We started Puddles reduction of 10mg/day (she's getting 20mg twice daily now) on the Prednisone and all has been fine eating great and pink everywhere. HOWEVER... I think we have another UTI. She just finished a round of 375mg Amoxi trihydrate/Calvulanate (2x's/day) that was presecribed on 1-16-18 for 10 days. She had a positive response immediately from the antibiotic. This morning she went out and squatted several times and is going out a lot more frequently. Of course it's Sunday and all the vets are closed. I have 3 Clavamox tablets same mg and still in the foil. They expired in 2015, can I still give those to her? I know they have probably lost some of their effectiveness but maybe she would benefit somehow from them. Is there anything we can do in addition to the vet to help, prevent these?
Homoeopathic Cantharis helps with urine infections and I have also found giving a cranberry extract tablet daily helps prevent them.
Hi
If tablets are in a popper foil pack then it is very unlikely that the efficacy is diminished - perhaps one or two percent, if that, so I would give them to Puddles. Very often UTI's are persistent and more than one course of antibiotics is necessary. The bacteria can linger for many weeks so it is important to address the infection with antibiotics but also, especially if the preds have done their job and brought the AI disease under control, it is wise, and usual practice, to lower the preds to the next stage in the reduction protocol. This link is very informative and the quote is below.
http://veterinarycalendar.dvm360.com/complications-immunosuppressive-therapy-proceedings?pageID=1
When administered at high doses and/or for prolonged periods of time, glucocorticoids are most commonly associated with bacterial urinary tract infection. In one study of dogs treated with long-term (greater than 6 months) glucocorticoids for pruritic diseases, urinary tract infections were documented in almost 20% of treated patients. An important clinical point to keep in mind is that dogs with hypercortisolemia, be it of exogenous or endogenous origin, may exhibit no clinical signs of urinary tract infection, and may have little sediment evidence of urinary tract infection, making urine cultures the most definitive diagnostic test to establish the presence of urinary tract infection in such animals.
Cantharis can help, as Catherine says, and cranberry extract. I have also heard that apple cider vinegar is very good, but I haven't any experience using it.
https://www.petinsuranceu.com/dogs-and-apple-cider-vinegar/
The main objective is to reduce the preds in a controlled way until there is little effect on Puddles immune system and then the UTI's shouldn't be a problem.
Jo
Thank you for the information. We have reduced her Prednisone by 10% and the 10th day will be 2-4-18. If we stay by the chart in an earlier post (Michael Day) then we will not reduce again until the 10th day. I am taking her to the vet for the UTI tomorrow and will have blood work ran then. If her PCV is high enough should we move to the next reduction or do what the doc suggests? They are still in the foil and the doctor mentioned the last time that she may need to do a culture. I am in the US, is cranberry extract tablets and Cantharis easy to find and what should I be looking for?
Hi
Each stage of pred reduction has to be made based on clinical signs eg., resolution of the disease, blood results, secondary infections, acceptable/unacceptable signs of drug induced Cushing's syndrome. The vet and owner should be prepared to adjust the protocol at any time. With each reduction it is best to try to get to 10 days, monitoring daily, and then reassess. If the dog is doing well then you can eek that stage of reduction out to 12 -14 -16 -21 days before the next reduction. It isn't written in stone but if you can take each stage to it's optimum then there is a better chance that a relapse won't happen.
Weaning a dog off too quickly is very likely to lead to a relapse, and then the whole dosing procedure has to start again, and because there is a build up of pred in the body the vet may have to introduce another drug to use alongside the preds.
Leaving the dog on the high doses for too long can cause many complications and some can be serious, so it is important to find a balance and get a feel for what you are seeing in front of you rather than blindly and rigidly sticking to a drug protocol without tailoring it to the individual. The situation can change on a daily basis. You know Puddles better than anyone and you are the best person to read her clinical signs.
Veterinary science coupled with experience is very important when treating a dog with an AI disease but common sense also needs to be applied when trying to assess the whole situation and make decisions how to move forward. It is important to work with your vet but also for them to also work with you, and if your vet can't do this then you should find another vet who will.
You can get cranberry tablets on-line or from a health food store but the Cantharis is a homoeopathic pill that may have to be bought from a homoeopathic pharmacy or you may find it is available on-line in the US. Some pharmacies in the UK sell homoeopathic remedies and supplements like cranberry so it might be the same in the US.
It sounds as if Puddles is doing well. Just check her every day and reassess. It is a steep learning curve for sure.
