CIMDA

Hello,
Pepper has been drug free since Monday. She had her last dose of cyclosporine on Sunday.  Even though she has been below therapeutic levels for skin conditions for some time, she has become more itchy since coming completely off. I cannot pinpoint anything else that may be causing her increased itch, for instance anything different flowering nearby etc. Yesterday she stopped itching so much but has been sad and now has swollen back leg joints. Her temp has gone up to 38.5 last night & then 39.2 this morning. I began worrying she was relapsing and so took her to my vet at lunch. She doesn't think that she is relapsing. She thinks her temp should be consistently higher if she was relapsing. (It was 38.9 & 39.1 while we were there.) She said her joints seem more painful, but only her back leg joints are swollen. Her ears are also looking a bit infected so we have began easotic with her. Normally Pep's temp this past year has been between 37.5 & 38. This is the hottest I have seen her since her IMPA. My vet seems to think perhaps her temp could vary now & she may have a new normal due to not being on the immune suppressent medications. As she has previously always been on them when I have tested her.

I have taken her to get accupuncture this afternoon and she was very tender (& hot) in a spot in her back as well as her back legs. (Her temp was back at 38.6). After the accupuncture her hot spot in her back loosened and felt cooler to touch. I also got them to do some allergy accupuncture points as well as for her joints/arthritis.

So we are hoping she is just sad and uncomfortable due to arthritis & her itch & ears.
We have exhausted all options when it comes to treatments for Pep's allergies. But my vet has
said that in the states they are starting to use gabapentin to treat itchy skin dogs and she is suggesting we trial it with pepper. With it also providing her some pain relief for her arthritis.

Does anyone have any knowledge about this? Is there any possible problems with it and her Impa?
I don't want to give her anti inflammatorys as we may still need to give her pred for her allergies (if they get too bad. However I am trying to hold out on that) or if she relapses.

Anyone's thoughts would be great.
Hopefully the accupuncture makes her feel better.

Hi

It is really good to read that Pepper is drug free - what a long journey it has been!  It is also a success story, especially with all the ups and downs you and Pepper have experienced.

I don't have any experience with treating  AI dogs in remission with Gabapentin, so I can't comment other than I would be very cautious about giving a dog who has a genetic predisposition to AI disease, and has been on long term immunosuppressive treatment, any drugs that are not necessary.  I can understand trying drugs in a generally healthy dog, but one has to be very careful about trigger factors when you have a dog in remission with an AI disease.  Have you tried all the other 'regular' drugs used for skin allergies?

I think acupuncture is very effective for so many conditions and I have it myself, it certainly helps me enormously, so perhaps you would consider carrying on with this therapy for a while longer and giving it a chance to work for Pepper.   How about some gently physiotherapy too.

I would expect a full blown relapse of IMPA to show with very high temperature - possibly 40+.

I hope she improves very soon.

Jo

Thanks Jo. It has been a very long journey & the thought of her relapsing after all my efforts with her & what she has had to endure is heart breaking.

After some more reading and thought about the gabapentin I think you are right. In that it may be best not to go there. From reading it doesn't seem like it's that affective used on its own as a pain relief and not definate about working for allergies either. So it doesn't seem worth the risk when it is such a question mark whether it will actually help anyway. It may just cause a whole new set of problems.

I feel too now that some regular acupuncture may be the safest option and it is one thing that may help for both her allergies and joints. At Pep's lowest point on the steroids when we began to reduce her and started the cyclosporine I remember her having similar problems, now that I think about it. She was having trouble in her back end and also had a painful spot in her spine. She was very down too like she is now. She had the typical saddle back Cushing look then. Which I have noticed this last week that her back has been having that saddle back look again. Which I thought was odd as she is now off drugs. I wonder if this saddle back look is related to the sore spot in her back and problems in her back end? Back when she had these problems previously was when I first tried the accupuncture with her. After a number of regular sessions she picked up again. Her back improved and she wasn't having problems with her hind legs.
Perhaps (aside from the itch) her problems at the moment are to do with a recurring problem in her back? I don't want to put her through any scans/X-rays so I think giving the acupuncture a good go is the best option.


As for allergy drugs she has been on cyclosporine and steroids. Cyclosporine is too expensive for me to keep her on and I don't like the risks of increase in cancer etc that it may cause. She does not tolerate steroids well but if I have to I will need to resort to low doses when needed. She can no longer have the desensitising vaccines since her IMPA. I have her on supplements and omegas etc for her skin as well as all the special shampoos etc. We have exhausted all options on allergy checklists. I have also looked into natural therapies and removed all chemicals from her environment. She has had food sensitivity testing done and is on a special diet. Don't know what more there is to do.

Thanks for your reassurance about the temperature in terms of relapse. I only have a month to go before bubs arrives and I absolutely couldn't bare if pep relapsed now. I cannot afford the treatment (cyclosporine) again & can't see she could handle being put on those doses of steroids again.
Relapse is always going to be something I am paranoid about.

Hi

Unfortunately anyone who has had a dog with an AI disease lives in fear of a relapse but as time goes on, the fear turns to more of a concern and if you are like me I used to get up in the morning and the first thing I would do is to look at my dog - and if all looked OK I was happy, and I got on with the rest of my day - and this happened day after day, after day. So although the anxiety doesn't ever go away totally one can relax a bit as time goes on.  With your babby coming in a month you need to have a whisper in Pepper's ear - fingers crossed she will listen and stay in remission.

I hope the acupuncture helps.

Jo

Peppers temp hasn't increased, however after two sessions of accupuncture & chiro she appears to be getting worse rather than better. Her hocks are very swollen. She is having trouble getting up and changing position in her back end. She doesn't like moving around so lays and sleeps most of the time. I have her booked in on Thursday to have X-rays done on her spine & hips. As well as I am going to get complete bloods & thyroid bloods done on her.
She had some problem areas in her lower back and neck but not anything the vet thought should make her seem as miserable as she is, and considering how stoic she normally is. But then she found a very tender spot in peppers hip, which almost caused pepper to show teeth. Which I have never ever seen her shown any signs at all of aggression. So we are going to X-ray her to see what we can find. I do not want her knocked out so they have warned me that the results may not be conclusive. But after all her previous times of being knocked out and the result I don't want to do it. Hopefully we can get some answers.

