hello from Merlin and his mum

[Whippets Rule]

I am quite concerned about Merlin. He seems to be losing weight. I hadnt realised until tonight but he actually looks quite thin. I will weigh him on Monday at the veys but he is noticably thinner. Would this be something that steroids would cause? We know that all was normal two weeks ago when full bloods were run.
Merlin also seems very sad, he's stopped wagging his tail and just seems flat the past couple of days. He's drinking huge amounts and the peeing is ridiculous. I know thats not his fault and I feel very sorry for him. He has also last night,developed a third swelling on his good front leg. He has a purple "blood clot" type swelling at wrist and elbow and now one half way between the two. I am really worried about him now.

[Jo CIMDA]

Hi

Yes all that you describe is predictable when a dog like Merlin is on high doses of steroids for prolonged periods of time. 

When the steroids start to affect the dog in this way the dose MUST be significantly lowered regardless of when the preds were last reduced of or how much they were reduced.  There comes a time when you MUST lower the preds for the safety of the dog - especially so if the blood is clotting.

Against my better judgement,  I obeyed the vet and in doing so I lost my beloved dog. She died as a result of the pred's overwhelming effect on her body.  It is a harsh lesson and one I will never recover from.  You have gone through so much with Merlin - take notice of the signs.  I would hate you to have the regret that I have. 

The Aza is established now and should support the drug protocol enough to enable the preds to be lowered.  That is why it was introduced in the first place.  Let it do its job.

I don't think your vet has much experience in these matters.

Jo

[Whippets Rule]

Thank you. I reduced pred last Tuesday (16th) to 7.5mg twice a day. Do you think I should reduce again tomorrow to 5mg twice a day? I'm happy to be guided by you because if I'd listened to the vet we would have reduced aza 3 weeks ago but I said no. Looking at his weight loss, its definitely muscle loss. Even on his head he has lost muscle.

Ok so this morning I have reduced pred to 5mg twice a day. Ive texted tge vet and explained why and she fine with it. She's still waiting for the RVC to get back to her but they have all his history now so we should hear soon. I think if they want me to reduce aza I am going to ask the vet not to and to trust my gut and see if we can get Merlin off the steroids completely for a while and if he does ok then we reduce frequency of aza. If I'm wrong and it doesnt work THEN I will be totally guided by them but at the moment I want to trust my gut. Platelets last week were 450 so its unlikely he'll destroy them all on todays reduction so i dont feel there's any risk to him right now in terms of platelets.

[Jo CIMDA]

Wow, I detect an element of control back and that is great. 

Sometimes the vets have less idea than the owner, mainly because they don't have the experience - which isn't meant to be derogatory.  It is not rocket science and the more experience you have the less you need your vets instruction but it is always best to have their blessing - which you have.  Your vet is learning too.

The major worry and clinical signs, when preds are saturating the body, is lack of appetite and extreme weakness and very high respiratory rate.  If Merlin shows these symptoms then you must lower the preds further. 

I can remember years ago when a dog was on high doses of preds and had to come off them very quickly due to other complications, the hospital reduced to just above the required dose that a dog would need if it was on replacement hormone therapy for adrenal insufficiency.  This girl was reduced from 50mg preds a day to 10mg a day in one go.

This is not regular practice but given the circumstances, as long as the dose is just above the replacement hormone dose (prednisolone 0.2-0.3 mg/kg - BSAVA Small Animal Formulary 6th Edition) then the dog won't be in danger of adrenal insufficiency, and the necessity of reducing the steroids quickly is achieved.   This would only be done if the dog's life was in danger, or if it needed surgery (or similar) where clotting or healing or infection might be a problem.

Jo

[Whippets Rule]

Merlin has been crying this morning but I don't know why. He has had a high respiration rate for two weeks and it still is high. The blood clot at his elbow has doubled in size and again he is back with a full leg pressure bandage. I hope and pray that I can leave him on 5mg twice daily for another week,just to be sure of platelets because yesterdays reduction to 5mg won't really show anything on his bloods for another week. I want to get him down quickly but am very concerned about risk of bleeding if he gets too low as on past experience it has been a fine line and with open pressure sore on one paw and an open ulcer on the leg with blood clots, I would think he could bleed out completely. He really isn't well however and I am scared for him either way at the moment.

[Jo CIMDA]

Merlin may have an infection - that is the first consideration, so perhaps your vet might speculatively treat with antibiotics.  It always worth having a few in just in case.

I hope he improves soon.

Jo

[Whippets Rule]

Just back from the Vets. Merlin has a serious problem with infection. His pressure sore is badly infected. This has happened in 24hrs and his bad paw is now badly swollen. His skin is thin and he has several small tears on his legs and one os these is also infected. he also has an eye infection. I saw a locum vet tonight and she is running full bloods as she is concerned that the Aza is causing white cell suppression. If it is then we have to reduce frequency of Aza as soon as possible which is a blow. She agrees that his rapid breathing is down to the steroids but she said he will likely have to stay on a low dose. They are running an in house platelet count as well as sending to lab but the in house readings are always wrong as they often come out as lower than they really are.

