CIMDA

Canine Immune Mediated Disease => Systemic / Inflammatory (AIHA, IMTP, Evans, SLE, IMPA, SRMA) => Topic started by: BrookeR on November 01, 2019, 08:26:57 PM

Title: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on November 01, 2019, 08:26:57 PM
Itís been too long since I have last been on here. I always mean to check in every now and then but life gets busy. Sadly my pep (impa sufferer) is having trouble walking. She has a very swollen elbow and limping badly.
I was out one day 3 weeks ago now and she was fine when I left and when I came home she was limping. On the odd occasion that no one is home (myself and my partner both work from home) she sometimes would get up on the lounge. Then when she jumps off she hurts herself. I had believed that this is what happened this day I was out. As it appeared that she was limping on her front leg. She is a staffy and has really bad muscle wastage especially in her chest/shoulders due to the long term pred uses.
We have had a lot going on the last few weeks including my 6 year old having surgery so unfortunately I have had to try keep pep comfortable until I could focus on her. She improved some for a week or more but has been struggling again more the last few days. I noticed her elbow was swollen a few days or so in and then it appeared to not be as bad for a while but now itís looks more swollen again.

Pep is now 12 years old and is prone to pancreatitis as well. She also has bad arthritis mainly in her back legs. Which is causing her to have trouble getting up since she is having to rely on her back legs more while she protects her front elbow. Our whole house is tiles which makes things a lot harder for her. Especially when she hurts herself. I donít mop the floor anymore as this makes it impossible for her to walk. I have put a non slip runner coming from her bed down the hallway. I have considered getting toe grips for her to see how they go. Being a staffy she loves laying her belly our starfish on the cold tiles. Itís impossible to stop her so I have to try always be around to help her get up so she doesnít slip out and hurt herself more. However, it doesnít matter how many things I put in place to help her she always seems to go out of her way to not use them....

We have not needed to up her pred in years. She is only on 2.5mg pred per day and her liver levels are still quite high. I donít feel that she is going to handle an upping of pred again. So Iím looking into all other options prior to doing so.
She has put on a little weight at the moment and weighs 16kgs. She was on 1/2 tablet tramadol twice a day which I have upped to 3/4 tablet. She no longer has omega oils due to her pancreatitis and is only on Rosehip canine joint supplement, as she canít have any of the seafood ones due to her intolerances/allergies. She is also taking denosyl.
There are a number of things I have considered trying in the past, but my vet has felt they were too much of a risk with pep. She is allergic to many plants and also has food intolerances which add extra concern when deciding on supplements etc to give her. At this point in time Iím feeling some risks may be worth taking as I feel upping pred is going to be an option that will lead down a bad path.

Has anyone tried arnica with their impa dog? I have been giving this to my son who just had surgery and it occurred to me that this may be an option to try with pep.

Also in the past I had considered magnets and cbd oil before, but my vet wasnít comfortable with either..
I feel that pep has injured her shoulder but impa relapse is always in my mind. Previously though when she has relapsed (which was a long time ago now), within days she would be so bad that she could not walk at all. It has been 3 weeks or so now and she hasnít got like that. Also she is still wanting to follow me even though she is in pain, she has no fever and she isnít hanging her head in pain doing the egg shell walk. They were all things she previously did with a relapse. I have an appointment on Monday with our vet for her to see pep and see what she thinks but I am concerned she will want to up her pred. So Iím trying to look into other options.
The last time Pep had trouble 2-3 years ago now my vet thought she had relapsed and continued upping her pred. She got really sluggish and we checked her bloods and her liver levels were through the roof. We dropped her right back and she was fine.

Itís summer time here and this is the exact time of the year that pep first got impa and the time she has trouble with relapses, skin problems etc each year. Whenever we have hot days she always limps and struggles. Arthritis is supposed to be worse in the cold but she has always been the opposite.

She now has lumps coming on her in different places and with her age, cancer is a possibility but one I decided there was nothing to achieve by doing tests for. As she is too old and fragile to try put her through anything if we found out.

Another new problem is we are having trouble with her eyes being red and dry at the moment. She does have dry eye which I am still managing as I always had but the white parts of her eyes have started to become red. My vet looked closely at them and couldnít find any cause. So we had a round of amacin which improved it but it has now just come back again.

Anyoneís experience on the use of arnica or any other thoughts of other options would be much appreciated.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on November 03, 2019, 01:36:29 PM
Hi Brooke and welcome back!

I am so pleased that Pepper has managed to achieve long term remission with IMPA.  It was a long journey for her and you.

From what you have written, it seems that this limp, and swelling around the joint, is isolated to just one leg and this indicates that it is more likely to be an injury or just old age - how wonderful that can be said about Pepper!

Personally, I wouldn't give more pred and if she is only on 2.5mg a day I doubt it is having much effect other than her adrenal glands won't be making as much of her daily requirement of glucocorticoid. So have you considered weaning her off the pred and going down the route of a conventional anti-inflammatory, such as Rimadyl or Metacam?  I wouldn't touch Previcox because that caused kidney failure in one of my dogs.   

If you would prefer to try alternative remedies, you could try Yumove (not sure if you can get it in Australia).  I know of many people who give CBD oil to their arthritic dogs, but it would be better if you had your vet's blessing.   

Arnica is a good remedy to promote healing but I don't know if it will help in this case.  Rhus Tox is a good homoeopathic remedy for stiff joints, so that might be worth a try or if you have a homoeopathic pharmacy in OZ they may be able to make a remedy just for Pepper.

Resting is essential when treating an injury but it is very difficult to control what Pepper will get up to when you are not around.

Do you give Pepper dry eye ointment?  If not then in the UK you can buy Viscotears from the chemist, and I would give those a try.

I do hope she improves very soon.

Lovely to hear from you.

Jo


Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on November 04, 2019, 08:32:04 PM
Hi Jo,
Itís nice to hear from you again. I hope all is well with you.

Yes pep has been on optimmune (cyclosporine) eye ointment for a couple of years or so now. I also regularly throughout the day put hylofresh lubricating tears in her eyes. Her body never likes this time of year and it is very dry here in australia this year in particular. Weíve also had heavy smoke from fires some distance away. Lots blowing around and lots of people have had trouble with hayfever and allergies, so Iím wondering if this has had an effect on her too. Possibly causing her red eyes. They have improved some the last couple of days and the air has also cleared from the smoke.

We saw my vet yesterday and she said the swelling in peps elbow could not be normal arthritis. She thinks that sort of level of swelling could only be caused by impa. I asked about cancer and she said it is very uncommon in the elbow where her swelling is. She also thought that with the amount of swelling if it were cancer than she doesnít believe Pep would be walking at all and would be in extreme pain. She suggested an X-ray which may show white coloured fluid if it is impa. She said fluid from impa is higher in protein and can show more of a white colour on xrays. If it were cancer there should be some sort of signs of erosion around the bone. Sorry that may not be the actual terminology she used but thatís how I understood.

I asked what we would achieve from an X-ray? If itís impa we have to up the pred. If itís cancer we up the pred/pain killers. She said Ďyes thatís correct, unless you plan on cutting her leg off.í (Which I donít.) So I decided not to do the X-ray for now. I really donít like upping the pred but there didnít seem like any other option. I had upped her tramadol the previous night and it didnít help and she started to be a little sedated.
Her limp/walk had also gotten worse after I wrote on here. Not the true Ďeggshell walkí but due to the pain swelling in her front elbow there was more emphasis on that leg.
I agreed to go up to 10mg once a day. This is under immune suppressing doses. But the last time she had a true relapse, not quite 4 years ago. That is the dose I gave her (even though our vet wanted me to give twice this). I tried 10mg and it took a couple of days but she came good at that dose. So that is where we are up to. Trialling 10mg of pred (once daily) for a few days with the 3/4 tramadol twice daily. If no response I may consider the X-ray. Iím not sure what else to do. Then I guess we go up pred more :(


One of her limp nodes in her neck was slightly more enlarged than normal, no fever and her other joints were a bit swollen but slightly less than the last time I saw our vet in September. At which point she had said her back hocks were a little swollen. But likely normal arthritis.

Our vet didnít think it was septic as there was no increased heat in that joint and no wound where contaminants could have gotten in.

Is there anything else that could cause an extremely swollen elbow? Could she have fractured it jumping off the lounge? She has a lot of muscle wastage in her chest, which is very noticeable seeming she is a staffy.


Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on November 07, 2019, 04:54:23 PM
Hi Brooke

Usually, IMPA will not occur in only one joint.  The typical presentation is swelling on multiple joints, and usually with a high temperature.