If the tests come back with something or with nothing next week I feel I am going to need to start giving her pain medication if she does not improve. As she looks terribly uncomfortable. But while she is off the drugs I want to have these blood tests run first so they aren't tainted.

She is still eating and going to the toilet, however isn't getting as low as she normally would when she wees.


If I have to put her on pain meds is there any preferred one in terms of decreasing the risk of any trigger of her IMPA?

Hi
So sorry to hear about Pepper, I do hope you have an improvement soon.
Mollie was put on Pardale V tablets, which is 400mg paracetamol/9mg Codein, it did take the edge off her pain and helped.  Tramadol did not suit her, one of it's side effects is anorexia, and that's exactly what happened to Mollie, when she arrived at the Referral Centre they took her off them immediately. 
Mollie also has IMPA, and has just started Cyclosporine as the steroids were giving her bad side effects so they needed to start reducing, so far it does seem to be helping.
Hope you find the right pain killers for Pepper.

Thank you for sharing your experience. I appreciate hearing what others have tried, as I don't have any experience with pain killers.

Pepper has been doing better the last couple of days. She seemed to fall in a heap after her last acupuncture for a day or so, which had me really worried. But I have heard this can happen after acupuncture. However, previously when pepper has had it done she has always been more perky afterwards. She is still a bit slow getting up in the back end and stiff when first walking. But is back to following me around everywhere and not miserable like she was. Still no temp either...phew.

She had X-rays done today and complete bloods/total t4. Still waiting on bloods, but the X-rays were all clear. They did her spine, hips, hocks and other limb joints. 13 films in total and all looked normal, no changes in bone since the impa, which is great. Her joints were a bit fluffy, though whether this is just arthritis is unknown.

Big news here this week. The release of the new allergy drug Apoquel, being used in the states, has been brought forward here and is expected as early as April. There is a webinar next week that my vet is going to try and record for me. She is going to ask if they have used or tested in impa dogs or dogs with similar auto immune disorders.

As much as I don't like using drugs with pepper and also new drugs that do not have a long history of use. I am interested in finding out more about this, as we need something to control peppers allergies. It must be terribly uncomfortable being so itchy all the time and also with a baby due soon I am not going to be able to keep up the 24/7 maintenance routine required to keep pepper drug free and free from infection. I am going to need to find a trade off and use something for her. Whether it be steroids at low doses or this Apoquel.
I have read quiet a few bad reviews from owners online, but there is always going to be bad reviews on anything. Vets seem to be praising it. I know there will always be side effects just need to decide how bad they are and if it may be worth it for some more quality of life (without itch) for her.
Does anyone have any experience with Apoquel or thoughts on it?

Hi Brooke,
I don't know anything about the drugs you mention but  about ten years ago I  had personal experience with acupuncture when treated for 2 frozen shoulders by a very experienced elderly Chinese trained  doctor recommended by my GP.

I always felt worse (more pain than before) afterwards but wasn't sure if that was due to the stress of travelling   to his clinic on trams and trains  and jarring  my joints in the process so I continued to persevere with it.

One one occasion I had  severe acute pain  shooting down my arm during the treatment and the doctor had to remove the pins to get it to stop.  I was pleased when he retired and returned to live in China very soon after that incident.
My vet does acupuncture but fortunately Jasper does not have a condition for which  it is an option so I haven't had to weigh up the pros and cons.  Dogs are so stoical about pain and we never know how they are feeling.

Hi

I didn't know of this new treatment but this link if very informative.
http://www.barfplaats.nl/forum/viewtopic.php?t=131266

and this might be useful if you haven't found this site.

http://www.theinternetpetvet.com/apoquel-alert-serious-side-effects-of-new-dog-allergy-medication/

Have you tried colostrum? This is supposed to be good too.

Jo

Thanks jo, I will have a look at your links shortly.

I had came across the use of colostrum only recently in my hunt for something that may help pepper. I found info about bovine colostrum being used to treat allergies amongst other things and it sounded worthy of looking into. Also she showed no reaction to beef on her nutriscan testing, which further satisfied me. I suggested it to my vet. She hadn't heard of its use, but researched into it via her veterinary network. She is so dedicated to pep and whenever I bring these crazy ideas to her she never dismisses me, and always takes the time to do some research into it.
With the colostrum she was concerned about its use to boost and stimulate an immune response. She was concerned that for a dog like Pepper prone to auto immune disorders (having impa) that this may be a risk of stimulating a bad reaction like vaccines etc can do. That her immune system was unpredictable and over stimulation was a trigger concern.

Whenever I get her to look into something she likes more hard published facts and reads up veterinary papers etc and info from sources via her veterinary web. On the more obscure things like is it is hard to find published papers etc on. Usually she only comes across some studies done in humans and not much substantial in the use in dogs. It is good that she wants to find credible facts about the use of these things for Pep's safety. But we have been through all the well tested options with her and now are down into the more natural ones that are just not tested that well in animals yet. As with a lot of natural therapies.

I currently have her looking into using a bioflow (magnetic collar) for arthritis for Pep. But she has found papers suggesting there have been side effects caused by the polarity and strength of some products on her veterinary information network. So she is still having more of a look into it.

There is going to be goods and bads with every treatment option, eventually we I'll just have to weigh up the safer (& happier for pep) option and take the plunge.

Thanks for the links I will check them out now.

A bit has happened since my last post. We have continued with acupuncture but it doesnt seem to be making any improvement now. Pepper has become depressed, lethargic, weak in the back end, stiff and just wants to lay down and sleep all the time. She is still eating treats, but I have begun to have to hand feed her to try get her to eat her meals. She is still pooing & weeing normal and her temp before she gets up in the morning is usually 38 or hovering just above or below.

We had a total t4 test done which came back low 19 (22-49). So we re-run the test but sent it to Jean Dodds hemopet lab this time and had a complete thyroid 5 profile done. TgAA results are still pending, but the other results suggested NTI (non- thyroidal illness).

