pimobendan.
I do think that it is time pedigree dogs has some outcrosses to widen the genetic pools.

I am so sorry that Elsie has had an unfortunate accident.  I do hope she continues to improve.  There is always something!!!!!

And I am so sorry about your Pip.  I trust that the vet will be able to control her heart condition.  As for your last question, absolutely.  Pedigree dogs are far to interbred and out-crossing is the only way to introduce new genes into these lovely breeds. The current list of diseases that have been caused bu depletion of genes is just not fair on these lovely dogs and their devoted owners.

I wish you all well. 

[Erica]

Hi Jo and Catherine
I hope you are well and have had a good summer.
I have come back to ask about Elsie and her steroid protocol and gastro (maybe) issues.
Looking back at my diary I seem to have been very slow reducing Elsie's steroids. (I was giving Elsie 2mg one day and 1mg the next back in July).
She is currently on 1mg EOD. She hasn't had any gastro protectant for a month.
For the past few days she has shown her pain response (trembling) after eating. This morning she did the 'play bow' also, stretching. She has a good appetite, has recently been in season and has been happy to come for a walk.
I took her to the vet who gave her a good exam.
Elsie had a normal temp, slight discomfort in the tummy area, a slightly increase lymph node in her rear armpit. The vet gave me omeprazole and thinks the problem is gastric. She said to discontinue the steroids.
 The vet took bloods. Her CRP is normal, lipase normal, everything else okay but she has a low white cell count. The white cell count is lower than it was in July.
My questions -
Is it okay to just stop the steroids now?
What could cause the white cell count to be low?
Will the omeprazole work quickly to help any gastric problems? She had previously been on ranitidine.
The vet said to monitor her over the weekend.
Many thanks if you can help, and apologies for posting with questions instead of just good news.

[Jo CIMDA]

Hi Erica

From the symptoms that you describe it does seem as though Elsie has some sort of gastric issue.   I hope the Omeprazole sorts it for her. Ranitidine isn't used anymore.

 Another consideration would be pancreatitis.  See how things go and certainly get back to the vet if there is no improvement.   

The low white blood cells could be what is called a 'stress leucogram' and this is very non-specific but it does indicate that something is not quite right.

 A stress leucogram is when the neutrophil numbers are high-normal to increased and the eosinophils and lymphocytes are low-normal to decreased. These are all white blood cells.

Yes, it is perfectly fine to stop the prednisolone.  The weaning down process has been very slow and with a dose of 1mg every other day there is no problem in stopping it altogether.

If she is still eating, then make sure that it is a low fat diet and better to give more smaller meals than just a couple of big ones.

I do hope that she improves very soon.

Best wishes
Jo

[Erica]

Thanks Jo and sorry for delayed reply.
My initial thought was pancreatitis as I have an older dog who has suffered with this in the past. The vet said she tested for lipase in the blood and this was normal.
I don't think Elsie tolerates the omeprazole very well. Certainly at the start of her treatment last year we stopped using omeprazole. However as she is older we thought it might work.
At the weekend I have her 10mg on an empty stomach in the morning and fed an hour later. She still had some discomfort. I gave her 10mg before tea but she vomited her food an hour after eating.
Today I have the omeprazole with her breakfast and she had some discomfort but it was shorter lived.
I am not sure what is going on with her. She doesn't have diarrhoea which she usually does with stomach issues. She hasn't been on a significant dose of steroids for three months. Anyway, I am going back to the vets tomorrow. I will keep you posted.xx