The dose of pred is now an anti inflammatory dose, so perhaps this will do some good and reduce the inflammation in the joint. You can only try.

 If Pepper can have the x-ray without being put under sedation or a general anaesthetic then you may as well go for it if the increase in preds isn't effective.  It may show up the cause.

Euphrasia is a homoeopathic tincture that can be use to soothe the eyes.  Just a couple of drops in cooled boiled water can help but if Pepper's problem is immune mediated then it probably won't have much effect.

I do hope this increase in pred will do the trick.

Jo
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on November 07, 2019, 08:19:35 PM
Hi Jo,

Yes thatís why I have been so puzzled that it seemed just to be that joint in particular.
So I decided to go ahead with the X-ray to see what was going on and if there was a fracture. Once i decided and booked the appointment her swelling began to decrease and she started gradually walking better. She still has some swelling and is still dipping her head when walking on that leg but even during the day while she was at the vet our vet noticed a decrease in swelling. She is only at 10mg once daily which she has been on for 4 days now. Unfortunately they sedated her (with pain relief). I really donít like doing that but felt like it was important to see what was going on before upping the pred. As I donít feel her liver will last long with a much higher dose.

Unfortunately the X-ray showed up a quite large area missing from the outside edge of her elbow. Like a bite had been taken out of it. A big corner piece missing :(  There was also a strange marking almost looked like a little hole/chip midway down below her elbow & before her wrist, in the centre of her bone that only showed on one X-ray. My vet has sent to a specialist to get their opinion on whether they think cancer or erosive poly arthritis. I was only reading up again on this the previous night prior to her X-ray. There is a picture of a staffy in michael j days book with rheumatoid arthritis and it always catches my eye. I did have X-rays done of pep a few months after she initially got diagnosed with impa to check if it looked erosive but at that point everything looked fine. I also mentioned about doing the blood test to check for the rheumatoid factor back then, but I donít think we ended up doing it as the vet at the time said they didnít believe that was it and I donít know if the test was even available in australia then.
My vet also took a small amount of fluid from peps joint (not enough to make the noticeable decrease in her joints swelling) while she was sedate. Normally she would ask me prior to doing this but when I came to pick her up she asked did I want to send it off. Since it was already collected I agreed. She wanted to see if that could give more of an idea if the cells were cancerous or just likely impa.

So we are now waiting to hear back on the results from the fluid taken and the specialists thoughts on her xrays. We have have decided to stay at 10mg once daily until we get results. My vet said she more thinks itís impa and erosive rather than cancer. But it really seems to be that one joint that is causing trouble which is not consistent with impa. I know erosive poly arthritis is really rare but also cancer in the elbow is rare too. But this is pepper and she seems to like going for the more rare diseases :(

My vet wants to try arthritis injections with pep but I feel the risk is too high. But if this is erosive impa we would have to assume all her other joints will be bad too and therefore I think we need to take a risk and try give her some joint supplement to try even slightly help. She is only on rose hip canine for her joints at the moment which is only anti inflammatory and doesnít have any effect on trying to prevent/heal damage. So my vet has given me 4cyte to try. We are waiting until after the weekend before trying just in case. It has rosemary extract in it which in the past I had read could cause seizures. My vet assured me she doesnít feel there being a problem and this is the best option to try.
I was rereading over my old notes last night and found some that said MSM (found in egg shells) given to dogs with RA showed no cartilage degeneration. So I want to mention this to our vet. I did at one point give pep ground up egg shells at a certain dose. So Iíll need to try find my notes on that. We have had to stop her fish oil due to her pancreatitis.

I really value your feedback Jo. With your vast knowledge it greatly helps to have another opinion and some extra knowledge from someone who follows and sees the story of all these dogs with impa and other similar disorders. We are forever great full for all your help over the years
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on November 11, 2019, 10:27:46 AM
The specialists said peps X-rays could be erosive poly arthritis or cancer. They said there was shadow down towards her wrist which looked like fluid consistent with poly arthritis. The small strange area in the middle of her bone they didnít see as anything of significance at this point. They suggested bone or tissue samples to be sure, if joint fluid was inconclusive..
The joint fluid sample taken came back not showing any cancerous cells. My vet didnít write on their form peps history of poly arthritis so as not to taint their response. The pathologists report said there were no cancerous cells and increased neutrophils which they suggested as being suspected poly arthritis.

The swelling in her elbow went down when we went to the vets on Thursday then it went back up again and she struggled to walk at all on Friday. It was also really hot Friday which is when she has always had trouble walking even prior to whatís going on now. By Saturday she was walking better. The swelling started to go down Saturday arvo and was significantly down Sunday. She was better again Sunday with her walking and today once she was walking was the best she has been in a while. Still dipping her head and having some little stumbles when getting up but quite better than she has been.

Tomorrow we are forecast for catastrophic fire danger where we live and we live right on the bush. I am very apprehensive about tomorrow. Iím worried about our family, our house, our business (which we run from home) and Pep. Pep is normally terrible in the heat (in terms of not being able to walk well) and she doesnít handle change or stress well. Iím worried how she will be if we have to go evacuate. So i have decided with my vet to slightly increase her pred more and reassess in a few days when the fire danger has subsided some. Her liver wonít handle increased pred for long but I canít afford to put her on other drugs like cyclosporine again and she is too old to put her through that again anyway. We have been holding off increasing in hopes she will improve. But with the catastrophic weather forecast for the next few days I think we should try increase, to try get her more comfortable with all that could be going on. If we wait too long  and donít go up we may have to go up even higher in dose and then we will have less time due to her livers health. We also need to be concerned about her pancreatitis.
We are in a bad place right now with no good options :(
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on November 12, 2019, 07:25:25 PM
Oh Brooke, I am so sorry all these things have come at once.  I have seen on the TV,  the fires in Queensland and it must be such a worry for you, on top of all the investigations to find out what is wrong with Pepper's leg.

I do think a slight increase in pred is a good way to go.  Did the blood results show a marked high level of liver enzymes?  I hope not, but as you know the liver can take some pounding,  producing exceptionally high enzymes before it becomes a significant problem.  I hope the blood results show that you have room to increase the preds before having to truly worry about her liver.  I know you give liver support, so this should help.

It is so frustrating after having x rays done that a definitive diagnosis can't be reached but I have always been under the impression that cancer is not difficult to diagnose, so the fact that it is not obvious on the x rays  has to be a good thing for Pep. One of my dogs had cancer in the bone on his foreleg,  just above his wrist, and the pain was excruciating for him, and it was not a swelling that reduced because it was bone mass, not fluid,  so again I am hopeful that this is not Pepper's problem. 

From the feedback, it is likely to be an isolated joint problem, maybe due to older age, or the start of IMPA.  Rheumatoid arthritis is very rare and it also occurs in more than one joint.  I know the photograph you describe in Prof Day's book, and it is quite alarming. 

All you can do is to try the increase in pred and hope it brings Pepper some good relief.  Perhaps restrict her exercise for a week.  You have bigger things to worry about at this time.  I wish you safety,  for you and your family, and your neighbours and pets, and if you are evacuated then I hope you can return home very soon.

Take care
Jo




Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on November 15, 2019, 08:44:47 PM
Hi Jo,
Unfortunately it looks like this dreaded fire danger weather is not going to let up and they are predicting more on its way next week.  :-[

I have an appointment on Monday to do bloods and check Peps liver levels. We will see what that comes back with, I am expecting not great results.

I am very sorry to hear that one of your dogs had cancer and was in terrible pain. Your description makes sense to me and makes me less inclined to think thatís what pep has.

I have been wondering and reading more about infectious (septic) arthritis. Pep didnít have a red area that was particularly hotter over her joint or any wounds so this was disregarded. But I have been reading (not sure how reliable the info is as itís from the internet) but it can be caused by

ē penetrating trauma;
ē haematogenous spread;
ē ear infection;
ē gastrointestinal infection;
ē urinary tract infection;
ē pyoderma;
ē anal sac infections;

I also read that ĎIt is well recognised that pre-existing joint disease can predispose to haematogenous spread. Examples of this include osteoarthritis, immunemediated joint disease and blunt trauma that can precede the infection by a few days.íí
Typical physical examination findings are:
ē lameness Ė more chronic cases may be mild
 ē warm swollen joint with pain on manipulation;
 ē redness or discolouration of overlying skin;
ē joint effusion;
ē local lymph node enlargement;
ē muscle atrophy; and
ē monoarticular.