Blood tests showed (according to lab report) 'mild normocytic, normochromic, pre or non-regenerative anaemia likely anaemia of chronic disease. Mild elevation alp & alt: marginal cholangiohepatopathy which is not aetiologically defined. & elevated globulin'.
An electropharesis was requested which showed 'a mild elevation in alpha 2 globulins (3-11) & gamma globulins (8-22). Elevations of alpha 2 globulins can be seen with acute inflammatory diseases which may be localised or systemic in nature. The elevation of gamma globulin fraction is broad based & mild suggesting a polyclonal (inflammatory) pattern as well but likely more chronic in nature. A variety of conditions including gingivitis, vasculitis, renal disease & skin disease can be responsible as well as the non-specific inflammation that may be associated with neoplasia (ulceration, infection, necrosis etc).'

The biggest sign when she had impa was her raging temperature. But she does not have that. Her hocks are very swollen. X-rays have been done and hips, spine and all joints appear normal. She is not standing with her head down low like she was with impa.
I do not want to run joint taps, or ultrasounds again. As I don't want to knock her out and we cannot afford the cost especially considering how much she has cost us this past year (which is absolutely astronomical & pains me to think of). Whenever we run tests with her they never seem to come up with answers, just more questions.

We decided to try her on NSAIDs to see if she improved. The logic being if she didn't improve it was most likely the impa back. I gave her some previcox this morning, but there has been no improvement yet and it is now late afternoon. Im not sure how long is feasible to wait before we can dismiss & conclude its not working.
I'm starting to think it has to be impa back, but why is there no temp? If it is impa & she has no raging temp can we try treat her with low doses of steroids (after waiting the required time to be off the NSAIDs). A low dose to make her comfortable & able to get about, but not completely immune suppressed? Cyclosporine is just too expensive we cannot put her back on that especially with Bub arriving in 3-4weeks. Otherwise we would have to try azathioprine, I am under the belief it is cheaper.

My only other thought was if she had some sort of pinched nerve/back pain? Would NSAIDs work for that? I thought they were to treat pain & inflammation due to soft tissue, oesteoarthritis & surgery. I wasn't sure if they acted on nerve/neoropathic pain. If so could we try something like gabapentin that from my understanding is more for that type of pain?

Any thoughts? I'm feeling that it has to be impa :( But I don't understand how she doesn't have a temp?

HI

I get the feeling it is not IMPA.  I wouldn't rush to do joint taps either. In general inflammatory AI diseases carry a high temperature so I wonder if she has an infection? It could be a thyroid problem.

In the past has she had any kidney issues?  Have you considered using something like Tramadol as opposed to a NSAID?
Azathioprine is cheaper but it is still cytotoxic so perhaps not a great idea either.

I'm so sorry she is having these problems.  She hasn't given you any time to breathe out, has she?

Jo

Hi Jo,
The TgAA results came back negative. So Jean from hemopet has concluded her sluggishness etc is not caused by hypothyroidism.

I am not going to have any joint taps done on her. We know she has abnormal cells in her back legs already but specialists last time decided these were just at bad arthritis levels.
I feel the results will be the same this time and not tell us much more.

If she had some infection shouldn't that also cause her to have a temp?

She hasn't had any kidney issues previously.

My vet said that tramadol was used to treat pain, but didn't have any anti inflammatory properties. As her back legs (hocks) were so swollen she didn't think it would work on its own.

We started the NSAIDs Saturday morning and it is now early Monday morning & there hasnt really been an improvement. I had thought a couple of times she looked kind of better but it hasn't continued consistantly.

We were giving her until mid today to asses if they worked. Because she has been like this for a few weeks now my vet felt her problem was more chronic and the NSAIDs would need longer than usual to try reduce the inflammation & provide relief.

I just don't know what else to do now.

Hi

I am sure Peppers other thyroid results must have been within normal levels too. 

Infection can be present with a low grade rise in temperature.  An inflammatory immune response should carry a high temperature.

I'm glad she hasn't had any previous kidney problems.  It is a shame Previcox hasn't has much effect.  You could try another like Rimadyl or Metacam.  Personally, I prefer the alternative NSAIDS.

I would give longer for the Yumove (or similar, I can't remember what Pepper is on) to take effect, and this can take a few weeks.

Now Pepper is over the chronic IMPA and relatively drug free, is there a homoeopathic vet you could take her to, to optimise her good health?

Jo

Yes her other thyroid results were within normal range. (But low total t4). She was slightly low and jean said on close look at her results/ her symptoms & considering her history.,It may be worth a trial of thyroxine. But she didn't feel her symptoms were caused by a sluggish thyroid. She felt a non thyroidal illness was the cause.

Pepper is still on omega oils & has been on rose hip canine for her joints for months now. Due to her allergies we are quite limited in what we can give her. Also there is no trustworthy homeopathic vet anywhere remotely nearby & we are not able to travel at this point in time with her (with the baby being so close).

Jean suggested to try dlpa. I looked it up and it's an amino acid used to treat chronic pain & depression. It also is supposed to prolong the effects of acupuncture. I have mentioned it to my acupuncture vet & she is looking into it.
We have acupuncture tomorrow, hopefully that brings some relief. I am stopping the NSAIDs now as they don't appear to be helping. But my acupuncture vet can assess if she sees any improvement tomorrow after she has been on them.

The only other thing we have thought of is when Pep last saw the specialist & had an ultrasound done back in April 2015. She had an enlarged spleen. The specialist at the time didn't think think this was a problem for her. She said some dogs can just have larger than normal spleens for their breed. But she said to keep an eye on it down the track if problems arose. I have thought her tummy looked more bloated than usual lately. Tomorrow when we get acupuncture I am going to get the vet to have a feel around her tummy & see what she thinks. I have noticed when I help her up in the back end by placing hands around her tummy she appears uncomfortable. But whether that is from her tummy or her back/leg pain I'm not certain.
I may get her to check the X-rays we did the other day and see if anything is visible there. As much as I didn't want to sedate her for an ultrasound. If she finds anything when palpating her tummy or on the X-rays to make them believe that her spleen could be the problem. I think I may need to do it. It's kind of the last thing to be done, to rule other things out. I just don't feel this is all being caused by arthritis, considering how fast she has gone down & her unwillingness to eat. As well as the NSAIDs not working at all.
If nothing comes back on the ultrasound though I guess we just have to go with the arthritis being the problem. My vet is still wanting to trial the gabapentin, as she said she has had good results with it when treating pain. There isn't really any other options, she cannot be left how she is. It's not quality of life.