I am extremely worried for Merlin tonight as he is a mess. I have arranged to see the locum next week simply because she has given a better response to my questions and seems more proactive than my regular vet. She said they have been treating Merlin for 8 months but we're no further in terms of his health. She also wants to put Merlin on Symalin(think thats what its called) to support his liver but she needs to read up tonight to make sure none of the ingredients cause any blood thinning.

[Jo CIMDA]

Hi

Of course the Aza is causing white cell suppression - that is what you want  and the sole purpose of using the drug in the first place!

The thin skin is absolutely a result of the preds and not the Aza.    Merlin needs antibiotics because his immune system is suppressed and he can't fight it without support of antib's - but the vet should know this!

Infection in a dog like Merlin is common and to be honest should be expected.  I doubt his skin will heal properly, and therefore he will continue to get infections if his skin is broken, until his pred dose is much lower - thankfully you have the Aza to maintain some immunosuppression as you lower the dose of steroids.  Try to keep some antibiotics in stock for a future event so that you can give them to him when he needs it and not keep rushing back to the vet.

I really worry about some advice that's given.

I hope the antibiotics will kick in soon and Merlin will be feeling much better.

Jo

[Jo CIMDA]

Samylin is similar to SAMe and is very good for liver support, as is milk thistle,and that is a good idea for Merlin.  You can buy it without prescription and probably a lot cheaper than getting it from your vet.

Jo

[Whippets Rule]

Ok blood results show no bone marrow auppression so we carry on the samedose of Aza. Shge said she wants him kept on a low dose of pred ultimately but I don't so I figure I'll win this one. In housae platelets are 433 so external lab results need to confirm this as in house platelets are often a bit off.

She doesn't want him having anything with milk thistle as its anti fibrotic and can cause blood thinning apparently.

Am leaving him on 5mg pred twice daily until next week when I will reduce again to 2.5mg twice daily.

I am seeing the same locum next Tuesday just for continuity because she did at least respond positively etc.

My vets are not willing to give me antibiotics to keep on stand by and only want to prescribe as and when something arises.

Merlin has Noroclav this time as his paw is quite swollen again and she doesn't understand why he always has Therios tablets, although they have worked up until now.. It looks awful.

I have to be honest and say that money is getting tight as his bills over the last few weeks have been between 90 and 170 per week. I can still manage but we need some stability so I can rebuild funds.



This is the boy tonight. He has multiple sores and infections in them and infected eyes....

[Penel CIMDA moderator]

Poor Merlin, it's one thing after another isn't it.  I really hope you can see some improvements in these sores in the coming days.

[Jo CIMDA]

Poor boy!  In time, and when the preds are very low or every other day, you will look back and be able to see just how much the prolonged, high doses of pred have contributed to (or caused) his current skin problems.  Thankfully, these problems should resolve but it takes time for the skin to recover. 

To encourage new cell growth,  I would have him on Natural Vit E and therapeutic doses of essential fatty acids.

Some info about Therios

Therios are flavoured antibiotic tablets which can be given directly or in food. They contain the well known antibiotic cefalexin, which is safe and effective for many types of infection in dogs and cats. Therios is particularly used for skin infections (superficial and deep pyoderma) and urinary infections. It can also be used to treat infected wounds, and a wide range of other soft tissue infections. Therios is usually dosed twice daily. The dose rate and length of treatment course vary depending on the nature of the infection to be treated.



He should feel much better soon.

Jo

[Whippets Rule]

Hi

Do you think it will be ok to try and get him off pred completely? I wanted to try and to see if we could get him just on aza and maybe an every other day dose of aza at that.

I'm not 100% sure of what I'm doing. I read a Clinicians Brief article which talks about gettiong off Pred and then adjusting aza once off pred. This is what I would like to try and do.
Next week if platelets are still good I would like to get him diwn to 2.5mg pred twice daily and maybe do that for two or three weeks,make sure we have stability and then perhaps try 2.5mg once daily, all the while keeping aza as 25mg once a day.

Does this sound feasible? This is unknown territory for me as we added aza six weeks or so ago and his platelets haven't dropped below 400 yet.

Ok so lab results back and platelets have dropped by 100 down to 350 no clumps. But we have gone from 10mg of pred to 5mg twice daily in 21 days so maybe not a huge surprise.

[Jo CIMDA]

Hi

One never knows if a dog will come off pred totally and successfully.  You do stand a better chance if Aza or another combination drug is being used. 

My experience is the pred is reduced to quite a low dose (sometimes to every other day) and then, instead of continuing to reduce the pred the Aza is given every other day (usually on alternate days to pred).  The pred dose remains the same for a couple of weeks before the pred is reduced again -  and again  - until the dose is low enough to stop or to go every other day. 

Once this stage has been reached you then start to gradually reduce the Aza to every third day, and then every fourth day etc.........

If you want to know more then I suggest you email me at  cimda@aslog.co.uk

Jo

[Whippets Rule]

Thank you, I have emailed you as there is much I still don't understand regarding dosage reduction.