Jo
I took Puddles in yesterday for her CBC and the UTI. I was supposed to collect another sample 7 days after her diagnosis so the vet could test the effectiveness of the Clavamox. I forgot to do the second sample and took one in yesterday and they said she showed great improvement between the two samples so they would keep her on the Clavamox for 2 more weeks and felt sure it would be gone at that time. Her PCV was up to 40% from 36% on 1-15-18 so that was some great news but has to go on Denamarin because of her liver values, Doctor said better to be safe than sorry. Thank you again for all your help and advice and wanted to share the good news. I am waiting to hear back from the hospital on medicine schedule and will let you know what they say. Regardless I think she will have to stay on this dosage for at least a week or two since I reduced her towards the end of last week.
That's really positive. Thank you for the update. Denamarin is a good supplement for liver support.
Fingers crossed
Jo
Today is the 10th day of Puddles first reduction from 50mg to 40mg. On the reduction chart from Michael Day it states to wait 10-28 days before reducing. How can you tell whether to start the reduction at 10 days or wait longer?
Has Puddles had a blood test since 15th January? If not I would not reduce the Preds. until you know what her PCV is. I would not like to leave it too long either to check that her PCV is still going up or is stable. My dog with AIHA always had a blood test first before we reduced her medication and because she had regular blood tests we were able to reduce more often but by smaller amounts so it was slower if that makes sense! I can understand not wanting to give medication for longer than necessary but if you go too quickly your dog called relapse and end up having to have high doses again.
Yes, she had one done on the 29th and her PCV was at 40 from 36. I had already reduced her down by 10mg prior to the 29th and she had a UTI when it was 40.
I forgot to add I reduced her down by 10mg about 4 days prior to the test in the 29th.
Hi
It is always best to take each reduction to 10 days - assuming the clinical signs allow - and then eek it out to 12 - 14 -16- 18+ days if you can, checking every day that she is coping with the side effects of the preds and there is no signs of relapse.
The slower you can do the reduction the better but you must respond to any clinical signs that suggest the pred dose is becoming too much.
A PCV of 40 is great news!
Jo
She definitely has the muscle mass loss, drinks and pees a lot, has the pot belly, and is eating whenever and everything she can. Her panting isn't bad at all and is usually when she lays on top of the blankets. Her breathing has improved since we reduced her the last time. Are there any other signs that would indicate a need for reduction. I'd love to stretch her out another week to 10 days. I built her a ramp over the weekend because I don't want her to damage her muscles on the stairs and is now on Denamarin so hopefully this will help her liver. Are there any other signs we need to watch for. Our goal is to go 18-20 days.
Hi
All that you describe is to be expected - and Puddles is doing well. The extreme signs to look out for are going off food, extreme depression, shallow, fast breathing and really struggling to get up to her feet.
You will assess her every day and then make the decision whether to reduce the preds that day or not. Some vets expect to blindly reduce the preds every month without even monitoring the side effects. This won't happen to puddles.
Jo
Thank you for the responses and all the information. I trust and value what the Drs. say but I also know many of them are bound to what is "text book" and sometimes (seems more often than not) that just doesn't work. I can't imagine how much time you spend helping out with issues like we have and I just want to thank you for your time and knowledge, it's very comforting during times like this when we need quick, accurate and mind settling information.
Aw that is really nice of you.
It is a tough time, more so for the humans, because the dogs seem to accept things and are to a degree oblivious, but we have the worry. It is worth it though.
Jo
We started Puddles on Azathioprine Monday before last because her PCV had dropped and the vet was concerned she was relapsing. She is now on an acid inhibitors and 12.5mg Prednisone twice daily. She gets Clopidigrel in the morning and Denamarin only at night. Because her PCV had dropped the vet added Azathioprine daily for the first week and is now every other day starting this past weekend. We are also giving her an Omega 3 fish oil tablet in the morning. She is having major muscle atrophy and now hardly walks at all. When I go to pitch her up she lets out a little yelp as she's in pain (weighs 55 pounds). She is eating good and is drinking but not putting the effort to go after it as in the past. The vet did some blood work again today and her PCV was 41% and white blood count was low to normal. We reduced her dosage of Prednisone from 15mg twice daily to 12.5mg daily on Sunday due to the atrophy and was told by the Vet that we would look at reducing it this upcoming Monday after the Azathioprine has been in her for two weeks. We are very concerned with the lameness, she is having problems getting up from laying down and is only walking about 5-10 feet before stopping and just standing there. We are also worried about her being in pain when I pick her up. We took her to the vet yesterday because of the lethargy and noticed her urgine had a strong odor to it. They said she had bacteria in her urgine and started her on an antibiotic. The vet thinks it is mostly from the Prednisone's side effects but I'm wondering if it could be something else. As always thank you so much for your time and help.