So sorry to read about poor Pepper. A couple of thoughts - have you tried giving Pepper  fish oil and Glucosomine  for the joint pain/arthritis?  Both are used for humans and I know people who giver them to their dogs on vet's advice. Both are available over the counter from  from supermarkets/pharmacies.

You mentioned in a previous post hat  the blood results indicated slight anaemia. It is not a pleasant thought, but has your vet considered that Pepper may be developing IMHA as well as her current condition?   Before Jasper was diagnosed with IMHA he was lethargic, not eating, and had an enlarged spleen.   

Yes pepper takes salmon oil for her joints and rose hip supplement. Through nutriscan Tati g we found she has a problem with white fish but is fine with salmon. With the majority of glucosamine supplements coming from shellfish I don't feel confident with her white fish allergies that she wouldn't have a problem with it.

I did bring Imha up to my vet (as I read the about the enlarged spleen being a sign & looked into other symptoms that seemed to fit also) but she said to forget about it. That there were other factors that ruled it out. I don't know much about it but I thought she said something about peppers anaemia being non regenerative and that it should have been regenerative for it to be Imha? I could be wrong that that is what she said but I had mentioned it & she seemed certain that was not the case.

 I hope it is not  IMHA - but  it occurred to me that while  Pepper was on immune suppressant medication for her other condition , if she did have it, the symptoms would not have been apparent because  the anaemia would have  been under control.   Has your vet done a PCV test recently?  Or examined Pepper's urine to see if there  is blood in it?  I don't understand the regenerative vs non-regenerative  thing either - or understand how your vet can be so sure which kind it is.

Yes that thought occurred to me to & was another reason I bought it up.
Peppers urine was tested a couple of weeks ago and there was no blood in it. That was one of the first tests we did. I'm not sure about the pcv test.
Perhaps Jo can shed some light on the blood results I listed about pepper & whether or not they are suggestive of Imha?

Hi

I don't know if this helps:

Immune mediated haemolytic anaemia (IMHA) can be subdivided into to categories. 

IMHA and AIHA (autoimmune haemolytic anaemia)

AIHA is idiopathic, meaning there is no underlying cause and it is primary AIHA.  This is usually non-regenerative and spontaneous and therefore it occurs as an autoimmune destruction of the immature red cells (reticulocytes) within the bone marrow.  This will be seen on the blood results as a low red cell count (HCT -  haematocrit, or PCV - packed cell volume) with no regeneration ie., no reticulocytes coming through from the bone marrow. These effects can be see with, for example, leukaemia as well as primary autoimmune haemolytic anaemia, and this is why some vets will want to do a bone marrow biopsy before treating AIHA with immunosuppressive doses of steroids.

In contrast, IMHA is secondary to an underlying cause (this is an immune response to something else going on in the body such as a parasitic disease, haemangiosarcoma etc., ) and this presents as regenerative anaemia, ie., the PVC or HCT is on the low side but the reticulocytes are high indicating that the bone marrow is responding to the lack of red blood cells in the circulation of the blood.  In these cases the primary cause or disease has provoked an immune response and the red cells are being destroying within the circulation of the blood. The primary cause has to be diagnosed and treated as well as the immune response for a good outcome.

In general if a dog has non-regenerative AIHA, I feel a lot more confident about it being treated with immunosuppressive doses of prednisolone etc.  I do worry when I hear that a dog has regenerative IMHA and is being treated with immunosuppressive drugs only without looking for an underlying disease. 

Jo

Is there usually a temp with either of these?

Pepper had acupuncture today and we only did thyroid points (which we have never done before) to try and see if stimulating her thyroid made any difference. She had it done at lunch time and as the afternoon went on she was more perky. She ate all her dinner on her own without me hand feeding her. Then she went outside and tried chasing the mower & playing with her ball. Barking & had a little run. This was a dramatic improvement on what she has been for the last few weeks. She has only really been going out briefly morning and night to go to the toilet and come back in. Only walking at a very slow stiff pace. She hasn't had any NSAIDs since yesterday morning at 10.30am.

I don't want to get too excited but I have never seen her have this sort of  improvement from acupuncture. Perhaps it is worth while giving her a trial of thyroxine. Jean had suggested a trial may be worthwhile even though she didn't have hyperthyroidism but considering her slightly low levels and her history.

On palpating peppers stomach my vet did not feel she was uncomfortable in terms of her spleen either.
i guess I just wait now & see how she is tomorrow & then decide whether to trial the thyroxine.

Anaemia can also be one of the symptoms of Hypothyroidism. Also Addison's. Increased ALT can also be seen in both.

Hi

A brilliant response to acupuncture!  I have experienced similar.  Also perhaps the acupuncturist might consider treating her stomach (the whole gastrointestinal system) because this can be an area that if out of balance can cause all sorts of other problems.

Yes there is a temperature with both IMHA and AIHA.

Personally, I am not in favour of giving thyroid hormones if the dog is not hypothyroid.  I have seen too many complications in dogs that are inappropriately treated.  These are hormones and if the thyroid is working then don't throw it into confusion by supplementing with thyroid hormones it doesn't need.  The thyroid gland system is so clever and sophisticated and it knows exactly how much the body needs.  It self regulates production to optimise its function.   If you supplement when it is not needed the thyroid glands will shut down and you are then guessing how much replacement hormone is required.

I hope her improvement continues.

Jo

Unfortunately peppers improvement didn't continue. She was okay for another day and then continued to get worse. Yesterday she could not get up unaided & for most of the day could not walk either.

She had acupuncture again using the same thyroid points, but it had no affect this time.

She had a low dose methadone injection for pain relief which did not help to make her any less stiff. All her lymph nodes are enlarged & she has a very sore point in her lower back. Needle samples have been taken of her lymph nodes behind her knee & neck & sent away checking for lymphoma.

She now has dry eye :( as well and an infection in one eye.
It feels as if her immune system is just going into self destruct mode.

She has had two doses of gabapentin for pain relief & is having another first thing in the morning. So far that has shown no improvement. If that fails our last resort is to give her pred & see what happens.

She still does not have a temp (her biggest sign last time with impa). Last time she had impa all her lymph nodes were up. She does not have the same look she had when she had impa of having her head hung down etc. But I'm wondering if the absence of her temp is changing her symptoms. She was never weak in her back legs before. But we also now know she has bad arthritis in her back legs. So perhaps that has worsened her symptoms if it is impa?