All of these she had except the joint didnít really feel a lot warmer than others and it wasnít red. Pep has brown skin and tan hair covering her elbow so Iím not sure how you could see red. Can we rule septic arthritis out based on this?
Is a trial of antibiotics an option?

I have remembered after reading the above info. At our most recent vet appointment that was maybe a few weeks prior to this all happening. Around peps bottom she had a little cut and bit of swelling. We just left it to monitor as she has had trouble with her anal glands in the past and has had times where she has gotten pussy and swollen around her bottom when she has been dragging it on the pebblecrete.
Is it possible she could have septic arthritis or am I reading too much into it? The swelling has reduced but could the pred do that? She is still in pain on that elbow and dipping her head when she walks. We are now on 1/2 tramadol twice daily and 15mg pred twice daily.


I have also tried to find info about erosive poly arthritis which has been difficult. But I came across a list of types and one being Feltyís syndrome. The info mentions an enlarged spleen which pep has. When we had an ultrasound done a number of years ago early in her diagnosis the specialist found this and at the time said she wasnít sure if it was significant. Feltyís syndrome also involves rheumatoid arthritis. Pep was diagnosed with impa and now it is looking to be erosive. Iím not really familiar with the difference between the two. Rheumatoid arthritis gets treated with immune suppressing drugs too. We never tested pep for the Rheumatoid factor. Could her impa have been rheumatoid arthritis? I didnít think so but donít know enough about it. I thought Iíd read you never achieve remission with rheumatoid arthritis and it requires lifelong drugs and not a good prognosis. Pep was on such a low dose of pred there for ages so that wouldnít seem to me that she could have had rheumatoid arthritis.
I might need to give the reading a rest for a bit as it can be easy to read to much into things.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on November 16, 2019, 02:04:05 PM
Hi Brooke

Septic arthritis commonly occurs in more than one joint and there is always a hot swelling, as would be expected if there was infection present.  So it seems unlikely that Pep has this form, also I would presume that any infected fluid would have shown up on the small amount of synovial fluid the vet took from her joint.   Personally, I wouldn't use antibiotics unless Pep needed it.   I think the swelling around the anus is not related to Pep's joint problem.

Prednisolone is an anti-inflammatory drug in the right dose, and it seems Pep is on that dose, and it is not specific to any particular area, so perhaps the increase in pred could have reduced the swelling around her bottom.   Pep doesn't fit in to the clinical signs of Felty's syndrome, so I wouldn't worry about that, and her IMPA wouldn't have been Rheumatoid arthritis.  The presentation is different and Pep doesn't have deformed legs etc.

DVJM360 is a very good website for all veterinary conditions, but I wouldn't over read because it will just drive you crazy.  See this link:


http://veterinarymedicine.dvm360.com/recognizing-and-treating-immune-mediated-polyarthritis-dogs

I do hope you escape the fires.  Stay safe.

Jo
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 05, 2020, 08:20:03 PM
Sadly it seems we are nearing the end of Peps journey .... I saw our vet yesterday and these were her thoughts (which I had felt was coming). We are now going to weekly visits for her to monitor Peps condition.

Since last writing on here we decided pep had been relapsing and upped her pred. Her swelling went down and limp improved. She was still not walking right though and had some limp. So I began giving her 4cyte for her joints and started MSM. After starting the msm she began walking without any limp anymore, she was greatly improved. However Pep wasnít tolerating the pred this time and was experiencing side effects that you would normally get at much higher doses. She got a urine infection before Christmas which we treated then came back and we treated again but within days of going off the antibiotics she began showing symptoms again so yesterday I took her back and the infection is still there. We have sent away to culture and see if it has become resistant to the antibiotic. She takes tribussen this is the only one we have used with pep in years as she is allergic to cephalexin and we have been worried others are too closely related. So I donít know what we will do.
Added with the urine infection which came back with a vengeance in January we also had a bout of pancreatitis. She had been getting sick in the night and getting up every few hours, licking her lips. Food was the only thing that settled her. We started her on antacid and then within a few days she began vomiting and tests confirmed pancreatitis and bad urine infection.  Pep has lost a lot of weight/muscle. We have got through the pancreatitis bout but she is continuing to loose weight at a fast pace. She had been having muscle wastage gradually from being on the pred since she was 7 (this year she turns 13). But it has just increased at a fast pace. I thought the up in pred had caused it. We were only just at anti inflammatory doses but she seemed to be having side effects of much higher doses. But we have dropped back some and still she is dropping weight. She is down to a mere 13.3kg. She is just skin and bone her front legs now are bowed at the elbows. She is starting to have trouble walking and is weak in her back end. Her back legs have been slipping out on the floor and she has been stumbling on them. Yesterday she started to limp a bit on her front leg. My vet thinks she is relapsing again. We had got her stable prior to her pancreatitis attack. Her diet is cooked kangaroo mince, broccoli, carrot, beans and sweet potato and nothing else. So it canít get much more low fat. we thought the pred may have caused the attack and so dropped another 1/4 of a tablet per day. My only other thoughts were the kids left some food laying around that she got (however they are normally good as I always hound them how important it is not to leave food pep may get) or she ate cat poo from the cat that sneaks in our yard from next door at night. 24th jan was her pancreatitis bout, urine infection and when we dropped the pred 1/4 of a (5mg) tablet. Normally we donít drop by 1/4 s but she is extremely sensitive so we thought this the best option.

We havenít gone looking for cancer so canít rule that at as a cause. I know she is now almost 13 but the drastic weight loss seems more like something else going on. I have asked my vet can we give digestive enzymes to see if that helps. She believes that pep doesnít have epi because her poos are perfectly formed. But I have read digestive enzymes are good supplemented for old dogs. She previously has said no to trying but now says we are at the point where risk is not so important. Yesterday we started her wearing  a magnetic collar and also gave her a zydex injection. We had these reserved as things we thought were too risky to try in terms of triggering impa. But now itís at the point where time has run out and the risk is not so great anymore. She is fading away. :(
I know I have had so much time to prepare for this, but no amount of time is enough to prepare for loosing your best mate who you have been with 24 hrs a day 7 days a week for the past almost 13years. We have been through so much together and she has always been there, even when I go to the toilet. :)
Iím so grateful I have been able to work from home all her life so we have spent all that time together but itís so heartbreaking now coming to this point and the thought of how big of a hole will be left.
Iím broken

Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Catherine on February 05, 2020, 09:27:10 PM
I am not sure whether I have suggested this before to you, but giving a daily cranberry extract tablet may help ward off urine infections. I have certainly found it has helped with my dogs. Also Canikur Pro Paste is good for upset digestion although I realize the pancreatitis needs something stronger.

Has Pep had any recent blood tests? It could be the start of kidney failure, but sometimes that can be slowed down with diet and medication.

I can identify with you on being prepared, but not being ready to make that final decision. It is so difficult, for you seeing your beloved dog becoming thinner and maybe not wanting to eat but at the same time still has quality of life. So I would go with anything extra the vet can give to make her feel a bit better.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 05, 2020, 09:49:29 PM
Thanks Catherine. I actually mentioned cranberry juice to my vet yesterday but hadnít realised there was cranberry extract tablets. She will be calling me to discuss the results of the urine culture when it comes back so I will further discuss this with her. Thank you.

Pep still has a ravaging appetite. I have always weighed out her food and so she always has the same but is loosing weight. I may try upping her daily intake slowly perhaps she needs more now as her body may not be absorbing nutrients from her food so effectively anymore. But I worry about giving her too much in case her pancreas flares up again. She canít get anymore of a low fat diet though. I havenít heard of canikur paste, I will look into it. Shes not vomiting now (she was a bit with the pancreatitis) and her stools are perfectly formed, she just keeps loosing condition. I suggested doing a worm test on her because we have never given her work tablets since she was diagnosed with impa. But my vet said that if her poos look fine she canít see worms being significant enough to cause this.
Yes she had bloods done again last week and her liver and kidneys all seem fine according to my vet as that was one of the first things I questioned too.
Thanks greatly for your reply, some more for me to think about. :)
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Catherine on February 06, 2020, 08:58:00 AM
The cranberry juice usually has sugar in it. These are the type:  https://www.naturesaid.co.uk/cranberry-5000mg.html I give one daily, cut up and mixed in with the dogís meal as they are a bit sharp tasting! If there is any sign of a urine infection I will give another one during the day. But if the dog has not had them before I would suggest starting with either a half or quarter for a few days just to make sure they do not cause diarrhoea!