Hi
If Puddles weighs around 25kg (55 lbs) and she has been on high doses of prednisolone for a couple of months, then I don't doubt that the clinical signs you are seeing is due to the high doses of prednisolone. The symptoms are very typical of a dog who is saturated with prednisolone, so at this stage, don't even think it could be something else until you have significantly lowered the dose.
As her PCV is very good I feel you and your vet should consider a further, significant reduction in preds now and not wait until Monday. This prolonged, high dose is making her feel really unwell and as soon as you make a significant reduction you will make her feel so much better and her body can then start to recover from the onslaught of the steroids. Larger dogs do not cope so well with prolonged, high doses of prednisolone.
Azathioprine starts to take effect after 10 days but it doesn't reach its full potential for many weeks so I don't see why you have to wait to lower the preds. A PCV of 41% is very good and it doesn't indicate a relapse - and the low white cell reading is typical of a dog who has been on prednisolone. Sometimes the long term use of preds can inhibit bone marrow production and this can keep the PCV from going into the normal reference range, so when you have lowered the pred dose you might even see an increase in the PCV.
I think you will see a difference in Puddles within a few days of a much lowered dose of pred.
Jo
My wife and I totally agree. How much would you lower the dosage of Prednisone, what would be a significant amount? Do you think it could possibly be the Azathioprine, her dosage is 50mg?
Hi
Only you and your vet can decide how urgent it is to lower the preds based on visible examination of clinical signs and blood results. Your vet has noted this already by reducing the preds from 15mg twice a day to 12.5mg a day, which is a very significant reduction, but if necessary this dose can be reduced to a physiological replacement dose if Pebbles clinical signs are not improving as hoped.
A dog that has been on long term steroids cannot suddenly be taken off them because of the adrenal dependency, so the minimum dose, if absolutely necessary, would be a physiologic replacement dose of 0.2-0.4mg/kg/24hrs (BSAVA Small Animal Formulary). This drastic reduction might be necessary, if for example, if a dog had been put on immunosuppressive therapy and the dose needed to be significantly reduced because the dog needed urgent surgery, but for Puddles now the dose has been reduced to 12.5mg a day that should make a big difference but if appropriate, you could lower that even further to 0.2-0.4mg/kg/24hrs, but your vet has to decide this. The dose can be taken to the lowest dose as long as you give enough to support the adrenal glands.
Azathioprine is usually well tolerated but of course some dogs can't tolerate it. The dose she is on is fine. Azathioprine: 2mg/kg/24hrs. Plumb's Veterinary Drug Handbook, eighth edition.
If you are not seeing any improvement in Pebbles clinical signs then perhaps you should take her back to the vet before next Monday and discuss a further reduction.
I do hope things start to improve soon.
Jo
Our prayers were answered!!! I think it was the UTI making her feel extra cruddy and wearing her down (what little she has left). She is still a little sluggish but is walking a lot better, going down and up the ramp to potty and I even saw a little shuffle/jog yesterday for liver. After reading various posts on this forum and messaging some other members I am convinced it is the prednisone's side effects which can be turned around. As bad as I despise the drug and understand it's the necessary evil we will continue to work with our vet keeping Puddle's best interest in mind. I was at the vet recently and saw a technician literally picking up the rear of a Golden Retriever so she/he could walk. My wife and I both agree not to let Puddles get to that point which was my concern earlier as we thought she was nearing that earlier this week. Our plans are to take her in on Monday or Tuesday for another PCV check. By then the Azathioprine will have been in her for 2 weeks and will feel the added cushion of the additional suppressor will help. It truly is a journey of peaks and valleys and I can't thank you, Andrea Gotham, Karen Sexton and Susan Crowther enough for all your help and advice.
This is wonderful news. I am so pleased you are starting to see an improvement - and it should continue from here on.
The UTI's do bring them down but by now you should be seeing some benefit of less pred. Preds are lifesavers but there comes a time when they can o more harm than good and that has to be acknowledged and acted upon. I am so delighted for you.
It is a steep learning curve for sure, and it is a big shock when it first happens, but now you are on the way up!
Jo