I have dreaded impa returning, but at this point it is really our only hope :(
Assuming the gabapentin doesn't have a turn around in the morning, steroids is our last option. As nothing else has helped.
I hate filling her with drugs, but it feels like we have reached the end of the line & it's the only option.
I want to try whatever we can before giving up on her & there isn't really any where else to go once we try the steroids. We could do an ultrasound, but I cannot see that they will pick anything up that is going to be treatable. We have pretty much tried all drugs that should have helped any problems they may find with an ultrasound.
The baby has started moving its head down too and only 3 weeks to go. As much as I don't want to go through impa again (& don't know how we will). Im hoping the steroids work & that's what it is because I cannot handle having to lose her at this point :(

Were her freeT4 and TSH levels well into the normal range or were they borderline?

Hmmm... it is very confusing.  Enlarged lymph nodes but no temperature??? Sore point in her back???  I wonder if the two are related or are you looking at two different problems?

Sore point in back and enlarged lymph nodes could be an immune mediated problem and, like you say, you may not have any other option but to give her steroids.  If you are going to go down that route then I wonder if your vet will consider giving Pepper an injection of Dexamethasone?  If she improves, and this could be rapid, then you can probably assume it is an immune mediated problem and then a course of steroids might be the way to go.  If she doesn't improve then nothing is lost because the duration of action of one Dex' injection is 48-72 hours and you don't have to wean down.  It is safe to give a one off injection.

Are you treating her dry eye? Does she have any muscle wastage - especially around the eyes/head? 

I do hope she improves soon.

Jo

Yes my vet is under the impression it is likely there may be more than one problem going on with her.
It is Saturday morning here and my vet is not open again until Monday. She has given me steroids to have with me & I have to email her this morning with how pepper has gone with the gabapentin. She is going to email back and advise what to do. Which the plan was if it hadn't worked, give her the steroids. Unless she has since thought of another option.
Otherwise perhaps the injection of Dex may have been an option if it were a week day & she was open. But she didn't want to leave me all weekend with her if she didn't improve from the gabapentin. I can have & give the steroids myself, but not an injection.

I have antibiotic ointment for her dry eye and tear lubricant. Which I only started using yesterday. We are going to treat the infection first & then retest her tear sample. It was very low originally so I'm assuming it still will be & then we will start the cyclosporine eye ointment.

I had wondered if her face perhaps looked a bit drawn & muscle wasted. Also her limbs/legs i had thought looked kind of drawn, & had mentioned it to my acupuncture vet. But she is not my ordinary vet who has been dealing with peppers impa all along. As she is a staffy & therefore quite muscly, it is hard to notice. Sometime back now (before all this recent drama) she had one of her eyes go funny & that side of her face appeared to droop. There was concern at the time she was developing another immune disorder. But we left her and she improved. That eye has since become one that she squints in on and off. But her face hasn't  appeared to be droopy in that side anymore. They had told me if she had the immune disorder that droop should have remained permanent.

Hi Catherine,
I have tried attaching a copy of her thyroid report, but couldn't get it to work. So I have just entered it below.


Test Requested                Result                           Case Specific                                   General Range Units

T4                                     1.01                              1.30 - 3.20                                      0.80 - 3.80 ug/dL
Free T4                             0.83                              0.75 - 2.00                                      0.55 - 2.32 ng/dL
T4/FT4 Ratio                     1.22 See below                                                                    1.25 - 1.75
T3                                     40.6                              30 - 70                                            30.0 - 70.0 ng/dL
Free T3                             1.70                              1.6 - 3.5                                          1.60 - 3.50 pg/mL
Thyroglobulin
Autoantibody(TgAA)         3 Negative                    < 10                                                < 10 %

FINAL REPORT TgAA is normal (negative), so her sluggish thyroid function is not due to heritable thyroiditis.
Suggest following the recommendations below. Best wishes, Jean

MORE COMMENTS On further reviewing these results and her long case history and other recent labs
provided, the T4 and free T4 were on the low side of the Case Specific range for her breed type and age.
Final interpretation depends upon the TgAA result. Given the detailed history and these results, I think
that boosting her basal thyroid levels would be appropriate.

Suggest a 6-8 week conservative dose trial of thyroxine at 0. 2 mg twice daily, given at least an hour
before or three hours after any food or treat containing calcium or soy to ensure absorption.

Was there no TSH result? Is Pepper spayed? (The results can be affected if she is near to having a season).

On the one hand it is not good to start her on thyroid medication if the thyroid is not causing the problems. On the other hand, if it is borderline, it is not good to wait until all the numbers "add up" as she could end up having unnecessary treatment for the problems she has now.

It is a difficult one, and you have to try and look at it with an open mind. Do not try and fit the symptoms to HypoT but at the same time if there ARE physical symptoms then it may be worth considering.

I have experienced borderline results with some of my dogs. One, in particularly was having increasing ALT and GGT levels over some months (as well as some physical symptoms that were not the common HypoT symptoms.) My vet was pushing for my dog to have liver tests but I was not convinced there was a problem with her liver. So we started her on thyroid medication and she improved and.....her ALT and GGT went back to normal levels!

No, there was no tsh result. I'm not sure what that is? The tests run was everything that hemopet offers.

Yes pepper has been spayed since she was a puppy.

I got some thyroxine from the vet before the weekend (just in case) & was going to decide whether to trial it, as I know it takes some time to work. I haven't given her any at this point, as I hadn't decided yet.

Pepper hasn't for most of the time in the last two days been able to get up and walk. Once I have her up she has maybe been actively (very slowly/stiff & stumbly) been able to walk around for an hr or two and then has gone back to sleeping. Yesterday we gave her another dose of gabapentin & didn't feel there was a marked improvement. So later in the afternoon we gave her an inflammatory dose of pred. She had the pred at 3.30pm and just lay quite doped out on her bed all night. We thought we'd try an inflammatory dose first, so as not to wipe her out too much considering how sensitive she is to drugs & what she had already had the last couple of days. Then if not response give her the night to recover & up to immune suppressant doses in the morning.