Also at the first sign of a UTI I start the dog on homeopathic Cantharis tablets. This was some advice I got from Jo some years ago: ďCantharis is really good for cystitis and if there is blood in the urine then perhaps the 'acute' treatment protocol should be used.  [/]"Give one tablet every 15 minutes for three hours, then one tablet hourly for the rest of the day.  After this give one tablet three times daily for three further days or until all symptoms have disappeared". from: Heal Your Dog the Natural Way by Richard Allport.  FYI, the chronic protocol is:  "Give one tablet three times daily for one week , followed by one tablet twice daily for three weeks".

I keep some Canikur Pro Paste handy although, thankfully my dogs rarely get diarrhoea. I thought it was just for diarrhoea but I have found it good for when they have been sick, to give it for a few days.

I am glad her kidneys and liver are fine. It may be some type of malabsorption.

Good signs, her still wanting to eat and her poos being solid. If you can not see any evidence of worms that is good too. The only thing I will say is to rule out tapeworms. These are a lot harder to see, sometimes they just look like a grain of rice in your dogís poos.

With her meals, perhaps you can try giving her several smaller meals a day.


Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 06, 2020, 08:38:30 PM
Thanks greatly for your help Catherine. I have made a note for myself about the cantharis & canikur paste.
I spoke with my vet yesterday and the urine infection is not resistant to the antibiotic pep is on. So we are starting it again and doing a longer course. She was fine with me starting the cranberry too. I actually found a place here in australia that sells it in powder form. Itís the same place I get her msm from. Greenpet Cranberry Powder it is made from 100% pure human-grade freeze-dried cranberry powder. No additives or sweeteners added.  Suitable for dogs, cats and horses. So I have ordered some of this. My vet is still not keen on giving her digestive enzymes and is sending me info to read about it. Which I assume is info trying to convince me to not use.

After reading your initial post I thought more about peps food intake and realised that back last year around November when she first starting having all the problems with her elbow. I had thought she had put on extra weight and maybe that was adding stress to her joints so I cut back her food by 50g-60g per meal. I feed her 3 equal meals a day and also a smaller supper. I have been doing these spaced out meals since she got impa to try help her liver. Normally she also snacks on kangaroo mince throughout the day but since the pancreatitis I have only been giving her vegie water (the water her vegetables have been cooked in). I had forgot that I dropped her food intake and hadnít even thought that this decrease in food back then could be causing this wastage or adding to it if there is something else. As it was some time ago I cut her back and so much has been happening since. Last time she got pancreatitis I cut all carob drop treats and had to up her meat and veggies intake. I had to up it considerably to get her back to a healthy stable weight.

I upped her lunch and dinner meal yesterday but then this morning and through the night she was lip smacking again and yawning like she was prior to her pancreatitis attack. So Iím worried her pancreas may not handle the food increase. Maybe I need to try do a little more gradually or add more smaller meals and space out more? Not sure whether it would be better to give the pancreas time to rest between bigger meals or to give often smaller meals?

There is no more of a low fat diet I can give her to help her pancreas, but I need to give her food also because it looks like Iím starving her and low fat diet isnít going to add weight especially when I canít up the quantity because her pancreas keeps getting mad. The digestive enzymes are the only thing I can think of. What else can be done to help the pancreas?
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on February 07, 2020, 11:56:01 AM
Oh Brooke,  I have read through your posts and Catherine's very useful replies and I am so sorry you are having these problems with Pep.

I do wonder if she should be weaned off the preds, and if necessary this should be replaced with another drug (Avoid Previcox).  Preds can cause pancreatitis and it certainly won't be helping.  As you know it also causes muscle loss and in some breeds they lose weight when they are on preds, so an alternative might be a consideration.  I have also known older dogs not to tolerate the side effects of preds as well as they did in the past.

The good news is her kidney and liver values are good and this makes me think that whatever is the root cause of her current clinical signs, it could be resolved.  My concern was kidney failure but that is not the case. Pancreatitis is a tricky one to deal with sometimes - acute pancreatitis is urgent and very different in terms of how you respond, to chronic pancreatitis - and I don't see that enzymes would be a problem because she would likely just pass any excess through - and they might just help.

I have a book called:  The Pet Lovers Guide to Natural healing for cats and dogs by Barbara Fougere BVSc

'Pancreatitis - what you can do'
For chronic pancreatic problems,a highly digestible, low-fat, low fibre diet is recommended.  Protein should be of high quality and easy to digest.  Give small amount of food frequently rather than one big meal daily.  Each meal should be supplemented with digestive enzymes.  Low fat recipes should be fed under the supervision of your veterinarian.

Natural therapies:
Supplements:
Powered digestive enzymes
Cobalamin
Vitamins A, D, E, K, (these fat soluble vitamins may be low in a low-fat diet)
Vitamin B Complex or a multivitamin and mineral mix

Bach Flower remedy:
Rescue remedy is appropriate for pancreatitis: Olive and hornbeam for recovery.

Homoeopathy
Acute attacks Iris Versicolor 30c


My daughters dog had terrible problems with pancreatitis - usually acute - and Iris Versicolor  30C really worked, if she caught it early enough, but that might vary from dog to dog.

It sound like you have a vet who is will ing to work with you, so it might be worth discussing some of the above.

I do hope Pep can stabilise very soon and get back to he normal self again.

All the best
Jo


Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 07, 2020, 08:39:51 PM
Thanks jo. Lots of helpful things to think about and discuss with my vet.
Iíd desperately love to get pep back down lower on the pred, as I know itís not helping with the pancreatitis, recurring urine infection and muscle/weight loss. My vet has suggested trying Azathioprine, but I would rather not go down the path of another immune suppressing drug. She is so frail and old now I donít think she would handle it or that I want to do that to her. If Iím honest I donít think I could do it again with her at this point. When we did the cyclosporine with her she was only 7 and in much better condition to deal with it and itís nausea and other side effects.
 We tried to decrease her pred by 1.25mg when she had the pancreatitis attack and my vet believed this week when I saw her that pep was relapsing again so we had to go back up that drop again. If she really was relapsing it seems something keeps triggering her. Whether the immune system is active due to the urine infection which may be contributing however the infection could have been also a result of the dose increase due to the impa so it's hard to know which order. Either way it isn't helping her signs resolve.

On a Facebook forum I am on, another Aussie has had good success with her impa dog by giving synovan injections. I was always too scared to try as my vet couldnít find any info of their use in impa dogs and we were worried that they may trigger her and sheíd have a bad reaction . But we decided we were at the point where risks need to be taken. She had one zydex injection last week then we go back again this week for another at our weekly check up. We are also going to test her poo for worms. We have discussed possibly checking her vitamin b12 too.

I am still not completely sure that she was relapsing. Itís summer here and pep always has all her problems in summer. She does not like the heat and possibly there may be an environmental trigger around at this time of year. Whenever we had consecutive hot days in the past she would limp and then would do so for a few days after before coming good again. She just had troubles in the heat and for a few days after. Anyway the 4 days prior to see my vet we had over 43 degree Celsius temps. So that leaves still some doubt in my head that she was definitely relapsing. We donít want to do joint taps on her. But Another thought My vet had is measuring Peps C-Reactive Protein. She said it is typically elevated with poorly controlled IMPA and normal with osteoarthritis. She said there are other factors that can influence C-Reactive Protein so it may give us a false positive also for a separate inflammatory condition. But it could be a means for measuring response to prednisolone rather than joint aspirates. I questioned about the pancreas possibly still being inflamed and if that would cause it to be positive.  She said yes but  together with other tools (ie Spec CPL quantitative specific pancreas lipase measure-)-it may be useful.

My vet sent me a heap of studies to read on digestive enzyme use and how they saw no benefits and some cases where the dogs got bleeding from taking them. She said if we are going to try there is no point unless we use the prescription strength one, used for treating epi. I feel I still would like to try but donít want to use the prescription strength. The place I get peps msm from (Greenpet) and I have also ordered some cranberry powder from sells one called Ď Synbiotic 180-S Probiotic & Enzymesí . Itís not prescription strength and I discussed with their naturopath what ingredients was in it because pep is very sensitive. She said they have never had any dog get sick from it and didnít seem to think there was anything she should react to in it. Iím going to have to try discuss further with my vet next week.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on February 11, 2020, 07:12:31 PM
Hi Brooke

Well true to form, Pep is keeping you on your toes.  It must be difficult to assess when you live with such extreme hot weather conditions.  How you tolerate such temperatures, I don't know, and it must be awful for the animals too.