It's 5am now and pepper has wanted to go outside. I put her down from our bed and she stood on her own straight away (no weakness in her back end). She didn't pause at all and walked straight away outside without hesitation. It previously had been taking me some time to get her stable enough to stand after laying down for so long. Then she would normally try take a couple of steps & flop down again. She had no pause or trouble at all this morning. She has done a poo and wee and laps around the yard smelling for possums. I almost struggled keeping up with her. It is still dark, but she appears to be walking normal?? No stumbling or stiffness. I had to chase her back inside (as there is lots of mozzies out) and she has done a little cat nest like spin around to find the right position to lay back down on her bed. Not a movement she could ever pull off before & without any sign of stumbling.
????
I will leave her now until it gets light and see how she is then. Maybe it's just some crazy fluke she is feeling good for a while. I won't get too excited & wait to see how she is when it's light. So I can check her better. Bizarre?

I have harped on for so long about thinking pepper has a thyroid problem to my vet & results keep coming back to suggest it's not true. A thyroid problem surely could not produce her to be unable to walk & weak in the backend to the extent that I have described? Even with the negative results I still havent been able to get it fully out of my mind though.

A TSH test is to test the thyroid stimulating hormone. I am in the UK and it is usually done here but other testing labs. may use different methods.

It does sound unlikely that the thyroid could be causing the extreme weakness although HypoT can cause some limping, weakness, slowness. Her thyroid may be okay, there could be another reason for her problems OR some of them could be due to one problem and some to the thyroid. :-\

But if she seems to be improving at the moment perhaps the steroids are the way forward. Don't forget the gastroprotectant! :)

Sorry to read about Pepper's continuing problems. So many ups and downs - and mostly downs it seems recently.  So stressful as you await the birth of your baby.  Have you noticed if the weather has an effect on her stiffness?  People often find that humidity makes their joint problems worse.

I have tried paying attention to the weather and there doesn't seem to be any consistency with certain weather.
I feel she has more than one thing going on. Her skin disease (atopic dermatitis) is involved, exactly how much I am unsure.

I have given pep another inflammatory dose of pred at 10.30am.  I had been waiting to hear back from my vet. She has been corresponding with me via email over the weekend.
Over the morning (since 5am) pep has gradually got stiffer. But she had the last pred at 3.30pm yesterday. It's now 12pm & she is still looking stiff (she is still getting up on her own and walking around, just stiffer than she was earlier). But i will give the pred some more time to work before I start getting too into worrying about whether it was actually the pred that made her better.
Or wondering if it was gabapentin or who knows what else?

So its looking like it was the IMPA returning  for Pepper. She never had a temperature, which i thought was a given for an autoimmune disorder? But pepper has always been special by having reactions that aren't normal.

After trying anti inflammatories, gapapentin & Methadone, none of these made any difference. Prior to giving her the pred for most of the time she could not get up or walk in the end. But after giving her the Pred she is now getting up on her own & walking around & following me around more like usual. She is only on an anti inflammatory dose & still has times where she appears a little stiff. I really didn't want to go back up to immune suppressing levels with her again. But I am assuming that if she stays at this dose, she may be able to maintain this level of mobility. However, she will more than likely not get any better & we may never be able to reduce her dose, as she would worsen?

From my understanding, the correct thing to do would be to go back up to immune suppressing levels & get back on top of the IMPA. Then we could try to reduce her down again & she may get back down to this inflammatory dose (or lower) & be able to maintain better mobility than she has now at this dose.

Is that correct? I really don't want to have to go back up though :(

We cannot afford to put her back on cyclosporine & last time she had pred for her impa she didn't last very long before her liver levels got to alarming levels. Azathioprine I heard is slightly cheaper, but I don't think it will be cheap enough. Im glad she is still here with us & I would like her to be for as long as she can. But with pred really being our only option (as the others are too expensive) I don't know how long this will give us with her. But I don't see any other options.

I cannot believe that she was down to below skin therapeutic doses of cyclosporine (a level that should have been doing absolutely nothing for her) & then dropping her that last step off them all together caused her to relapse. Perhaps her skin disease is her trigger? When she first got impa we had taken her off her desensitising vaccines & all medications for 2 weeks so that we could have her intradermal testing repeated. After a week and a half she started developing a temperature. It then took around another 2weeks to get the impa diagnosis.


If anti inflammatories or heavy pain killers didn't work to improve her condition. I'm assuming that's because as fast as they were trying to reduce the inflammation, her body & immune disorder was building up more inflammation. Whereas pred switches off in a way her destructive immune system to prevent it from building up more inflammation. Is this correct?

So if this is the case would we even seen any improvement adding extra joint supplements & continuing acupuncture?
Also that poses the question that if I leave her at the current inflammatory dose, will her body gradually end up continuing to build inflammation up (as its not suppressed) & she will slowly get worse?


Sorry that's a whole lot of questions, but I am just trying to male sure that I understand it all correctly so that I can make the best choice for Pepper & also our budget.
Thanks

Pepper remained at the inflammatory dose again today and she was no longer slightly stiff looking as she had the day before. This time the gap between her pred doses was just over 24hrs. She was not stiff or slow at all before her next dose. Her demeanour was much more herself too and she even wanted to play.
Perhaps she does not need to go up a dose?

Her lymph node test came back as reactive lymph nodes, so negative to lymphoma. Yay!

Hi

Much of veterinary medicine is speculative and I think you have done the right thing by trying everything else first and then the preds.  Thank goodness she has responded - aren't preds marvelous?

You have seen a remarkable difference with just an anti-inflammatory dose of preds, and to be honest this is not unusual, but the proof of the pudding - so to speak is if this improvement lasts and if it does, then whether she will return to the clinical signs when you start to reduce the steroids. It is difficult to know but I think it might be worth the gamble to try her on the current dose and see what happens in a week or so.  If she relapses then you know what you have to do - up the preds to 1mg/kg/12hrs.

Preds are the best drug to deal with IMPA, and to be honest if she were mine I would try preds before any of the others anyway, because IMPA usually responds so well.

Have a quiet word in her ear and tell her to get better, and very soon, before baby arrives.

Jo

Thanks Jo, for your thoughts. Yes I'm so glad she responded to the pred when all else failed. They really have been a life saver for her on more than one occasion.

She is still doing really well on the inflammatory dose, so as long as she maintains this i think its best to leave her until the baby arrives. Then we can take the step & see if reducing her causes her symptoms to return.
I am going to take her to my vet tomorrow & have her check if her lymph nodes have all gone down & see what she thinks. As well as check her infected eye is looking better.

Let's hope she can maintain this dose until baby arrives & I can be back at home to keep an eye on her.

Another week has passed & pepper is still walking normal. So it seems like this dose of pred, 10mg once daily, (she weighs 19-19.5kg) is going to maintain her. I am glad & thankful that preds exist.

I took her back to my vet at the end of last week and she was happy with her progress. All her lymph nodes had gone down, except her neck was still a bit enlarged.

She has now started to get the pred munchies & is drinking & peeing more. Her coat is getting that horrible pred feel/smell & falling out. But she is still here and walking around, so that's the main thing.


I discussed with my vet our thoughts on her relapse and we are feeling like she is probably going to have to be a pred dog for life now. We have both read literature that shows an increase in cases of & relapses of impa in summer months. Whether this is due to environmental triggers is suggested but uncertain.

I had been thinking for some time now Pep's  allergies may have been her trigger. When she first got the impa we had taken her off the desensitising vaccines that she had been on for 4years or so, to have her allergies reassessed. So she was on nothing for her atopy for 2 weeks (at the height of summer) & that's when it all started. This time round we got her just off the cyclosporine  (also at the height of summer) & she hadn't been on pred for months & she relapsed. Whether the desensitising vaccines have had some permanent bad effect on her immune system or it is just that her immune system just gets to a point where the allergies are too much & the impa is its self destruct mechanism, I don't know.
But I do wonder if this is her trigger. Even with all the preparations (supplements, diet etc) & maintaining work (removing chemicals from our home, & environmental factors such as mowing, weeding, washing, vacuuming etc). As well as general upkeep on her through bathing etc. All that I have done to maintain her allergies without drugs, and it seems that is not enough to control them.
So with pred or cyclosporine being the treatment for both atopy & impa (but cyclosporine being too expensive) it's looking like pred is unfortunately going to have to be her fate.


Baby is still sitting put at the moment, we are thinking maybe next week he/she will decide to arrive. Hopefully once baby arrives & pep has been stable on this dose for a while. As well as now that Summer is just ending, we can then try reduce her to a lower pred dose. It would be good to get her to the lowest dose possible and maintain her there, to try minimise liver damage, muscle wastage etc (her worst side effects previously). At least we have been able to maintain her this time at a lower dose than when she was first diagnosed (20mg daily).

Good news that Pepper is free of the joint pain which  prevented her from enjoying life.
Interesting that your vet thinks that summer is a trigger factor.   I wonder if that is the  case everywhere.   We have  very dry summers here  - the grass   is dead  so no grass seeds to cause allergies.

Since my last comment I have been pondering the impossibility of doing reliable research concerning summer triggers.
For a start, how do you define summer?
It's officially autumn here now but the temperatures are still in the thirties.
The local parks  have been predominantly bare of grass since late December but  who knows what seeds and other allergens blow in from rural areas with  the dust  on days we get gale force hot winds?
Anyway, I'm pleased that Pepper is feeling better.  Hope  everything goes well in the last week of your pregnancy. 

Hi

There is certainly a school of thought that AI disease can be seasonal and this could  be due to the change in climate and all the lurking unseen triggers out there, or in some cases the increase use of vaccination during the holiday season.  It is impossible to know all the potential triggers, and individual dogs will react differently.

I am very interested in your research Polly.  Geographically it will change, even in a relatively small country like the UK,  and no two summers or winters are the same, but it will be an interesting study.  What about global warming too! How does this affect the allergens out there?

Jo

Hi

I'm so pleased, and relieved for you, that Pepper is feeling much better. 

You know, it's not such a bad thing for a dog to be on a low dose of pred and if you can get it down to a low every other day dose - how bad is that if the dog remains in remission?  I have had to accept this in the past.  It is whatever is best for your dog and the quality of life the steroids achieve. A low dose of pred will hopefully keep Peppers allergies at bay too.

You will have to wean her down from this dose and hopefully it will have done the trick.  How about discussing with your vet about reducing them very slowly, from the first reduction, almost as if her body won't even notice the reduction.  This could be done as long as the side effects are tolerable.

I'm looking forward to hearing your baby news.  Won't be long now.

Jo

It's a girl!
On the 10th March we welcomed Zara Louise into the world. She was 3890grams & 53cm long.
I'm super thrilled to now have my pigeon pair.
Gratefully my mum looked after Pepper whilst I was in hospital & she has maintained well. She is a very proud big sister.

I came inside first by myself (after being in hospital) & Pep was so so excited to see me that she almost knocked me over & went crazy kissing me. After she settled some she went back to the door looking to see what else (or who) was to come in. She was super excited when we bought Zara in & gave her gentle kisses to her hair at the back of her head.
The couple of days before I went into hospital she did not leave my side & even had to have a foot or something touching me at all times. She knew what was coming.

She has since been busy keeping an eye over Zara. She is such a good girl. She always checks to see that she knows where Zara is before she will settle. As well as getting upset if Zara cries.

That's wonderful news.

Wow!  That is fantastic news.  I have a huge smile on my face.

I am so glad you and your baby girl are well and back home with the family.  I bet Pepper was beside herself to see you.

Zara Louise is a lovely name.

Don't over do it! Let others take charge for a while.

Thank you for letting us know. Congratulations!
Jo
 

Hello' I haven't been on here for a while as I've been pre-occupied with a baby that doesn't sleep :(
On the positive Pepper has been a lot less time consuming & easily maintained. I've barely had to do anything to her other than her pred. I've been able to drop back her baths to 1 every 2 weeks & haven't had to do the crazy upkeep of vacuuming, mopping, washing etc.
She gets an ear infection maybe once every month or two but I have been able to manage this with a week of easotic.
I just wanted to drop back in and update on her progress. She is doing better than she has in a long time. She looks great and has lost some weight & is looking in top condition. Everyone keeps commenting on how fantastic she looks and how full of life. They cannot believe she is 9 and how well she is getting around considering how bad she has been. She has been running around crazy all the time like she used to when much younger.