 If you use Azathioprine it won't have any real effect for several weeks. I think the question is, does Pep really need immunosuppressive treatment????     Synovan injections will not have any effect on IMPA.  I think they work well for some dogs with arthritis but not all dogs.    Have you considered weaning her off pred and giving a NSAID such as Metacam. This might be an alternative to giving Synovan but again it is just an anti-inflammatory and will not address an immune problem.   

I am not sure if C-Reactive Protein test will tell you anything.  It doesn't identify a specific inflammatory response, so it is not diagnostic.  A positive just suggests that there is inflammation somewhere in the body and this can be a multitude of things.

Your vet seems so good at discussing things with you.  I hope you are able to come up with a plan for Pepper this week.

Jo
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 17, 2020, 08:37:30 PM
Hi Jo,
Yes pep is definitely following her usually form of keeping me on my toes.
The hot weather has been terrible. I normally like summer but itís been so humid and hard to do anything even in air conditioning. So I canít imagine how it had been for Pep. Luckily it has cooled down a since those 43 + degree days and we have had constant storms now on and off. Which have still been causing it to be muggy but no where near like it was.

In the past, the two times we have tried nsaids with pep she has ended up even worse & quickly and had to go back on and up with pred. So I donít want to try that as I donít feel she will do wel. I know the Synovan wont help with the impa, but we believe she has normal arthritis at play as well. Especially after seeing the state of her elbow on the X-ray we have been wanting to try the Synovan with her. Hopefully it may help with her normal arthritis and the poor state of her joints. I just was worried it may cause a relapse or trigger a bad reaction from her, thatís why I hadnít Tried sooner. She has had 2 injections so far and is okay, with no bad reaction.

I ended up deciding not to do the c-reactive protein test. Instead we did a poo sample and tested her b12 levels. We also tested her urine again which looked fairly good, but my vet said she still wanted to run another course of antibiotics just to make sure. As she didnít believe it was 100% perfect looking at under the microscope. Pep had maintained her same weight from the previous week and her joints looked a bit better. My vet admitted she thought the week prior pep had looked so bad that we would be discussing putting her to sleep very soon :( But she was greatly impressed by how pep looked this week in comparison to the previous week. The week before she had her head down and didnít want to move anywhere. This week her head was up and she was pacing around. She did however get very anxious on the way there. Normally she is fine going to the vets, but in the car she was panting like crazy, shaking and so anxious looking. Even after we got there she continued to pace around looking anxious. My vet seemed to think maybe itís because our visits were only a week apart and she is getting less tolerant to being poked and prodded. I donít know what was going on. We go back tomorrow so Iíll see if she does the same then.

Since I last wrote on her I have started giving pep cranberry powder. She has been fine with it so far. I have also upped her food back to almost normal level and she isnít appearing sick or showing signs of pancreatitis.
The poo sample came back negative to all types of worms including negative to Guardia. I had expected the b12 sample to come back low, but it came back elevated! My vet said this can be caused by liver disease :(
We didnít do bloods as we had only done those the week prior (her liver levels had looked fine then). I am going back tomorrow and we will be running bloods to check her liver levels again.

 I checked the trace vitamins and minerals supplement that I give pep and realised that since she has lost weight and I had also dropped her food back (a while back when she had trouble with her elbow) I hadnít readjusted her dose. So I have been giving her too much for almost 2 months! Iíve been trying so hard to make sure I get everything right as she is on so much different medication/supplements at different times and being fed 4 times a day. Getting up every night every 2 hrs or so with her has me so exhausted and makes it so hard for my brain to concentrate. I feel terrible that I may have been poisoning her. My vet said that over supplementing could cause her b12 to be up hence why I thought to check the trace vitamins and minerals supplement and therefore saw my terrible mistake. But I have been reading since and read somewhere  that b vitamins are water soluble and will just get weeíd out if you take too many. Iím not sure if this is true or not? It is hard to find info on over supplementing. There is lots of other vitamins and minerals in the supplement, too not just bís....which is concerning. I have stopped giving her the supplement since I realised my horrible mistake.

 I have now sadly started to think more that she is in liver failure or has cancer. The night before last she got up in the early hours of the night and was panting and appeared anxious. I didnít feel it was hot. I calmed her quickly and she settled and stopped panting. She did this on one other occasion over the weekend. Her poos had been normal (I have been watching every poo and wee she does)  but last night she did a very runny poo. I have been writing down everything. I.e when she eats, wees, poos, what meds she has and when etc. Just so I can keep an eye on everything. I noticed she is still weeing more frequently than I thought she should be. I emailed my vet with my concerns and said I wanted to drop the pred back again. She wasnít happy about it, I agreed to wait until our appointment tomorrow when we check her bloods. I have, however, stopped the losec as she hasnít been looking sick anymore and out of all the drugs/supplements she is taking this seems the least necessary. That is one less thing her liver has to process. I did also read some sources that said antacids were bad for dogs with liver disease, but my vet said she still uses all the time in dogs with liver disease.

My vet feels Peps joints are of more concern than her liver in terms of her quality of life. She always seems to get annoyed with me when I panic about her liver and want to drop the pred back. I feel bad because I must be the most annoying patient (owner). I throw so much information at her and question everything because I want to understand and make sure I am doing the right thing. I have had bad experience from past vets and that has caused me to question everything and make sure I am comfortable with what we do with pep. I completely trust my vet now. She has been with us since not long after peps impa diagnosis. But I know pep better than anyone else and she doesnít usually follow the Ďtextbook rulesí or the Ďnormalí when it comes to symptoms and conditions. So even though I trust my vet, sometimes I feel I need to trust my gut and follow what I feel is best for pep because no one knows her better than me. I donít mean to offend my vet and seem like I donít trust her. But it must come off that way sometimes, which I feel terrible for.
Also because I work from home, I am with pep 24/7 and have been since she was 8 weeks old. So I pick up on the tiniest little changes and signs that most people wouldnít notice. Then panic about them and question my vet as to what they could be a sign of or what I think they are.
So I have decided to have email silence with my vet until our appointment and maintain the pred dose as she wanted. I donít want to annoy her anymore. I suppose another day or so to get the bloods results isnít really going to make a difference. If she does have liver disease it is likely too late to change from what I have read. The signs donít really show until the disease is progressed.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Catherine on February 17, 2020, 09:00:33 PM
Thank you for updating us - it must have taken you ages to type it all out - but it is good to have detailed information.

Well....there seems to be some good news there and I am glad to hear that Pep, on the whole has improved since the previous week. As she is getting older and maybe some of the medication is taking its toll then that may be why she has a runny poo now and again or an anxious moment. Sometimes older dogs start to wake in the night and wander about or whine.

Some of your post sounds just like me! I have felt awful if I have made a mistake with regard to the medication or treatment of my dog, even though it was minor. But we are only human and coupled with lack of sleep and worry it can happen. Also, the bit about bad experiences in the past with vets, questioning everything your vet says etc. - that's me! I tend to "apologize" to my vet for questioning him at times, but seeing as I have been right and he has been wrong at times, he accepts my questioning him. So hopefully your vet understands too.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 17, 2020, 11:07:52 PM
Thanks so much Catherine for your kinds words. I have been quite down in the dumps the last couple of days, but you have really uplifted my spirits. Much appreciated.
You are right too. I need to keep reminding myself of how old Pep is in the equivalent human years and realise there is going to be up and down days and things that don't make sense. That happens a lot with old people, so it must be the same in dogs. It's hard thinking of her as being so old when we have been together so long and I just feel like she is my mate who has grown with me and hence should age like me. Ive never had an old dog before and didn't realise they could have night restlessness. I had moved away to uni by the time my childhood dog got really old and only then saw her briefly on visits. Actually a lady I was talking to while in my vets waiting room the other day said her old dog was restless at night and had dementia and would get up in the night pacing and wanting food as if it had forgot that it had eaten. So perhaps pep's night restlessness is just old age.

Yes at times I have been right too and my vet has been wrong. She even admits that the times I have been right that she kicks herself a little that I am so in tuned with Pep and perceiving things that are wrong with her. She has commented many times that when I have pushed about something being wrong with her that I am often right, so she always takes my concerns seriously.
I know she understands, but I still feel bad for being 'that' patient/client.

Thanks again Catherine, you have perked me back up ready to take on whatever comes next.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Catherine on February 18, 2020, 09:02:06 AM
Thanks for taking the time to say that Brooke and I am glad it helped.

Although some vets think they know it all, good vets appreciate owners who are vigilant. I am sure it makes their lives a bit easier to have an owner rattle off their dog's symptoms, history etc. It also helps the dog for an owner to keep their own records of blood tests, illnesses etc.

But we do need to take a step back now and again and not worry so much - it is just knowing when we can do that. :-\
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on February 18, 2020, 04:30:09 PM
Hi Brooke

You, Catherine and me - and probably many others too - we have all done those things that perhaps we shouldn't have done in attempt to do the right thing for our dogs, and we have all gone with our gut feeling or knowledge and over ridden the vet and have been right.  I challenged a specialist once about Bonnie's treatment of AIHA and she disagreed with me and because she was a Veterinary 'Specialist' I listened to her and ignored my own experience, knowledge and gut feeling, and Bonnie died as a result, so it is important to work together with your vet and listen to your own feelings and assessment of a situation.  You are so in tune with Pep and have always done right by her and thank goodness your vet acknowledges this and you can work well together.

Pep is better than she was a week ago and this is such good news.  She  has been able to improve, indicating that her body is still functioning and repairing when it needs to, and this says a lot.   The liver has to be significantly damaged and the enzymes significantly raised before there is any serious liver damage, and even then, unless there is true liver failure confirmed by clinical signs and blood results,  the liver has the ability to regenerate.  From what you say about her last liver function blood test, she is not at a  level that you should worry about.   

She is an old girl and from what I know about Pep she will not give in easily.  Maybe the Synovan has kicked in and she is in less pain, and maybe it is just making her feel a whole lot better. Old dogs do change in habit and character.  Usually they get more quirky but more adorable as they age  (the same isn't always true of humans!). 

I hope the latest bloods put your mind at rest.

Best wishes
Jo



Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 18, 2020, 07:29:32 PM
Thanks jo and Catherine. I am and will always be forever grateful for finding this forum years ago now and you both on it. Hands down the most valuable resource in helping Pep on her journey and keeping me sane through it. Whenever I feel lost and need a sounding board I can come here.

Jo, Iím so very sorry to hear what happened to Bonnie. This is why we do all act a little crazy and a little desperate at times because itís a life of someone we love at stake. We are trying to protect them at all costs. Not everyone understands having a dog that is more than a just a pet, but an actual member of your family. The people on this forum do and luckily my vet is one who is very invested in her patients and really does care and go above and beyond to help. So I know she understands why I am like I am. But I must remember to try restrain some when I can.

Pep just did another poo and it was solid and normal formed. So Iím feeling better about that. She had a very restless night and we were up every couple of hours, but it was hot (first hot day we have had in a while). I think the heat caused her to be more restless and annoyingly there has been a neighbours cat visiting our yard. Pep was particularly sniffing around last night every time we went outside, so Iíd say it had been there and was bothering her.
She is still much better than she was. Her demeanour is more perky and she is not so distant with better mobility. She is back up to her normal food levels and is having no lip smacking or signs of sickness.
Yes I think I need to accept her habit and character may have just changed some due to her ageing and keep reminding myself that. Sheís has gotten slower which will happen with age. I need to keep reminding myself that this is going to continue to happen as time passes.

Pep is definitely a fighter. She is so unbelievably resilient. She can get down so low, but she just pulls herself together and claws her way back each time. She loves her family and wants to be here. As long as she keeps fighting, Iíll keep fighting for her.

Iíll keep you updated how her bloods go. We plan on sending them to the lab rather than doing in house so they are more accurate. Thatís how we did the last one. This way unfortunately takes a bit longer to come back but itís better to keep consistency.

I will make sure Iím on my best behaviour today and try to keep my questioning within reason. Best just to wait and see what the results say and as long as she is looking better thatís really the most important thing.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on February 20, 2020, 01:23:02 PM
'I think the heat caused her to be more restless and annoyingly there has been a neighbours cat visiting our yard. Pep was particularly sniffing around last night every time we went outside, so Iíd say it had been there and was bothering her. '


That made me laugh Brooke,  The day that Pep is not bothered about your neighbour's cat loitering in her back yard, is the day you worry!

Hope all goes well at the vets.

Jo
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 20, 2020, 08:44:27 PM
Ha ha yes, you are right. Next door is a bit of an animal sanctuary (on an acre block). Pep loves the neighbours pig, she likes the calf, the sheep & puppies. But the cat....There is no love there at all. Even when she has had bad impa days in the past she can still get herself mobile if that cat is in her yard.

Unfortunately I was right, Peps liver levels were up. They have been higher than this when we have been at really high doses back around first impa time when on immune suppressed levels. But at the low dose we are on they are higher than they have ever been before. We were at this dose only recently when she had the pancreatitis bout and her levels where quite a bit lower. That combined with the increased vitamin b12 is concerning and my vet has told me to back off the pred. She is very concerned though that pep is going to have trouble with her joints once we drop.

To make things worse she slipped badly getting up the night before last on the tiles. She had been waking perfectly fine and came and lay down beside me in the kitchen. I snuck into the bedroom quickly hoping she wouldnít realise Iíd gone, so she wouldnít get up. But she realised Iíd gone. I didnít see her getting up as id walked around the other side of the bench, but when I heard sheíd moved I went to see and she was stuggling to walk as her back leg kept slipping out and she was limping on the front. As if she had done something getting up as she was perfectly fine before she sat down. The following morning her back ankle was huge. I asked my vet if she could hurt herself slipping/twisting on the tiles and if that could cause swelling. She said with pep you canít rule anything out, but generally unless she has pulled a ligament she shouldnít have swelling caused by that. She said if you let me joint tap I can give you an answer. But Iím not going to do that. She walked fine all day on it, but by the time it got to night she would have some trouble when she first got up. It is very puffy and i would think if that was impa she would be in more pain. So we are off to a bad start before we have even dropped the pred.
I am going to order some Dr Buzbys toe grips today to try see if that can help her on the tile floors in our house. I do have runners at certain places for her, Mattís in the living area and I normally lift her whenever I am there. But sometimes I quickly go into another room to grab something hoping she doesnít realise and then she does and tries to get up on her own. Sometimes she is fine but if itís hot or she has done something like this she can struggle.

As for the liver. My vet suggested an ultrasound to try see if there is cancer and to check adrenal glands, for Cushings, pancreas, kidneys etc. Itís a lot of money and whenever we have done ultrasounds in the past they have never been conclusive and leave us with more questions. She assured me they wouldnít knock pep out. If they were going to I definitely wouldnít be interested. For now Iím thinking no. I donít know that I want to see cancer and I donít know that itís going to change anything.

My plan is we try drop the pred back if she struggles and becomes too uncomfortable we go up to a dose she can maintain good mobility and be comfortable at. We keep her there until her liver begins to make her uncomfortable and then hopefully Pep tells me when she has had enough. If I know there is no hope I donít want her to suffer.

Pep is allergic to dandelion and so we have never given her milk thistle as I have been scared they seem too closely related. I have been in touch with my human naturopath about milk thistle. She said Ď Both Dandelion and St Mary's thistle (aka milk thistle) are both members of the Asteracea family which is a family containing plants with lots of flowering heads. These are often blamed for many an allergic reaction from people who take herbs, however working with the liver can initiate healing reactions, which can often look like allergic reactions...í
She suggested trying to give in drop form. One drop first then increase gradually if she tolerates. I discussed with my vet. She doesnít like herbal things and I have had to email my naturopath again and make sure there will be no alcohol, sweeteners or other additives (still waiting to hear back). She likes the facts and safety that standards and regulations have been followed when made by large drug companies. She wants to try Denmarin. I agreed that I would like to give her this (we currently give her denosyl by them) but I want to initially try with the drops. So we can test how she goes gradually and not have to buy a whole box of it (as itís quite expensive).

Yesterday pep stopped weeing and drinking so much (prior to us dropping pred which I will be doing this morning). I havenít been giving her anymore antacids, Iím stopping that extra stress on her liver. Iím wondering if the cranberry powder is starting to have affect and that has caused her to stop weeing and drinking so much. I would really like to get the urine infection under control as it worryís me  a little that that could be triggering her to keep relapsing. My only other thought is she could have cancer and could that cause her to keep relapsing?
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Catherine on February 21, 2020, 08:50:13 PM
Is it all the liver levels that are elevated - ALKP, ALT, GGT etc.? Are any other levels elevated? Sometimes you can not just go with blood test results because they can be affected by other things. It may be the beginning of something like liver cancer or something else.