I have her down to 5mg of pred a day, but have decided to leave it at this dose, as we are just about to come into summer here. She will need something to help her allergies. Peps vet and I feel that summer is her worse danger period in terms of relapse for the impa. Whether it's seasonal or if it's when her allergies get out of control we can't be certain. But we have been monitoring her bloods & they look good to keep her at this dose until after summer. Also my vet is due to have a baby at the end of November so we don't want any relapses to happen while she is off.

I have accepted that pred is going to be a way of life for Pep now. Seeing how happy & fantastic she is doing, makes the decision easier. She is getting more quality of life & that's what I want for her.
The steroids seem to work a lot better for her at this low dose than cyclosporine did. She was still in pain on it & it was costing a ridiculous amount more of money:

Hopefully now I can get my daughter sorted & sleeping better. But I'm so so happy at how well Pep is doing. Thanks again for all the help and advice everyone has given me along the way to get her to this point.

That's great news.  It is so good to know that Pepper is doing well.   If the 5mg of pred suits her, and keeps her on an even keel, then it is right to keep her on this dose.  Much better this way than relapsing over and over again.  I also think pred is a better drug than the Cyclosporin, but they all have their place and are necessary at times.

I do hope you can get some quality sleep.  I remember this well when my second child was born.  He didn't sleep through the night until he was 17 months old.  Not that I am wishing this for you, but it happens and his problem was largely down to his teeth all wanting to come through at once.

Many thanks for the update on Pepper.  Wishing you all well.

Jo

Thanks jo. I find Peppers demeanour/appearance to be the best way to judge her. Right now she looks and seems better in herself than she has in a long time. Even before she got impa, iin her terms of her weight & allergies. So I do believe leaving her as is for now is the best thing to do.

My son slept through the night from the second week I brought him home from hospital. Zara is now just over 6 months old & still mostly up every 2 hrs. She is lucky to sleep even an hr in the day time as well. Considering the lack of sleep she has, she is actually a very happy baby. That is before the last few days. She has been crazy chewing on her hands & anything else she can get in her mouth for many months now. She drools lots & has the red cheeks (all the signs of getting teeth), but still no sign of anything!
The last few days she has been irritable, which is unlike her. She is also particularly rashy in her cheeks & plucking at her ears, even making them bleed. I really hope we see some teeth soon. Did your son end up getting teeth all at once?

Hi Brooke, Good to know that Pepper is doing well. Hope all goes well with the baby Zara's teething too. I haven't been on this site for ages either. Jasper is  doing well. Completely off pred now and fully recovered from  cruciate ligament surgery despite a few bumps along the way.  He is again able to do his voluntary work as a pet therapy dog at a local hospital.

Oh that's fantastic polly, so glad for you and jasper!
That is really great he is volunteering as a pet therapy dog. I always thought pep would be great doing that too. As we used to take her into the nursing home when my pops were in their with dementia & they loved seeing her. She was such a good girl when we took her there too.

Hi Brooke and Polly

What is so great about this forum is when people don't post for a while it is usually because their dogs are doing well.  After all the terrible months and sometimes years of worry it is hoped that the owner reaches a stage, when their dog is doing well, where they can look at their dog each morning and say 'Yep, you are fine' and get on with their day.  It appears that you have both reached that stage and that is a result!

Off subject:  My son was a nightmare and would only sleep for about 20 minutes between feeds and by the time he was 6 months he had 4 teeth and they kept coming, and he had them all by the time he was 17 months.  Sleep deprivation is an understatement! My apologise to other members for this indulgent post.

Jo

Hi Brooke,

I'm new to the forum and just trying to catch up on who everyone is and what their dogs are struggling with, etc. I am happy to see that Pepper is doing better than when you originally posted. I skimmed through this thread and I didn't see that you got a lot of answers to the original question about Gabapentin, so I thought I'd tell you what my experience has been with it. I am in the US, and I guess it is prescribed here more often. My Gracie has severe IBD and can't tolerate NSAIDs, so when her arthritis and spondylosis developed the vet put her on Gabapentin. She has done beautifully on it. I never see any indication of arthritis pain any more, and she has never had any side effects that I am aware of. Of all the medications she takes, that is the one that I am least worried about. If this question comes up for you in the future I would say give it a try. Gracie has benefitted from it and suffered no ill effects.

Hi Gracie & Bo,
Welcome to the forum, it is a great place. I have found it so valuable to get feedback from others who have been in the same or similar positions. Especially when dealing with immune mediated diseases, which aren't very common and hard to find info about where I am. The forum is a fantastic support network & has helped me keep it together a number of times.

Im glad to hear the gabapentin worked for you. We tried the gabapentin with Pep when she relapsed from IMPA & unfortunately she still could not walk and was still in lots of pain after taking it. We have had to go back on steroids & are now on a dose of 5mg (18kg) per day.
She is doing the best she ever has. We are right in the middle of our hottest summer in history here and I am pretty much not having to do anything for her in terms of her allergies. I am only bathing her once every 3weeks maybe.  Every month or two she gets an ear infection which clears up with 5 days of easotic.

We have just had our first course of antibiotics since her diagnosis with IMPA, Its been two years of being terrified to give her antibiotics & trying to avoid at all cost. But she got a really bad urine infection & we had no other choice. We tried a different one with her that she hadn't had before after researching those least likely to cause a reaction. She also is allergic to cephalexin (amongst many other things) & breaks out in hives from it. So that was another worry other than the risk of impa. But we have survived through the antibiotics without a problem and she is doing great!.
Her only other problem is when we have consecutive really hot days she has a little trouble getting up and gets a bit limpy of an afternoon. The heat must cause her joints to swell and pain her. But she wakes up the next morning fine.
I thought arthritis was supposed to be bad in the cool, but she is the opposite. I have read some reports saying that people with rheumatoid arthritis complain about the heat causing pain though. Does anyone else experience this with their dogs?
I had hoped to get her down to a lower dose of steroids but if we decide to try reduce her it wont be until winter.

Thanks for checking in on me. I have been meaning to come online and give an update as it has been a while.
I'm still struggling with a baby that doesn't sleep though :( So I've been a bit short on time.

That's a lovely update Brooke.  I am so pleased that Pepper, on the whole, has the AI problem under control and is managing to enjoy life.  Urine infections and ear problem can happen in a healthy dog, so as long as this can be controlled it is very acceptable, - so great news.

Sorry about baby not sleeping though - it doesn't last forever!!!!

Jo