I think, as Peps is an older dog, that, unless anything can be done to help, it will not help having various procedures. It is a difficult choice, as an ultrasound say may show something nasty and then you will feel awful, especially if nothing can be done. Or you still might not get a diagnosis and you will still feel awful thinking that there could be something but it was not able to be determined. You can not win!

Despite Peps's slips, she still sounds as though she is fairly okay so I think your plan sounds good and just go day by day with her. I have never heard of toe grips, it is amazing what they can do to ease dog's problems.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 21, 2020, 08:51:31 PM
I have ordered some of D.R. Buzbys toe grips and am now looking into hock braces for Peps back legs. She has no muscle left and her joints are in terrible condition (most likely missing bone like we saw on her elbow X-ray). My vet doesnít seem to think she could get swelling from slipping/twisting getting up. I donít believe this. I know when I see her this week she is going to insist that itís impa. I donít think her impa is completely in remission but I do feel there is other things going on with her joints as well. We donít have the option to go up in pred anymore so I want to do anything I can to help her joints in other ways. This wonít help if it is impa but there is more than just impa happening in her joints. Our whole house is tiles and itís becoming very hard for her. We have Mattís in the living area, and runners near her bed. I try lift her when Iím there but she still gets up sometimes without me.

I feel she hurt her elbow from jumping down off the lounge. The X-ray showed she had bone damage but I believe the jumping irritated it more and caused the swelling. The swelling went up and down and wasnít consistent with increasing pred dose. At some points it went down without increasing the pred. She doesnít jump anymore so her main problem legs  is the back legs slipping out and having no support. So Iím thinking it may be worth trying hock braces.

One of the ones Iím looking at has ceramic powder in them that is supposed to reflect body heat back into the body and promote healing, reduce pain and inflammation. I have seen these before but been worried if they would have any bad effects for dogs that have impa? Here is some detail.

ĎBack on Track products are therapeutic and made from a fabric which contains polyester thread embedded with a fine ceramic powder. The ceramic powder reflects the dog's own body heat back into the body in the form of FAR infrared waves, which is a thermal heat.
FAR infrared waves have many benefits:
- Increases blood circulation and oxygen supply to tissues.
- Reduces inflammation and swelling in muscles and joints.
- Eases muscle pain and tension.
- Hastens the healing process.
- Warms the muscles prior to exercise, thereby reducing the risk of
  strain and injuryí

Pep doesnít like the heat and normally is worse on really hot days with her joints. So that is another reason I am questioning. But thatís really hot humid days and this should be more natural body warmth?

Have you heard of anyone use this type of brace with an impa dog? Or have any thoughts on whether it may have negative effects? Iím just not sure about the Ď Increases blood circulation and oxygen supply to tissues.í
 and whether that would be a good or bad thing for impa?
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 21, 2020, 09:07:43 PM
Hi Catherine,
My vet rang me at school pickup time so I didnít get to write down what she said and it was a bit hard to hear. But i sure she said those three were all elevated. We also know b12 is higher than normal from the test the previous week. Which my vet said was a sign of liver disease/cancer. We only ran liver bloods this time and not a complete blood profile. The beginning of liver cancer has been in my mind. I think thatís what my vet is thinking.
My vet said some levels can be affected by other things like her urine infection. But for them all to be up and more than before at this pred dose itís not normal for pep and it seems more sinister.

The only other thing that is still in my head I read somewhere when researching msm. That msm had effect on cortisol absorption in the body somehow. I canít find anymore info on this though. If her levels are still high this week we plan on dropping the msm to see if that makes any difference.

Yes thatís my exact thoughts about the ultrasound. I donít feel itís going to be beneficial.
Just going to add more questions and worry.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Catherine on February 21, 2020, 09:13:49 PM
Is the problem that Peps feet are slipping on the tiles when she gets up or that her legs are too weak to get up?  Do your mats move easily? Would it help (if they are not already) to try and "stick" the mats to the tiles so they do not slip? I am sure there are things you can put under rugs etc. that do not damage the floor underneath. Maybe a rubber mat would "anchor" better?

I know Peps will want to be wherever you are but to save her running (and slipping) when you do not want her to could you not "contain" her somehow - playpen, baby gates, that type of thing?

I have no idea about hock braces although I had a quick look. Personally I would not be in a hurry to get them as they could cause more problems. Hopefully the  toe grips will help.

Perhaps someone else on here has used them.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 21, 2020, 10:11:10 PM
Thanks Catherine. Her feet are slipping on the tiles. But it would also be happening now as they are getting weaker, because she used to be fine. She doesnít slip out, outside on the pavers, or on carpet or Lino. She only slips out on the non textured tiles.

Being a staffy she likes to lay her belly out on the tiles to cool herself. So she will go out of her way to lie somewhere that there is no matt. The matts that there is do not slip, itís just that they are not everywhere and she follows me from room to room putting washing away, going into the kitchen, to the toilet etc.
So maybe trying to contain her is a good idea. But she wonít like it and since I donít think she has a long amount of time left. Iíd rather her be happy and do what she wants rather than contain her.

You can get braces that donít have the ceramic powder in them and are just for support. So thatís another option.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Catherine on February 22, 2020, 12:05:28 PM
I totally understand not wanting to contain her if it means upsetting her although she may be a quick learner and know that you will soon be back in the room after a few minutes. I do not know the layout of your home and how much she is getting up off the floor. It was just if it was something open plan and as you walk from a kitchen area say to a lounge area (but still in sight) it might be easier if she did not follow you. Of course, cantankerous dogs  :) would still get up inside the pen.... ::)
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on February 23, 2020, 04:57:59 PM
Hi Brooke

If Pep was an ageing dog without all the AI problems that she has had, her back end weakness I would say is due to her getting older and her muscles not being as strong has they were.   All old dogs will have trouble gripping smooth floors. 

It is difficult, knowing her past medical history, not to think of it being an AI problem but the chances are it is just old age.  The floor matt's always had to come out when my dogs got older and sometimes I had to put a towel-sling under their middle to get them to their feet.  Once they were up and had their balance they were OK.  I think their mind is telling them that they can just jump up to their feet and rush off, but their body is telling them something different.   My 91 year old mum said to me, up here (pointing to her head) you feel the same - and she is right. You can't tell a dog that she is getting old and to slow down (my hubby can't tell me that either!)   Unless Pep is in pain and has a high temperature, that would usually accompany IMPA or an other inflammatory AI disease, then I doubt it is this.  The steroids she has been on will weaken her muscles, so add that to her getting older and this is a double whammy.

I also think slipping on the floor could cause some soft tissue/ligament damage.   Reducing the pred will lower the liver enzymes.  I hope with the Synovan injections she is having, and lowering the pred, that she will start to gain strength and feel more comfortable, and if she does have some degree of osteoarthritis then the Synovan should help.  If you can strip back any unnecessary supplements that might help her liver to cope, but don't panic about raised liver enzymes unless they are significantly raised.

  I do think the toe grips are a good idea.  I have known people to use them to good effect.   I don't know about the brace as I haven't come across it before.

I feel as if I personally know Pep and I can imagine this older lady carrying on as if she were a youngster.  I love the oldies. They get more precious with every passing year.

Jo
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 23, 2020, 08:18:23 PM
Thanks jo. I believe you are right about pep thinking she is young and thinking she should be able to just jump up and do all she used to. It sounds funny but I see it in her eyes, the way she looks at me sometimes. Like she wants to do something like jump up on the bed, but she needs help and is sad/annoyed or unsure why she canít .
She took off across the back yard a million miles an hour last night about 11pm, barking as she flew. There was a possum (or possibly a cat) on the far fence which ran down along the side fence and took off over the back fence. I tried so hard to catch her to stop her before she hurt herself, but there was no chance of that..... afterwards she seemed a bit frazzled. She can still move very fast if she wants to, but will feel it afterwards.

Pep has no temp and once she is up she is fine. She is a lot slower though than previously and you can hear her nails more on the ground. Like she doesnít lift her feet up as much as she used to. She does seem to struggle a bit getting down sometimes too. She stands there almost Ďstutteringí (if there were such a word for movement). Like she is trying to safely get herself down and starts to go then changes her mind and moves her leg slightly and tries again or sometimes she just flops down. Itís like she is trying to get her legs in the right place because once she is down she has trouble moving them if they are in an awkward position.
My vet did also say the same at one point. That Pep has no muscle now and no support so she will struggle getting up and down, as well as have slipping, due to that and her history. Regardless of if there is anything else going on.

Thanks for reassuring me and helping me understand the differences in an old dog.
Hopefully pep will tolerate the toe grips. Before impa when she was young she used to have to wear booties to stop her chewing her feet (allergies). She didnít like the front ones and always ripped them off straight away. But for most of the time she left the back ones on. Luckily they were also her worst feet and are now too. So hopefully she will leave them on and not pick at them.

Iíve seen pep make a mockery of test results before when they were certain she had plasmacytoma that had metasized. So I am always skeptical about her test results. The best way to judge pep has always been just by watching her and her demeanour. So I think I will just continue doing that and try not panic so much about bloods. Even if she has liver cancer or something Pep is going to be the one who shows me how she handles that. She likely wonít follow the normal rules anyway.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on February 24, 2020, 06:41:57 PM
Hi Brooke

It is hard to accept the signs of ageing but it is preferable to her having an AI disease and having to put her back on a cocktail of drugs that have nasty side effects.

If she can take off after a possum or a cat then she is still in charge.   I love her 'never give in' character.

Jo


Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 26, 2020, 07:30:32 AM
Yes, she really is one special character and so determined to not give in. That helps me stay determined too.

Unfortunately she slipped bad again yesterday and was limping bad last night and today. I really hope that is all it is and not another relapse. She had her last synovan injection yesterday and each time she has had those she has been a bit off for the following couple of days. So that's another thing to consider and it has been hot again the last couple of days. I need to give her some more time before panicking about a relapse. However, this is around the same amount of days passed that it has been the last few times we have dropped back by 1/4 pred and then limping or swelling came. Each time we have gone back up again 1/4 pred.

Some good news, her toe grips arrived this afternoon and make a big difference for her walking on the tiles. She isn't slipping out like she was, so hopefully with some rest her limping may also improve. Fingers crossed. No more slipping out is a positive, so I am going to take that as a small win.

Another small win we had is that at Pep's check up yesterday (Tuesday) she had gained 400g (since last Wednesday).

Also her urine showed no blood (which is a first for her in some time) but the ph was still up and my vet looked under the microscope and said it wasn't completely clear, but lots better than it was. She sent it off to culture anyway. She said if it only showed minimal growth she was okay with that.

The vet nurse rang me today and said her ALT level was back (we only tested ALT this time). My vet was away today and is going to ring me tomorrow once the urine culture is back to discuss further. Last Wednesday her ALT was 318. On Friday we dropped her back by 1.25mg pred per day. Yesterday (Tuesday) it was 304. I think around 80 is normal? So it dropped back, but not by very much.

If she does have cancer. Have you had any experience with impa dogs getting cancer and this causes them to continue to relapse?

The other thing I am wondering about is something I read in dogs naturally magazine. An article called 'MSM: Does your dog need it?' Its the article that actually put me onto msm. However one paragraph concerned me and I discussed it with my vet and she wasn't sure about it either. We decided to go ahead, but its been in the back of mind all along especially now that her ALT levels are much higher than they have ever been at this same pred dose.

'Chronic Pain
MSM is a natural analgesic and blocks the transfer of pain impulses through the nerve fibers. MSM also blocks the inflammation process by enhancing the activity of cortisol, a natural anti-inflammatory hormone produced by the body.'

I am unsure if this means that msm used with pred could increase ALT levels? I cannot find any other reference to this in other literature. I have found a few people also questioning this, but in human use and they have no answers listed. I contacted the animal naturopath I got the msm from and brought this up with them and asked their thoughts. They said they hadn't came across any similar cases, but would suggest stopping the msm and checking if her ALT levels drop.  I discussed this with my vet last week when we first found out her ALT had gone up. I had said if it was still high this week my thoughts were to drop the msm and also try risking trying milk thistle with her. I got some milk thistle without any alcohol in it from my human naturopath on Monday and have it on standby.

I will wait until tomorrow to discuss further with my vet. Hopefully the limping improves so we are not forced to go back up the 1/4 pred.

If she does have cancer. Have you had any experience with impa dogs getting cancer and this causing them to continue to relapse?
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Catherine on February 26, 2020, 08:45:30 AM
I am glad the toe grips are helping Peps. Also good news about a little weight gain and her urine improving.

What are the normal levels for ALT? They may be different to the UK ones so it is difficult to make a comment on the figures you give. My AIHA dog's ALT (and ALKP) went high when she was on high doses of Preds. but did return to normal.

I do not know about MSM but had a quick look at some information. Not all natural things are good and some dogs (and humans) can be affected by natural things. Personally I would not worry about giving too many supplements at the moment and see how things go.

Lastly, I think it may help to take a step back and relax. ::) When my AIHA dog was very ill I became very stressed and well meaning people told me to relax. Of course it is easier said than done, but I have to tell you, Brooke, that a lot of dogs do pick up on our stress. I know it is so difficult to do, especially if, like I had, a dog that picks up on your every emotion.

Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 26, 2020, 08:05:16 PM
Peps ALT has been high before at high doses of pred and came down as we dropped back . But we are at a much lower dose of pred now and getting the high ALT. We were on the same pred dose around only a month ago when I wrote on here and her ALT wasnít this high. My vet is concerned that itís not normal for Pep and itís an unusual worrying spike. I thought the vet nurse said 80 was normal and pep is 304. Iíll have to find out more today when my vet calls. Itís hard to get accurate info from the vet nurse. I used to keep copies of all her blood results but started looking too much into them and decided it best to leave to my vet. Previously I kept copes when I was going to a different vet that I didnít trust and liked to check everything myself and compare. My vet now always cross checks all peps new tests with her past ones over the years and tells me when we discuss.
I want to start by dropping the msm, as I agree with you and I have read too that some people (dogs would be included) donít agree with msm.

Will try my best to relax. I know you are right Catherine. Pep is absolutely a dog that picks up on my emotions. She senses everything and feeds off it. I always try to remind myself that, but it is so hard. I must try harder.
Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on February 27, 2020, 06:38:03 PM


Hi Brooke

Take a look at these links.  The increase in Pep's ALT might be due to muscle damage or at least contributing to the raised levels.

Jo


https://www.dvm360.com/view/canine-liver-enzymes-so-many-questions
ALT

ALT is found primarily in the cytosol of hepatocytes. It's released with increased cell membrane permeability or cell death. ďOf all the liver enzymes, ALT is the most liver-specific,Ē says Dr. Lidbury. On rare occasions, ALT activity can be increased in patients with severe muscle injury. But, in general, ALT is considered a sensitive and specific marker of liver injury. ďWhen hepatocytes die, then you get leakage,Ē Dr. Lidbury says. ďALT can also leak when you have just cell membrane damage. You don't have to have necrosis for ALT to go up. Also, severe ALT increases don't necessarily mean you have irreversible disease. Sometimes we misinterpret really high ALTs as irreversible disease and a poor prognosis. If you have a dog with acute liver injury, it might have a sky-high ALT, but if you can support the dog through that initial injury, then the disease could be reversible, and the liver can get back to normal. The liver has such great regenerative capacity.Ē



https://www.whole-dog-journal.com/health/liver-disease-in-dogs/
ALT is an enzyme that may be released with any source of damage to the liver. Blunt trauma, anaphylactic reaction, systemic illness such as thyroid disorders, and other problems that have nothing to do with the liver can cause an elevation of ALT in the blood. Just because ALT is elevated doesnít mean the liver is failing, however. This result is interpreted in conjunction with clinical signs and other bloodwork and imaging changes.

Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: BrookeR on February 28, 2020, 06:09:59 AM
Thanks Jo,  Iíll have a read through these. Sounds interesting.

We went back to the vet today as Peps urine culture grew a moderate growth again. So my vet wanted to take a needle sample directly from her bladder to eliminate any exterior contaminants. We have sent this away for culture.

I also got her to check peps ears as I noticed they were a bit waxy. She also has a mild infection in both ears, one worse than the other.

I have stopped giving the msm. We are going to wait until Wednesday the week after next to recheck her ears and ALT levels (unless she becomes unwell in the meantime).

She is still a bit limpy, but is much more herself personality wise and has been more perky. I had to wake her during the night to get her to do a wee to make sure she could hold long enough to have a full bladder for our appointment this morning. She was sleeping soundly and has been a lot more settled  at night and not getting up so much. Also no signs of sickness.

Title: Re: Itís been a long time- Pep having trouble with swollen elbow
Post by: Jo CIMDA on February 28, 2020, 12:34:26 PM
Hi Brooke

Your last paragraph is a treat to read and it bodes well.  I hope the urine result comes back good. 

Great news.

Jo